The Hair Loss Profile and Index: A New Classification System for

Transcription

Volume 13, Number 1
Hair Transplant Forum International
❏
January/February 2003
forum
Volume 13, Number 1
The Hair Loss Profile and Index: A New
Classification System for Pattern Balding
Bernard H. Cohen, MD Miami, Florida
or 50 years, the
Hamilton-Norwood
system has been used
to characterize the stages
and severity of baldness. In
2000, James Arnold, MD,
introduced an alternative
system based on the natural
Figure 1. Ten-zone map of scalp (standardized template). Three sets of dots indicate
principles of biodiversity.
dimensions to be measured.
Building on Dr. Arnold’s
insightful (and unpublished) observa- loss. Their mosaic combinations
tions, I introduced a new classification conform to the classic Norwood
system at the 2002 Chicago ISHRS
renderings. The second template is a
meeting. The full manuscript was
100-cell weighted bar graph with 11
published in the October issue of
fields (see Figure 2). Each field
Cosmetic Dermatology. Reprints are
represents one of the 10 zones. The
available.
number of cells assigned to each field
The new system is nothing more
is proportional to the relative size of
than a single sheet of paper that is
that zone. The vertical axis defines the
printed with two standardized temterminal hair density. The horizontal
plates—a map and a chart. All that’s
axis defines the fields.
required is a
patient and a
Terminal 100%
Terminal 75%
pencil. The
Terminal 50%
system can
Terminal 25%
depict the
Miniaturized 100%
No Hair
density,
distribution,
2. Blank bar graph (standardized template). The bar graph matrix contains 100 cells and 11 fields. The
and total hair Figure
number of cells assigned to each field is proportionate to the size of the zone.
mass of every
possible balding pattern. The first
template is a 10-zone map of the
Method (Briefly)
scalp (see Figure 1). The zones are
The examiner identifies the location
sequentially numbered to reflect the
of Zones 1 through 10 and the three
usual progression of male pattern hair pairs of dots on the patient’s scalp (see
F
Figure 3). Typically, the forehead
measurement is 8.5 to 9.5cm. If it is
greater than 11cm, one may assume
that Zone 2 is hairless. The distance
continued on page 249
Regular Features
President’s Message ............................. 246
Co-Editors’ Messages .......................... 247
Notes from the Editor Emeritus ......... 248
Life Outside of Medicine .................... 258
Cyberspace Chat ................................. 272
Letters to the Editors .......................... 275
Once Upon a Time ............................. 276
Surgical Assistants Corner ................... 279
Feature Articles
Trepidation, Peril, and
Opportunity ...................................... 251
Copycats, Borrowers, and
Plagiarists ......................................... 253
The Independent Internet Marketing
Site: A Symbiotic Confederation? ...... 255
Toppik Enhances Patient Experience ... 257
Hair Repair ......................................... 259
10th Annual Meeting of the ISHRS ..... 263
A Photographic Look at the
Meeting and Award Winners ..... 264–265
The Internet—Curse or Godsend
for Surgeons? .................................... 277
Training and Developing New
Assistants .......................................... 281
Official publication of the International Society of Hair Restoration Surgery
245
❏
Volume 13, Number 1
Hair Transplant Forum International is published bimonthly by the International Society of Hair
Restoration Surgery, 13 South 2nd Street, Geneva,
IL 60134. First class postage paid at Schaumburg,
IL and additional mailing offices. POSTMASTER:
Send address changes to Hair Transplant Forum
International, International Society of Hair
Restoration Surgery, 13 South 2nd Street, Geneva,
IL 60134. Telephone: 630-262-5399, U.S. Domestic
Toll Free: 800-444-2737; Fax: 630-262-1520.
President: Robert S. Haber, MD
Executive Director: Victoria Ceh, MPA
Editors: Michael L. Beehner, MD, and
William M. Parsley, MD
Surgical Assistants Corner Editor:
Shanee Courtney, RN
Managing Editor & Graphic Design:
Cheryl Duckler, [email protected]
Advertising Sales: Cheryl Duckler,
847/831-0499; [email protected]
Copyright © 2003 by the International Society of
Hair Restoration Surgery, 13 South 2nd Street,
Geneva, IL 60134. Printed in the USA.
The International Society of Hair Restoration Surgery
does not guarantee, warrant, or endorse any product
or service advertised in this publication, nor does it
guarantee any claim made by the manufacturer of
such product or service. All opinions expressed are
those of the authors, and are made available for
educational purposes only. The material is not
intended to represent the only, or necessarily the
best, method of procedure appropriate for the
medical situations discussed, but rather is intended
to present an approach, view, statement, or opinion
of the author that may be helpful to others who face
similar situations. The ISHRS disclaims any and all
liability for all claims that may arise out of the use of
the techniques discussed.
Hair Transplant Forum International is a privately published newsletter of the International Society of Hair
Restoration Surgeons. Its contents are solely the
opinions of the authors and are not formally “peer
reviewed” before publication. To facilitate the free
exchange of information, a less stringent standard
is employed to evaluate the scientific accuracy of
the letters and articles published in the Forum. The
standard of proof required for letters and articles is
not to be compared with that of formal medical journals. The newsletter was designed 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).
The ISHRS Golden Follicle Award sculpture, as seen
on the cover of this issue, was designed by Francisco
Abril, MD. Dr. Abril offers for sale, copies of a small
bronze hair follicle sculpture (10" high). For more
information, please contact: Clinica Dr. Francisco
Abril, PO dela Habana, 137, 28036 Madrid, Spain.
Phone: 34-1-359-1961; Fax: 34-1-359-4731.
Volume 13, Number 1
President’s Message
One of the
privileges of
serving as president of the ISHRS
is the opportunity
to let my voice be
heard on this
page. My principal task is to
shepherd the
Society through
Robert S. Haber, MD
Mayfield Heights, Ohio the year, keeping
it healthy and strong. But lurking in
the shadows are elements of danger!
Internet sites that may not serve our
best interests. Fractured alliances
amongst our members that could
bring a negative spotlight on our
field. Business practices that may be
unethical, or worse. Pretending that
these problems do not exist serves no
useful purpose, and I therefore must
make this message a call to arms! A
challenge not to let complacency
defeat us. A warning not to ignore the
risks that face us. A reminder that
only united in the common goal of
our patients’ best interests will we
continue to grow and flourish.
You can take up arms in a number of
ways. Ensure that in all your actions
you adhere to principles of ethics and
decency that go well beyond the tenets
of our code of ethics. Critically examine your advertising, your approach to
the consultation, your surgical technique, and your expressed and implied
attitudes regarding your colleagues and
competitors. Responsibly remind those
colleagues who are going astray of the
better pathway, without initiating a
war. We can lift each other up, and we
can just as easily drag each other down.
We are challenged by Internet sites
that sometimes do not serve our best
interests. We must therefore learn to
educate them and see to it that visitors
to these sites obtain accurate information. We are challenged by powerful
groups that can out-market the rest of
us. We must therefore learn to market
ourselves more wisely. We are challenged by unethical competitors. We
must therefore lead by example and,
when necessary, allow the due process
available within the Society to address
and correct these problems. We are
challenged by our own anxieties that
there will be fewer patients around the
corner. We must therefore spread the
word to the public and create more
patients for us all.
By staying united, by staying true
to high ethical standards, even when
others do not, by educating the press
and the lay public, these challenges
will wither for lack of room to grow.
We must each fight for our future!✧
Bob Haber, MD
To Submit an Article or Letter to
the Forum Editors
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E-mail: [email protected]
Submission deadlines: March/April issue, February 10; May/June, April 10.
246
Volume 13, Number 1
❏
Co-Editors’ Messages
One of my
ourselves first and foremost as colleagues
and also as physicians. If each one of us
thinks back to when we got started,
who helped us, and how we improved
our skills over the years, we would
realize that if the leaders in the field at
that time held all of their cards close to
their chest and pursued an “elitist”
philosophy to keep us out, we wouldn’t
be practicing in this wonderful specialty
today. When someone who is just
getting started in hair surgery comes to
my office, I find it valuable to imagine
myself five years from now bumping
into that person at a hair meeting. Do I
want him to warmly greet and thank
me as we approach each other? Or do I
want him to bruskly walk by, remembering back to when I tried to push him
off the park bench and didn’t offer him
a seat? Similarly, if I come up with what
I think is a better way to do a hair
transplant procedure, should I keep it
to myself, create an “exclusive mystique”
the ideas of other people who don’t
develop them themselves.”
In the same issue, Mackay observed
that “if I give you a dollar and you
give me a dollar, we each have a dollar.
But if I give you an idea and you give
me an idea, we each have two ideas. A
candle loses nothing by lighting
another candle.” I couldn’t help but
think of our field of hair transplantation as I read these words. I think his
message was that everyone benefits
when we share ideas with one another.
Our patients certainly benefit from
the expanded knowledge and skills we
have when we share our insights with
our colleagues at meetings, in our
offices, and in print.
It may be naïve to assume that, as
practitioners of the same trade, we are
not in competition with each other to
some degree, or that we are not businessmen and women as such. However,
it is nice to think that we consider
favorite columns
in our local
Sunday paper is
“Mackay on
Business.” He
recently related
the story about a
news reporter
who once
Michael L. Beehner, MD
complimented
Saratoga Springs, New York
Thomas Edison
on his inventive genius. Edison
replied, “I am not a great inventor.”
“But you have over 1,000 patents to
your credit,” protested the reporter.
“Yes,” Edison replied, “but about
the only invention I can really claim
as absolutely original is the phonograph. I’m an awfully good sponge. I
absorb ideas from every source I can
and put them to practical use. Then I
improve them until they become of
some value. The ideas I use are mostly
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Every profession
needs them.
They drive us
forward. They
inspire us. They
seem to have
special gifts.
They make us
say: “I should
have been able
to come up with
Louisville, Kentucky
that idea myself!” These are the “lateral” thinkers,
those innovators who seem to have
shed the constraints of institutionalized thinking and are able to think
“outside of the box.” Instead of being
satisfied with slow, steady progress,
they make their field jump forward.
Our field has some of these special
people, and we are the better for
them. While impossible to mention
all of these innovators, I would like to
point out a few.
In the 1930s and 1940s, early
innovations were predominantly
found in Japan. Drs. Sasagawa,
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Okuda, and Tamura not only discovered that full-thickness autographs
would work, but also used single-hair
grafts in work similar to some of our
advanced work today. Language
barriers and conflicts prevented the
work of these valuable innovators
from reaching and influencing the
rest of the world. John Greenleaf
Whittier’s words are most appropriate here: “For all sad words of
tongues or pen the saddest are these:
It might have been.” So many problems for the first 25–30 years of
transplantation could have been
avoided with knowledge of these
studies. After years of delay, Dr.
Norman Orentreich performed
studies with scalp autographs and
proved the donor dominance of male
pattern alopecia. His studies were not
appreciated by the major medical
journals and were published in the
Annals of the New York Academy of
Science in 1959. From that day
forward, there was no stopping the
development of hair restoration.
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Scalp reductions were started in the
mid-1970s, but overcoming tension
and removing a significant amount of
tissue were a problem. Enter Dr.
Patrick Frechet in the early 1990s.
His idea of the stretchy rectangular
material with hooks (the Frechet
extender) was a major innovation and
is still used to stretch the skin and
avoid the use of unsightly expanders.
While it can be painful, the patient
doesn’t have to hide for a few weeks.
When slot deformities of the crown
after multiple reductions were creating significant problems, Dr. Frechet
developed the triple transposition
flap. His work is done without
assistants, giving further evidence that
he has never been shackled by traditional medical process.
With the development of minigrafts
and the multibladed knife, most
physicians were trying to put rectangular grafts into round holes or
distorting the skin to place them into
slit incisions. Dr. Gary Hitzig decided
247
❏
Volume 13, Number 1
Notes from the Editor Emeritus
Here we are
into another
year, my 36th in
this intriguing
field of hair
restoration
surgery. Although we have
many fine
textbooks (and
Richard C. Shiell, MBBS
another edition
Melbourne, Australia
from Walter
Unger about to appear), we could still
fill books with what we DON’T know
about the human hair growth cycle.
An Internet discussion between a
dozen members of the ISHRS concerning the numbers of hairs per square
mm on various parts of the scalp
recently brought this to my attention.
There was further disagreement on the
distinction between transitional and
vellus hairs and how they should be
counted (and did it really matter
anyway!).
To the layman, hair seems such a
simple structure, yet nothing could be
further from the truth. Unlike a
homogeneous nylon fibre of similar
diameter, the human hair is incredibly
complex. It has an outer cuticle made
of a single layer of overlapping cells,
like roof tiles. Inside is a cortex made of
packed macrofibrils arranged around a
central medulla. Each of the
macrofibrils (diameter 200nm) is
comprised of hundreds of microfibrils
of diameter approximately 7n. Each of
these in turn is comprised of rope-like
strands of keratin, which are made
from polypeptide chains arranged in an
alpha helix.
The mechanism that produces the
hair fibre is unbelievably complex and
the interactions between the dozens of
growth factors and inhibitory factors
are only just beginning to be
unravelled. The vascularity of the skin
and hair follicles is well-known by
cutaneous surgeons, but the reason for
the myriad nerve fibrils that surround
each hair follicle can only provoke
speculation and wonder. No doubt
248
much of this is vestigial and would be
useful in creatures that change the
density, texture, and color of their coat
on a seasonal basis. Remember also the
chameleon, which can change its skin
color in seconds to match that of its
environment.
While human scalp hairs are relatively coarse at around 50 microns and
sparse at 1–5 per sq mm, merino sheep
produce fibres at 5 microns (up to an
incredible 50 per sq mm). The record
seems to be held by the Australian
platypus, however, which has fur with
an amazing 900 fibres per sq mm.
Hair Research
There are a number of Societies and
journals for scientists with an interest
in hair, wool, and feathers. The major
journals are J. Investigative Dermatology
and Experimental Dermatology, but
there are dozens of other specialty
journals, such as Cell, J. Cell Biol, J.
Cell Sci, and J. Biol Chem, that carry
articles of interest to hair researchers.
