Areas of unethical behavior practiced today

Transcription

forum
HAIR
TRANSPLANT
I N T E R N A T I O N A L
Volume 19, Number 5
September/October 2009
COLUMNS
150 President’s Message
151 Co-editors’ Messages
Areas of unethical behavior practiced today
William R. Rassman, MD Los Angeles, California
154 Editor Emeritus
156 Hair Sciences:
Interview with Drs. Felix
Brockschmidt and Markus
Nöthen
174 How I Do It: The running
subcutaneous suture
177 Hair’s the Question
179 Letters to the Editors
The following is an article by Dr. William Rassman, one of the most respected senior members of our
profession. It should give all of us cause for concern and make us reflect on the damage—firstly to the patient, and secondly to us all—if we allow unethical practices to flourish. Unethical practices have always
existed in medicine and cosmetic surgery is regarded as the “business end” of medicine where we are providing services for healthy patients (commonly called customers). If we apply this notion of customers (rather
than patients), and argue that the customer is always right, we will allow unwise and unnecessary practice
philosophies to develop.
180 Surgeon of the Month
181 ABHRS News
182 Classified Ads
FEATURE ARTICLES
158 Day-by-day review of
the ISHRS 2009 Annual
Scientific Meeting
171 Acne scar reconstruction
with hair grafts
173 Different orientation of
the incisions: an efficient
method to facilitate the
implantation process
176 Committee on database
of hair restoration
results on patients with
cicatricial alopecia and
hair diseases other than
androgenetic alopecia
SAVE THE
DATE!
Revolution &
Evolution
I am disturbed that there is a rise in unethical practices in the hair transplant comWe have no obligation to protect those
munity. Although many of these practices
have been around amongst a small handful
doctors in our ranks who practice unof physicians, the recent recession has clearly
ethically, so maybe the way we respond
increased their numbers. Each of us can see
evidence of these practices as patients come
is to become a patient advocate, one on
into our offices and tell us about their expeone, for each patient so victimized.
riences. When a patient comes to me and
is clearly the victim of unethical behavior, I
can only react by telling the patient the truth
about what my fellow physician has done to them. We have no obligation to protect those doctors in our
ranks who practice unethically, so maybe the way we respond is to become a patient advocate, one on
one, for each patient so victimized. The following reflects a list of the practices I find so abhorrent:
1. Selling hair transplants to patients who do not need it, just to make money. I have met with
an increasing number of very young patients getting hair transplants for changes in the frontal
hairline that reflect a maturing hairline, not balding. Also, performing surgery on very young
men (18-22) with early miniaturization is in my opinion outside the “Standard of Care.” Treating
these young men with a course of approved medications for a full year should be the Standard
of Care for all of us.
2. Selling and delivering more grafts than the patient needs. Doctors are tapping the well of the
patient’s graft account by adding hundreds or thousands of grafts into areas of the scalp where
the miniaturization is minimal and balding is not grossly evident. I have even seen patients who
had grafts placed into areas of the scalp where there was no clinically significant miniaturization present. Can you imagine 3,000-4,000 grafts in an early Class III balding pattern? Unwise
depletion of a patient’s finite donor hair goes on far more frequently than I can say.
3. Putting grafts into areas of normal hair under the guise of preventing hair loss. There are
many patients who have balding in the family and watch their own “hair fall” thinking that most
of their hair will eventually fall out. A few doctors prey on these patients and actually offer hair
transplantation on a preventive basis. This is far more common in women who may not be as
familiar with what causes baldness and do not have targeted support systems like this forum.
They become more and more desperate over time and are willing to do “anything” to get hair.
They are a set-up for physicians with predatory practice styles.
4. Pushing the number of grafts that are not within the skill set of the surgeon and/or staff.
 page 153
Official publication of the International Society of Hair Restoration Surgery
Hair Transplant Forum International
Volume 19, Number 5
Hair Transplant Forum International is published bi-monthly by the
International Society of Hair Restoration Surgery, 303 West State
Street, Geneva, IL 60134. First class postage paid at Chicago, IL and
additional mailing offices. POSTMASTER: Send address changes
to Hair Transplant Forum International, International Society of Hair
Restoration Surgery, 303 West State Street, Geneva, IL 60134.
Telephone: 630-262-5399, U.S. Domestic Toll Free: 800-444-2737;
Fax: 630-262-1520.
President:
Edwin S. Epstein, MD
Executive Director:
Victoria Ceh, MPA
Editors:
Francisco Jimenez, MD
[email protected]
Bernard P. Nusbaum, MD
[email protected]
Managing Editor, Graphic Design, & Advertising Sales:
Cheryl Duckler, 262-643-4212
[email protected]
Surgeon of the Month: Vance W. Elliott, MD;
Cyberspace Chat:
Sharon A. Keene, MD
The Dissector:
Russell Knudsen, MBBS
How I Do It:
Bertram Ng, MBBS
Hair’s the Question:
Sara Wasserbauer, MD
Surgical Assistants Corner Editors:
Laurie Gorham, RN
[email protected]
Basic Science:
Satoshi Itami, MD
Andrew Messenger, MBBS, MD
Ralf Paus, MD
Mike Philpott, PhD
Valerie A. Randall, PhD
Rodney Sinclair, MBBS
David Whiting, MD
Scientific Section:
Nilofer P. Farjo, MD
International Sections:
Asia:
Australia:
Europe:
South America:
Sungjoo Tommy Hwang, MD, PhD
Jennifer H. Martinick, MBBS
Fabio Rinaldi, MD
Marcelo Pitchon, MD
Review of Literature:
Dermatology:
Plastic Surgery:
Marc R. Avram, MD
Sheldon S. Kabaker, MD
Copyright © 2009 by the International Society of Hair Restoration
Surgery, 303 West State Street, Geneva, IL 60134. Printed in the
USA.
The views expressed herein are those of the individual author and are
not necessarily those of the International Society of Hair Restoration
Surgery (ISHRS), its officers, directors, or staff. Information included
herein is not medical advice and is not intended to replace the considered
judgment of a practitioner with respect to particular patients, procedures,
or practices. All authors have been asked to disclose any and all interests
they have in an instrument, pharmaceutical, cosmeceutical, or similar
device referenced in, or otherwise potentially impacted by, an article.
ISHRS makes no attempt to validate the sufficiency of such disclosures
and makes no warranty, guarantee, or other representation, express or
implied, with respect to the accuracy or sufficiency of any information
provided. To the extent permissible under applicable laws, ISHRS
specifically disclaims responsibility for any injury and/or damage to
persons or property as a result of an author’s statements or materials
or the use or operation of any ideas, instructions, procedures, products,
methods, or dosages contained herein. Moreover, the publication of an
advertisement does not constitute on the part of ISHRS a guaranty or
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Hair Transplant Forum International is a privately published newsletter
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President’s Message
Edwin S. Epstein, MD Virginia Beach, Virginia
It is an honor and a privilege to serve the members of
the ISHRS as your president during the next year. I wish
to take a moment to reflect on the Amsterdam meeting,
which was a successful event in so many ways. Amsterdam is a unique city with its canals, parks, cyclists, and
museums, and I hope everyone had an opportunity to
explore and enjoy its culture and beauty. The international
diversity of the meeting was apparent from the opening
ceremony during which members from various countries
recited in their native language excerpts from the modern
Hippocratic and Physician Oaths.
The average attendee shows up to learn, but has relatively little knowledge
as to the enormous undertaking by the Scientific Committee and ISHRS staff. I
want to congratulate Dr. Ken Washenik for organizing this conference, despite
such distractions as the birth of his first child, Ava Grace, and all his other
hair-related commitments. Kudos to Drs. Paul McAndrews and Tommy Hwang
(Chairs, Advanced Review Course); Dr. Jean Devroye (Live Patient Viewing); and
Tina Lardner (Chair, Surgical Assistants Program). The efforts of the ISHRS staff
are invaluable to the success of this meeting, and I applaud Victoria, Kimberly,
Jule, Liz, and Amy for all their hard work and dedication.
The Gala was highlighted by the Follicle Award presentations, our highest
recognition. The Golden Follicle recipient was Dr. Robert Haber. Bob has been a
huge contributor to the ISHRS as a Forum editor, past president, and numerous
committee involvements. He coauthors a textbook with Dr. Dow Stough, and is
most deserving of this recognition. Dr. Bernard Cohen was the Platinum Follicle
Award winner. Bernie has not only been a visionary, but has the unique ability to
make the transition from imagination to reality as an inventor of surgical devices,
most notably for tissue extension and hair mass measurement, and a mapping
classification for hair loss. In addition, the Distinguished Assistant Award was
awarded to Patrick Tafoya. Patrick has been involved in hair restoration for over
20 years. In addition to teaching many surgical assistants, he has developed
technical and ergonomic solutions to assist them. My congratulations to our
Follicle Award winners, as well as to the recipients of research grants.
At the Business Meeting we had some changes in the Board of Governors. Dr.
Damkerng Pathomvanich (Thailand) retired after 3 years of service, of which I would
like to thank him for his contributions. Congratulations to Dr. Jerry Cooley (USA)
who was elected vice-president; Dr. Carlos Puig (USA), treasurer; and our newest
Board Members, Drs. Alex Ginzburg (Israel) and Arthur Tykocinski (Brazil).
We introduced an Audience Response System that enabled the moderator
and panels to query the audience. This allowed for impromptu surveys by the
audience after topics were presented and debated. This was not only fun and
maintained audience interest, but also provided valuable information, insights,
and opinions. We are looking into purchasing a system for use in future meetings.
One person came up to me and observed that “there was nothing new this year.”
Well for those new to hair restoration, there is a vast amount of new knowledge.
For those more advanced, there may only be one or two “new” things learned,
but this can have a major impact on your practice and results. So I challenge
you all to begin now the process of thinking up new abstracts and evidenced
based studies for next year’s meeting.
At the Amsterdam meeting, we initiated our first Newcomer Program, which
was a huge success with over 120 attending. It afforded the opportunity for the
ISHRS leadership, past presidents, and involved members to express their passion
and enthusiasm for the ISHRS, and to provide a buddy system throughout the
meeting to share ideas and answer questions. We plan to continue this program
in Boston, and I encourage all members to participate.
 page 152
150
Co-editors’ Messages
Bernard Nusbaum, MD Coral Gables, Florida
Paco Jimenez, MD Las Palmas, Spain
This issue begins with Dr. William Rassman’s article on unethical
behavior related to HRS, such as
selling hair transplants to patients
who do not need them or selling
more grafts than the patient needs,
for the sole purpose of making more
money. These wise reflections are
even more significant when coming
from this well-respected colleague
who in the early 1990s was one of
the first to introduce the concept of
megasession in HRS, although at that time a megasession
was equivalent to a hair transplant session of 1,000 or more
grafts, a “small” session by today’s standards.
In my opinion, there are a handful of unethical doctors
and HT centers or franchises that inflate the number of grafts
just to make money, but there are many others who simply
believe that HT is a procedure in which one has to make as
many hair grafts as possible, in other words, “the more the
better,” as simple as that. Basic traditional concepts, such as
creating a high mature hairline, being conservative in dealing
with young patients, etc., are discarded. Dr. Rassman asks:
How is it possible for someone to transplant 3,000 grafts in a
class III balding patient? Simply, either by lowering the hairline to unacceptable limits (which increases the area of the
recipient zone to an area similar in size to a Norwood type
IV-V) or by transplanting more FUs per cm2 than needed. (Dr.
Sharon Keene reported in the March/April 2009 Forum that
40-50 FUs/cm2 is the normal FU density in frontal hairline
of normal individuals and there is no need for more.) Therefore, besides intentional unethical behavior, there may well
be some doctors who simply follow erroneous principles in
basic HT concepts due to inadequate training.
There used to be a workshop at the ISHRS meetings called
“Back to the Basics” led by Drs. Dow Stough and Russell
Knudsen. This was a superb workshop, which should be
 page 152
As we settle down to our daily
routine we can reflect upon the Amsterdam meeting and, of the variety of
topics discussed, some that stand out
in my mind are: trichophytic closure,
follicular unit extraction (FUE), and
low level laser therapy (LLLT).
Most of us who perform the
technique can attest to the fact that
trichophytic closure has significantly
improved the appearance of our strip
excision scars. When it works well, it
is difficult to locate the scar upon casual observation when
back-combing through the donor zone. I would like to commend Dr. Paco Jimenez for his presentation identifying the
depth at which the “bulge” regenerative cells may be damaged and possibly result in permanent loss of donor follicles.
In this regard, I have always felt that the trichophytic excision
should be as superficial as possible, as all that should be
necessary to remove is simply the epidermal layer. There
are no “miracles” or scarless surgery, however, and this
technique is not a panacea as results are less than optimal
in areas of wound tension and subsequent scar spread.
On another note, FUE, as expected, has progressed toward
automated instrumentation such as the mechanical rotary
instruments that have appeared on the scene and should
improve the efficiency of this technique. FUE appears to be
“here to stay” and, without question, the noninvasive nature
of the technique is quite appealing to prospective patients.
Since the San Diego meeting, live patient results have been
presented that look quite good. One always hears the mutterings in the crowd among skeptics who feel that results are
not as dense as those accomplished with equal numbers of
FUT strip grafts. As with any surgical technique, FUT results
must be technique and patient dependent. Further studies to
evaluate survival rates and close monitoring of transection
rates should settle some of the questions still surrounding
 page 152
Editorial Guidelines for Submission and Acceptance of Articles for the Forum Publication:
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6.
Articles should be written with the intent of sharing scientific
information with the purpose of progressing the art and science of hair restoration and benefiting patient outcomes.
If results are presented, the medical regimen or surgical
techniques that were used to obtain the results should be
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Authors should acknowledge all funding sources that supported
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Trademarked names should not be used to refer to devices
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Although we encourage submission of articles that may only
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151
Submission deadlines:
October 5 for November/December 2009 issue
December 5 for January/February 2010 issue
February 5 for March/April 2010
President’s Message
 from page 150
The next annual meeting will be in Boston in October
2010. Dr. Paul McAndrews has accepted the position of
Program Chair. His support cast will include Drs. Robert
Niedbalski and Ricardo Mejia (Basics Course Chair and
Co-chair); Tommy Hwang and Glenn Charles (Board Review
Chair and Co-chair); Ivan Cohen (Workshop Chair); Mark
Di Stefano (Live Patient Viewing Chair); Nicole Rogers, Ken
Washenik, and Bob Leonard (Newcomers Chair).
This meeting truly demonstrated the international flavor
of our membership. The majority of attendees were nonNorth American, and we had excellent attendance from many
countries that either have difficulty with U.S. visas, or found
it easier not to travel to the U.S. We recognize the need for
more “off-shore meetings,” and while we have contracts
signed for our annual meetings through 2013, we plan to
increase our workshop programs outside North America.
