Update on Efficacy of Generic Finasteride

Transcription

f orum
HAIR
TRANSPLANT
Volume 25
Number 2
March/April
2015
I N T E R N A T I O N A L
Inside this issue
President’s Message........................54
Co-editors’ Messages.......................55
Notes from the Editor Emeritus:
Richard C. Shiell, MBBS...................57
Cyberspace Chat: The Treatment of
Men with Finasteride: Scientific and
Anecdotal Evidence ......................61
How I Do It: Designing the Hairline:
The Role of the Thumb.......................64
Complications & Difficult Cases:
A Close Call with Donor Area
Harvesting on a Patient with
Irradiated Scalp..............................65
Ask the Fellows................................68
Introduction to UK Hair Restoration
Surgery Clinical Standards.............73
Hair’s the Question...........................76
Review of the Literature....................79
Regional Societies Profiles:
Society of German
Hair Surgeons.................................80
Letters to the Editor .........................81
Meetings & Studies:
Review of the 6th Annual Hair
Transplant 360 Workshop................ 84
Review of the Japan Society of
Clinical Hair Restoration 19th
ASM & Live Surgery Workshop....... 85
ISHRS Annual Giving Fund
Year-End Report............................... 86
Messages from the 2015 ASM
Program Chair.....................................88
Surgical Assistants Chair................89
Classified Ads...................................90
PLAN TO ATTEND!
www.ishrs.org/AnnualMeeting.html
Update on Efficacy of Generic Finasteride
Edwin S. Epstein, MD, FISHRS Richmond, VA, USA [email protected]
Finasteride 5mg was approved by the U.S. Food and Drug Administration (FDA) in 1992 for the treatment
of benign prostatic hyperplasia, and in 1997 for male pattern hair loss (MPHL) in the 1mg dose. For many years,
because of cost and availability issues of finasteride 1mg, physicians, especially outside of North America, have
suggested that patients divide brand or generic 5mg finasteride into quarters. Recently, numerous hair transplant
physicians have commented on anecdotal reports by their patients of increased shedding and progressive hair loss
noted after changing from brand to generic finasteride 1mg. This raises several questions about generic medications: how does the efficacy compare to brand, how are generic drugs regulated, are there variations among
generic manufacturers, and is the active ingredient evenly distributed in the tablet?
Using bioequivalence as the basis for approving generic copies of drug products was established by the “Drug
Price Competition and Patent Term Restoration Act of 1984,” also known as the Hatch-Waxman Act. This Act
expedites the availability of less costly generic drugs by permitting the FDA to approve applications to market
generic versions of brand-name drugs without conducting costly and duplicative clinical trials. At the same time,
the brand-name companies can apply for up to five additional years longer patent protection for the new medicines
they developed to make up for time lost while their products were going through the FDA’s approval process.
Brand-name drugs are subject to the same bioequivalence tests as generics upon reformulation.
According to the FDA website, a generic drug is identical or bioequivalent to a brand-name drug, and must
follow the same standards as the innovator drug:
• Contain the same active ingredients as the innovator drug (inactive ingredients may vary).
• Be identical in strength, dosage form, and route of administration.
• Have the same use indications.
• Be bioequivalent.
• Meet the same batch requirements for identity, strength, purity, and quality.
• Be manufactured under the same strict standards of FDA’s good manufacturing practice regulations
required for innovator products.
In order to obtain FDA approval to market a generic drug, companies must submit an abbreviated new drug
application (ANDA). The ANDA process does not require the drug sponsored to repeat preclinical (animal) and
clinical (human) research on ingredients or dosage forms already approved for safety and effectiveness. Instead,
generic applicants must scientifically demonstrate that their product is bioequivalent (i.e., performs in the same
manner as the innovator drug). Bioequivalence is often demonstrated by studies measuring the time it takes the
generic drug to reach the bloodstream in 24-36 healthy volunteers. This determines the rate of absorption, or
bioavailability, of the generic drug, which is then compared to that of the innovator drug. The generic version
must deliver the same amount of active ingredients into a patient's bloodstream in the same amount of time as the
innovator drug. Bioavailability is usually assessed by measuring the area under the plasma concentration–time
curve (AUC).1
For FDA approval, a generic manufacturer must demonstrate that the 90% confidence interval for the ratio of
the mean responses (usually of AUC and the maximum concentration, Cmax) of its product to that of the brandname drug is within the limits of 80% to 125%. While AUC refers to the extent of bioavailability, Cmax refers to
the rate of bioavailability.2
The 80-125% criterion is used to compare two treatments to evaluate bioequivalence. The bioequivalence test
states that we can conclude that two treatments are not different from one another if the 90% confidence interval
falls completely within the range 80-125%. The 80-125% criterion cannot conclude that the drugs are the “same,”
only that they are not “different.” For drugs with a narrow therapeutic index range, small differences in dose or
serum concentration may have therapeutic failures or adverse events, and the acceptance range of 80-125% may
need to be smaller.3
[ page 59
Official publication of the International Society of Hair Restoration Surgery
Hair Transplant Forum International
Volume 25, Number 2
Hair Transplant Forum International is published bi-monthly by
the International Society of Hair Restoration Surgery, 303 West
State Street, Geneva, IL 60134 USA. First class postage paid
at Chicago, IL and additional mailing offices. POSTMASTER:
Send address changes to Hair Transplant Forum International,
International Society of Hair Restoration Surgery, 303 West State
Street, Geneva, IL 60134 USA. Telephone: 1-630-262-5399,
U.S. Domestic Toll Free: 1-800-444-2737; Fax: 1-630-262-1520.
President: Sharon A. Keene, MD, FISHRS
[email protected]
Executive Director: Victoria Ceh, MPA
[email protected]
Editors:
Mario Marzola, MBBS
Robert H. True, MD, MPH, FISHRS
[email protected]
Managing Editor, Graphic Design, & Advertising Sales:
Cheryl Duckler, 1-262-643-4212
[email protected]
Controversies: Russell G. Knudsen, MBBS, FISHRS
Cyberspace Chat: John Cole, MD; Bradley R. Wolf, MD, FISHRS
Difficult Cases/Complications: Marco Barusco, MD
Hair Sciences: Jerry E. Cooley, MD
Hair’s the Question: Sara M. Wasserbauer, MD, FISHRS
How I Do It: Timothy Carman, MD, FISHRS
Meeting Reviews and Studies: Henrique Radwanski, MD
Regional Society Profiles:
Mario Marzola, MBBS; Robert H. True, MD, MPH, FISHRS
Review of Literature:
Nicole E. Rogers, MD; Jeffrey Donovan, MD, PhD
Copyright © 2015 by the International Society of Hair Restoration
Surgery, 303 West State Street, Geneva, IL 60134 USA. Printed
in the USA.
The views expressed herein are those of the individual author
and are not necessarily those of the International Society of Hair
Restoration Surgery (ISHRS), its officers, directors, or staff.
Information included herein is not medical advice and is not
intended to replace the considered judgment of a practitioner
with respect to particular patients, procedures, or practices. All
authors have been asked to disclose any and all interests they
have in an instrument, pharmaceutical, cosmeceutical, or similar
device referenced in, or otherwise potentially impacted by, an
article. ISHRS makes no attempt to validate the sufficiency of
such disclosures and makes no warranty, guarantee, or other
representation, express or implied, with respect to the accuracy or
sufficiency of any information provided. To the extent permissible
under applicable laws, ISHRS specifically disclaims responsibility
for any injury and/or damage to persons or property as a result of
an author’s statements or materials or the use or operation of any
ideas, instructions, procedures, products, methods, or dosages
contained herein. Moreover, the publication of an advertisement
does not constitute on the part of ISHRS a guaranty or endorsement
of the quality or value of the advertised product or service or of any
of the representations or claims made by the advertiser.
Hair Transplant Forum International is a privately published
newsletter of the International Society of Hair Restoration Surgery.
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.
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).
www.ISHRS.org
March/April 2015
President’s Message
Sharon A. Keene, MD, FISHRS Tucson, Arizona, USA [email protected]
I am pleased to share with you that ISHRS member response to the new affidavit, confirming our members’ commitment to performing “critical to quality” aspects of surgery
themselves, has been a success. Current membership renewals
remain at the same high percentage rate, and overall membership continues to grow. I would like to express my personal
appreciation to all those who have shown their support for
this important policy.
There have been occasions where respected peers have had to re-think their
practice management approach, understanding there is no way to allow unlicensed
technicians to perform surgery “under their watchful eye” without contributing to the
growing problem of unlicensed medical practice, and violating the ISHRS position
that unlicensed personnel should not be making incisions or excisions on any patient.
Patients who seek hair restoration surgery deserve and expect to have a hair restoration
doctor perform their surgery. But just as importantly, we have yet to identify a legal
governing body in any country that supports unlicensed medical personnel performing
incisions/excisions on a patient.
Recently, there have been questions raised regarding robotic operations in hair
restoration surgery (HRS). This issue has been discussed with several of our members
who have been operating robots. In particular, Past President and Follicle Award
recipient Dr. Paul Rose has been a strong supporter of the ISHRS position to curtail
the activity of unlicensed technicians in HRS. He has recently clarified his support
for the ISHRS policy that requires all incisions and excisions be under the control of
a licensed medical professional practicing within their legal capacity. He made clear
he supports a paradigm where only licensed medical providers would operate the
controls of this sophisticated and complex machine. It is the case that just because
unlicensed personnel could be trained, doesn’t mean they should be trained to do
this. Past experience has shown that allowing this type of behavior fostered improper
activity where some technicians actually performed surgery for doctors who did not
know how to do it themselves. As was shared previously, HRS embodies more than the
technical aspects of surgery—appropriate diagnosis, pre-operative care, intra-operative
management of medical issues, and post-operative care depend on appropriate medical education and training. In other fields where complex machines are used, such as
radiology, technicians are required to have education, certification, and licensure as
well as continuing medical education requirements.
While many hair restoration surgeons feel they have talented and loyal staff—
individuals who could “learn anything”—that is not how medical licensure works.
Patients and governments do not allow us to legally “lend our license”—even to those
who we think are skilled and intelligent—if they haven’t earned the right to practice
medicine. Most doctors could teach a patient with high blood pressure what medications to use to control their blood pressure or how to treat their asthma, but we do not
allow patients to prescribe to themselves. The same is true for many minor surgeries;
a trained patient could do it themselves, but we don’t allow that. Governments grant
medical licensure to individuals who have the ability to integrate complex medical
information because they have completed necessary education, testing, and training,
and have promised a commitment to continuous medical education, ethical devotion
to a patient’s best interests, and are subject to medical board oversight.
Increasingly, fewer members recall the “old days” of punch and plug surgery. When
done poorly it could be very disfiguring; when done with mediocrity, it could still be
unsightly. Today, with follicular unit grafting, even some of the most mediocre transplant results do not result in disfigurement—just disappointing cosmesis for patients
who are learning to have high expectations, and sometimes a waste of donor hair.
Nevertheless, despite innovations in surgical techniques, devastating consequences
remain possible with improperly performed surgery or poor patient selection. One of
the planned sessions at our annual meeting will review surgical complications—some
[ page 58
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www.ISHRS.org
March/April 2015
Co-editors’ Messages
Mario Marzola, MBBS Adelaide, South Australia [email protected]
Professor Rodney Sinclair was a featured speaker at our Kuala
Lumpur conference last year. Currently, I have been helping him
to add surgical hair restoration to his well-established practice of
general dermatology and medical hair restoration in Melbourne,
Australia. What a stark reminder this has been of just how many
little things are needed to get it going. So much has to fall into
place before we can perform an operation with any degree of
comfort, let alone to any great standard. The Operating Room
table, the chairs, the lights, the microscopes and their lights, all
the instruments, disposables, drugs, drapes, feeding and watering the patient and staff, the music for ambience, and of course,
good coffee! Staff? Yes, staff is the most important and most
difficult. Good, experienced, reliable, caring, and professional
staff is gold. Thankfully, Dr. Russell Knudsen, who also practices in Melbourne, has allowed us to use some of his surgical
technicians when they are not needed in his office. Together with
my staff we are gradually building local knowledge from the
ground up. Don’t let anyone tell us that hair restoration surgery
is a simple procedure. To achieve anywhere near high standard
results takes an enormous amount of organization without too
many compromises. So many things can conspire to diminish
the experience and outcome for us and the patient. As Murphy
said… if it can go wrong, it will go wrong.
It’s been a big challenge and still is, so why do it? Well
quite simply the ethos in Professor Sinclair’s office of con-
tinual questioning, teaching, and learning
is addictive. Post graduate students and
researchers abound, so brain stretching
conversations happen every day.
Your editors are very happy with our
new column, “Ask the Fellows.” What
a brilliant way of checking something
that may have concerned us recently. All available with a
quick scan over the subjects that we can pass or home into
depending on our interest. They are well written and concise
and showcase the depth of knowledge we have in the ISHRS,
which is also freely shared. A warm thank-you to all our contributing Fellows.
Because our patients need to take finasteride over a long
time, it is understandable that they seek the most economical
way of sourcing the drug. In our lead article, Dr. Edwin Epstein
describes all the problems that may arise with the use of generic
finasteride and in tablet splitting. This is good basic knowledge
that will guide us in our directions to our patients. We’ve been
taught to look for counterfeit dollar notes but now counterfeiting
drugs may also become a problem.
We hope you enjoy reading our second issue for 2015, packed
as usual with news and views.u
Robert H. True, MD, MPH, FISHRS New York, New York, USA [email protected]
How would you reply to this question from a patient? “Doctor, after my surgery, can I shave my head without there being
any way for others to see that I had a hair transplant?” I have to
answer this question based on my own experience with both FUT
and FUE by answering, “Probably not. Most, if not all, patients
will have to leave their hair 2–3 mm or longer to conceal signs
of harvesting by either method.” I think many of us do have
patients in our practices who heal so well with trichophytic
scars and with well dispersed small punch FUE that it is truly
difficult to see the scars when the head is shaved. However, I do
not see how any of us could answer this patient question with
an unequivocal “Yes.” If you disagree, and can show evidence
to the contrary, please write to us.
Related to this question, is the promise of “scarless surgery.”
Unfortunately, the advertisement of FUE as scarless surgery
has become relatively commonplace. There are even some who
advertise and promote FUE as a “non-surgical” treatment. On an
objective level, such claims are just medically false. Biopsies of
extraction sites do show scarring. Therefore, such advertising is
misleading and unethical. I see many young men in my practice
who come to me for an opinion about their “unsightly scarring”
from FUE procedures performed elsewhere. For many of these
patients, I do not see scarring and spotty hairless areas beyond
the norm with well-performed FUE, however, they feel they were
mislead because they had been told there would be no scar even
with their head shaved.
I have also had some patients in my
practice, despite my telling them there
are scars with FUE, who also feel that
they have to wear their hair longer than
they want to conceal the extraction sites.
As physicians who seek to be ethical practitioners, we all owe it to our
patients and to the public perception of
the integrity of our profession to be fully
honest and forthcoming in describing and promoting our services.
I believe the ISHRS can and will take a stand on this issue,
something I will welcome. But it also is incumbent for each of
us individually to assure our own practices measure up in ethical
advertising and also to challenge those practitioners who are in
clear violation, whether they be members of the Society or not.
I hope and expect you will enjoy this issue of the Forum.
Thanks to our excellent contributors, there are some very interesting articles. Remember this is the Forum, which means
we depend on you and our membership to share opinions and
experiences. Please consider making a submission.u
55
www.ISHRS.org
March/April 2015
INTERNATIONAL SOCIETY OF HAIR RESTORATION SURGERY
Vision: To establish the ISHRS as a leading unbiased authority in medical and surgical hair restoration.
Mission: To achieve excellence in medical and surgical outcomes by promoting member education, international collegiality, research, ethics, and public awareness.
2014–15 Chairs of Committees
American Medical Association (AMA) House of Delegates (HOD) and
Specialty & Service Society (SSS) Representative: Carlos J. Puig, DO, FISHRS
(Delegate), Paul T. Rose, MD, JD (Alternate Delegate)
Annual Giving Fund Chair: John D.N. Gillespie, MD, FISHRS
Annual Scientific Meeting Committee: Nilofer P. Farjo, MBChB, FISHRS
Audit Committee: Robert H. True, MD, MPH, FISHRS
Bylaws and Ethics Committee: David Perez-Meza, MD, FISHRS
Communications & Public Education Committee: Robert T. Leonard, Jr., DO, FISHRS
CME Committee: Paul C. Cotterill, MD, FISHRS
Regional Workshops Subcommittee: Matt L. Leavitt, DO (Chair) &
David Perez-Meza, MD, FISHRS (Co-Chair)
Subcommittee on EBM and Research Resources: Marco N. Barusco, MD
Subcommittee Expert Panel: Paul C. Cotterill, MD, FISHRS
Core Curriculum Committee: Anthony J. Mollura, MD
Fellowship Training Committee: Robert P. Niedbalski, DO
Finance Committee: Ken Washenik, MD, PhD
FUE Research Committee: James A. Harris, MD, FISHRS
Hair Foundation Liaison: E. Antonio Mangubat, MD
International Relations Committee: Bessam K. Farjo, MBChB, FISHRS
Membership Committee: Michael W. Vories, MD
Nominating Committee: Sungjoo Tommy Hwang, MD, PhD, FISHRS
Past-Presidents Committee: Carlos J. Puig, DO, FISHRS
Pro Bono Committee: Edwin S. Epstein, MD, FISHRS
Scientific Research, Grants, & Awards Committee: Carlos J. Puig, DO, FISHRS
Surgical Assistants Committee: Janna Shafer
Surgical Assistants Awards Committee: Tina Lardner
Ad Hoc Committee on Database of Transplantation Results on Patients
with Cicatricial Alopecia: Jeff Donovan, MD, PhD
Ad Hoc Committee on Issues Pertaining to the Unlicensed Practice of Medicine:
Carlos J. Puig, DO, FISHRS
Ad Hoc Committee on Regulatory Issues: Paul T. Rose, MD, JD
Subcommittee on European Standards: Jean Devroye, MD, FISHRS
ISHRS Representative to CEN/TC 403
Subcommittee on Alberta, Canada Standards: Vance Elliott, MD, FISHRS
Task Force on Finasteride Adverse Event Controversies: Edwin S. Epstein, MD, FISHRS
2014–15 Board of Governors
President: Sharon A. Keene, MD, FISHRS*
Vice President: Kuniyoshi Yagyu, MD, FISHRS*
Secretary: Sungjoo Tommy Hwang, MD, PhD, FISHRS*
Treasurer: Ken Washenik, MD, PhD, FISHRS*
Immediate Past-President: Vincenzo Gambino, MD, FISHRS*
Alex Ginzburg, MD
Robert S. Haber, MD, FISHRS
James A. Harris, MD, FISHRS
Francisco Jimenez, MD, FISHRS
Melvin L. Mayer, MD, FISHRS
Paul J. McAndrews, MD, FISHRS
William M. Parsley, MD
David Perez-Meza, MD, FISHRS
Arthur Tykocinski, MD, FISHRS
*Executive Committee
Global Council of Hair Restoration
Surgery Societies
Membership proudly includes:
American Board of Hair Restoration Surgery
Asian Association of Hair Restoration Surgeons
Association of Hair Restoration Surgeons-India
Australasian Society of Hair Restoration Surgery
Brazilian Society of Hair Restoration Surgery
(Associação Brasileira de Cirurgia de Restauração Capilar – ABCRC)
British Association of Hair Restoration Surgery
French Hair Restoration Surgery Society
Ibero Latin American Society of Hair Transplantation
(Sociedad Iberolatinoamericana de Trasplante de Cabello – SILATC)
International Society of Hair Restoration Surgery
Italian Society for Hair Restoration
Japanese Society of Clinical Hair Restoration
Korean Society of Hair Restoration Surgery
Polish Society of Hair Restoration Surgery
Sociedad Iberolatinoamericana de Trasplante de Cabello
56
Editorial Guidelines for Submission and
Acceptance of Articles for the Forum Publication
Bernard Nusbaum, MD
1.
Articles should be written with the intent of sharing scientific
information with the purpose of progressing the art and science
of hair restoration and benefiting patient outcomes.
