New Storage Buffers for Micrografts Enhance Graft Survival and

Transcription

Volume 13, Number 3
Hair Transplant Forum International
❏
May/June 2003
Volume 13, Number 3
forum
May/June 2003
New Storage Buffers for Micrografts
Enhance Graft Survival and Clinical
Outcome in Hair Restoration Surgery
Walter Krugluger, Karl Moser, Joerg Hugeneck, MD, Katharina Laciak, Claudia Moser Vienna, Austria
Introduction
Preparation and storage of human
hair follicle grafts during micrograft
transplantation procedures in hair
restoration surgery are crucial steps in
maintaining follicle cell growth and hair
shaft elongation. High viability of
follicle graft cells during transplantation
is essential for survival of the transplant
and therefore determines the clinical
outcome of the procedure. There are
different factors influencing the viability of the graft. Mechanical irritation of
the follicles during preparation is one
factor. Furthermore, it has been shown
that during storage of micrografts in
commonly used buffers the viability
decreased, which limits the duration of
the transplantation sessions. This might
be due to the absence of nutritional
factors, changes in environmental pH
and osmolarity, depletion of energy
stores for the anaerobic pathway in the
follicle cells, or other not yet defined
mechanisms. However, the commonly
used conditions for graft storage in hair
restoration surgery are not satisfactory
today; this influences the outcome in
micrograft transplantation procedures.
In the past, studies have been performed to optimize the storage buffers
for micrografts. These studies focused
on temperature conditions, salt composition, or the effect of nutrients sup-
plied to the storage buffers.1–4 Although
some effect of storage temperature,
nutrients, or salt composition has been
demonstrated, no clear improvement of
storage conditions was found in in vitro
assay systems.
All the performed studies focused on
prevention of follicle cell necrosis (which
might be induced by the absence of
nutrients for the aerobic or anaerobic
pathways), mechanical damage of the
follicle cells during preparation, or
necrotic cell death due to the production
of oxygen radicals or other toxic metabolites during the storage period.
Another pathway of cell death,
apoptosis, has so far not been investigated as a possible cause of follicle cell
death during storage. Apoptosis is an
active form of cell death, in which
fragmentation of DNA and cell death is
induced by specific signals entering the
cell. Many stimuli have been identified
that can induce apoptosis, including
death signals by soluble molecules like
tumor necrosis factor, loss of survival
factors (absence of insulin or other
hormones), radicals released after tissue
injury (oxygen radicals, nitric oxide
(NO), and metabolites of the arachidonic acid (AA) pathway, respectively),
or loss of cell-cell interactions.5,6 All these
mechanisms result in the activation of an
continued on page 333
Regular Features
President’s Message ............................. 326
Co-Editors’ Messages .......................... 327
Notes from the Editor Emeritus .......... 328
Pioneer of the Month ......................... 343
Cyberspace Chat ................................. 344
Once Upon a Time ............................. 346
Surgeon of the Month ........................ 349
Letters to the Editors .......................... 351
Hair Repair ......................................... 355
Surgical Assistants Corner .................. 359
Feature Articles
Hair Loss Remedies: Lotions
and Potions ....................................... 329
The Arrector Pili Muscle May
Contribute to the Integrity of the
Follicular Unit .................................. 332
Hair Loss Profile and Index ................ 335
Body Type and Balding ...................... 337
A Look Back at the 9th Annual
Live Surgery Workshop ..................... 339
Strontium: A Potent and Selective
Inhibitor of Sensory Irritation and
Topical Anti-inflammatory ............... 347
Policies, Procedures, and Guidelines
of the Fellowship Training Programs
of the International Society of Hair
Restoration Surgery .......................... 352
Official publication of the International Society of Hair Restoration Surgery
325
❏
May/June 2003
Volume 13, Number 3
Hair Transplant Forum International is published
bi-monthly by the International Society of Hair
Restoration Surgery, 13 South 2nd Street, Geneva,
IL 60134. First class postage paid at Schaumburg,
IL and additional mailing offices. POSTMASTER:
Send address changes to Hair Transplant Forum
International, International Society of Hair
IL 60134. Telephone: 630-262-5399, U.S. Domestic
Toll Free: 800-444-2737; Fax: 630-262-1520.
President: Robert S. Haber, MD
Executive Director: Victoria Ceh, MPA
Editors: Michael L. Beehner, MD, and
William M. Parsley, MD
Surgical Assistants Corner Editor:
Shanee Courtney, RN
Managing Editor & Graphic Design:
Cheryl Duckler, [email protected]
Advertising Sales: Cheryl Duckler,
847-831-0499; [email protected]
Copyright © 2003 by the International Society of Hair
IL 60134. Printed in the USA.
The International Society of Hair Restoration
Surgery (ISHRS) does not guarantee, warrant, or
endorse any product or service advertised in this
publication, nor does it guarantee any claim made
by the manufacturer of such product or service. All
views and opinions expressed in articles, editorials,
comments, and letters to the Editors are those of
the individual authors and not necessarily those of
the ISHRS. Views and opinions are made available
for educational purposes only. The material is not
intended to represent the only, or necessarily the best,
method or procedure appropriate for the medical
situations discussed, but rather is intended to present
an approach, view, statement, or opinion of the author
that may be helpful to others who face similar
situations. The ISHRS disclaims any and all liability
for all claims that may arise out of the use of the
techniques discussed.
Hair Transplant Forum International is a privately
published newsletter of the International Society of
Hair Restoration Surgeons. Its contents are solely
the opinions of the authors and are not formally “peer
reviewed” before publication. To facilitate the free
exchange of information, a less stringent standard
is employed to evaluate the scientific accuracy of
the letters and articles published in the Forum. The
standard of proof required for letters and articles is
not to be compared with that of formal medical journals. The newsletter was designed to be and continues to be a printed forum where specialists and
beginners in hair restoration techniques can exchange thoughts, experiences, opinions, and pilot
studies on all matters relating to hair restoration. The
contents of this publication are not to be quoted without the above disclaimer.
Volume 13, Number 3
President’s Message
These have become
difficult times to
preside over an
International
Society. A Society
with many members who may find
themselves in
political opposition
to American
policies and
Robert S. Haber, MD
Mayfield Heights, Ohio
interests. A Society
with members who might fall victim to
the temptation to believe in stereotypes
and prejudice. A Society whose very
existence depends on a cooperative and
supportive International community.
And yet I am confident that the
Society will emerge from this period of
time stronger than ever, because the
very diversity that brings together
divergent viewpoints is coupled with
the maturity and collegiality that is
required to face and conquer these
conflicts.
The ISHRS has forged friendships
between people of divergent backgrounds, views, nationalities, and
religions. We are a united nations of
sorts, yet one that appears to have been
more successful in guiding ourselves
into a closely-knit and mutually
respectful alliance.
I have found myself sitting next to and
conversing with erudite scholars and
gifted surgeons from “third world”
nations not generally thought of as
contributing to the art and science of our
field. I always come away from these
interactions pleasantly surprised, and
very pleased that our small area of
interest brings together individuals from
so many backgrounds and nations.
Our governments could look to us for
a lesson in politics. Find a common
thread to bind us, and cooperation
follows. Certainly, we do not all agree
about everything. Rather, we seem to
disagree about most things. But at the
end of the day we still enjoy each other’s
company, enjoy socializing, and look
forward to the next day’s challenges.
Headlines aside, the business of the
Society is proceeding smoothly. Works
in progress include the formalization of
the ISHRS Fellowship Training Programs Guidelines, the goal of which is
to codify the process by which future
hair transplant surgeons should be
trained. This will be invaluable to us as
we seek to further enhance the reputation of the field.
We can also look forward to interesting and possibly controversial findings
from the committees looking into
artificial hair fibers and the Internet.
The remainder of the committees are
busy carrying out their duties. The
Society is in capable hands.
The ISHRS-sponsored Live Surgery
Workshop in Orlando was successful,
and the New York meeting is taking
form as well, and should be an extraordinary experience. Make plans to
attend.
See you in New York!✧
Bob Haber, MD
The material published in the Forum is copyrighted
and may not be utilized in any form without the
express written consent of the Editor(s).
To Submit an Article or Letter to the Forum Editors
The ISHRS Golden Follicle Award sculpture, as seen
on the cover of this issue, was designed by Francisco
Abril, MD. Dr. Abril offers for sale, copies of a small
bronze hair follicle sculpture (10" high). For more
information, please contact: Clinica Dr. Francisco
Abril, PO dela Habana, 137, 28036 Madrid, Spain.
Phone: 34-1-359-1961; Fax: 34-1-359-4731.
Please send submissions via a 3½" disk or e-mail, double space and use a 12 point type
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Louisville, Kentucky 40202-1745
E-mail: [email protected]
326
Submission deadlines: July/August, May 15*;
September/October, August 10.
*Please note earlier submission deadline
for this issue.
Volume 13, Number 3
❏
May/June 2003
Co-Editors’ Messages
Six years ago, I
wrote an article
for the Forum
that presented
my “Top Ten
List” of things in
hair restoration
surgery that
needed improvement (Jan. 1997).
I thought I would
Michael L. Beehner, MD
Saratoga Springs, New York update the list for
2003, and also provide two additional
more upbeat lists—one listing the “Top
Ten” good things about our specialty
presently, and the other a list of the
ten biggest changes since 1989, the
year I started in hair transplantation.
Remember, these are simply the very
subjective opinions of one of your
editors. Here goes:
Top Ten List of Things That Need
Improvement (negatives)
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1. Very difficult to get started in HT.
Having a trained staff available,
starting a flow of patients, expense
of starting, paucity of training
programs, etc.
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A recent article
from Dr. Richard
Shiell about
“plagiarism”
caught my
interest. In the
surgical area of
hair restoration,
perhaps this is an
admirable quality,
not one to cause
Louisville, Kentucky
censorship. In
creating transition zones and hairlines,
we often create solutions in our minds to
bring about a pleasing result. In order to
create a soft natural hairline, we often
look at spatial distributions and place
grafts in any irregular pattern to accomplish this goal. In an attempt to avoid
the old “bowl” look to the frontal
hairline, we throw in undulations in a
random fashion, using our imagination
to create asymmetry and irregularity—
then start naming and categorizing these
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2. Still too many “pitted” grafts (FUs
and others) at front hair line by too
many HT clinics.
3. Over-aggressive harvesting of
donor hair for mega-size cases
(3,000+) with concomitant risk of
wide donor scars.
4. Specialists who do very occasional
hair cases, attend no meetings, and
do poor work.
5. Not enough “individualization” in
HT. Too many doctors/clinics
“paint all the rooms the same
color.”
6. Too many front hairlines have that
“transplanted look.” Too round,
too perfect, too dense at the edge,
lack of “micro-contouring”—or,
worst of all, too “pluggy.”
7. Too many hair surgeons do not
align the angle of their grafts
acutely enough.
8. Negative comments and attitudes
tend to dominate many of the
Internet hair sites.
9. Use of “lay consultants” can lead to
inappropriate candidates having
HT surgery (with subsequent
disastrous consequences).
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10. Still too many doctors who feel they
have to put everyone else down in
order to push themselves up.
Top Ten Good Things in Hair
Restoration Surgery 2003
1. The annual ISHRS meeting is
outstanding, with more and more
good research reports every year.
2. Much greater sense of “collegiality”
among hair surgeons in general
3. Large majority of results today are
excellent.
4. Most HT doctors are quite open to
other surgeons observing their
practices.
5. Using large numbers of very small
grafts yields far more natural
results.
6. Less alopecia reductions and the
negative consequences of same
(scar, stretchback, etc.).
7. More public figures have had HT,
which makes it more acceptable in
public’s eye.
8. Excellent “live surgery workshops”
now take place a few times a year.
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creations. To quote Ansel Adams: “There
is nothing worse than a sharp image of a
fuzzy concept.” The truth is that we have
no need for all this creativity. Nature tries
to guide us if we would only listen. All
we have to do is closely observe and
attempt to categorize nature’s own
hairlines and follow them. Thus far, very
little attempt to study natural hairlines
has been made, but much can be done.
What are the natural patterns of a soft
hairline? Where do natural undulations
occur and with what frequency? What is
the most common location for temporal
points in relationship to the eyebrows or
orbit, and what is the natural range of
locations? How about vertex patterns?
Once we know these natural patterns
and their variations, we will be armed
with material to use in problem solving.
An understanding of natural patterns
will be followed by compiling knowledge
on how to use them. When and how
would you want to use natural mounds
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(undulations) on the frontal hairline?
Which patterns would you use on a
narrow head, or a wide head? On which
people should you use a frontal forelock?
We appear to be concentrating on
Problem B (application) before we have
reasonably resolved Problem A (knowledge of natural patterns).
This is not to say that some excellent
work has not already been done. Dr.
Beehner’s work in studying frontal
forelocks and Dr. Craig Ziering’s work
with hair direction patterns in the vertex
come to mind. Dr. Jim Arnold has
suggested mosaic patterns of alopecia
and has made observations on the vertex
(suggesting the name “coronet” for the
second smaller area of loss inferior to the
larger “crown” pattern). Dr. Limmer,
through the use of stereomicroscopes,
introduced the hair restoration world to
follicular units as the natural pattern
(Dr. Headington wrote an article in the
327
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May/June 2003
Volume 13, Number 3
Notes from the Editor Emeritus
Decline in
Patient
Numbers
There seems
little doubt that
hair transplant
patient numbers
are declining
worldwide in
spite of the
Richard C. Shiell, MBBS
higher skills of
Melbourne, Australia
practitioners
and the unprecedented quality of
modern results. There are individual
exceptions, of course, as some large
clinics and individual practitioners seem
to be able to maintain numbers by
expensive advertising and PR campaigns.
Nevertheless, even they admit that the
return per dollar spent has declined
significantly in recent years. Our
Websites gain plenty of “hits” and result
in some consultations, but the patients
tend to be young and in early stages of
baldness, and very few graduate through
to the operating room in my practice.
What Is Going On?
First, there is little doubt that the
balding male in the Western world is
now more likely than ever before to cut
his hair short rather than resort to
transplant surgery or wigs. The fashion
for long hair that has persisted since the
mid-1960s is over. Let us hope that the
new fashion for short hair does not last
50 years as it did from 1914–1964.
Second, medical treatment of baldness is delaying surgery. This is often a
good thing as desperate young men in
their late teens and early 20s are known
to be poor candidates for hair surgery.
Many older patients are unrealistically
expecting a “miracle cure” within a year
or two when transplantation now
would be their better option.
Third, the new techniques involving
small grafts and FUT in particular have
greatly increased the initial cost of hair
restoration surgery. A first-up charge of
$7–10,000 is much more likely to
frighten the patient away than a charge of
$2–3,000, even if the latter patient knows
that follow-up surgery will be necessary.
328
Fourth, we surgeons have become
more aware of the progressive nature of
male and female baldness and the
psychological factors that sometimes
accompany hair loss. We are more
aware of diffuse alopecia in males and
females and are cautious in our approach to these patients. Litigation is
becoming more common and overall
many of us now reject perhaps twice the
number of patients for surgery that we
did a decade ago.
Fifth, for persons used to conducting
research on the Internet, there is an
abundance of conflicting advice and
even negative advice regarding hair
transplantation. The unhappy patients
seem much more ready to tell of their
experiences than do the satisfied clients
who make up the vast majority of our
patients. This makes it extremely
confusing and alarming for anyone
seeking information on a surgical
remedy for baldness on the Internet.
Finally, members of the general
public seldom see good hair transplants any more, as the best examples
are almost totally indistinguishable
from normal hair. Sometimes even the
linear donor scars are too faint to be
noticed by hairdressers. What is very
conspicuous is the bad or incomplete
transplant of the past. This is what the
average hairdresser and man on the
street has in mind when we speak of
hair transplants. It is little wonder that
the public and even medical practitioners are cautious about recommending
surgical hair restoration.
“A Patient’s Story”
Many of us were deeply moved by
this well-written piece, in the March/
April 2003 Forum, from a patient who
has had 20 years of anguish and regret
from an unsatisfactory series of reduction and transplant procedures. I would
like to say that it could not happen
today, but unfortunately this is not the
case. Because patients have become
much more discerning these days, they
expect a greater degree of perfection in
their results, and when this is not
delivered, they can feel all the pain and
disappointment so eloquently expressed
by the anonymous author.
The author felt that a ban on the use
of Sales Consultants would solve much
of the problem. While a glib salesman
might be the initial source of some
problems, I would like to remind
readers that the surgeon has the ultimate moral and legal responsibility to
accept or reject a patient, or to modify
the course of treatment suggested by the
Consultant. It is the doctor’s duty to
make sure that the Consultants in their
employ or in the employ of a large
company are adequately trained so that
patients are not being misled. If patients are unhappy, no one benefits
from the surgery in the long term.
I cannot overemphasise the importance of conservative management. A
patient under 25 years of age should
“earn” his transplant after a couple of
years of medical management. If he has
a possibility of type 5 baldness or
greater, then the transplant must be
planned as if the patient was not using
finasteride. We have no guarantee that
the patient will continue to use such
drugs over the coming decades. Indeed,
current experience in my practice shows
that about half the patients do not
continue for more than a year or two.
Fashion Swings
In the March/April Forum, I spoke of
the pendulum of scientific fashion. Since
the mid-1990s, the pendulum of surgical
opinion has swung so far that the FU has
attained almost sacred status. Ignoring
the fact that the vast majority of patients
never utilise all their potential donor
hairs, it is declared categorically that the
microscope MUST be used to prepare
these sacred offerings prior to implantation. Little mention is seen in the Forum
of the Choi technique that is practiced
widely in Japan and Korea and has been
adopted in a small number of clinics
outside Asia. The one-handed dissection
without magnification works well with
coarse Asian hair, however, microscopes
are certainly used to obtain Choi donor
material at the DHI clinic in Athens and
Volume 13, Number 3
❏
May/June 2003
Hair Loss Remedies: Lotions and Potions
Matt L. Leavitt, DO Heathrow, Florida
Introduction
Over the past two years, there has
been a marked increase in the number
of products being promoted as solutions to hair loss. These formulations
and devices pander to the population’s
desire to find some way to halt this
visible sign of aging.