We have all been affected by the changes in the global
economy. Membership dues will remain unchanged, and we
will continue to streamline programs designed to increase
the value of your membership. We have a task force to look
into increasing our membership. I welcome and encourage
your ideas as to this task, and will be contacting many of
you personally especially about allied medical societies in
which you are associated, and colleagues who may already
do hair surgery but are not current members. The more we
teach and share ideas, the better the quality of our results,
and the more potential patients we can generate.
U.S. President John Kennedy challenged us: “Ask not
what your country can do for you, ask what you can do
for your country.” I wish to make a similar challenge to all
ISHRS members: to get more involved in committees, to offer to give lectures during our basic and advance courses,
to submit abstracts and posters, and to get involved in OPERATION RESTORE. While our next meeting in Boston in
October 2010 sounds far away, now is the time to plant the
seeds (and follicles) for next year. I want to be available for
your thoughts, suggestions, and yes, even complaints, by a
dedicated email address: [email protected].
Jimenez Message
Nusbaum Message
included in the meeting program every year, and which I
would recommend be of obligatory attendance for every
new ISHRS member. We need to emphasize these basic
concepts and put less emphasis on “numbers” and “gigasupermegasessions,” etc. As Dr. Rassman indicates, only a
“limited number of doctors can safely perform these large
sessions,” and, in my opinion, only a limited number of
patients need them.
this technique. Finally, the general consensus continues to
mount on this side favoring the fact that LLLT has some positive effect on hair growth. We long for more data quantifying
this effect within a targeted zone with scientific evaluation
of optimal dosage and frequency of application.
The Amsterdam meeting was a tremendous accomplishment at the highest academic level and I extend well-deserved congratulations to Dr. Ken Washenik, the Scientific
Committee, and Victoria Ceh and the ISHRS staff.
 from page 151
Paco Jimenez, MD
SAVE THE DATE!
Revolution & Evolution
Advances in Hair Restoration Surgery:
Revolutionary Concepts and
Evolutionary Techniques
 from page 151
Bernard Nusbaum, MD
2009–10 Chairs of Committees
Note: Committees are in the process of being assigned.
2010 Annual Scientific Meeting Committee: Paul J. McAndrews, MD
American Medical Association (AMA) Specialty & Service Society (SSS)
Representative: Paul T. Rose, MD, JD (until 12/31/09) &
Carlos J. Puig, DO
Annual Giving Fund Chair: Matt L. Leavitt, DO
Audit Committee: Robert H. True, MD, MPH
Bylaws and Ethics Committee: Robert T. Leonard, Jr., DO
CME Committee: Paul C. Cotterill, MD
Core Curriculum Committee: Edwin S. Epstein, MD
Fellowship Training Committee: Vance W. Elliott, MD
Finance Committee: Carlos J. Puig, DO
Hair Foundation Liaison: E. Antonio Mangubat, MD
Live Surgery Workshop Committee: Matt L. Leavitt, DO
Media Relations Committee: Robert T. Leonard, Jr., DO
Membership Committee: Marc A. Pomerantz, MD
Nominating Committee: Jennifer H. Martinick, MBBS
Past-Presidents Committee: Bessam K. Farjo, MBChB
Pro Bono Committee: David Perez-Meza MD
Scientific Research, Grants, & Awards Committee:
Michael L. Beehner, MD
Surgical Assistants Executive Committee: Laureen Gorham, RN
Surgical Assistants Awards Committee: Cheryl J. Pomerantz, RN
Task Force on Hair Transplant CPT Codes: Robert S. Haber, MD
Website Committee: Ivan S. Cohen, MD
Ad Hoc Committee on Database of Transplantation Results on Patients
with Cicatricial Alopecia: Nina Otberg, MD
Ad Hoc Committee on Feasibility of Product Endorsement:
Ad Hoc Committee on Regulatory Issues: Paul T. Rose, MD, JD
Evidence Based Medicine (EBM) Task Force: Sharon A. Keene, MD
Strategic Task Force (#3) on Increasing Physician Membership:
Strategic Task Force (#5) on Resources for Training Assistants:
152
2009–10 Board of Governors
President: Edwin S. Epstein, MD *
Vice President: Jerry E. Cooley, MD*
Secretary: Jennifer H. Martinick, MBBS*
Treasurer: Carlos J. Puig, DO*
Immediate Past-President: William M. Parsley, MD*
Michael L. Beehner, MD
Vincenzo Gambino, MD
John D. N. Gillespie, MD
Alex Ginzburg, MD
Robert S. Haber, MD
Sharon A. Keene, MD
Jerzy R. Kolasinski, MD, PhD
Robert T. Leonard, Jr., DO
Bernard P. Nusbaum, MD
Arthur Tykocinski, MD
Surgical Assistants Representative:
Emina Karamanovski
*Executive Committee
Unethical behavior
patient results and testimonials are not uncommon.
Lifestyle Lift, a cosmetic surgery company, settled
a claim by the State of New York over its attempts
to produce positive consumer reviews publishing
statements on Web sites faking the voices of satisfied
customers. Employees of this company reportedly
produced substantial content for the web.
 from front page
The push to large megasessions and gigasessions are
driven by a limited number of doctors who can safely
perform these large sessions. Competitive forces in the
marketplace make doctors feel that they must offer the
large sessions, even if they cannot do them effectively.
A small set of doctors promote large sessions of hair
transplants, but really do not deliver them, fraudulently collecting fees for services not received by the
patient. Fraud is a criminal offense and when we see
these patients in consultation, I ask you to consider
your obligation under our oaths and our respective
state medical board license agencies to report these
doctors.
5. Some doctors are coloring the truth with regard to
their results, using inflated graft counts, misleading
photos, or inaccurate balding classifications. False
representation occurs not only to patients while the
doctor is selling his skills, but also to professionals in
the field when the doctor presents his results. Rigging
The hair transplant physician community has developed
wonderful technology that could never have been imagined
20 years ago. The results of modern hair transplantation
have produced many satisfied patients and the connection
between what we represent to our patient and what we can
realistically do is impressive today. Unfortunately, a small
handful of physicians have developed predatory behavior
that is negatively impacting all of us and each of us sees
this almost daily in our practices. Writing an opinion piece
like this is not a pleasant process, but what I have said here
needs to be said. According to the American Medical Association Opinion 9.031: “Physicians have an ethical obligation to
report impaired, incompetent, and/or unethical colleagues
in accordance with the legal requires in each state….”✧
Dr. Russell Knudsen’s Note: Ironically, we used to complain about “low-balling” where the patient is under-quoted
the necessary number of grafts to achieve his or her goals, thereby requiring them to return for extra sessions. Now
we have the more frequent problem of “high-balling” where the patient is being quoted more grafts than necessary
to achieve the patient’s goal. Whether the physician is doing the quoting, or a paid consultant, it is the physician’s
responsibility for what happens afterwards. If you know the physician involved when you see a patient with a strange
quote, you may feel comfortable having a conversation with them about the situation. We are, however, responsible
primarily to the patient, and Dr. Rassman urges us to swallow our discomfort about reporting colleagues when seeing
fraudulent behavior, and act in the patient’s best interests. I wholeheartedly agree.
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AFTER
Notes from the Editor Emeritus
Richard C. Shiell, MBBS Melbourne, Australia
Some hair transplant surgeons I have known
There are some really memorable,
and at times odd, characters in the
HT profession. The problem is that
some of the guys are still alive, although none ever joined the ISHRS.
To prevent possible embarrassment,
I have concealed the names of some
of the living.
London Plastic Surgeon Philip Lebon was an early starter
in the Hair Transplant field and published his first paper on
HT in the British Journal of Dermatology in April 1963 (75;
170). He was pretty vague about dates and as his first cases
were done in a hospital setting he had no personal records
of the precise date. It was in 1962 or 1961 when he was a
Surgical Registrar at Highlands General Hospital in London,
England. I knew him pretty well during my years in Britain
in the 1970s but have lost touch with him since that time.
He was a Cockney (central Londoner) and a very flamboyant character, and was the first medico I ever heard using
the “F” word in front of his patients. He used it frequently
and with great effect like the Scotsman Billy Connelly does
on TV today, but this was back in 1969. Hair transplantation
was never a big part of his cosmetic surgery. I introduced
him to the motorized punch in 1975, although I had been
using it myself since 1969. Entering into Juri flaps in a big
way when they were introduced in the mid-1970’s, he soon
struck some legal troubles, but shrugged it off and bounced
back like a true Cockney
The English have a very tolerant attitude toward dogs
and they are frequently seen in hotels and restaurants. My
main memory of his Weymouth St. consulting rooms is of
his tiny 2-man elevator and of an enormously long and aged
greyhound dog, lying full length over three cushions on an
antique settee. The docile animal would open an eye as each
new patient entered the room and then, failing to recognize
a member of the staff, promptly go back to sleep. Meanwhile
the lady patient (they were mostly females) would try to find
somewhere else to sit in the small waiting room while keeping a wary eye on the extraordinarily large animal.
Myles Wislang of New Zealand had a brilliant mind and
was not only the Gold Medalist in Anatomy on the way to
his medical degree at the University of Otago, but a concert
violinist of rare talent. He was also a photographer of such
excellence that an exhibition of his enlarged photographs of
the New Zealand Alps was given in the Auckland Art Gallery before going on world tour, sponsored by one of the
pharmaceutical companies.
He was also decidedly eccentric. Married a couple of
times, and with numerous children, he was careless about
matters like parking fines, payment of the rent on his professional rooms, and more seriously his annual Medical
Registration. When I first met him in the early 1970s, he
was heavily into natural medicine, yoga, and the alternate
lifestyle. Patients reported ringing the doorbell, hearing the
command “come in,” and being confronted by the sight of
a man in a kaftan, standing on his head in the corner of the
office. They had not been entered in the appointment book
and had arrived in the middle of Myles’ Yoga session.
He sold his practice in the early 1980s to go to Ireland
and then Israel to perform Emergency Surgery, which had
become his latest passion. I knew the doctor who bought
his practice and he assured me that nearly every former
patient of Myles who required further surgery had already
been done and he had to rely entirely on new patients. Myles
returned a few years later and “squatted” in Auckland and
recommenced HT practice in his former territory. He never
became a member of the ISHRS and never moved from the
4mm plug technique.
Alf Morrow of Birmingham was not your typical stayat-home British doctor. To start with he had worked in the
West Indies after graduation and had married a very lovely
registered nurse who ran his home and office very competently and bore him two delightful children. He would come
to a wine bar with us after work occasionally but did not
drink. He claimed, probably correctly, that the only point
in drinking was to change your state of mind, thus unless
you intended to get drunk there was no point in drinking.
He was a highly intelligent man and we did not attempt to
argue with his impeccable logic as we ordered another glass
or two of red wine for ourselves.
Alf had worked in the Venereal Disease lab of the Pathology Department in Barbados and was absolutely paranoid
about “germs and things.” I worked with him in England in
the days before AIDS made its appearance in the Western
world. He was, nevertheless, very aware of the dangers of
Hepatitis B and his performance after pricking his finger
one day in the operating room is indelibly etched on my
mind. First he swore very loudly and profanely while ripping off his two pairs of latex gloves, frightening the life out
of the poor patient and nursing assistants who were in the
O.R. with him. After frantically washing the blood off his
punctured finger, he proceeded to suck it with the vigor of a
poddy calf attacking a feeding bottle in a farmyard. He then
proceeded to question the patient in detail about his recent
and distant sex life and lifestyle in general, before gradually
settling down to re-glove and resume the operation. It was
a performance worthy of an Academy Award.
So scared of blood borne viruses was he, that this extended also to the blood in his meat. While most of us liked
our steak rare or medium he always demanded his steak
be “very well done” as a matter of course. These are pretty
vague terms and one accepts some leeway depending on
154
whether the chef is French, Italian, or British. Alf was the
only man I have ever known to send a steak back THREE
times for further abuse on the griddle. On the final occasion the chef emerged personally with the poor little lump
of tortured protein and placed it before Alf with a grunt of
obvious disapproval. No doubt he had been curious to see
the cut of this culinary “nut” who would eat a lump of hot
charcoal and pretend to like it. With the advent of AIDS and
the recognition that it was blood-borne, Alf quickly dropped
out of the hazardous profession of Hair Transplantation and
returned to full-time General Practice.
Wayne Bradshaw, the wild man from West Australia,
should enter the history books as the man who finally
convinced the doubting and conservative hair transplant
profession of the value of small grafts. He certainly did not
invent the process as small grafts and even single-hair grafts
had been around for decades. In fact they dated back to the
Japanese in the late 1930s. It was a small case of mine that
he saw in the late 1970s that prompted him to completely
abandon 4mm punch grafting and switch to “quarter grafts”
for more extensive cases of baldness.
He did many cases in Australia and had his assistants
do a lot on his own scalp in the early 1980s. He turned up
at the New York HT meeting in 1984 with his very impressive transplant contrasting greatly with the traditional “plug
jobs” sported by many other physicians at the meeting. He
was an exceedingly extroverted character but had not been
scheduled to speak at the meeting. O’Tar Norwood generously gave him half of his 30 minute spot scheduled for 9 am
on the Saturday morning (those were the days when favored
speakers had up to half an hour at the podium).
Wayne gave his address in the morning. Followed by an
invitation for audience members to inspect his transplants,
the talk went 15 minutes over time and upset the schedule
of the entire day. It was, nevertheless, the highlight of the
meeting. Despite the fact that many surgeons, such as Pierre
Poutoux of Paris, had been quietly using small grafts for
years, quarter grafts were now “kick-started” into history.
Wayne never received any recognition for his pioneering efforts but in 2000 we gave Dr.Carlos Uebel a Platinum Follicle
Award in belated recognition of his quiet contribution to both
minigrafting and megasessions. Carlos had presented both of
these concepts to unsympathetic audiences in America as far
back as 1982, well before Wayne appeared in New York.
Wayne was also the initiator of the Large Bilateral Alopecia Reductions that held favor for a while in the late 1980s
and early 1990s. Dr. Mario Marzola quickly realized the
perils of the bilateral approach and left the field to Bradshaw
who knew no fear.
Wayne set up a branch practice in New Zealand in 1990s
and flew in and out of Auckland on surgical forays from time
to time. By this time he had added liposculpture to his bag
of tricks.
Wayne could dance all night and yet still turn up “bright
eyed and bushy tailed” at the start of the next morning’s
program. He was a high achiever, and in addition to running
a busy general and cosmetic surgery practice in the city of
Wannaroo in the outer suburbs of Perth, he found time to
act as City Mayor for several terms.
He is now back working as a GP in a county seaside
township in West Australia. I dined with him five years ago
and he was still full of energy and vitality. His wife and
seven children have stuck with him and I keep waiting for
his “next trick.”