2. If results are presented, the medical regimen or surgical techniques that were used to obtain the results should be disclosed
in detail.
3. Articles submitted with the sole purpose of promotion or
marketing will not be accepted.
4. Authors should acknowledge all funding sources that supported
their work as well as any relevant corporate affiliation.
5. Trademarked names should not be used to refer to devices or
techniques, when possible.
6. Although we encourage submission of articles that may only
contain the author’s opinion for the purpose of stimulating
thought, the editors may present such articles to colleagues
who are experts in the particular area in question, for the purpose of obtaining rebuttal opinions to be published alongside
the original article. Occasionally, a manuscript might be sent
to an external reviewer, who will judge the manuscript in a
blinded fashion to make recommendations about its acceptance, further revision, or rejection.
7. Once the manuscript is accepted, it will be published as soon
as possible, depending on space availability.
8. All manuscripts should be submitted to [email protected].
9. A completed Author Authorization and Release form—sent as
a Word document (not a fax)—must accompany your submission. The form can be obtained in the Members Only section
of the Society website at www.ishrs.org.
10. All photos and figures referred to in your article should be sent
as separate attachments in JPEG or TIFF format. Be sure to
attach your files to the email. Do NOT embed your files in the
email or in the document itself (other than to show placement
within the article).
11. We CANNOT accept photos taken on cell phones.
12. Please include a contact email address to be published with
your article.
Submission deadlines:
April 5 for May/June 2015 issue
June 5 for July/August 2015 issue
August 5 for September/October 2015 issue
October 5 for November/December 2015 issue
www.ISHRS.org
March/April 2015
Notes from the Editor Emeritus
Richard C. Shiell, MBBS Melbourne, Australia [email protected]
Don’t throw the past away
You might need it some rainy day
Dreams can come true again
When everything old is new again
So goes the 1974 song penned by my fellow countryman
Peter Allen in conjunction with American singer Carole Bayer
Sager. So it is also with hand-operated biopsy punches and scalp
reductions. I thought I had demonstrated the superiority of motorized punches as far back as the 1970s when I introduced our
ultra-sharp carbon steel Australian punches to the Hot Springs
meetings in 1975 and 1979. I did not bother to take out a patent
and they were copied extensively throughout the world.
At around the same time, many of us agreed that around
3.5mm was the smallest size punch that could be reliably cut
without causing follicular damage. Pierre Pouteau, the celebrated
and vastly experienced Parisian transplanter, was using 2.0mm
punches, which certainly gave a less tufted effect, but his growth
rate per graft seemed unacceptably low to me. I was wrong again,
and the “top guns” of today are using dull punches of 0.8mm
diameter and a claimed transection rate as low as 3%. I notice
that they do not claim it is easy, and I wonder how the average
HT surgeon scores with this meticulous procedure?
Now let us turn our attention to the scalp reduction or alopecia
reduction operation, which has been virtually “dead” since 1996.
This was introduced to the hair transplant world by the Blanchard
Brothers of Montreal and Dr. Martin Unger of Toronto almost
simultaneously in 1978. A more widely read paper on the same
subject by surgeons at the Bosley Clinic in Beverly Hills served
to further promote this procedure. Around 1980, it took off with
patients and surgeons alike and within 2 years the Transform
Clinic in the UK, of which I was Director of Surgery, had done
2,000 cases. By 1983, I was regrettably able to coauthor a paper
on the complications we had seen.
The big attraction was that within 30 minutes the patient could
rise from the operating chair minus about 35cm2 of his baldness.
This procedure could be repeated at intervals of 3-6 months.
Like most miracles, there were drawbacks and the residual scalp
could stretch back some 30-50% in this period. Note that this
stretch was in the adjacent scalp, not the central scar, which was
generally less than 1mm wide. Thus, to remove a 10cm bald area
was not possible in 3 procedures of 3.5cm each, but because of
the stretchback and increasing tension within the scalp, it could
take 4, 5, or even 6 operations to close the bald area (typically
3.5 + 3.0 + 2.5 + 2.0 + 1.5cm).
Dr. Patrick Frechet later introduced an ingenious Scalp
Extender, which was inserted under the scalp to speed up the
process by increasing the advancement of the hairy sides and
preventing stretchback. This enabled him to remove a 10-12cm
bald area within 3 surgical procedures.
The other problem was that the more one tried to close the
bald area, the more the hair direction appeared to be abnormal
and, with a central scar, the patient looked as if he had been
struck on the head with a meat cleaver. A variety of different
surgical approaches were introduced. C,
J, Y, U, and M shape excisions were the
most popular, but each had its drawbacks
and one was still left with a detectible scar.
Z-plasty only seemed to make the scar
worse so the ever-inventive Dr. Frechet
developed his ingenious Triple Flap procedure and received
our 1st Annual Golden Follicle Award for his efforts in 1994.
The only drawback was that although the procedure worked
well in the hands of Dr. Frechet, very few had his touch and
experience, scalp reductions were becoming unpopular, and the
method gained very few adherents. More would have tried had
it not been that “mini- grafting” from scalp strips was slowly
creeping onto the scene and was being refined by microscopic
dissection of the actual follicular units. While labor-intensive,
it was safe and much of the work could be delegated to trained
staff. Furthermore, the final results were extraordinarily natural
in appearance.
This is the situation we have reached in 2015. Although
experiments continue with attempts to prevent temporary loss
of transplanted hair and speed up the procedure with robotic
machines, there seems to be no move to return to reductions
and flaps.
Should we be doing more scalp reductions and flaps?
I put this question to former AR guru and ISHRS Past President Mario Marzola and in part his reply was:
“I don’t think the routine alopecia reductions will ever make
a comeback! The same applies to flaps and 4mm grafts. In accidents or burns or large excisable areas of scarring alopecia,
maybe there is still a place, and certainly in hairline lowering
where, associated with scalp expansion, it still has a role.”
It is a fact that undesirably high hairlines in females can
be easily moved a centimeter or two by a frontal advancement
procedure (even more with prior insertion of an inflatable tissue expander). The residual scar is barely detectible and seldom
requires improvement. Unwanted transplants or frontal scars in
men can similarly be removed with one or two easy procedures.
Another former Forum Editor and ISHRS Past-President
Russell Knudsen commented:
“I think that AR is now a repair procedure for those who
know its value and have been trained in how to do it correctly.
Lateral AR can ‘lift’ the balding margin to the previous grafts or
remove cicatricial alopecia. Not much other value I am afraid.
If used in extensive male pattern baldness to ‘reduce’ the bald
area, it must have widely spaced galeal sutures to minimize
stretchback as described by the late Dr. Gerard Seery in 1997. I
don’t know of anyone doing this today. Of course, strip surgeons
doing 3,000+ grafts practice the same technique in the donor
area. Can we call this ‘donor reduction’?”
Lateral, posterior, and U-shaped reductions are still employed
to help bridge an area of baldness that has appeared since the first
transplants some decades earlier. Hopefully, the use of finasteride
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Editor Emeritus from page 57
over the past 15 years has minimized this baldness progression,
but there are probably a vast number of former patients who have
not used the drug or who even know about it.
Should Reduction techniques be taught at ISHRS teaching
courses?
I believe that this should be occurring regularly, rather than
adventurous young surgeons working alone without the benefit
of our vast collective experience. As far as I know, I was the only
person to perform a scalp reduction at a hair meeting within the
past 20 years (Sydney, 2005). Drs. Marzola, Martin Unger, and
I did three to packed operating rooms and temperatures of 90+
degrees at a meeting in Rio de Janiero in 1992. The procedure
was not made easier by large video cameras lenses almost at the
wound margins and massive bleeding due to the heat. Although
a relatively simple surgical procedure, there are the usual traps
for young players and valuable tips can be passed on by those of
us who have learned from experience. I have seen more serious
flap and reduction problems caused by overconfident Plastic
Surgeons without specific training than by members of the more
cautious and trained hair transplant fraternity.
March/April 2015
Medico-Legal Barriers
A recent barrier to the use of alopecia reduction and advancement and pedicle flaps has been instituted by our Medical
Insurers. Many modern policies will only permit Board-certified
surgeons to perform these procedures or alternatively they charge
a much higher annual premium for others who plan to do them.
The fact that strip removal and any associated undermining prior
to closure is almost identical to a scalp reduction seems to have
“slipped under the radar.” Perhaps this is why all hair transplantation in places like France and Singapore is now restricted to
Plastic Surgeons.
Bibliography
See the excellent book chapters listed below for detailed
accounts of past and present ancillary procedures and many
references.
1. Marzola, M., et al. Ancillary Surgical Procedures. Chapter
18. In: W. Unger, Ed. Hair Transplantation, 5th Edition.
Informa Health Care Press, 2010. (with accompanying
DVD)
2. Marzola, M. Surgical Female Hairline Lowering.I In: S.M.
Lam, Ed. Hair Transplant 360. JayPee Press, 2014. (with
accompanying DVD)u
President’s Message from page 54
caused by unlicensed technicians performing hair restoration
surgery. Unlicensed technicians generally do not see patients
in follow-up to know when they make an error. In contrast, we
as doctors are accountable and must learn from our mistakes. I
would like to encourage all members to gather any cases they
feel will assist in this learning process and submit them for the
planned Complications Panel at the annual meeting in Chicago.
Despite our ongoing efforts to eliminate the unlicensed
practice of medicine among former doctors’ assistants—most
of whom were at one time employed by hair restoration doctors,
the ISHRS recognizes the majority of our staff are honest, loyal,
and respected team members. We continue to reward them with
special recognition at our meetings, and to encourage their participation in training fellow assistants at sponsored workshops. It
is with great pride that the ISHRS in conjunction with Dr. James
Harris is sponsoring the first “stand alone” Surgical Assistants
Workshop. I encourage anyone who has recently hired new staff
to utilize this valuable training opportunity.
Finally, for those who have been reading the series on low
level laser therapy (LLLT), the third and final part has been
completed, but for space constraints will not be included until
our next edition. I do not promote or critique any one device.
My intention with this series was to educate and elicit a critical
look at the science as well as the devices that apply it, in order
to assist members in making their own decisions and recommendations to patients. Hopefully, every doctor will be able to
determine whether a particular device may be helpful to treat
hair loss for their particular patient. What I can say for certain,
questions remain about the optimal device and dosing schedules,
and like clothing—no matter what the tag may say—there is no
such thing as “One size fits all”!u
ISHRS 2015 PRACTICE CENSUS
On a biannual basis, the ISHRS collects practice data from members in an effort to analyze trends
and properly report to media on the state of Hair Restoration Surgery. The 2015 Practice Census Survey
will be e-mailed to ISHRS Physician Members in April. We ask that you please complete the survey.
It is very important to get a solid response rate.
It is shorter in length this year, and we are offering several incentives for participation. The data
report will be released to all members and published on the ISHRS website.
Thanks in advance!
58
www.ISHRS.org
March/April 2015
Generic Finasteride from front page
The Federal Food, Drug and Cosmetic Act (FFDCA) established the “180-day exclusivity” period, during which the
FDA will not approve other ANDAs for the same product. Dr.
Reddy’s, an international generic pharmaceutical company based
in India, was awarded a 180-day period of marketing exclusivity for finasteride 1mg on January 2, 2013, which expired on
July 1, 2013. Since then, the following generic manufacturers
also produce finasteride 1mg and 5mg: Accord Healthcare Inc.,
Actavis, Aurobindo, Camber, Hetero Labs, Mylan, Sun Pharma,
Teva, and Zydus (5mg).
Increasingly, generic pharmaceutical active ingredients are
made outside of the United States. This has raised concerns
about drug quality and regulation in various countries, and the
potential for counterfeit drugs. The FDA reported that 40% of
finished generic drugs, and 80% of active ingredients, are coming into the United States from overseas sources.4 In July 2012,
Congress passed the Food and Drug Administration Safety and
Innovation Act (FDASIA). In summary, it allows the FDA to
inspect foreign facilities, to increase penalties for adulterated
or counterfeit products, and to collect user fees from industry
to fund the reviews of innovator and generic drugs, medical
devices, and bio-similar products, and to expedite the development, review, and approval of “breakthrough therapies.” On
February 14, 2014, The New York Times published an article
titled “Medicines Made in India Set Off Safety Worries,” which
noted that “India is the second-largest exporter of generic and
OTC drugs to the U.S., supplying 40% of the US market.” They
reported that the FDA has increased inspection of Indian plants,
with new penalties and warning letters, and expressed concerns
about potential counterfeit operations in China, and frustration
with their efforts to increase inspections.
Counterfeiting occurs throughout the world, but it is most
common in countries where there are few or no rules about making drugs. An estimated 10-30% of medicines sold in developing
countries are counterfeit. In the industrialized world (countries
such as the United States, Australia, Japan, Canada, New Zealand, and those in the European Union), estimates suggest that
less than 1% of medicines sold are counterfeit.5 The only way
to know if a drug is counterfeit is through chemical analysis
done in a laboratory. Counterfeit drugs may look strange or be
in poor-quality packaging, but they often seem identical to the
real thing. In March 2013, the FDA formed a new Cyber Crimes
Investigation Unit, a special team within their Office of Criminal
Investigations (OCI), devoted to combating rogue Internet pharmacies. This unit works with other domestic and international
agencies to track down the operators and suppliers of websites
that illegally sell prescription drugs.
Tablet splitting is a widespread practice to allow for dose
flexibility and cost advantages for consumers. On July 21, 2009,
the FDA posted “Tablet Splitting: A Risky Business” on its
consumer site (www.FDA.gov), which noted: “FDA does not
encourage the practice of tablet splitting unless it’s specified in
the drug’s professional prescribing information. If a patient is
considering splitting a tablet, FDA recommends that the patient
gets advice directly from his or her doctor or pharmacist to determine whether it is appropriate or not for a particular drug.”
Possible risks to consumers include confusion over the dose, as
people may forget to split them, and tablets may be difficult to
The many different pill shapes and sizes.
split evenly due to size, shape, and technique. Several studies
have shown weight variability of unscored split tablets, even
those split by pharmacists.6 These concerns are especially relevant in drugs with a narrow therapeutic index.
Concerning the practice of splitting finasteride 5mg, two issues come into question: How evenly distributed is the drug in
half or quarter fragments, and does splitting affect the clinical
outcome? The U.S. Pharmacopeial Convention (USP) sets the
standards for identity, strength, quality, and purity of medications, which are enforced by the FDA. The amount of active
drug is never 100% evenly distributed in any tablet. One study
looking at the uniformity of distribution of finasteride in 5mg
halves and quarters showed a high mean average content in
both (2.88, 1.33).7 Another study concluded that drug content
variation in half-tablets appeared to be attributable primarily to
weight variation during the splitting process, highly determined
by the ability of patients to split tablets perfectly in half.8 A
Veterans Affairs study noted that 4/12 products that failed the
weight-uniformity test when split in halves, varied in tablet shape
and hardness.9 Splitting devices also vary in quality and design.
Among various manufacturers, finasteride 5mg tablets vary in
size and shape; thus fragmentation, powdering, and fragment loss
may occur with splitting. In addition, patients should be advised
not to split more than one pill at a time to be stored for later use
as exposure to heat, moisture, humidity, and other factors could
affect drug efficacy.
A review of the clinical pharmacology of finasteride is relevant to its therapeutic index range. Finasteride is a competitive
and specific inhibitor of Type II 5α-reductase with preferential
inhibition of the Type II isozyme, and is 100× selective for the
Type II 5α-reductase over Type I isozyme. For both isozymes,
the inhibition by finasteride is accompanied by a reduction of
the inhibitor to dihydrofinasteride and adduct formation with
NADP+. The turnover for the enzyme complex is slow (t1/2
approximately 30 days for the Type II enzyme complex and
14 days for the Type I complex). This may explain its long
relative clinical effect on hair loss. In terms of absorption,
Merck’s original study in 15 healthy young male subjects, the
mean bioavailability of finasteride 1mg tablets was 65% (range
26-170%), based on the ratio of area under the curve (AUC)
relative to an intravenous (IV) reference dose. Relative to an
[ page 60
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Generic Finasteride from page 61
intravenous reference dose, the oral bioavailability of finasteride
is approximately 80%. The bioavailability is not affected by
food. Maximum finasteride plasma concentrations are reached
approximately two hours after dosing and the absorption is
complete after 6-8 hours. The mean terminal half-life is approximately 5-6 hours in men 18-60 years of age and 8 hours
in men more than 70 years of age.10
The concerns of adverse events and post-finasteride syndrome have initiated discussions among physicians in terms
of titration of dose to potentially reduce symptoms, or patient
concerns over potential side effects, yet still maintain efficacy
for hair loss. In the original dose ranging study with finasteride
for male pattern hair loss,11 efficacy was demonstrated at 0.2mg
for all end points including hair count, investigator and patient
self-assessment of hair growth, and global photography. Efficacy
results were similar at 1mg and 5mg doses, which were superior
to the 0.2mg dose. Some suggested regimens are ¼ tablet every
other day, ¼ three times per week, and a “titration” program
of 1mg per week for 1 month, 1mg twice a week for 1 month,
then 1mg every other day. Fewer side effects and better patient
compliance, without reduced efficacy, have been observed.12
However, controlled clinical trials using 1mg, 5mg, and placebo
arms have not shown a dose-dependency relationship for sexual
side effects in both androgentic alopecia and benign prostatic
hyperplasia age groups.13,14
Several hair transplant surgeons anecdotally report comments
from patients that shedding occurred after switching from brand
to generic finasteride, or the generic seemed less effective. Explanations for this might include placebo effect, counterfeit drug,
or quality control differences in batches or processing. Based on
my research of FDA requirements for generic approval, and the
relative long effective half-life of finasteride Type II isozyme
complex, the splitting of generic finasteride 5mg should be an
equally effective alternative to the 1mg generic, or to the brandname drug, despite the potential for fragment loss during splitting.
60
March/April 2015
References
1. Merck Manual; http://www.merckmanuals.com/professional/clinical_pharmacology/pharmacokinetics/drug_bioavailability.html
2. Wikipedia
3. www.fda.gov
4. www.fda.gov
5. “Counterfeit Drugs: Fighting Illegal Supply Chains.” Howard Sklamberg testimony before Congressional Committee
of Energy and Commerce, February 27, 2014.
6. Rosenberg, J.M., J.P. Nathan, and F. Plakogiannis. Weight
variability of pharmacist dispensed split tablets. J Am Pharm
Assoc. 2002; 42:200-205. doi: 10.1331/108658002763508498.
7. Al-Haddab, M. Drug content and uniformity in commonly split tablets in dermatology. J Am Acad Dermatol.
2014(May); 70(5): Supplement 1, AB151.
8. Hill, S.W., et al. Analysis of drug content and weight uniformity for half-tablets of 6 commonly split medications. J
Manag Care Pharm. 2009(Apr); 15(3):253-261.
9. Polli, J.E., S. Kim, and B.R. Martin. Weight uniformity of
split tablets required by a Veterans Affairs policy. J Managed Care Pharm. 2003; 9(5):401-407.
10. Merck & CO., INC.
11. Roberts, J., et al. Clinical dose ranging studies with finasteride, a type 2 5α-reductase inhibitor, in men with male
pattern hair loss. J Am Acad Dermatol. 1999; 555-563.
12. Email communication with Drs. Michael Beehner, Ron
Shapiro, and Russell Knudsen.
13. Gormley, G., et al. The effect of finasteride in men with
benign prostatic hyperplasia. N Eng J Med. 1992; 327:11851191.