The latest statistics report that an
estimated 80 million men and women
are affected by hair loss in the United
States. Only 3% of this staggering
number search out some sort of solution, whether it is medical, surgical, or
non-medical.
There are only three medically proven
methods of dealing with hair loss: hair
transplantation, minoxidil, and
finasteride. Surgical hair transplantation
is the only one of these methods that
provides a permanent solution. Both
minoxidil and finasteride require
continued use to become and remain
efficacious; once discontinued, hair loss
ensues.
Despite the availability of these
proven methods, there is an enormous
segment of the public suffering from
hair loss who try unproven hair loss
remedies. Numerous products claiming
to be “natural,” “safe,” “drug free,” and
effective against hair loss are heavily
marketed in the media. These “buzz
words,” coupled with the virtual
anonymity of purchase, are attractive
and are garnering huge attention.
Historically, there have been two
dramatic influxes of these types of
products. The first began in 1988 and
was spurred by the 1988 FDA approval
of minoxidil, marketed as Rogaine®.
Copycat products could not offer
clinical statistics to substantiate their
claims and, eventually, the Federal
Trade Commission (FTC) stepped in to
regulate these products.
In 1996, the introduction of Rogaine
5% and Rogaine’s new over-the-counter
status raised further awareness in the
public in addition to the 1997 introduction of Propecia® (finasteride).
The expiration of the patent on
Rogaine in December 2000 started the
next big increase of hair loss products.
Minoxidil (marketed as Rogaine), which
had been sold over the counter since
1996, now was in the public domain and
available to other manufacturers.
This generation of non-prescription
products that proclaim to be natural,
safe, and effective solutions for hair loss
are usually not what they claim.
Products are often based on minoxidil
in some form, saw palmetto (an unproven herbal remedy), and/or other
products that claim to be DHT inhibitors. Propecia is the only DHT inhibitor the FDA has approved for hair loss.
Distribution of these potentially bogus
products has never been easier, and
consumers can purchase them anonymously from numerous Internet sites.
The FTC has been slow to regulate
efficacy of these unproven products.
What Works
Minoxidil is the first of the drugs
approved for hair loss. Introduced in
1988 after the FDA gave its approval,
Rogaine has been an effective medication
for hair loss for both men and women.
The topical formulation is now available
in 2% and 5% strengths, and has been
over-the-counter since 1996. The
treatment is a hair growth stimulator and
works by activating potassium channels
in follicular cells. VEGF and prostaglandin synthase expression is indicated.
Numerous clinical studies have been
done and reported for both hair growth
and hair maintenance end points.
Finasteride is the newest medication
to be approved by the FDA for hair
loss. Approved in 1997, it is a 5-alpha
2 reductase blocker and lowers DHT
levels, which results in hair maintenance and may result in hair growth.
Clinical studies show a remarkable
90% of the study either gained or
maintained their hair over five years
compared to placebo.
Hair Restoration is the only permanent solution for hair loss. A surgical
treatment, the procedure transplants
viable hair from the donor area to the
recipient locations.
What Is Trendy?
Currently, the products generating
the most interest are Avacor, nioxin,
dutasteride, and saw palmetto.
Avacor®, from Global Vision 2001, is
a heavily marketed product that is a
three-fold system of a DHT blocker,
topical solution, and scalp detoxifying
shampoo. It claims to be an all-natural,
herbal formulation that is effective
immediately, with results shown in 4–6
months. It is a hair-growth stimulator
based on a formulation of 2,4-di-amino6d piperidino-pyrimidine 3 oxide, or, in
other words, minoxidil 2%.
It also contains sabal serulate, an
androgen modulator, more commonly
known as saw palmetto. While the
company uses “clinical” data to support
its claims, they are in actuality a “nonpeer-reviewed, non-double-blind,
seemingly scientific study subsidized by
the makers of the product.”1 The average
cost is $220 for a 3-month supply.
Nioxin® is a cleanser scalp therapy
and scalp serum. The product contains
niocidin, which inhibits demodex
produced lipase.2 However, “there has
never been any study, that I am aware
of, that implicates demodex lipase in
hair loss” or “that shows that hair will
benefit from getting rid of mites or
their lipase.”3 Nioxin is based on
bionutrient actives and protectives.
Their primary methodology is to clean
the scalp of DHT and to provide
chemically enhanced hair with moisture/vitamin nourishment. Primarily
available in salons, the product can now
be found in other retail outlets.
Dutasteride, from Glaxo Smith
Kline, is the most promising of the
products or medications outside of the
three therapies mentioned above.
Approved by the FDA only for use with
prostate therapy, it was not submitted
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May/June 2003
Volume 13, Number 3
Hair Loss Remedies
continued from page 329
for male pattern baldness. It is a DHT
blocker that blocks both forms of 2alpha reductase enzymes (type 1 and 2).
Early studies show promising results,
that is, slightly better than finasteride;
however, the potential side effects
require further trials and testing for
overall efficacy and safety. Other early
indications show that it has a longer
half-life than finasteride and that the
safety data is consistent with DHT
reduction. It is still awaiting phase III
trials. Dutasteride has been marketed
with the brand name Avodart®.
Saw palmetto is available from
multiple sources. It is an over-thecounter herb that has been claimed as
effective as a supplement for thinning
hair. It has shown to be beneficial in
men with benign prostatic hyperplasia,
but does not affect testosterone, DHT,
or PSA levels.4 It has exhibited alpha
androgenetic receptor blocking activity
in vitro.5 General usage recommends
taking 400mg of standardized extract
with 100mg of beta sitosterol daily. It is
claimed that results will appear in five
months.
There are numerous other products
and devices available to the consumer.
A random sampling of the most
prominent products is shown in the
following text. The products have been
categorized by the operative mechanism
or by their key, active ingredients.
Lotions, Potions &
Shampoos
Herbals, minoxidil-based, oils,
and vitamins
Folliguard Extra, from Jungle MD, is
very similar to Avacor both in terms of
usage and formulation. Specifically, it
uses a system of DHT blocker and scalp
detoxifying shampoo. Its active ingredients are minoxidil 2% and saw palmetto. It costs approximately $200 for a
3-month supply.
Hair Advantage, from Daniel Rogers
Laboratory, is extremely similar to both
Avacor and Folliguard. It uses a DHT
blocker, nutrient serum, and scalp
detoxifying shampoo. Its ingredients are
330
composed of loniten (better identified as
minoxidil), saw palmetto, tarakaci,
notoptcryl, maidenhair tree, vaccinium
murtillus, and equisetum. The estimated
cost is $180 for a 3-month supply.
Xandrox also claims to contain a
DHT blocker as well as a topical
solution. Its active ingredients are
minoxidil (12.5% micronized), azeleic
acid 5%, and betamethasone valerate.
The company reports that the 12.5%
micronized minoxidil works on the
temple and hairlines (non-responsive
areas), while they say the azeleic acid
can act as a DHT inhibitor.
Herbal Products
Hair GenesisTM, from Dr. Geno
Marcovici and Sunset Marketing, sells
for $270 for a 3-month supply. It uses a
system of a special shampoo, conditioner, supplements, and a serum. It
also uses “botanicals” to inhibit type I
and II 5-alpha reductase and decrease
DHT. Results are claimed to appear in
6 months and it is described as being
safe for both men and women.
Nu HairTM, from Biotech Corp, sells
for $180 for a 3-month supply. It
claims to be a “supplement” for thinning hair. Its active ingredients are he
shou wou, saw palmetto, horsetail,
henna, rosemary, progesterone, and
nettle.
Hair PrimeTM, from Universal
Biologics, sells for $210 for a 3-month
supply. It requires a regimen of shampoo, lotion, and primer to deliver
“nutrients.” It has two herbal and
vitamin supplement tablets containing
pantothenic acid, biotin, and zinc. It
claims to be a natural herbal treatment
and that 9 out of 10 people have
healthier hair growth.
Biologic Products
Emu Oil, studied by Boston University Medical Center, is a topic product
that sells for $9.50 an ounce. Its
“credentials” cite a Dr. Michael Holick,
who reported a clinical study showing
that Emu Oil accelerated skin regenera-
tion and stimulated hair growth. They
claim that 80% of hair follicles began to
grow hair in non-clinical studies.
Thymuskin, from Biotechne Complex Inc., sells for $210 for a 3-month
supply. It is a topical solution that must
be massaged directly into the scalp. It
contains the extract of calf thymus
glands and claims to boost immune
function. The company admits it is not
effective for male pattern baldness or
androgenetic alopecia, the most common types of hair loss.
FNS, or Follicle Nutrient Serum,
from Osmotics, sells for $65 for a 4ounce tube. It is a topical solution that
claims to contain a unique delivery
system of nutrients. It has a three-fold
mechanism that includes a growth
hormone potentiator, a cell culture
medium, and a vehicle. It is marketed as
a cosmetic product and will not be
submitted for FDA approval. No trials
have been performed to date.
Vitamin & Mineral Products
Hair -ZXTM, from Vitafree, sells for
$250 for a 3-month supply. It is a threepart system including a shampoo, a
topical, and a DHT blocker. It is
available through the Internet and direct
sales. It claims to regrow lost hair as well
as to produce larger, healthier follicles.
FolligenTM is available in three formulations: a cream for hairlines, a lotion for
denser areas of hair, and a solution
therapy spray for misting over the hair.
It is available through the Internet and
direct sales. It is a copper peptide–based
product. Its functionality is based on
the theory of increasing blood supply to
the scalp to combat hair loss.
TriaxonTM is a topical treatment. It is
available through the Internet and
direct sales. It is comprised of a combination of vital nutrients and vitamins
and reports it has a higher level of active
ingredients designed to promote new
growth. It claims to help reduce DHT
levels by 90% and to give users immediate results.
EPM, from Sumitomo Electronics, is
an over-the-counter topical treatment
Volume 13, Number 3
comprised of 10 amino acids. Its active
ingredient is epimorphin. No clinical
trial data is available and it is not
available in the United States.
Miscellaneous Products
Kevis®, by Farmaka, sells for $650–
$975, depending on the package you
choose. It is available through the
Internet and direct sales. It includes a
topical lotion, a shampoo, and a topical
“accelerator” that must be applied with
applicator and massaged. It claims to
block DHT or the androgen receptor.
The company indicates clinical testing
done in Europe.
Procyanidin B-2 is a combination
shampoo, lotion, and primer as a
regimen to deliver nutrients. It is a
polyphenol compound, found in
apples, which is said to act on hair
epithelial cells as a growth-promoting
factor. Their own study indicated “an
increase in the number of hairs and the
diameter of hairs in the designated scalp
area compared to placebo.” No statistics
or data were provided.
RevivogenTM, from Advanced Skin
and Hair, costs $99 for a 3-month
supply. It is available over-the-counter
and includes a scalp therapy formula and
bio-cleansing shampoo. It says it is an
anti-DHT product, and claims there are
no systemic side effects and is safe for
men and women. Does not have FDA
approval. On their own Website, it states
that it is “not a drug, medication,
treatment, or cure for hair loss.” It also
claims internal study performed showed
significant decrease in hair loss in 3
months.
Rx Products
Nizoral®, by Janssen Pharmaceuticals,
is a shampoo containing ketoconazole
2% (an anti-fungal agent).
Ketoconazole, taken in tablet form, has
been shown to lower serum testosterone. The effect has been compared to
that of minoxidil 2%. It is available in
1% form over-the-counter or in 2%
form as a prescription.
Spironolactone is a potassium sparing
diuretic, used in treatment for blood
pressure, and has been found to have
anti-androgen activity. It is a DHT
blocker in topical form and must be
applied daily followed by the application
of a minoxidil solution. It is available by
prescription in tablet or foam.
Devices/Other
Non-medical; Non-camouflage
LaserComb, by Lexington International, claims to use photobiostimulation
with low-level, cold beam laser therapy.
It claims to show improvements or
activation of hair in the first 5–10 weeks.
It requires usage twice a day for 10
minutes per session. It has had some
mixed reactions. Some of the positive
responses are from respondents using
other forms of hair loss remedies. It has
begun FDA clinical trials. It sells for
$695.
HairogenicsTM is a hair storage service
in a temperature-controlled vault. The
principle involves storing hair until
cloning or other reproduction methods
are viable. Concerns revolve around the
extraction of hair and that DNA taken
from existing hair would be sufficient for
any cloning or reproducing possibilities.
Based in Oregon, cost is an initial $50
plus $10 per annum for storage.
Dermal Fusion, by Ryan Livingston,
claims to be a hair “multiplication”
technique in which microscopic
biopsies of hair or scalp tissue are
removed without scarring or blood.
Follicles are multiplied in a type of
incubation chamber and a pipette then
inserts surviving cells. The procedure
claims immediate hair growth without
any trauma or a resting phase. It is
generally believed to be a hoax.
It is worth noting the similarity
among most of these products in terms
of their recommended treatment
regimen and ingredients. Many of the
❏
May/June 2003
so-called natural products actually
contain minoxidil in some form, which
is a clinically-proven hair loss remedy.
Many of these “treatments” do not
provide sufficient information on their
formulations or will disguise some of
their ingredients with terminology not
usually recognized by the public.
Almost unilaterally, there is a DHTblocker listed, but with no identification. Clinical trials are alluded to, but
not supplied in many instances; substantiation of claims is usually lacking.
There is often no satisfactory mechanism of action that has been provided.
Summary
Over 50% of the male population has
cosmetically significant male pattern
hair loss in their 50s. There is pressure
on individuals to look younger both
socially and in the workplace. Society
wants superior solutions and wants
these solutions now. There is a growing
interest in anti-aging treatments, herbal
formulas, and holistic medicine.
Businesses are attempting to take
advantage of this demand. They offer
products that are not efficacious and are
misrepresented. Better education on the
proven methods of treating hair loss is
needed. Hair transplantation, Rogaine,
and Propecia are the only clinically
proven medical hair loss treatments.
Until a new drug is found, cloning is
perfected, or genetic therapy refined,
they remain the best solutions for the
hair loss population.✧
BIBLIOGRAPHY
1. Altcheck, Douglas, MD, Mt. Sinai
School of Medicine, in Men’s Health
magazine, September 2002.
2. Nioxin product literature
3. Washenik, Ken, MD, PhD. “Pharmacologic Treatment of Androgenetic Alopecia,” presentation 2002.
4. Wilt, et al. JAMA 280:1604–1609,
1998.
5. Goepel, et al. Prostate 38:208–215,
1999.
Let that bomb, when it comes, find us doing sensible and human things—praying, working, teaching,
listening to music, bathing the children, playing tennis, chatting to our friends over a pint and a game of
darts—not huddled together like frightened sheep and thinking about bombs.
—C.S. Lewis
331
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May/June 2003
Volume 13, Number 3
The Arrector Pili Muscle May Contribute to
the Integrity of the Follicular Unit
Francisco Jimenez, MD Canary Islands, Spain; Enrique Poblet Albacete, Spain;
Francisco Ortega Canary Islands, Spain
In his landmark paper using micro-
scopic horizontal sections, Headington1
described a new way to evaluate the scalp
microscopic anatomy in unit structures,
especially useful for dermatopathologic
diagnosis. Thanks to his paper, we have
learned that hair follicles are normally
distributed in unit structures named as
follicular units, which are composed of
one- to four- or even five-hair follicles
and their associated sebaceous glands
and arrector pili muscles. However,
Headington did not focus his attention
on the morphologic relationship of these
muscles with the follicular unit.
In a recently published article, we
showed evidence that the AP muscle
forms a single muscular structure per
follicular unit.2 To demonstrate our
anatomic model proposal, we performed
serial horizontal microscopic sections of
a follicular unit at the isthmus level,
following the course of the AP muscle
from the upper isthmus down to its
follicular attachment. Figure 1 shows the
most superficial section, in which we can
identify a thick muscle bundle (painted
in dark for better definition) located at
the periphery of the follicular unit (this
follicular unit is composed of four
terminal hair follicles). A deeper section
(Figure 2) shows how the thick AP
muscle unit starts to split into thinner
muscle fascicles. A deeper section (Figure
3) shows how three muscle fascicles are
directed towards the insertion point,
attaching to their corresponding hair
follicle. Finally, Figure 4 shows the
remaining AP muscle fascicle attaching
to the fourth hair follicle of the unit.
Based on these serial sections, we have
drawn a schematic three-dimensional
representation of our proposed anatomical model of the follicular unit of the
scalp (Figure 5) in comparison with the
traditional anatomical view (Figure 6).
We believe that the traditional anatomical concept (based on the microscopic
analysis of vertical sections) of “one-hair
follicle associated independently to one
AP muscle” should be changed rather to
the concept of “one AP muscle unit
shared by all the follicles contained
within a follicular unit.”
There are reasons to believe that the
AP muscle might play a more important role than the mere hair shaft
elevation. Our data suggests that it
could contribute to maintaining the
integrity of the unit. In this regard, we
imagine the AP muscle acting as a
string that ties together all the hair
follicles of each follicular unit at the
isthmus level, similar to a lace around a
bunch of flowers.
Another possible function of the AP
muscle that has attracted our attention
is its influence on the control of sebum
secretion from the sebaceous gland.
This hypothesis, mentioned in the
literature by other investigators, has
never been proven. We have noted that
as they approach the follicular attachment zone, thin sheets of the AP
muscles closely invest and penetrate
between the sebaceous lobules, suggesting that a contraction of these muscle
fascicles should increase the secretion of
the sebum from the sebaceous lobules
to the follicular canal.