We often forget that wool and
feathers share the embryology of hair
and have many features in common. In
Australia, wool research at the CSIRO
(Commonwealth Scientific and Industrial Research Organisation) has been
going on for well over 70 years, funded
by a levy on every kilogram of wool
sold and every egg laid. There are other
wool research centres in the UK,
Germany, South Africa, and New
Zealand. It is a pity that more of this
immense accumulation of scientific
knowledge and experience in genetics,
molecular structure, endocrinology,
and physiology cannot be channelled
into human hair research, but the
wheels of bureaucracy turn slowly.
Research centres in the USA, England, Europe, and Asia are often
University-based, but may be funded
by large cosmetics manufacturers.
Human hair cloning will be under
investigation at many centres, large
and small, but is highly secretive and
the difficulty of the process must not
be underestimated. Even if solved
tomorrow, the practical application of
such technology to the treatment of
human baldness may take a further
decade.
Dutasteride
Dutasteride is on sale in Sweden
under the brand name “Avolve.” In the
USA, it has been approved by the FDA
for use in benign prostatomegaly and is
being marketed as “Avodart.” Judging
from the Internet, it is already doing a
roaring trade amongst the members of
the balding population who have been
anxiously awaiting its release for several
years. David Whiting reported in
Chicago that dutasteride in a dose of
2.5mgm daily reduced serum DHT by
93% (compared with 65% for
finasteride). At this dose, serum testosterone levels rise by an average of
19%. Dutasteride is being marketed in
0.5mg tablets so patients will need to
multi-dose to achieve these levels.
Sexual side effects are about double
those of finasteride at around 4%. By
the way, for those of us over 60 and
interested in its effects on the male
urinary system, it is said to improve the
urinary flow within 1 month, rather
than 6 months or more for finasteride.
Cost of Meetings
In the September/October Forum, I
commented on how few doctors from
the continents of Asia, Africa, and
India attended our meetings. In
Chicago, an Indian doctor politely
pointed out to me that the cost of
meetings in North America was a
serious inhibiting factor. Not only is
the financial exchange a great disincentive but the price one can obtain for a
transplant operation in many countries
is very low in US dollar terms. While a
1,000-graft procedure in the USA will
provide a first-class ticket around the
world, a similar operation in Australia
will only buy a business-class ticket,
and in India you may need several such
procedures to buy an economy ticket
Volume 13, Number 1
❏
Hair Loss Profile and Index
continued from front page
the cells beneath the
line may be shaded
or simply counted
(see Figure 4). The
shaded bar graph is
the patient’s Hair
Loss Profile. The
total number of
shaded cells is the
Figures 3A, B, and C
Hair Loss Index.
between the dot pairs in the central
At times, Zone 10 might have a
bridge and vertex is measured and
diffuse density that is lower than
recorded only if it is discernible. The
expected. This may be confirmed by
lower edge of Zone 7 is located in the performing a surface hair count using
area slightly above or below a line that a contact video microscope or handis circumferentially projected around
held lens. If the average density of
the back of the head from the top of
Zone 10 is less than 200 terminal
the ears.
hairs per square cm, Zone 10 should
Attention is then directed to the
be represented with less than 25
blank bar graph. The vertical axis has
shaded cells. Other times, Zone 10
6 density values that designate the
may have isolated areas of low density,
percentage of terminal hairs in each
such as a wide donor scar from
zone compared to Zone 10. Zone 10
previous HT surgery. The actual
(with the few exceptions below) is
location and size of the scar can be
arbitrarily assigned the value of
visually represented in the 25-cell
TERMINAL 100%. The MINIAfield. The hairless scars are depicted
TURIZED 100% designation applies by leaving blank a horizontal row of 2
to zones with only fuzzy, hypopigto 5 cells in the center of the field. In
mented, vellus-like hair. The NO
cases of female pattern alopecia, there
HAIR designation applies to zones
is often a lowered density in the
whose surface is truly free of any hair.
lateral left and right portions of Zone
The intermediate categories (TERMI- 10 with normal density in the central
NAL 25%, 50%, and 75%) are
three-fifths. This may be depicted by
determined by visually comparing the lowered density in the first and fifth
amount of hair to the amount of
columns of the 5-column field.
visible skin. Alternatively, these
Zone 3 defines the frontal forelock.
categories might be thought of as
However, it is not uncommon for the
Mild, Moderate, or Severe.
forelock to exist as an isolated island
The density of each zone is deterof dense hair on the anterior portion
mined and plotted on the graph. It is
of the scalp. Sometimes the forelock
important that the points on the
may be quite anterior—as seen in
horizontal axis span all columns of the
patients with foreheads of less than
field (with the few exceptions below).
9cm—suggesting that perhaps it is a
When all the fields have been plotted,
part of Zone 2. Other times the
forelock
Terminal 100%
may
Terminal 75%
Terminal 50%
be in
Terminal 25%
the
Miniaturized 100%
same
No Hair
location
deFigure 4. Completed Hair Loss Profile and Index. Estimated density for each zone has been entered by hand on blank bar graph.
picted
Measurable distances have been recorded. Total number of cells in each bar graph column equals index.
A
B
C
by the graphics—as in patients with
foreheads of 10 or 11cm. In either
case of the isolated forelock, the surrounding Zones 1 and 2 usually have
no hair or a much lower density than
Zone 3. Their density should be
documented in Zone 1 and 2 fields.
In cases of an isolated frontal forelock,
it is critical that the distance between
the forehead dots be measured and
recorded.
The system may be used with three
levels of precision, the details of which
are enumerated in the published
manuscript. Level 1 requires simple
observation and estimation. It is the
lowest level of precision and is described above. Level 2 precision
requires actual surface hair counts
(with video microscope or hand lens)
to determine the density of selected
fields. Level 3 requires 4mm punch
biopsies of selected fields with terminal hair counts performed on crosssectioned specimens.
Discussion
The Hair Loss Profile is a concise
and comprehensive characterization of
the distribution and density of an
individual patient’s hair loss. It may
be applied to both men and women
with pattern balding as well as
patients with scarring alopecia. The
Profile (and Index) may serve as a
standardized method of communication between physicians. It may also
be used for patient education, consultation, and counseling. The three
perspective graphics may serve as
standardized anatomic charts for
matters pertaining to hair loss or scalp
surgery. A 15mm tumor described as
located in Zone 6, left becomes verbal
shorthand for what would otherwise
require a drawing or photograph to
describe.
The Hair Loss Index is a single
value representing the amount of
original hair that still remains in spite
of the balding process. It is an expression of the patient’s relative hair mass.
How bad is a patient’s baldness? The
249
❏
Volume 13, Number 1
Hair Loss Profile and Index
continued from page 249
sequence, and speed of
Hair Loss Index replies: On a
pattern evolution, insights
scale of 1 to 100, he scores a 64.
might be gained into
A working model for an
predicting the final stage to
interactive computerized
which baldness might
version has been developed
progress. It may find a place
and was demonstrated at the
in forensic medicine as a
meeting. The physician
means of identification (i.e.,
examines the patient and then,
fingerprint). The data
using a mouse, electronically
might also be analyzed to
shades the density values on to
determine relationships
the bar graph. Within a
between hair loss patterns
moment, the patient’s 100and unrelated phenomena.
cell Hair Loss Profile appears.
Are there links to environSimultaneously, a five-tonemental factors, genetics,
gray Hair Loss Graphic is
ethnicity, or other medical
created. It’s a shaded version of
the map depicting each zone
Figure 5. Print out from working model of interactive software. Cells are highlighted via computer disorders? Not an unreasonmouse to create profile. Ten-zone map of scalp is automatically shaded in tones of gray to create able proposal. Three years
in a three-view perspective.
graphic. Shaded cells are automatically tallied to create index.
ago, before the software was
The total quantity of hair is
to hair loss. The data may be used to
conceived, a Boston medical group
automatically calculated and appears
track and characterize the growth
reported that men with severe vertex
in a window labeled Hair Loss Index
response to minoxidil and finasteride. balding had a 36% higher risk of
(see Figure 5).
It may be used to track patients with
coronary artery disease.✧
Because the software generates
untreated hair loss in order to follow
digital data, the system may be used
its progression. By comparing age,
to perform statistical analyses related
250
Volume 13, Number 1
❏
Trepidation, Peril, and Opportunity
Russell Knudsen, MBBS Sydney, Australia
Reprint of address presented at the 10th Annual Scientific Meeting of the ISHRS, October 10, 2002, Chicago, Illinois.
I have been asked to assess the
current state of our “specialty” and
offer some personal thoughts on the
future of our profession.
Trepidation
If our techniques and results are
better than ever, what challenges exist
that threaten our specialty? I see four
main challenges: First, increasing
medical litigation (with increasing
insurance premiums); second, governmental regulation of “right-to-practice”; third, Internet advertising
practices; and fourth, loss of “professionalism” in our specialty. In my view, the
first three challenges stem from the
changing public perception of our
professionalism as physicians/surgeons.
Increased patient education and
autonomy, together with increased
marketing and advertising, has repositioned the cosmetic surgery industry.
The public (and other members of the
medical fraternity) are increasingly
asking: Is cosmetic surgery medicine or
business? In other words, do we have
patients or customers?
There has been a global rise in an
entrepreneurial approach to health
care. In cosmetic surgery, the hype is
similar to that used to market other
lifestyle products. We need to ask
ourselves: Are ethical standards a
casualty of the promotion of cosmetic
surgery? Is our specialty seen as part
of the beauty industry, rather than a
procedure to meet health needs?
However, on the other hand, should
not patient autonomy include the
freedom of adults to purchase these
treatments, provided the advertising
surrounding them remains within the
ethical boundaries of truthfulness?
With regard to advertising, the
Australian Medical Association’s
position states: “The promotion of a
doctor’s medical services as if the
provision of such services were no
more than a commercial product or
activity, is likely to undermine public
confidence in the medical profession.”
Traditionally, the medical profession
prohibited advertising in its codes of
ethics. This was to minimize the
opportunity for patients to be misled
by claims of superiority of a technique
or individual. Historically, in many
countries, family physicians were seen
as “gatekeepers” to specialist services.
The demise of paternalism in both
society and the professions has encouraged increasing criticism of this
model. Ironically, the modern
gatekeepers to the public appear to be
self-appointed Internet entrepreneurs.
The development of the entrepreneurial model of medicine has encouraged both medical and non-medical
entrepreneurs. Advertising and
marketing are usually comparative,
and success is frequently due to the
size and momentum of the advertising
budget. Interestingly, I believe the
evolution of modern hair restoration
surgery has inadvertently aided this
process. The development of total
micrografting or follicular unit
transplantation has involved a less
hands-on approach by the surgeon,
especially if done with a “stick and
place” manner. This has created time
leverage for the surgeon that has
demonstrable financial rewards.
Ironically, or perhaps inevitably, some
medical assistants and non-medical
entrepreneurs have come to regard
doctors as non-essential to the procedure, or at best as having a limited
role. Perhaps we doctors need to
reclaim the operation? In other words,
be more personally hands-on. What
other surgery allows such delegation
of the operative procedure?
The first challenge, as mentioned
above, relates to increasing medical
litigation. This increase in medical
litigation is partly due to increased
patient education and autonomy,
which has empowered the patient to
seek redress for injury or perceived
injury. Balancing this should be our
increased care in promoting the
benefits and likely outcomes of hair
restoration surgery, thus leading to
more realistic patient expectations.
This is crucial because unrealized
patient expectations are the greatest
cause of medical litigation in our field.
The second challenge is increasing
government scrutiny and regulation.
Internationally, there is recognition
that the Cosmetic Surgery Industry is
largely unregulated. Australia, New
Zealand, France, and the United
Kingdom (England) have recently
either proposed, or enacted, regulations restricting the right to practice,
or promote, cosmetic surgery. This
trend will continue and spread, unless
we are seen to be serious about
regulating ourselves.
The third challenge is Internet
advertising practices. The typical
Internet user is male, post-pubertal,
and educated. Perfect! Regular advertising in print or broadcast media is
prohibitively expensive for single
practitioners and is dominated by
high-volume group practices. How do
single physicians compete? In contrast, Internet advertising is relatively
cheap and targeted to those genuinely
interested. Perfect! Or is it? In my
view, Internet advertising on commercial hair sites is a double-edged sword.
Websites are unregulated, and there
appears to be a Wild-West mentality
operating with derision of individual
surgeons and techniques common.
The legal jurisdiction over such claims
is unclear. Discussion groups on hair
sites are dominated by opinions, and
scientific rebuttal is derided as selfserving or protectionist. Some commercial sites claim to be consumer
orientated but accept product advertising with minimal critical control.
Recently, eponymous Websites with
251
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Volume 13, Number 1
Trepidation
to society is to guarantee competence, inevitable if we remain open to new
acronyms mimicking professional
provide altruistic service, and conduct ideas. Second, an advertising and
societies such as the ISHRS (Internaour affairs with morality and integrity. marketing “free-for-all” environment
tional Society of Hair Restoration
Societal attitudes to professionalism
encourages entrepreneurial efforts that
Surgery) have appeared as consumer
have changed from supportive to
may jeopardize standards. We must
advocates. Negative messages such as:
increasingly critical, with physicians
commit to more honest advertising.
“Can you trust your surgeon?” and
being criticized for pursuing their
Third, leverage is a financial ideal, not
“The only safe choice in hair restoraown financial interests and failing to
a patient ideal. Assistants performing
tion” abound. Again, on these
self-regulate in a way that guarantees
most of the procedure and the inInternet sites, claims of lack of selfcreasing use of non-medical consultregulation and absence of accountabil- competence. Recently, a Charter on
Medical Professionalism was develants threaten our credibility as
ity of our specialty are made.
oped in collaboration between the
physicians. How can consultants
Ironically, one Website that derides
European Federation of Internal
properly advise patients on the need
the ISHRS as having no standards for
Medicine, the American College of
for prescription medication like
membership, has its own Code of
Physicians and American Society of
finasteride? Last, is a continuing
Ethics that paraphrases the ISHRS
Internal Medicine, and the American
perceived loss of professionalism.
Code of Ethics almost word for word
Internet users have stated: “Secret
except for Article 7: “When communi- Board of Internal Medicine. This was
published in both Annals of Internal
techniques are acceptable because hair
cating with the public, members will
Medicine and Lancet.1
restoration surgery is more big businot use disparaging remarks that
ness than big medicine.” In other
could be regarded as detrimental to
The Charter cites three fundamenwords, we are perceived as selling to
the practices of ISHRS members.”
tal principles: first, primacy of
customers rather than
A number of
treating patients.