Anthony Pignataro of the USA first came to my attention
at the Chicago meeting of the American Academy of Facial,
Plastic and Reconstructive Surgery at the Drake Hotel in
June 1995 (see Hair Transplant Forum Int’l., Vol. 5, No. 4, p.
7). While lecturing to the gathering on the joys of hair he
reached up and snapped off his own unit, which was attached to titanium implants embedded in his cranium. I had
been forewarned by someone who had seen his party trick
previously and I captured it on film for the Forum. Nothing
came of this novel “Osteo-integrated” method of attachment,
however, and it faded into history.✧
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155
Hair Sciences
Nilofer Farjo, MBChB Manchester, England
The European Hair Research Society (EHRS) held its 14th Annual Meeting in Graz, Austria, July
2-4, hosted by Daisy Kopera, Professor of Dermatology. Graz, a university town, is located in southwest Austria and is the country’s second largest city. The congress program included advances in
hair biology, pathology, diagnosis, therapy, hair genetics, psychosomatics of hair and its associated
disorders, and hair care and cosmetics.
In this edition I would like to focus on two talks given at the meeting: the Ebling lecture and the Schweizer award winner.
Each year the EHRS sponsors a lecture in memory of the late Professor John Ebling, an internationally renowned zoologist. His hair research work was mainly devoted to understanding how hair growth and sebaceous gland activity is
regulated, particularly the role of the endocrine system. Past lecturers include Roy Oliver, Colin Jahoda, George Cotsarelis,
and Rodney Dawber. This year’s invited guest speaker for the prestigious Ebling lecture was Dr. Kurt Stenn who spoke on
Bioengineering the hair follicle: paradigm and paradox.
There are several approaches to new therapies in treating hair loss including cellular transplantation. This includes using
autologous trichogenic cells or cell aggregates. The important cells for the creation of new follicles are dermal cells (inducer)
and epidermal cells (responder). Those companies involved in research are either using a single cell approach, where the
inducer cells are injected to stimulate the responder cells, or
Kurt Stenn, MD
a two cell approach, which involves using both epidermal and
dermal elements in a two cell construct. This second concept
Vice President and Chief Scientific
is the one used by Aderans Research. Dr. Stenn went on to
Officer, Aderans Research.
explain their trichogenic patch assay using two cell types
Kurt Stenn is Vice President and
injected into adult mice. The cells are injected subcutaneously
just above the muscle layer, which resulted in the formation
Chief Scientific Officer of Aderans
of new mice hair follicles. The next step in the research inResearch. He is a preeminent scholar
volved using a human xenograft assay that involved using
in the area of hair follicle research
scalp cells from transplant patients, multiplying these in
who previously served for 10 years as the Director of Skin
culture, and then injecting them intradermally into skin from
Biology at Johnson & Johnson. Prior to that, he was a proa face-lift procedure. Again hair growth was demonstrated.
fessor at Yale University for 20 years, as well as Director
Clinical trials are currently underway with phase I safety
of Dermatopathology Laboratory Services at Yale.
studies completed and phase II trials ongoing.
An interview with Drs. Felix Brockschmidt and Markus
Nöthen about the genetics of androgenetic alopecia
In 2008 the EHRS launched a new annual award for the best original basic research presentation at an Annual EHRS Meeting in honor of Prof. Jürgen Schweizer (former head of the Differentiation of Normal and Neoplastic Skin Research group at
the German Cancer Research Center, Heidelberg). The award is sponsored by L’Oreal and honors the contribution made by Dr.
Schweizer to the understanding of hair keratins.
The winner at this year’s meeting was Felix Brockschmidt from the University of Bonn who spoke on Genetics of Male Pattern
Androgenetic Alopecia: Androgen Receptor and Recent Findings on Chromosome 20p11. There have been several studies reported
on the subject of genetics in AGA and the recent development of genetic testing for variants of the androgen receptor gene has
made this a very topical issue. Below I interview Dr. Brockschmidt and his clinical lead, Markus Nöthen.
1. The androgen receptor (AR) gene, the first gene reported
to be associated with AGA, has been found to be located
on the X chromosome. Can you describe the mechanism
of action of the androgen receptor?
The AR protein mediates the action of androgens—the
hormones testosterone and dihydrotestosterone (DHT)—that
have been found to be essential for the development of AGA.
DHT is a metabolite of testosterone and is more active than
testosterone and with a much higher affinity for binding to
the AR protein. After binding to the AR, the protein is activated and translocates into the nucleus of a cell, where it
acts as a transcription factor that is then responsible for the
transcription of other genes. Transcription is the first step in
transforming a gene into a protein. This provides a blueprint
(transcript) for the writing of a protein, the so-called RNA.
2. What are the different alleles that have been described
for the AR gene and what does this mean in terms of
predisposition to AGA?
The whole genomic region around the AR gene is strongly
associated with AGA, which means that the alleles of many
genetic variants located in this region are found more frequently among bald men than among non-bald men. The
crucial question is: Which of these variants is the true causative variant that confers the functional effect? Is it possible
that there is more than one causative variant? These are
unresolved questions. Confirmation of the presence of the
causative variant(s) would certainly provide the best prediction of the later development of AGA.
156
3. The allele association in your studies on the AR has an
etiological fraction of 0.46, which indicates other genes
working to drive full expression. You have now identified other genes; can you describe these genes and their
etiological fraction?
AGA is not a monogenic disorder, that is, a disorder in
which there is only one causative gene in an affected individual. It is obvious from the genetic studies performed to
date that at least several genes contribute to the development
of AGA. Using currently available technology and samples,
we are able to identify the genes with the strongest effects.
However, it is likely that many more genes with moderate
or small effects exist. With an etiological fraction of 0.46,
the AR gene seems to be the major susceptibility gene for
AGA. Last year we published a genome-wide study in which
we attempted to identify new susceptibility genes or loci for
AGA. We were able to identify a new susceptibility locus
on the short arm of chromosome 20 that showed strong
association with AGA (the second strongest genome-wide
association signal after the AR gene). We estimated the
etiological fraction for the best marker at this new locus as
0.32, which underlines the importance of this locus in the
development of AGA. The association signal we discovered
is not within a gene, but it is in proximity to known genes.
(Editor’s note: this means that the causative gene on chromosome 20 has not yet been identified.)This may suggest
that this genomic region regulates the expression of one or
more nearby genes. The paired box 1 gene (PAX1) is one
such interesting candidate: in contrast to other genes in this
region, it is expressed in scalp tissue
7. What do you see as the value of the current genetic testing that measures the predictability of developing AGA
depending on whether you have the high-risk or lowrisk AR allele? Do you think that a test that includes all
the known genes would add any further information to
predicting the extent of hair loss?
The currently available tests are only based on the association findings around the AR gene. This is definitely a
major locus for AGA, but its predictive power is not satisfying.
Other loci such as the new locus on chromosome 20 will
have to be incorporated to improve the predictive power of
such tests. With the identification of more loci the predictive
power will steadily improve.
8. There have also been several studies looking at CAG
repeats including relating this to response to finasteride
therapy and to the risk of development of female pattern
hair loss. Can you describe what this means and give us
your views on the value of these tests?
Genetic association studies undertaken in small samples
must be viewed with caution. Independent replication is always required before results can be accepted as true findings.
The predictive value of any replicated findings will determine
whether they can be translated into clinical practice.✧
4. Can you relate the different genes to differences in prevalence of AGA in different racial groups?
It would certainly be very interesting to understand the
genetic reasons for the ethnic differences in AGA prevalence.
However, it will be necessary to identify the true causative
variants before such studies will be possible. At the moment
our work focuses on individuals from Middle Europe, but
we are very interested in establishing collaborations with
investigators working with other ethnicities.
5. In your studies you describe single nucleotide polymorphism, or SNPs (pronounced snips). Can you describe
what this means?
SNPs are characterized by an exchange of a single base
in the DNA, and they are the smallest genetic variations
in our genome. The genome of the European population
contains approximately 10 million of these variable sites.
Together with other genetic variants, they account for the
individuality of the genome of each human being. Only a
small fraction of the variable sites in the human genome has
consequences in terms of disease development, physical
appearance, etc. It is the aim of our research to identify the
specific sites involved in AGA.
6. Have you any idea if the contribution of each gene is
additive, for example, having all the genes means you
progress to Norwood stage VII?
The effect of the chromosome 20 locus seems to act in an
additive fashion to the AR locus. Since not all AGA loci have
yet been identified, the phenotype cannot be fully explained
at the present time.
157
Felix F. Brockschmidt, PhD
Scientist, Department of Genomics, Life
& Brain Center, University of Bonn
After three years of studying law
at the University of Trier, Felix Brockschmidt studied biology at the University
of Bonn where he graduated in 2004. He
worked at the Institute of Human Genetics at the University of Bonn from 2002 to 2004 and was involved in the
research on androgenetic alopecia. In 2004 he started as
a PhD student at the Department of Genomics at the Life
& Brain Research Center at the University of Bonn and
received his PhD degree in 2008. Since then, Felix Brockschmidt is working as a post-doctoral fellow. His main
research focus is genetics of androgenetic alopecia.
Markus M. Nöthen, MD
Director, Institute of Human Genetics,
University of Bonn
Markus Nöthen received his MD
degree from the University of Würzburg. He was trained as a human
geneticist at the University of Bonn
and worked there till 2001 as a clinical geneticist and
scientist. From 2001 to 2004 he was Professor of Medical
Genetics and Director of the Center of Medical Genetics
at the University of Antwerp, Belgium. In 2004 Markus
Nöthen became the Alfried Krupp von Bohlen und Halbach
Chair of Genetic Medicine at the University of Bonn. Since
2001 he has been founding head of the Department of
Genomics at the Life & Brain Research Center and since
2004 Director of the Institute of Human Genetics at the
University of Bonn.
Day-by-day review of the 2009 ISHRS
Annual Scientific Meeting
Thursday • July 23, 2009
Colin Westwood, MD Manchester, United Kingdom
Opening Ceremony. Hippocrates told us “first do no harm”
and a meeting in which there was debate, disagreement, and
controversy began in a mutually inclusive fashion. A random
selection of individuals representing different ethnicities each
recited a passage from the modern version of the Hippocratic
Oath in their own language. Simultaneous English translation
appeared on the screen. It was an impressive beginning.
Surgical Techniques I session chaired by Dr. Ron Shapiro.
Dr. Steven Chang talked about painless anaesthesia (recently reported in the past Forum issue, July 2009). Dr. John
Gillespie questioned the use of sedation, which was banned
in many countries unless an anaesthetist is present.
Complications and Postoperative Care. Dr. Kuniyoshi Yagyu spoke about hair transplantation in high-risk cardiac
patients. Clopidogrel and aspirin must be stopped 1 week
prior to surgery, anticoagulants 3 days before. He intensively
monitors the patient’s cardiovascular condition.
To commemorate the international diversity of the Society, 16 physicians each read
portions of the Hippocratic and Physicians Oath in 16 different languages.
ISHRS President Bill Parsley opened by thanking all the
people who had come a great distance. He reminded us
of the three great names lost in the in the recent past; Blu
Stough, who taught us how “to learn”; David Seager, who
taught us how “to do”; and Jim Arnold, who taught us how
“to teach.” Hot off the press was the launch of ISHRS website
forum and a cicatrial alopecia database.
Cicatricial Alopecias. The first topic on the program was
scarring alopecias. Drs. Jerry Shapiro and Nina Otberg
clarified the distinction between scarring and non-scarring alopecias, and opened the debate of whether hair
transplantation could be an alternative for these diseases.
They emphasised the importance of diagnosis, particularly
as grafting cases of lichen plano pilaris, for instance, were
disappointing. This was echoed in the panel discussion
when Drs. Jerry Cooley and Jeffrey Epstein said they do not
transplant these patients. Dr. Francisco Jimenez reported
that in his experience frontal fibrosing alopecia might show
good growth at 6 months but only about 10% survival at
2 years. Dr. Gholamali Abbassi found that when the cause
of the scarring alopecia was trauma, the results after hair
transplantation were excellent, but if it was inflammatory
in nature, they were very disappointing.
Complications and Post-Operative Care session chaired by Dr. Melvin Mayer.
What can go wrong with flaps and how this can be
rectified was the subject of Dr. Geza Sikos’s talk. He also
recounted the case of a patient who had already been refunded by a previous surgeon because of poor results and
who returned 10 months after surgery with Dr. Sikos complaining of no growth and wanting a refund. Dr. Sikos was
able to demonstrate from his records and photographs that
the patient was in fact pulling out his own grafts! He did
not receive a refund.
The importance of gravity and lying flat to reduce facial
edema postoperatively was shown by Dr. Tommy Hwang.
Dr. Michael Beehner showed yet another study that confirmed that chubby grafts grow better than skinny grafts. The
survival of 1-hair skinny grafts can be as low as 60%.
Video Presentations—Excisional Harvesting. A number of
authors then showed a video presentation of their personal
way of dealing with the donor area harvesting. Dr. Paul Straub
showed excellent results from trichophytic closure; Dr. Craig
Ziering demonstrated the “tunnel technique,” which involves
making intermittent tunnels with tenotomy scissors; and Dr.
Dae-young Kim used a bent razor blade in a plastic syringe to
plane off the trichophytic strip. Dr. Alex Ginzburg repaired a
wide donor scar with a W-Plasty and trichophytic closure. Dr.
Glenn Charles called his closure a “hybrid two-layer technique”
because it relied on deep as well as superficial sutures.
Cicatricial Alopecia panel moderated by Drs. Nina Otberg and Jerry Shapiro.
Surgical Techniques. Dr. Robert True discussed combining
strip harvest and follicular unit extraction in one procedure. Dr.
Richard Keller showed his concept of identifying the temporal
points by palpation (reported in the Forum 2009; 19:2).
Interactive Video Session on Donor Area Harvesting, Excisional section
chaired by Dr. Paul Rose.
158
Lastly, Dr. Loek Habbema focused on the psychological
aspects of female hair loss. Low to moderate density is adequate for most males but females want dense cover. They
do not want a “see through” look in the wind, rain, or the
bathroom. He emphasised that hair care is part of the female
daily make-up regime. He felt that overall hairpieces and hair
additions were the best answer for women. After a full day
of listening to many different opinions on the best surgical
techniques it was a very appropriate end.
Questions at the microphone.
This session generated a heated debate. Dr. Beehner
questioned whether Dr. Charles’s technique might jeopardise
vascularity. Dr. John Cole, ever the devil’s advocate, asked
why he was seeing wide scars in patients who had had a
trichophytic closure. He then answered his own question
by saying that often up to 60% of transected hairs do not
grow. Dr. Jeffrey Epstein thought that scars arose when the
trichophytic strip was 2 millimetres deep. Dr. Francisco
Jimenez echoed this point because his research had shown
the stem cell containing bulge could lie as shallow as 0.81.6 millimetres.