14. Roberts, J., et al. Clinical dose ranging studies with finasteride, a type 2 5α-reductase inhibitor, in men with male
pattern hair loss. J Am Acad Dermatol. 1999; 555-563.u
www.ISHRS.org
March/April 2015
Cyberspace Chat
John P. Cole, MD Alpharetta, Georgia, USA [email protected], and
Bradley R. Wolf, MD, FISHRS Cincinnati, Ohio, USA [email protected]
The Treatment of Men with Finasteride:
Scientific and Anecdotal Evidence
John P. Cole
Bradley R. Wolf
If women were told
(JC) How do we
manage the very young
that there is a medicapatient with a strong
tion that 65-80% of the
family history of androtime could stop the aggenic alopecia, who is
ing of their faces for at
advancing to a NW 5
least 5 years with minor
at a young age? In such
side effects, how popuindividuals, hair translar would that drug be?
plant surgery is not an
The scientific evidence
optimal option. Medical
suggests that finastetherapy is the obvious
ride is a miracle drug
answer, but what should
that prevents most men
we consider when medifrom prematurely losing
Figure 1. Pre-treatment (left) and after 7 years of Propecia (right).
cal therapy fails? We
hair that is genetically
all know the clinical
programmed to die. Our
studies, but what is our
patients should be enpersonal experience and
couraged not to outlive
how does personal expetheir hair! (See Figures
rience govern our deci1-4.)
sion making progress?
(JC) With this in
(BW) Edwin Epstein
mind, Jim Vogel represents a well-written
cently presented the
and well-referenced
case of a 22-year-old
lead article in this issue,
male who lost hair fol“Update on Efficacy of
lowing an 11-month
Generic Finasteride,”
course of generic 1mg
Figure 2. Pre-treatment (left) and after 8 years of Propecia
that explores scientific
finasteride (Figure 5).
evidence concerning finasteride. But does our knowledge What would you do and which questions would you ask?
end there? Of course not. Physicians have been prescribing What percentage of men are non-responders to finasteride?
finasteride in one form or another for 23 years during which What would your next course of action be? These questions
time much anecdotal evidence has accumulated. Anecdotal triggered an interesting debate.
evidence (information passed along by word-of-mouth but not
documented scientifically) leaves verification dependent on the The Anecdotal Evidence
credibility of the party or parties presenting the evidence. We
Ed Epstein pointed out that his experience with finasteride
leave it to you to assess the credibility of the information based was similar to the Merck study mentioned above. This seems
on those presenting the evidence.
to be a similar experience for Jerry Wong, Jim Vogel, and
Bill Parsley. Ron Shapiro feels that 70-80% respond with no
The Scientific Evidence
progression or more hair. Bob Haber feels that at the very least
(BW) From the original Merck studies: Investigator assess- finasteride slows down the progression of hair loss. Personally,
ment was based on a 7-point scale evaluating increases or de- a large percentage of my patients refuse to take any form of
creases in scalp hair at each patient visit. This assessment showed medication. In those men who take Propecia, I (JC) see about
significantly greater increases in hair growth in men treated with an 80% response.
Propecia® compared with placebo as early as 3 months (p<0.001).
Years ago, Bill Parsley studied his patients’ response to
At 12 months, the investigators rated 65% of men treated with Rogaine®. He was unable to find a single patient who had demPropecia as having increased hair growth compared with 37% in onstrated clinical improvement on Rogaine alone. Vance Elliott
the placebo group. At 2 years, the investigators rated 80% of men points out that Rogaine is very beneficial in his female patients.
treated with Propecia as having increased hair growth compared Personal experience (anecdotal evidence) indeed seems to
with 47% of men treated with placebo. At 5 years, the investiga- govern our treatment protocols. Dr. Parsley states that “the true
tors rated 77% of men treated with Propecia as having increased gold standard is how it works in your hands and in your office.”
hair growth, compared with 15% of men treated with placebo.¹
[ page 62
61
www.ISHRS.org
Cyberspace Chat from page 61
Figure 5. Dr. Vogel’s patient before (left) and 11 months after (right)
Bill Parsley, Ron Shapiro, Brad Wolf, and Bob Haber pointed
out a concern we are seeing with the generic finasteride. Vance
Elliott stated that he’s had only one patient who has NOT lost hair
when switched to generic finasteride, so he strongly advocates
the brand name (Propecia). Men who did respond to Propecia
at times fail on the generic version of finasteride. Therefore, if
a patient fails to respond to finasteride, make sure you give him
a trial of name-brand Propecia or quartered 5mg finasteride.
Bill Parsley points out that, while he has seen no problems with
5mg generic finasteride, he would not start a patient on generic
1mg finasteride or generic minoxidil in the first year. Bill and
many others have found that the combination of minoxidil and
finasteride is much better than finasteride alone.
In his article, Ed Epstein lists the manufacturers of generic finasteride and reminds us that we should report finasteride failures
to the FDA. Is this an industry-wide issue or company specific?
John Gillespie notes that many widely prescribed drugs including metformin, Synthroid, Norvasc, and Amoxil are dispensed
in generic form, so it does not make sense when men are failing
on generic finasteride. Ed points out that generic manufacturer
applications are required to show 80-125% bioavailability. The
question remaining is what percentage of counterfeit generics
has filtered into the marketplace.
Then there is the concern about compliance. How frequently
did they take the medication? Many men stop suddenly because
they see no improvement. Others may take the product sporadically because they see little improvement. It is also possible that
finasteride slows the progression of hair loss in some who appear
to be non-responders. Russell Knudsen pointed out that there is
an “aggressiveness index” in some patients who will not have
a complete cessation in balding while on finasteride when they
are experiencing significant and rapid balding. Bill Parsley noted
that some young male patients really want a hair transplant so
they will pretend to take the medication, appear to fail treatment,
and then seek a hair transplant. Some physicians recommend
that patients start on finasteride 3-4 months prior to surgery to
improve the donor area. Why, when there are supposedly no
receptors for DHT in the donor area?
Editor’s note (RHT): Yes, it appears to make no sense to
prescribe finasteride for the donor area. But I can think of one
reason: if you know you are harvesting from an area that you
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March/April 2015
think will probably be affected by progression of balding, putting such patients on finasteride helps to promote the longevity
of follicles transplanted from outside the “safe zone.”
Russell Knudsen referred to a case where the patient continued
to lose hair on finasteride, but he had significant recovery when
dutasteride, 0.5mg per week, was added to his medical regimen.
Of course, as Jim Vogel points out, another option is to switch your
patient to dutasteride. Jerry Wong reflected that he has at least 3 patients who did really well on dutasteride after they failed finasteride.
A Closer Look at Finasteride
(BW) The potential side effects of chronic finasteride use
should be completely explained to all patients who begin treatment. This can be accomplished by verbal and/or written instructions. Some physicians choose to have their patients read and sign
a document specifying the mechanism of action and the known
side effects of chronic finasteride use. Finasteride should not
be administered to men who have an elevated prostate specific
antigen (PSA). It is recommended that men over 49 years old
have a PSA level drawn prior to starting finasteride.
Other important points to be considered when prescribing
finasteride include: it takes an average of 6-12 months after
starting to see results and 6-12 months to lose the effects after
stopping treatment, always have the patient take photos before
initiating finasteride treatment for objective comparison, and
success is dependent upon the number of existing anagen and
miniaturized hairs present at the time of initiation of treatment.
The following forms of finasteride are currently available:
Brand finasteride 1mg (Propecia), generic finasteride 1mg, brand
finasteride 5mg (Proscar), generic finasteride 5mg. Benefits and
negatives are listed below:
Brand 1mg (Propecia)
Benefits: The gold standard, no counterfeits, optimal results
seen as soon as possible, no pill cutting necessary for therapeutic
dose, can dose in 1mg increments or less, private practice can
dispense from the office.
Negatives: Most expensive alternative.
Generic 1mg
Benefits: Approximately one-third of the cost of Propecia
and will decrease in price in the future, can dose in 1mg or less
increments.
Negatives: Manufactured off shore by generic makers with
reported poor quality control/counterfeits, difficult to dispense
from physicians’ offices, many reported treatment failures.
Brand 5mg (Proscar)
Benefits: None
Negatives: Same as for generic 5mg—more expensive than
generic, no greater efficacy than generic.
Generic 5mg
Benefits: Inexpensive alternative for treatment, consistent
good results, available at pharmacies in the United States for
as little as $10 per prescription, no reports of treatment failure.
Negatives: Must divide for therapeutic dose, variable amount
of finasteride in each fragment, loss of ingredient with cutting,
smallest dose is 1.25mg, if taken every day-higher chance of
side effects.
www.ISHRS.org
My Anecdotal Experience
(BW) Based on my experience prescribing finasteride to men
since it became available in 1992, I use the following criteria to
determine which form to prescribe:
Brand name 1mg (Propecia): I prescribe this to patients
who can afford it and, given the alternatives, request it to avoid
the chance of treatment failure. I dispense it from my office at
a reduced price compared to retail pharmacies. When starting
treatment, it is the gold standard to determine the initial response
to the recommended therapeutic dose (1mg/day).
Generic 1mg: This became available in 2013 and is a popular
alternative due to its reduced price. As reported by others, I have
seen multiple scenarios in which its use has led to treatment
failure. This includes men who have been on Propecia for a
long time and noticed shedding and/or thinning after taking the
1mg generic for 3-6 months. In some instances, the generic is
substituted for Propecia by the pharmacist unbeknownst to the
patient. They usually see a cessation of shedding/thinning with
resumption of Propecia. Patients who have originated treatment
with generic 1mg have seen no results and subsequently have
seen results when switched to Propecia. I have a patient who had
good results with one generic but was switched to another generic
by his pharmacy and saw shedding/thinning. This resolved with
resumption of the original 1mg generic. If patients are started
on or switched to 1mg generic, I inform them that they should
be aware of either no results or shedding/thinning in 3-6 months
and should switch to Propecia. I do recommended generic 1mg
for men who have been on brand name 1mg for 6-12 months
who want reduced price. These patients are warned to look for
shedding/thinning and change to brand name 1mg or ¼ generic
5mg immediately.
Finasteride 5mg: The brand name (Proscar) and generic
have the same effect, so I therefore see no need to use Proscar.
For some reason, generic 5mg finasteride has not suffered the
same pains as generic 1mg finasteride. When originating treatment with quartered generic 5mg finasteride (at most 1.25 mg/
day), I have never had a treatment failure or a patient complain
of shedding/thinning when switched to generic 5mg. Generic
5mg finasteride would seem to be the ideal option, but when
informed of all the options, some patients choose not to use
generic 5mg for three reasons: 1) they prefer not to split pills,
2) they do not want to risk ineffectiveness by having the active
ingredient unevenly distributed in the tablet, and 3) they don’t
want to risk the increased chance of side effects by taking 0.25
mg/day more than recommended. These are patients who want
the highest chance of success without regard to cost and choose
to use Propecia.
March/April 2015
mend that patients 50 and older take 1mg Propecia or 1.25mg
generic finasteride every third day. If patients experience side
effects and are concerned, it is recommended that they reduce
their dosage by half or stop the medication altogether. It is puzzling to me that the dosage reductions described above have not
led to complaints of shedding or thinning in patients, some who
had taken 1mg finasteride/day for 10 years or more. Why is this?
If testosterone in men decreases with age, is there a concomitant decrease in dihydrotestosterone (DHT), making decreasing
finasteride doses effective?
As patients age, the side effects from finasteride, decreased
libido and/or erectile dysfunction, are common without ingesting
finasteride. As men get older, their testosterone level gradually
declines—typically about 1% a year after age 30. Testosterone
peaks during adolescence and early adulthood. It is important
to determine in older men if a low testosterone level is simply
due to the decline of normal aging or if it is due to a disease
(hypogonadism).²
Testosterone decline is not inevitable with age, according
to Australian scientists. Older men in excellent health can
maintain their hormone levels. Two study centers in Australia
recruited 325 men over the age of 40 (median age 60) who had
self-reported excellent health and no symptom complaints. To
test blood testosterone levels, the researchers took blood samples
from the men nine times over three months. They excluded men
from the study who took medications that affect testosterone. Age
had no effect on testosterone level: “The modest decline in blood
testosterone among older men, usually coupled with nonspecific
symptoms, such as easy fatigue and low sexual desire, may be
due to symptomatic disorders that accumulate during aging,
including obesity and heart disease. It does not appear to be a
hormone deficiency state.”³
Examining the scientific and anecdotal evidence, in conjunction with years of experience, leads each to his or her own
rationale for prescribing finasteride. There is no doubt that it has
proven to be an effective medication.
References
1. Merck prescribing information: http://www.merck.com/
product/usa/pi_circulars/p/propecia/propecia_pi.pdf
2.See http://www.mayoclinic.org/healthy-living/sexualhealth/in-depth/testosterone-therapy/art-20045728
3. See http://www.sciencedaily.com/releases/2011/06/110607121129.
htmu
Reduced Dosing
Anecdotal evidence has shown that doses of less than 1 mg/
day are as effective as 1mg/day. Russell Knudsen may have
been the first to report dosing less than 1mg/ day, prescribing
rather 1mg three times a week. Bill Parsley often starts patients
on ¼ mg per day, a 1mg tablet quartered. I have been using
reduced doses for a number of years. I start men who choose to
use quartered 5mg finasteride on at most ¼ tab (1.25mg) every
other day, which is 2.5mg every three days. If patients who are
40 years old and older choose Propecia (1mg), they are started
on 1mg every other day. Any patient who is overly concerned
about side effects are started on a reduced dose. I often recom63
www.ISHRS.org
March/April 2015
How I Do It
Timothy Carman, MD, FISHRS La Jolla, California, USA [email protected]
Hairline design and execution can be one of the most challenging aspects of hair transplant surgery.
It is the very first feature that is directly viewable in the hair transplant patient, and is often that which
leads to the general overall impression of a “natural” vs. “man-made” appearance. Dr. Muhammad Ahmad
describes his system for creating hairline designs in his practice setting.
If you have a suggestion or a tip you employ in your practice that you would like to share with your
peers in the ISHRS, please feel free to email me at [email protected]
Designing the Hairline: The Role of the Thumb
Muhammad Ahmad, MD Islamabad, Pakistan [email protected]
Hairline design is the most important point in hair transplant
surgery. Basic hairline design follows guidelines discussed in the
literature.1-4 Creation of the hairline is one of the biggest concerns
for the patient and one of the most difficult and artistically demanding aspects for the surgeon.4 The newly designed hairline should
have two important features. First, it should look like a natural
one (in terms of hair angles and distribution). Second, it should be
individualized. With advances in hair transplant surgery, comes
new innovations that have resulted in the use of more equipment
in our field (e.g., the laser-guided device for hairline design).5,6
Many points should be kept in mind before deciding a definitive hairline: shape of the forehead, angle of inclination, age of the
patient, severity of hair loss, and the patient’s expectations. Attempts to over-standardize the hairline will result in aesthetic failure. Below is a simple and low-tech method of marking hairline.
Figure 2. Different thumb positions showing changes in the hairline.
Method
First, the anterior mid-point is marked in the midline on
forehead. It is marked at a distance above the mid-glabellar line
that is equal to or greater than the distance from the mid-glabellar
line to the tip of the nose. This is in keeping with the “Rule of
Thirds” in facial proportion (Figure 1A).
Next, the surgeon marks the hairline on the lateral sides starting
from the outer edges of the eyebrows (Figure 1B). The surgeon
then uses his or her left thumb to position and mark the left half of
the hairline (Figure 1C). Last, the thumb is moved to the right side
to position and mark the other half of the hairline (Figure 1D). (A
left-handed surgeon would use the thumb on his or her right hand.)
other part of the procedure will have as much as impact on the
patient’s appearance. The position and shape of the hairline is
the template on which present and future surgery is patterned.7
The literature mentions various hairline designs (triangular, oval,
flat, crescent, etc.), but it takes years of practice to know which
hairline would suit each individual patient the best.
The above thumb method easily mimics the hairline and can
be used to design many hairline types—from triangular to oval
to crescent—whatever best suits each patient (Figure 2). Because
the hairline is illustrated by the full width of the thumb, this
method also gives the patient and surgeon a three-dimensional
view of the anticipated hairline, which helps in making adjustments according to the patient’s preferences.
Discussion
Proper marking of the hairline is the most important factor
determining the ultimate naturalness of the results. A proper
hairline design suitable to the shape of the forehead and adjusted
to the overall facial profile will result in a natural hairline. No
Conclusion
Using a thumb is a very easy method to mark a hairline and
can help illustrate to the patient the proposed result of the hairline
in transplant surgery.
References
Figure 1. Method of marking the hairline.
64
1. Unger, W.P. Hair Transplantation, 3rd Ed. Marcell Dekker:
New York, 1995; pp. 105-110.
2. Rose, P. Considerations in establishing a natural hairline.
Int’l J Cosmetic Surg. 1998; 6(1):24-26.
3. Seery, G. Guidelines for designing and locating hairline.
Am Cosm Surg. 1998; 15:21-25.
4. Rovira, R.V., et al. Importance of hairline study previous
to hair transplant. ESHRS Journal. 2010; 53-54.
5. Shiao, T.K., and I.S. Shiao. Laser-guided hairline design and donor strip marking. Hair Transplant Forum Int’l. 2007; 17(2):53.
6. Ng, B., et al. Laser-assisted hairline placement. Hair Transplant Forum Int’l. 2008; 18(5):169-172.
7. Parsley, W.M. Frontal hairline design. In: M.R. Avram
and N.F. Rogers, eds. Hair Transplantation. Cambridge
University Press: New York, 2010; pp. 35-48.u
www.ISHRS.org
March/April 2015
Complications and Difficult Cases
Marco N. Barusco, MD Port Orange, Florida, USA [email protected]
I have previously presented a case report in this column describing the management I use in transplanting patients with irradiated scalps and the potential dangers we may encounter. The previous case focused
more on managing the recipient site and trying to avoid poor growth and tissue necrosis while achieving a
cosmetically pleasing result for the patient. This is a different case, which required a slightly different approach and, as it turned out, could have been complicated during the donor removal phase of the procedure.
A Close Call with Donor Area Harvesting on a Patient with
Irradiated Scalp
The objective of this case description is to highlight important
decisions that we need to make pre- and intra-operatively when
assessing donor areas for procedures in these patients in order
to minimize the risk of complications.
Fortunately, the outcome for this patient was excellent and
she is extremely happy with her results, not only in her physical
appearance but, even more importantly, in her self-confidence
and psyche. So this case incidentally also highlights the difference we are able to make in a patient’s life with a “simple”
surgical intervention and how important our job is to our patients.
Background
M.P. came for a consultation with me in 2013. She was 55
years old at the time. She was accompanied by her husband of
many years. As I introduced myself, I started to visually assess
her hair and could not see any obvious hair loss, so my initial
thoughts were that she would be another one of the countless
patients who need only medical therapy, if anything, for their
perceived—and not yet visible—hair loss. It was not to be so.
The problems with her hair started at age 17 when she had to
undergo surgery for a brain tumor located in her cerebellum. For
about 4 years before she was diagnosed and operated, she suffered
from debilitating headaches and a progressive ataxia that made it
difficult for her to walk normally. For a female teenager, it was very
difficult to cope with this situation. Then the diagnosis of the tumor
was finally made and emergency surgery was indicated due to the
imminent danger of herniation of her brain stem from the mass
effect and increased intra-cranial pressure caused by the tumor.
The tumor was partially resected and was diagnosed as a
Cerebellar Pilocytic Astrocytoma. After the procedure, she developed aseptic meningitis and was finally released home after
a lengthy hospital stay. Because the tumor was not completely
removed with the surgery, she had to undergo radiation therapy
to prevent recurrence, which caused hair loss over a large area of
her parieto-occipial scalp (Figures 1, 2, and 3). The silver lining
was that with intensive physical and occupational therapy she
recovered most of her motor abilities. Fortunately, she has not
had recurrence of the tumor.
But the long-lasting physical and psychological scars from
this experience would be a constant source of anxiety for her.
Due to the hair loss that she experienced in her occipital scalp,
she was not able to ever pull her hair up or go swimming. On a
windy or rainy day she would worry that the areas of hair loss
would become visible. For a young woman in her teens, this was
really bad. Though eventually she married, and her husband is
very supportive of her, encouraging her every step of
the way, she carries deep
emotional scars from what
she had to endure.
After an emotional
conversation, I examined
her scalp and determined
that she had an extensive area of post-radiation
alopecia covering most
of her occipital scalp and
extending laterally into the
parieto-temporal areas. I Figure 1. Pre-operative view of the area of hair loss.
also noticed a vertical scar
along the midline of the inferior posterior area of her
occiput, extending into the
upper neck. On palpation,
I could feel that there was
a soft spot on the inferior
area of her occipital bone.