North American
…an advertising and marketing “free-for-all”
members of the
Opportunity
ISHRS are listed
environment
encourages
entrepreneurial
efforts
as members on
I believe we can
this Website. The
arrest
this slide in
that may jeopardize standards.
Website claims
respect. We have an
that it is “The
opportunity, but
Only Safe Choice in Hair Restorapatient’s welfare; second, patient
action is required. Medical professiontion.” Are consumers to believe there
autonomy; and third, social justice.
alism must be taught explicitly. Setting
are no known “safe” hair restoration
The Charter also espouses a range of
and maintaining standards is crucial.
surgeons outside North America? Or
professional responsibilities that
Re-certification and revalidation are
are these the only “safe” surgeons in
include commitment to professional
now regarded as professional obligaNorth America? The acceptance of
competence, commitment to improvtions. Self-regulation measures must be
member advertising by this commering quality of care, commitment to
fair, objective, and transparent.
cial “independent” consumer-protecscientific knowledge, and a commitI believe that self-regulation can be
tion site raises questions about
ment to maintaining trust by manag- a two-level process in hair restoration
potential conflict-of-interest issues.
ing conflicts of interest. These core
surgery. First, at the specialty level
Isn’t this just a marketing group?
responsibilities involve taking the
with involvement of ISHRS, ESHRS
Surely we can do better than this? Or following actions: self-regulation,
(European Society of Hair Restoration
does fear of the mega-advertising
defining and organizing the education Surgery), ABHRS (American Board of
groups mean that the end justifies
and standard-setting process for
Hair Restoration Surgery), and
the means?
current and future members, and the
IBHRS (International Board of Hair
The fourth challenge is the perobligation to engage in both internal
Restoration Surgery), for example.
ceived loss of professionalism of our
assessment and external scrutiny of all These bodies can be responsible for
specialty. Physicians have dual roles as aspects of professional performance.
setting formal standards of practice.
healer and professional, which are
Second, at the professional level, the
Peril
linked by codes of ethics that govern
relevant Medical Boards can remain
Let’s consider the issues that put us responsible for disciplinary matters.
behavior and are empowered by
at peril in our field. First, in my view,
science. Professionalism entails a
For our specialty to be involved in
is complacency. We have not reached
societal contract that allows us auself-regulation, we must develop a Core
the end-point in development of our
tonomy and the privilege of selfCurriculum of knowledge for training
techniques. Further improvement is
continued bottom of next page
regulation. In return, our obligation
252
Volume 13, Number 1
❏
Copycats, Borrowers, and Plagiarists
Richard C. Shiell, MBBS Melbourne, Australia
Since
Norman Orentreich wrote the
first set of pre- and post-operative
instructions some 40 years ago, there
has been a good deal of literary
“borrowing” as one surgeon after
another uses pre-existing brochures as
a basis for his own literary effort.
Providing this is not a direct transcription and some effort has been
made to add one’s own mark or
“flavor” to the new work, there is
generally no objection to this common practice.
However, some surgeons are too lazy
to change the wording or even rearrange the copied paragraphs. I recall,
many years ago, being quite amused
and somewhat flattered to discover
that a new surgeon had simply
blacked out my name and address,
added his own, and photocopied my
meager four-page brochure as a
handout to prospective clients. Such
amateurs seldom last more that a few
months in professional life, so there is
no need to ring your attorney.
Another surgeon of my acquaintance
copied the then-current Bosley Bro-
chure almost exactly but put in his
own photographs in black and white
instead of Bosley’s expensive full-color
printing. He was a minor player in a
far away country, and if Larry ever
found out about it, he certainly took
no legal action.
Times have changed, hair restoration surgery is now much more
competitive and commercial, and
such behavior is likely to earn a writ
for breach of copyright. If you are also
a University figure, a charge of plagiarism can be extremely damaging to
your academic career. The vicechancellor of Australia’s largest University was dismissed from his post in
June 2002 when such a charge against
him was proven.
Translation of a work from one
language to another might seem a safe
enough exercise, as few North Americans are multilingual (except in Spanish
or French ). Here, the “copycat” fails to
recognize that we now live in a global
village and with the speed of modern
travel and written communication,
nothing remains secret for long.
If you are too busy or too lazy to
write your own book or brochure, then
it is wise to play by the established
rules. If you wish to use part of the
work of another author, then write and
ask permission and do not forget to
make the appropriate acknowledgment
in your text. If you wish to use the
entire text as your patient handout and
include your name on the cover, this
can also generally be arranged with the
author and his publisher along with
the payment of suitable royalties.
All of the above should seem
obvious but, somehow, with the
pressure of modern life, some doctors
have forgotten or chosen to ignore the
ethics taught at Medical School and
make up their own rules. Unfortunately for the offenders, detection is
now much more likely and the
punishments even more damaging.
These range from censure by your
peers and the resulting professional
disgrace to heavy fines for breach of
copyright. Shortcuts of the legal and
moral process can be expensive or even
terminal for the offender.✧
We stand at the crossroads to decide
our future. We have the power to
improve public perception of our
specialty. We need the collective will
to act. We also need to think big.
Surely it’s better to increase the size of
our market, which is currently only a
fraction of the concerned balding
population, than to fight over a
smaller market share, isn’t it?
United we stand, divided we fall.✧
Trepidation
in hair restoration surgery, preferably
with international support. Standardization is desirable. We must accept
peer-review certification. The recently
offered (by ABHRS) “Certificate of
Added Qualification” seems a step in
the right direction, as it is open to all
physicians wishing to practice. Let’s
remember, self-regulation is preferable
to external regulation.
REFERENCE
1. Medical professionalism in the new
millennium: a physicians’ charter.
Lancet 2002; 359:520–522 (and
Ann Intern Med 2002; 136:243–
246).
Someone has to go to the edge and be willing
to risk falling off so the rest of us can know
when to turn back.
—Hank McGraw, as quoted in Sports Illustrated
253
254
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Volume 13, Number 1
Volume 13, Number 1
❏
The Independent Internet Marketing Site:
A Symbiotic Confederation?
William H. Reed, MD La Jolla, California
The “Internet Marketing Sites” (IMSs) what is an acceptable outcome. Some with. Far more vital than this physician-centered model, from my 30in hair restoration have elicited the
observers consider a transplant unacexpected full spectrum of responses
ceptable if meticulous inspection by a year experience with physician
groups, is the group that is run by a
ranging from favorable to critical.
sophisticated eye reveals a coupled
semi-autonomous entity. This person,
Although Tony Mangubat, MD,
follicular unit graft, for example. It is
in the above general medical model, is
makes many good points about how
also difficult to reach consensus
semi-autonomous of all parties: the
they might be better (see “Shrinking
regarding what weight to give the
hospital, the insurance companies, the
the Specialty of Hair Restoration
technical parameters (transection
Surgery, ISHRS Forum, September/
rates, in vitro times, etc.). Accordingly, patient, as well as the physicians.
There is a healthy tension (speaking
October 2002, Vol. 12, No. 6; p.
there will always be some disagreeeuphemistically) from such semi223), I would like to disagree with
ment over what is “good” or “not
autonomy that discourages too much
some of his premises and conclusions
good” with both the technique and
and propose that they, as they curresult. Isn’t it ironic that the source of action being taken because of “clubbiness.” All parties are disgruntled from
rently exist, offer a unique opportunity the negativity amongst consumer
time to time (if
to be of service to
not most of the
the patient, to the
time), but there is
doctor, as well as to
Fostering an organization wherein power-sharing
a vitality and
the evolution of hair
and a dynamic tension exist amongst its
honesty with such
restoration.
power sharing. In
With respect to
constituents can be in the best interest of all.
our situation, the
the points made by
involved parties are
Dr. Mangubat:
not the hospital, insurance company,
groups is often based upon the
1. Negative marketing shrinks the
forceful arguments of the surgeon? For patient, and doctor, but rather patient
and physician. I would suggest that
market size. I disagree that elaborating example, the term “minigraft” is an
“clubbiness” is a central problem,
upon the spectrum of quality shrinks
unfavorable term in the cyber comwhether it be “clubbiness” that results
market size. Rather, increasing patient munity, but “coupled follicular unit”
from the (negative) emotional support
confidence that the closet is not full of is, perhaps somewhat begrudgingly,
in the chat rooms of the IMSs or the
“dirty little secrets,” by admitting
gaining acceptance. Therefore, for
“gold standards” and self-righteous
that poor outcomes occur, will grow
many reasons, including ourselves,
the market size. “Growing the marnegative opinions will always be a part indignation of an entrenched physician establishment. (Shouldn’t the
ket” would then be based upon
of an honest discussion of hair transhelping the consumer become confiplantation. It would be more intellec- story of Dr. Manny Marritt’s ostracism
dent that they can avoid a poor
tually honest if he/she who opines the by “clubbiness” when he introduced
the small graft in the early 1980s make
outcome. In any case, would it be
negativity would qualify the statehonest to deny the poor outcome by
ment as an opinion, but humility too us wary of the risk of centralized
authority, physician hubris, and of
considering only the positive? If so,
often does not appear to be a compohistory repeating itself?)
and we do include the necessary
nent of today’s communication style.
consideration of poor outcomes, such
3. The “Advocate”-run IMS. What is
discussions will inevitably be per2. The problem of “clubbiness.” Dr.
needed to fill the above semi-autonoceived as negative by some. UnfortuMangubat suggests that physicianmous position is an “advocate.” The
nately, hair transplantation is not like run groups are the better answer to
person needs to be a consumer advothe beef industry that Tony uses as an the IMS. This sounds right at first
cate and an advocate for hair transplanexample of successful, positive market- blush. After all, we are the doctors.
tation. As an advocate for hair
ing. Beef is a relatively homogeneous
With further thought, however, this
product beyond having a certain fat
sounds like “an Old Boys Club” if ever transplantation, he or she would also
be an advocate for most competent
content and tenderness, being a
there were one. I’ve seen, as I’m sure
certain anatomical part, being factory- many of you have in your areas, many physicians. An example of such a
person, in my opinion, is Spencer
farmed…. With hair transplantation,
such cliques in the various hospital
on the other hand, it’s very unclear
medical staffs I’ve been associated
255
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Volume 13, Number 1
Internet Marketing
5. Most of us are doctors, not marketwhat it means to say that any surgical
Kobren. Spencer Kobren, in my
ers or business-types. Such a participatechnique is an evolving art form, and
experience, has shown himself to be
tory role rather than ownership role in
by acknowledging that the patient
very objective and open-minded, in
an IMS seems to make sense not only
shares a variable degree of responsibilfact more open-minded than many of
for “airing dirty linen,” but also for all
ity for the outcome depending upon
my peers! For example, his methodical
of the other aspects that make a
the
specifics
of
the
situation.
open-mindedness has resulted in his
confederation of physicians successful.
concluding that both
Surely we can do
follicular unit extraction as well as combiI feel the independent IMSs offer a format for a truly better than
hiring “in-house”
nation grafting might
successful confederation, one wherein the needs of when it comes to
be considered in the
marketing, to
right circumstances.
one of its segments (i.e., the consumer) are met in a Internet
He’s free to modify his
opinion as we all do,
mutually beneficial relationship and with a high savviness, and to
addressing all of
but the point is that
degree of integrity by the needs of another of its the issues that
he is not inflexibly
have to be
dogmatic and hypersegments (i.e., the surgeon).
addressed by
critical as he has
someone in the
occasionally been
4. Can we physicians “police” ourselves? IMS. Such services aren’t cheap for
portrayed. In my opinion, he is
IPAs (Independent Physician Associamotivated by concerns for the patient’s My experience of several decades in
tions) in the general medical world,
medicine
is
that
physicians
have
never
welfare. He knows that what is good
and successful IPAs don’t try to tackle
for the patient is what will be good for adequately policed themselves—is
those organizational issues with their
the physician, for himself, and, second- yours different? Disciplinary action by
doctors.
physician-run groups has been prearily, for “growing the market.” As a
For these reasons, I think the IMSs as
empted by the clubbiness and by the
consumer advocate, he reserves the
they currently exist and with the semifear of litigation in my experience. We
right to judge the results. Inasmuch as
autonomous “advocates” who currently
all agree that the ISHRS is not an
there is no greater advocate of hair
head them (e.g., Spencer Kobren, Pat
organization that is meant to perform
transplantation than he, we should be
Hennessey) are responsive to the
such
a
function.
It
certainly
makes
it
comfortable with entering into a
consumer, are approachable and
clear that education is its mission
dialogue with him about his construcresponsive to physicians, are strong
tive criticism. That he doesn’t qualify to rather than certifying quality more
directly. ABHRS is a good “snapshot in advocates of hair transplantation, and
judge, although he has inspected more
deserve our support. Theirs is not an
time” of the quality of a surgeon’s
transplant than most of us, makes as
work, but it lacks an ongoing commit- easy job and is one that I think few
much sense as saying the consumer
physicians would want to try or would
doesn’t qualify to have an opinion about ment regarding disciplinary issues.
be successful in duplicating.
Therefore, as Dr. Mangubat says,
the transplant that he received.
lacking
any
change
of
policy
from
the
Many point to Kobren’s strongly
6. Conclusion. I feel the independent
ABHRS or ISHRS, another organizaworded statements. There are some
IMSs offer a format for a truly successtion is needed to address disciplinary
statements that I, personally, would
ful confederation, one wherein the
issues. I doubt that there are many of
tone down with changing a word here
needs of one of its segments (i.e., the
or there, and he seems very receptive to us who want to be in the daily confrontation with such policing issues. (It consumer) are met in a mutually
such considerations. However, he feels
beneficial relationship and with a
sounds like an ugly business.) I think
anger to the degree that we, the
high degree of integrity by the needs
the “advocate-run” IMS with its “consurgeons, don’t acknowledge the
of another of its segments (i.e., the
sumer
advocate”
is
an
excellent
solution
spectrum of the quality of work and
to this problem. If we disagree with the surgeon). The “integrity,” in my
judgment that have injured patients’
opinion, requires the semi-autonomy
decisions (or even the style) of the
lives, both today as well as in the past.
of the “advocate” as described above.