Follicular Unit Extraction. A number of different methods
were presented. Dr. Jose Lorenzo uses a hand-held punch
and then extracts the graft with a two forceps technique. Dr.
James Harris now uses a motorized blunt punch. Dr. Alan
Bauman has a manual self-rotating punch. Dr. Yves Crassas
uses a fully automated technique. His machine punches and
sucks the graft into a fluid receptacle. Conflicting advice was
given about tumescence;
Dr. Alan Bauman does use
tumescence, Drs. Jim Harris and Mark Di Stefano
do not.
Speciality Talks. Dr.
Torello Lotti lectured on alopecia areata. He reminded
us that it is an autoimmune
disease present in 1% of
the population and there is
no age or sex preference. A
large number of patients recover without treatment. He Featured guest speaker Dr. Torello Lotti,
outlined various treatments Professor and Chairman, Dermatology
including topical dithranol Department II, University of Florence, Italy.
and systemic steroids.
Dr. Edwin Epstein revealed the latest evidence on the
prophylactic use of finasteride. Finasteride and dutasteride
may have a role in the chemoprevention of prostate cancer.
Both have been shown to reduce the incidence of prostate
cancer by 24%, however, studies were not continued beyond
7 years. The finding of an increased incidence of high-grade
prostate cancer in the finasteride study group is felt to be
spurious, and was not observed in the dutasteride study.
Female Hair Loss. The final session concerned female
hair loss. Dr. Gholamali Abbassi felt female pattern hair loss
was different to male androgenetic loss and finasteride was
not effective. Dr. Sharon Keene explained the pilot study in
female genotyping. Females tend to have a third of the 5alpha reductase receptors in the frontal and occipital areas
compared to males. This is controlled by the androgen receptor gene on the X chromosome. Genotyping may identify
a subgroup of women responsive to finasteride.
Friday • July 24,
2009
Jerry Cooley, MD Charlotte,
North Carolina USA
Friday’s lectures covered
the gamut from medical
treatments and low level
laser to surgical topics including hairline design,
donor closure, and practical
pearls.
Medical & Non-Surgical
guest speaker Dr. Won-Soo Lee,
Treatments. After an intro- Featured
Professor, Department of Dermatology;
duction by Dr. Ken Wash- Director, Institute of Hair and Cosmetic
enik, Dr. Won-Soo Lee, from Medicine, Yonsei University Wonju College
Yonsei University Wonju of Medicine, Wonju, Republic of Korea.
College of Medicine in Wonju, Korea, presented phase III data
on dutasteride for male patterned hair loss.
Because finasteride only blocks type II 5-alpha-reductase,
which results in incomplete DHT suppression, there has been
interest in dutasteride, which blocks both type I and type II
enzymes. A previous study in the U.S. of 416 men showed
that dutasteride 2.5mg was superior to finasteride 5mg at 24
weeks. Dr. Dow Stough had also published a study showing
that dutasteride 0.5mg was superior to placebo after 1 year
in 16 pairs of identical twins. Dr. Lee presented results of this
Korean study that adds to this growing body of evidence. In
this study, 153 men took dutasteride 0.5mg or placebo. At 6
months, the dutasteride group showed significant superiority
over placebo in terms of objective hair counts and patient
assessments. Surprisingly, there was no difference in the
incidence of side effects between the two groups. Several
audience members expressed concern over the safety of
dutasteride in young men because of reports of decreased
sperm counts and the very long half life of this drug. Further
clinical studies with longer durations will hopefully address
these concerns.
Next, Dr. Nilofer Farjo discussed the mechanism of action of minoxidil. It has been proposed that minoxidil may
stimulate hair growth by affecting potassium channels within
the cell; however, the presence of these potassium channels
had never been shown in human hair follicles. In their study,
they showed that human follicles do indeed have potassium
channels, that tolbutamide (a potassium channel blocker) induced catagen in vitro, and that minoxidil only stimulates one
type of potassium channel in the hair follicle. This suggests
the possibility that another drug that blocks both potassium
channels may work better than minoxidil, similar to how
dutasteride appears to work better than finasteride.
Dr. Paul Rose presented a conceptual review of mesotherapy, which involves microinjections of conventional
or homeopathic medicines, vitamins, minerals, and amino
159
acids. Small amounts
of biologically active
compounds are delivered directly into
the mesoderm (middle layer of skin). Although primarily used
for lipolysis, Dr. Rose
discussed how this
treatment might theoretically be applied to
hair loss.
Dr. Bessam Farjo
then discussed prosDesign Panel moderated by
taglandin receptors Interactive Hairline
Dr. Russell Knudsen.
in scalp hair follicles,
which is a hot topic given the recent approval of bimatoprost
in the U.S. for eyelash lengthening. Dr. Farjo presented data
from their study showing that human scalp hair follicles do
indeed express prostaglandin receptors, showing the possible role for prostaglandin agonists in treating hair loss.
Next, Dr. Alan Bauman reviewed the clinical data that led
to the FDA approval of bimatoprost for eyelash lengthening.
He also showed some very impressive clinical photos from
his own practice, and discussed the complementary use of
eyelash tinting and perming to produce optimal results.
An overview of over the counter products for hair growth
was given by Dr. Hugh Rushton. He noted that reports of hair
growth treatments are present 4,000 years ago in historical
records. In particular, he focused on the objective parameters
that should be used on evaluating hair growth agents: 1)
number of hairs/cm2; 2) hair length; and 3) hair diameter.
He then discussed various treatments, and pointed out how
poorly done studies can make it look like objective improvement occurred when it really hasn’t. Skepticism over claims
by hair treatment companies seems to be warranted.
Hairline Design. An interactive hairline panel followed,
allowing the audience to vote on various hairlines proposed
by experts. Somewhat bafflingly, the audience consistently
voted for hairlines proposed by incoming ISHRS President Ed
Epstein. Charges of vote rigging were not substantiated.
Donor Area Closure-Single vs Double. The next panel tackled
the question of single versus double layer for donor closure.
Dr. Bob Haber argued for single layer, pointing to the lack of
clear benefit to using subcutaneous sutures. Surprisingly, Dr.
John Cole was chosen to argue for the double layer, although
he specializes in follicular
unit extraction and rarely
does strip harvesting. Dr.
Cole presented results of a
study showing that a doublelayer closure produced thinner scars in those who had
at least one prior surgery. It
became apparent that individual surgeons rely on their
Featured guest speaker Dr. Michael
personal experience and that
Hamblin, Associate Professor, Department no clear evidence exists either
of Dermatology, Harvard Medical School;
Principal Investigator, Wellman Center for way. Also, the use of wider
Photomedicine, Massachusetts General
strips for larger sessions may
Hospital; Member of Affiliated Faculty of
change how this debate is
Harvard-MIT Division of Health Sciences
framed in the future.
and Technology, giving the Advances in
Hair Biology Lecture.
LLLT. Next was a panel on low level laser treatment
(LLLT). Dr. Michael Hamblin from Harvard Medical School
presented the basic biology behind LLLT. He noted that the
chief photon receptor in cells is the mitochondria. Nitrous
oxide is released, resulting in increase blood flow as well as
increased ATP production. Surprisingly, one benefit of LLLT
may be in the generation of reactive oxygen species, which
according to Dr. Hamblin are actually good in small quantities because they increase the transcription factor NF-kB,
which in turn has numerous benefits including protection
from oxidant stress, the stimulation of proliferation, and the
inhibition of apoptosis. Although many are still skeptical of
LLLT devices for hair growth, the science behind this technology appears solid and we will doubtlessly hear more about
its beneficial role in hair restoration in the future.
Dr. Grant Koher presented a study using a 650nm LLLT
device in female pattern hair loss, demonstrating decreased
hair loss, increased hair counts, and improved hair quality
after 52 treatments (26 weeks). This was followed by a panel
discussion of LLLT and hair restoration with surgeons who
have extensive experience with this in their practice.
Two Mega vs. One Giga. Following this, a debate was
held on the issue of “two megasessions” (Dr. Sharon Keene)
versus “one gigasession” (Dr. Arthur Tykocinski). Various
pros and cons were discussed, with good arguments on
both sides, although a general trend for ever larger sessions
cannot be ignored. A panel discussion afterwards further
explored this practical controversy.
Controversy Panel on Two Mega Sessions versus One Giga Session,
moderated by Dr. Tony Ruston.
Surgical Techniques. The day ended with a series of
practical talks. Dr. Bertam Ng presented an insightful discussion on hairline design with reference to “beauty” and
“attractiveness” rather than just “naturalness.” By studying
“beautiful” celebrities, Dr. Ng developed recommendations
for hairline design based on the relationship of the distance
between the glabella to nose tip compared to the distance
from nose tip to chin. The optimal location for the frontotemporal junction and temporal angle were also discussed.
In this commentator’s opinion, this was one of the finest
presentations of the conference.
Dr. Henrique Radwanski presented a nice discussion of
combining hair transplantation with tissue expansion and
flaps to correct a variety of hair loss problems due to scalp
injuries. He showed numerous examples of how he achieves
excellent results by using these complementary techniques.
Dr. Michael Beehner presented the results of a study he
did to compare graft survival with standard FU grafts and
“paired” grafts in which 2 FUs were placed in the same site.
Whether comparing 1+2 vs 3 or 1+1 vs 2, there appeared
to be substantially lower survival in paired sites, which is
consistent with this surgeon’s experience as well as a vote
taken of the audience. Next, Dr. Jennifer Martinick discussed
coronal sites (lateral slits) versus sagittal sites. She prefers
lateral slits but still uses sagittal when there is significant
existing hair and the head is not shaved. When the audience
160
was polled, about 30% used lateral slits only, 30% used
sagittal only, and 40% used both. The use of computerized
voting from the audience greatly added to the educational
value of the day’s lectures.
Saturday • July 25, 2009
Paul C. Cotterill, MD Toronto, Ontario, Canada
Hair Cycling and Hair Analysis. The morning kicked
off with a very eloquent lecture presented by Dr. Dominique Van Neste, who gave the Norwood Lecture. Dr. Van
Neste’s lecture, titled Dynamic Aspects of Hair Cycling and
Growth, illustrated beautifully the importance of employing
hair growth measurements over time as opposed to only
using static measurements such as scalp biopsies. With
the use of weekly contrast enhanced photo
trichograms, individual
hair follicles in various
stages of growth were
able to be followed. By
using Dr. Van Neste’s
dynamic measurement
techniques, the effects of
drugs such as finasteride
on the growth of hair
follicles can be more ac- Featured guest speaker Dr. Dominique Van
private practice at Brussels’ Hair Clinic
curately measured and Neste,
in Belgium, giving the Norwood Lecture.
assessed over time.
Dr. Jerzy Kolasinski demonstrated the benefits of a recently
developed scalp hair scanner that employs epiluminescence
microscopy and software that allows hairs in the scalp donor
and recipient areas, which have been clipped and dyed, to be
assessed for hair density and degree of miniaturization. This
scanner appears to have great benefits in evaluating potential
surgical candidates in a manner that is objective and reproducible. Dr. Andreas Finner followed with a talk that stressed
the importance of digital imaging techniques as a means of
providing reproducible, standardized data for the assessment and follow-up of ongoing treatments for androgenetic
alopecia, and that with the use of these imaging techniques
more accurate multi-centre studies will be achievable. Dr.
Francisco Jimenez presented a beautiful paper illustrating
his dissections of an anagen follicle that demonstrated that
the bulge region is at a depth of 1.66mm but that stem cells
can be found along the isthmus from 0.76-1.65mm. These
findings have direct implications regarding how much tissue
can be removed with trichophytic closures.
The last paper of the first session was given by Dr. John
Cole. He presented his results of hair mapping studies that
compared Caucasian and Korean hair densities and follicular
group densities that showed that Korean hair densities are
higher than previously thought. Additionally, as a result of
Dr. Cole’s studies, the finding of a higher percentage of 1and 2-hair follicular groups obtained by strip excision when
Hair Cycling and Hair Analysis session moderated by Dr. Bernard Nusbaum.
Breakfast with the Experts, Hairline Design table led by Dr. Ron Shapiro.
compared to FUE techniques, which by virtue of the way in
which FUE grafts are obtained, allows for more hairs per
graft. As such, Dr. Cole feels that Koreans are better suited to
FUE-type techniques.
Specialty Talks. The second session of the morning was
a variety of very entertaining talks that covered a broad
spectrum of subjects. Dr. Shigeki Inui’s talk described his
findings during his search into the life of Dr. Okuda. It was
fascinating to learn that Dr. Okuda practiced as a general
practitioner with an interest in ophthalmologic diseases
and, in 1939 (well before Dr. Norman Orentreich’s 1959
paper), published a paper that described the use of punch
grafts for eyebrow loss. Drs. Inui and Kenichiro Imagawa
were able to find and visit the Okuda Ophthalmology Clinic,
opened in 1930 and still being run today by his grandson. His grandson had no idea of the importance of his
grandfather’s contribution to the origins of modern day hair
transplantation. Saskia de Jong followed with an excellent
description of the different kinds of hair pieces, weaves, and
additions; which ones are better and for what purposes.
Dr. Colin Westwood cautioned hair restoration surgeons
when considering treating transgender patients. He claimed
that being transgender is not directly linked to a hormonal,
chromosomal, or environmental cause. Mr. Konstantinos
Giotis’s study of 800 patients on the psychology of hair
loss confirmed that most people with hair loss were very
concerned and, on a positive note, most patients having
hair restoration were happy with the results. The lecture
given by Dr. Andrea Marliani on body dysmorphophobia
reminded us all that, especially in hair restoration practices
where he feels that as high as 20% of patients with hair loss
suffer from this affliction, we must pay close attention to
what the patient is telling us so we can recognize the signs
and suggest medical treatments or refer to someone who
can. Kimberly Miller urged us all to consider adding Twitter
to our daily routine as a way of increasing the presence
of our websites with the aim of letting others know about
your practice and ultimately increasing referrals. Dr. James
Vogel finished the session by presenting how he proposes
to set photographic standards in hair restoration that are
clear and reproducible, consistent with complementary
backgrounds. We all see too often the presentations at our
meetings that have inappropriate, poor-quality photos. A
common thread that was occurring in many of the morning
lectures was for consistency and reproducibility and accuracy in what we do in order to relate the most meaningful
results to others.