She had no pain in these
areas. Capillary refill was
adequate and the skin,
although thin, was supple
and with a good amount of
Figure 2. Pre-operative view—right oblique.
subcutaneous tissue. Luckily for her, the remainder
of her scalp hair was thick
and showed no signs of
miniaturization. She has
medium to coarse hair caliber, with an overall density
of 75-80 follicular units
per square centimeter.
Based on the above,
an FUT procedure was
proposed to add hair to
Figure 3. Pre-operative view—left oblique.
the irradiated scalp area,
staying away from the soft
spot that was noticed in her inferior occipital area. As part of
the pre-operative work-up, her medical records were reviewed
and a skull series X-ray was ordered (Figures 4 and 5), which
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Complications from page 65
confirmed the lack of occipital
bone near the foramen magnum. No hardware or cranioplasty material was present,
other than a few surgical clips
in her cerebellum.
Case Presentation
History
The patient is otherwise
healthy. No medications other
than over-the-counter health
supplements. She is allergic to
Codeine (it caused her to feel
anxious and “shaky”). No other
surgical history.
Regarding her hair loss,
there is no hair miniaturization and no history of female
pattern alopecia in either side
of her family.
Physical Examination
Figure 4. Pre-operative skull X-ray—lateral
view.
Figure 5. Pre-operative skull X-ray—AP
view.
M.P. is a healthy 55-yearold female. Very pleasant, with good eye contact but emotional
when talking about the hair loss problem. General physical exam
is normal other than a slight tremor and ataxia of the extremities.
Scalp exam shows areas of hair loss as previously described,
along with the scar from the neurosurgery. Anterior scalp, midscalp, and crown areas are fully covered with medium to coarse
caliber hair, with no signs of miniaturization and overall density
of 75-80 follicular units/cm2.
After considering all options and discussing all potential problems and complications of the hair transplant surgery, the patient
and her husband decided to follow through with the procedure.
Intervention
1. Pre-operative management
a. Mupirocin ointment to both nostrils three times daily
was started 3 days prior to the procedure and continued
for a total of 5 days (MRSA prevention).
b. Hair and body (except face) were cleansed with Hibiclens
(4% chlorhexidine) once daily starting 3 days before
surgery.
2. Intra-operative management
a. Pre-operative photographs and marking were done and
her hair was washed with chlorhexidine.
b. I opted to take a donor strip high in the occipital area,
leaving about 1cm of hair between the edge of her hair
loss and the lower edge of the donor strip. This was done
in an effort to avoid excising into the irradiated scalp
(Figure 6).
c. Donor density measurements were taken yielding an
average density of 75 FU/cm2.
d. Donor elasticity measurement using the Meyer-Pauls system yielded an elasticity of 18%, so I knew that the area was
somewhat tight. Based on this observation, the maximum
width of the proposed donor strip was kept at 12mm.
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March/April 2015
e. Planned occipital
strip of donor tissue was marked,
taped, and shaved
according to my
normal protocol.
f. Before anesthesia,
the skin was prepared again with
Hibiclens.
g. S i n c e t h e d o nor area in this Figure 6. Proposed donor strip before harvesting.
case was located
above the recipient area, the
anesthetic ring
block was done
to include both
the recipient and
donor sites inside
the ring, to avoid
causing the patient to feel both
the donor site and Figure 7. Proposed recipient area avoiding the
the recipient site soft spot.
anesthesia separately (Figure 7).
h. Sterile drapes were applied to expose only the shaved
strip of donor hair to be removed.
i. Just before harvesting, a small amount (6cc total) of
normal saline was injected for tumescence along the
donor strip.
j. Donor harvesting was done per my usual protocol using
a single-blade scalpel.
k. The scalp had a normal amount of subcutaneous tissue, and
I stayed above the galea aponeurotica. The first incisions
were made with a width of 10mm, instead of 12mm, to
test for skin elasticity. After the removal of the strip, the
scalp was noticed to be very inelastic, particularly in the
central area of the strip, with very limited movement inferiorly and superiorly. At maximum approximation, there
was still a 3-4mm gap between the edges of the wound.
At this point, I felt that familiar “spine chill” that we feel
when this happens, and I am sure I thought of a couple of
expletive words, but managed to keep them to myself.
l. I decided to do a small amount of undermining superiorly
(3-4mm), but not inferiorly, in order to prevent going
into the irradiated area and to preserve the blood supply
coming into the wound. Even with the undermining, the
gap still persisted at 2-3mm.
m. 4 small galeotomy incisions (1cm in length) were made
along the donor incision, to improve mobility and stretching. They failed to do much.
n. Towel clamps were gently applied and after 5-10 minutes, the gap was reduced to 1-2mm.
o. At this point I decided not to pursue any more strategies
to close the gap completely, to avoid too much trauma
to the already frail tissue.
p. Deep sutures were attempted, but the tissue started to
tear so this was abandoned.
q. Skin sutures were applied with 4.0 Mononylon, approxi-
r.
s.
t.
u.
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mating the skin edges as much as possible but gently,
without putting too much pressure on the edges. The
resulting gap of 2mm was left open to heal by secondary
intention (Figure 8).
After sutures were applied, the suture line was covered
with Bacitracin ointment and was occluded with sterile
Telfa and sterile gauze.
Hibiclens solution was used to prepare the recipient area
of the scalp.
No tumescence or epinephrine were used in the recipient
area, in order to preserve the vascular supply as much as
possible.
Before the recipient sites were made, the skin was cleansed
with Hibiclens. 18-gauge needles were used to create the
recipient sites, bent to create a depth of 3-4mm. Densepacking was avoided. Instead, we opted for even distribution of hair, knowing that the patient would come back if
necessary for a second surgery for density (Figure 9).
March/April 2015
level laser treatments were done in the office every other
day for the first 10 days.
Patient Evolution
On a routine phone call on the night of the procedure, the
patient stated that she was having significant pain in her donor
site (7-8 out of 10), particularly the central portion of it, but the
pain was adequately controlled with a combination of Ibuprofen
and Hydrocodone/APAP. She denied any major bleeding and the
bandage stayed dry overnight.
On the first post-op day, the donor bandage was removed and
the donor area looked good, with a small amount of coagulated
blood now filling the gap between the edges. The patient’s pain
was better (5-6 out of 10) and she continued to show good progress and good healing.
Fortunately, the patient recovered without any problems, and
the sutures were removed on the 14th day post-op. No tissue
necrosis was noted on the donor area, and the incision showed
nice granulation and healing.
The patient came for follow-up visits at 4, 8, and 12 months,
and steady hair growth was noted in the recipient areas. At the
12-month visit, she had a big smile on her face and her husband
was also very happy with the changes he noticed on her. She
was feeling much more confident with her hair and could not
wait to have another, smaller procedure to improve density in
the area that was treated. The final donor scar measures 2mm in
width at its widest point. The patient is able to conceal it with
no problems and is not worried about it (Figure 10).
Figure 8. Donor area immediately after closure; notice the gaps highlighted
by the yellow areas.
Figure 9. Recipient area immediately after graft placement.
v. The patient tolerated the procedure well. A total of 1,693
follicular unit grafts were transplanted (we had originally
planned for 1,800-2,000 FUs).
w. Patient was instructed to return to the office the next day
for a post-operative evaluation and hair wash. I advised
her of the possibility of increased pain in the donor site,
due to the tight closure. I also discussed with her and her
husband the possibility of hair loss along the incision and
the possibility of an area of necrosis that would have to
be addressed later, if necessary.
3. Post-operative management
a. Patient was prescribed pain control according to our
standard protocol.
b. Patient was instructed to take Cephalexin 500mg tablets
3 times a day for 10 days, due to the open gap left along
the donor site.
c. Hair washes were performed daily at the office and low
Figure 10. 12-month’s post-op. Good growth and results. Donor scar is
shown in the yellow rectangle.
Thoughts and Pearls
This case illustrates very well how we are sometimes surprised by intra-operative observations as far as the elasticity of
the donor area. Countless cases have been reported on necrosis
and hypertrophic scarring that occurred from donor areas that
were too tight and/or the strip removed was too wide.
In this patient, even though all steps were taken to assess the
donor elasticity before the strip was taken, the added precaution
of taking less than what I marked is what I believe helped avoid
a much worse complication, together with not undermining inferiorly in this particular patient and with the choice of leaving a
small gap in lieu of trying to pull the skin together with the sutures.
We must always be thinking about potential unexpected problems, and should always be prepared to manage intra-operative
complications. But the best approach is always to try to prevent
problems.u
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March/April 2015
Ask the Fellows
We are pleased to continue our Ask the Fellows series in which unanswered clinical questions
identified by participants at the Kuala Lumpur meeting are answered by our Fellows. As we saw
last issue, their replies are clear and comprehensive. It is evident that we have a great deal of
knowledge and wisdom contained within our Society.
Why are more doctors now preferring FUE?
David Josephitis, DO, FISHRS
There are many different ways in which to address this observation. Over the past decade, there has been a great rise in the
number of FUE procedures performed worldwide. In fact, there
was a six-fold increase in the total number of patients undergoing
FUE from 2007 to 2013, whereas during the same time period,
there was very little growth in the yearly average of FUT.* There
appears to be more of an evolution in the use of FUE going on
than there is simply more physicians choosing FUE over FUT.
One factor among many may be that the indications for the use
of FUE have been growing as physicians have improved their
techniques leading to a concomitant increase in yield, a lower
transection rate, and a more reliable result. FUE has opened up
hair transplantation to more candidates than ever before. There
are those patients who psychologically did not want the strip
procedure and those patients who desired a shorter haircut who
are now becoming new patients. FUE has been found useful as
a way of getting more donor out of patients previously unable
to do any more strip procedures. The procedure has also found
value in giving surgeons an ability to harvest additional hair from
other areas of the body, which was not practical before. And these
are just a few examples. FUT may continue to be the procedure
of choice for the majority of surgeons and their patients, but the
broadening use and benefits of FUE will surely drive the field
of hair transplantation to an ever-widening audience.
*International Society of Hair Restoration Surgery: 2007 &
2013 Practice Census Results. Retrieved from www.ishrs.org
Media Center.
I met several unsatisfied patients after FUE from another
clinic: Why and what should I do?
Sara Wasserbauer, MD, FISHRS
This is always a tricky question: how do you deal with a dissatisfied patient who has had work done somewhere else? The
first order of business is to be professional. Try to refrain from
passing judgment on the previous surgeon since you were not
in the operating room during that last surgery to see for yourself
what might (or might not!) have been done. It does harm to our
profession as a whole when one surgeon belittles another in
front of a patient.
Next, get as many facts as you can—including exactly what
was done—and get the medical records from the other clinic. This
might tell you why they are dissatisfied. Were their expectations
higher than what could reasonably be accomplished? Did they
start on medical treatment or have they had further hair loss since
the surgery? Your question specifically notes that these were FUE
patients and there is currently a lot of hype and false promises
being promulgated on the Internet regarding that method of hair
transplantation in particular, so be aware that the other clinic may
not be completely to blame for an unsatisfied patient.
68
Finally, assess how well equipped you are to rectify the situation. As physicians, we have a tendency to want to help everyone, and we can have a higher opinion of our own work than is
warranted! (And I am not exempting myself from this category!)
If you understand what the problem was with the each patient’s first surgery and it was a fairly simple issue (such as not
transplanting enough grafts or progressive hair loss), consider
re-transplanting the patient yourself, but be cautious. Additional FUE is possible after a first (unsatisfactory) attempt, as
is traditional strip surgery depending on the patient, so you are
likely to have additional resources for obtaining grafts for your
patient, but you still may not be able to reach the patient’s goals
for his or her hair.
There are many options for getting a reasonable result for
these patients (including SMP and starting medical treatment
among others!), and making the effort on their behalf can be
enormously rewarding. When in doubt, consult your fellow hair
surgeons and always choose what is in the best interest of the
patient, even if it means not treating them yourself.
How do you treat female androgenetic alopecia as well as is
possible with androgenetic alopecia?
Shelly A. Friedman, DO, FISHRS
Female androgenetic alopecia is also known as female pattern
hair loss (FPHL) and can be treated in several ways:
1. Hair transplantation. Hair Transplantation in women is
very successful as long as the donor region is insensitive
to dihydrotestosterone (DHT). Unlike males, who typically
do not bald or thin over the posterior occiput and parietals,
women frequently experience scalp thinning over the parietals
and occasionally over the posterior occiput. In the younger
woman, it is difficult to “read the future” regarding future
areas of hair thinning. Statistically, more women are not good
candidates for hair transplantation as compared to their male
counterparts.
2. Low level laser therapy (LLLT). LLLT has proven to be very
successful in controlling future hair loss and miniaturization.
By increasing adenosine triphosphate (ATP), there is a release
of energy and stimulation of the metabolic process required
for hair growth. There is also a release of nitric oxide resulting
in an increase in scalp blood flow. LLLT has the following
effects:
a. Increases cell survival
b. Reduces follicular apoptosis
c. Reduces inflammation
d. Increases the anagen phase and decreases the telogen
phase
e. Increases hair tensile strength
f. Reverses miniaturization
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3. Minoxidil (Rogaine®). Minoxidil acts as an arteriolar vasodilator that opens potassium channels. Minoxidil sulfate is
the active metabolite that stimulates hair follicles.
4. Spironolactone (Aldactone): Spironolactone is a potassiumsparing diuretic with antiandrogen properties that has been
successful in stopping hair loss in some women.
5. Finasteride (Propecia®). Finasteride inhibits type II 5-alphareductase, interfering with the conversion of testosterone to
5-alpha-dihydrotestosterone. Propecia is not FDA cleared for
women due to potential birth defects.
What technical factors increase the risk of necrosis in the
recipient area?
Scott A. Boden, MD, FISHRS
Scalp necrosis caused by localized microcirculatory collapse
is a serious complication and can occur in both the donor and
recipient areas.1,2 Any factor that decreases the blood supply may
induce an ischemic or potentially necrotic response in both the
donor and/or recipient area.3 Although the scalp is well vascularized, risk of recipient area necrosis is increased when local blood
supply is compromised and cannot meet vascular demand within
the recipient zone. Pre-existing medical conditions including
prior scalp surgery (e.g., recipient site scarring, scalp reduction,
brow lift), diabetes mellitus, and atrophic skin changes may
predispose a patient to recipient area necrosis.
Avoiding recipient area necrosis is critical; early recognition of potential vascular compromise may prevent progression. At the first sign of delayed capillary refill or cyanosis, the
surgeon should stop and assess possible contributing factors.
These factors may include “dense packing” of incision sites
that overwhelm local blood supply or incision sites that are too
large or deep, causing damage to the local vascular bed. Risk of
ischemic injury and scalp necrosis can be mitigated by limiting
concentration of epinephrine-containing solution and thereby
avoiding excessive vasoconstriction.
Patients who smoke should be encouraged to quit or at
least stop smoking in the weeks prior to and following surgery.
Nicotine may cause vascular lesions from inflammation3 and
have deleterious effects on microcirculation. For smokers who
undergo hair transplantation, it is recommended to reduce epinephrine concentration, avoid dense packing techniques, and
follow the patient closely in the post-operative period.
References
1. Konior, R.J. Complications in hair restoration surgery. Facial Plast Surg Clin North Am. 2013(Aug); 21(3):505-520.
2. Unger, M.G. Postoperative necrosis following bilateral
scalp reduction. J Dermatol Surg and Onc. 1988(May);
14(5):541-543.
3. Perez-Meza, D., and R. Niedbalski. Complications in hair
restoration surgery. Oral and Maxillofacial Surg Clin North
Am. 2009(Feb); 21(1):119-148.
How can I minimize my FUE transection rate?
Robert M. Bernstein, MD, FISHRS
For the past 2½ years, I have performed FUE exclusively using the ARTAS® Robotic System, as I found that my yield was
higher using the robot than with handheld devices. The basic
principles to reduce transection apply to both manual and robotic
techniques, although I find them easier to apply with the robot.
March/April 2015
1. Patient selection. Patients with tight or tough scalps are
generally the best candidates for FUE. Patients with loose,
distensible scalps generally have the greatest transection
rates and are often poor candidates.
2. Motorized devices. A motorized or robotic device will have
less side-to-side movement than when using fingers to rotate
the punch.
3. Tension. A mechanical tensioner is applied to the scalp to
create very consistent traction on the area to be robotically
harvested. In regular FUE procedures, manual traction can
create tension to decrease tissue movement and decrease
transection.
4. Tumescence. The superficial injection of fluid just before
extraction can help in some, but not all, FUE cases to
decrease transection by increasing rigidity (stability) and
slightly changing the angle of the hair.
5. Angle of entrance. The angle that the punch enters the scalp
should be less acute than that of the emergent hair. The
robotic device adjusts for this automatically.
6. Speed of rotation. Rapidly rotating punches seem to cause
less transection than slower ones.
7. Punch sharpness. Blunt dissection seems to yield less transection than a very sharp punch.
8. Punch depth. A more superficial punch depth causes less
transection on cutting, but may cause more damage (shearing) on the extraction step.
9. Punch size. A larger punch will always cause less transection than a smaller one, although it will also produce more
scarring. The punch size needs to be determined on a caseby-case basis.
10. Magnification. The greater the magnification used, the
more control you will have over the extraction and the less
transection.
11. Graft selection. The larger the FU selected (with respect to
# of hairs), the greater the transection, but the smaller the
FUE the more scarring/hairs harvested. These two factors
have to be balanced with the aesthetic needs of the patient.
12. Extraction. There is less trauma to follicles when extracted
manually (i.e., with forceps) than with suction.
Bibliography
1. Bernstein, R.M. Integrating robotic FUE into a hair transplant practice. Hair Transplant Forum Int’l. 2012; 22(6):
228-229.
2. Rose, P.T., and B. Nusbaum. Robotic hair restoration. Dermatol Clin. 2014; 32:97-107.
How do you harvest follicles in an FUE megasession?
Craig Zeiring, MD, FISHRS
Careful planning of the donor site in an FUE megasession
is crucial. Typically, the donor area is completely shaved, but
this is not always the case, especially if the patient has previous
strip scarring. We harvest follicles with the SAFE system and
the ARTAS® Robotic System. Whether we use manual or robot,
the donor area is marked with a surgical marker or China pencil.
The donor area is mapped out to predict yield and to keep spacing
even and cosmetically ideal
For a manual FUE megasession, (I use the SAFE system) the
donor area is mapped. An appropriate sized punch is selected
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for the patient. The angle and direction are carefully evaluated.
The RPM is selected, with appropriate tension applied by the
assistant, and the first punch is performed. It is immediately
harvested to evaluate for surrounding tissue as well as possible
transection. The puncture depth is determined by the surgeon,
in order not to bury the follicle. The angle is adjusted by the
surgeon to avoid transection. A few additional follicles are
harvested and quickly evaluated for transection. Once the angle,
depth, and RPM are appropriate for the patient, the section of
donor is harvested and extracted. Each attempt at extraction is
well thought out, well executed, and repeated many times. Care
is taken to avoid overharvesting, with the goal of approximately
15% of donor follicles being removed. The remaining mapped
donor area is harvested and extracted, with careful observation
to see if any transection is occurring. For patients who have
previous scars, care is taken to harvest between the scars, without
overharvesting.
For ARTAS robotic FUE, the donor section is mapped out
using the tensioner. The puncture depth, coring depth, angle,
and RPM are determined by the system, but continuously adjusted by the surgeon at the hair pendant. We use a paper grid
to determine the placement of the tensioner, and with each
placement of the tensioner, ensure that the skin blanches and
the tensioner is tight to the scalp. Occasionally, tumescence is
performed. Approximately 5-10 punches are made at the start
and harvested to evaluate if the appropriate amount of tissue surrounding the bulb is present and if any transections are present.
Once the appropriate settings are determined, the robot harvests
the follicles within the tensioner. The first grid is fully harvested
and harvest continues with random extraction of follicles while
the robot is harvesting within the tensioner to ensure a minimal
amount of transection. Typically, 1-2 grids are done at a time
without stopping to reduce the amount of time spent in the robot.