I share his anger, though mine is laden advocate, then we should discuss the
with dismay and sadness. Such anger is matter with the advocate. A successful Fostering an organization wherein
power-sharing and a dynamic tension
advocate has to be receptive to all
necessary and appropriate for a true
exist amongst its constituents can be
parties. Were this to fail, then we have
patient advocate. Certainly, anger has
the right to “vote with our feet,” that is, in the best interest of all.✧
to be tempered with knowing that
to walk away from the organization.
hindsight is 20/20, by understanding
256
Volume 13, Number 1
❏
Toppik Enhances Patient Experience
Craig L. Ziering, DO New York, New York
For the past year, we have offered
Toppik Hair Building Fibers to our
patients to observe the product’s
effectiveness as a cosmetic cover-up,
and its value as part of the patient’s
overall treatment.
Toppik is a “shake-on” product
manufactured by Spencer Forrest,
Inc., a 20-year-old company who also
produces a similar product, Courve.
Spencer Forrest creates products for
daily use that thicken the hair and
conceal any signs of scalp showthrough. These products are ideal for
patients immediately after transplant
surgery to conceal signs of surgery or any
post-operative thinning until the grafts
begin to grow. They are also used to
conceal hair loss for patients who are
postponing surgery but want a
temporary solution. They can be used
in conjunction with minoxidil and
Propecia® to show immediate results
for patients who hope to ultimately
experience an increase in hair shaft
diameter and regrowth. They can also
be used to supplement density in
patients with very limited donor hair.
A jar of Toppik Fiber contains
keratin protein fibers (derived from
wool), which come in eight different
colors to match most shades of hair.
The fibers cling to existing hair,
including the finest vellus hairs, by
virtue of a static electrical charge that
causes a magnet-like attraction to
human hair. When shaken into a
thinning area, the fibers are usually
indistinguishable from real hair in
appropriate candidates, even to the
trained eye. While they are resistant
to wind, rain, and perspiration,
Toppik Fibers remove easily with any
shampoo.
The product is remarkably effective
in achieving its stated goal. In most
cases, patients’ thinning hair immediately looks far thicker. This has been
true for both men and women with a
wide range of hair conditions. Postoperatively, we recommend that it not
be used until crusts have formed, and
may subsequently be safely applied.
One of its greatest virtues is in masking any post-operative thinning, and
in effectively concealing any crusts or
other signs of the procedure immediately post-operative.
I find it most beneficial in men and
women with diffuse thinning. It is
tremendously useful for patients to
use during the waiting and early
growth phase post-operatively (2
weeks–6 months, men; 2 weeks–8
months, women).
Because it provides immediate
gratification, it is remarkable to watch
the morale transformation for patients
severely troubled and discouraged by
their loss and yet limited in donor
hair or money, or who are approaching their restoration with small
surgical sessions over an extended
period of time.
We have observed no negative
responses to Toppik (no irritation,
infection, reaction, etc.) and a very
high level of satisfaction. We have also
found this type of product to be an
excellent means of maintaining
contact with prospective hair transplant patients who are not quite ready
to commit to surgery. Quite a few of
these people later returned to schedule surgery after repeatedly contacting
our office for reorders of Toppik.
The company has just created
complimentary “starter kits” that will
contain small bottles of all 8 colors of
Toppik. To obtain them, you may
contact Spencer Forrest, Inc.
directly.✧
Dr. Ziering has no financial interest in any Spencer Forrest products.
For more information or to register, contact:
Valarie Montalbano
Phone: 407-333-4200, ext. 141 • Fax: 407-333-9464
Last ch
ance
Regist —
er
today!
More than 22 live surgeries in multi-ORs, hands-on training, intensive
observation, work side-by-side with the leaders in hair restoration
257
❏
Volume 13, Number 1
LIFE Outside of Medicine
Submitted by Jim A. Harris, MD Englewood, Colorado
Mario Marzola, MBBS Adelaide, Australia
“In vino veritas,” and in being true
to yourself, you may find wine. Dr.
Mario Marzola and his wife Helen,
of Adelaide, Australia, have taken a
fork in the road of life, one with wine
on the horizon. Although it seems
that this path is a departure from the
one we have seen them traveling, it
isn’t such a radical change. Mario’s
father made wine at home in the
traditional Italian style and Helen
has always had an interest in food
and wine. Although Helen had been
second in charge at Mario’s practice,
she realized that she couldn’t be his
nurse forever. She then obtained a
diploma in Wine and Beverage
Marketing and is in the process of
obtaining a Bachelor of Applied
Science in Winemaking. For Scrabble
fans out there, it is the field of
oenology. The dream for this venture
started about four years ago, and
after endless discussions over many
good bottles of wine, they decided to
purchase a vineyard.
Hindmarsh Island, at the southern
most point in Australia, is the site of
their Pelican’s Landing Maritime
258
Wines vineyard. As a side note, the
island is shaped like a certain part of
the female anatomy. When viewed
from the vantage point of a plane, the
bridge connecting the mainland to the
island looks like a certain part of the
male anatomy touching the island.
Helen says that it makes people feel
“naughty” when crossing the bridge.
Needless to say, ideas about incorporating this bit of geographical trivia
into the branding of their wine have
met some resistance. Naughty and
wine…quite the combination!
The property is 80 acres in a “nontraditional” grape-growing area. It is
this aspect that makes the endeavor
that much more “adventurous.” To
date, 18 acres are under vine, with 11
devoted to Cabernet Sauvignon, 5 to
Chardonnay, and 2 to Viognier. These
three will allow them to make the
straight varietals as well as sparkling
Cabernet, Chardonnay/Viognier
blend, and Methode Champenoise for
the Chardonnay.
The plans for the vineyard are
straightforward: use a “hands-on”
approach to understand the vineyard
cycle intimately and then plant the
remaining area, as funds are available.
The first 11 acres were planted in
October 2001. With this, they expect
to have a small crop to “play” with in
2003, followed by full production in
2004. Their first wines should be
available in 2005, so reserve your
commemorative case now!
As if starting a vineyard isn’t enough
to keep them busy, the restoration of a
run-down 1850’s schoolhouse on the
island will. The plan is to restore the
building to its original state to serve as
the outlet for wine tasting and sales.
Mario and Helen find several
aspects of the venture exciting and
challenging. Mario, having spent time
in his youth (not all that long ago) on
a rhubarb and fruit farm, now has an
opportunity to return to his agricultural roots. The vines, which are
known for their temperamental and
demanding nature, present a challenge to Mario and Helen. The goal is
to maximize the potential of each vine
through the careful balance of just the
right amount of water and careful
pruning. This will result in small
grapes with the optimal levels of
sugar, acid, and anthocyanins (the
pigment responsible for the color of
wines). The other challenge they
delight in is the production of a great
product and getting it out to the
consumers to challenge those in the
already saturated Australian market.
There are some definite similarities to
the hair transplant business here.
Finally, Helen and Mario hope to
leave a legacy to their children. The
exposure to life on a farm, the mix of
fun and hard physical work, will be a
lesson of a lifetime. It is their hope that
the vineyard will leave a legacy for the
family that will last well beyond the
debate of FUT vs. mini-/micrografts.✧
Volume 13, Number 1
❏
Hair Repair
Vance W. Elliott, MD Edmonton, Alberta, Canada
This column details cases of patients who have presented with different concerns and problems, requiring repair or modification. Cases selected
illustrate the need for a creative approach to these problems using multiple treatment modalities, surgical and otherwise. Each case has been sent to a
panel of surgeons with expertise in our field of surgery, and often in others as well. Their suggested management plans are presented and discussed here.
Comments from the readership are invited, as well as cases for possible presentation, at [email protected].
Figure 1
Figure 2
Case 2: D.H.
This gentleman is in his early 40s.
Twelve years prior to presentation, he
had a flap performed. His postoperative course was complicated by approximately 2cm of tip necrosis. The
patient went on to have two sessions of
grafting into the area of the postnecrotic flap tip and four revisions of
the scar in the nape of the neck where
the distal flap had been harvested. The
last revision had been complicated by a
post-op wound infection.
This man’s hair loss continued, such
that he has been wearing a hairpiece
behind the flap for six years.
His goals were to re-create a more
natural hairline, improve the appearance of the nape scar, and discontinue
the hairpiece.
James Arnold, MD
Saratoga, California
This patient has three significant
problems:
1. His continuing loss of hair
2. An unnatural hairline
3. The wide, unsightly scar behind
his left ear
Of the three, I believe his continued
loss of hair is the most serious. Without stabilizing his hair loss, corrective
surgery at this point will be of no
value. Additional hair loss in this
patient would reveal much larger
problems with his flap, and the larger
problems will be uncorrectable by any
Figure 3
surgical approach. I would begin
medical stabilization immediately
using finasteride and, as Dr. Whiting
suggested in Chicago, “some minoxidil
as well.” If this patient is unwilling to
commit to long-term medical treatment, I would not perform any
corrective surgery. Even our best results
now will appear grossly inadequate if
he allows his hair loss to progress.
His second problem, the hairline, is
ideal for the corrective surgeon in that
it is too high, too straight, and too
dense. The exaggerated height gives
the surgeon plenty of room in front of
the hairline to soften the line and add
natural curves. I would use fine grafts
beginning 2cm in front at the
centerline and bend the line back
toward the lateral corners to create a
temporal recess on each side. The
patient could easily afford to supply
as many grafts as needed because
frontal density already exists and
relatively few grafts would provide the
desired softness and natural curves.
His third problem is the scar behind
the ear, which is still wide and unsightly after four revisions. I suspect
the scar is there to stay since it has
been reduced or closed four times to
no avail. I would suggest ignoring the
origin and location of this particular
scar and consider a new approach.
Approach this scar as we approach the
scars we see elsewhere on the scalp
when revision is not an option. I would
plan to transplant the scar.
Figure 4
Transplanting, rather than revising a
surgical scar, is unusual, plus, transplanting hair into the donor area seems
odd. Yet, it is probably the most
practical approach in this situation. A
relatively small number of grafts would
be required to acceptably disguise the
area, and hair from above can also be
used to help cover the site.
This patient also has crown loss that
would benefit from the softening
effect of small grafts. I would consider
treatment of the crown only after the
other work is complete. Grafts used
elsewhere, at the hairline and in the
scar, will be of greatest value to this
patient. And again, grafts at this time
will only be of value if his progressive
hair loss is checked.
Bernard Cohen, MD
Coral Gables, Florida
Although this patient poses a difficult
problem, establishing priorities and
performing them in a conservative
manner can best achieve the solution.
My thoughts would be as follows:
➤ What areas truly require cosmetic
correction and which are acceptable as is?
➤ Is there adequate tissue to perform
the cosmetic corrections?
➤ Will the corrections cause new
problems or worsen the existing
problems?
➤ Will the corrections endure should
the hair loss continue?
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Volume 13, Number 1
Hair Repair
It appears that the left-sided occipital scar can be covered by hair. Furthermore, if this is as good as the area
looks, after multiple attempts at
correction, one should conclude that
there simply is inadequate laxity in
the area for a good correction.
Plan: This area should be left
untreated.
The right frontal angle looks fine
and the left frontal angle is not all
that bad. It would, however, benefit
from correction with a small triangular advancement flap.
Plan: Optional correction of left
frontal area. Correction will not
adversely effect what is performed
elsewhere on the scalp nor deplete any
donor tissue.
It appears that transplants have
significantly improved the frontal
hairline. The flap now has a feathered
border and the area lost to tip necrosis
has been filled in. The patient’s
remaining donor area is not well
visualized on the photos, but I would
assume it is minimal.
Plan: Further refine the hairline
with follicular unit grafts without
fully depleting the donor area.
The central bridge and vertex are
still quite hairless.
Plan: The bridge and anterior vertex
area can be filled in with the final
remaining donor tissue. Leave the
posterior vertex bald. If the bridge
and vertex are corrected via scalp
reduction, I fear it would further
widen the prominent scar in the left
occipital area.
All of the above will endure only if
finasteride stabilization is successful.
Troy Creamean, DO
Corpus Christi, Texas
This patient is the perfect example of
the complications that can come about
with what seems to be a straightforward surgery. This is a case in which, if
you are fortunate enough to improve
his appearance in the long run, you are
truly an expert in the field.
260
I didn’t get a photo of his donor
site, but I will assume he has enough
donor area to deal with his issues at
hand. I would address his flap loss
area, his front hairline, and his
balding area just posterior to his flap
all at the same time with grafts. I
wouldn’t address his flap donor scar
area until after he has had grafts done
to the frontal area. I would create a
transition zone along the front of his
flap following the same strange
direction that you get with these
flaps. This is fine, as many people
have this variant from the usual
frontal hairline and you can work to
create what would be a more natural,
less surgical look for him.
I would do the same to the area
where the flap tip was lost and place
follicular units in the scar tissue. Be
careful not to place them close together, to ensure that they are not
devascularized. In reviewing his
photos, I would not cut out the scar in
the post-necrotic area. Not all is lost in
this area and I think he will get a great
cosmetic result by placing grafts over
this area. If you start to cut out scar
tissue in a serial fashion, you may find,
as with his flap scar area, that little is
achieved with scar excision and a lot of
effort is expended, and you would be
much better off simply placing grafts
in this area. By the looks of the photos,
grafts will grow in this area, and
transplanting here is less risky than
scar excision in an area that has already
had a major post-op complication.
Flaps are wonderful for moving a lot of
hair all at once, but they can be much
more problematic than grafts. It is so
important to stage flaps to help
prevent tip necrosis.
I would put large slots directly
behind his flap. He will never lose that
thick hair from the flap and the flap
hair is excellent coverage to put 2mm
or 3mm slots behind. This is virgin
scalp, so I wouldn’t expect the area to
be problematic. Then, at the crown
(depending on his balding pattern), I
would transition this in a similar
fashion as I proposed for the front
hairline, but in a rotational semi-lunar
pattern, so that the hair “feathers” in a
layered fashion over the crown.