Growth Factors. Dr. Jerry Cooley started the growth
factors session by describing the potential benefits of va-
161
sodilators and external applications of ATP applied to the
scalp, followed through the use a new device that measures
scalp oxygenation, which could lead to new treatments to
enhance graft survival. Dr. Moonkyu Kim presented his
results on in vitro hair organ cultures that showed that
previous hair growth measurements were not as good when
compared to new staining methods, such as Ki-67 and
Tunnel, that stain proliferating matrix cells and apoptotic
cells, respectively. The use of a hair transplant patient’s own
platelet rich plasma (PRP) that contains essential growth
factors has become a hot topic. Dr. Carlos Uebel presented
his study findings using follicular units soaked in PRP that
showed superior hair density results. More testing needs
to be undertaken to assess this technique’s true benefits,
what concentrations of platelets is optimum, and what type
of patient is best suited to this technique. Dr. Craig Ziering
finished this session giving the audience an update on the
studies he is involved with using human foetal fibroblasts
to increase the production of wnt proteins that promote
wound healing and growth factors and, ultimately, when
injected into the scalp, may promote hair growth. Initial
clinical trials proved to be positive, with more clinical trials
under way. The most intriguing aspect of this technique is
that, contrasted to the ongoing application of topical finasteride and minoxidil, only a single application of therapy
is required to achieve an increase in hair count and hair
thickness. (Dr. Nilofer Farjo wrote a very succinct article
in the July/August 2009 Forum that reviews wnt signalling
and the gist of the ongoing studies.)
Hair Cloning, Duplication, and Research. The last session
of the day started with Dr. Bessam Farjo explaining that
although clinical studies taking dermal papillae cells from
a patient, multiplied in culture and re-injected back into
the host to induce new hair follicles formation, are ongoing, the results are not predictable. The answer may lie in
growing stem cells in vitro to a hair follicle stage and then
implanting the hair follicle. Dr. Neil Sadick reintroduced a
long-standing observation that with female pattern hair
loss, inflammatory infiltrates could be a factor contributing to hair loss. However, the new wrinkle may be that the
culprit may be an immune-based trigger and that antigen
targets have yet to be identified. These preliminary findings
bring to light the possible benefits of topical corticosteroids,
NSAIDs, and even red light lasers. Dr. Damkerng Pathomvanich presented his very preliminary findings of an ongoing study where he would aspirate adipose fat and isolate
stem cells to be re-injected and used for treating AGA. At
5 months post treatments definitive results are premature,
with more results to follow.
The very last lecture of the day given by Dr. Coen Gho
was greatly anticipated. He described that by using his
technique of extracting individual hair follicles, in a form
vaguely similar to FUE, the part of the follicle that remains
in the dermis will multiply and regenerate the same number
of hairs, with the same characteristic, as the follicle that
was extracted! If consistently successful, as he suggests,
this would be a tremendous advance for hair restoration;
however, he failed to produce results that anyone could
qualify and deflected questions to a later time such that he
has more data to give us. Very frustrating, so we will just
have to wait and wonder.
Sunday • July 26, 2009
Bessam K. Farjo, MBChB Manchester, United Kingdom
Eyebrows and Eyelashes. The day started with a talk on
eyelash surgery complications by Dr. Alan Bauman. He plants
a maximum of 40-60 per lid. He mentioned a 10% incidence
of hordeolum or stye, and rarely, chalazion cyst, epiphoria,
and trichiasis. Dr. Kamran Jazayeri showed a nice result of a
post-trauma lower eyelid transplant using a 0.7mm manually
bent blade for better control in making the coronal incisions.
Dr. Steven Chang studied dense packing using the eyebrow.
He showed that 92 grafts per sq cm looks similar to 40-50
per sq cm due to 14% fall in growth rate. It was noted that
he used 20G needles for coronal or perpendicular incisions.
Dr. Nilofer Farjo ended the session confirming recipient site
influence on slowing down growth rate after eyebrow transplants in a small ISHRS sponsored study.
Potpourri. Dr. Jorge Gaviria started the next group of talks
reporting on trichophytic closure with emphasis on ethnic
hair. He showed better results using the technique in 92%
of cases after 4 months and 90% less detectability when
assessed by a physician. Dr. Bob Haber then introduced a
new harvesting knife that offers control over width, angle,
and depth of the incision as well as simultaneously making
the scoring cut for the trichophytic closure. Dr. Samir Abu
Ghoush presented a considerable range of scalp, beard,
and moustache post-trauma hair surgery results. Dr. Ciro
De Sio proposed guidelines to standardize photography in
particular avoiding artifacts in the background and avoiding
direct flash light on the subject.
Donor Area Closure. The final session of the meeting
addressed donor area closure. Dr. Arturo Sandoval demonstrated how he does his interrupted strip extraction skipping the post auricular area to avoid this high tension area.
The patient gets an occipital scar and two parietal ones at
a slightly higher level. Dr. Kulakarn Amonpattana, a fellow of Dr. Pathomvanich, argued that although not always
advantageous, the W-plasty is better than a Z-plasty when
revising widened donor scars. Dr. Antonio Pastorale told us
he routinely recommends two transplant sessions using two
separate parallel sites. He only uses trichophytic closure in
a third session when he removes both scars. Dr. Dae-young
Kim recommended keeping the trichophytic incision to no
more than 0.5mm in depth to avoid damage to the sebaceous
gland. Dr. Parsa Mohebi showed us the advantages of his
laxometer device in the pre-op assessment of the donor
laxity. Dr. Jack Yu from China presented his technique of
beard to scalp transplant using FUE. It was an unusual
method using a new “coring” needle-like instrument and
custom forceps to harvest the grafts. Dr. Zhengwu Sun was
the final Amsterdam speaker. He said that to prevent bad
scars he now limits donor width to a maximum of 2cm, uses
a post-op bandage for 2 days, applies interrupted rather
than continuous suture, and removes half of the sutures
Eyebrow and Eyelash Transplantation and Treatment session moderated by Dr.
Jeffrey Epstein.
162
after 2 days. He also feels more comfortable with pre-op
antibiotics routinely.
After the end of the general session, a small group of us
joined the ISHRS chartered tour bus heading north of Amsterdam. It was a beautiful day where we first visited the site of
the historic windmills at Zaanse Schans. The one we entered
is still being used to crush peanuts to produce cooking oil.
This was followed by the demonstration of the making of the
traditional dutch wooden clogs. A stroll through the picturesque cheese making town of Edam followed including some
sampling of course! Next was the small town of Marken and
Potpourri session moderated by Dr. Robert Haber.
a ferry crossing to the fishing village of Volendam. Exhausted
but a great time was had by all as we made it back to our
hotels for an early night for a change!✧
Congratulations to Daily Eval Winners…
…who won the daily evaluation incentive prize drawings! Each winner received a certificate for $250 off of an
upcoming ISHRS annual meeting:
Thursday: Dr. Anthony Mollura
Friday: Dr. Rajesh Rajput
Saturday: Dr. Kulakarn Amonpattana
Sunday: Dr. Romeo V. Bato
Overall Eval: Dr. Brian Goertz
Thank you to everyone who completed the evaluations. We appreciate your feedback so we can continue to
improve the annual meeting.
Physicians & Medical
Assistants Wanted
Hair Club,® the industry leader in hair restoration, is
expanding and opening new centers throughout the USA.
We are seeking talented physicians and medical assistants
with experience in follicular unit hair transplantation to work
with us in our expanding markets.
If you are interested in working with a team that makes
a difference in people’s lives, you like to travel and enjoy
working with motivated professionals,
we invite you to contact us:
HR Department (800) 251-2658
Email: [email protected]
www.hairclub.com
Experience More.TM
163
2009 Annual Scientific
Meeting Committee
Thank you to the 2009 Annual Scientific Meeting
Committee for a great conference!
Dr. William Parsley (left) presents a program chair
plaque of recognition to Dr. Ken Washenik (right) for his
efforts in chairing the 2009 Annual Scientific Meeting.
Drs. Paul McAndrews and Sungjoo
Tommy Hwang chaired the Advanced
Review Course.
Program Chair Dr. Ken Washenik (left) and President Dr. William
Parsley (far right) present certificates to committee members Drs.
Arthur Tykocinski, Vincenzo Gambino, and Alex Ginzburg.
Dr. Jean Devroye chaired the Live Patient Viewing session.
2009 Annual Scientific Meeting Committee
Ken Washenik, MD, PhD, Chair
Gholamali Abbasi, MD
Jean Devroye, MD
Vincenzo Gambino, MD
Alex Ginzburg, MD
Sungjoo Tommy Hwang, MD, PhD
Paul McAndrews, MD
David Perez-Meza, MD
Arthur Tykocinski, MD
Tina Lardner
Not pictured: Drs. Gholamali Abbasi and David Perez Meza.
164
Tina Lardner chaired the
Surgical Assistants Program.
ISHRS Leadership
ISHRS Board of Governors and Past-Presidents,
July 22, 2009, Amsterdam
ISHRS Executive Committee, July 22, 2009, Amsterdam
Seated L to R: Jerry Cooley, Jennifer Martinick, William Parsley,
Edwin Epstein, Bessam Farjo.
Standing L to R: Victoria Ceh (Executive Director), Paul Straub, Paul
Cotterill, Carlos Puig, E. Antonio Mangubat, Michael Beehner, Vincenzo Gambino, John Gillespie, Robert Haber, Paul Rose, Russell
Knudsen, Robert Leonard, Sharon Keene, Bernard Nusbaum, Jerzy
Kolasinski, Damkerng Pathomvanich, MaryAnn Parsley.
L to R: Jerry Cooley, Edwin Epstein, William Parsley, Jennifer Martinick, Bessam Farjo.
Global Council of Hair Restoration Surgery Societies
Meeting, July 23, 2009, Amsterdam
L to R: Edwin Epstein (ISHRS), Sotaro Kurata (Japan), Akio Sato (Japan),
Marcelo Pitchon (Brazil), Piero Tesauro (Italy), Ciro DeSio (Italy), Rajesh
Rajput (India), Kuniyoshi Yagyu (Japan), Sajiv Vasa (India), Vincenzo
Gambino (Italy), Tommy Hwang (Korea), Russell Knudsen (Australia),
Nilofer Farjo (U.K.), William Parsley (ISHRS), Yves Crassas (France), Jennifer
Martinick (Australia), John Gillespie (Canada), Frank Neidel (Germany),
Malgorzata Kolenda (Poland), Jerzy Kolasinski (Poland), Greg Williams
(U.K.). Not pictured: Bessam Farjo (ISHRS), Victoria Ceh (ISHRS).
ISHRS Meeting Staff
L to R: Kimberly Miller, Liz Rice-Conboy, Victoria Ceh, Jule Uddfolk,
Amy Hein.
Thank you,
Photographers…
Thank you to
Dr. Kuniyoshi and
Mrs. Wakako Yagyu,
and Dr. Robert Haber,
our official photographers
of this year’s meeting.
165
2009 Grants & Awards
2009 ISHRS Research Grants
Protocol: Influence of Topical Minoxidil Solution on Donor
Hair and Transplant Growth in Hair Transplantation
Protocol: Controlled Release of Growth Factors in Follicle
Transplants
Lead Researcher: Dr. Andreas Finner
Lead Researcher: Dr. Rodney Sinclair
Team Member: Dr. Leslie Jones
Protocol: TricoSave Closure
Lead Researcher: Dr. Gabriel Krenitsky
Protocol: Marshall’s Solution: A New Graft Holding Solution
Viability Study
Lead Researcher: Dr. Nilofer Farjo
Team Members: Dr. Bessam Farjo, Dr. Michael Philpott,
Jamie Upton
Dr. Michael Beehner (center), Chair of the
Scientific, Research, Grants and Awards
Committee, presenting certificates and research grants to Drs. Andreas Finner (left)
and Nilofer Farjo (right).
2009 ISHRS/IHRF Joint Research Grant
��
��
��
For the second year the ISHRS has partnered with the International Hair Research
Foundation (IHRF) to offer a research grant in the amount of $10,000, funded by the
IHRF. Two research projects were selected this year.
��
��
��
Protocol: The Sprague-Dawley Rat as a Model of Follicular Unit Transplant Viability
Lead Researcher: Dr. William Lindsey
Team Member: Dr. Joseph Goodman
Dr. Nicole Rogers (left) accepts the
grant from Dr. Vincenzo Gambino
(center) on behalf of the International
Hair Research Foundation and Dr.
Michael Beehner (right) on behalf of
the ISHRS.
Protocol:Use of Narrow-Band UVB (311 nm) to Treat
Inflammatory Alopecias (Prior to Hair transplants)
Lead Researcher: Dr. Nicole Rogers
2009 Poster Winners
1st Place
Hector Sandoval, MD
“Shingle Point to Shingle Point”
2nd Place
Malgorzata Mackiewicz-Wysocka,
MD, PhD
“TrichoScan - A New Method for
Diagnosis of Hair Loss”
166
Best Practical Tip
Jorge Gaviria, MD
“Dense Packing Improvement with Custom Magnification Loupes and LED”
HAIRCHECK® HAS FINALLY ARRIVED.
REVOLUTIONARY NEW DEVICE MEASURES
HAIR THINNING, HAIR BREAKAGE, AND
RESPONSE TO PRODUCTS.
• HairCheck® is the latest version of the cross section trichometer. HairCheck® can actually measure hair. It simultaneously
measures the number of hairs and their diameters, generates a single value, and displays it as the Hair Mass Index (HMI). With
HairCheck®, you can quantify and distinguish between shedding, thinning, and breakage.
• HairCheck® will have you thinking and talking about hair measurement from a totally new perspective. For the very first time,
you’ll be able to measure hair… quickly and easily. HairCheck® generates a meaningful numerical score that becomes the
basis of every hair evaluation. You won’t have to make visual estimations or compare imprecise photographs.
• HairCheck® helps explain the dynamics of hair behavior, in an easy-to-understand manner. It provides scientific evidence of
how much hair is present, in a localized, pre-measured area of scalp. It can even measure the severity of hair breakage in
situations where the hair is damaged, and generates a single numeric value and displays it as the Hair Breakage Index (HBI).
• HairCheck® uses a published hair bundle isolation method that can be learned in 20 minutes. No formal training is required
(instruction manual and DVD are included). The actual bundle measurement takes less than 3 minutes. No hair is cut; no hair
is damaged. Use it on wet or dry hair that’s one inch or longer.
• The HairCheck® system includes the basic auto-calculating device, 6 disposable
cartridges, a template with inkpad to demarcate a pre-measured site, and a locating
strip that ensures your return to the same site on subsequent measurements.
HairCheck® is highly accurate. A one-step calibration maneuver is performed
before each measurement.
Developer was recipient of
the ISHRS 2009 Platinum
Follicle Award.
WITH HAIRCHECK® YOU’LL BE ABLE TO:
• Measure the Hair Mass Index (HMI) to determine how much hair is present in a
localized area of scalp. Repeat the HMI measurement, at the same site, at a later
date to determine if the HMI has increased or decreased.
• Detect early diameter reduction… years before visible thinning appears. Simply
compare the HMI of the affected area to the HMI of the permanent fringe to identify
early thinning.
• Measure the effectiveness of products that promise to make hair appear thicker
and fuller. Obtain scientific evidence to find out if they actually work.