Finally, another intriguing fact is that
the follicular attachment zone of the AP
muscle concords with probably the
most critical portion of the hair follicle,
the bulge zone, which is thought to
contain stem cells responsible for hair
follicle regeneration.3 Besides a possible
protective role of the muscle fibers over
the stem cells, the interaction of this
muscle with the stem cells and its role
in hair cycling is an interesting subject
for investigation.✧
Figures 1 to 4
Figure 5
Figure 6
332
REFERENCES
1. Headington JT. Transverse microscopic anatomy of the human scalp.
Arch Dermatol. 1984; 120:449–56.
2. Poblet E, Ortega F, Jimenez F. The
arrector pili muscle and the follicular
unit of the scalp: a microscopic
anatomy study. Derm Surg. 2002;
28:800–3.
3. Cotsarelis G, Sun T-T, Lavker RM.
Label-retaining cells reside in the
bulge of the pilosebaceous unit:
implications for follicular stem cells,
hair cycle, and skin carcinogenesis.
Cell 1990; 61:1329–37.
Volume 13, Number 3
❏
May/June 2003
Buffers for Micrografts
continued from front page
45,0
40,0
Figure 1. Follicles from at least 4 different patients were
stored in quadruplicate for 5 hours at room temperature
in the indicated buffers. Hair shaft length was measured
at day 0 and day 5, and HSE was given as percent
elongation from day 0 to day 5. a: p<0.001, b: p<0.0001.
35,0
b
30,0
b
25,0
20,0
15,0
10,0
a
5,0
0,0
PBS
PBS-S
TCM
intracellular key enzyme, caspase-3,
which in turn activates the degradation
of nuclear DNA.
Each of these described pathways is a
possible candidate as causative mechanisms in the reduction of cell viability
in isolated, stored micrografts for
transplantation. In addition to inflammatory mediators, toxic cell metabolites
(NO, oxygen radicals, and AA metabolites), and loss of cell-cell interactions
during preparation, withdrawal of
serum (and therefore survival factors in
stored micrografts) might also cause
apoptosis in follicle cells.
Because apoptosis induced by these
mechanisms is a rapidly induced form
of cell death (minutes to hours) compared to necrotic cell death, apoptosis
likely influences the micrograft viability
more than necrotic cell death. Therefore, we have performed an in vitro as
well as an in vivo study on graft viability, at the laboratory of Moser Medical
Group in Vienna, to investigate a
possible beneficial effect of micrograft
storage buffers containing inhibitors of
different apoptotic pathways.
Study Design
The study was performed at the
Biotechnology Department of Moser
Medical Group at Vienna. An in vitro
system was established to evaluate hair
shaft elongation in isolated micrografts
stored for 5 hours at room temperature
50
Percantage of HSE change compared to HSE in TCM
Percantage of hair shaft elongation d0/d5
50,0
40
30
Figure 2. Follicles from at least 4 different patients
were stored in quaduplicate for 5 hours at room
temperature in TCM and TCM supplemented with
inhibitors of apoptosis. Hair shaft length was measured
at day 0 and day 5, and HSE was given as percent
change to follicles stored in TCM only. a: p=0.02,
b: p<0.01, c: p<0.001.
b
20
c
a
10
0
-10
a
-20
TCM--S
in different buffers containing inhibitors of apoptosis.
Whole hair follicle culture was
performed in tissue culture medium
containing nutrients for isolated hair
follicles as described elsewhere.7,8 To
evaluate the beneficial effect of storage
buffers containing inhibitors of
apoptosis, the conditions were slightly
modified, using 10% fetal calf serum in
the culture medium, which has been
shown to inhibit hair shaft elongation in
culture. These conditions mimic the in
vivo situation, where prestored, grafted
follicles are directly influenced by serum
after transplantation. Therefore, our in
vitro system is ideally suited to evaluate
the effect of storage buffers on graft
survival. Cultures of stored micrografts
were evaluated for hair shaft elongation
for a period of 5 days, with data being
expressed as a percentage of hair shaft
elongation from day 0 to day 5.
The buffers used in this study were
based on buffered salt solutions (phosphate-buffered salt solution, PBS) as
well as buffered tissue culture medium
(TCM). To the basic buffers, different
concentrations of inhibitors of
apoptosis were added. We evaluated the
effect of autologous serum, protein
hormones (buffer TCM-1), and inhibitors of apoptotic pathways induced by
oxygen radicals (buffer TCM-2), nitric
oxide (buffer TCM-3), or arachidonic
acid metabolites (buffer TCM-4).
TCM TCM-1 TCM-2 TCM-3 TCM-4 TCM-5
The in vivo study was performed with
patients who had given informed
consent to the study. Buffers proven to
have a significant enhancement of hair
shaft elongation in the in vitro system
were used under routine conditions. In
groups of 5 patients, 50 micrografts
were stored separately in the defined
buffers and were transplanted to a
defined region on the patient’s scalp.
Hair growth was evaluated and documented every 14 days for a period of 6
months.
Results
In vitro hair shaft elongation: In vitro
hair shaft elongation demonstrated a
beneficial effect of tissue culture medium
containing the essential amino acids,
vitamins, and salts for cell survival.
Storage of micrografts in the TCM
resulted in a significant increase in hair
shaft elongation compared to micrografts
stored in PBS (2.3%±0.6% vs 28.4%±
3.9, p<0.0001; Figure 1), suggesting
increased viability of follicle cells.
For micrografts stored in the buffered
salt solution PBS, the addition of 10%
autologous serum demonstrated significant enhancement of hair shaft elongation from 2.3%±0.6% in PBS alone,
compared to 6.2%±2.2 in PBS+10%
autologous serum (p<0.001; Figure 1).
To investigate the effect of inhibitors
of apoptosis, different concentrations of
333
❏
May/June 2003
Table 1.
In vivo evaluation of different
storage buffers
Days after
transplantation
Day 14
Micrografts were stored up to 3 hours in
the different storage buffers. Transient hair
loss and/or hair growth was monitored on
day 14, day 30, day 60, and day 90 after
transplantation. ND: Hair length was not
determined due to transient hair loss or nonsignificant hair shaft elongation. Hair length
was given as mean standard deviation of
patients with hair growth.
Volume 13, Number 3
Day 30
Day 60
Ringer’s solution
n=5
PBS
n=7
TCM
n=4
TCM-3
n=6
Hair loss
2/5
2/7
0/4
0/6
Hair length (cm)
ND
ND
ND
0,4 0,1
Hair loss
5/5
6/7
1/4
0/6
Hair length (cm)
ND
ND
1,2 0,2
0,4 0,1
Hair loss
5/5
6/7
1/4
0/6
0,7 0,5
0,8 0,4
2,5 1,0
2,6 0,4
5/5
6/7
1/4
0/6
1,8 0,7
2,1 0,6
3,4 1,3
3,6 0,4
Hair length (cm)
Day 90
Hair loss
Hair length (cm)
survival factors (TCM-1), inactivators of
oxygen radicals (TCM-2), inhibitors of
nitric oxide (TCM-3), or inhibitors of
AA metabolites (TCM-4) were added to
TCM. Storage of follicles in TCM-3 or
TCM-4 significantly increased in vitro
HSE compared to TCM alone (33.9%±
7.1%, p=0.01 and 32.8%± 6.1%,
p=0.02, respectively; Figure 2). Addition
of protein hormones to TCM demonstrated enhanced hair shaft elongation
only in combination with inhibitors of
nitic oxide (TCM-5). Steroid hormones
had no effect on in vitro hair shaft
elongation. Typical morphology of
follicles stored in PBS, TCM, or TCM-3
is presented in Figure 3.
PBS
TCM
solution. However, hair growth started
earlier and with higher growth rates of
the hair shaft compared to Ringer’s
solution (Table 1). Furthermore, the
period before the transient hair loss was
prolonged in some patients after storage
of the micrografts in PBS.
Micrografts stored in the TCM-3
buffer demonstrated no transient hair
loss in all 6 patients included in this
group (Table 1). In addition, hair
growth started immediately after
transplantation, resulting in hair shaft
elongation, which is comparable to
non-transplanted hairs (Table 1). The
typical course of hair growth of a
patient where micrografts were stored in
TCM-3 is demonstrated in Figure 4.
TCM-3
Discussion
Storage of isolated micrografts for
periods of up to several hours occurs
A
B
C
Figure 3. Microphotographic picture (12.5× magnification) of
typical follicles observed after 5 days in culture, containing
10% fetal calf serum. A: storage for 5 hours in PBS, B: storage
for 5 hours in TCM, C: storage for 5 hours in TCM-3.
In vivo graft survival: The in vivo
study was performed with PBS containing serum, TCM, and TCM containing
inhibitors of nitric oxide (TCM-3) as
storage buffers. Fifty micrografts of
patients undergoing routine hair restoration surgery were stored under routine
conditions in these buffers and transplanted to defined regions on the scalp.
Micrografts stored in PBS showed the
typical transient hair loss after approximately 1 month of transplantation, as it
is observed in the routinely used Ringer’s
334
Figure 4. Typical time
course of a patient where
follicles were stored in
TCM-3. Pictures show
the patient 1 day after
transplantation, 60 days,
and 90 days after
transplantation. No
transient hair loss was
observed.
during routine micrograft transplantation procedures. During preparation
and storage of the micrografts, different
factors influenced the viability of the
follicle cells and therefore the clinical
outcome of micrograft transplantation.
Due to mechanical damage during
preparation, absence of nutrient supply,
and loss of the in vivo microenvironment in isolated micrografts, a transient
hair loss is normally observed in hair
restoration surgery. This transient hair
loss, and the reduced growth rates early
after transplantation, which influences
clinical outcome and patients’ satisfaction, has remained an unsolved problem. Some attempts have been made to
overcome this problem with no significant improvements so far.
It is known that apoptotic cell death
in transplanted organs is a limiting
factor in graft function. During the in
vitro period of grafts, apoptotic cell
death can be caused by a lack of growth
factors and toxic metabolites, such as
oxygen radicals and metabolites of the
AA pathways.5,9–11 After transplantation,
apoptosis is caused in the graft after
reperfusion of the organ. This phenomenon, known as ischemia-reperfusion
injury, was observed in different
transplanted organs and is mediated by
induction of inducible nitric oxide
synthase (iNOS) and generation of
excess NO.12–14 All the apoptotic
pathways might also induce apoptosis
in stored micrografts and therefore limit
graft viability and survival.
In our recent work at the Biotechnology Departement of Moser Medical
Volume 13, Number 3
❏
May/June 2003
Hair Loss Profile
3
4
2
1
8
5v
6
5
5v
5
6
10
7
10
10
4
6
4
8
6
4
8
3
2
5
8
5
8
5v
5
7
10
2
1
1
10
9
2
9
COPYRIGHT — B H COHEN MD, CORAL GABLES, FL , 2002
Forehead_____cm
Vertex_____cm
Bridge_____cm
Hair Loss Index
Terminal 100%
1
2
3
4
5
5v
6
7
8
9
10
Terminal 75%
Terminal 50%
Terminal 25%
Miniaturized 100%
No Hair
COPYRIGHT — B H COHEN MD, CORAL GABLES, FL , 2002
Above are enlarged pictures of Dr. Bernie Cohen’s drawing and graph for using his Hair Loss Profile and Index concept.
ISHRS members can make a copy of this page to use in profiling their patients and for communicating this at meetings
also. —MLB/WMP
335
336
❏
May/June 2003
Volume 13, Number 3
Volume 13, Number 3
❏
May/June 2003
Body Type and Balding
Paul M. Straub, MD, FACS Torrance, California
The typical image of the fat baldheaded man often seen in caricatures or
typecast in the movies, such as Danny
Devito, may not be happenstance. A
recent article in Dermatologic Surgery,
February 2003, by Yun et al1 discussed
the relationship between liposuction of
abdominal fat and an increase in breast
size in females. They reported that 34%
of their female patients noted an
increase in breast size following abdominal liposuction. This was explained in the following manner.2
Adipose tissue contains 5-alpha reductase, which converts testosterone to
dihydrotestosterone; however, abdominal fat produces a ten times greater
amount of dihydrotestosterone than fat
from other portions of the body such as
the thighs, hips, or omentum.3 The
breast size increase was explained by a
change in the ratio of active androgens
to estrogens in the circulation. No
mention was made of the possible effect
in males, but knowledgeable medical
and surgical hair physicians should be
able to extrapolate this information to
males. Abdominal fat is unique. It
appears that low abdominal fat results
in low circulating dihydrotestosterone.
This phenomenon is not noted in any
other body fat. Diminution of abdominal fat, whether by liposuction or
weight loss, diminishes both 5-alpha
reductase and dihydrotestosterone and,
as a result, we may assume, the tendency toward hair loss. Conversely, a
gain of abdominal fat, we would think,
should increase 5-alpha reductase,
dihydrotestosterone, and a tendency
toward hair loss. This is only an unproven theory at this point, but further
investigation may prove that we should
add abdominal obesity to the list of
factors contributing to hair loss along
with heredity and aging. Should this
prove to be so, there may come a day
when we will advise our patients that by
controlling their weight they will
contribute to controlling their hair loss.
It is now proven that some women can
increase their breast size by
liposuctioning their abdomens. It is
possible that some men may diminish
their rate of hair loss by liposuction.
The Physicians Health Study reported that men who had crown
balding had a 36% greater chance of
having a heart attack and bypass surgery
than those who did not.4 No increased
risk was noted with receding hairlines.
It is firmly established that abdominal
obesity increases the chance of cardiac
problems. It is quite possible that we
have a triad of abdominal obesity,
crown balding, and coronary artery
disease. Further studies are needed to
confirm this.✧
abdominal obesity
crown balding
coronary artery
disease
REFERENCES
1. Yun P, Bruck M, Felsenfeld L, Katz
B. Breast enlargement observed after
power liposuction: A retrospective
review. Dermatologic Surg. 2003;
29:165-7.
2. Samdal F, Birkeland Kl, OseL,
Amland PF. Effect of large-volume
liposuction on sex hormones and
glucose and lipid metabolism in
females. Aesthetic Plast Surg.
1995;19:131–3.
3. Killinger DW, Perel E, Danilescu D,
et al. Influence of adipose tissue
distribution on the biological
activity of androgens. Ann NY Acad
Sci. 1990;595:199–211.
4. Manson J, et al. Archives of Internal
Medicine, as reported by Associated
Press.
Editor Emeritus
other centres where Caucasian hair
predominates.
The cost of FUT has seldom been
discussed and the editors of peerreviewed journals generally cut any such
references in papers presented to them.
Apparently, it is undignified to bring
talk of money and expense to the
patient into a scientific paper.
Cost and patient-satisfaction comparisons between the various methods
have not been attempted to my knowledge, as they are extremely difficult to
undertake and assess.
It is my experience that 300 micrografts
and 1,200 small minigrafts with slight
transections will give better coverage on a
type 5 bald scalp than 1,500 perfect FUs
at the same price. It is only logical that it
should be better as with the former
method grafts are extracted from approximately 27 square cm of donor strip while
in the latter only 15 square cm of donor
scalp has been utilised. It would require a
massive follicle loss of nearly 50% to
equate the two procedures on a hair per
dollar basis. Case selection is an important factor here as not every patient is
suited for, or prepared to accept, the larger
minigraft unit.
FUE and CAG
New terms and new techniques
continue to fascinate us and even old
techniques for alopecia reduction and
laser recipient sites may be poised for a
comeback. Anyone who thinks that we
are in a static field that has reached its
zenith is much deluded. I have been
asked to speak on what I see as the future
of hair restoration at the New York
meeting, and it will be very difficult to
fit this into the allotted 10 minutes.✧
Richard Shiell, MBBS
337
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May/June 2003
Featured
Volume 13, Number 3
Speakers
If you haven’t done so already, make plans to attend the 11th
Annual Scientific Meeting! The program planning is well underway, and the meeting is guaranteed to be cutting edge! Our
featured guest speakers include the following:
ANGELA M. CHRISTIANO, PHD, is a world-renowned researcher in the field of hair follicle research. She is an
Associate Professor of Dermatology and Genetics & Development at Columbia University in New York. Her research
focuses on the genetics and biology of hair loss, which has led to landmark discoveries of two genes involved in inherited
hair loss. Dr. Christiano has published more than 145 peer-reviewed publications and more than 40 reviews in the area
of inherited skin disorders, and she serves as the Editor of Experimental Dermatology. She has recently initiated research
on exploring tissue engineering and cell therapy as a method of treating hair loss, joining forces with British researcher
Dr. Colin Jahoda.
JULIANNE IMPERATO-MCGINLEY, MD,
is Chief of the Department of Endocrinolgy, Diabetes, & Metabolism at
Cornell and Rochelle Belfer Professor of Medicine. During the early 1970s, Dr. Imperato conducted an expedition to
the Dominican Republic to investigate reports of an isolated village where children appearing to be girls turned into men
at puberty. Her research into this phenomenon led to our understanding of dihydrotesterone’s role in normal development as well as its contribution to acne, prostate enlargement, and hair loss. This paved the way for the development of
finasteride, the first rationally designed oral medication for androgenetic alopecia. Dr. Imperato will share this fascinating story, which has had such an important effect on our specialty.
JUSTIN D. KURALT is a consultant for Total Medical Compliance, Inc., a company dedicated to assisting health
professionals to comply with state and federal regulatory laws. Mr. Kuralt and his company have trained over 5,000
physicians in North and South Carolina on how to comply with Occupational Safety and Health Administration laws,
and the recently passed Health Insurance Portability and Accountability Act (HIPAA). Mr. Kuralt will
focus on what U.S. hair restoration surgeons need to know to comply with this law and, more
generally, what all surgeons need to do to safeguard patient privacy rights. Mr. Kuralt has a
background in pharmaceutical sales and in coaching sports, experiences that have uniquely
prepared him for his current position.