In his post-auricular scar area, I
would do several things. First, I would
not do another scar revision. I would
assume the prior surgeon was good and
that this patient has tissue that forms
bad scars. However, I would remove
part of the flap scar in harvesting the
grafts for the front reconstruction; so
over two graft sessions the flap scar is
less to contend with. At some point,
after healing from the above transplant
session(s), I would look at cosmetics to
this area. I would wait until we are
near completion with the frontal work
so there is no further trauma to the
back. At the time of his last session to
the frontal area, I would propose
placing grafts over this flap scar area in
the back. I would use a CO2 laser on
the scar area around one month after
the previous graft session. This will
take the vascular blush out of the scar
so it blends in with the skin around it,
but it will turn very white. This white
coloration makes it more noticeable by
increasing the hair-to-scalp contrast of
pale scalp and darker hair. After the
CO2 laser area has healed, I would get
him to the best “permanent makeup”
artist to have the scalp in this area
tattooed. I have seen several such cases,
and they looked very good. The
tattooing helps break up the contrast. I
then would place grafts in the posterior
scar area on his last session along with
refining his frontal line.
In summary, I would spend extra
time with him to give him an understanding of what I feel should be a
calculated staged reconstruction of
several areas that have already had
post-operative complications and need
to be addressed conservatively. I
would try to get him to commit to
this at the beginning.
Gerard Seery, MD
Carmichael, California
In view of this patient’s multiple
failed surgeries and extensive undermining and traction closures to his
Volume 13, Number 1
scalp, it is unlikely that further
surgery would confer benefit. There is
every likelihood, if not certainty, that
the scalp, including the donor area, is
now extensively plasticized (stretchatrophied), making the tissues refractory not only to surgery, but also to
transplantation.
Micropigmentation would help, but
few, if any, hair restoration practitioners currently in practice possess
expertise for this. Prior to his retirement from the Hair Transplantation
Clinic of Sacramento, my associate,
Alvaro Traquina, MD, developed a
sizable micropigmentation practice,
with patients referred from all over
California. Our experience was that
patients were highly satisfied with
results. I am aware of at least one
practitioner who refers patients to his
favorite tattoo artist, who apparently
does good work.
Artificial fiber implantation would
also be relevant, but unfortunately
this treatment is still subject to an
FDA ban in the United States. It is
hoped the ISHRS, FDA, and the
manufacturers of fibers certified and
approved in other countries will get
together and arrange for clinical trials
to be held in the United States.
Should this come to pass, patients
with exhausted donor areas, caught in
the limbo of half-baked results, could
benefit from technological improvements that have occurred since the
ban came into effect 20 years ago.
Where does this leave this patient?
In trouble, I’m afraid. He is still
relatively young and further hair loss
is probably inevitable. He would be
well advised to become better friends
with his hairpiece on which he is
likely to become increasingly dependent with the passage of time.
Martin Unger, MD
Toronto, Ontario Canada
This patient presents with extremely difficult problems, and I will
personally be very interested in how
those physicians who do not do scalp
reductions try to help this unfortunate patient.
My own approach to helping this
patient would be in three distinct
stages. In Stage One, I would primarily
correct the almost non-existent frontotemporal angles (this can commonly
occur after flaps if they are not properly planned in the first place). My
correction of this problem would
consist of a U-shaped scalp reduction
behind the flap, during which I would
deliberately remove more tissue
laterally than in the anterior midline
region. This would re-create the
fronto-temporal angles and at the same
time raise the anterior hairline slightly
in preparation for Stage Three.
In Stage Two, after three months or
more, I would improve the extremely
wide scar in the post-auricular area.
My approach here would be a “donor
area scalp reduction” with PATE. The
tissue expander would be placed
medial to the scar, and the expansion
cycles would be continued until no
further progress was gained with
additional cycles. Then, as much of the
scar as safely possible would be excised.
This process could be repeated again in
three or more months if the scar was
still too wide after the first operation.
Attempted improvement of this type of
scar by serial excision alone is doomed
to failure, just as his other operations
in this area were.
In Stage Three, I would create a new
and more natural hairline with hair
transplantation anterior to the original
one (now that the original one has
been raised in Stage One), and during
the same transplantation, I would
create a natural transition zone behind
the flap as well. Follicular units/
micrografts would be used for the
transplantation in either one or two
sessions, depending on the blood
supply to the areas involved. In the
face of diminished vascularity in this
area, I would use two sessions four to
six months apart.
The end result: a happy patient who
can once again lead a normal life, and a
physician who can be justly proud of
his role in achieving this outcome.
Vance Elliott, MD
Edmonton, Alberta Canada
This man came to see me three years
ago. Initially, I recommended that he
have the left fronto-temporal angle
❏
elevated with a triangular advancement
flap as mentioned by Dr. Cohen, as well
as two sessions of grafting, six or more
months apart. At that time, the patient
was only interested in grafting. I did
not plan to revise the nape scar, as it had
already been through four sessions of
revision by his original surgeon (although one had been complicated by
infection, possibly reducing effectiveness). Finasteride treatment was explained and started, and the patient was
advised to consider it mandatory
protection in the long term.
His initial surgery involved right
temple and occipital harvesting to
produce slot multi-unit grafts for the
thinning area behind the flap and
follicular units for the anterior edge of
the flap to create a widow’s peak and
multiple mini-peaks along the hairline. This proved quite effective at recontouring the flap and creating more
“movement” in the hairline. The
patient was pleased with the effect
and now requested elevation of the
left fronto-temporal angle.
In the second procedure, three
components were planned:
1. A triangular advancement flap was
performed to elevate the left frontotemporal angle. The tissue excised
was dissected into grafts. The
original temple scar left from the flap
was used for the vertical incision and
was revised, as it had been noticeable
to the patient. This was done with
the expectation of a finer scar, due to
a lower tension closure than in the
original flap rotation.
2. The flap tip in the right frontotemporal angle was excised as an
ellipse, as sufficient mobility was
present and I was not satisfied with
the progress of grafting into the scar
tissue. Elliptical excisions in this
area that are closed with minimal
tension leave a fine scar, which is
then easier to conceal with grafts
than a large area. The grafts in the
scar were dissected and re-used
around the incision site.
3. Donor harvesting was performed
and the bald area behind the flap
was grafted again, as well as the
central hairline.
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Hair Repair
The above produced an improved
hairline contour, which satisfied the
patient, and also provided reasonable
density behind the flap. The patient
still would like more density behind
the flap, which illustrates the difficulty in competing with the excessive
frontal density of a flap in a patient
who balds behind it. Flaps that have
been “density-diluted” by pre-op
tissue expansion are somewhat better
in this regard.
The neck scar was injected one
month after the second procedure with
Kenalog and lidocaine in the hopes
that this would help flatten and soften
the tissue prior to revision, which the
patient requested I attempt. The scar
became purple after injection for 3
weeks, and then over the next 6 weeks
there was some flattening and fading of
the pink color. This effect was enough
to enable the patient to cut his hair a
little shorter in the area.
The patient removed his hairpiece 10
months after the last surgery, but
continues to desire revision of the neck
scar. I am concerned with tension in the
area and the reliability of the skin in
this area to produce fine surgical scars.
Summary
Opinions are diverse as to how to
help this patient. Certainly non-surgical
modalities must be considered in his
situation, as well as corrective surgery
that involves tissue excision as well as
grafting. Finasteride is vital for this man,
as his situation will be made worse by
AGA progression. Of key importance is
identifying a problem list and making
priorities for staged correction. The
patient must be fully aware of this at
the start, and recognize that the process
is likely to take 1–3 years.
Round defects in normal scalp
contract significantly during healing,
often to half their original diameter.
Does scar tissue exhibit similar wound
contraction behavior? If so, then
perhaps this patient’s scar could be
treated by scattered, multiple punch
removals of round pieces of scar tissue.
Leaving these sites open, similar to
original punch donor harvesting,
would produce zero-tension post-op,
yet through wound contraction result
in a net reduction of scar size over the
next several days. The scattered sites
might also break up the scar outline,
further reducing visibility.
This question will be posed to the
panel in the next column, where a
case of problematic donor site scarring
is presented.
I thank the panelists who generously shared their energy and experience to make this column possible.
Please send comments, questions,
and cases to: [email protected].✧
Beehner Message
around my discovery, patent every
aspect of it that I can, and garner as
much commercial advantage as possible for myself? Or am I willing to
share my discovery with others, hoping
to lift them up along with myself,
perhaps even harboring the hope that
they will give me feedback and suggestions that will even improve upon my
original idea?
On a lighter note, I had to laugh
when I read Dr. Richard Shiell’s
advice for newcomers in the last
issue, where he recommended doing
your first “solo cases” on friends and
relatives. I had always thought they
would be the last people on earth
you’d want to do your first cases on,
as you would have them around for
the rest of your life to remind you of
how bad you once were! One ENT
doctor that visited our office had an
ideal group of patients to get started
with; he was a consultant at a nearby
Veterans Hospital, where there was
an ample number of eager and
willing bald candidates for his early
efforts in hair replacement.✧
one must remember that visiting
doctors are required to listen to
lectures and conversations in 50
versions of the English language. This
is stressful enough, even to those of us
for whom English is our native tongue.
meetings this coming summer, with
the ESHRS meeting in Berlin in late
May and the DHI “Masters Meeting”
June 1–7. This will convene in Athens,
move out onto the Aegean with stops
at the glorious Greek islands, followed
by live surgery in Athens and Rhodes.
An experience not to be missed!
Happy New Year to all!✧
Michael L. Beehner, MD
Editor Emeritus
to the USA. Hotel costs are even more
expensive with the six days at the
Chicago Marriott costing more than an
International return ticket. Registration and extras add another thousand
dollars or more. One must also consider the problems caused by time
away from the office and the body
stress of long flights, time zone
changes, and foreign food. In addition,
262
European Meetings
For those who can stand the pace,
there are back-to-back European hair
Richard Shiell, MBBS
Volume 13, Number 1
❏
10th Annual Meeting of the ISHRS
Colin Westwood, MD Cheshire, United Kingdom
Day 1: Thursday, October 10, 2002
After the problems of the 9th Annual
Meeting in Puerto Vallarta, in which
the attendance was below 300 and
half the speakers stayed away, everyone was hoping this meeting would
restore the status quo. We were
rewarded with an exceptional educational experience. There are about
700 ISHRS members and well over
500 came to this meeting.
There was an air of confidence;
perhaps because it was the 10th Annual
Meeting and it took place in Illinois,
the home state of the ISHRS. In my
opinion, the outstanding success of
this meeting relied heavily on the
relaxed efficiency of Dr. John Cole’s
organization.
Over the past ten years, hair restoration has become increasingly recognized as a serious, credible speciality
based on sound research. The ISHRS
has shown itself to be committed to
education with workshops, to innovation with research grants, and also to
promotion in spreading information to
the public. Dr. Dow Stough made all
these points in his opening address.
He discussed previous meetings from
Dallas in 1993 through Toronto, Las
Vegas, Nashville, Barcelona, Washington, San Francisco, Hawaii, and Puerto
Vallarta to the present. He mentioned
that the ISHRS had weathered storm
and after storm and had taken on a
disciplinary role.
The Board of the ISHRS had proposed to correct free of charge any poor
results from previous operations.* The
only provisos being that the patients
present themselves for inspection and
assessment.
This altruism was popular, but not
universally accepted. At later open
discussions, a number of members
voiced reservations. Most notable
amongst these were Drs. Gerard Seery
and Marc Pomerantz. Their view was
that members might be exposed to
malcontents who would never be
satisfied, whatever treatment was given.
Also, there was the worry that this
might be seized upon by malpractice
lawyers as a green light and an endorsement for their work. Dr. Pomerantz put
the situation very eloquently when he
sketched the scenario of the patients
that come to you complaining of the
previous doctor from whom they
received treatment and who, in the
course of time, consult a third doctor
to complain about your treatment.
Dr. Tony Mangubat argued equally
strongly for the “party line.” He
pointed out that past techniques were
comparable to the Starr-Edwards valve
that at its time was “state of the art.”
It was a close-run thing but probably
the ISHRS just won the argument by a
narrow margin.
Dr. Russell Knudsen spoke of four
challenges to our practice of hair
restoration surgery (reprinted on page
251).
Dr. Richard Shiell spoke on the topic
of patients done long ago with the
large grafts, and achieved some balance
with his contribution. He admitted
that surgery performed 30 years ago
often achieved poor results, and he very
honestly showed a grade VII who had
had plug grafts at the age of 18, 30
years ago. On the other hand, he
pointed out and showed examples of
many old results still looked good
today. Paradoxically, with thinning of
the grafts and greying of the hair, some
even looked more natural.
Debates
Certain themes appeared to dominate this meeting and kept recurring.
One was the ISHRS suggestion to
correct previous poor results. The other
was follicular unit extraction or the
“Fox technique.”
This debate was successfully mounted
as a contest between a frocked and
wigged Dr. William Rassman (looking
amazingly like Cher in her hippy days)
and Dr. Jennifer Martinick in the
costume of a boxing kangaroo.
Dr. Rassman gave a very full account
of this technique. Later, on the third
day, he gave a further talk along with a
video. Also, in the live patient demonstration, he showed two very satisfied
patients who had undergone this
procedure. He reminded us that not
every patient qualifies for FUE. Dr.
Rassman introduced us to the “Fox”
classification of one to five. A class-one
patient yields 80% or more viable
follicles, a class five 20% or less. A
skilled operator can produce a class one
from a class two. Features of this
technique include a very large donor
area, super tumescence (with the FOX
biopsy only, not with the routine
harvesting of FUs), and extremely sharp
1mm punches. The punches are only
inserted to a depth of 2mm, and the
follicular units are then grasped with
forceps and gently pulled out.
Dr. Martinick questioned a procedure that accepts 20% follicular loss.
*Clarification on Corrective HRS Procedures for Dissatisfied Patients
In regards to the ISHRS endorsing or collectively organizing corrective transplants free of charge to dissatisfied former patients, there appears to be a misunderstanding of the
discussions and decisions that took place at the ISHRS Board of Governors meeting on October 9, 2002, and the General Membership Business Meeting on October 11, 2002,
in Chicago.
To clarify, at the Board meeting there was no motion made nor any action taken regarding this topic. The Board considered an informational report from Dr. Limmer proposing
to conduct a patient survey to assess patient satisfaction by an independent firm. Staff was asked to research costs of engaging an independent firm.