If transections are present, then the robot is paused, and the settings adjusted, and the robot is allowed to harvest an additional
5-10 follicles before proceeding. The spacing between follicles
is typically 1.8 mm to allow sufficient donor follicles to remain.
Patient position is important for maximal harvest as well as
patient comfort. We have the patient typically in a donut pillow
for comfort and to keep the patient still. Occasionally, we have
patients on their side in order to harvest the follicles at more
difficult angles.
With both harvesting techniques, particular care is taken to
feather the donor area for optimal post-op aesthetics.
Please note that all harvesting is completed in one day. If a
patient is receiving more than 1,500 grafts, then the recipient
sites are made the afternoon before.
How do you avoid poor growth?
Wen Yi Wu, MD, FISHRS
Poor growth can arise because of graft dehydration, physical
trauma to the grafts, excessive placing time, popping of grafts,
grafts placed too deep, piggybacking, empty recipient sites, bent
grafts, and/or poor graft angle and direction.
Good visualization is critical to successful graft placement:
• Use magnification when placing.
• Keep all eyes on the target; the placers need to limit the
number of times they look away from the recipient sites
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March/April 2015
to avoid losing the positions, increasing the chance of
missed sites, piggybacking, and wasted time.
Follow a pattern; this is more efficient than randomly
placing the grafts and continually searching for empty
sites.
Leave donor hair a little longer; this helps the placer
locate the filled sites and make adjustments easier.
Control bleeding; excess bleeding is one of the common
causes of poor visibility, traumatic placing, and prolongation of procedure time.
Avoid graft dehydration:
• Make sure that all grafts are submerged at all times in
the holding solution.
• Spray grafts frequently when not in solution.
• Limit the number of grafts taken out of solution and
placed on a finger for implantation.
Maintain proper graft sizing:
• A snug fit of the grafts and incisions is crucial.
• When grafts are too big, forceful insertion is necessary,
which can lead to multiple failed attempts and popping.
• When grafts are too small for the sites, buried grafts and
piggybacking may result.
Maintain proper incision spacing and depth:
• When sites are too close, popping may occur.
• Incisions that are made too deep may cause increased
bleeding, buried grafts, and pitting.
• Incisions made too shallow may lead to difficult graft
insertion and popping.
How do you prevent and manage bleeding during
megasessions?
Melvin L. Mayer, MD FISHRS
Remember the THREE P’S:
PREVENTION: There are many supplements, medications,
and activities that increase coagulation time. Since blood is the
“glue” that initially holds the graft in place, supplying nutrients
and hydration, it is preferred to have the blood as viscous as possible on surgery day. Therefore, you should advise patients to
avoid ASA, fish oil, and blood thinners such as Eliquis, Xarelto,
Plavix, Coumadin, and several others for about one week prior
to surgery. You should also take a detailed history including
ALL medications and understand the action of each. Before any
anticoagulation is discontinued, you should work in consultation
with the patient’s treating physician.
To help prevent excessive bleeding, it is imperative to limit
the depth of the incision to the varied length of the follicular units,
usually 3.5-6.0mm. Also, the width of the blade is important to
match a snug fit. You might consider decreasing the density of
receptacle sites.
PRESSURE: Allow tumescence including 1:100K dilution
of epinephrine in normal saline to set for 5-10 minutes before
making receptacle incisions. Typically 10cc’s in the front half
and the same in the crown usually suffice. Repeating the dose
using a #30 gauge needle after a couple of hours may be helpful.
Spraying frequently with cold, normal saline is helpful. It is a
must to keep the recipient field CLEAN and DRY, refreshing
the gauze frequently used to apply GENTLE PRESSURE on the
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most recently placed graft. If a graft “pops,” replace it quickly
to stop bleeding and again hold GENTLE PRESSURE while
picking up another graft with the forceps.
PATIENCE: Rotate staff, if available, to help reduce anxiety
when placing an oozing patient. Keep your level of frustration
down; realize that occasionally you will have a patient who
takes 1-2 hours longer than usual to place. Always use the “art
of gentle insertion.”
How do you prevent and treat donor infection?
Eileen Tan, MBBS, FISHRS
In general, hair transplantation surgery is considered a clean
procedure. Antibiotics prophylaxis is not mandatory for every
patient except in immunocompromised state. I would like to
share some useful tips to prevent scalp infection after surgery.
Pre-operative. One useful preventive tip is to prescribe an
antiseptic wash, such as Cetrimide or Hibiclens, to be used 3-5
days prior to the procedure. Make sure that the patient does not
have an active scalp condition or folliculitis, which requires
medical intervention, before scheduling an elective surgery.
Intra-operative. To prevent surgical site infection, doctors and
other healthcare providers will take several aseptic measures to
ensure that the surgical site is as clean as possible. This includes
cleaning the skin at the surgery site with chlorhexidine solution.
Post-operative. Daily washing of the hair is important after
the surgery. Shampooing helps remove blood and debris and
will gently dislodge the “crusts” or scabs on both the donor and
recipient sites. Topical antibiotic creams, such as mupirocin, are
applied to the donor site for the first 2 weeks.
Treating Donor Site Infection
Donor site infection is fortunately rare. The signs of scalp
infection include localised tenderness, painful and itchy bumps,
purulent discharge, and crusty appearance. Bacteria culture
is advised to be taken from the inflamed site prior to starting
antibiotics. A topical antibiotic ointment and oral anti-staphylococcal antibiotics are prescribed for several days. Good hygiene
practices, such as using clean towels, avoiding scratching, and
avoiding excessive sweating, aid in the wound healing process.
Patient Instructions
To prevent infections in skin wounds, follow these tips:
• First control bleeding, and then clean the wound with
soap and water.
• Keep all foreign matter (i.e., hair, clothing, dirt, and
fluids) out of the wound.
• Do not try to remove matter embedded in the wound.
• Use sterile materials for the first dressing of the wound.
• See your doctor for final, definitive cleaning of the
wound.
What is the correct way to report our cases? Graft count or
hair count?
Vance Elliot, MD, FISHRS
My preference has always been to record both graft count and
hair (follicle) count. We record the number of grafts of each type
and the average follicle content in each graft category and then
calculate the estimated total follicle count transplanted based
on those numbers. In my opinion, both numbers are important.
In the call for abstracts for the ISHRS annual meeting, the
March/April 2015
following guidelines are given: “For ISHRS meeting presentations and articles for the Forum, it is important to report on the
number of hairs, and not only the number of grafts. If you have
HairMass Index data, then you should also include it. You should
also disclose the methodology used to calculate all rates (e.g., survival rate, transection rates). Finally, you should include proper
pre- and post-operative photographs (before and after photos)
when reporting your cases. Photographs must be high quality,
clear, have good lighting. For examples of proper photographs,
go to: http://www.ishrs.org/content/faculty-information-2.”
How long should be the duration of time out of body from
the time of extraction to placement?
Steven Gable, MD, FISHRS
There are many factors that contribute to the survival of follicular unit grafts, and the length of time when a graft is extracted
from the body and placed back is absolutely crucial. There have
been several studies demonstrating decreased graft survival the
longer time that a graft is out of the body. In 1996, Dr. Bobby
Limmer’s landmark study1 showed out of body graft survival
rates of 95% at 2 hours, 86% at 6 hours, 88% at 8 hours, 79% at
24 hours, and 54% at 48 hours after extraction when the grafts
were stored in chilled normal saline. Since this report, many
studies have been performed showing the effects of temperature
variation of the holding solution (room temperature vs. cooler
temperatures), alternative storage solutions (Lactated Ringer’s
solution, Plasmalyte A, HypoThermasol®), additives (ATP),
and many other solutions on graft survival. However, the basic
tenet that these studies are compared against is the time out of
the body, and the overall goal is to achieve a high survivability
of the grafts not only in the short term, but also prolonged times
out of the body.
In practice, hair restoration physicians should plan the procedures to minimize the amount of time that the grafts are out of
the body knowing the above statistics for normal saline, and also
for alternative solutions as well. For practical purposes, focusing solely on time out of body, I plan my cases so that all of the
grafts are placed within a goal of 6-8 hours after the strip has
been removed, or 2 hours after the grafts have been extracted via
the FUE (follicular unit extraction) method, alternating between
graft extraction and placement so the grafts are placed as soon as
possible. Also, if I am planning for a long case when the grafts
may be out of the body for longer than 4 hours, I incorporate
alternative storage solutions with strict temperature controls to
maximize graft survivability.
Reference
1. Limmer, R. Micrograft survival. In: D. Stough and R. Haber,
editors. Hair replacement. St. Louis (MO): Mosby, 1996;
pp. 147-149.
How do you prevent and treat post-operative facial edema?
Humayun Mohmand, MD, FISHRS
Edema, or swelling, caused by the retention of tissue fluid
begins almost immediately at the time of surgery and its development continues for a short but variable period of time.
Post-inflammatory edema usually appears 3-5 days after surgery
when it moves down over the forehead and reaches the periorbital region.
[ page 72
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Ask the Fellows from page 71
Prevention is the best treatment and includes both physical as
well as pharmacological measures. Physical Measures include
the following:
1. The fluid is massaged away.
2. A cool pack is placed over the forehead for 15 minutes,
3-4 times a day.
3. The patient is encouraged to sleep with upper body
elevated at 45 degrees.
Pharmacological measures include corticosteroids, which
are commonly used for preventing edema. However, there is
no conclusive evidence that oral or injected systemic corticosteroids prevent or control edema after hair transplant surgery.
Some have claimed to have reduced incidence of post-operative
swelling from 20% to less than 5% by using systemic corticosteroids and adding 50mg of triamcinolone acetonide to 50ml
of lidocaine (1 mh/ml) for operative anesthesia.
The Abbasi solution has important implications in prevention of post-operative facial swelling. It consists of 100-200ml
of N/S, epinephrine 1ml (1:1000), and triamcinolone 40mg. It
reduces post-operative edema by 95-97%. Since 2005, I have
used it on 8,000 patients with less than a 2% incidence of postoperative edema. However, elderly patients with loose skin have
an increased incidence even with this solution. Use of ice packs
helps bring down the swelling in such patients.
How do you treat a patient with general miniaturization of
hair in both the recipient and donor regions?
T.K. Shiao, MD, FISHRS
General miniaturization of hair, including recipient and donor
areas, is found in diffused unpatterned alopecia (DUPA). DUPA
was first described by Dr. O’Tar Norwood in 1975, but only fully
incorporated into hair transplant workup by Drs. Bernstein and
Rassman 1997 publication, Follicular Transplantation, Patient
Evaluation and Surgical Planning.1
In addition to the regular Norwood Classes, there are two
additional types: diffuse patterned alopecia (DPA) and DUPA.
Despite their similarities during early stages (diffuse thinning
in the front, top, and vertex with persistence of frontal hairline),
their prognosis and treatment modality are vastly different.
DUPA, while uncommon in males, is the predominant type
of hair loss in females. These patients have diffuse thinning in
both the donor and recipient areas; that is, the miniaturization
process occurs over the entire scalp, so that the person lacks
a stable permanent zone. Under magnification, their donor
density is in the range of 1.0-1.5 hair/mm2 with donor miniaturization in excess of 35% (often 50% or greater). Because
the donor hair is undergoing the same balding process as the
recipient area, the hair that is transplanted will eventually thin.
The transplanted DUPA patient may experience extensive
shedding of existing miniaturized hair in the area that receives
the new grafts, continued loss after the transplantation, and
a donor scar that may become visible over time. This condition is therefore a relative contraindication for hair restoration
surgery.
In treating suspected DUPA, non-androgenic differential
diagnoses must be first considered, especially in women. Workup
includes anemia, thyroid disease, connective tissue disease,
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March/April 2015
gynecological conditions, and severe emotional problems. Medical therapy includes minoxidil, finasteride (when appropriate),
LLLT, and conservative hair transplant, preferably FUE harvesting small number of grafts over a large donor area.
Case
Presentation
H.M. was a
52-year-old female
in good health. She
first noticed her
hair loss when she
was 45. Her hair
loss progressively worsened and
showed no sign of
stopping. She had
no significant past
medical history
and had a clean
social history.
Significant family history is that
her mother started
wearing wigs in
her 40s. H.M. was
using 2% Rogaine
and several nutritional supplements
from her hair stylist at the time of
presentation.
H.M. Before (top) and after (bottom)
Physical examination showed Ludwig type II pattern with significant thinning in
the donor area, microscopic examination showed normal density
of 100 FU/cm2 but only 1-2 fine hairs in most FUs.
Initial treatment plan included topical minoxidil, intensive
LLLT therapy using LaserCap, and a small 309 FU FUE session
for the posterior two-thirds of her left part and the ipsilateral side
of the vertex. ACell was placed with the grafts into the recipient
sites and also used to fill the donor sites.
Over the next 21 months, H.M.’s hair showed significant
improvement. However, on the untransplanted side of the vertex, the scalp still showed through and H.M. wanted her entire
part strengthened. In a second FUE, we harvested 488 FUs
and transplanted each FU with two plucked hairs into her part
and vertex. She continued the same medical regimen (topical
minoxidil + LLLT) post-operatively, and at 6 months notable
improvement can be seen. Between her 6-month and 12-month
follow-up, H.M.’s antiaging physician put her on testosterone
supplement along with ¼ of 5mg finasteride. Photos of her at
12-month follow-up are shown below. In this case of DUPA,
medical therapy with topical minoxidil, aggressive LLLT, and
conservative surgical treatment using FUE and ACell resulted
in a very satisfied patient.
Reference
1. Bernstein, R.M., and W. R. Rassman. Follicular transplantation: patient evaluation and surgical planning. Dermatol
Surg. 1997; 23:771-784.
www.ISHRS.org
What creates the perfect hairline?
Bertram Ng, MBBS, FISHRS
The basic in hairline design is well described in Unger’s
and Lam’s textbooks.1,2 Here are just some of my personal tips.
Naturalness: The hairline has always been described as the
upper frame of the face. It should be created in such a subtle
way that the eyes remain the focus of attention.
Density: If you cover a small area with a good density, the
patient is happy to pay for a second procedure to cover more. If
you cover a large area with low density, the patient will either
demand a refund or a free session, or badmouth you on the
internet. So don’t be too generous in offering a low hairline.
The lowering of just 1cm will demand an extra 300-400 grafts.
Aspect: Here, aspect refers to the ratio between the height
and width of the forehead. When lowering the frontal hairline,
you may have to bring forward the temporal hairlines as well.
The fronto-temporal points should be located in a line above
the lateral canthus.
Symmetry: Take some pictures of the hairline you’ve drawn.
Ask the patient to check the camera pictures as well as the mirror reflected images. Explain that there may be a discrepancy in
symmetry between the two. Retrace the hairline until the patient
is happy with both.
Widow’s peak: Setting a midpoint with the widow peak may
reveal any facial asymmetry. Try not to create one unless the
temporal hairlines are equal distant from the midline.
Orientation: Ask the patient how he or she would like to comb
his or her hair. The angle and direction of the transplanted hair
should flow with the existing ones to help in styling.
March/April 2015
Hair transplantation should be considered in Ludwig type
2-3 hair loss after non-surgical treatment has been tried for 6-12
months. Assessment of donor hair is the most important factor
determining the result because not everyone is a good candidate.
The consequences and complications of the procedure, such
as the shock loss, must be discussed with the patient to avoid
unrealistic expectations.
After surgery, non-surgical treatment should be continued to
prevent further hair loss and stabilize the existing hair, because
the hair loss will otherwise worsen.
Reference
1. Rogers, N. Medical therapy for female hair loss (FPHL).
Hair Transplant Forum Int’l. 2014; 24(3):86-88.u
References
1. Unger, W., et al. Surgical Planning and Organization. In:
Hair Transplant, 5th Edition. Informa, 2011; pp. 106-190
2. Lam, S. Creative Thinking Through Case Studies 360. In:
Hair Transplant 360 for Physicians. Jaypee, 2011; pp. 143169.
What are the best ways to treat female alopecia?
Kongkiat Laorwong, MD, FISHRS
Women who present with hair loss should have a detailed
medical history, scalp examination, and workup to rule out the
other causes that can be treated, such as polycystic ovarian cyst,
hypo- and hyper-thyroidism, or chronic iron deficiency, and
scalp biopsy should be done if necessary before the diagnosis
of female pattern hair loss (FPHL).
The treatment should start with non-surgical options and then
consider the addition of hair transplantation. The non-surgical
treatments include topical 2% and 5% minoxidil lotion or foam
type (only FDA approved), oral spironolactone, finasteride,
contraceptive pills, ketoconazole shampoo,1 low level light
therapy (LLLT), and platelet rich plasma (PRP) injection. These
treatments can be combined to make the results better and increase patient satisfaction; patients should be encouraged to try
treatment for at least 6-12 months.
During treatment, follow-up and monitor the result or progression with dermoscopy, HairCheck, and global photography,
and also monitor for side effects.
State-of-the-art
instrumentation for hair
restoration surgery!
For more information, contact:
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Madison, New Jersey 07940 USA
Phone: 800-218-9082 • 973-593-9222
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www.ellisinstruments.com
73
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March/April 2015
Introduction to UK Hair Restoration Surgery Clinical Standards
Greg Williams, MBBS, FRCS (Plast) London, UK [email protected]
The British Association of Hair Restoration Surgery
(BAHRS) convened a meeting on January 26, 2014, to discuss
and establish BAHRS Members “Common Practice” on the
subject of Optimising the Patient Experience and Graft Care
with a view to establishing an initial set of UK Hair Restoration
Surgery Clinical Standards on the same subject. The Association
is unaware of a similar set of standards having been agreed upon
and published by any other ISHRS Global Council Regional
Association Member.
It is acknowledged that “common practice” does not necessarily entail “best practice” and that there might be an individual,
or minority of individuals, whose practice is outside the norm
but from whom the majority could learn and adapt their practice.
Common practice therefore is only a measure of activity at one
point in time and might vary when the same parameters are
discussed in the future.
Also, for this purpose, “common practice” was taken as the
practice undertaken by the majority of respondents. This is therefore dependent on the number of respondents at the time of the
survey. For example, if 11 out of 20 respondents performed an
activity in a certain way, that would be deemed common practice.
If the same 11 individuals performed an activity, but the survey
was taken at a later date when there were 23 respondents and 12
did not perform the activity that way, then it would no longer
qualify as common practice.
From the 2014 BAHRS Members “Common Practice” a
subset of items was selected where it was agreed upon that the
common practice represented best practice and there was no
debate or controversy about this. This was then collated as a first
version of the UK Hair Restoration Surgery Clinical Standards,
which was ratified at the BAHRS Annual General Meeting on
July 26, 2014. This first version is limited to a small number
of standards relating to optimising the patient experience and
graft care, but will be built upon in the future adding standards
to do with follicular unit extraction, infection control, systems
and safety, etc.
It is hoped that other regional associations (and the ISHRS)
will develop and adopt similar sets of Clinical Standards that
will be accessible to patients from the relevant regions to educate
them on what they should expect before, during, and after their
hair transplant surgery.
Professional Standards Developed
The following UK Hair Restoration Surgery Clinical Standards (Version 1, 2014: “Optimising the Patient Experience and
Graft Care—Sharing Protocols and Establishing UK Common
Practice”) have been developed by the British Association of Hair
Restoration Surgery (BAHRS) in conjunction with the BAHRS
Professional Standards for Hair Transplant Surgeons following
the January 26, 2014, meeting.
These UK Hair Restoration Surgery Clinical Standards (Version 1, 2014) represent recommendations only, but patients can
expect that all BAHRS Hair Transplant Surgeon members will
follow these standards in principle unless there are individual
circumstances when an alternative practice may be used. It is
74
anticipated that further versions will be developed as other areas
of BAHRS Common Practice are established.