KATHERINE M. ROTHMAN is president and founder of KMR COMMUNICATIONS,
INC., a Manhattan-based firm specializing in consumer oriented public relations that
represents beauty, health, and cosmetic clients, including numerous hair restoration surgeons and cosmetic surgeons. Within a year of the creation of KMR COMMUNICATIONS, INC., the firm was named one of the top 50 healthcare public relations firms in
the United States. Ms. Rothman has authored numerous articles and given presentations
at conferences on how physicians can successfully use public relations to expand their
practice.
PLEASE NOTE: The ABHRS and IBHRS Boar
ds met on April 9
Boards
xams until Sunda
y,
and decided tto
o postpone the fir
first
ex
Sunday
st IBHRS e
Oct
ober 19, 2003, in Ne
w Y
ork City
o coincide with the last
October
New
York
City,, tto
da
y of the ISHRS Annual Meeting.
day
338
Volume 13, Number 3
❏
May/June 2003
A look e
t th
back a
Mike Beehner, MD
Saratoga Springs, New York
Drs. Matt Leavitt and David Perez
once again welcomed the hair transplant
community of the world to Orlando for
yet another great ISHRS-sponsored
“Live Surgery Workshop” experience,
this being the 9th meeting. I’m sure the
120-plus physicians present would agree
that there was no finer venue in the
world for learning the fine points of HT
surgery. Matt and David pulled out all
the stops to make this the best meeting
yet. The weather cooperated and there
was full attendance, despite some fears
by the meeting organizers that world
events may cause some not to travel by
air. Valarie Montalbano once again
served as the meeting coordinator,
making all of the preparations beforehand and also keeping track of everything during the workshop. Ron Kirk
served as the OR nursing coordinator for
the live surgery and the research projects.
Thirty-five faculty members attended
and shared their knowledge and surgical
Dinner at Mykonos (L-R): William Parsley, MD; Ricardo
Mejia, MD; Patrick Frechet, MD; Paul McAndrews, MD
skills with the attendees, many of whom
were from countries all over the world. A
distinguished research faculty, which
included Maria Hordinski, MD, Vera
Price, MD, Jerry Shapiro, MD, and Ken
Washenik, MD, PhD, was on hand for
Friday’s research symposium. The lovely
Hard Rock Hotel served as the quarters
for the meeting amidst beautiful Universal Studios. Procyte sponsored a cocktail
party the first evening for all of the
attendees, followed by a Pharmaciasponsored event at Pat O’Briens in
Universal Studios on Thursday, and
topped off by a sumptuous sit-down
meal on Friday, sponsored by Merck, in
Universal’s Land of Adventure area.
On the first day of the meeting, Dr.
Perez coordinated a panel of speakers for
a Beginners’ Workshop, which was well
received and covered all of the essential
aspects of getting started in hair transplant surgery and understanding the
fundamentals.
The format was slightly altered this
year, to allow for less back-and-forth
travel from lectures to the surgery center.
The number of lectures was reduced
from past years, and there was a greater
emphasis on panel discussion of topics
such as office setup and design, the
consultation, pre- and post-op care,
donor harvesting/closure, hairline
design, and the making of recipient sites.
The television crews at the surgery
center, as usual, did an outstanding job
of filming the live surgeries, so that
several viewers could circulate through
the ORs and watch the surgeries directly,
while the majority of viewers watched it
on the TV set with a discussion leader
present to help out.
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RIDAY, MARCH
ARCH 7
FRIDAY
Marcelo Gandelman, MD
Sao Paulo, Brazil
We were welcomed at the Portofino
Bay Hotel by the sweet Valarie
Montalbano (the exhausted woman
behind a successful man).
Our eye opener was the first lecture
by the Coordinator of the Special Cases
section, Dr. Michael Beehner: three
cases of successful harvesting of 288,
407, and 772 FUs using the beard
area—the last resource of donor hair.
Dr. Marcelo Gandelman conducted a
piece about Eyebrow and Eyelash Reconstruction and Dr. Matt Leavitt shared his
considerable know-how with hair trans-
Participants observe Dr. Leavitt demonstrate donor harvesting.
plantation in women with Female Pattern
Alopecia, giving details about etiology
and psychosocial significance, and
showing very interesting results.
Our dynamic Co-Chairman, Dr.
David Perez-Meza, addressed the
subject of hairpieces, the transition to a
transplant, and how to give the patient
a better outlook for this change in life.
John Vincent, the renowned expert in
non-surgical planning who outlined the
gradual elimination of hairpieces during
the hair transplantation phase, assisted
in this topic.
Dr. Melvin Mayer’s Temple Points
categorization added to the Norwood
Classification four new parameters:
Normal, Thinning Temporal Points,
Parallel Temporal Points and Reverse
Angle Temporal Points. The classification and surgical techniques were most
appreciated for their applicability.
Dr. Beehner expanded on his Frontal
Forelock, a very important first approach to people with a scarce donor
area or those who are not in favor of
having repeated surgeries. He described
the concept of the “mirror image” at the
part side to improve the natural look.
Dr. Leavitt and Bruce Marko expertly
outlined Pediatric and Adolescent
Cases, while Dr. Perez-Meza coordinated the Ethnic Patients segment.
Our experienced Dr. Mayer also
expanded our understanding about the
particular follicular characteristics of the
hair in patients of African descent and
how to address these special needs
during surgery, while Asian Patients was
the topic chosen by Dr. Robert
Niedbalski, who introduced the concept
of the three C’s: Color=Black,
Caliber=Coarse, Curl=Totally Absent.
Dr. Arturo Sandoval gave us a
splendid lecture that shared his very
impressive vast experience in hair
transplantation on Hispanics. Dr. Paul
McAndrews coordinated the section on
Hair Transplant Pearls, and focused on
339
❏
May/June 2003
the Management of Large Cases using
Medical and Surgical treatments. Dr.
Craig Ziering shared his advanced
approach to the “crown” area, setting
guidelines of whorl classification and
how to reconstruct it.
Dr. Alfonso Barrera outlined the
advantages of “dense packing” and how
to get better density.
The next part of the day’s activities
took place at the Metro West Surgery
Center, Dr. Leavitt’s state-of-the-art
facility of Medical Hair Restoration.
Here, Drs. Perez-Meza, Barrera, and
Volume 13, Number 3
Don Kadunce made a practical demonstration on a Hispanic female patient.
The audience coordinator was Dr.
Arturo Sandoval.
Drs. Leavitt, Tony Mangubat, Steven
Holt, and Greg Shannon skillfully
continued top of next page
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Summary of Scientific/Research Presentations
Mike Beehner, MD Saratoga Springs, New York
Last, he reported that researchers are
Confocal Microscopy
Update on Minoxidil Therapy
actively seeking new vehicles for increasing
Dr. Maria Hordinsky spoke about the
Dr. Jerry Shapiro spoke on what was
the penetration of minoxidil into the scalp.
modality of confocal microscopy, a fairly
new regarding minoxidil therapy and of
expensive technique that can be used to
new efficacy data that showed there was a
Hair Loss in Women
visualize the vasculature and nerves around
dramatically increased response when it
the follicular structures. It allows the
was started early. A randomized, placeboDr. Vera Price reviewed how a clinician
visualization of these areas in 3 dimensions
control, double-blind study of 391 men
would approach hair loss in females. She
and the examination of whatever cell type
by 6 different centers through 48 weeks of stated that an extensive battery of hormone
one wants to study. It essentially shows
therapy with 2% and 5% minoxidil
lab tests is not necessary if menstrual cycles
“digitalized layers” of the anatomy of the
therapy and placebo, showed that the 5%
are regular. In the history, she emphasized
mixture produced 45% more hair at 48
asking about disordered menses, severe cystic hair. Furthermore, it can be used to show
changes affected by various therapies, such as
weeks compared with the 2%.
acne, gallactorrhea, and any virilization. If
finasteride. One study that looked at changes
Dr. Shapiro also reported on another
any of these are present, she recommends
after 9 months of finasteride therapy showed
retrospective study by two independent
ordering testosterone, DHEAS, and
reviewers using global photography to
prolactin levels. In females with poor dietary that confocal microscopy was able to show a
evaluate results in which “mild density
habits, or in the young menstruating female, deepening of the follicles themselves, an
increase of nerves encircling the hair follicles,
increase” was noted by 54–62% of
a TSH, serum Fe, and ferritin levels are
and an increase in melanocytes.
patients using 5% and 38–44% of those
probably worth getting.
using 2%; and that 17–30% increase with
Dr. Price also spoke about the fact that
placebo. “Moderate density increase” was
women with “female pattern baldness”
Hair Cloning
noted in 30–40% of patients using 5%
usually retain their frontal hairline, whereas
Ken Washenik, MD, PhD, Medical
and 16–32% in those using 2%; and in
most men don’t. Some possible reasons
Director of Bosley, discussed the recent
7% on placebo. Most of these patients
might be that women have lower levels of 5advances regarding hair in the field of tissue
were in the Hamilton 2–4 stages.
alpha reductase in the frontal area follicles
engineering. He reviewed the theories
Reporting briefly on unpublished
compared to men. They also have increased
behind what is most commonly referred to
findings on minoxidil therapy in females,
levels of aromatase and lower levels of
as hair multiplication or hair cloning,
Dr. Shapiro reported no significant
androgen receptors.
technology that involves harnessing the
difference between the 5% and the 2% in
Speaking of “senescent alopecia,” Dr. Price follicle-inducing potential of follicular
a 9-center study. But, if one of the centers
defined this as the progressive, gradual loss
fibroblasts from the dermal papilla (DP).
is removed from the study, which had
of hair in the later decades of life. It is not
The possibility of creating new hair
quite different results, the 5% showed a
clear whether this is distinct from androgefollicles, folliculoneogenesis, would answer
26% increase in hair versus 20.7% for 2% netic alopecia or is simply a continuation of
one of the major unmet clinical needs in
therapy, which is statistically significant.
it in later life. In a study comparing men
hair transplantation—limitations in donor
He noted the safety of minoxidil,
over 60 who had no apparent increased loss
hair supply. The ability to isolate DP cells,
stating that it normally results in serum
with those who did, histologic studies and
expand their number in culture, and then
concentrations less than 5ng/ml. Levels of
hormonal assays were fairly similar in the
re-implant them into the scalp where they
21.7ng/ml are necessary to affect a
two groups in both the frontal and occipital
could induce the formation of new hair
cardiovascular change. Thus, there is a low areas, which support the diffuse nature of
follicles could ultimately lead to a source of
risk for overdose. Also, there are no known senescent thinning. It is noted that it seems
unlimited donor hair.
drug interactions. There was no increase
to respond to minoxidil therapy.
Dr. Washenik reviewed the only public
in adverse medical events in patients treated
Dr. Price also noted one study that
report of human hair grown from cultured
with minoxidil as compared to controls.
showed that 42.5% of women treated with
DP cells. This work by Tom Barrows, PhD,
Dr. Shapiro also reported that the
2% minoxidil had an increase in hair weight
of the Aderans Research Institute, was first
likelihood of a female developing a
versus only 2% with placebo. She recomrevealed at a tissue engineering 2002
problem with increased facial hair was
mended starting with 2%, then increasing to conference in Switzerland.
related to whether there was some prethe use of 2% in the morning and 5% in the
Over the next few years, augmentation of
treatment facial hair or not. In those who
evening, and finally to using 5% twice a day
follicle-based transplants with cell-based
did have some, 22% experienced an
if it is tolerated. She emphasized the
transplants should become a reality. The
increase of this problem with treatment,
importance of the patient using it for a full
ability to add density at will by implanting
while only 6% of those with no preyear. If they are not willing to do this, it
a limitless number of follicle progenitors is
treatment facial hair noted this as a
shouldn’t be started.
very exciting. However, a great deal of work
problem after therapy. No cardiovascular
needs to be done before this technology can
changes were found in females either.
become a reality.
340
Volume 13, Number 3
carried out another Female Patient case.
Dr. Ziering, assisted by Drs. Ricardo
Mejia and Gabriel Krenitsky, efficiently
demonstrated Ziering’s Crown Technique, while Dr. Gandelman, skillfully
assisted by Dr. Puig, undertook the task
of an Eyelash Reconstruction Surgery.
Many doctors also lent a hand, thus
contributing to the excellent result.
Dr. Mayer put into practice his
❏
May/June 2003
morning lecture with an African
Descent Patient, elegantly assisted by
Drs. Shelly Friedman and Robert
Nieldbalski, while Dr. Grant Koher
coordinated the audience.
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ATURDAY, MARCH
ARCH 8
SATURDAY
Paul McAndrews, MD
Pasadena, California
I was given the task to write about the
interesting information presented on
the fourth day of the Workshop.
The lecturer that made the biggest
impression on me was Dr. Patrick
Frechet. Dr. Frechet described his scalp
extension surgery, in which he brings
the temporal hair-bearing scalp together
in 2–3 surgeries and, in the process,
removes approximately 200cm2 of
balding scalp in the mid-forelock and
vertex. This leaves a much smaller area
(frontal forelock) that is needed to be
covered by hair transplants. The scalp
extenders, made of a silicone bio-elastic
material with hooks, are stretched 10–
15cm and attached to the galea in both
tempero-parietal fringe areas. Over the
next 4–6 weeks, the extenders slowly
come back to their resting position and,
in the process, gradually stretch the
donor scalp. Following the alopecia
reduction, the slot formation is corrected by a triple-flap surgery.
My personal belief is that every
procedure should directly focus on the
limitation of that procedure. The
limitation of hair restoration surgery is
that there is a fixed amount of good
genetic hair that we can transfer to the
balding area. There are many techniques and technologies in the field of
hair restoration that are focused on
helping make the procedure more
efficient for the doctor, but disrespect
this actual limitation to hair restoration
surgery. Therefore, any technique or
technology should focus on using this
very limited donor supply as efficiently
and wisely as possible.
Before hearing Dr. Frechet, I put
most alopecia reduction surgery in the
category of “not using the limited
donor hair efficiently or wisely.” Dr.
Frechet opened my eyes. His technique
of scalp extension surgery with the
Frechet Extenders followed by slot
correction is probably the most efficient
Welcome Cocktail Reception (L-R): Alex Ginzburg, MD; Nicolas
Lusicis, MD; Alejandra Susacasa, MD; Celia Gandelman; Marcelo
Gandelman, MD; Arturo Sandoval, MD; Ana Sandoval
and conservative use of the donor hair
in patients with very significant balding. There remains one problem with
Dr. Frechet’s procedure, however, and
this is—there is only one Dr. Frechet.
Dr. Frechet made this surgery look easy,
like all masters in their field do, but in
reality this surgery is extremely difficult
to master.
Dr. Rolf Nordstrom discussed a
suture material made out of silicone.
This suture, after being stretched and
placed in the deep tissue, has a tendency to return to its resting position.
The two main indications for this
suture are 1) to prevent scar widening
and 2) to enhance serial alopecia
reductions.
Dr. Leavitt described a newly refined
Minde knife for making the recipient
site incisions.
The new Minde knives have different
angles—15 degree 1mm, 40 degree
1.3mm, and 40 degree1.5mm. Each of
these blades goes to a depth of 4mm to
6mm depth.
These new blades have the advantage
of uniform depth, uniform angulation,
and stay very sharp throughout the
procedure.✧
It is hard to do justice to a meeting with such a large variety of different learning experiences as the Orlando Workshop offers year
after year. It is hoped that everyone—master and novice alike—will make it a point to at least once in their career feast at the
banquet of learning that is available in Orlando each March. —MLB/WMP
ISHRS FELLOWSHIP TRAINING PROGRAMS
NEW GUIDELINES
The ISHRS Fellowship Training Committee has formalized the Policies, Procedures, and Guidelines for ISHRS Fellowship
Training Programs. Please see page 352.
If you have a current HRS fellowship training program or are interested in developing a program and becoming a Director
or Co-Director (now or in the future), there will be a Fellowship Training Program Orientation Workshop at the 2003 Annual
Meeting in New York (October 15–19, 2003). The Orientation is intended to review the new process and guidelines and
answer questions. This workshop will be free of charge and anyone with an interest is encouraged to attend.
It is the intent of the Committee to conduct annual continuing education programs for ISHRS fellowship Directors and CoDirectors in an effort to teach and enhance their skills in teaching adult education. We hope to see you at the Orientation in
New York!
Sincerely,
Carlos J. Puig, DO Chair, ISHRS Fellowship Training Committee
341
342
❏
May/June 2003
Volume 13, Number 3
Volume 13, Number 3
❏
May/June 2003
Pioneer of the Month
Felipe Coiffman, MD
William M. Parsley, MD Louisville, Kentucky
Dr. Felipe Coiffman was the first
physician to use strip excision for donor
harvesting. His story began in 1926
when he was born in the Ukraine. His
parents, concerned with the unrest in
Europe, moved to Colombia in 1932.
He turned out to be an excellent student
and entered the National University of
Colombia at age 19, which he then
followed with a residency in General
Surgery. He had an interest in Plastic
Surgery and came to New York, where
he completed a 2-year fellowship (1954–
55) at Mount Sinai, studying under Dr.
Arthur Barsky. Afterwards, he returned
to Colombia and joined the faculty at
the National University of Colombia.
In the early 1960s, a patient brought
him a copy of the latest Reader’s Digest.
It happened to contain an article about
Dr. Norman Orentreich and his work
with plug grafts for hair restoration.
The patient said he wanted Dr.
Felipe Coiffman, MD Bogota, Colombia
Coiffman to do that procedure for him.
Dr. Coiffman consented and thus
started transplanting hair as an adjunct
to his plastic surgery practice, but he
didn’t like the shotgun appearance of
the donor area. He started removing the
donor tissue with a single-blade strip
excision, which he then divided into
small squares. In order to plant these
grafts, he developed a square punch.
His first article on this technique was
published in Plastic and Reconstructive
Surgery in 1977. Later, he performed a
few scalp reductions, but stopped
because he didn’t like the scars.
Dr. Coiffman is world renowned in
General Plastic Surgery and has a 4volume textbook called Cirugia Plastica,
Reconstructiva y Estetica (Plastic
Surgery, Reconstructive and Aesthetic).