At the General Membership Business Meeting, during the Pro Bono Foundation Committee report it was reported that the program was being finalized and members
encouraged to participate. At this time, lengthy discussion took place regarding including a category for providing corrective HRS procedures to dissatisfied former patients in the
Pro Bono Foundation program. The group was reminded that the Pro Bono Foundation was originally formed to provide pro bono work to the indigent and to trauma/burn victims.
No motion was made nor action taken.
At the December 3, 2002, Board of Governors meeting, there was discussion regarding this topic during the report of the Pro Bono Foundation Committee. It was stated that
the focus of this Foundation is to provide pro bono work to indigent people that have suffered hair loss as a result of burns, trauma, or congenital deformities, etc. and would benefit
from an HRS procedure. It was decided that at the present time it is not the mission or the purpose of the Pro Bono Foundation to assist patients dissatisfied with a former HRS
procedure. —Victoria Ceh, Executive Director, International Society of Hair Restoration Surgery (ISHRS)
263
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Volume 13, Number 1
Volume 13, Number 1
❏
Awards Night
Bobby L. Limmer, MD, receives a plaque and presidential pin
from Daniel E. Rousso, MD, Past-President,
acknowledging his service as President
Richard C. Shiell, MBBS, presents research team with an
ISHRS research grant. Pictured L–R: Michael L. Beehner, MD,
Matt L. Leavitt, DO, David Perez-Meza, MD, and
John P. Cole, MD.
Program Chair John Cole, MD, (L) receives an award from
Richard C. Shiell, MBBS.
Gerard Seery, MD, (L) winner of Platinum Follicle
Award with Golden Follicle Award winner
Matt Leavitt, DO
Cheryl Pomerantz, RN, receives an award from
Bobby L. Limmer, MD, for her service as
Surgical Assistants Program Chair.
Russell Knudsen, MBBS, and Dow B. Stough, MD, receive an
award from Bobby L. Limmer, MD, acknowledging
their service as Co-Editors of the Forum.
2001–2002 ISHRS Board of Governors (October 9, 2002)
Seated: Mario Marzola, MBBS (Secretary), Bobby L. Limmer, MD (President), Robert S. Haber, MD (Vice President), E. Antonio Mangubat, MD (Treasurer)
Standing: Ronald Shapiro, MD, Melike Kuelahci, MD, JungChul Kim, MD, Paul T. Rose, MD, James Arnold, MD, Paul C. Cotterill, BSc, MD
Absent from photograph: Marcelo Gandelman, MD (Immediate Past-President), Rolf Nordstrom, MD, Arturo Sandoval-Camarena, MD
265
❏
She felt that there might be rare
indications, such as very nervous
patients, tight scalps, and wide scars.
Dr. Rassman admitted the drawbacks
and included a further one of unscrupulous practitioners who might
perform old style plug grafts under the
guise of a “Fox” procedure. He said it
was a procedure that a certain group of
patients will demand and at least some
doctors will have to perform.
A second debate was “Density is the
only issue.” A bearded Dr. Konstantinos
Minotakis proposed this. He pointed
out that only 25% of patients have a
second procedure in five years and
when graft density falls below 20–35
follicular units per square centimetre,
patient satisfaction falls dramatically.
A newly bearded Dr. James Arnold
countered the argument. If density was
the only issue, why were wigs and flaps
not more popular? Dense and natural
was the ideal, but maximum density
today could lead to shortage tomorrow.
A dense frontal region or forelock can
look unnatural when the surrounding
hair thins and leaves the grafts isolated.
The third debate also turned out to
be the third recurring theme of the
meeting—artificial hair. Dr. Gerry
Brady presented a 55-year-old patient
who had undergone eight scalp
reductions and four hair transplants.
There was no remaining donor hair
and the only answer was artificial hair.
He had had 3,500 artificial hairs
implanted into his scalp.
Dr. Piero Schiavazzi should have
provided Dr. Brady’s rebuttal. In his
absence, another antipodean, Dr.
Richard Shiell, stood in and argued
against something that he actually
favors. Later, he had plenty of opportunity to push the positive side of the
argument. Like the altruism of the
ISHRS, this is an issue that generated
discussion and divided opinion.
Talks
The standard of these sessions was
very high. Large amounts of practical
knowledge were dispensed. In addition, there was also a great deal of
scientific information that was interesting, but not always of instant practical
use. Dr. Paul Rose discussed controlled
cell death and its possible role in hair
loss. Dr. Moon Kyu Kim informed us
266
about control of hair growth through
an assortment of genes. One gene that
he mentioned, “sonic hedgehog,”
cropped up on at least a couple of
more occasions during the four days of
the course.
Dr. Sungjoo Hwang’s studies in
transplanting hair on the back, the
hand, and the leg suggested that the
recipient area had a profound affect on
hair growth.
Dr. Francisco Jimenez-Acosta took a
very interesting look at the arrector pili
muscle. He pointed out that the
traditional image of an individual
arrector pili muscle for every hair was
incorrect. In actual fact, each individual
FU has a single muscle. Projections of
the muscle split off to encompass each
hair. The hypothesis is that the muscle
is crucial to the integrity of the FU,
and we all know that transecting the
FU impairs hair growth.
One could not help wondering how
important the integrity of this muscle
might be to Dr. Rassman when he is
pulling out the FU.
Dr. Elise Olsen reminded us of the
different forms of hair loss in women.
Apart from Hamilton and Ludwig
patterns, there is also the Olsen Pattern
or Frontal Accentuation, previously
called the “Christmas Tree” loss. This is
characterized by miniaturization. Most
commonly this is central, but it can
also adopt bitemporal or parietal
patterns. Finasteride is contra-indicated and ineffective in women.
The day ended with a double act
from Dr. Matt Leavitt, discussing
trendy non-surgical hair loss remedies, and Dr. Robert Haber, covering latest developments. Dr. Leavitt
said there were 80 million people in
the USA with hair loss problems.
25% of them should be readily
amenable to treatment; in fact, less
than 3% present themselves for
treatment. The rest are being wooed
by “alternative” therapy.
There has been a massive increase
in over-the-counter remedies for hair
loss. Many contain saw palmetto,
which has a minoxidil-like affect;
others actually contain minoxidil,
which is now available without a
prescription. Additional products
like Avacor and Kevis are reputed to
block dihydrotes-tosterone (DHT).
Volume 13, Number 1
Thymuskin extracted from thymus
glands supposedly exerts a beneficial
affect through influencing the
immune system.
Dr. Haber mentioned Copper
peptide, which also is a DHT blocker.
He said that DHT is abundant in the
blood and that a topical treatment is
unlikely to have any significant effect.
Fluridil is a potent topical antiandrogen that might show some
promise. Finally, dutasteride trials
seem to show significant superiority
over finasteride in terms of hair
growth. Long-term safety is unknown.
Humor
Many serious points were presented
in a witty manner; sometimes comments from the floor were as memorable as the official presentations. I
have already mentioned Dr. Pomerantz’s
remark in reference to dissatisfied
patients. Dr. Mike Beehner injected
some sharp humor with a rhetorical
question during the debate on the Fox
procedure. He addressed Dr. Rassman
saying that Dr. Rassman had been at
the forefront of advances. He was one
of the first to perform 1,000 grafts,
then 2,000 grafts, and then 3,000
grafts. This inevitably resulted in larger
donor sites. If patients now were
clamoring for “no scar” surgery, did
Bill not feel that he was in some way
responsible for generating this demand? Everyone, including Dr.
Rassman, appreciated the irony and
humor of the question.
The first day ended with a reception
in the 95th floor of the John Hancock.
Workshops
There were more workshops in this
meeting than there have been in the
past. I find this slightly frustrating,
because they all looked useful and
interesting, but you could only hope
to attend two or three. Even then,
there is the problem that they either
commenced at 7 AM or else occurred in
the afternoon in tandem with the main
meeting. Therefore, it was either a very
long day or one missed out on some of
the main meeting.
I did attend Dr. Mangubat’s “Advanced Computer Applications,” and I
was glad I made the effort.
Saturday was very busy. In the early
Volume 13, Number 1
afternoon there was the presentation
of “Doctors and Their Patients.” At
2.30 PM this session had to end
because time was needed for the live
surgery session, the rest of the main
meeting, and the Instrumentation
workshop. I would have liked to
attend the main meeting, which
included Dr. Rassman’s video of the
Fox technique, but because I was one
of the contributors, I was committed
to the Instrumentation Workshop.
The Instrumentation Workshop was
not well attended, probably for reasons
already mentioned. There were perhaps
equal numbers of presenters and
attendees.
Dr. Arthur Tykocinski introduced the
session. He took us through the range of
instruments used in his surgery.
I discussed the importance of
disposable instruments in the light of
novel infections including diseases
caused by prions, which are resistant
to all forms of sterilization.
Dr. Cole demonstrated his “glow
chamber,” which is an oblong block of
crystal like plastic that has a portal for a
fibre optic cable. When plugged in, the
whole block glows, providing a cold
self-illuminated surface for cutting.
Dr. Isabel Banucci showed her graft
dispenser, in which five rows of grafts
can be lined up. They taper into a tiny
funnel, the tip of which can be introduced into an incision. The planter can
then move from one incision to the
next, never having to take her eye off
the area. Of course, one hand holds the
dispenser and the other a pair of
forceps, so a third hand is needed to
dab and clean the area. Dr. Banucci
solves this by taping gauze around one
William Rassman, MD Los Angeles, California
of her fingers. She can then place the
graft, dab the area, and move on to the
next graft.
Dr. Jerry Wong presented a precision cutting instrument that he uses
to cut blades for incision sites. He
uses Personna prep blades and can
❏
obtain dozens of samples from a single
blade. He cuts sizes from 0.75mm
upwards. These blades are exceedingly
sharp, sharper than a Sharp Point.
They can be mounted on a Sharp
Point holder. Dr. Wong finds that he
can estimate the correct size when he
looks at the graft. Because the blades
are so sharp, there is little bleeding
and grafts also can be introduced into
smaller holes. Dr. Wong finds that
grafts for which he might use an 18G
needle (1.4mm) easily go into a
1.2mm site. Possibly the fact that the
incision is oblong rather than triangular might be helpful. Jerry can plant
40 grafts per square centimetre with
ease into his incision sites. He says his
colleague, Victor Hasson, plants over
60 grafts per square centimetre.
The instrument costs $1,900, and
Dr. Wong has no financial involvement.
This instrument will last a lifetime, so it
would make economic sense for many
practices. It probably would not be
popular among surgical suppliers.
I am glad that I did not miss this
session. Anyway, I am sure I will be
able to catch Dr. Rassman’s video at a
future date.✧
Day 2: Friday, October 11, 2002
Richard C. Shiell, MBBS Melbourne, Australia
Plastic surgeon Dr. Donald Hause of
Dr. Athur Tykocinski of Brazil added
The Friday workshops were well
Sacramento has taken over the practice
a note of caution pointing out that in
attended by the coffee-quaffing,
of our most recent Platinum Award
older patients, smokers, and diabetics
muffin-munching ISHRS members
winner, Dr. Gerard Seery. He performs
densities of greater than 30 per sq cm
who had paid in advance and who
many alopecia reduction procedures
could lead to areas of scalp necrosis,
may otherwise have stayed in bed to
and confirms his mentor’s findings of
and it was safer to keep below that
nurse their hangovers from the
the importance of deep plane fixation as
figure in these patients. When preparReception and other first-night
the method to prevent stretchback. He
ing his grafts under the microscope he
revelries of the previous evening.
has further discovered that continuous
likes to identify Follicular Groups and
The first scientific session was titled
CV-3 Gortex with alternating bites to
use these in the centre front zone of
“Controversies, Dilemmas, and Revelathe periosteum and galea is superior to
the scalp to achieve added density.
tions,” and was led by Dr. David Seager
the 2-0 Nylon that was formerly used.
Follicular Groups are clusters of 3–5
of Toronto who bravely tacked the
Dr. Brad Wolf of Cincinnati spoke
prickly subject of hair survival in dense- hairs found where two follicular units
on the safety levels of Lidocaine and
exist close together.
packed follicular units. He stated that
epinephrine in hair restoration surgery.
Dr. Jerzy Kolasinski from Poland
there was no problem with survival of
Apparently there is no sound historical
deserves special commendation for
grafts at a density of 30 or more per sq
or clinical basis for the accepted figure
bravely rescinding his earlier recomcm as long as they were carefully
of 7mgm per kg for Lidocaine when
mendation of Monocryl as the ideal
prepared by expert staff and totally
used together with epinephrine. Doses
immersed in saline prior to insertion. It suture material in HT surgery. This
of up to 55mgm per kg have been used
was a great relief to those of us who
was also extremely important that the
safely in liposuction surgery.
had already tried and rejected this
receptor slits were not too large or the
Dermatology Professor Dr. Jerry
scalp circulation could be compromised. suture some years earlier. He noted
Shapiro of Vancouver spoke on the
It was recommended that 19-gauge slits that 10% of his patients had an
importance of establishing an accurate
inflammatory reaction to the material
be used for the larger FUs and 20–21gauge slits for the 2- and 1-haired units. that took 3–4 months to dissolve.
267
❏
diagnosis prior to hair restoration
surgery. Conditions such as chronic
telogen effluvium and diffuse alopecia
areata are often overlooked and may
become much worse after surgery.
Patterned scarring alopecia, follicular
degeneration syndrome, and frontal
fibrosing alopecia can all mimic
androgenetic alopecia. Diagnosis is by
scalp biopsy with transverse sectioning
of the follicles.
Dr. John Frank of San Francisco,
from the MHR Group, presented the
results of a joint research project
investigating the effects of steroids and
diuretics on post-operative facial and
periorbital edema. They found that the
size of the operation was not important
and that IM Decadron followed by a
tapered dose of oral Prednisolone gave
the best effects. This was followed by
oral Prednisolone alone. Lasix alone was
the least effective at preventing edema.
Dr. Joerg Hugeneck from the Moser
Group in Vienna spoke on improved
storage medium for transplants during
graft preparation. Details will be given
in a later edition of the Forum.