General Principles and Practice
Patients undergoing hair restoration surgery should expect
a BAHRS Hair Transplant Surgeon member to abide by the
principles found in:
• The General Medical Council’s (GMC’s) 2013 publication
Good Medical Practice: http://www.gmc-uk.org/guidance/
good_medical_practice.asp
• The Royal College of Surgeons of England’s 2008 publication
Good Surgical Practice: http://www.rcseng.ac.uk/publications/docs/good-surgical-practice-1 (and the future version
that began development in 2014)
• GMC Guidance, 2008: Consent: Patients and Doctors Making Decisions Together: http://www.gmc-uk.org/guidance/
ethical_guidance/consent_guidance_index.asp
• The Academy of Medical Royal Colleges, 2008: A Clinician’s
Guide to Record Standards—Part 2: Standards for the Structure and Content of Medical Records and Communications
When Patients Are Admitted to Hospital: https://www.rcoa.
ac.uk/sites/default/files/FPM-clinicians-guide2.pdf
Principles and Practice Specific to Hair Restoration
Surgery
With Regards to Pre-Operative Patient Preparation,
BAHRS Hair Transplant Surgeon Members Should:
• Routinely send written clinical information to their patients
before the day of surgery including general information about
hair transplant surgery and the consent form for the planned
surgery.
• Routinely send written instructions to their patients to stop
doing or taking certain things the day of surgery (such as
smoking, non-steroidal anti-inflammatory drugs [NSAIDS]
including aspirin if more than 75mg, some vitamin supplements, and some herbal remedies).
• Routinely orally instruct their patients to do certain things
(such as donor site scalp massage) or take certain things (such
as minoxidil or finasteride) before the day of surgery, but the
specifics of the instructions may vary from patient to patient.
• Routinely photograph their patients before surgery using
standardized lighting, positioning, views, and background.
With regards to Intra-Operative Patient Care, BAHRS
Hair Transplant Surgeon Members should:
• Routinely use an antiseptic to wash their patients’ scalp/hair
immediately pre-op.
• Not routinely give their patients an intravenous sedative as
part of the procedure.
• Routinely use a combination of lignocaine and bupivacaine
as local anesthetic to perform their hair transplant procedures.
• Routinely give their patients intra-operative analgesia.
• Routinely give their patients refreshments at a set stage during
the procedure.
www.ISHRS.org
• Routinely provide their patients with audio-visual entertainment during the procedure.
• Routinely clean their patients’ hair at the end of a “strip”
procedure.
• Routinely monitor their patients’ pulse, blood pressure, and
oxygen saturation during the procedure.
• Routinely try to reduce the potential for swelling after the
use of tumescent fluid—either pharmacological with, for
example, oral prednisolone, or physiological, such as sleeping
position advice or the use of topical ice packs.
With regards to Post-Operative Patient Care, BAHRS Hair
Transplant Surgeon Members should:
• Supply their patients with analgesic and/or anti-inflammatory
medication post-operatively.
• Advise their patients to wash their hair around the “strip”
donor site within 48 hours.
• Provide their patients with advice on post-operative follicular
unit extraction (FUE) donor care.
• Provide their patients with advice on post-operative recipient
site graft care.
• Supply their patients with written post-operative care instructions.
• Supply their patients with an out-of-hours emergency contact
telephone number.
With regards to Graft Care, BAHRS Hair Transplant Surgeon Members should:
• Chill the follicular unit grafts during the procedure.
• Consider the maximum safe “out of body” time for follicular
unit grafts to be 8 hours, but would routinely try to have
follicular unit grafts implanted within 6 hours of extraction/
removal.
• Not allow Hair Transplant Surgical Assistants to make follicular unit extraction (FUE) incisions.
• Supervise Hair Transplant Surgical Assistants who extract
FUE grafts.
With regards to Patient Follow-Up, BAHRS Hair Transplant
Surgeon Members should:
• Routinely have their patients telephoned in the first week
after surgery by a member of their team.
• Routinely see their patients at least once for follow-up of the
hair transplant result.
• Routinely take post-operative photographs to document the
outcome of the hair transplant.
• Periodically ask their patients for written feedback (Patient
Experience Questionnaire).
With regards to Recording the Patient Experience—
Medical Notes, BAHRS Hair Transplant Surgeon Members
should:
• Have varied consent forms for different types of hair transplant procedures (e.g., scalp, eyebrows, beard/moustache,
scars, revision/reconstruction, etc.) that cover risks and
complications.
• Routinely record the hair transplant surgery start time and
finish time.
• Routinely record volume/dosage of local anesthetic used
during the hair transplant procedure.
• Routinely record total number of follicular unit grafts trans-
March/April 2015
planted and the breakdown of follicular units with respect to
number of hairs.
• Routinely tell their patients the number of grafts/hairs transplanted.
• Routinely record procedure complications or adverse events.
• Routinely offer to send a letter to their patients’ General
Practitioner regarding the hair transplant surgery.
Editor’s note: I want to thank Dr. Williams for sharing
the Practice Standards adopted by the BAHRS. I think this
is a very significant accomplishment and hope that other regional societies of the ISHRS will consider adopting similar
standards.
Agreeing on practice standards is not an easy thing to
do. Earlier in my career I was in charge of the quality assurance programs and Joint Commission Accreditation for two
hospitals in the United States. Part of what we had to do was
develop practice standards that could be used to measure quality of physician and institutional performance. This was hard
work that entailed extensive review of the medical literature
to establish an evidence base for practice standards and then
coming to agreement in committee on the exact wording of
standards. In order to pass the committee, there had to be
unanimous agreement.
In establishing its standards, the BAHRS has used practice
surveys and simple majority as the basis for setting standards.
I wonder if this is really rigorous enough to establish true
standards. I wonder if standards would be more reliable if
practiced by 75% or more of intermediate to advanced practitioners and supported by literature citations. I also think
that standards should allow for inconsequential variation.
For example, the BAHRS standards include the recommendation to: “Routinely use a combination of lignocaine and
bupivacaine as local anesthetic to perform their hair transplant
procedures.” I think this would read better and better reflect
legitimate variations in practice if it included the phrase “or
related local anesthetic agents.”
As Dr. Williams points out this is only a first step in an
ongoing and evolving process. I think the BAHRS has made
a great beginning for us all. –RHT
Executive Director’s note: For the past several years, the
ISHRS has had an ongoing project to define current and best
practices in hair restoration surgery (HRS). The project examines all aspects of the HRS practice, including diagnostic
skills, patient education and consultation routines, surgical
procedure routines, personnel utilization, and management
of quality assurance and risk management. These aspects
have been categorized into 14 modules. Overall, the goal of
the project is to identify important learning objectives for the
ISHRS’s continuing education programs by examining the
gap between “best practices,” compared with the “current
practices.” The first three modules have been completed.
Data analysis has been conducted and a manuscript is being prepared for publication of the first three modules. The
ISHRS membership will be notified when the publication is
released. –VCu
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March/April 2015
Hair’s the Question*
Sara Wasserbauer, MD, FISHRS Walnut Creek, California, USA [email protected]
*The questions presented by the author are not taken from the ABHRS item pool and accordingly will not be found on the ABHRS Certifying Examination.
I got a new toy a few Christmases ago—a magnifier for my iPhone camera. I have to tell you: I
LOVE this thing! For diagnositic usefulness during a consult, you cannot beat magnification (Dr.
Nicole Rogers even won the poster competition in Alaska with a little device like this)! If you are not
already using it for your patients, having a camera like this (or a video microscope) enables instant
analysis and feedback for your patient. They will love it and you will, too. Now let’s test your skills
for diagnosing some of these commonly seen photomicrographs of the scalp.
1. This patient has been:
A. Shaving his hair recently
B. Plucking out his own hair
C. Using keratin hair fibers (aka Toppik®, etc.)
D. Getting regular “Brazilian blowouts”
4. The following microscopic photo is an example of:
A. An ingrown hair
B. Diffuse folliculitis
C. Donor area 6 months post FUE hair surgery
D. Follicular plugging
2. This patient shows evidence of:
A. Exclamation point hairs indicating trichotillomania
B. Alopecia areata
C. Loss of follicular openings
D. Miniaturization
5. What recently happened to the hairs in this photo?
A. They were recently backcombed as evidenced by their
ruffled cuticle.
B. They were recently cut as shown by their blunt (i.e., not
tapered) ends.
C. They show evidence of recent electrolysis.
D. They recently experienced a laser hair removal treatment.
3. The above microscopic photo was most likely taken on which
part of the patient’s body?
A.Hairline
B.Chest
C.Beard
D. Donor area
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6. The brow hairs in this photo are evidence of:
A. Trichotillomania due to their short lengths in various
stages of growth
B. Recent trimming due to their blunt (not tapered) ends
C. Recent growth from transplantation due to their various
stages of growth
D. Recent thermal or chemical damage due to their blunt
(not tapered) ends
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A
7. The hairs in this photo are:
A. Almost 100% miniaturized
B. Fine women’s facial hairs
C. Located at the back of the patient’s neck
D. Brow hairs
8. Compare these two photos of African American hair (same
scalp, 1cm apart); one shows affected area of scalp and the
other an unaffected area. What might be causing the alopecia
in the affected area photo?
Affected:
Unaffected:
A. Trichotillomania, as evidenced by the hairs of multiple
lengths present
B. Scarring (cicatricial) alopecia, as evidenced by the loss
of follicular ostia present
C. Androgenetic alopecia, as evidenced by the miniaturization present
D. Folliculitis decalvans, as evidenced by the peri-follicular
inflammation present
C
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March/April 2015
B
D
Bonus Question
9. The following photo pairs A:B and C:D were taken to illustrate the growth of grafts in the transplanted areas. Both
patients had androgenetic alopecia. Which of these photos
represents the DONOR area?
A. A and D are the donor areas.
B. A and C are the donor areas.
C. B and D are the donor areas.
D. B and C are the donor areas.
[ Answers on page 78
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Hair’s the Question from page 77
1. C. When I first saw this through magnification, I thought it
was a recent haircut, but since the fibers are so much finer
than the rest of the hair answer A is incorrect. Had the hairs
been plucked, you might see an empty follicular ostia, but that
is not the case. “Brazilian blowouts” can cause breakage, but
again, that would be seen further along the shaft and would
not leave such fine fragmentary fibers on the scalp surface.
2. D. Miniaturized hair among a few robust follicular units
is consistently seen in androgenetic alopecia. Exclamation
point hairs are narrower at the base and are a characteristic
finding in several alopecias including alopecia universalis,
totalis, and areata. In this photo, follicular openings can be
seen. Trichotillomania would show broken hairs in various
stages of growth.
3. D. “Dis is Dee Donor Area!” (I think Arnold Schwarzenegger
said that). Chest hair contains more single and double-haired
follicular units. Beard hair likewise would lack a 5-hair follicular unit and tends to have less uniformity to the hair shaft
and a thicker caliber (hair shaft diameter).
4. D. A hair is growing OUT, so it is not an INgrown hair. Donor
area 6 months post FUE would show small scars and a diffuse
folliculitis would involve more of the FUs in this photo than
just one!
5. B. Recent electrolysis would show a profound lack of hair
and recent laser hair removal would either show the same
OR some singeing with resultant peri-follicular erythema if
in the immediate past. Backcombing does ruffle the cuticle,
but that cannot be seen at this level of magnification.
March/April 2015
6. A. I actually used this photo to prove to a young man that
he was actually pulling out his own hair. The ends are blunt,
so this is not new growth, and trimming would have left the
hairs more or less the same length. For those of you who answered D, you can give yourself a half point, but the answer
is incorrect since it would be difficult (though admittedly
NOT impossible) to have chemical or thermal damage in
brow hair.
7. D. Note the predominance of single-haired follicular units and
directionality. These are not vellus hairs, as would be found
on a female face, they are terminal and do not demonstrate
interspersed miniaturization so much as a caliber (i.e., hair
shaft diameter) gradient. Even hairs at the back of the neck
would have some multi-haired follicular units. (Don’t believe
me? Get some magnification and look for yourself!) However,
I will give a half-point for answering C.
8. B. These two photos were taken within a centimeter of each
other and demonstrate how cleary the loss of follicular ostia
can give you the diagnosis of a scarring alopecia. Those with
sharp eyes will also note a few tiny fibers from a keratin hair
concealing powder (Toppik, etc.). There is no peri-follicular
erythema in this photo, and although an argument could be
made for miniturization in the “affected” photo, it is clearly
not present in the “unaffected” photo, and thus androgenetic
alopecia is not the whole answer.
9. B. I know this questions seems a little like “alphabet soup,”
but B is correct since the photos labeled A and C have little
to no miniaturization present. Miniaturization is the hallmark
of androgenetic alopecia and can readily be seen in a microscopic analysis of a scalp.u
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78
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March/April 2015
Review of the Literature
Nicole E. Rogers, MD Metairie, Louisiana, USA [email protected]
Long-term Side Effects in Men Taking Finasteride
Singh, M.K., and M.R. Avram. Persistent sexual dysfunction and depression in finasteride users for male
pattern hair loss: a serious concern or red herring? J Clin Aesth Dermatol. 2014; 7:51-55.
In this commentary, the authors review data about long-term
side effects in men who took finasteride. They specifically review
the largest randomized, controlled trials to date investigating
incidence of sexual side effects with finasteride. The 1992 Finasteride Study Group (895 men) showed no reports of irreversible or prolonged sexual side effects. Kaufman’s 1998 study on
finasteride for male pattern hair loss (MPHL) (1,558 men for 1
year, 1,215 men in the blinded extension over 5 years) showed
that sexual side effects resolved in all patients after discontinuation of the drug and also resolved with time in most men who
stayed on therapy. The only double-blind, randomized, controlled
trial to report persistent sexual side effects was the PLESS trial
(2003), in which only 50% of finasteride users with sexual side
effects had symptoms resolve after discontinuation; whereas just
41% of the placebo group had resolution. In the Prostate Cancer
Prevention Trial (2007), none of the 17,313 participants reported
persistent sexual dysfunction.
In terms of depression, the authors found one retrospective
case series of 19 patients who developed mood changes after
starting finasteride for MPHL. All resolved after discontinuation of the drug. One prospective study followed 128 finasteride
users for depressive symptoms over 1 and 2 months. Although
the incidence increased with finasteride usage, all symptoms
resolved after discontinuation of the drug. Overall, these large
studies stand in contrast to the biased and poorly designed publications by Irwig et al. reporting persistent sexual side effects and
depressive symptoms even after discontinuation of finasteride.u
e
Challenges Associated with Eyebrow Transplantation
Umar, S. Eyebrow transplant: the use of nape and periauricular hair in six patients. Derm Surg. 2014; 40:1416-1418.
Here the author describes challenges associated with eyebrow
transplantation, namely obtaining hairs that are soft enough in
caliber to mimic a natural eyebrow. He describes the use of FUE
to harvest hair from the nape of the neck and hairline margin.
In his report he uses a rotary tool with a modified 19g needle
to transplant 4 women and 2 men. For each patient, 200-600
grafts were harvested from the back of the scalp. He reports
good healing in this area but admits that long-term outcomes
are unknown and that women who wear their hair in a ponytail
should be well-informed prior to surgery.u
e
Outcomes of FUE
Avram, M.R., N. Rogers, and S. Watkins. Side-effects from follicular unit extraction in hair transplantation. J Cut Aesth Surg. 2014;
7:177-179.
In this letter to the editor, the authors discuss important outcomes of follicular unit extraction (FUE). Although this technique
is favored for its lack of a linear scar, the authors point out that in
some cases there can be atrophic white scars measuring less than
or equal to 1mm, and patients should be aware that this is not a
completely “scar-less” procedure. In addition, the authors point
out that in some very large FUE cases, grafts are harvested from
outside of the permanent donor zone. If follicles taken together
from high risk locations are then transplanted together, the patient
may develop localized loss of grafts in that area. To avoid this,
the authors recommend mixing all of the grafts together before
placing them back into the areas of thinning. Finally, the authors
point out that there are no established guidelines for how many
follicular groupings can be safely harvested before the harvested
donor area appears too thin. As with all things in medicine, both
physician and patient should be aware of the short- and longterm consequences of FUE.u
79
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March/April 2015
Regional Societies Profiles
In this installment of our ongoing series profiling Regional Societies that are members of the ISHRS, we are pleased to have
a report from Dr. Frank Neidel, current President of the Society of German Hair Surgeons.
Society of German Hair Surgeons
Frank Neidel, MD Düsseldorf, Germany [email protected]
Manfred Lucas, MD, Ursula Halsner, MD, and Sibylle Eberle,
MD founded the Society of German Hair Surgeons in 1994. We
hold annual meetings. Our next meeting will be November 28,
2015.
The current officers are: Frank Neidel, MD, President; Ursula
Halsner, MD, Vice president; Danuta Sobczak, MD, Treasurer.
There are about 20 hair restoration practitioners in Germany and
10 of them are members in the Society. Drs. Frank Neidel, Ursula
Halsner, and Andreas Finner are also members of the ISHRS.
Hair transplantation has become a common procedure in
Germany. There is a trend for physicians of many different
backgrounds to try offering it; however, too many of them are
without basic education in hair transplantation. Advertising is
allowed in in Germany within a well-defined framework; “before
and after photos” are not allowed. Hair restoration is increasingly
recognized in the media, and HRS is growing in acceptance by
both patients and the medical community. Most of us are quite
busy, but may not do procedures every day. Some of the doctors
(L to R) Drs. Frank Neidel, Dusseldorf; Helena Olbrich, Stuttgart;
Danuta Sobczak, Freiburg; Andreas Finner, Berlin; Gerd Westphal,
Berlin; Joachim Beck, Heidelberg
80
do not do hair transplant procedures
exclusively. In Germany, 80% of the
procedures are FUT and 20% FUE. I
think this makes sense given that most
of out patients have lighter, finer hair.
In 2015, 3-4 ARTAS® Robotic Systems are expected to be introduced in
Germany.
Currently, I am not aware of any
research on cell-based therapy that is
Frank Neidel, MD
going on here. Drs. Frank Neidel, Andreas Finner, and Ursula Halsner are
all active in educational programs in and outside of Germany.
We are fortunate in our Society to have an open, collegial
atmosphere and easy communication.
How can the ISHRS help us in the Society of German Hair
Surgeons? We would like to see ISHRS publications for the
media and patients and some of the web site translated into the
German language.
Dr. Frank Neidel is a specialist hair restoration surgeon
with over 25 years experience. He has performed over 6,000
surgeries.
His strong involvement in hair transplantation is evident
through being a member in leading medical societies and in
his scientific collaboration with teams of experts at the skin
clinic of Bochum University, the clinic of Lake Constance in
Lindau, the “Rosenpark” clinic in Darmstadt and the “Rosengasse” clinic in Ulm.
His primary practice is located in Düsseldorf, Germany.
Dr. Neidel also supervises hair transplantation clinics as
an advisory doctor abroad in Holland (Transhair NL) and
in Moscow (RTH). He is president and a board member of
societies for hair transplantation including the Association of
German Hair Surgeons in Berlin and the European Society
of Hair Restoration Surgery in Paris, and is a member of the
ISHRS. His extensive subject knowledge can also be found in
several medical specialty textbooks in which Dr. Neidel has
contributed as an author.u
www.ISHRS.org
March/April 2015
Letters to the Editors
Re: Transition from forceps to implanters
Francisco Jimenez, MD Las Palmas Gran Canaria, Canary
Islands, Spain [email protected]
After visiting many colleagues and attending numerous meetings and workshops, I have seen and tried a variety of methods
for the insertion of grafts into a recipient scalp.
After more than 10 years using fine-tip forceps for inserting
grafts, either with the stick-and-place method or with pre-made
sites, I decided 5-6 years ago to switch to implanters and I
continue to use them to this day. The reason for this letter is to
reflect on the issues that could be encountered when making the
transition from the use of forceps to implanters.
Readers may recall that the use of implanters started in Korea in the early 1990s, and that for a long time only our Korean
colleagues used them. I remember trying Choi implanters in the
mid-90s, but for some reason I found them inefficient at that time.
I was probably not persistent enough with their use to assess
their advantages. At that time (in the mid-90s) in Europe, as far
as I know, only the Greek DHI group managed by Kostas Giotis
used implanters. In the past 5-10 years, a remarkable increase
in the use of implanters has occurred. Those new to the field
adapt readily to their use, but even veterans like myself can be
persuaded of the advantages they offer.
If you want to start using implanters, I advise you to visit a
colleague, watch videos, or read about the techniques required.