• Determine the percentage of broken hairs. Perform a proximal and distal HMI
measurement on the same isolated bundle to determine the Hair Breakage Index
(HBI) or percentage of broken hairs. No pre-measured scalp site is required
TO MEASURE HMI
TO MEASURE HBI
For more information call 1-800-233-7453 or visit www.haircheck.com
HairCheck® is a mechanical hair-measuring device
It is not intended for the medical diagnosis of hair loss or the medical management of hair loss treatment.
167
2009 Awards
Follicle Awards
Distinguished Surgical Assistants Award
Dr. Robert Haber, 2009 Golden Follicle Award recipient and Dr.
Bernard Cohen, 2009 Platinum Follicle Award recipient.
Patrick Tafoya, 2009 Distinguished Surgical Assistants Award
recipient with MaryAnn Parsley, Surgical Assistants Award
Committee, and Tina Lardner, Chair of the Surgical Assistants
Auxiliary.
Outgoing Board and Officer Plaques
Dr. William Parsley, President, accepts the
president’s award and pin from Immediate
Past-President, Dr. Bessam Farjo. Victoria
Ceh, Executive Director, applauds.
A plaque of appreciation is presented to Dr. Damkerng Pathomvanich
for his service on the ISHRS Board of
Governors.
Dr. Jerry Cooley accepts a plaque for his
service as Treasurer for the past two years.
A plaque of appreciation is presented to MaryAnn Parsley for her
service as the Surgical Assistants
Representative to the Board.
Dr. Edwin Epstein accepts a plaque for his
service as Vice President.
168
169
170
Acne scar reconstruction with hair grafts
Guillermo Blugerman, MD, Diego Schavelzon, MD Buenos Aires, Argentina Email: [email protected]
The Problem
Surgical Technique
Acne affects a large percentage of the population, both
men and women. However, it is most prevalent in 95% of
young male adolescents, where it is observed in varying
degrees. In addition, acne tends to be more aggressive in
men than in women due to the androgens that stimulate
the production of sebum in the glands that lubricate the
hair follicle.
The loss of the typical structure of the pilosebaceous follicle is usually one of the consequences of acne, and once
the acute infection process goes into remission, it may leave
atrophic or hypotrophic dermal scars (Figure 1).
The lesions caused by acne vary from comedones (or
blackheads) to true abscesses that result in dermal and
subcutaneous cell tissue injuries, leaving scarring sequelae
of different severity.
The follicular unit extraction (FUE) technique is
recommended. We look for
hair whose quality matches
the quality of the patient’s
beard hair, such as hair from
the sideburns, thorax, pubic
area, or, ultimately, hair from
the scalp, since hair in this
area tends to be thinner and
scalp skin has less melanin,
which could counteract the
effect by causing residual
hypopigmentation.
The implantation technique will be selected accord- Figure 2. Acne scar at the end of the
procedure.
ing to the existing scars. If the
scar is atrophic, incisions will be made with needles or
micro blades. However, if the scar is hypertrophic, a punch
of 0.7-1.0mm will be used for extraction and such scarring
tissue will be replaced by a hair graft (Figures 2 and 3).
We have observed that
fixation of facial skin grafts
is better than the one observed in the scalp. Therefore, there is little possibility
of grafts popping out from
their insertion incisions. It
is not necessary to secure
it externally; the scarring
process will, on its own,
adhere the transplanted
tissue to the new site.
Figure 3. Hair graft in acne scar.
A
B
Figure 1. A: Acne necrotizing lesion; B: Acne alopecic and atrophic scars.
Solutions to Date
Most treatments for acne scars are aimed at leveling the
epidermal and dermal scarring by means of dermabrasion
or laser skin resurfacing. Another approach is to increase
the dermal or subdermal volume using filling material injections.
Other minimally invasive surgical techniques include subsicion, dermal grafting, and punch excisions of the scars.
Our New Innovative Approach
Most cases of acne scarring lesions in the beard or moustache areas leave scars with hair follicle destruction as seen
in patients with scarring alopecia.
The beard hair follicle of an adult has volume in itself.
The loss of this volume, when the pilosebaceous structure
is destroyed by the acute inflammatory process, results in
hypotrophic scars.
In these cases, follicle replacement will serve two purposes. First, it will provide epidermis, dermis, and subcutaneous
volume like any other skin graft, and second, it will provide
the hair shaft that will give the color and the necessary
texture for the concealment of the alopecia.
Based on our experience in the use of follicular units in
hair transplantation, we have learned how to deal with the
delicate hair follicle structure.
The Importance of This New Approach
This approach toward acne scarring for hair transplant specialists and dermatologists is important for many reasons:
1. HT centers have the doctors and technicians, as well as
the necessary materials, for immediate implementation
of this technique with zero investment.
2. This is another way of recycling and attracting former
patients as you can refer to the data base and find candidates for this technique.
3. The target of this new hair transplant technique is similar
to the one used for androgenic alopecia—males aged 20
or older who care about their image. These acne scarring
patients tend to have the same “desperation” to improve
their image as the ones losing their hair.
171
 page 172
Acne scar reconstruction
 from page 171
Conclusion
A new treatment of facial scarring alopecic lesions caused
by acne in men has been introduced, based on reconstruc-
tion through hair follicle transplants to address both filling
and hair restoration.
Based on our experience, patients’ satisfaction has been
highly rated. In most cases we have complemented this
technique with fractional CO2 laser to further improve the
skin surface.✧
Now taking orders!
Female Hair Loss Workshop
DVD/Video Set
Includes all presentations and operations performed during the July 17-19,
2009, Poznan workshop.
For further information to reserve your
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www.ISHRS-CHOPIN.com
172
Different orientation of the incisions: an efficient method
to facilitate the implantation process
Alex Ginzburg, MD Raanana, Israel Email: [email protected]
Since 2002 there have
been discussions among
hair restoration surgeons on
the comparison between the
following methods of making the incisions:
1. Perpendicular to the
existing hair, or coronal angled grafting
(CAG)
2. Parallel to the existing hair, or sagittal angled grafting
(SAG)
uses these tiny blades to
create the incisions since the
difference in their size is so
small that it is usually difficult for the technicians to see
whether the incisions are, for
example, 0.7mm or 0.9mm.
A
B
This mistake may result in
Figure 1. Two intraoperative procedures showing the different orientation for the
the implantation of one hair
incisions.
into incisions made for two
hairs, or even in the implanA
B
tation of two hairs into incisions made for three hairs.
Therefore, the grafts would
not be implanted where the
Drs. Jerry Wong and
physician wanted.
Victor Hasson were the first
To avoid this confusion, I
surgeons to propose the Figure 2. A young patient before treatment and14 months after 1,320 FUs implanted in suggest changing the direcincisions made with different orientations.
perpendicular incision, or
tion of the incision accordCAG. These authors coning to the length of the blade
A
B
sider that CAG is the best
as follows.
method because the folStep 1. In most cases I
licular units (FUs) may be
begin with a coronal incisafely transplanted closer
sion for 1-hair FUs, using a
together with greater resquare chisel blade of 0.6sultant density. According
0.7 depending on the thickto Drs. Wong and Hasson,
ness of the hair. For 1-hair
there are several reasons for Figure 3. A 40-year-old man before treatment and 11 months after one procedure of 2,150 grafts it is not important
FUs using the same technique.
this including:
whether we use SAG or CAG.
1. There is reduced injury to the subdermal vasculature The physician can decide which angle he or she prefers.
(CAG is shallower than the deeper penetrating parallel
Step 2. I make sagittal incisions using a square chisel
(sagittal) oriented blade)
blade of 0.9-1.0mm for 2-hair FUs.
2. The coronal incision decreases the wound length with
Step 3. I make coronal incisions using a 1.1-1.2mm blade
more acute angulation than the sagittal incision.
for 3- or more hair FUs or I use an SP90 depending on the
3. With the coronal incision, the pressure is largely in an patient and the hair characteristics (Figure 1).
upward and downward direction whereas with sagittal
incisions, outward pressure is created when a graft is
With this different orientation for the incisions, we can
placed in a lateral direction. This lateral pressure in- see clearly which incision is matched to 1-, 2-, or 3- or more
creases popping.
hair FUs, so that we can be certain that all the grafts are
4. Coronal incisions are associated with less bleeding, which being planted in the correct way.
is a common cause of popping.
One may think that changing angles may jeopardize the
blood supply. This might have been true when incisions were
In my opinion, both CAG and SAG methods create good made with larger blades for minigrafts but not today when
results. When the grafts are placed coronally, there is a small blades between 0.6-1.2mm are used. For the past 5
greater illusion of density because the incisions can be years I have been using this technique and never have had
angled more acutely, which in turn can create a greater a case of necrosis or other significant related complication
shingling effect. In women, however, I prefer to create sagittal (Figures 2 and 3).
incisions to avoid injury of the existing hairs.
References
Technique
1. Wong, J. Sagittal vs coronal slits in the coronal corner.
Many hair restoration surgeons make the incisions first and
Hair Transplant Forum Int’l. 2002; 2: 37-40.
then let the technicians introduce all follicular units into the 2. Hasson, V. Perpendicular angled grafting. In: R. Haber and
incisions. However, problems might occur when the surgeon
D. Stough, eds. Hair transplantation. 117-25.✧
173
How I do it
Bertram Ng, MD Hong Kong, China Email: [email protected]
Dr. Bertram Ng’s note: The use of a two-layered closure for closing the donor wound is recommended in strips wider than 1cm, tight scalps, in repeat excisions, and in patients with hyperelasticity of the scalp. Below, Dr. Bill Parsley describes how he performs the running subcuticular suture
without knots using Biosyn as the absorbable suture.
The running subcutaneous suture without knots
William M. Parsley, MD Louisville, Kentucky Email: [email protected]
For the last 16 months I have been using a
running subcutaneous suture without knots
exclusively and have found that my strip
scars are considerably improved. This technique was first mentioned to me several years
ago by Dr. Ed Epstein and, more recently, by
Dr. Arthur Tykocinski (but with knots).
A
B
The Technique
C
D
1. Insert an absorbable suture about 5mm
beyond the point of incision and then run
it horizontally in the space between the
bottom of the bulbs and the galea. Stay
above the neurovascular plexi but avoid
wandering superiorly and catching some
hair follicles. I use 4-0 Biosyn but any
braided absorbable suture should work E
equally well (Figure 1A).
2. Secure the end of the suture, if not using a
knot, either with a hemostat or lead-free
small fishing sinker. The latter is easy to
clamp onto the suture (Figure 2A).
3. Take big subcutaneous bites up to a
centimeter in size. Where the fat is too Figure 1. Diagrams of Procedure: These figures show diagrams of the steps in the running SQ closure, starting
broken up or weak to hold a suture, take after the strip excision. A: The initial placement of the running horizontal SQ absorbable suture (not shown is
from the skin with sinkers or hemostats). B: The closure of the surface defect. C: Pulling up
small bites of the galea being careful to securingonitstheexit
suture and clipping it at the skin junction. D: Retraction of the suture beneath the skin.
avoid vessels (Figure 2B).
E: An alternate method using SQ knots if knotless technique is not desired.
4. Avoid using the suture to pull the edges
together during suturing. Tension clamps are used in
advance of the suture to pull the skin edges together, and Practical Tips
then on the already sutured section to pull the edges even
• Use tensions clamps or your forceps to pull the SQ
closer together.
together rather placing much tension on your suture.
5. Upon reaching the end of the incision, run the suture back
The SQ will pull together but not the skin surface
out of the skin about 5mm past the end of the incision
edges.
and secure it with hemostat or another lead-free fishing
• The galea should not be visible before the skin surface
sinker (Figure 2C).
closure. The follicles on the opposing walls should be
6. Pull on the fishing sinker and cut the end of the suture
parallel. The term “subcutaneous suture” has been
at the skin level after closing the skin with a running
used by many doctors to label what in reality are
suture (usually with a trichophytic closure). The suture
dermal sutures. In this technique it is truly “subcuwill retract under the skin (Figure 1B, C, and D).
taneous.”
• Hemostats can get in the way and occasionally snap
Some may be skeptical that fat will not hold the suture.
the suture. The use of lead-free clampable sinkers
I know of one surgeon who left a length of suture out of the
can avoid this problem and not affect the outcome.
skin at each end for a week and did not observe any pulling
• The important aspect is really the subcutaneous cloback into the skin, demonstrating that the suture could hold
sure. The decision to “knot” or “not knot” the ends
its tension even without tying a knot.
of the SQ suture is mainly a personal preference.
174
Theoretical Advantages
•
•
•
•
•
A
It closes all of the dead spaces.
It aligns the hair follicles better.
It relieves much of the tension on the skin closure
without damaging the follicular shafts.
It creates no confined space as do interrupted dermal
or subcutaneous sutures.
It leaves no buried knots that can spit or cause discomfort.
Is it the answer to all bad scars? Unfortunately, no. There
are still some occasional slightly stretched scars but so far
they seem to be less than my scars from my previous technique of combined dermal interrupted sutures/cutaneous
running sutures.
Give it a chance. You may find that a higher percentage
of your scars are difficult if not impossible to detect.✧
B
C
Figure 2. Operative Photos: A: Non-lead sinker clamped on the suture to secure edges. B: Closing of the SQ fatty layer.
C: Use of tension clamps to get a closer approximation.
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175
Committee on database of hair restoration results on
patients with cicatricial alopecia and hair diseases other
than androgenetic alopecia
Nina Otberg, MD Potsdam, Germany; Jerry Shapiro, MD Vancouver, British Columbia, Canada Email: [email protected]
The ISHRS has founded a committee for the registration of
hair restoration results on patients with cicatricial alopecia and
hair diseases other than androgenetic alopecia. The committee
consists of 6 members: Drs. Nina Otberg (chair), Valerie Callender, Jeffrey Epstein, William Parsley, Jerry Shapiro, and Ken
Washenik. Together we created a registration form for the outcome of hair restoration surgery in patients with hair diseases
other than androgenetic alopecia. The form is designed to collect
general patient information (age, gender, ethnicity), information
on the underlying cause of hair loss (primary cicatricial alopecia
with subtype, secondary cicatricial alopecia, temporal triangular alopecia, aplasia cutis congenita, and alopecia areata),
information on previous or ongoing medical treatment for the
hair loss, histopathological reconfirmation via biopsy, disease
duration, area of involvement, information on the procedure
(scalp reduction, hair transplantation), information on treatment
outcome, complications, and patient satisfaction.
We are asking every ISHRS member to help to create a
database of hair restoration results on patients with these
difficult scalp disorders. The database will help us to optimize
patient selection, treatment outcome, and patient satisfaction. It will help us to create guidelines for the surgical treatment of each scalp disorder and will allow us to be more
confident in managing patients with cicatricial alopecia and
other rare hair diseases.