After the coffee break, incoming
ISHRS President Bob Haber, MD,
moderated a session entitled “Roadblocks to Hairloss.” He presented a brief
review of the literature on finasteride
and pointed out that even in the
absence of increased hair numbers,
finasteride could be extremely beneficial as it could lead to an increase in
hair volume by virtue of increased
diameter of target hairs.
Dr. Fabio Rinaldi from Milan, Italy,
demonstrated with global photography
that there was a slight improvement of
hair growth in transplant patients who
had received finasteride for 4 months
prior to and 48 weeks after surgery,
compared with those who did not use
finasteride at all. This finding was not
surprising but it is good to see an
objective study in support of a belief
that is already widely held in our
profession.
Dr. Russell Knudsen of Sydney,
Australia, presented the results of an
audit of his new patients over the
years 2000 and 2001. Of 325 new
patients, 68% agreed to try
finasteride. Of the latter group, 81%
were still using it 12 months later.
Those who had given up cited cost,
268
acne flare-up, sexual problems, failure
to see improvement, and acceptance
of their baldness as their main reasons
for doing so. Of those who received
Propecia® alone, 50% later elected to
undergo hair transplantation.
Dr. Bernard Nusbaum of Miami,
Florida, summarised a fascinating
study by Dr. Marty Sawaya of Orlando, Florida, and co-workers on “The
Effects of Finasteride on Apoptosis and
Regulation of the Human Hair Cycle”
(Eur J Dermatol, 2001;11:304). I hope
that this will be covered in more detail
elsewhere in the pages of the Forum,
but in summary the results suggested
that alterations in the levels of Caspase
1-9 and inhibitors of apoptosis play a
role in the development of androgenetic alopecia. Apoptosis is a unique
mechanism of programmed cell death
by which organisms control cell
numbers and destroy unwanted cells.
Defects in apoptosis can lead to disease
pathogenesis, such as in cancer, where
there is insufficient destruction and
cell accumulation occurs or neurodegeneration such as multiple sclerosis
where excessive cell loss occurs.
Carlos J. Puig, DO Houston, Texas
Celebrated investigator Dr. David
Whiting presented the results of
follow-up studies on the effects of
1mgm finasteride on males aged 41–
60. Maximum effect was seen at 6
months and maintained through the
24 months of the trial. Three percent
of older men complained of sexual
side effects and the PSA levels generally halved as in younger patients. Dr.
Whiting also said that topical
finasteride does not work because of
the amount of circulating DHT in
the scalp. There was no reduction in
Volume 13, Number 1
hair loss in women as judged by
global photography. The good growth
claimed by both males and females on
the placebo treatment was not confirmed photographically.
Marna Ericson presented a splendid
series of images showing the affect of
finasteride on hair follicles as viewed
microscopically.
During the luncheon recess, the
ISHRS Annual Business Meeting was
conducted and Drs. Mario Marzola
confirmed as Vice President; Paul
Rose, Secretary; and Tony Mangubat,
Treasurer, for the coming year. After a
ballot, Drs. Leavitt and Seager were
elected to the new ISHRS Board
replacing retiring members Drs. Rolf
Nordstrom and Marcelo Gandelman.
Eighty-three new members were
welcomed to the ranks of the ISHRS.
The afternoon Scientific Session
featured New Ideas and Advancements.
Dr. Vance Elliott of Canada led off
with the observation that the preauricular areas were safe to use if
required and care was taken to avoid
the underlying nerves and vessels.
These areas have the advantage of finer
gauge hair and frequently become
white earlier than other donor regions.
Dr. Jennifer Martinick of Perth,
Australia, spoke on gradual transplantation working from the premise of
“last out, first in.” This is not a new
concept, being frequently employed in
the days of 4mm plugs, but it seems to
have been forgotten this past decade.
Using this technique, the bald areas are
gradually filled so that the patient
improves 1–2 Norwood stages per
operation and the hairline and central
crown zones are tackled last of all.
Dr. Sungjoo Hwang of Seoul, South
Korea, is a well-known researcher and
presented results of his study into the
effect of follicular transection at various
levels on hair thickness and survival
when implanted into the thigh and
forehead, respectively. Eighty singlehair follicles were harvested from Dr.
Hwang’s own occipital scalp and
divided into 4 groups. Twenty were left
intact, 20 divided at the level of the
bulb, 20 at ¼ way from the bulb, and
20 at ½ way from the bulb. Ten of
each group were implanted into the
Dr. Hwang’s thigh and forehead using
the KNU Implanter. The results after
Volume 13, Number 1
12 months showed that the intact
hairs implanted into the forehead grew
better than those implanted into the
thigh (73% vs 65%) while approximately 30% of hairs transected at
either the bulb, ¼ and ½ way up,
grew in either site. Transected follicles
transplanted into the thigh did slightly
worse but the sample and implant
material was small and this may have
been an artifact due to loss of the
original tiny fragment in the leg.
The important finding here is that
only 30% of transected follicles grow
but these ALL produced hairs that
were approximately half the diameter
of the original hair.
Dr. Gregory Keller of Santa Barbara,
California, presented a new system
developed with Dr. Sajjad Khan that
enabled the worker to dissect under
high magnification without problems
of posture and restricted focal depth
provided by existing dissecting
microscopes. Using a video camera
and flat screen monitor, they claimed
that the new system cost less than
conventional microscopes and was
highly ergonomic.
Dr. Carlos Puig of Houston, Texas,
attempted to establish a correlation
between hair mass and the Norwood
baldness classification and found that
hair-mass measurements were very
observer dependent.
Dr. Seery, a now retired Plastic
surgeon from Sacramento and the
Platinum Follicle Award winner, has
devoted much of the past 3 years to
writing on the technical aspects of
alopecia reduction surgery. Quoting
from his numerous published papers,
he once again demonstrated that deep
plain fixation of the galea to the
underlying periosteum resulted in up
to 50% more tissue removal than in a
traditional low-tension procedure and
prevented significant stretchback.
Dr. James Arnold of Saratoga,
California, also retired, spoke on The
Biodiversity of Hair. He stated that
each man has his own distinct
pattern of hair loss and each hair is
different and independent of every
other hair. Norwood classified baldness into 10 types for convenience but
in fact every pattern is different and
the Hamilton/ Norwood patterns are
just generalisations.
While agreeing with Dr. Arnold’s
views on the diversity of baldness
patterns, Dr. Bernard Cohen of Florida
threw his hat into the ring with a new
and rather complicated classification
system. Identifying 10 separate scalp
hair zones, he scores each of the 10
zones on a scale of 1-5 to establish a
Hair Loss Profile and Hair Loss Index.
While really very good, I doubt it will
catch on with our surgeons. Interestingly, at this meeting, Drs. Marc
Pomerantz and Melvin Mayer both
suggested changes to the existing
Norwood Classification, which is now
some 30 years old and urgently in
need of modification.
Next was a session on Scalp Reductions, moderated by Dr. Mario Marzola
of Adelaide, Australia. He said that he
uses the procedure far less than in the
past and that it now represents only
5% of his hair work. Of the 11 reductions he has performed during the past
year, 8 were of the M-type and 1 was a
lateral. The remaining 2 were to excise
areas of triangular alopecia and lichen
planopilaris.
Dr. Martin Unger from Toronto,
Canada, still performs large numbers of
alopecia reduction including those
with extenders and the PATE manoeuvre, but at 150 per year this is much
fewer than past years.
Dr. Patrick Frechet of Paris still uses
scalp reductions with the Frechet
Extender as the cornerstone of his
practice. After complete closure of the
potential bald zone, he utilises his own
Triple Flap procedure to break up the
central slot. He has now performed
over 1,500 of these flap procedures and
claims a necrosis rate of only 0.5% in
the flaps. These amazing results he
attributes to careful surgery and even
more careful case selection. The at-risk
patients include those over age 50,
smokers, diabetics, patients who are
obese, and those with old scars in or
near the base of the flaps. He now feels
that even these patients can be converted into acceptable risk by the
application of minoxidil 5% twice
daily for 2 months prior to surgery.
The final session of the afternoon was
devoted to a number of free papers. Dr.
Nilofer Farjo from Manchester, UK,
spoke on hair removal using the
Lynton Intense Pulsed Light machine
❏
(bandwidth 650–1100nm). She was
able to get total permanent removal
but cautioned that this could take up
to 6 sessions and the machine settings
for each individual required considerable experience.
Brazilian surgeon Dr. Antonio
Ruston spoke of his method for
correction of old abrupt hairlines
using of a 0.75mm punch and the
Lightsheer (800nm) laser.
Frank Badamo from the NHI Group
also discussed methods of repair of old
transplants and emphasised that the
use of small grafts alone does not
protect the patient from poor work. An
error in surgical and aesthetic judgment, along with a failure to communicate about realistic expectations,
remains a major problem.
In the final session of the afternoon,
recipient area necrosis was mentioned
several times. This is an entirely new
phenomenon and in spite of continuous
reassurance about the safety of the dense
packing of small grafts, it was not seen
until this past decade. Drs. Seager and
Tykocinski had addressed this question
earlier in the day, and it is obvious that
with dense packing there is a decreased
margin of safety. Parameters such as
decreased tissue vascularity due to
smoking and diabetes and the relative
size of grafts and donor slits are very
critical once a density of 25 grafts per sq
cm is exceeded.
The evening was free but, as it was
this author’s 64th birthday, he was
delighted to receive not one, but
TWO birthday cakes. The first, at
the President’s Cocktail Party,
measured 2 square feet and another
at the Medicap-sponsored Music
Evening was only slightly smaller.
This put an end to the question
posed by The Beetle’s immortal
speculation “Will you still feed me,
when I’m 64?” Considerable virtuosity was exhibited at the musical
evening with Drs. Rassman (piano),
Mangubat (saxophone), and Puig
(string bass) being of professional
standard. Dancing and refreshments
continued until after 1 AM and the
leftover cake fed 5,000 at the coffee
breaks on Saturday.✧
269
270
❏
Volume 13, Number 1
Volume 13, Number 1
❏
Parsley Message
to work on using a vise to transform a
round punch into a rectangular
punch; thus, the slot punch was
developed, and now rectangular grafts
can be placed into rectangular holes.
This invention is still enjoying wide
usage among transplant doctors.
Not all innovations were totally
successful, but hats are off in order to
give them accolades for an incredible
effort. Dr. Bill Rassman’s development
of the Carousel was clearly a case of
lateral thinking that came close to
overtaking the field by allowing gentle
placing of grafts with great speed.
Unfortunately, some usage problems
have presently side-tracked its development. This was followed shortly by
the Hair Implanter Pen (HIP) by Dr.
Pascal Boudjema. Many of us thought
this device would also transform the
field with its suction tip allowing
extremely fast planting. Clogging,
expense, and a slow learning curve
unfortunately brought it down. Still,
these devices are innovative and
deserve credit for the effort. The Choi
and KNU implanters seem to be
working through many of the obstacles and hopefully will have widespread use in the future.
Dr. Jim Arnold is one of our field’s
great free thinkers. Among his many
developments is the Minde blade,
which limits the depth of the recipient incision site, thus reducing the
vascular damage during graft placement. Dr. Guillermo Blugerman, Dr.
Eric Eisenberg, and Dr. Isabel
Banuchi seem to constantly be
creating clever devices that improve
our quality and save us time. How
about Dr. Marcelo Gandelman’s use
of the hair shaft as a suture to reconstruct eyelashes? Dr. Mike Beehner’s
design of the frontal forelock and Dr.
Ron Shapiro’s concept of building the
parietal “humps” have been incorporated in transplant designs worldwide.
Not all innovations are in the form of
instruments and technique. In my
opinion, Dr. O’Tar Norwood’s
development of the Hair Transplant
Forum and Dr. Dow Stough’s concept
whose worth is yet to be determined.
of the ISHRS rank as two of the top
Finally, hair multiplication is presinnovations ever in our field.
ently being investigated by Drs.
But we can’t overlook the granddaddy of developments. In 1988, Dr. Washenik, Unger, and Cooley among
Bobby Limmer came up with the idea others. This procedure consists of
culturing dermal papillae cells with
to use stereomicroscopes to create
some yet to be determined cells or
grafts with less transection. This
factors to later be injected into the
magnification also reminded us that
bald scalp in order to grow hair. Hair
the follicular unit was the basic
building block of natural hair growth, supply might be unlimited and success
here could very well outstrip all
as reported four years earlier by Dr.
Headington. The shock waves are still developments that have preceded it.
The above doctors were picked out of
settling. For many, this is the gold
standard of hair transplantation today. many that deserve praise. Unfortunately, it was impossible to list everyStereomicroscopes had been around
for years. What was new and what was one. The point is that we still have
new for all the above innovations were these gifted individuals among us
today, and the future should prove very
the ideas. Gifted people with great
interesting.✧
energy are a powerful force. They
make the developments; others
contribute by making them better.
So what is new? Actually, there are
several promising developments. It is
my opinion that Dr. Jerry Wong’s
idea of lateral (coronal)
orientation of recipient
site incisions is a
significant development that will find its
place in our field over
the next few years. His
realization that the
alignment of the hair
shafts is perpendicular
to the hair angle
demonstrates the
State-of-the-art
power of close observation. Dr. David Seager
instrumentation for hair
has now been successfully achieving acceptrestoration surgery!
able density in one
procedure—some of
For more information, contact:
you may remember
when it required four
21 Cook Avenue
procedures. Follicular
Madison,
New Jersey 07940 USA
Unit Extraction (FUE)
has revived the old
Phone: 800-218-9082 • 973-593-9222
punch method, but
Fax: 973-593-9277
with a new twist—an
attempt is made to
E-Mail: [email protected]
punch out single
follicular units in the
www.ellisinstruments.com
donor area. It is
another innovative idea
271
❏
Volume 13, Number 1
CYBERSPACE CHAT…
Editor:
Edwin S. Epstein, MD
Richmond, Virginia
Please send your
comments/questions to:
[email protected]
NERVE BLOCKS
David Seager, MD,
Cam Simmons, MD
Toronto, Canada
We have been pleased with supraorbital and supratrochlear nerve blocks
for our patients but still need ring
blocks for the lateral anterior hairline
and frontotemporal areas. As you
know, the ring blocks must be topped
up regularly as the procedure continues, or patients may experience discomfort.