He is currently working on the 3rd
edition of this text. At 76, he is also still
active in hair restoration, currently
performing mini- and micrografting
techniques.
Presently, he is an Emeritus Professor
of Plastic Surgery at the University and
is living in Bogota with his wife Fanny.
None of their three children—
Bernardo, Gladys, and Sandra—has
decided to follow Dr. Coiffman into
medicine. For his work with donor
harvesting, Dr. Coiffman is honored as
a Pioneer.✧
Follicle Storage
Group, we were able to develop storage
buffers for isolated micrografts, which
prevent apoptosis, overcome the
transient hair loss, and clearly improve
the clinical outcome in micrograft
transplantation. Because it is known
that hair shaft elongation in micrograft
culture is negatively influenced by the
addition of serum, we used a model
culture system using fetal calf serum to
study the effect of priming the
micrografts with various inhibitors of
apoptosis during a 5-hour storage
period before the addition of serum.
We found that storage of micrografts
in TCM significantly enhanced hair
shaft elongation in vitro, which was
further enhanced by the addition of
inhibitors of apoptosis. In addition, our
in vivo studies demonstrated that
micrografts stored in these antiapoptotic buffers can overcome the
transient hair loss in the majority of
patients. From these experiments, we
conclude that apoptotic cell death is the
major event causing decreased graft
viability and, in turn, is the major cause
for transient hair loss. With our buffers,
apoptotic cell death in the stored
micrografts can be prevented. The
increased viability of cells of transplanted follicles leads to an immediate
start of hair growth after transplantation with no transient loss of the
transplanted hair shaft. Furthermore, a
“bystander effect” was observed in
follicles that were located near the
transplanted micrograft, leading to
enhanced hair growth in the neighboring follicles. This might be explained by
enhanced production of hair growth
factors, such as vascular endothelial
growth factor, in appropriately stored
micrografts.
In summary, our study demonstrates
that storage buffers that prevent
apoptotic cell death in micrografts can
overcome the transient hair loss observed in micrograft transplantation.
These buffers lead to an immediate start
of hair growth and therefore to a clear
improvement of the clinical outcome in
hair restoration procedures.✧
Editors’ Note: Although quite technical and lengthy, we feel the above article is an important one and worth sharing with the
world hair transplant community. In the interest of conserving space, we are not listing the references cited. Please contact the
authors for these by e-mailing [email protected] —MLB/WMP
343
❏
May/June 2003
Volume 13, Number 3
CYBERSPACE CHAT…
Editor:
Edwin S. Epstein, MD
Richmond, Virginia
Please send your
comments/questions to:
[email protected]
TRANSPLANTING MINORS
James E. Vogel, MD
Baltimore, Maryland
There is no way a 17-year-old male
can be certain of anything, let alone his
anticipated methods of handling a single
hair transplant session should Propecia®
not work for him and maintain the rest
of his hormonally vulnerable hair.
Furthermore, can they truly comprehend
the informed consent about the procedure? This is an elective cosmetic
procedure, which the parents should not
sign for on the kid’s behalf. The best
advice is to implore him to stop seeking
a HT doc to do the case because he may
find one! I am not against a young adult
having a very conservatively placed
hairline using follicular unit grafting, but
17 is too young. The exact age-appropriate time for this early HT is clearly an
unresolved question and subject to many
factors that must be carefully assessed.
Russell Knudsen, MBBS
Sydney, Australia
You should judge each case on its
merits, but all of us have seen 30something men who were operated on at
20 (in a panic) and wish they had never
started—not because it looks terrible,
but because they are now committed to
further fill-ins when it no longer bothers
them. I tell young men that the 24month finasteride results are generally
better than at 12 months, and encourage
them to wait for maximal results.
I can predict what will happen if you
refuse. It happened to me with a 17year-old I had convinced to take
finasteride for 18 months despite
numerous pleas to commence surgery. At
18 months, he decided to get a second
opinion from a clinic (businessman
owner/consultant) that was only too
344
happy to agree to surgery. He finally
reappeared 10 months post-surgery very
sheepish and dismayed by the results of
his (low-average quality) surgery. My
hand was forced and I performed two
sessions to fill in and soften the dimpled
frontal micros. He is happy now, though
still anxious, and I hope that I would
still not have offered surgery to his virgin
scalp to this day. He is now 21.
Moral of the story: Do what you
think is correct, don’t expect the patient
to always agree, or that other surgeons
won’t take the money and run.
Marc R. Avram, MD
New York, New York
First, I would have a discussion with
his legal guardian before doing anything. It is difficult, but I would resist
transplants at this stage. The idea of
discussing a corrective surgery, before
the original surgery is done, would give
me great pause. I would encourage a
second opinion from another surgeon.
The more educated patients and
guardians are as to the pros and cons of
a HT at this age, the less likely the case
will haunt you in the future should you
decide to proceed.
Robert S. Haber, MD
Cleveland, Ohio
I do not have a lower age limit for
HT, but apply the same esthetic and
ethical conditions to all patients. My
youngest HT patient was 19, was Class
VI, had been losing his hair since age
15, and told me he wanted the head of
hair of a 45-year-old man. He met all
my conditions, and we proceeded. He
was a rare exception.
Louisville, Kentucky
At this time, I can’t see any good
reason to transplant a 17-year-old. They
are depressed, panicked, and certainly
not thinking clearly. Plus, they have no
real concept of aging. It is up to us to
protect them from making big mistakes;
after all, we are the professionals. Many
extremely bald older men are happy and
content, but at 20, were probably
depressed and feeling disfigured. After
10 or so years, they adjusted and it
wasn’t too much of a problem. With a
transplant, we might give them relief for
10 years and a problem for 50 years. For
me, the biggest problem in transplanting
is the continuing hair loss. If I could
change anything in my practice, it would
be to turn the clock back and have
rejected some of them at the time.
I am now pushing the earliest starting
age to the late 20s, and still only if I feel
comfortable with the possible future
hair loss.
Tony Mangubat, MD
Seattle, Washington
In my practice, age 25 is my selfimposed limit for considering HT;
however, sometimes you must bend the
rules. Most patients that are insistent on
surgery just want to be proactive in
their treatment, which is good, but it
also compels them to have surgery by
anybody who will do it. Unfortunately,
a patient will always find someone to
do the surgery if they are unswerving in
their quest. How many of us have sent
patients away on medical therapy, only
to have them come back in a year with
a poor looking HT that they are now
asking us to fix?
So after placing these young patients
on Propecia® and Rogaine®, I leave
them with one thought: If they ever get
the uncontrollable urge to have surgery,
come back and talk to me. If I cannot
talk them out of it, I will perform a very
Volume 13, Number 3
small forelock (200–300, 1–2-hair
grafts) dispersed widely in the forelock.
They feel better about doing something
about their hair loss and a sparse
distribution will never look unnatural
even in the event of progression to a
class VII. In the final analysis, they
almost universally feel that the HT
worked, even though all we did was
simply give the medical therapy sufficient time to work and saved them the
mistake of having a major HT session
with potentially marginal results.
Richard C. Shiell, MBBS
Melbourne, Australia
Most of us “older guys” came by this
decision not to transplant young males
as a result of trial and error over many
years. I hope that the younger HT
surgeons do not have to learn by their
own mistakes, as it can be costly in this
litigious age.
Of course there will be exceptions,
but better to send these exceptions to a
more experienced colleague for evaluation rather than take the whole risk
yourself. If he is ethical, he will send the
patient back to you for surgery. I
provide this service for some of my
younger Australian colleagues.
I agree that there should be no
minimum age carved in stone but,
having said that, a guy under 23 has to
have a 2-year “trial by Propecia®” and a
very stable personality before he gets a
transplant from me these days. Even
guys of 23–25 make me nervous if there
are any suspected borderline psychiatric
problems.
I have frequently had young men
dissolve into tears on being told that I
want to postpone surgery. They frequently have unrealistic attitudes
towards what the surgery will do for
them and do not seem to comprehend
what I am trying to tell them about the
limitations of hair transplantation.
Michael L. Beehner, MD
Saratoga, New York
I certainly consider myself as openminded as anyone in trying to help the
young male who has early signs of hair
loss, but I can’t conceive of any situation
in which I would transplant a man
under the age of 21, other than guiding
him with medical therapy, informing
him about non-surgical hairpiece
options, camouflage, and just “being
there” for him and following him yearly.
In around 15–20 young men, over
the past 6–8 years, I have agreed to do a
“forelock” type of transplant and did do
so. In the “Propecia® era” these have all
been at least 23 years of age, which is
my unofficial “subconscious” minimal
age for performing hair surgery. In
every case, I imagined the absolute
worst progression of MPB I could, the
hairline was set high (usually around 8–
8.5cm above the supra-eyebrow line),
and in recent years the forelock was
constructed to be non-dense and mostly
constructed of follicular units, grading
the density inward.
A 17-year-old is really not capable of
giving truly “informed consent” to such
a decision. That young man has 55–70
years of life ahead of him, all of which he
will live with MPB, which will be
progressive, despite Propecia®, Rogaine®,
and wishful thinking. I think it is
irresponsible of us to let such a young
man direct what will happen surgically
on his head. I recognize that there will
always be some clinic somewhere where
he will eventually get what he wants. I
also think we put ourselves at medicallegal and even physical risk with such
men. A certain percentage of them are
going to be profoundly unhappy with
what you do, when 5–10 years go by and
they evolve into a Norwood Class VI or
VII, and some of them will be unstable
enough to physically threaten their
doctor. We already have people on the
Internet making such threats.
“STICK-AND-PLACE” ETHICS:
THE ASSISTANT’S ROLE
Bob L. Limmer, MD
San Antonio, Texas
Since day one in1988, we have used
the stick-and-place method. I have
never felt threatened by this method
perhaps because I design the placement,
discuss it with each “planter,” and float
between the cases to observe. My staff
brings all questions to me. There is no
question about who is in charge. It is, in
my opinion, completely unethical for
any physician to act as a front for a
non-physician run operation, especially
when that physician is not an expert in
the field he is supervising. The only
means we have to control this phenom-
❏
May/June 2003
enon is through the State Board of
Medical Examiners.
Chris Gencheff, DO
Madison, Wisconsin
I place approximately 90% of my
grafts. I sliver and cut all my grafts,
creating FUs, minis, and micros. I make
all the openings and slits initially and
then place the grafts. I do not do the
“stick-and-place” method. I average 800
to 1,200 grafts per surgery. Of course,
this is an average and usually it can be
more than that.
I am too compulsive to let my
assistants do the full procedure. (But,
make no mistake, I do use assistants.) I
do find that the results are more
consistent if one individual is typically
performing the procedure. I feel the
“supervising” method certainly takes
the art out of transplantation. I believe
there is no substitute to experience and
good medical judgment to produce a
consistent aesthetic result.
Damkerng Pathomvanich, MD
Bangkok, Thailand
In my practice, I make my own
recipient sites, and this ensures a uniform angle of hair growth and hair
direction. I alternate with my nurses to
insert the grafts. I use stick-and-place on
the temple, and any leftover grafts are
usually done by myself. Although hair
restoration needs teamwork, I personally
think that the surgical assistants should
have a limited role, and not dominate
the procedure. Physicians should be
actively involved with the surgery, rather
than doing other things at the same
time. Stick-and-place should be done by
the physician, and not purely by the
assistants. In this manner, the doctor is
still the captain, the assistants remain
part of the team, there is no conflict of
interest, and you won’t hear the question: Where is the doctor?
Alfonso Barrera, MD
Houston, Texas
It is convenient for the surgeon to
allow technicians to cruise along and do
most of the procedure, but it is more
appropriate that the surgeon remain
involved throughout the procedure. I
tell you the patients do appreciate and
value this, and not only that, they are
willing to pay more.
345
❏
May/June 2003
Volume 13, Number 3
nce Upon a Time…
“Norman Orentreich reviewed the past 50 or more years of hair transplant surgery and looked to the future,
which, he believes, may lie in transplantation of dermal papillae.”
—O’Tar Norwood, MD, reviewing Dr. Orentreich’s talk at recent AAD meeting in Dallas
(Vol. 2; No. 3, January/February 1992)
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“For the past two and a half years, I have been doing most of my transplants by the micrografting technique totally.… I am planting
grafts containing one to four hairs placed into 16- or 18-gauge needle recipient sites. Although it is a very labor-intensive technique, the
results—as compared with the standard transplants I have been doing for some 22 years—justify every bit of the additional labor.”
—Bobby L. Limmer, MD (Vol. 2, No. 2, November/December 1991)
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“When it is time for history to record the progress of our specialty…I am sure that one of the most significant contributions for the
advancement of the work we do…will be the institution of The Hair Transplant Forum (International).
More than anything else, more than any technique, greater than any innovation, it has brought us together and
from this union our specialty will progress and our patients shall benefit.”
—Robert Cattani, MD (Vol. 3, No. 2, January/February 1993)
Cyberspace Chat
In the 10 years that I have been
involved in hair transplantation, I have
used the stick-and-place technique. I
have personally made every single stick
followed immediately by an assistant (an
RN or an MD) who inserts. Of course, a
technician can do placement as well.
As surgeons, we are the artists, and
we are also in charge of the case.
Therefore, we must remain with the
patient and participate throughout.
This would help to prevent technicians
from working independently, while
hiring doctors to supervise their cases.
Craig Ziering, DO
Beverly Hills, California
I believe that surgical techniques have
become very refined and all experienced
surgeons can do “good” work. However,
the critical phase of modern hair
restoration is the design, arrangement,
and density distribution of grafts. There
are many variables such as design of
hairline with natural patterns, mounds,
clusters, and random singles. Other areas
of concern are the central core where we
may want to place more than 1 follicular
unit in a site to achieve greater density.
Also, there are the temporal peaks, the
posterior whorl (crown), the lateral
hump, transition zones, and fringe.
I am comfortable with my staff
346
placing grafts as instructed according to specialist who actually orchestrates and
my plan, provided I have created the
participates in the procedure.✧
design via my recipient
sites. I believe it is a
disservice to our patients, as well as a
potentially destructive
force to our industry, to
delegate the creation of
sites to our assistants no
matter how talented
they are. Furthermore, I
believe this may be
illegal in several states. I
know that in New York,
State-of-the-art
California, Ohio, and
Massachusetts, only
instrumentation for hair
RNs can give IM
restoration surgery!
injections and local
anesthesia (medical
assistants are not
For more information, contact:
allowed to), and it
would logically follow
21 Cook Avenue
that they are not
Madison,
New Jersey 07940 USA
allowed to create sites by
penetrating the skin
Phone: 800-218-9082 • 973-593-9222
with a needle or blade. I
Fax: 973-593-9277
encourage each patient
to evaluate the surgical
E-Mail: [email protected]
team to ensure that the
“surgeon” is not just a
www.ellisinstruments.com
paid observer, but is also
a hair transplant
Volume 13, Number 3
❏
May/June 2003
Strontium: A Potent and Selective
Inhibitor of Sensory Irritation and
Topical Anti-inflammatory
William H. Reed II, MD La Jolla, California (The author has no financial interests in Cosmederm Technologies.)
Cosmederm Technologies
(www.cosmederm.com), a La Jolla,
California company, has studied
strontium salts in water and their
effects on:
1. Prevention of erythema (produced by a topically applied skin
irritant, aluminum/zirconium salt
solutions).1 (See Table 1.)
2. Management of the immediate
symptoms of skin irritation1 that
are produced by a number of
substances used in dermatological
products and procedures such as
7.5% lactic acid and 70% glycolic
acid. (See Table 2.) Key to scale: 1
is transient, barely perceptible
irritation and 4 is continuous,
intensely uncomfortable irritation.
3. Control of histamine-induced
itching.2 (See Table 3.)
Mean Erythema Scores
Background Data
Prevention of Erythema
Time After Challenge (Days)
Table 1
Management of Immediate Symptoms of Skin Irritation
Mean of Sting, Burn, Itch
What are strontium’s applications
in hair restoration? At the very
least, strontium is effective for the
short-term management of postoperative itching, but there are
other intriguing possibilities.
Minutes
Table 2
Control of Histamine-induced Itching
The skin has a variety of sensory
nerves to conduct touch, vibration,
position sense, and temperature.
These “delta” fibers are thinly myelinated and conduct at variable speeds
(5–120m/sec). In addition, there are
nerves that transmit stinging, burning, and itching. These nerves are
exquisitely responsive to subtle,
transient changes of their surrounding
biochemical milieu and also are responsive to certain forms of mechanical
stimuli (e.g., wool) and to elevated
temperatures. They are unmyelinated,
thinner, and transmit much more slowly
(0.5–2m/sec). They are often called
VAS (cm)
Related Physiology
Minutes
Table 3
“nociceptors” (from Latin, “to injure”)
and are present throughout the dermis
and extend to the outermost layer of the
viable epidermis. When stimulated, they
depolarize and synapse in the dorsal root
ganglion (DRG) of the spinal cord and
the impulse would continue to the
thalamus via the lateral spinothalamic tract. With adequate stimulation, however, the impulse can
traverse interneurons in the DRG
and produce a retrograde depolarization down the activated fiber.
Additionally, local conduction of
depolarizing signals within the
terminal arborization can occur.
Both instances trigger the exocytosis of inflammatory mediators at
the site of the irritant.3,4
One of the principle mediators
of inflammation that is released in
humans is substance P. Substance P
causes erythema and edema by
direct binding to the endothelium
of the postcapillary venule. It also
initiates chemotaxis, cellular
activation of inflammatory cells,
and degranulation of mast cells
with histamine release and the
precipitation of itching and
additional vascular dilatation and
extravasation. Other inflammatory
peptides are also activated by these
nerves and the process is termed
“neurogenic inflammation.”