The registration form can be downloaded from the ISHRS
website. Please fill out one form for each patient and send it
back to the committee via mail or email at ninaotberg@gmx.
com. Instructions can be found on the ISHRS website.
Scarring Alopecias
Cicatricial or scarring alopecias comprise a diverse group
of scalp disorders that result in permanent hair loss. The
destructive process can occur as a primary or secondary cicatricial alopecia. Primary cicatricial alopecia refers to a group
of idiopathic inflammatory diseases, characterized by a folliculocentric inflammatory process that ultimately destroys the
hair follicle. Secondary cicatricial alopecias can be caused by
almost any cutaneous inflammatory process of the scalp skin
or by physical trauma, which injures the skin and skin appendages. Regardless of whether a cicatricial alopecia is primary or
secondary in nature, all scarring alopecias are characterized
clinically by a loss of follicular ostia and pathologically by a
replacement of hair follicles with fibrous tissue.
Cicatricial alopecias are psychosocially distressing for the
affected patient and medico-surgically challenging for the
treating physician. Hair regrowth cannot be achieved in areas
of scarring; therefore patients depend on wigs, hairpieces,
and other camouflage techniques.
Hair restoration surgery, including hair transplantation
and scalp reduction, is the only available treatment to restore
a natural looking hair density in patients with cicatricial
alopecia. However, the treatment outcome is very difficult
to predict. Any surgery may result in a reactivation of an
underlying inflammatory process or difficulties with wound
healing. Hair transplantation may result in a limited graft
survival or in a loss of transplanted hairs months and years
after the surgery due to an inflammatory scalp disease.1-3
Temporal Triangular Alopecia (TTA)
TTA is a non-scarring, non-inflammatory alopecia on the
fronto-temporal scalp. Lesions can be present at birth but
mostly develop in the second to sixth year of age. TTA seems to
be unresponsive to medical treatment. However, few cases are
reported on successful hair restoration surgery in TTA.4,5
Aplasia Cutis Congenita (ACC)
ACC is a non-inflammatory scalp disorder characterized
by the absence of a portion of skin at birth. ACC is part of
a heterogeneous group of disorders and most commonly
manifests as a solitary defect on the scalp, but sometimes
it may occur as multiple lesions. At birth, the lesions may
have already healed with scarring or may remain superficially eroded to deeply ulcerated. Very little is known on hair
transplantation results in ACC. Occasionally involvement of
the dura or the meninges can be found in ACC, therefore, an
MRI is mandatory before surgery.
Alopecia Areata (AA)
AA is an inflammatory, non-scarring hair loss condition.
AA usually presents with round patches of hair loss but can
also affect the entire scalp (alopecia areata totalis) or the
entire body (alopecia areata universalis). AA is usually a contraindication for hair restoration surgery since disease activity
can be triggered and may result in a partial or total loss of
preexisting and/or grafted hairs. However, at least one case of
recalcitrant alopecia areata has been reported on successful
hair transplantation6 and this is the main reason to include
this disease in the current protocol.
References
1. Otberg, N., et al. Diagnosis and management of primary
cicatricial alopecia: part I. Skinmed. 2008; 7:19-26.
2. Wu, W.Y., et al. Diagnosis and management of primary
cicatricial alopecia: part II. Skinmed. 2008; 7:78-83.
3. Finner, A.M., N. Otberg, and J. Shapiro. Secondary cicatricial and other permanent alopecias. Dermatol Ther.
2008; 21:279-94.
4. Bargman, H. Congenital temporal triangular alopecia.
Can Med Assoc. 1984; 131:1253-4.
5. Wu, W.Y., et al. Successful treatment of temporal triangular alopecia by hair restoration surgery using follicular
unit transplantation. Dermatol Surg. 2009; June 2. [Epub
ahead of print].
6. Unger, R., T. Dawoud, and R. Albaqami. Successful hair
transplantation of recalcitrant alopecia areata of the
scalp. Dermatol Surg. 2008; 34:1589-94.✧
176
“?”
Hair’s the Question
Sara Wasserbauer, MD Walnut Creek, California
Editors’ Note: This is the first submission of a new column that will help us check our knowledge
about different hair disorders. Dr. Sara Wasserbauer, who will be in charge of this column, is a Diplomate of the American Board of Hair Restoration Surgery and an active member of the ISHRS. She
practices hair restoration full-time at her office in the Bay Area, outside of San Francisco, in Walnut Creek, California.
Dr. Wasserbauer earned her medical degree from the Medical College of Ohio. After finishing her training in Internal
Medicine in Denver, Colorado, she completed her fellowship in hair transplantation (September 2004-September 2005)
with Dr. Matt Leavitt in Orlando, Florida. The answers to these multiple choice questions will be found at the end of the
column along with a brief explanatory note.
Diffuse Hair Loss
As hair surgeons, we are used to seeing all manner of pattern hair loss, but diffuse hair loss is a different animal altogether. Plus, since diffuse hair loss is less often a surgical problem, I find myself having to mentally switch gears whenever
I am confronted with it. To that end, here is a little mental “brush-up” for those of you out there like me who like to quiz
yourself. Good luck!
1. Diffuse hair loss should be considered abnormal in which
of the following cases:
a. In a young male patient who is shedding 100-150
hairs per day.
b. Anagen hair loss.
c. In anyone with a family history of Androgenetic
Alopecia.
d. Hyper- or Hypothyroidism.
2. Which of the following is NOT among the differential
diagnoses for diffuse hair loss?
a. Short anagen syndrome, loose anagen syndrome, or
anagen effluvium.
b. Alopecia areata, totalis, or universalis.
c. Hair breakage due to chemical or genetic causes.
d. Trichotillomania or traction alopecia.
3. In the differential diagnosis of diffuse hair loss, which is
the most common?
a. Loss of telogen phase hairs commonly identified
clinically by the “nubbin” of the released bulb at the
end of the shaft.
b. Alopecia Universalis.
c. Anagen phase hair loss most commonly resulting
from radiation or chemotherapy.
d. Early androgenetic alopecia presenting as episodic
shedding.
4. Which of the following can cause diffuse hair loss?
a. Hairs prematurely moving into telogen phase from
anagen phase due to a variety of causes including
diet, medical conditions, and emotional stress.
b. Physiologic stress including severe and sudden weight
loss, surgical trauma, high fever, parturition, loss of
blood, and chronic illness.
c. Drug treatment with beta-blockers, ACE inhibitors,
antidepressants, OCP and hormone replacement
therapy.
d. All of the above are correct.
5. Which of the following would be an indication for a scalp
biopsy in a patient with diffuse hair loss?
a. Diffuse hair loss starting 2 months after an illness
with high fever and significant blood loss.
b. Diffuse frontal (possibly pattern) hair loss, with a
history of patchy loss and re-growth.
c. Diffuse hair loss starting 2 months after beginning treatment with beta-blockers and anti-fungal medications.
d. Diffuse hair loss also involving the brows starting
1-3 months after bariatric surgery.
6. Lab evaluation of diffuse hair loss in any patient should
include:
a. VDRL or RPR to rule out syphilis.
b. CBC, Ferritin, TSH, T3/T4.
c. Complete metabolic panel and total testosterone
level.
d. Serum Zinc, B-vitamin, and Biotin levels.
7. Diffuse anagen hair loss:
a. Can be normal in some cases.
b. Is only caused by radiation or chemotherapy.
c. May require work-up for heavy metal poisoning.
d. Is inconsistent with a diagnosis of alopecia areata.
8. A 35-year-old female patient complains of chronic diffuse hair loss, thin hair, and slow hair growth. She has
had shedding and thinning hair since her teens. She is
a strict Vegan vegetarian but takes no drugs, and has
an otherwise unremarkable medical history. Labs are all
normal. You feel comfortable telling her that:
a. She likely needs to add more protein to her diet and
come back for a follow-up in 6 months to 1 year.
b. Iron, Zinc, B-vitamin, and Biotin supplements will
help as will 5% Rogaine and daily Spironolactone.
c. She is a candidate for either Propecia with daily Yasmin
Oral Contraceptive Pills or hair transplant surgery.
d. Any plan for hair transplant surgery should concentrate
grafts on the top frontal area and should only move
1,200-1,800 grafts at a time to minimize shock loss.
 page 178
177
Hair’s the Question
 from page 177
9. In evaluating a patient with diffuse hair loss, which of
the following would be a reasonable initial step:
a. Examining the hair for breakage and taking a history
for chemical damage.
b. Scalp biopsy.
c. Lab tests.
d. Questionnaire and targeted medical history for
trichotillomania.
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Answers
1. B. Anagen hair loss is never normal and is typically
associated with radiation or chemotherapy. Diffuse
hair loss can affect both sexes at any age and shedding
100-150 hairs per day is normal. Thyroid conditions,
both hyper- and hypo-, can cause diffuse telogen hair
loss. Even without a clear Savin or Norwood pattern
classification on exam, episodic shedding can be an
early presentation of androgenetic alopecia in both
sexes.
2. D. Both trichotillomania and traction alopecia would result
in focal hair loss. Hair breakage due to chemical or genetic
causes can result in either focal or diffuse hair loss. The
others all result in diffuse loss and would be considered
in the differential diagnosis of diffuse hair loss.
3. A. Telogen effluvium is not a complete diagnosis by
itself, but as a sign of an underlying condition (from
whatever cause) it is the most common presentation
of diffuse hair loss. In a hair transplant practice, the
self-selection bias may lead one to choose D. Answer
B, “Universalis,” only sounds common.
4. D.
5. B. You would be suspicious for diffuse alopecia areata.
The others are very likely to be telogen effluvium and
would not require scalp biopsy unless you could not
exclude areata or the hair loss was chronic.
6. B. You would add the others if the history and physical suggested risk factors for these specific conditions.
Biotin is a useful supplement but many practitioners
may simply choose to supplement empirically with Bvitamins or Zinc if they thought it would be helpful.
7. C. Anagen hair loss is never normal. Radiation treatments, chemotherapy, alopecia areata, and heavy metal
poisoning can all cause anagen hair loss.
8. A. Vegan vegetarians or any patient on a very restricted diet are at risk for diffuse hair loss. Causes include low protein, iron, zinc, and fatty acid deficiency.
Hopefully, off-label 5% Rogaine AND Spironolactone
(an anti-androgen in a female not otherwise using
contraceptives) made you feel a little uncomfortable
choosing B. Hair transplant would not be the best initial option for this patient, especially without further
work-up and trials of other treatments first. Propecia
is inappropriate in a young female patient who is
actively trying to conceive.
9. A. Scalp biopsy and lab tests should follow an initial
history and physical exam. Trichotillomania is more
likely to cause focal hair loss and so would not be appropriate as a first step to evaluate someone with diffuse
hair loss.✧
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178
Letters to the Editors
Konstantinos Giotis, DHI Medical Group
Athens, Greece
Re: Hair Restoration Surgery Is Not the
Airlines Industry
One of the most interesting sessions of the ISHRS meeting
last month in Amsterdam was without a doubt the MEGA
vs. GIGA session.
Both sides had some great arguments and it seems in
the end the giga was the winner. The paradigm given that,
sure, if you were going to FLY direct to a destination, it is
much preferable to a three-stop flight, seemed to win the
audience.
This simplification of the issue is dangerous...we all know
the problems that mega sessions have created for our industry when an inexperienced team full of enthusiasm and
greed perform such mega sessions.
Let’s face it, how many teams in the world can produce
consistently good results? We all know that mega sessions
require large, well-trained teams and long hours.
Hair follicles are so complex yet so fragile, who can guarantee that all follicles will survive that long trip with many
stops, handled by many assistants for so many hours?
And can we afford to waste even one hair follicle? Is this
what our patients deserve?
First DO NO HARM was the Hippocratic declaration.
Now we have giga sessions for FUE—12,500 follicles in
6 hours proclaimed an email I received today by a clinic in
Europe—I am very concerned with this race.
This is “MORE FOR LESS”: More time, more discomfort
for the patient, probably more scars, and sure more money.
But, in my opinion, also more risk of less hairs to grow and
more unhappy patients.
The study I presented at the ISHRS meeting will continue,
and we have found a large number of patients are very unhappy with their hair restoration experiences. Over 2,000
from many countries participated in this study—which
still continues. Seventy percent were disappointed with
their previous treatments and 20% very disappointed. I am
certain that number will rise if the other 10% knew that
some of their hair follicles of their mega sessions had been
destroyed forever.
So I am deeply concerned what will happen with giga
sessions as many doctors and clinics will jump on this new
era for hair restoration.
How many teams throughout the world today and in
the next 2 years can perform 6,000 to 8,000 grafts or more
giga sessions?
Hair restoration has made some great improvements in
the last 10 years but it is far from reaching the safety levels
of the Airline industry. In fact, we are much behind other
cosmetic and plastic surgery procedures or other medical
procedures in general. Till we reach that level of recognition
and acceptance, I strongly propose “LESS IS MORE.”
If THINK–FEEL–SAY–DO is the norm on most human
activities, then FEEL–FEEL–FEEL–FEEL should be the priority for our industry.
This is the direction DHI Medical Group (www.dhiglobal.
com) is heading, and we all should work together in common
goal with specific protocol and guidelines.✧
Nilofer Farjo, MBChB Manchester, United Kingdom day long. We took the opportunity to have a family holiday
Re: Inspection visit to Dr. Pathomvanich’s
that was much enjoyed even with the 32°C/90°F weather.
Fellowship in Thailand
As part of the fellowship scheme, a fellowship director
Visiting colleagues around the world is definitely a great
learning experience not to mention the chance to see wonderful countries. On June 26, 2009, we had the pleasure of
visiting Dr. Damkerng Pathomvanich at his clinic in Bangkok.
Bangkok, Thailand, is a bustling city of over 10 million with
exciting cultural attractions, plenty of modern facilities, a
good public transport system, and great food! Don’t drive
anywhere though as the traffic moves at a snail’s pace all
Dr. Pathomvanich operating with his fellows Dr. Parvin Sadrolodabaei, general surgeon
(left), and Kulakarn Amonpattana plastic surgeon.
has to be inspected every 5 years to ensure that they are
continuing to follow the guidelines set out by the ISHRS. As
I am a member of the fellowship committee, I was asked to
report on Dr. Pathomvanich’s program. Currently he has 2
fellows with him. They both recently attended the Amsterdam meeting with one giving an oral presentation and the
other a poster presentation.
Fellowship Training
The requirements of the training program are quite rigorous and include keeping case logs of training surgeries,
a written training program that includes details of daily,
weekly and monthly activities for the fellows, research
projects, and journal articles. The clinic environment has to
be inspected to ensure compliance with health and safety
regulations including infection control. At least two surgical
procedures are observed by the inspector and a number of
patient notes are reviewed. Fellows are required to participate in planning, performing procedures, and aftercare;
attend meetings; work on a research project; and present
their findings.✧
179
Surgeon of the Month: Robert H. True, MD, MPH
Maurice Collins, FRCSI Dublin, Ireland
If one wanted to illustrate the extraordinary level
of surgical professional who
is attracted to hair restoration, we could do no better
than introduce Dr. Robert H.
