New Storage Buffers for Micrografts Enhance Graft Survival and
Transcription
New Storage Buffers for Micrografts Enhance Graft Survival and
Volume 13, Number 3 Hair Transplant Forum International ❏ May/June 2003 Hair Transplant Forum International 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 Hair Transplant Forum International ❏ May/June 2003 Hair Transplant Forum International 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 Restoration Surgery, 13 South 2nd Street, Geneva, 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 Restoration Surgery, 13 South 2nd Street, Geneva, 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 size. Remember to include all photos and figures referred to in your article as separate attachments (JPEG, Tiff, or Bitmap). For e-mail submissions, be sure to ATTACH your file(s)—DO NOT embed it in the e-mail itself. We prefer e-mail submissions with the appropriate attachments. Send to: William M. Parsley, MD 310 East Broadway, Suite 100 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 Hair Transplant Forum International ❏ 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) ○ 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. ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 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, William M. Parsley, MD 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 ○ 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). ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 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. continued on page 351 ○ 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 ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ (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 continued on page 348 327 Hair Transplant Forum International ❏ 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 continued on page 337 Volume 13, Number 3 Hair Transplant Forum International ❏ 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 continued on page 330 329 Hair Transplant Forum International ❏ 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 Hair Transplant Forum International 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 Hair Transplant Forum International ❏ 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 Hair Transplant Forum International ❏ 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 continued on page 334 333 Hair Transplant Forum International ❏ 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 continued on page 343 Volume 13, Number 3 Hair Transplant Forum International ❏ 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 Hair Transplant Forum International 336 ❏ May/June 2003 Volume 13, Number 3 Volume 13, Number 3 Hair Transplant Forum International ❏ 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 continued from page 328 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 Hair Transplant Forum International ❏ 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 Hair Transplant Forum International ❏ 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. ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 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 continued on page 340 339 Hair Transplant Forum International ❏ 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 ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 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 Hair Transplant Forum International 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. ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 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 Hair Transplant Forum International 342 ❏ May/June 2003 Volume 13, Number 3 Volume 13, Number 3 Hair Transplant Forum International ❏ 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 continued from page 334 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 Hair Transplant Forum International ❏ 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. William M. Parsley, MD 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 Hair Transplant Forum International 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. continued on page 346 345 Hair Transplant Forum International ❏ 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) ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ “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) ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ “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 continued from page 345 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 Hair Transplant Forum International ❏ 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. continued on page 348 347 Hair Transplant Forum International ❏ May/June 2003 Volume 13, Number 3 Strontium continued from page 347 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 continued from page 327 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.✧ William M. Parsley, MD Volume 13, Number 3 Hair Transplant Forum International ❏ 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 Hair Transplant Forum International 350 ❏ May/June 2003 Volume 13, Number 3 Volume 13, Number 3 Hair Transplant Forum International 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 continued from page 327 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? N,, ON TIIO T N Please let us know—we are trying to complete our records. If you N E E T T T AT A ! ! N ON attended this first “World Congress in Hair Restoration Surgery” in TIIO NT EN TE TT AT A 1993, please send an e-mail to: [email protected] 351 Hair Transplant Forum International ❏ 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. 352 Volume 13, Number 3 Hair Transplant Forum International ❏ 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. continued on page 354 353 Hair Transplant Forum International ❏ May/June 2003 Volume 13, Number 3 ISHRS Policies & Guidelines continued from page 353 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 Transplant Forum International 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 Hair Transplant Forum International ❏ May/June 2003 Volume 13, Number 3 Hair Repair continued from page 355 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 Hair Transplant Forum International 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.✧ Toppik Makes Thinning Hair Look Full and Natural in 30 Seconds Toppik fibers are pure keratin, colored to match the 8 most common hair colors (black, dark brown, medium brown, light brown, auburn, blonde, gray & white). You simply hold the Toppik container over the thinning area and shake it in. In seconds, the fibers combine with the patient’s remaining hairs to give the undetectable appearance of a fuller head of hair. Toppik resists wind, rain and perspiration. It is totally compatible with all topical treatments for hair loss. And Toppik is ideal in conjunction with hair transplant surgery, as it effectively conceals any post-operative thinning. For a free tester kit containing all 8 colors, call, fax or email: Spencer Forrest, Inc. 64 Post Road West Westport, CT 06880 Before Toppik After Toppik Phone: 888-221-7171, ext. 10 • Fax: 203-226-2369 • Email: [email protected] • www.toppik.com 357 Hair Transplant Forum International RS C ear ISH olleague ❏ May/June 2003 s, Follicle latinum year to P d n a lden each The Go enerally given uted most g re trib awards a ed to have con ation (Platim e o e t s d re r sthose e of hair r to the hair re c n ie c s e o h ) t e d o r ld t a o n llicle Aw n in general (G y be o F m u n a professio tions m toration ward). Nomina the Awards A of Follicle embers eneral memm y b d g e submitt e and from the se take spee t lea nk Commit f the ISHRS. P you thi y o h w ip h g a s ber outlinin deser ving of n i e r a s c i e hat cial nomine not sufficient t r u o y It is that rofes r award. in the p particula has been active “great guy.” e he or sh 0 years or is a prestigious 1 r o f remely sion s are ext committee con d r a w a s a t n y These b ie . judged ast award recip ave e r a d n p a f oh ntirely o candidates wh our e g in t is r s oking fo ution to We are lo enuine contrib g made a . n professio D 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, S Best reg . Shiell, MBB , Grants C d r r a a e s e ch Rich ntific, R tee ie c S , ir Cha mmit ards Co 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 Hair Transplant Forum International ❏ 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! continued on page 360 359 Hair Transplant Forum International ❏ 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 Hair Transplant Forum International ❏ 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 Hair Transplant Forum International ❏ May/June 2003 embers, M S R H Dear IS earch that Res are e r a w a $1,200 y not be You ma he value of US ants from plic to t Grants o successful ap should be t ns available S. Applicatio cribed forms R es the ISH only on the pr 003. d e t 1 le p ly Ju , 2 line com itted by on, please out e m b u s i th and applicat nce and In your esearch experie ther with rr toge your prio your project, t will be of c f nature o think this proje nce of hair c u s o d ie why y e ar t an h t o t benefit n. io restorat ards, Best reg . Shiell, MBBS , Grants C h Richard ientific, Researc c Chair, S ds Committee r a w A and 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 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] 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 Hair Transplant Forum International ❏ 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: William M. Parsley, MD 310 East Broadway, Suite 100 Louisville, Kentucky 40202-1745 E-mail: [email protected] *Please Note: All entries will be returned if incomplete or not adhering to guidelines. 363 Upcoming Events Hair Transplant Forum International ❏ 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 E-mail: [email protected] October 15–19, 2003 11th Annual Meeting of the ISHRS New York, New York USA International Society of Hair Restoration Surgery 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 International Society of Hair Restoration Surgery 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