I can’t resist a brief digression to
mention type C neurons have
specific receptors for capsaicin
(Zostrix). Stimulation of these
receptors does what you would
expect with production of
erythema and edema. Continued
stimulation, however, results in
reduced sensitivity to subsequent
irritant stimuli. There are also
specific H1 receptors on type C
fibers, which are targeted with
topical antihistamine therapy.
Glucocorticoids, of course, have been
the mainstay for anti-inflammatory
therapy resulting from neurogenic
inflammatory reactions.
347
❏
May/June 2003
Volume 13, Number 3
Strontium
Possible Mechanisms of Action
Strontium has been reported to
directly suppress neuronal depolarization in animals.5,6 It also may act
directly upon non-neuronal cells that
have immunoregulatory functions.
Additionally, strontium salts can
suppress various cytokines such as
TNF-a, IL-1a, and IL-6 in in vitro
cultures.7 Strontium is a divalent ion
and can traverse calcium dependent
ionic pathways. Though capable of
precipitating neurotransmitter release,
strontium is less potent than calcium
and it may therefore act by this mechanism to inhibit calcium-dependent
pathways.
Possible Applications in
Hair Restoration
1. At the very least, strontium is a
worthwhile use for short-term relief
of post-operative itching while the
patient is waiting to respond to a
topical glucocorticoid solution. I
have used strontium on patients for
itching and have found it very
useful.
2. My experience has been that the
patient who complains of post-
operative itching usually has a
history of itching and scaling of the
scalp. When this is the case, such a
patient might benefit from prophylactic use of strontium.
3. Post-operative edema may respond
to topical application of strontium
salts due to its anti-dilatory, its antiextravasatory, and its anti-inflammatory properties.
4. An under-explored area of hair
transplantation is the role of inflammation modulation in maximizing
outcome parameters. For example,
free radicals are released with
inflammation and may be a contributing factor in transplant shock.
Transplant shock may have a direct
relationship to final hair counts and
hair mass. Management of inflammation with strontium salts in water
is appealing due to the likelihood of
safety, efficacy, and their low cost.
If you would like to obtain some
samples or would like to participate in
further investigation of strontium
applications, you can call Cosmederm
at 858-550-7070 or write them at 3252
Holiday Court, La Jolla, CA 92037.✧
REFERENCES
1. Hahn GS. Strontium is a potent and
selective inhibitor of sensory irritation. Dermatol Surg. 1999; 25:1-6.
2. Zhai H et al. Dermatology 2000;
200:244-246.
3. Baluk P. Neurogenic inflammation
in skin and airways. J Invest
Dermatol 1997; 2:76-81.
4. Szolcsanyi J. Neurogenic Inflammation: Reevaluation of Axon Reflex
Theory. In: Geppetti P, Holzer P,
editors. Neurogenic Inflammation.
New York; 1996, pp. 33–42.
5. Gutentag H. The effect of strontium
chloride on peripheral nerve in
comparison to the action of “stabilizer” and “labilizer” compounds.
Penn Dent J 1965; 68:37–43.
6. Silinsky EM, Mellow AM. The
relationship between strontium and
other divalent cations in the process
of transmitter release from cholinergic nerve endings. In: Skoryna SC,
editor. Handbook of Stable Strontium. New York: Plenum Press;
1981, pp. 263–285.
7. Celerier P, et al. Modulatory effects
of selenium and strontium salts on
keratinocyte-derived inflammatory
cytokines. Arch Dermatol Res 1995;
287:680-682.
Parsley Message
Archives of Dermatology about this 4
years earlier, but without much notice by
our field), and Drs. Wong and Hasson
observed that hairs in a follicular unit
tended to line up perpendicular to their
exit angle, giving support to perpendicular grafting as possibly being more
natural than parallel grafting. Dr.
Bernard Cohen has devised a clever plan
for classifying hair loss, which considers
the chronology of normal loss by using
10 scalp regions. The trend in new
techniques over the past several years has
been to focus on natural human patterns
and anatomy, with the above efforts
pointing the way. We badly need more
work in observing, classifying, and
understanding natural patterns—both
macro and micro patterns. If we don’t
know the natural patterns, it is unlikely
348
we will consistently create them. So
please let us avoid conjuring up patterns
in our minds and apply our efforts to
copying nature. As Jean Baitaillon wrote:
“Really we create nothing. We merely
plagiarize nature.” We would do well to
follow his advice.
Dr. Arturo Sandoval-Camarena, along
with Dr. Hector Sandoval Gonzales,
recently held their third Experts Only
Meeting in Guadalajara. A small number
of hair restoration doctors were invited
to discuss techniques and concepts in a
more intense fashion than can be
accomplished in other meetings. Morning lectures were followed each day with
several surgical cases demonstrating
various techniques, particularly newer
techniques. The facilities were first class
and many doctors brought their assis-
tants to give more consistency to their
procedures. This year, Drs. Walter
Unger, Bill Rassman, Daniel Didocha,
Sheldon Kabaker, Paul Rose, Ron
Shapiro, Mike Beehner, Charles Curtis,
Matt Leavitt, Dow Stough, Tony
Mangubat, Robert Haber, Marcelo
Gandelman, and I attended the meeting.
For someone truly interested in hair
restoration, this was Valhalla. Ideas were
only surpassed by the hospitality and by
Arturo’s singing. Dr. Sandoval tries to
keep a flow of new people and ideas
coming in to the meeting. For next
year, plans are to have this meeting at
their new branch office in Mexico City.
In the July/August issue of the Forum,
we plan to have a write-up of meeting
highlights.✧
Volume 13, Number 3
❏
May/June 2003
S urgeon of the Month
alute to
Arthur Tykocinski, MD
Jerry E. Cooley, MD Charlotte, North Carolina USA
Arthur Tykocinski, MD, was born in
São Paulo, Brazil in 1965. As a youngster, Arthur was very shy and loved
science. His father was an economist and
his mother was a manager, and both
worked at the same company, a wellknown Brazilian jewelry store. At the age
of 5, his older sister, Tamara, was
diagnosed with systemic scleroderma.
The family visited many hospitals all
over the world to get the best medical
care for her. This experience had a
profound impact on Arthur and helped
inspire him to pursue a medical career.
Arthur attended private school in
São Paulo. He studied medicine at the
well-known Santa Casa de São Paulo
Medical School. He then completed a
residency in dermatology followed by a
three-year fellowship in dermatologic
surgery. During his fellowship, his
chairman asked him to start performing hair restoration at the medical
school. His initial impression was,
“Hair transplantation? That’s ugly!”
But after reading many current articles
on hair restoration, he began to change
his mind.
The following year, he attended his
first transplant conference, which was
held in El Salvador in 1994. Although a
small conference, many well-known
surgeons were there. Arthur learned a
tremendous amount from these experi-
Arthur Tykocinski, MD, São Paulo, Brazil
enced surgeons and made valuable
friendships. While he did not have
much knowledge about transplantation
to share at the time, he did know a lot
about soccer. Because the World Cup
was being held at the same time, soccer
was a hot topic, and the others seemed
to know almost nothing about the
game. So he shared his soccer knowledge and became “part of the team.” He
visited one of these friends, Dr. Paul
Cotterill, in his office the following
year. He remains grateful today for the
knowledge he gained and for the
hospitality of Paul and his family.
In 1996, Arthur was exposed to the
concept of follicular unit transplantation at the Annual Live Surgery Workshop in Orlando. He met Dr. Ron
Shapiro there, and after visiting him in
his office and watching his technique,
he committed himself to this new
technique and never looked back. “Ron
was more than a teacher,” Arthur says.
“He was a great friend.”
“As everyone wants,” Arthur comments, “I also want in my hair transplants a great volume with perfect
artistry. I am very interested in the
relation between blood vessels and graft
density. The goal is to increase density
without increasing the risks.” A typical
case for Arthur now is over 2,000
follicular units. Occasionally he uses
“follicular groups” when he believes it
will add greater density and volume. In
particular, he uses what he calls the
“stick-and-place Brazilian technique” to
plant grafts. An assistant helps place the
graft immediately after Arthur makes
the incision with a SharpPoint blade.
He is proud to have his sister Tania,
who is a dentist, assist him since
beginning his practice. “She is my most
important medical assistant and has
helped me a lot in developing my
techniques,” he says.
In his free time, Arthur loves action
sports such as surfing, skating, and
snowboarding. He is not married yet, but
believes it won’t be long after meeting his
“incredible girlfriend Daniela!” He is
currently busy building a new house on
a beautiful beach near São Paulo, and he
says that he expects to be visited by
many friends from the ISHRS. We hope
he is building plenty of extra rooms.✧
349
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May/June 2003
Volume 13, Number 3
Volume 13, Number 3
Letters to the Editors
❏
May/June 2003
More About “One-Pass Hair Transplant”—Our Two Year Experience
We have read with extreme interest
Dr. David Seager’s article, based on his
clinical experience, on the advantages of
obtaining a high-density transplant in a
fewer number of sessions.
Dr. Seager clearly explains problems
linked to a high number of sessions,
coming to the same conclusions that we
have during recent years.
“The first session always grows the
best” is certainly true, because microscarring and consequent impaired vascularity
probably reduce the growth rate of
transplanted hair and the final result.
In the past two years, we have adopted
a new technique, similar to the one
described by Dr. Seager, consisting in
the transplantation of 2–3,000 units in
the same session.
The donor strip, excised from ear to
ear, is about 16×1.4cm and is dissected
into single- or double-hair grafts. We
use 19-gauge needles to prepare recipient tunnels, so we can place the grafts
closely enough together to obtain an
adequate density (30–40cm2), reproducing the appearance of the miniaturized pre-existing hair.
In this way, we have the best aestethic
results with a “natural” look, especially
on the hairline.
This technique is extremely suitable
for female androgenetic alopecia,
usually characterized by a more refined
hairline and marked miniaturization, in
which macrografts are not advised. It is
also suitable in men with low-grade
androgenetic alopecia in which it is
possible to obtain high density in only
one session. We also have had good
results in men with marked androgenetic alopecia (IV, VI Norwood –
Hamilton) where we program two
sessions, one for the frontal and another
for the vertex area, with a final highdensity result. In this way, we reduce
costs, surgical trauma, post-operative
stress, and risks of bad scarring in the
donor area linked to multiple surgical
excisions.
During the past two years, we have
adopted this new technique in about
120 transplant sessions. The results
have been really encouraging and we
feel reassured by Dr. Seager’s experience
and his clear statement.✧
3. Scalp lifts and flaps have almost
disappeared.
4. The need for and dependence upon
a relatively large, highly-skilled staff
of assistants is much greater.
5. Patients can actually be transformed
in their appearance, with faces
framed with full, natural heads of
hair, which was hard to achieve with
the methods of the 1980s.
6. The existence of the Hair Transplant Forum provides for almost
instant exchange of new information and techniques.
7. The existence of the ISHRS, with
all the positive ramifications that
have come from its existence: a
common identity and set of ethical
standards, an annual coming-
together to share new ideas and
information, etc.
8. Hair transplants have come “out of
the closet” in the public’s mind, to
a large extent.
9. The specialty is much more
complex, and it is increasingly
difficult for someone new to the
field to get started. (This difficulty,
though, is offset by the large
number of quality meetings that
are available, which were almost
unheard of in the 1980s.)
10. There is the availability of medical
therapy to use in combination with
the surgical therapy.✧
Michael Beehner, MD
Fabio Rinaldi, MD,
Paola Bezzola,
Elisabetta Sorbellini
Milan, Italy
Beehner Message
9. The expected arrival of Walter
Unger’s new Hair Transplantation
textbook, which will give our field
an updated authoritative text for
the first time since 1994–95
(Unger and Stough’s texts).
10. Patients are better informed
regarding HT. Due to the Internet
(this aspect is positive), physician
Websites, TV surgery shows, and
print media.
Top Ten Biggest Changes Since
1989
1. The large graft is virtually dead,
after reigning inexplicably for 30
years (1959–1990).
2. Alopecia reductions are rarely done,
as compared to the late 1980s.
Did you attend the 1st ISHRS Annual Meeting in Dallas in 1993?
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AT
A
1993, please send an e-mail to: [email protected]
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May/June 2003
Volume 13, Number 3
Policies, Procedures, and Guidelines of the
Fellowship Training Programs of the
International Society of Hair Restoration Surgery (ISHRS)
Introduction & Goals of Training
The purpose of the Fellowship Training Program is to assist the Fellow in developing the medical and surgical skills necessary to practice
aesthetically sound, safe hair restoration surgery. The Program ensures they are properly trained by providing trainers with whose practice
provides exceptional opportunities to acquire expertise in hair restoration surgery. To ensure that all trainers do indeed provide such an
educational environment, all programs must meet specific guidelines both in terms of the credentials of the Program Director and the
Program’s site. To ensure compliance with the guidelines, the ISHRS Fellowship Training Committee (FTC) will review programs both at
application and during periodic site visits.
Furthermore, the Fellowship Training Program wants Fellows to become proficient in the scientific skills necessary to develop study
protocols so as to contribute sound research to the knowledge about hair loss and restoration, with the communication skills necessary to
contribute to the body of hair restoration literature.
Programs
Fellowships may be one or two years in duration. As the primary purpose of the Program is to provide Fellows with an exceptional
opportunity to acquire hair restoration surgery experience, there is a minimum caseload requirement. One-year programs are required to
perform at least 70 cases per year per Fellow. Two-year programs are required to perform 50 cases per year per Fellow.
Directors
The Director of an ISHRS Fellowship Training Program shall be: a licensed physician in the state in which the Program is located, of high
ethical and moral character, and a member in good standing of the ISHRS who has practiced hair restoration surgery for more than ten (10)
years. The director should be academically oriented and committed to personally contributing to the professional education of the Fellow.
The Director should have hospital privileges. The Director should be proficient at hair restoration surgery, and be actively involved in
100 cases per year in the one-year programs or 65 cases per in a two-year program.
The Program Directors shall attend one continuing education meeting annually conducted by the Fellowship Training Committee
(FTC) for the express purpose of improving their teaching skills.
Director Application Process
Each Training Program Director Applicant must apply to the ISHRS for approval of his/her Program by submitting a Director Application Form along with the documents outlined within. The facilities, training program and Program Director will be evaluated. The
Applicant must be a member in good standing of the ISHRS who has practiced hair restoration surgery for more than ten (10) years.
The following are required of all Program Director applicants:
1. A completed application form with a nonrefundable US$1,000 application fee.
2. Case log documenting a caseload of 100 cases per year for a one-year program or 65 cases per year for a two-year program. This log is
intended to document that the practice is sufficient to expose the trainees to all aspects of hair restoration surgery.
The case log shall include:
• Patient initials or ID number
• Date of surgery
• Type of procedure (e.g., transplant, scalp reduction, hair lift, etc.)
• Size of procedure (e.g., if a transplant, the number of grafts)
• Special notes (e.g., complications, pre op problems that add complexity)
3. Ten percent (10%) of the cases submitted must qualify as complex. These are the cases that have special notes as indicated in paragraph 2. Complex cases should include pre- and post-op photography, treatment plans, and operative and progress notes. They include
those patients who require reconstruction due to injury or prior surgery, are high risk because of a medical condition, or required the
management of a complication.
4. Proof of Advanced Cardiac Life Support (ACLS) Certification.
5. Program Director applicant’s Curriculum Vitae (CV).
6. Copies of medical school degree, residency and post-residency certificates, all current state medical licenses and specialty board
certifications.
After review and approval of the Director’s written application the final step in the approval process will be a site visit by the ISHRS
Fellowship Training Committee. The focus of the site visit will be:
1. Survey the facility to ensure there is adequate space and equipment.
2. Space allowed for the Fellow to office and study.
3. Available library and access to reference materials.
4. Compliance with Occupational Safety and Health Administration (OSHA) or non-U.S. equivalent, including manuals and compliance logs.
5. Emergency treatment and evacuation policies and procedures in place.
6. If a program has more than one site or facility, then all must meet the site standards. An additional fee may be charged for peripheral
site visits, or random visits to multiple site programs.
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Volume 13, Number 3
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May/June 2003
The Fellowship Training Program Director may not identify the Program as an ISHRS Fellowship to trainees or potential trainees until
after the approval by the ISHRS Fellowship Training Committee (FTC), and the Board of Governors of the ISHRS.
Co-Directors
All Programs must have a designated training Director responsible for the Program and actively involved in the training of Fellows. Some
may wish to designate Co-Directors to help with the teaching responsibilities. Co-Directors must apply for designation with the same
application documentation as the Training Director. The Director and the Co-Director must meet all of the requirements of a director as
established by the ISHRS.
The Program Co-Directors shall attend one continuing education meeting annually conducted by the FTC for the express purpose of
improving their teaching skills.
While physicians who do not meet the criteria for Director or Co-Director may help with teaching, their cases shall not be used to meet
the minimum case standards for the Program or the case log of the trainees.
Program Changes
Should either the Training Program or the Program Director have a change of status, the FTC will re-evaluate the Program. In the event
of the death, transfer or disability of the Program Director, the FTC will re-evaluate the Program and make recommendations to the
Board of Governors of the ISHRS as to the continuance of the Program under an interim Program Director.
If the Program relocates to a facility within the same city, where the patient base and referral patterns are the same, the Fellows may be
permitted to continue their training at the new location pending FTC review and approval of the new location.
If a Program Director leaves the Program before completion of the Fellow trainee’s training period, the program is no longer approved
by the ISHRS. The ISHRS is aware that academics change positions occasionally. It is the responsibility of the Program Director to plan
changes in position well in advance so as not to interrupt or preclude the Fellowship Training Program. Although the ISHRS and the FTC
are sympathetic to the trainees desire to complete their education, it is neither the FTC’s nor the ISHRS’s responsibility to ensure the
completion of the trainee’s education. Transfer to another approved training program will be considered on an individual basis.
Re-Evaluation Process
The purpose of site visits is to ensure that the standards outlined for the ISHRS Fellowship Programs are being met. It is the responsibility of the Fellowship Training Committee to ensure the highest quality education exists within the ISHRS Fellowship Programs.
