Fractional CO₂ Laser Before Follicular Unit Extraction Hair Transplantation With Platelet-Rich Plasma for Secondary Cicatricial Alopecia

Secondary cicatricial alopecia is characterized by permanent destruction of hair follicles resulting from trauma, burns, infection, radiation, or other non-follicular pathological processes. Hair transplantation using follicular unit extraction (FUE) is an established surgical treatment for stable secondary cicatricial alopecia; however, graft survival and cosmetic outcomes may be compromised by fibrosis, reduced vascularity, and poor tissue elasticity within scarred recipient sites. Fractional carbon dioxide (CO₂) laser has been suggested to improve scar quality by promoting tissue remodeling, neovascularization, and wound healing, potentially enhancing the recipient bed before hair transplantation. Platelet-rich plasma (PRP), which contains a high concentration of growth factors, may further improve graft survival and hair growth by stimulating tissue regeneration.

This prospective comparative clinical study was conducted to evaluate whether preoperative fractional CO₂ laser treatment improves the outcome of FUE hair transplantation combined with intraoperative PRP injection in patients with stable secondary cicatricial alopecia. Twenty participants of both sexes with stable secondary cicatricial alopecia and realistic treatment expectations were enrolled. Patients with chronic systemic diseases, pregnancy or lactation, platelet or blood disorders, history of keloid formation, scar duration less than one year, or inadequate donor sites were excluded. The study was approved by the Research Ethics Committee of Tanta University Hospitals (Approval No. 34430/1/21), and written informed consent was obtained from all participants before enrollment.

Participants were assigned into two treatment groups. Group A received three sessions of fractional CO₂ laser treatment at one-month intervals before surgery, followed one month later by FUE hair transplantation combined with intraoperative PRP injection. Group B underwent direct FUE hair transplantation combined with intraoperative PRP injection without preoperative laser treatment. PRP was prepared from autologous venous blood using a double-centrifugation technique and injected into the recipient scar tissue during the transplantation procedure. Hair grafts were harvested using the FUE technique from the donor area and transplanted into the scarred recipient site according to standard surgical protocols.

Participants were followed for nine months after hair transplantation. Clinical assessment included standardized photographic evaluation by three blinded dermatologists and two plastic surgeons. Dermoscopic examination was performed before and after treatment to evaluate follicular regeneration and the percentage of scar surface covered by growing hair. Patient satisfaction and scar severity were also assessed using validated scar assessment scales. The primary objective was to determine whether preoperative fractional CO₂ laser enhances the clinical outcome of FUE hair transplantation with intraoperative PRP in patients with secondary cicatricial alopecia. Secondary objectives included evaluation of dermoscopic hair regrowth, patient satisfaction, and changes in scar assessment scores

Inclusion criteria

• Patients with stable secondary cicatricial alopecia. Male or female participants. Participants with realistic expectations regarding treatment outcomes. All hair types (silky, curly, or normal hair). Presence of an adequate donor site for follicular unit extraction (FUE). Ability and willingness to provide written informed consent.

Exclusion criteria

• Extremes of age. Chronic systemic diseases, including hepatic or renal disease. Receiving chemotherapy or systemic corticosteroid therapy. Platelet disorders or other blood disorders. Pregnancy or lactation. History of keloid formation. Scar duration less than 1 year. Absence of a suitable donor site for hair transplantation