When I became interested in trying them, I got in touch with
my fellow countryman, Dr. Jose Lorenzo, who kindly showed
me some of his videos and shared some tips with me for implanter use. These tips are described in detail in a couple of
Forum articles that I highly recommend.1,2 I use basically the
same setup Dr. Lorenzo describes in these articles: 2 technicians loading the grafts in four implanters (two of 0.8mm and
two of 1mm). The only thing I have changed recently is that
I like to use another technician whose role it is simply to pick
up the implanter and place it in my fingers. In this way, I do
not need to move my shoulder, elbow, hands, or arm, which
means less movement, less fatigue, and a consequently faster
insertion speed. I saw this technique in a video presented by
one of our Korean colleagues at a couple of our ISHRS annual meetings.
When switching to implanters, you will encounter the following issues:
1. How many implanters to buy? At the beginning, just get two
0.8 and two 1.0 implanters and a few needles. Do not spend
too much money until you are sure you want to switch to
implanters. Then, ask your best technician to take over responsibility for the implanters: he or she has to learn how to
assemble the different parts of the implanter, how to sterilize
the implanters, how to change new needles for each case, and
how to change needles during a case if they become blunt.
If the technician takes good care of the implanters, they can
last for years.
2. You will also need two technicians able to load the grafts
in the implanter needles. With practice, sufficient speed can
be quickly attained. The good thing is that they can practice
over and over again with just a few grafts that can be saved
and placed in formalin.
3. Finally, the third important part is for the surgeon to practice
the insertion of the implanter needle into the skin and the hair
follicle graft release. Though the use of any new instrument
and technique involves a period of adaptation, the learning
curve in this particular instance is quite short compared
with that for the stick-and-place method with forceps. Use a
silicon scalp model to practice and feel comfortable with the
implanters in your hands. The most difficult part is insertion
of the graft at the adequate depth, because at the beginning
there is a tendency to insert the graft too deep by pushing
the implanter while triggering the shooter. This might cause
folliculitis and cysts.
As somebody who has tried various insertion methods, I
am in a position to assess and compare the advantages of the
implanters. The most important advantage for me has been that
I can now insert more grafts in less time and with less fatigue.
Additional advantages of the implanters are less trauma to the
hair follicle graft (because the follicle is never grasped at the
delicate dermal papilla, but only at the superior dermis during the
implanter loading), minimal trauma to the recipient site (the slit
made with the needle is immediately filled with a snug-fit graft),
and the previously mentioned short learning curve, especially
important for those new to the field.
As a final comment, if a colleague were to ask me to recommend one particular graft insertion technique, I would simply
recommend the technique that works best in their hands and
that most suits their practice. All types of insertion techniques
achieve excellent results in expert hands. For me and for my
practice, I choose implanters, but if, for example, you do not
want to be involved in the insertion part, and prefer to make the
recipient sites and delegate to your technicians the task of inserting the grafts, then implanters are not for you. Again, no graft
implantation technique is better than any other provided you do
not forget that the ultimate goal of graft implantation is to place
the grafts with the minimal possible damage and distribute them
in the most aesthetic manner and in sufficient quantity to satisfy
the patient’s expectations when the hair grows.
References
1. Lorenzo, J., and X. Vila. Introduction to the use of implanters. Hair Transplant Forum Int’l. 2011; 21(4):121-122.
2. Lorenzo, J. Introduction to the use of the implanter: part II.
Hair Transplant Forum Int’l. 2011; 21(5):170-171.u
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Letters to the Editors from page 81
Re: “State-of-the-Art FUE: Non-Shaven Technique” (Hair
Transplant Forum Int’l. 2014; 24(5):161, 166-169).
Jae Hyun Park, MD Seoul, Korea [email protected]
I have personal experience with more than 10,000 cases of
hair transplantation surgery and have used non-Shaven FUE
(NSFUE) since 2006. I have no knowledge about the operating
technique that Dr. John Cole introduced to Korea in 2008, and
have not had the chance to observe the procedure to date.
Most hair surgeons are aware that NSFUE is a delicate and
difficult surgery that physically and mentally tires both the patient
and surgeon, since it is highly time consuming.
I would especially like to relay a message of gratitude to Dr.
Cole, who is greatly advancing FUE surgery around the world,
and I would also like to state my personal opinion as follows.
1. Does a sharp punch become dull very soon?
This is not a usual occurrence. If a sharp punch actually
becomes dull very soon, it would be an important problem to
address. However, there are many factors that affect the degree of
punch dullness. Firstly, the company and the product to which the
punch tip belongs, is very important. Additionally, hair coarseness, skin texture, punching depth, and method of implantation
have an effect as well. Analogously, a knife produced for the
purpose of cutting meat does not easily dull on cutting 200-300
pieces of tofu. I have rarely experienced a punch that rapidly
becomes dull in my vast clinical experience. Furthermore, if a
punch tip actually becomes dull, it is generally changed to a new
tip. Changing tips takes approximately just 1-2 minutes.
2. What is the duration of the operation?
There are 3 major steps that take up a long period of the
operation time in a typical NSFUE procedure.
The first is pre-trimming the hair prior to surgery. This step
does not increase the actual operation time, since it is done by an
assistant prior to surgery. However, it is still a time-consuming
and laborious step for both the assistant and the patient.
The second is the time required to seek the next target hair
to punch after completing the previous one. This step takes a
longer time in pre-trimmed cases and requires a very high level
of concentration. With fewer amounts to harvest or a wider pretrimmed area, the time needed to locate the next trimmed hair
will be longer. In direct NSFUE, the surgeon visually seeks the
next target in the adjacent area while the previous punching is in
progress, thus reducing the required time. This leads to a shorter
operation time. Critically, it takes much time to find pre-trimmed
hair among crowded long hair.
The third time-consuming step is the extraction. Flipping
and extracting over long strands of hair to find the punched graft
requires expert skill. A well-trained assistant must be assigned
for this procedure in order to lower the discard rate caused by
capping, as well as to decrease the out-of-body time and injury
to hair follicles. There are a few tips to decrease the extraction
time. First is the use of an ATOE forceps, which was developed
by Dr. Cole for the purpose of FUE.
An ATOE forceps is very useful in NSFUE. It is very difficult
to conduct graft extraction by flipping over long strands of hair using the two-handed forceps extraction technique. Using the ATOE
forceps makes it much easier to extract the punched graft while
82
March/April 2015
turning over long strands of hair. Second is the fine control of the
punching depth. For instance, if 2.8mm is the minimal depth that
enables extraction, 3.0mm is the depth that makes easier extraction
possible without a significant increase in the transection rate (TR).
TR increases if the depth is over 3.2mm, so I mainly choose 3.0mm
as the punching depth in such cases, since this can prevent the graft
from being dried up or damaged during the extraction process.
My personal target goal is approximately a 10% transection
rate in NSFUE. (For reference purposes, I have a target of approximately 5% in total shaven FUE.)
Thirdly, I perform surgery with 2 assistants on my right and
left sides. I demarcate 8-10 areas from one ear to the other side
according to the amount of grafts to harvest prior to starting
the procedure. When I finish punching the left side, an assistant on the left conducts extraction, while I move to the right
for punching the next zone. When I move to the next zone to
proceed with punching, I skip 2 or more zones in a box zone
from the punched zone, in advance. If there is a zone from 1
to 8, I usually start punching from zone 6, and move to zone 3,
while skipping zones 4 and 5. This enables easy extraction of
grafts without encroaching individual operator hand space when
punching the next zone.
There is no similar pre-trimming time in direct NSFUE
and the required time to seek the next target to be punched is
also decreased. There is no difference in extraction time. Accordingly, shortening of the operation time is possible. This is
an important issue in NSFUE where extremely long operation
time is crucial.
3. Position for operation.
My personal opinion is that direct NSFUE should be done in
the sitting position. This sitting position is essentially required
for the direct NSFUE technique, because it is not hindered by
long hair, and it is easy to find the hair exit angle.
4. Is tumescence required?
Surgeons usually decides this on a case-by-case basis according to his or her preference. I personally prefer to use tumescence.
With tumescence, I can conduct easier and consistent punching.
Methods that help with consistent punching can be of great help,
especially in situations similar to that of NSFUE where there are
many surrounding barriers.
5. Is it difficult to see the angle of the hair emergence with
long hair?
This is correct. It is the biggest challenge of the direct NSFUE
technique, which requires a long and steep learning curve. I can
provide a few surgical guidelines to reduce the learning curve
and to get better results, as follows:
a. Direct NSFUE must be performed in the sitting position.
b. Use the ATOE forceps and a motorized punch with both
oscillating and rotating modes.
c. Punch from the inferior to superior-ward and upward,
because blood flows downward. It is very important to
secure a clear operation field.
d. Use multiple clips to hold the hair within a 1cm-wide
area, and undo clips sequentially from the bottom.
e. Conduct clipping less than 1cm wide, if possible. To
adjust the natural hair exit angle, it is more advisable
to punch immediately after undoing the clip if possible,
www.ISHRS.org
rather than finding hair to be punched by throwing the
long hair backwards. Therefore, it is better to have a
narrower width of clipping.
f. It can be difficult to determine the hair exit angle when
hair gets tangled and sticks to one another due to blood
clot. For such cases, it is advisable to prepare a sterilized
saline spray and comb. Lightly spray the saline and comb,
thus making the direction of hair more noticeable.
g. When undoing the clip from the bottom, sometimes the
clip indents the hair, resembling a curl. Since it resembles
a curl in the hair, it makes it difficult to find the hair’s
exact exit angle. The saline spray and combing can make
it easier to find the direction and angle of the hair strand
in such situations.
h. Despite the prevailing controversy, if tumescence is
used, and an assistant conducts a little traction on skin
in an upward direction, easy punching and reduced TR
are facilitated.
Applying the various surgical tips will permit easier finding
of the hair exit angle and direction. However, finding the exact
hair exit angle and accurately processing punching is still an
extremely difficult process. However, there are always obstacles
and hurdles in new operations. The future of hair transplant
surgery is leaning towards NSFUE. Many outstanding surgeons
worldwide will continue to discuss and discover improved operation techniques and know-how.
6. What is the transection rate?
Every surgeon views TR differently, but I aim for a TR of
10% or below using the NSFUE technique. If the punch is very
superficial, the TR can be lowered. However, the extraction
takes a long period of time, and the survival rate can be lowered
because the proportion of skeletonized grafts increases, and the
grafts are out of body for longer. Recently, increasing experience and know-how of the method has led to a generally slightly
less than 10% TR.
I anticipate a further decrease in TR.
7. Others
The surgeon can make a direct selection of the hair strand
for punching in the direct NSFUE method. Additionally, the
hair can be cut according to the quantity sought for extraction,
without over trimming. Therefore, even in cases of punching
more than 2,000 grafts, the possibility of surgery being obvious
due to over trimming is low.
8. Conclusion
It is my personal opinion that non-shaven FUE will be one of
the most important future techniques of hair restoration surgery.
I anticipate that more discussion and interchange of ideas will
promote further innovation of NSFUE.
March/April 2015
Reply to Dr. Jae Park from Dr. John Cole
Non-shaven FUE is the future for hair transplant surgery. As
Dr. Park states, there are many who want FUE to avoid a strip
scar, however, they also are unable to shave their head. For this
reason, I introduced non-shaven FUE in 2003. I introduced the
totally non-shaven technique in Korea in 2008.
Initially, we offered shaven patches, which is the same
thing as Dr. Park’s shaven strips. We discovered within the
first year that shaven patches limited the number of grafts we
could obtain, as much of the donor area was non-shaven. The
chief complication of shaven patches was linear areas of thinner
density, which resulted in linear patches having a moth-eaten
appearance. The result was as bad as a strip scar in the author’s
opinion. Therefore, I believe that shaven patches or shaven strips
should NEVER be performed.
If a physician is going to shave a portion of the donor area,
while leaving the remainder of the hair long, the preferred method
is to shave the entire safe donor area while leaving the surrounding hair long. Of course, this requires long hair, which is more
common in women. Grafts should then be harvested in an irregular, diffuse manner so that there is no resulting extraction pattern.
We prefer the totally non-shaven approach. We require approximately 1 hour to prepare a donor area for a 3,000-graft
non-shaven procedure. We do our best to trim only the grafts
that we intend to remove, however, we always seem to overtrim.
Overtrimming is preferable to undertrimming only because undertrimming decreases the desired graft count. We harvest grafts
nearly as fast as if the donor area is not shaven. Of course, my
speed is higher because I have performed over 1,000 cases of nonshaven FUE already. We also find that with practice, the follicle
transection rate is nearly the same as with a shaven procedure.
It simply takes time and practice.
It is always nice to find ways to cut corners. Using the
punch to cut hair as you proceed is one way. However, there
are problems resulting from this method. Hair follicles are
hard. When you use the punch to cut the hair shaft, the hair
follicles will accelerate the dulling of your punch. Asian hair is
often coarse and the dulling affect is greater with coarser hair.
It is far easier to use this technique with fine hair. The second
problem is that it is more difficult to approximate the hair shaft
exit angle when you leave the hair long. Hair grows along a
curve angled down toward the skin. With longer hair, this curve
will make the hair appear to exit more acutely from the skin
than it actually does. The physician must guess the true angle
with longer hair. The coarse nature of the hair requires greater
axial force from the physician to cut the hair follicles. This
greater axial force displaces the hair follicle and thus further
complicates the extraction process while increasing the risk of
follicle transection needlessly. The preferred method of nonshaven FUE is to pre-cut the hair shafts so that these risks and
complications are avoided. The author feels that saving time
is not acceptable when it carries greater risk to hair follicles.
There are many different types of skin. Some are hard, some
are soft, and some are rubbery. It is impossible to make generalizations from a limited number of Caucasian cases. One can assume
that Asian skin will be firmer and the follicles will be deeper and
coarser. There are Caucasians with deep follicles and firm skin,
however. In general, I like the firm skin of the Asian patient. I
feel it helps limit follicle displacement while excising the graft.u
83
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March/April 2015
Meetings and Studies
Review of the 6th Annual Hair Transplant 360 Workshop
October 23-26, 2014 • St. Louis, Missouri, USA
Marco N. Barusco, MD Port Orange, Florida, USA [email protected]
2014 was the 6th consecutive
year of the Hair Transplant 360
Workshop in St. Louis and my
first year as faculty. I must say
that it was an honor to have been
invited and I was very impressed
by what I saw. I had heard that
the workshop was a huge success
every year, and now I know why.
The Organizers
Drs. Sam Lam and Emina
Karamanovski are well known
for their organizational skills and
their hard work. This “dynamic
duo” works so well together that
they don’t even need to talk to
each other. They know exactly
what the other one wants and
share the same intense passion
for education and for our specialty. They made sure all of us
felt welcome, valued our input
and suggestions, and were very
gracious to all of us.
Vance Elliott, Ken Williams, Larry Samuels, Marco Barusco, Jim Harris, Sam Lam,
Emina Karamanovski, Nicole Rogers, Tina Lardner, Aileen Ullrich,, Heather Steward,
Robin Collins (Not pictured: Robert True)
The Program
The program was packed
and very intense. Drs. Lam
and Karamanovski put a lot of
thought into creating a program
that progressed very well over
each day. A physicians’ program ran concurrently with an
assistants’ program, with some
overlap. Lectures were given
in the morning and practical,
hands-on activities occupied
the afternoon. Opportunity for
interaction between faculty and
participants were plenty and at
the end of each day all of the
participants and us were exhausted but happy. The program
covered every aspect of the
procedure, from consultation
to post-op, both for strip surgery and FUE. Hairline design,
donor hair removal, recipient
site creation, graft preparation,
storage, and placement were
all well discussed and demonstrated.
Participants in the Anatomy Lab
The Venue
St. Louis University is a
beautiful university located near downtown St. Louis. The Participant and Vendor Feedback
campus is very large, occupying a large geographical area of
One common comment I heard from participants was how
the city. Old buildings share space with new, modern ones. The much time they had to interact with the faculty and each other
PASE (Practical Anatomy and Surgical Education) building is during the cadaver sessions. This is invaluable for a great learna beautiful 3-story building with a French-inspired interior full ing experience. The fact that the lectures were given in a more
of beautiful details and woodwork. The top floor housed the hall informal setting, which stimulated active discussion with the
where all meals were and coffee breaks were served and where participants, was also well received. Vendors also enjoyed plenty
the various exhibitors were set up, allowing for intense interac- of exposure and time with the faculty and participants, and all
tion with the participants/faculty.
of them were very happy with the event.
The middle floor contains offices of the university and a large
lecture hall with comfortable seating and a large stage area. The Conclusion
audiovisual equipment and resources are great and a unique
This was an intense but very rewarding event. I would like
3-D system is available for live demonstrations on patients and to personally thank Drs. Lam and Karamanovski for inviting
cadavers right from the stage, with the audience being issued me and for treating me so well. I look forward to next year.u
3-D glasses.
The lower floor of the building houses the anatomy labs,
which are extensive and large. One room is equipped with
high-quality microscopes for surgical training, and the other
with dissecting tables. Cadavers were numerous and the staff
incredibly helpful, making sure we always had what we needed.
Transportation to and from the various hotels used to house
faculty and participants was offered by the organizers and were
always on time and plentiful.
SAVE THE DATE
November 19-22, 2015
2015 SLU HRS Cadaver Workshop
84
www.ISHRS.org
March/April 2015
Review of the Japan Society of Clinical Hair Restoration 19th
Annual Scientific Meeting and Live Surgery Workshop
November 23, 2014 • Okamaya, Japan
Vincenzo Gambino, MD Milan, Italy [email protected]
The 19th Annual Scientific
cells, and he analyzed the signal
Meeting and Live Surgery Workconduction pathway in human
shop of the Japan Society of Clindermal papilla cells. He also studical Hair Restoration (JSCHR)
ied the induction of hair follicles
was held on November 23, 2014
using IPS cells in vivo.
at Okamaya Convention Center
In his presentation, “Research
in Okamaya, Japan. The meeting
Strategy and Future Regeneration
began with the welcome address
of the Hair Organ,” Dr. Koei Toyby Society President Shinsaku
oshima detailed his study on the
Kawada, MD.
use of fetal epidermal stem cells
The Korea Japanese Friendand mesenchymal stem cells, and
ship Session began with a prehow he succeeded in neogenesis
of functional hair follicles with
sentation by Dr. Chang-Hun Huh
hair cycle in mice.
entitled “Current and Future SurIn “New Nano Medical Treatgical Treatment for Androgenic
Alopecia.” He spoke about vari- (left to right) Sotaro Kurata, MD, Mrs. Irene Gambino, Prof. Vincenzo Gambino, MD, ment of Skin and Hair Using
Prof. Andy Goren, MD , Prof. Ralph M. Trueb, MD, Kuniyoshi Yagyu, MD
ous surgical approaches to HRS
Fullerene” Dr. Shigek Inui pre®
and his opinion that the ARTAS
sented his study on the antiRobotic System is the current best
oxidative effect of fullerene. He
option for FUE.
studied cell protection of hair
Dr. Gwang Soeong Choi’s
follicle cells and epidermal cells
paper, “Current Perspectives on
using 1% fullerene lotion.
Medical Therapeutic Options for
Dr. Yasusuke Ito presented
Androgenic Alopecia,” discussed
“Treatment for Alopecia Areata.”
the various current and promising
He talked about IFN-gamma
future treatments. Aside from
signal conduction pathway and
finasteride, dutasteride, and misuppression of JAK-STAT pathnoxidil, there are cell medicated
way. He also discussed targeted
Classic Japanese entertainment made for an enjoyable end to the evening.
treatments, such as cell secreted
therapy with JAK1/2 antagonist
factors, cultured cells of hair follicles, and platelet rich plasma, and JAK3 antagonist. In addition, he won the Hirayama Award
that are showing positive results. Low level laser and light of the JSCHR this year.
treatments are being used, but there is little peer review on their
At the closing ceremony and gala, Dr. Kwada and incoming
efficacy.
President Dr. Ryuichiro Kuwana spoke. Drs. Takahiko Morigudi
Dr. Ralph M. Trueb presented “Patterned Hair Loss, Hair and Kuniyoshi Yagyu presented awards. A traditional dinner
Aging, and Anti-aging Strategies.” He theorized that aside from and classic Japanese entertainment was graciously provided by
the currently recognized factors in hair loss and hair aging, fol- the JSCHR.u
licular micro-inflammation and fibrosis could also be co-factors
and new strategies could be developed.