Each site will be visited once every five years. The schedule of site visits will be made such that the visitation is a penta-annual event.
The Program will be asked three (3) months in advance of the inspection to prepare specific documents for the surveyors. They will
include in the least: current CV of the Directors and Co-Directors, teaching plans, case logs of prior trainees, emergency preparedness and
OSHA policies, or their non-US equivalents. The Director should see to it that observable cases are scheduled early in the day, and the
afternoon is left free to review the facilities, teaching plans, and policies.
Program Survey Process
Program surveyors, be they primary applications or re-evaluation, are selected by the FTC and are members of the FTC or an ISHRS
Board member who is a Fellowship Training Director. The surveyor must not practice in the same geographic area as the Program he/she is
surveying.
The site will be reviewed based upon adherence to these guidelines, the ISHRS Core Curriculum for Hair Restoration Surgery, and the
Site Survey Organizer outlined in Appendix 3. The FTC will review the completed Site Survey Organizer and make recommendations to
the ISHRS Board of Governors. An approved Fellowship may be re-surveyed with or without notice at any time.
Appeals
If a Program is found to be deficient during a primary or re-evaluation survey, the Program will be placed on probation and notified in
writing of the deficiency and the length of time probation. The probationary periods will be of such a length of time as to reasonably
enable the program to come into compliance relative to the deficiencies. The deficiencies must be corrected and documented as such to
the satisfaction of the FTC. Additional site visits may be necessary to document the correction of deficiencies.
A Program may request one extension of its probationary period. The request must be in writing and will be considered and answered
by the FTC within 15 days of receipt of the request. Extensions are at the discretion of the FTC only.
A program my appeal the probation decision to the FTC. Appeals must be made in writing, within 15 days of receiving the probation
notice. Within 30 days of receiving the appeal, the FTC will hold a hearing to review the probation decision and its appeal. The decision
of the FTC after the hearing of the appeal is final, and the Program must comply with the decision or lose its accreditation.
If a program’s accreditation has been revoked, it must submit a new application form and go through the application process to become
an accredited program.
Fees
Each Fellowship Program will be assessed a one-time non-refundable US$1,000 application fee and an annual fee of US$500. These fees
are intended to cover the cost of an initial site survey, and the re-evaluation survey every five years. There will be no additional fees unless
a repeat survey is needed to reinstate a probationary program. Under those circumstances the Program on probation will reimburse the
FTC the cost of the second survey.
It is anticipated that from time to time there will be grants provided to the ISHRS Fellowship Training Program by corporations or
individuals interested in advancing the education process in hair restoration surgery. The Fellowship Training Committee may, depending
upon the available funds designated for Fellowship Training, reduce or wave program renewal fees.
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May/June 2003
Volume 13, Number 3
ISHRS Policies & Guidelines
Reporting & Forms
Each Fellowship Training Director will be asked to submit a written status report annually to the FTC. The report shall include a list of
individuals enrolled in the Program, a list of individuals who have completed the program in the given year,* and any changes that have
been made to the Program. These reports shall include changes in the curriculum, trainees, site locations, faculty, Co-Directors, or
anything else that may impact upon the FTC’s decision to re-evaluate the Program. This report will also include a list of the trainees who
have successfully completed the program, and a letter recommending that ISHRS recognize their accomplishment.
*A certificate of completion will be issued to Fellows who have completed their programs. Please include Fellow’s name, address, start date, end
date, and program location.
The Survey Organizer will be provided by the FTC to every survey team and the Program Directors so they will have a clear understanding of what constitutes the current guidelines.
Fellowship Eligibility
Any physician accepted to an ISHRS Fellowship Training Program shall be licensed to practice medicine in the jurisdiction where the
Program performs surgeries and have high moral and ethical standards. He shall be board certified or qualified to take a specialty board.
In Programs outside the United States, the trainees must meet the licensing and board certification requirements of their country. No
credit will be given for training received prior to the trainee entering the Fellowship Program nor will any part of the Fellowship Training
be applied to residency training. All trainee candidates must have passed and received a certificate from an Advanced Cardiac Life Support
course. Additional criteria for Fellow eligibility may be added by the Program Director.
Education of the Trainee
Formal training in surgical anatomy, physiology and pathophysiology of hair loss in males and females, and surgical techniques shall be
sufficient so that each trainee upon completion of the Program is comfortable and competent to make a proper diagnosis, and design and
execute a treatment plan for patients with the most complex and difficult hair loss problems. It is the intent of the FTC that there is a
one-on-one relationship between the Fellow and the Director/Co-Director Faculty. The trainee to faculty ratio should always be 1:1.
The trainee must assist as the first assistant surgeon in at least 70 cases for a one-year program or 50 cases per year for a two-year
program, participating in the evaluation and treatment planning of the majority of these cases. The trainees will keep a surgery log of their
cases to include:
1. Patient initial or ID number
2. Procedure performed
3. The component of the procedure performed by the trainee
4. Date of surgery
5. The Program Director or Co-Director who participated in the case
The trainee must participate in one research project relating to hair loss, hair restoration, or cosmetic surgery; or the trainee may submit
two articles for presentation at an ISHRS meeting or publication in a recognized peer-reviewed medical journal.
It is strongly recommended that the trainee attend an ISHRS Annual Meeting, an ISHRS Advanced Review Course, and/or an ISHRS
Live Surgery Workshop.
The core curriculum of each Program shall include the topics outlined in Appendix 1. The recommended minimal bibliography for
each Program is included in Appendix 2.
ISHRS Recognition of a Trainee’s Program Completion
Upon receipt of the Program Director’s letter of recommendation certifying a trainee’s successful completion of the program, and the
trainees documented attendance of one ISHRS conference, the ISHRS will issue to the trainee a certificate documenting successful
completion of an approved ISHRS Fellowship Training Program.
Preceptorships
Preceptorships are not considered part of the ISHRS Fellowship Training Program.
Fellowship Training Committee
The FTC shall evaluate all training Programs. It is their responsibility to ensure that the highest quality of education exists in the
Programs approved by the ISHRS. It is their responsibility to deny applications that come to the ISHRS for unworthy or inappropriate
Programs.
The FTC will conduct annually a continuing education meeting for Program Directors and Co-Directors specifically designed to
improve their teaching skills.
Appendix 1: Core Curriculum
Appendix 2: Recommended Bibliography
Rev. 04.07.03
354
Volume 13, Number 3
Hair Repair
case 3
❏
May/June 2003
patient L.P.
Vance W. Elliott, MD Edmonton, Alberta, Canada
This column details cases of patients who have presented with different concerns and problems, requiring repair or modification. Cases selected
illustrate the need for a creative approach to these problems using multiple treatment modalities, surgical and otherwise. Each case has been sent
to a panel of surgeons with expertise in our field of surgery, and often in others as well. Their suggested management plans are presented and
discussed here. Comments from the readership are invited, as well as cases for possible presentation, at [email protected]. I welcome Drs.
Bob and Bradley Limmer and Bessam Farjo as panelists.
This patient is 30 years old and
presents for consultation after 15
sessions of HT with another physician.
His procedures were performed over the
entire balding area in this Norwood V–
VI man and averaged 250 grafts (micro/
mini) per session. His surgeries were
over a four-year period, beginning at
age 24. His former physician is no
longer in practice and surgical records
are not available.
He is healthy, without allergies to
Figure 1. Scar
medications, and is taking only Propecia®, which he has been using faithfully since
1998. He has had only slow progression of his crown loss since then, with no
change in the past two years.
His main concern is the large donor scar, which remains difficult to conceal,
despite two attempts at revision by his previous physician. He also is quite concerned about the “grafty” look that he has on top and would like more HT to
improve the naturalness of his hair.
On Exam: Moderately frequent graft pitting, but otherwise well-healed recipient
area. Minigrafts are well angled, but spaced too far apart. Donor fringe displays
only minimal signs of miniaturization at its edge. Temple hairlines have no signs of
miniaturization.
The donor area contains a 14cm scar 2–2.5cm in width in the occipital area
only. There are no other donor scars. The temple and supra-auricular areas have
excellent density and good laxity. In comparison, the occipital scalp has little laxity.
Troy Creamean, DO
Corpus Christi, Texas
This patient has a very long surgical
history for the amount of actual hair he
has on top.
I have had several donor site scars
that have been quite wide from my
aggressive harvesting after the first
session or two. This is a post-operative
outcome that can be handled.
There are several issues to consider in
this young man’s repair. The galea,
which spans front to back, is a very
dense tendon-like sheath with little to
no elastic fibers. This accounts for
many problems in some individuals and
could be the case here. He could have
stretch back of up to 50%, as in some
cases of scalp reduction. He also will
have tremendous scar tissue adhesions
to the underlying muscle and possibly
the pericranium. With all that has
already been done and remains to do,
he needs to come to terms with the fact
that there will always be some sort of
scarring. Fortunately, this is an area that
is hidden quite well.
The two options that come to mind
are serial excision or tissue expander
placement. As mentioned, his front line
needs a little more artistic refinement to
camouflage the operated look. This
creates the opportunity to do serial scar
excisions that also generate some hair to
place up in the frontal hairline. I would
likely recommend three scar revision
sessions.
I would measure the exact size of the
scar, and plan on excising a little over
40% of the original scar each excision. I
would widely undermine above and
below in the level of the loose fascia,
Figure 2. Top
Figure 3. Post-op
easily recognized by the extreme ease of
digital dissection. I would then evert
the superior flap and score the galea in a
checkerboard fashion. This releases the
galea to obtain stretch of the scalp you
won’t get, even if you undermine
anteriorly to his eyebrows. This must be
done very carefully, because the scalp
nerves and vessels lie just on the
opposite side of the galea. Once this is
done, I would place 3 or 4 retention
sutures with rubber shots. These take
the tension off your normal closure, but
do cause some minimal scarring.
If the scar responded nicely after the
first revision, I would proceed as
planned. If not, I would abort the serial
excision plan, wait on the front hairline,
and look to do a tissue expander
placement and serial expander injeccontinued on page 356
355
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May/June 2003
Volume 13, Number 3
Hair Repair
tions weekly with follow-up excision.
The advantage of the serial excision is
making progress without negative
appearance change. The tissue expanders are a minimum of two surgeries with
a time period where the patient has a
very noticeable large projection on the
back of his head. Hair for grafts can be
harvested at the time of scar excision in
either case.
Even with a scar of this size, I would
expect a nice result with serial excision.
At the very end I might consider
permanent make-up (tattoo) over the
final scar.
3. Modified scalp-lifting method to
elevate inferior fringe.
4. Grafting the scar itself.
Bessam Farjo, MD
Manchester, United Kingdom
Bradley L. Limmer, MD
San Antonio, Texas
The patient’s main concern is his
donor scar, and my instinct would be to
treat that issue first and let his scalp settle
before considering further grafting.
Assuming the two attempts to revise
the scar were done on the whole width,
I would try and deal with this by doing
serial excisions. I would start with
removing no more than a centimeter
(or whatever similar width his scalp
allows) from the lower bit of the scar.
After healing, I would then attempt
similar procedures until the width is
acceptable aesthetically.
Another idea is to reduce it with an
extender. I discussed this with Dr.
Patrick Frechet and he feels that the scar
is not wide enough for the extender to
be beneficial in this case. It is always
possible to put grafts in the scar but the
size of the scar and the patient’s desire
for more hair at the top makes this
impractical.
This patient presents a difficult
problem to solve. First, I would consider changing him to Avodart, as he is
still losing ground on Propecia®. I
would strongly encourage him to add
Rogaine®. I think it is important to do
the most we can for him medically,
since he is going to be difficult to
address surgically.
You will not be able to go after his
scar with standard excision. I feel
expanders will be needed, or possibly
the Nordstrom suture could be used as
an extender. I would recommend
correcting his donor scar prior to
addressing additional grafting, with the
exception of transplanting any hair
taken out during scar revision. This
would also buy time to see if he gets
any additional benefit from changing
his medical treatment.
Bobby L. Limmer, MD
San Antonio, Texas
This patient has two problems and
each one must be dealt with properly.
His “main concern” is his very wide
donor scar of 2–2.5cm width. I assume
his scalp laxity is very poor, as, after 15
transplants, I would be quite surprised
if it were anything but that.
The best option for this wide scar
would be chronic tissue expansion over
the usual period of about three months.
After tissue expansion was complete,
the entire scar area could be excised in a
Because of the width, simple revision
of this scar is highly unlikely to be of
great benefit. Procedures that could
potentially reduce this scar’s width will
be surgically quite involved, including:
1. Expansion of superior and inferior
hair-bearing areas first.
2. Use of extenders or Nordstrom
sutures to elevate the inferior hairbearing fringe.
356
All are somewhat challenging procedures, and may reduce the scar width,
but are not likely to totally eliminate
the scar.
Before any further grafting is performed, careful consideration of donor
availability is crucial. All methods of
donor harvest likewise need to be
considered. It would appear that the
lateral fringes or the parietal and temporal zones have some available donor hair.
Martin Unger, MD
Toronto, Ontario, Canada
single operation, and any hair in the
removed tissue could be transplanted to
the top of his head during the same
procedure.
If the patient would not accept
chronic tissue expansion because of the
disfiguration during the final 5–6
weeks, then the only other good option
is an Unger PATE procedure to the
“donor area.” With a width of 2–2.5cm
and a tight scalp, most likely two PATE
procedures would be required at least 3
months apart. Again, any original hair
in the tissue removed should be transplanted to the top during each procedure.
The third option is to transplant the
“donor area” using the temple and
supra-auricular areas as donor areas, but
these are probably needed for the top,
and would give a much poorer result to
the scar area than either of the two
choices above.
The second problem is the “grafty”
look on the top. This requires additional transplanting using tissue
removed during the tissue expansion(s),
additional grafts from the temple and
supra-auricular areas, or both. After 15
previous transplants, one would want to
limit additional transplanting procedures as much as possible and most
likely carry out only one or two additional transplantation sessions.
If the patient did have good laxity on
his dorsum, which would be almost
impossible after 15 previous transplants,
one could do a lateral scalp reduction
on the patient’s right-hand side (because
he parts from left to right), and then recycle any grafts within the scalp reduction tissue removed to the top of his
head. This could be repeated again in
three months if needed. This last option
is included more for completeness of
discussion rather than anything else, as
the likelihood of a loose scalp on the
dorsum after 15 transplants would be
very rare indeed.
Vance Elliott, MD
Edmonton, Alberta, Canada
At the time of his first consultation,
this patient and I discussed tissue
Volume 13, Number 3
expansion, and he had seen another
plastic surgeon who recommended it as
well. However, his job is in sales and he
felt he would be unable to cope with the
disfigurement of the expansion phase. I
felt that serial excision with a modified
scalp-lifting approach would require 2 or
3 procedures, and blending in his
existing grafts at least 2 HT sessions.
This patient appears even more “grafty”
in person than the photos suggest, so
grafting was a high priority to him.
The poor remaining laxity in the
occipital donor site all but ruled out this
area as a donor site. Fortunately, he has
tremendous supra-auricular and temple
donor hair and normal laxity there. This
patient and I discussed his donor scar
and recipient site concerns separately,
but eventually decided on combining the
surgical approaches to both, as he travels
from some distance and wanted to
minimize time off from work.
The superior aspect of the scar was
incised down through the galea and
blunt undermining was performed
approximately 6–8cm above and below.
The flaps were overlapped and approximately 50% of the scar was excised. The
galea of the inferior flap was sutured
with 2-0 Vicryl to the pericranium
above, in the manner described by Dr.
Seery for galeal fixation. The galea was
then closed, followed by the skin, leaving
the lateral margins of the incision open.
Once closure was obtained, bilateral
donor harvests were performed extend-
ing from the excision’s lateral margins,
forward above the ears to a point 2cm
behind the temple hairlines. This was
closed in a single layer in the usual
fashion, creating a single incision line
temple to temple. No vessels were
transected, and indeed the occipital
vessels were not encountered at all in the
scar excision. This likely indicates that
they had been previously sacrificed.
Grafts were placed over the frontal
scalp and the upper crown.
Post-operatively, the patient had pain
in the undermined areas, which required meperidine. This resolved by 48
hours. A second similar procedure is
planned at the 6-month mark.
This patient illustrates two major
problems:
1. How a straightforward plan of donor
harvesting can go awry if overdone.
2. The difficulty in successfully grafting
the entire balding area in patients
stage Norwood V and higher,
without harvesting through the
entire length of the donor site.
In my estimation, this patient has at
least 33cm of donor site length, from
tragus to tragus. However, less than half
of that length had been used to harvest
all the tissue in his 15 surgeries, leaving
other areas unused. The occipital donor
site’s capacity to be harvested again has
been exhausted, but he still needs more
grafting.
I have learned the lesson in my own
❏
May/June 2003
patients that, on the first and sometimes second harvests in an area, large
amounts up to, or exceeding, 1.5cm can
be excised without much closure
difficulty. This gives a false sense of
security, as problems inevitably occur.
Subsequent closures become difficult,
and result in increased post-op pain and
stretched scars. I now use a “pinch test,”
where the donor scalp is pinched
between the thumb and forefinger. If a
fold of scalp is easily produced, more
than 1cm can usually be excised
without significant tension. I do not
exceed 1cm, however, as this will enable
more than 3 procedures in the vast
majority of patients. This must be
tempered with experience, however, and
the area above and just posterior to the
mastoid process viewed as being the
most unyielding.
How does one maximize the amount
of donor scalp that is available for use
over time, while not overstepping the
scalp’s ability to tolerate stretch? By
harvesting longer, not wider, we will
not remove too many “trees” from any
one area of the “forest.” This gives
sustainable resource management. By
learning to harvest the supra-auricular
areas without cutting the many vessels
lying there, donor harvests of 1cm ×
33–35cm can be safely performed,
while not exceeding conservative
excision widths in any one surgery. This
can be reliably done with optimal use of
tumescent anesthetic technique.✧
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the patient’s remaining hairs to give the undetectable appearance of a fuller head of hair.