True. Hair restoration is a
fast-growing discipline with
an increasing public profile
that requires high calibre
surgical professionals to advance its theory and clinical
Dr. Robert H. True
practice. Robert, known as
Bob, does both and is also an active researcher. He brings a
wealth of experience and a rich medical background to the
field. Based in New York, Bob is Diplomate of the American
Board of Hair Restoration Surgery and a recognised authority on hair loss.
Bob did his undergraduate study at the University of
Wyoming, which he followed with a Bachelor of Science
from McGill University (Montreal, Canada). He received his
medical degree from McGill University Faculty of Medicine
and pursued postgraduate training at the University of Illinois, the Mayo Clinic, and Johns Hopkins. He also had a
distinguished career as the Director of Emergency Medicine
for St. Francis and as a decorated Clinical Director with the
U.S. Public Health Service Commission Corps.
Bob was introduced to surgical hair restoration in 1991 by
Dr. R.M. Elliott. Fascinated with the blend of artistry and detailed technique required, he was immediately drawn to the
practice. He spent six months working daily with Dr. Elliott
in a clinical preceptorship prior to beginning a full-time hair
restoration practice in New York in 1992. He has performed
more than 18,000 procedures and is proud to count among
his patients men and women from many nations and occupations, as well as many well-known personalities.
Bob has presented at many major professional meetings in the U.S. and abroad and published in professional
journals on a broad range of topics related to hair restoration. At the most recent ISHRS meeting in Amsterdam he
presented a novel approach combining FUT and FUE in the
same procedure. Among the first physicians to be certified
by the American Board of Hair Restoration Surgery, he serves
as an examiner and director for that body and will be the
president of the ABHRS in 2010.
Bob is senior partner of the True & Dorin Medical Group
P.C. His and Dr. Robert Dorin’s private practice is located
in Manhattan, with satellite offices throughout the northeastern United States, and is devoted solely to surgical hair
restoration and medical therapy of hair loss. In addition to
being partners, Bob True is also Dr. Dorin’s mentor in hair
restoration, a relationship that began when Dr. Dorin was
Bob’s patient while still in medical residency.
Born in 1947 in Cheyenne, Wyoming, Bob is the middle
of three children of a highway engineer and horticulturist.
Both parents were artistic and Bob believes they instilled
in him his love of design and artistry. He was inspired to
pursue medicine by his grandfather who was a general
surgeon (the second to set up practice in the frontier town
of Cheyenne).
Happily married for 35 years to Sandra, who recently
retired from being the founding Director of the Nurse Family
Partnership for the City of New York, they have two children. Their daughter Lynn is an independent documentary
maker and their son Mark is a general surgeon in Anchorage,
Alaska. They also have two grandchildren.
Bob and Sandra have worked extensively as volunteers with underserved communities around the world,
starting with south side of Chicago and including India,
Egypt, Jamaica, the Philippines and Marshall Islands, and
South Korea. Their work in recent years has focused on
the problem of HIV/AIDS and part of each year is spent in
Africa—Kenya, Tanzania, Uganda and most recently, this
summer, Malawi.
Bob is a keen amateur geologist and anthropologist who
enjoys exploring the remote wilderness areas and ancient
cultures of the American southwest. He is also an avid fly
fisherman, gardener, yoga practitioner, and long-distance
cyclist. On his 60th birthday he decided to take up running
and has now run several half marathons and will run his
first full marathon in New York later this year.
I asked Bob to describe why hair restoration is the specialism for him, he explains: “Well, I am by nature a contemplative, patient, and meticulous person. Knowing I have helped
someone resolve an important concern in their life is more
rewarding to me than any financial compensation. I enjoy
the sense of accomplishment that comes from well-honed
teamwork. And I thrive in an atmosphere of constant striving for perfection. In other words, hair restoration seems a
match made in heaven for me.”
Dr. Robert (Bob) True brings an impressive combination
of experience, expertise, and wider interests to the field of
hair restoration and, for that reason, he is our Surgeon of
the Month.✧
180
ABHRS NEWS
Peter B. Canalia, JD, Executive Director, ABHRS Lansing, Illinois
The American Board of Hair Restoration
Surgery has now been in existence over 11
years. Its 134 Diplomates hail from 15 countries. The January
2009 exam produced 10 new Diplomates from 5 countries.
They are: Marc S. Dauer, MD (U.S.), James A. Harris, MD
(U.S.), Jason Lukasewicz, DO (U.S.), Pekka J. Nyberg, MD
(Switzerland), Angela L. Phipps, DO (U.S.), Pathuri Madhusudana Rao, MD (India), Ana Trius, MD (Spain), Robert
A. Wadden, MD (Canada), William J. Woessner, MD (U.S.),
William D. Yates, MD, FACS (U.S.).
Consistent with its strong commitment toward Maintenance of Certification (MOC), the ABHRS recertification
exam was again administered both last January in Houston,
along with the Certifying Examination, and in Amsterdam
at the ISHRS Annual Meeting. Those who successfully
completed their 10-year recertification exam this year were:
Robert M. Bernstein, MD, Steven B. Hopping, MD, and Bradley R. Wolf, MD. (Results have not been determined for the
Recertification Exam held on July 22, 2009, in Amsterdam.)
The next Annual Certification Exam and Recertification
Exams will be administered at the Houston International
Marriott Hotel on Saturday, January 23, 2010.
We welcome Paul J. McAndrews, MD, as a new member
to serve as an Officer and Treasurer on the Board of Directors for a 1-year term of office. The Treasurer would eventually ascend over the years to Secretary, Vice-President,
and, ultimately, President. We commend our Immediate
Past President, Bernard Nusbaum, MD, for his leadership
and support and appreciate his valuable time. We also
commend the following colleagues who have completed
their first term of office on the Board of Directors and were
re-elected to serve a second term of 3 years: Glenn M.
Charles, DO, Bessam Farjo, MBChB, Robert J. Reese, DO,
Robert H. True, Jr., MD, and Walter P. Unger, MD.
The current Officers are: Daniel W. Didocha, DO, President; Robert H. True, Jr., MD, Vice-President; Glenn M.
Charles, DO, Secretary; Paul J. McAndrews, MD, Treasurer.
The other Directors not mentioned above are: Vance
W. Elliott, MD, John D.N. Gillespie, MD, Sungjoo Tommy
Hwang, MD, PhD, Russell Knudsen, MBBS, Bernard Nusbaum, MD, David Perez-Meza, MD, William H. Reed, MD,
and Marla Ross, MD.
The ABHRS Board of Directors unanimously adopted a
resolution designating the ISHRS CME Award as the necessary requirement for satisfying the CME component of the
Maintenance of Certification program of the ABHRS. The
application for the CME award can be obtained from the
ISHRS website at ISHRS.org. In addition, for the purpose
of consistency in adopting a uniform advertising policy,
the Board of Directors adopted a provision stating that,
as opposed to ”Board Certified” or “Certified by,” the only
appropriate way for ABHRS members to advertise their
certification status is as a “Diplomate of the American
Board of Hair Restoration Surgery.”
Doctor required for career
in Hair Loss Medicine
This is a dynamic role for a highly motivated doctor with a strong record of
achievement. The position will combine patient consultations with surgical procedures
under the supervision of the Consultant
Surgeon.
No prior knowledge of the specialty is
required as full training will be provided.
For more information see www.hrbr.ie. To
apply for this role, please email [email protected]
or send your CV to:
Hair Restoration Blackrock,
Samson House, Sweetman’s Avenue,
Blackrock, Co. Dublin
181
Classified Ads
Hair Techs Wanted
Must have at least one year of documentable experience and Reliability is a must.
Good pay for qualified, professional, independent techs.
Please submit resume to [email protected]
Laser for Sale
Revage 670 laser for sale. Best cold laser for Hair Growth in the industry. Normally retails for 60k,
less than 1 year old with just a few uses. Practice shutting down. Will sell for $29,900 OBO.
Call Danny at 949-689-9315 or e-mail danny@efficientlending.com
Seeking Hair Transplant Surgeon
Seeking physician to join me in established Hair Restoration practice in Miami, Florida
Contact Bernard Nusbaum, MD
[email protected]
Go to the New and Improved
ó
WWW.ISHRS.ORG
ó
Find A Doctor allows patients
to search by a variety of variables
including geographic region,
doctor’s last name, and technique/
procedure. Now physician
members can easily edit their
Physician Profile too.
ó
Media Center includes
the latest statistics and trends
in HRS, information about the
ISHRS, and press releases.
ó
Patient Stories
is one of the most
popular sections.
Talk with your
patients about
submitting their
hair loss and
restoration stories
and before and after
photos. You will be
listed as their surgeon
with a link to your
Physician Profile page.
ISHRS News
including
Regional Workshops
Program, Research Grants
program, award winners,
Member Recognition
program, fellowship
opportunities, latest
Membership Directory,
Surgical Assistants
Auxiliary searchable
membership database,
and discounts for
textbooks.
Promotional
Resources
COMING SOON
include expertly ��
written content, ��
��
the ISHRS
Members Only
logo and Inclusion in the Find a
Doctor list.
Information Resource
includes the Online Forum Archive
Search and the Ask the Experts.
The Leading, Unbiased, Peer-Reviewed Site
on Hair Loss and Restoration
The ISHRS website is a tremendous resource for patients and physicians. There is a
large bank of educational articles for patients on many aspects of hair loss and hair
restoration.
Promote Your Practice and ISHRS In order to better promote our profession, it is
important to increase our visibility on the Web and with the search engines. One easy
way of increasing our visibility on the Web is by placing a search-relevant text link on
your website. Adding a link on your website to the ISHRS website or making it more
search-relevant (using words in the clickable part of the link that are relevant to our
industry) increases the visibility of both your website and www.ISHRS.org.
Linking is Easy and Effective Go to http://www.ishrs.org/ishrs-links.
htm#link-to-us, select the link you want to place on your site, and then ask your
webmaster to copy-and-paste the applicable link code to your web page. The link will
take visitors to the home page of the ISHRS website.
182
EXCLUSIVE FOAM FORMULATION
Results. Enhanced Compliance.
Real Results
Visible results after 16 weeks of twice-daily use*1
93% of men rated scalp coverage as “improved”
or “stayed the same” after 16 weeks
Examples of a good response.
After 16 weeks of
twice-daily treatment
Before treatment
Before treatment
After 16 weeks of
twice-daily treatment
Not everyone responds to ROGAINE®. Individual results vary.
A tolerability and aesthetic profile that supports compliance
�� Does not contain propylene glycol,
a potential cause of irritation
�� Fast drying, non-greasy, non-sticky
*In a clinical study (N=352) of twice-daily use of Men’s ROGAINE® Foam vs placebo. 1. Data on file. McNEIL-PPC, Inc.
2. *In an in-home use test (n=300). 3. Independent Market Research Study. Gallaher Lee Research 2008.
© McNEIL-PPC, Inc. 2009
183
A d va n c i n g t h e a r t a n d
science of hair restoration
Upcoming Events
Date(s)
Event/Venue
Sponsoring Organization(s)
Contact Information
Academic Year
2008–2009
Diploma of Scalp Pathology & Surgery
U.F.R de Stomatologie et de
Chirurgie Maxillo-faciale; Paris, France
Coordinators: P. Bouhanna, MD, and
M. Divaris, MD
Director: Pr. J. Ch. Bertrand
Tel: 33 +(0)1+42 16 12 83
Fax: 33 + (0) 1 45 86 20 44
[email protected]
January 2009
International European Diploma for
Coordinator : Y. CRASSAS. MD, University Claude Bernard
of Lyon, Paris, Dijon (France), Torino (Italy), Barcelona
(Spain). Department of Plastic Surgery
www.univ-lyon1.fr
For instructions to make an
inscription or for questions:
Yves Crassas MD
[email protected]
September 17–18, 2009
BAAPS Annual Meeting
Incorporating the 2nd Congress of EASAPS
City Hall, Cardiff, United Kingdom
British Association for Aesthetic Plastic Surgery (BAAPS)
www.baaps-easaps.meeting.org.uk
Tel: +44 207 430 1840;
Fax: +44 207 242 922
October 2–3, 2009
ISHRS Regional Workshop
Follicular Unit Extraction
Denver, Colorado, USA
International Society of Hair Restoration Surgery
www.ISHRS.org/FUERegWrkshp.htm
Hosted by James A. Harris, MD
Tel: 630-262-5399;
Fax: 630-262-1520
November 6–8, 2009
An Intense Hands-On Cadaver Workshop for
Physicians & Surgical Assistants—Hair Restoration Surgery
St. Louis, Missouri USA
November 8–9, 2009
ISHRS Regional Workshop
1st Mediterranean Workshop for
Tel Aviv, Israel
December 12–13, 2009
15th Annual Scientific Meeting and
Live Surgery Workshop
Kobe, Japan
Practical Anatomy & Surgical Education,
Saint Louis University School of Medicine
In collaboration with ISHRS
http://pa.slu.edu
www.ISHRS.org/Tel-AvivRegWrkshp.htm
Hosted by Alex Ginzburg, MD
Japan Society of Clinical Hair Restoration
www.jschr.org
Hosted by Hiroto Terashi, MD
Tel: 314-977-7400
Fax: 314-977-7345
[email protected]
Tel: +972-9-7603406
Fax: +972-9-7408240
[email protected]
Tel: +81-78-382-6251
Fax: +81-78-382-6269
[email protected]
December 19–20, 2009
1st Annual Meeting of the
Indian Association of Hair Restoration Surgeons
Ahmedabad, India
Indian Association of Hair Restoration Surgeons
www.ahrsindia.com
Dr. Tejinder Bhatti
Secretary, Indian Association of Hair
Restoration Surgeons
Phone: +91-9923215042
[email protected]
May 20-22, 2010
XIII International Congress of ISHR
Capri, Italy
Italian Society of Hair Restoration
http://www.congresso.ishr.it/
[email protected]
HAIR TRANSPLANT FORUM INTERNATIONAL
303 West State Street
Geneva, IL 60134 USA
Forwarding and Return Postage Guaranteed
Dates and locations for future ISHRS
Annual Scientific Meetings (ASMs)
2010: 18th ASM, October 20–24, 2010
Boston, Massachusetts, USA
2011: 19th ASM, September 14–18, 2011
Anchorage, Alaska, USA
2012: 20th ASM, October 17–21, 2012
Paradise Island, Bahamas
2013: 21st ASM, October 23–27, 2013
San Francisco, California, USA
FIRST CLASS
US POSTAGE
PAID
CHICAGO, IL
PERMIT NO. 6784

Areas of unethical behavior practiced today

Transcription

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