Dr. Vincenzo Gambino provided insight in his presentation,
“Hair Transplantation on Patients Younger than 25.”
In “Clinical Utility and Validity of Minoxidil Response
Testing in Androgenetic Alopecia,” Dr. Andy Goren noted that
sulfotransferase enzyme activity can predict a patient’s positive
response to minoxidil therapy.
Presenting “Future Restoration Medicine Beginning from
Hair,” Dr. Yasuyuki Amoh detailed how he developed a system
th
of mass production of follicular stem cells by cell culture, and he
studied repair of injured tissue including regeneration of neuron
synapse using follicular stem cell in mice.
Dr. Manabu Ohyama presented “Strategy for Optimization
of Cellular Components for the Human Hair Follicle.” He noted
how he used multi-potential stem cell, including human IPS
SAVE THE DATE
December 5-6, 2015
20 Annual Meeting of the JSCHR
Dr. Ryuichiro Kuwana, Program Chair
Kochi, Japan
85
www.ISHRS.org
March/April 2015
ISHRS Annual Giving Fund
2014 Year-End Report
Dear Colleagues:
As we start another exciting new year with ISHRS, it seems appropriate to look back on 2014 and celebrate what has
been accomplished through the generous donations made to the Annual Giving Fund (AGF). It is inspiring that so many
members care enough about the ISHRS and the AGF mission to make such transforming gifts.
2014
To recap, while the ISHRS Annual Giving Fund fell slightly short of its 2014 fundraising goal of $47,500, it still supported
many valuable ISHRS initiatives. I want to personally thank all who contributed so generously this year making it possible
for us to raise $42,350. Each of you has helped the ISHRS achieve many of its philanthropic and educational goals. Your
kindness and ongoing support of the Society through your AGF donation is very much appreciated by the ISHRS leadership.
The proceeds from the year’s Annual Giving Fund were used to support several projects. Here is an example of what
your gifts helped to fund in 2014:
•
Operation Restore Pro Bono Program
•
Cicatricial alopecia research
•
Communications & public education, including website improvements and SEO
•
Support of the 9th World Congress for Hair Research
2015 GOALS
In 2015, we hope to reach our $40,000 fundraising goal. We will be reaching out to new and old members asking them
to carry the torch. It is my hope that many of you will be inspired by the important work that past donations have funded.
Your 2015 donation will help continue to fund the OPERATION RESTORE Pro Bono Program, hair research, and additional
public education via our www.ISHRS.org website in multiple languages.
PLEASE CONSIDER DONATING: For those who have not yet contributed, it is easy to support the Society. If you choose
to donate for 2015 or make another multi-year pledge, please complete the online donation form that can be found at http://
www.ishrs.org/content/ishrs-annual-giving-fund.
Or, if you prefer, you can contact Kimberly Miller at the ISHRS headquarters office at [email protected] with your credit
card information, amount of donation, and number of pledge years. New donors will receive a lapel pin, and we ask you to
wear it proudly at the ISHRS meetings. Those who make a 2015 charitable contribution to the AGF at the Trustee or Leadership Circle levels will receive two complimentary tickets to the Gala in their registration packets and will be acknowledged
during the Gala Dinner Dance and Awards Ceremony.
Your generosity in giving makes a concrete statement that you support the ISHRS and its initiatives. Thank you for your
consideration of a gift to the Annual Giving Fund. All gifts are tax-deductible within provisions of your national income tax
laws. Should you need additional information, please contact the ISHRS Headquarters at 1-630-262-5399.
Most sincerely,
John D.N. Gillespie, MD
Chair, ISHRS Annual Giving Fund
86
www.ISHRS.org
March/April 2015
Thank You to Our 2014 Donors
The ISHRS gratefully acknowledges the generosity of the following individuals who
have made donations to the Annual Giving Fund.
Trustee Circle: $2,000
Bernardio Arocha, MD, FISHRS
Mark A. Bishara, MD
John P. Cole, MD
Mark S. DiStefano, Sr., MD, FISHRS
Vincenzo Gambino, MD, FISHRS
John D.N. Gillespie, MD, FISHRS
Sara Wasserbauer, MD, FISHRS
Kuniyoshi Yagyu, MD, FISHRS
Leadership Circle: $1,000
Timothy P. Carman, MD, FISHRS
Glenn Charles, MD
Vance W. Elliott, MD, FISHRS
Edwin S. Epstein, MD, FISHRS
Koray Erdogan, MD
Bijan Feriduni, MD, FISHRS
SungJoo Hwang, MD, PhD, FISHRS
Grant F. Koher, DO, FISHRS
Samuel M. Lam, MD, FISHRS
Jose Lorenzo, MD
Emorane Lupanzula, MD
Mario Marzola, MBBS
William Parsley, MD
Damkerng Pathomvanich, MD, FISHRS
Asim I. Shahmalak, MBBS, FRCS
Piero Tesauro, MD
Anastasios Vekris, MD
Kenneth Williams, DO, FISHRS
Supporter's Circle: $500
Jonathan Ballon, MD, FISHRS
Michael L. Beehner, MD
James A. Harris, MD, FISHRS
Wolfgang Haindl
Barry H. Hendler, MD, DDS
Carlos Puig, DO, FISHRS
Nicole Rogers, MD
Cagatay Sezgin, MD
T.K. Shiao, MD, FISHRS
Arthur Tykocinski, MD, FISHRS
Conradin von Albertini, MD
Contributor’s Circle: $250
Kulakarn Amonpattana, MD
Julieta P. Arambulo, MD
Gerlinde Barnikel
Hyo Kang, MD
William J. Woessner, MD
Wen-Yi Wu, MD, FISHRS
INVITATION
Reflect, Rejuvenate, and
REGENERATE
The North American Hair Research Society
(NAHRS), with participation from the
Wilma F. Bergfeld, MD Australasian Hair & Wool Research Society,
CONGRESS CO�CHAIR
Cleveland Clinic Foundation the European Society for Hair Research,
the Hair Research Society of India, the
Angela Christiano, PhD Japanese Society for Hair Research, and
CONGRESS CO�CHAIR the Korean Hair Research Society, will
Columbia University
host the 9th World Congress for Hair
Research, which will bring together hair
Maria K. Hordinsky, MD biologists, dermatologists, cosmetic
CONGRESS ASSOCIATE CHAIR
University of Minnesota scientists and hair transplantation
surgeons for this three and a half day
comprehensive hair research meeting.
9th World Congress
for Hair Research
Miami • Florida • USA
A Comprehensive,
International
Hair Research Meeting
for the
Advancement of
Knowledge
In Hair Growth,
Hair and Scalp Disease,
and Clinical Care
Victoria H. Barbosa, MD, MPH, MBA
Plan to Attend
FOR INFORMATION AND REGISTRATION GO TO:
www.hair2015.org
For all inquiries, please contact
NAHRS Administrator, Victoria Ceh, MPA
[email protected]
Hosted by
International colleagues will present new
research, share experiences, and discuss
Valerie D. Callender, MD new directions for the advancement of
Howard University knowledge in hair growth, hair and scalp
disease, and clinical care.
Rush University
The Congress will include general
sessions, scientific posters, pre-Congress
workshops, networking opportunities,
Antonella Tosti, MD a full exhibits program, company
University of Miami sponsored satellite symposia, and more.
We invite you to attend!
Luis Garza, MD, PhD
Johns Hopkins University
Ken Washenik, MD, PhD
New York University/ Bosley
15WCHR EADV half pg FINAL.indd 1
Sincerely yours,
Congress Scientific Planning Committee
87
1/29/15 1:38 PM
www.ISHRS.org
March/April 2015
Message from the 2015 Annual Scientific Meeting
Program Chair
Nilofer P. Farjo, MBChB, FISHRS Manchester, UK [email protected]
Preliminary Program
Now that all the abstracts have been received for the Chicago
meeting, it’s time to work towards completing the program over
the next couple of months. The Annual Scientific Committee has
been working hard to assess the abstracts and once the scores
are collated, I will be putting the preliminary program together.
You will be notified in the next 4-6 weeks if your presentation
has been accepted, so thank you to all of those who have sent
in abstracts. Without your contributions, the meeting would not
be a success.
Please remember that if your abstract is chosen you will be
asked to submit your PowerPoint or video 6 weeks ahead of the
meeting. The moderator for your assigned session will check that
both the content of your presentation meets the required guidelines
for quality and time limit and also fulfils the learner objectives.
Invited Guest Speakers
We have confirmation of this year’s guest speakers. They will
cover a number of topics that I hope will be interesting to the
members: basic sciences, etiology of female pattern hair loss, the
latest research on Post-Finasteride Syndrome, and nutrigenics.
The invited speaker for the Advances in Hair Biology Lecture
is Valerie Horsley. She is the Maxine F. Singer Associate Professor of Molecular, Cellular & Developmental Biology at Yale
University. She has already received many honours for her work
on the cellular and molecular mechanisms that control stem cell
activity and function within epithelia. These honours include the
Presidential Early Career Award for Scientists in 2012. I have
asked her to speak on her work with adipocytes and their role
in regulation of fibroblast function.
Another of our honoured speakers is Andrew Messenger,
Professor of Dermatology at the Royal Hallamshire Hospital
in Sheffield in the United Kingdom. He will give the Norwood
Lecture in honour of O’Tar Norwood, a dermatologist, who is
a co-founder of the ISHRS and founder of this journal, Hair
Transplant Forum International. Dr.
Messenger is world renowned as an
expert on female pattern hair loss, so I
look forward to his update on the latest
theories behind the causes of hair loss in women.
Side effects of finasteride are still a controversial topic for our
patients. Mohit Khera, Associate Professor of Urology at Baylor
College of Medicine, has been invited to present the results of
his study on genetic and epigenetic factors in Post-Finasteride
Syndrome patients. This syndrome, characterized by persistent
sexual, neurological, and physical side effects after stopping
finasteride, can be a very devastating condition for patients,
but so far there has not been a convincing explanation for its
existence. Hopefully, Dr. Khera’s study will shed some light
on this condition.
Finally, we have a lecture entitled Natural Ingredients for
Activating Biological Targets in Hair and Skin that will be given
by Ranjit Bhogal, PhD, a research scientist with Unilever Ltd
in their Research and Development Division in Colworth in the
United Kingdom. Unilever has a long history of working on
hair biology research both in their own lab and in association
with leading universities. Dr. Bhogal will give us some insight
into another under researched topic, namely the interaction of
external nutrient factors on hair and skin.
Chicago the Destination
September is a great time of year to visit Chicago. The
weather is pleasant during the day with temperatures in the mid70s Fahrenheit (24°C ), but it can get a bit chilly at night 54°F
(12°C), so it would be advisable to carry with you a warmer
jacket or sweater for the evenings. The milder temperatures
also mean that there are no crowds of tourists, which makes it a
perfect time to enjoy sight-seeing without the excessive queues.
So come a few days ahead of the meeting and enjoy all the sights
that Chicago has to offer. See you there!u
SAVE THE DATE
September 9-13, 2015
2015 ISHRS Annual Meeting
www.ishrs.org/AnnualMeeting.html
88
www.ISHRS.org
March/April 2015
Message from the 2015 Surgical Assistants
Program Chair
Janna Shafer Bloomington, Minnesota, USA [email protected]
Excitement is building as the annual ISHRS conference in
Chicago this September will be here before we know it. Sara
Roberts, who works with Drs. Bessam and Nilofer Farjo, and
I promise to host a wonderful SA Program and Workshop this
year. Attending the SA Program and Workshop is the best way
to make new friends from somewhere in your own city or from
half way across the world. The SA Program and Workshop is
geared towards assistants with experienced skills and those
brand-new to the field. In 2013, Sara helped organize the surgical assistants training in a very successful ISHRS-sponsored
Regional Workshop in Manchester, UK. I have every confidence
she’ll do the same in Chicago.
We implore upon all the lead techs of each clinic to be more
active in the SA community. How
do you go about being more active?
Here are few suggestions: 1) empower
yourself and your co-workers by reading up on the ISHRS Forum newsletters, 2) share your pearls
and wisdom by contributing articles to the Forum, 3) become
a faculty member in the SA Workshop or participate in the SA
Program by giving suggestions for presentation topics or by
giving a presentation.
Please don’t hesitate to contact Sara or myself if you would
like to participate in the SA Program and/or Workshop at
[email protected] or [email protected]. See you in
Chicago!u
ISHRS REGIONAL WORKSHOP
SAVE-THE-DATE
May 1–3, 2015
Hosted by: James A. Harris, MD, FACS, FISHRS
Workshop chairs: Emina Karamanovski & Tina Lardner
Sponsored by: Hair Science Center of Colorado
Hands-on Surgical Assistant Training Program
Graft Preparation and Placement (FU-strip & FUE)
 over 20 hours of hands-on training
 live surgery observation
 learning in “real-life” surgical setting
 intimate group / instant feedback
 NEW: after the course, sponsoring
physician will receive the student’s
skill level evaluation
LOCATION
The Hair Sciences Center of Colorado,
FEE
$ 1,700 per student*
5445 DTC Parkway, Suite 1015
Greenwood Village, CO 80111 USA
To register [email protected] or 1-303-694-9381
Go to: http://www.ishrs.org/content/educational-offerings, and scroll to “ISHRS Regional Workshops” for Registration Form
*Includes access to online ISHRS Assistant Resource Center from the date of registration through May 15. 2015 (value of $2000 )
89
www.ISHRS.org
March/April 2015
Classified Ads
Hair Transplant Surgeon for NYC
Ziering Medical is searching for an experienced Hair Transplant Surgeon to join our Chicago, New York, and Dubai clinics.
Generous compensation package in an established market, with tremendous upside.
Interested candidates, please send your CV and cover letter to
[email protected]
Seeking Full-Time Physician Assistant
Immediate opening for a Full-Time Physician Assistant for a Hair Restoration Clinic in West Hollywood.
Must have experience with anesthetic injections and suturing. Knowledge of cosmetic laser treatments, injectables,
and fillers is preferred but willing to train ideal candidate. Some Travel involved and must have excellent communication skills.
Candidate will be trained in all aspects of hair restoration including hand-held Follicular Unit Extraction,
ARTAS Robotic System, hairline design, etc.
Please send résume to: [email protected]
Seeking Hair Tech
Hair Tech for busy practice just west of Boston, Worcester, MA. Experience not necessary, but very desired.
Work 4-5 days per week, your choice, paid at competitive rates.
Excellent benefits, 401 K, Vacation 2-3 weeks based on experience, 10 paid holidays, sick time and personal days.
Great place to work, people come and never seem to want to leave. Growing office.
Please email Bonnie Minardi, Head Technician, DiStefano Hair Restoration Centers, at [email protected].
90
www.ISHRS.org
March/April 2015
Plan to Attend
generAl SeSSionS
www.ISHRS.org/AnnualMeeting.html
The IShRS annual ScIenTIfIc meeTIng is The premiere meeting
of hair transplant surgeons and their surgical assistants.
You don’t want to miss it.










Combining FUE and Strip Surgery
Advances in Hair Biology
Update on Finasteride and Side Effects
Hair loss Diagnostic Dilemmas
Unique Issues in Ethnic Transplantation
live Patient Viewing
Small Group Discussion Tables
Interactive Panels
Female Pattern Hair loss
Management of Complex Cases
other offeringS









FUE Hands-On Mini-Courses
lunch Symposia and Workshops
Basics in Hair Restoration Surgery Course
Advanced/Review Course
Surgical Assistants Program &
Hands-On Workshop
M&M Conference
Exhibits Program
E-Poster Exhibits
Social program including optional tours
and activities, Welcome Reception,
Gala Dinner/Dance
neWcoMerS Are WelcoMe!
We offer a “Meeting newcomers Program”
to orient those who are new to the ISHRS
annual meeting. newcomers will be paired
with hosts. We want to welcome you,
introduce you to other colleagues, and be
sure you get the most out of this meeting.
2015 AnnuAl Scientific Meeting coMMittee
Nilofer P. Farjo, MBChB, FISHRS
Chair I UK
Sara M. Wasserbauer, MD, FISHRS
Advanced/Board Review Course Chair I USA
Ratchathorn Panchaprateep, MD
Advanced/Board Review Course Co- Chair I THAIl AnD
nicole E. Rogers, MD
Basics Course Chair I USA
Aman Dua, MBBS, MD
Basics Course Co- Chair I InDIA
Samuel M. lam, MD, FISHRS
Workshops Chair I USA
Marco n. Barusco, MD
M&M Chair I USA
Márcio Crisóstomo, MD
Live Patient Viewing Chair I BR A zIl
Jennifer H. Mar tinick, MBBS
Newcomers Chair I AUSTR AlIA
Janna Shafer
Surgical Assistants Chair I USA
John D.n. Gillespie, MD, FISHRS
Surgical Assistants Co- Chair I CAnADA
Damkerng Pathomvanich, MD, FISHRS
Immediate Past Chair I THAIl AnD
Jeffrey Donovan, MD, PhD I CAnADA
Piero Tesauro, MD I ITAly
international Society of hair restoration Surgery
303 West State Street I Geneva, Il 60134 USA
T E l 1 630 262 5399 or 1 800 444 2737
FAx 1 630 262 1520
91
info @ishr s.org I www.ISHRS.org
www.ISHRS.org
March/April 2015
HAIR TRANSPLANT FORUM INTERNATIONAL
Presorted
First Class Mail
US Postage
PAID
Mt. Prospect, IL
Permit #87
303 West State Street
Geneva, IL  60134 USA
Forwarding and Return Postage Guaranteed
Dates and locations for future ISHRS
Annual Scientific Meetings (ASMs)
2015: 23rd ASM
Chicago, Illinois, USA
2016: 24th ASM
October 19-22, 2016
Panama City, Panama
f orum
HAIR
TRANSPLANT
I N T E R N A T I O N A L
Advancing the art and science of hair restoration
Upcoming Events
Event/Venue
Sponsoring Organization(s)
Contact Information
March 3-6, 2105 &
May 26-29, 2015
Date(s)
University Diploma of Scalp Pathology and Surgery
Paris, France
University of Paris VI
Coordinators: P. Bouhanna, MD and M. Divaris, MD
www.hair-surgery-diploma-paris.com
Dr. Pierre Bouhanna, Course Director
[email protected]
March 28-29, 2015
AAHRS Scientific Meeting & Live Surgery Workshop
Bangkok, Thailand
Asian Association of Hair Restoration Surgery
Hosted by Damkerng Pathomvanich, MD, FACS
www.aahrs.asia
For details:
[email protected]
May 1-3, 2015
ISHRS Regional Workshop
Surgical Assistant Training Program:
Graft Preparation and Placement (FU-strip & FUE)
Denver, Colorado, USA
23rd Annual Scientific Meeting
of the International Society of Hair Restoration Surgery
Chicago, Illinois, USA
www.ishrs.org
Tel: 1-630-262-5399
Fax: 1-630-262-1520
9th World Congress for Hair Research
Miami, Florida, USA
North American Hair Research Society
www.hair2015.org
For details:
[email protected]
7th Annual Hair Restoration Surgery Cadaver Workshop
St. Louis, Missouri, USA
December 5-6, 2015
20th Annual Meeting of the JSCHR
Kochi, Japan
92
Hosted by James A. Harris, MD, FISHRS
Workshop Chairs: Emina Karamanovski & Tina Lardner
Practical Anatomy & Surgical Education (PASE), Center for
Anatomical Science and Education, Saint Louis University
School of Medicine
In collaboration with the International Society of Hair
Restoration Surgery
http://pa.slu.edu
Japan Society of Clinical Hair Restoration (JSCHR)
Hosted by Ryuichiro Kuwana, MD
For details:
http://www.ishrs.org/content/
educational-offerings
Dr. Samuel L. Lam, Course Director
Emina Karamanovski, Assistant
Course Director
http://pa.slu.edu
Dr. Ryuichiro Kuwana, Program Chair
[email protected]
www.jschr.org

Update on Efficacy of Generic Finasteride

Transcription

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