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357
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❏
May/June 2003
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Volume 13, Number 3
Call for
Nominations
2003 Golden & Platinum
Follicle Awards
The Golden Follicle and Platinum Follicle Awards will be presented at
the ISHRS 11th Annual Scientific Meeting, October 15–19, 2003, at the
New York Marriott Marquis in New York City. This is your chance to
nominate a deserving peer for one of these prestigious awards. Members
in good standing may mail, fax, or e-mail nominations with an explanation
of why the person is deserving of the award by August 15, 2003, to:
ards,
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Best reg . Shiell, MBB , Grants
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Rich
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and Aw
Scientific Research, Grants and Awards Committee
International Society of Hair Restoration Surgery
13 South 2nd Street
Geneva, IL 60134 USA
Or, fax to 630-262-1520; E-mail to: [email protected]
Specific information and accomplishments should be included on
the nomination. All nominees will be reviewed and voted upon by
the Scientific Research, Grants and Awards Committee. Award
recipients will be announced during the Gala Dinner at the 11th
Annual Scientific Meeting in New York.
DEADLINE: The deadline for nominations is August 15, 2003.
GOLDEN FOLLICLE
AWARD CRITERIA
PLATINUM FOLLICLE
AWARD CRITERIA
“Outstanding and significant clinical
contributions related to hair restoration surgery.”
“Outstanding achievement in basic scientific or
clinically-related research in hair pathophysiology
or anatomy as it relates to hair restoration.”
1. The recipient must have been the principal person
involved in clinical research or in developing
innovations or made a significant contribution
furthering the advancement of hair restoration.
2. The work of the recipient must have resulted in
demonstrated improved patient outcomes.
3. The recipient may not have been awarded the
1. The recipient must have been the principal investigator involved in basic scientific or clinically-related
research related to hair restoration.
2. The results of the research must represent significant
advancement the science of hair restoration.
3. The recipient may not have been awarded the
Golden or Platinum Follicle Awards within the
Golden or Platinum Follicle Awards within the
previous 5 years. (Exceptions may be made in the
previous 5 years. (Exceptions may be made in the
event of extraordinary circumstances regarding new
event of extraordinary circumstances regarding new
work conducted by the nominee.)
4. The recipient will preferably be a member of the
ISHRS, however, non-members whose work has
work conducted by the nominee.)
4. The recipient will preferably be a member of the
ISHRS, however, non-members whose work has been
significant may be considered.
been significant may be considered.
Please make sure to include your name, the person you are nominating and the reason they are deserving of the award.
358
Volume 13, Number 3
❏
May/June 2003
Surgical Assistants Corner
“The real art of conversation is not only to say the right thing at the right place
but to leave unsaid the wrong thing at the tempting moment.”
—Dorothy Nevill
OR Etiquette: Emphasizing Professionalism
Dear Surgical Assistants,
★
★
★
★
★
★
★
★
★ What would you say are the key points you emphasize in your team to ensure professionalism
in the OR?
Who sets the tone in your office’s OR?
How does the team compensate for changes in moods or changes in professionalism?
How do you handle obnoxious patients?
Do you monitor topics discussed in the OR?
How are poor behaviors handled in your office?
Who draws the line on etiquette?
What kinds of background do you find most beneficial? TV? Movies? Music? Who decides?
How much talking and discussion is allowed in your OR among the staff?
These are the questions I posed to Hildi Moore at Dr. Brad Wolf’s office. She graciously responded with how they
handle this very critical part of their office. As you know, once your patient is in your office, you have a job to do: treat
them as guests and give them the very best treatment possible. Part of that job must be ensuring that their surroundings stay professional and courteous from the moment they enter the office through their surgical day. From the input
that I have seen, most offices have a handle on this, but it is always good to review your practices to determine if you
are still doing the job you intended!
Also, you will note that Valerie Mitchell’s tips were inadvertently omitted last issue and appear below. I extend my
apologies to Valerie.
I have also included a brief note of the minutes from the Surgical Assistants Executive Committee so that you can see
the planning that is going on for the New York meeting. It will be an exciting time. Hope you are planning for it!
Next issue I will have The Eight Steps of a Successful Assistant and Coaching: Setting Goals for the Team. If any of you
are goal setters, let me know. This will be a time for fun ideas!✧
Shanee Courtney, RN
Phone: 303-694-9381 • E-mail: [email protected]
How Has Dr. Walter Unger’s Team Stayed Together So Long?
Valerie Mitchell, RN Toronto, Ontario, Canada
✭ In our office, most of our staff is RN, LPN, or Medical people (i.e., doctors from other countries, medical technologists—often with a degree). People with this level of education bring a degree of professionalism that nonmedical people sometimes do not have.
✭ Medical-type people are taught to think as a team. Our team travels together often. This helps us to know each
other better and work well together.
✭ With staff that are long-term, friendships develop outside the work environment and we support each other
through good and bad times.
✭ Dr. Unger takes a lot of time away from the office, so we get breaks from the physical demands of this type of work.
✭ Dr. Unger encourages a friendly, light atmosphere between him, the patients, and the staff.
Dr. Unger’s team has many experienced members that have been with him for more than 18 years. They are very professional and
knowledgeable, have a team approach to their day, and work together very well. I have had the distinct pleasure of visiting them
and witnessing great teamwork!
359
❏
May/June 2003
Volume 13, Number 3
Dr. Bradley Wolf’s OR Etiquette: How We Emphasize Professionalism
Hildi Moore Cincinnati, Ohio
✪ We emphasize respect for the
patient. At all times, you need to
keep in mind that this is a doctor’s
office and we are performing a
medical procedure.
✪ The patient sets the tone. We do 1
surgery a day (2 max.). Our focus is
strictly on the patient.
✪ Everyone is going to have days when
their mood isn’t the greatest. The key
is to keep the patient in mind. Bad
mood or not, this is still a doctor’s
office and we are still doing a
medical procedure. The patient is
bound to be anxious and we don’t
need to add to that by bringing
personal issues to the OR. Our goal
should always be to put the patient
at ease, make the long day as
pleasant as possible, be personable,
and do the best work. Changes in
professionalism should NEVER be
an issue in the patient’s presence!
✪ Because we only do 1–2 surgeries
per day, it is rare to get a truly
obnoxious patient. Some are nervous
or anxious, and we do our best to set
360
✪
✪
✪
✪
them at ease (i.e., answer questions,
explain each step of the procedure as
we go, show the patient the lab, let
them see us cutting grafts, show
them what the grafts look like, etc.).
We just go with the flow and let the
patient be the guide.
The patient is going to spend the
entire day in the OR (with breaks, of
course). We just go with the flow,
ask questions, find where the
patient’s interests lay, and go where
the patient’s mood leads. The key is
respect. Respect for the patient and
respect for all in the OR.
Our staff is very small—4 assistants,
1 Doctor, 1 Fellow. We have been
working together for some time and
have formed a very smooth team. If
there were any poor behavior, that
individual would be spoken to
privately and the situation handled
accordingly.
Dr. Wolf draws the line on etiquette.
We let the patient choose his/her
distractions. TV is the most common. We have a good-sized video
collection that is pretty diverse. We
also have a growing DVD collection
and satellite TV and a lap top
computer with wireless Internet
connection to surf the ‘net. Patients
can watch what they want, bring
their own videos/DVDs, read, surf,
talk about the world, or sleep!
✪ I don’t think anyone has ever asked
us to limit discussion anywhere. But,
common sense and professionalism
let us limit ourselves to talking about
issues that pertain to the procedure
or interaction with the patient while
in the OR. Personal discussions,
joking around, etc. is fine in the lab
while we dissect grafts, but where
there is a patient, we try to keep it
personable and professional.
✪ We cannot emphasize enough that
this is a medical procedure and
should be handled as such. We
respect our patients and try to make
a lengthy procedure as pleasant as
possible.✧
Volume 13, Number 3
❏
May/June 2003
It is my pleasure to introduce you to the team of Dr. Bradley Wolf. Some members of the team have traveled between
Cincinnati, Ohio; Aspen, Colorado; and Columbus, Ohio. Dr. Wolf has also traveled to a clinic in St. Petersburg, Russia.
(L-R): Viktor Senyk, Elena Marmilova, Hildi Moore, and Joe Bordonaro. Things we like to do outside of work are:
Viktor: playing with and spending time with his children, traveling, target shooting, guitar, reading, and watching
movies. Elena: playing with and spending time with her daughter, working out, traveling, shopping, driving cars, and
surfing the Internet. Hildi: playing with and spending time with her son, rollerblading, biking, driving cars, reading,
movies, and computers. Joe: fast cars, driving and working on cars, music, and guns.
Surgical Assistants Executive Committee Summation Report
Betsy S. Shea Saratoga Springs, New York
Your Surgical Assistants Executive Committee held a conference call on February 25, 2003. The participants included:
Marilynne Gillespie, RN, Co-Chair
Carole Jeanne Limmer, RMA, Co-Chair
Cheryl J. Pomerantz, RN, Vice-Chair
Shanee M. Courtney, RN, Member-at-large
Mary Ann W. Parsley, RN, Member-at-large
(absent) Betsy S. Shea, LPN, Secretary
(Staff ) Victoria Ceh, MPA, Executive Director
Suggestions for the Surgical Assistants
Meeting at the ISHRS Meeting in
New York:
➤ Change the time of the second day
of the conference in New York to
7:00AM–8:45AM.
➤ Have the continental breakfast offered
in the room as opposed to in the hall.
➤ Set the room in round tables for all
3 sessions (smaller rounds of 8
preferred).
➤ Have a warm-up/ice breaker activity
each morning.
➤ Co-Chairs to act as facilitators.
➤ Have a bowl/basket on each table to
submit questions and suggestions.
➤ Request a plated lunch.
Tours at the ISHRS Meeting in New
York: Victoria Ceh then asked the
group their opinions regarding ISHRSsponsored tours. Everyone felt positively about the idea of a Fashion/
Garment District Tour and an NBC
Studios Tour.
Format for presentations at the ISHRS
Meeting in New York: Victoria Ceh
then asked the group what would be the
ideal A/V set-up if there were no
budgetary constraints. The group
replied one screen and one LCD
projector with the idea that all presentations be in the form of PowerPoint. The
request was noted. Victoria Ceh will
check with the A/V vendor and consult
the budget to determine if this is
feasible and get back to the group.
Meeting in New York, and that Cheryl
would serve as interim representative
until that time.
A nomination was made to appoint
Cheryl J. Pomerantz, RN, as the
interim Non-Voting Surgical Assistants
Representative to the ISHRS Board.
Motion: Approve Cheryl J. Pomerantz,
RN, as the interim Non-Voting Surgical
Assistants Representative to the ISHRS
Board of Governors. Action: Approved.
Projects and initiatives for 2003: It was
suggested that the group focus on the
Assistants award this year. There was
also a suggestion to work on administrative regulations or policies and
procedures for the Auxiliary, in an effort
to provide structure for the functioning
of the group.
Surgical Assistants Award: It was
decided to continue with the attendance certificates, plaques for organizers, and certificates for presenters. It
was also decided not to judge or give
awards for oral or poster presentations,
but that we would move forward with a
distinguished service award.
It was then decided to vote for the
formal position at the Surgical Assistants Business Meeting at the Annual
361
❏
May/June 2003
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Volume 13, Number 3
Now accepting applications for
2003 ISHRS Research Grants
The ISHRS offers research grants for the purpose of relevant
clinical research directed toward the subject of hair restoration.
Research grants are typically in an amount of up to $1,200
(USD) each. All ISHRS members in good standing are eligible
to submit an application on a proposed project. The Scientific
Research, Grants & Awards Committee oversees the research
grant process including rating the proposals and determining
the awardees. The submission deadline to be considered for a
2003 ISHRS Research Grant is July 1, 2003.
Applications with instructions and
guidelines can be obtained via the
ISHRS Website at www.ISHRS.org
or by contacting the
Society headquarters office.
Attention Doctors and Surgical Assistants
Call for Nominations
2003 Distinguished Assistant Award
Presented to a surgical assistant for exemplary service and outstanding accomplishments
in the field of hair restoration surgery.
Examples of exemplary service may include, but are not limited to, extending superior patient care, developing new
protocols (related to clinical care or office management), active participation in ISHRS events and projects, assisting in
research or contributing to the advancement of the science of hair restoration surgery, implementing new tools or techniques, maintaining the highest standards, and dedication to the field of hair restoration surgery.
Members in good standing (assistants or doctors) may mail, fax, or e-mail nominations with an explanation of why the
person is deserving of the award by August 15, 2003. Eligible candidates must be members of the ISHRS Surgical Assistants Auxiliary, however, non-members whose service has been significant may be considered.
Nominees will be reviewed and voted upon by the Surgical Assistants Executive Committee. The winner will be announced during the Gala Dinner/Dance & Awards Ceremony on Saturday, October 18, 2003, at the 11th Annual Scientific Meeting in New York.
Submit nominations to:
Surgical Assistants Awards Committee
13 South 2nd Street
Geneva, IL 60134 USA
Or fax to 630-262-1520; E-mail to: [email protected]
The deadline for nominations is: August 15, 2003.
*Remember to include your name, the person you are nominating, and the reason he or she is deserving of the award.
362
Volume 13, Number 3
❏
May/June 2003
NEW* Guidelines for
Submitting Articles to
the Forum
*Any person submitting content to be published in the Forum agrees to
the following:
1. The materials, including photographs, used in this submission do
not identify, by name or otherwise, suggest the identity of, or present
a recognizable likeness of any patient or others; or, if they do, I
have obtained all necessary consents from patients and others for
the further use, distribution, and publication of such materials.
2. The author indemnifies and holds harmless the ISHRS from any
breach of the above.
In addition, all submissions to the Forum must be in electronic format: email, 3.5" PC-formatted disk, or PC-formatted Iomega Zip 100 disk. We
prefer Microsoft Word documents, however, WordPerfect and ASCII text
files are also acceptable. Please adhere to the following additional guidelines when submitting your article(s):
✔ E-mail submissions will only be accepted with an ATTACHED
document file—do not embed the file in your e-mail as we will be
unable to use it. Your e-mail program should have an option to
attach a file. When e-mailing an article, also be sure to attach any
graphic files as well. Artwork (images) must be separate attachments
(see bullet #3).
✔ If you are mailing your article, please submit both a hard copy of
the article(s) AND a disk with the article and any graphic files
(TIFF, JPEG) copied onto it. Before mailing, please be sure that
your article did in fact copy onto the disk.
✔ Any artwork, photos, or figures that are referenced in your article
must be enclosed with your mailed submission or saved on the disk
in either TIFF or JPEG format. Any graphics that are submitted
for scanning must be clean, original copies. When scanning photos
for submission, please scan in black and white at a minimum of
150 dpi; for best output, scan at 300 dpi. Keep in mind that
most figures appear no larger than 3 inches (width) in the
publication, so size accordingly. (This will also reduce the size of
your TIFF/JPEG file and keep it manageable.)
✔ Please submit clean originals and clear photos. If you need artwork,
graphics, or photos returned, please supply a self-addressed, stamped
envelope with your submission and they will be returned promptly.
Send your submissions to:
310 East Broadway, Suite 100
Louisville, Kentucky 40202-1745
*Please Note: All entries will be returned if incomplete or
not adhering to guidelines.
363
Upcoming Events
❏
May/June 2003
Volume 13, Number 3
Following is a guide to upcoming meetings and workshops related to hair restoration. For more information, contact the appropriate sponsoring organization at the number listed. Meeting organizers are reminded that it is their responsibility to provide the Forum Editors with advance
notice of meeting dates.
Date(s)
Venue
Sponsoring Organization(s)
Contact Information
June 2–7, 2003
Aegean Cruise H.T. Meeting
Athens, Greece
DHI Medical Group
John Cole, MD
Tel: 800-368-4247
Fax: 30 010 924 9378
October 15–19, 2003
11th Annual Meeting of the ISHRS
New York, New York USA
Tel: 630-262-5399;
800-444-2737
Fax: 630-262-1520
October 19, 2003
IBHRS Board Examination
New York, New York USA
International Board of Hair Restoration Surgery
Peter Canalia
Tel: 708-474-2600
Please note new date
and venue!
Colorado Blizzard Brings Out the Spirit of the ISHRS
On March 24, I found myself with my staff performing surgery in the “hollowed halls” of truly one of the “greats” in our
field of hair restoration, Dr. Manny Merritt. Yes, Manny has
retired, but Dr. Jim Harris has continued the legacy of excellent
hair transplantation in the Denver area.
April 18–20 brought four to eight feet of snow to the eastern
slopes of the Rocky Mountains, and particularly the foothills of
Denver. Our MHR office was totally out of commission, due to
the weight of the heavy snow. Facing a full schedule, an SOS call
went out to Shanee, Jim’s office manager.
Jim kindly allowed me, one of his competitors, to use his office that day for a fair fee, since he was on vacation. The following day the county building inspector allowed us back into our
surgery suite.
A big thanks to Jim and Shanee for saving the day for us.
Melvin Mayer, MD
HAIR TRANSPLANT FORUM INTERNATIONAL
13 South 2nd Street
Geneva, IL 60134
Forwarding and Return Postage Guaranteed
364
Thank You
The ISHRS would like to acknowledge the generosity of
the following members who have made voluntary contributions to the Society on their 2003 dues statements:
Isabel M. Banuchi, MD
Jae Heon Jung, MD
Jung Chul Kim, MD
Benjamin A. Royappa, MD
Arturo Sandoval-Camarena, MD
Shiro Yamada, MD
FIRST CLASS
US POSTAGE
PAID
CHICAGO, IL
PERMIT NO. 6784

New Storage Buffers for Micrografts Enhance Graft Survival and

Transcription

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