In the December 2001 Derm Surg
(27:12, pp. 1006–1009), Eaton and
Grekin describe regional anesthesia of
the face including techniques for
zygomaticotemporal and auriculotemporal nerve blocks. In theory, the
whole frontal forelock recipient area
could be anesthetized with four nerve
blocks on each side.
DENSE FU PACKING
Walter Unger, MD
Toronto, Canada
The question of the effect of density
of FUs on hair survival was studied by
Mayer and reported on at the 1998
ISHRS Annual Meeting. At 10 FU/
cm2, his survival rate was 97.5%; at 20
FU/cm2, 92.50%; at 30 FU/cm2,
72.5%; and at 40 FU/cm2, 78.10%.
(See the 2003 edition of Hair Transplantation for further details.) Others
have reported better results with
higher densities of FUs than Mayer,
but I think most of us should be wary
of densities of over 20 FU/cm2. As I
have pointed out before, if you can get
near 100% survival at 20 FU/cm2, you
should get near 20 × 2.3 = 46 hairs/
272
cm2 in one session and 92 hairs/cm2 in
two sessions. If you use FUs with more
than an average of 2.3 hairs in such
areas, you can get even higher hair
densities. Why the need to do this in
one session at the possible cost of
decreasing hair survival? Even those
who can get near 100% survival with
30, 40, or even 50 FU/cm2 in small test
areas cannot be sure of such survival
rates throughout their far larger
recipient areas and in typical everyday
practice.
Bob Limmer, MD
San Antonio, Texas
Our experience dates back at least to
1993 by which time we were dense
packing many cases. The routine
density allowing for a moderately
extensive area to be covered by 1,000
to 1,500 grafts settled down around
25 grafts/cm2 per cm. However, during
those years (1993 to present), there
were many cases in which localized and
sometimes not so localized zones were
planted at over 40 grafts per cm2
because of specific goals.
Concerning edema and necrosis with
dense packing, such edema can occur
under very dense packing. To this date,
I have seen neither reduced survival nor
necrosis of site regardless of density of
packing. It is my opinion therefore
that if small needles (19 to 23 gauge)
are used to create the recipient sites, it
is virtually and maybe absolutely
impossible to plant grafts densely
enough to cause necrosis.
Based on this experience, confirmed
by others using the needle tunnel stick
and place method, I think the fear of
dense packing should not exist. I know
of several reports of necrosis of limited
areas but these were with the use of
small punches to create recipient sites.
Marc Avram, MD
New York, New York
Like other procedures, complications
usually occur when the physician
“pushes the envelope.” For each
surgeon, that is slightly different. Is 8–
12 hours too long for the staff and
patient? Will two procedures of 1,500
grafts survive better than one 3,000
graft session? 99% of HT patients are
happy with no complications, and
should be. If the level of satisfied
patients is below that, the physician
should re-evaluate their consultation
and techniques.
Bill Rassman, MD
Beverly Hills, California
No one should do more grafts than
they can deliver effectively and efficiently. If one can do 1,000 grafts
safely but not 2,000 in a time-efficient
manner, then they should only do
1,000. In our hands, I believe 3,000 is
not an unreasonable number but that
would require a patient with a high
demand (full Class 6 or 7 patient),
good donor density, good donor laxity,
and the budget to afford it.
David Seager, MD
Toronto, Canada
I presented my first “One-Pass
Technique” case at the 1997 ISHRS
Convention in Barcelona and have
presented other, separate examples
almost every year since. The “SingleSession” examples that I showed were
exclusively on patients who were slick
bald prior to surgery. In all my cases,
recipient sites were predominantly
Volume 13, Number 1
made with 19-gauge hypodermic
needles (which are curved and almost
semi-circular). Probably 70–80% are
sagittal and 20–30% are randomly
more in coronal than sagittal. I don’t
believe that if they were all made with
chisel blade, completely coronal
recipient sites, they would have looked
any more natural. This is because my
grafts are all very small, and extremely
densely packed. With larger grafts,
especially mini-grafts, and in cases less
densely packed, coronal orientation
would then indeed have a cosmetic
advantage. With follicular units
prepared the way we dissect them at
our clinic (slightly fewer haired than
average), and densely packed, the
cosmetic difference between sagittal
and coronal is, in my opinion, of no
consequence. The potentially greater
vascular impairment of densely-packed
coronal sites may lead to a reduced
survival rate. I know I can consistently
get (greater than) 100% survival in test
patches on virgin scalps with my
technique. I don’t know of any survival
studies with 100% coronally-planted,
densely-packed follicular units.
DUTASTERIDE
Bernard Cohen, MD
Coral Gables, Florida
Dutasteride is a prostate shrinking
product of Glaxo Smith Kline. Unlike
finasteride, which inhibits 5 AR-2
only, dutasteride inhibits 5AR-2 and
5AR-1. The differences are: 1) Studies
show that dutasteride grew 92 new
hairs in a 1 inch square of thinning
scalp; finasteride grew 72. 2) Dutastride’s sexual side effects were in the
range of 5–11% vs 1–2% for finasteride.
3) The half-life of dutasteride is >240
hours vs 6–8 hours for finasteride. 4)
Dutasteride’s concentration in semen is
13× that of finasteride (sounds like a
lot, but it takes three liters of semen
from patients on finasteride to deposit
a harmful dose!). Most importantly,
finasteride has a biologic model and
dutasteride does not. Patients with
genetic 5AR-2 deficiency have no lifethreatening disorders and there is no
5AR-2 present in their brain tissue.
On the other hand, there is no biologi-
cal model for 5AR-1 deficiency and
there are measurable levels of 5AR-1 in
the human brain! Conclusion: The
blockage of 5AR-1 may have yet
unknown neurological implications.
Marty Sawaya, MD
Orlando, Florida
Glaxo presented the results from the
Phase II studies about three years ago
at the AAD in a closed session only to
the investigators involved in the
study. From what was presented, the
dutasteride side effects were very
similar to the finasteride side effects
(5 mg) tested dose. The company
probably knows more, but this is
what was given at the time of the
review of data. The main concern was
the long half-life of the drug, because
it may take patients a year or so to
return to baseline DHT levels once
they discontinue.
The theme then became, try patients
on finasteride first and, if they tolerate
it well, then perhaps a low dose of
dutasteride would be appropriate at a
once a week dose. Also, the results of
Phase II did show that 2.5mg gave
nearly 2–3 times more hair growth
than finasteride at 5mg, with even
frontal hair growth in some men.
Overall, I did not see many who
complained of side effects, and again
we were blinded as to what the patient
was receiving: there were four test
doses of dutasteride, 5mg finasteride,
and controls who received placebo.
At that time, the investigators were
very impressed by the results of what
Glaxo presented, and Phase III studies
were scheduled to start, but the merger
with SmithKline began, the project
was delayed, and then discontinued.
Dutasteride is a very potent dual
inhibitor, but should be used with
caution due to the long half-life. If
patients tolerate finasteride well, then
0.5mg of dutasteride may be appropriate before stepping up to 1.0mg or
higher.
William Parsley, MD
Louisville, Kentucky
The side effects appear to be similar
to finasteride. The problem comes with
the duration of the side effects. There
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have been some cases where the DHT
levels were still only 25% of the
baseline at 12 months after discontinuing the drug. This would make it
reasonable to start every patient first on
finasteride for a few months before
considering dutasteride, in order to
determine if the patient would have
side effects. Still there might be side
effects with dutasteride that would not
show up with finasteride.
Dutasteride was released to treat
BPH at 0.5mg. Because better hair
growth in the preliminary trials by
Glaxo was noted at higher dosages, the
tendency will be to use multiple
capsules in the off label use for hair
growth. This will be very expensive.
Because of the long duration of
action, the optimal dosage frequency
might be once weekly or even once
monthly. However, these less frequent
dosage schedules were not tested, so we,
and our patients, will be on our own.
Dutasteride works quickly and
reduces 99% of serum DHT within
24 hours of a 2.5 or 5.0mg dose.
GUARANTEES
Paul McAndrews, MD
Pasadena, California
I spend a significant part of the
initial consultation making sure the
patient’s expectations are realistic (to
the point that I underplay the results).
I do not have any written guarantee or
policy. I have only been asked if I
guarantee my work a few times. I tell
the patient that there are no 100%
guarantees in medicine. The initial
consultation is vital in establishing a
doctor-patient relationship built on
trust and, if results are not perfect, the
patient will know that we will be
working as a team to make things
right. With the few patients that ask
for a guarantee, I tell them that I will
refund his/her money if the hair
transplant does not work.
I had one patient whose expectations
were not met. He expected more
density on the frontal hairline, even
though the number of follicular units/
cm2 was exactly what I planted and
what we discussed. I performed a small
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Volume 13, Number 1
Cyberspace Chat
hair transplant to increase the density
in the frontal hairline for which I did
not charge him. He became my
biggest advocate (and most vocal). It
reminds me of the saying “What comes
around, goes around.” Life is too short
to have unhappy patients (who can
become quite vocal).
Vance Elliott, MD
Sherwood Park, Canada
The consent form I use specifies that
surgical results cannot be guaranteed,
and I explain this to the patient. I
emphasize that when done by skilled
and experienced staff, the results of the
procedure are very reliable and predictable, but that there are variables that
neither doctor nor patient can control
and occasionally there are complications, or less than expected graft
growth. If that occurs, we will work to
make it right. One important variable
is progression of hair loss. On the
consent form, I include that medical
treatment with finasteride and
minoxidil is important in the overall
result and in minimizing risk of
progressive AGA.
I believe that patients, given appropriate information about the importance of and methods to retard or halt
hair loss, have a responsibility in
achieving the best result possible.
For patients whose expectations are
not met, I try very hard to adjust
expectations to a level slightly below
what I think we can achieve in the
initial consultation. It is much harder
to adjust them after the fact. When I
have patients with these concerns, I see
them more frequently for follow-up and
try very hard to get them on finasteride
and minoxidil. (In my practice, the
patients who decline medical therapy
have a higher incidence of dissatisfaction
post-op due to progressive AGA.) I try
to demonstrate my interest in their
satisfaction, encourage more surgery
where appropriate, and in cases where I
feel growth has been less than I expected, do extra grafts at no charge.
I feel that the importance of frequent
follow-up visits and listening to the
274
patient’s concerns is vital is maintaining a good rapport. Patients who are
not angry with you and who feel you
have their best interests at heart tend
to be overwhelmingly willing to stick
with you and let you fix a complication
or address poor growth.
David Perez-Meza, MD
Maitland, Florida
The problem is not to promise good
results…the problem is to accomplish
what you promise.
Hair loss patients are particularly
susceptible to disappointment and
unhappiness, even with good results.
The surgeons must therefore be
particularly careful in selecting patients
and the specific surgical approach to be
used. Good communication involves
not only listening to and understanding the patient’s concerns, but also
informing them of all the options
available. Before and after can show
them similar patterns of hair loss with
post-operative results, but this is not a
“guarantee” about his/her result.
It is very important to explain to
patients what to expect after the first 2
weeks, and 3, 6, 9, and 12 months
after the surgery. I recommend the
patient to wait a full year for the final
evaluation and results after the surgery.
I usually guarantee a good healing
process in the donor area with acceptable scar and healthy donor area in the
future. For the recipient area: good
healing process, natural appearance,
and density according the surgical
plan. The communication between the
patient and the surgeon must continue
into the post-operative period.
Alan Baumann, MD
Boca Raton, Florida
As far as a guarantee, the closest
thing we offer is our “100% commitment” to each patient’s satisfaction.
This is expressed in the practice’s
mission statement, which every patient
receives. Certainly, as in any cosmetic
practice, realistic expectations need to
be established before the patient
undergoes any procedure. The time I
spend with patients (up to 60 minutes
in consultation) reviewing digital
preview images, before/after photos,
their goals, and individualized treatment plan, is geared toward what hair
transplants can (and cannot) do for
them. From early on, I have been in
the habit of under-promising and overdelivering. I think that in all practices,
you will see a small subsegment of
patients whose expectations will not be
reached, but a conservative approach to
the treatment plan is always the best
path. If a patient is truly unsatisfied, it
is up to the individual physician
to decide how to “make it right” in his
own way. It is impossible to deny a
patient’s feelings if they are truly
dissatisfied regarding their outcome,
so I prefer to seize the opportunity and
try to turn it into a positive experience.
Damkerng Pathomvanich, MD, FACS
Bangkok, Thailand
Since I started my practice I don’t
guarantee my results. This is made
clear to the patient from the outset but
I do show the patient my results and
track record. To patients who complain
about less than expected results prior
to six months, I will say to wait at least
one year and reevaluate. If the patient
complains about unfulfilled expectations, I usually do a simple calculation
of the total number of the follicular
units of the area of baldness, and
compare that with the follicular units
that were transplanted. I then explain
the ratio of follicular units transplanted
versus the total follicular unit needs. I
also take into consideration the available donor site, scar, and the number
of sessions. If the appropriate number
of recommended sessions was completed, but expectations still differ on
both sides, I will advise more sessions,
provided donor is still present, and will
charge normally. However, I give away
some grafts without charge. Last, I tell
the patient to take finasteride and
minoxidil 5% lotion and return for
follow-up in six months for another
evaluation.✧
Volume 13, Number 1
❏
Letters to the Editors
To The Members of the
t
n ISHRS:
i
I feel betrayed by my
Po
organization. For years, the
ISHRS has sponsored a spring
surgical observation meeting at a forprofit hair transplant chain clinic. The
ISHRS receives half of the fees generated from this meeting. Local television crews film the event, generating
tremendous publicity for the chain.
I have given several hair transplant
dissection courses, utilizing both
porcine tissue and human tissue, in
years past. Other members assisted
with these meetings. One of them was
given in conjunction with the ISHRS
meeting in Las Vegas years ago.
However, during none of these
meetings did we receive any advertising, sanction, funding, or Forum
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Dr. James Swinehart and
r
have written many
e Iletters
back and forth
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regarding the Live
u
Workshop. In addio
tion, we have invited
t
C
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Dr.
to
i attendSwinehart
o
the Workshop in
P the past.
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It is unfortunate that Dr.
Swinehart has chosen to make judgments on the ISHRS/Live Workshop
without ever attending a Live Workshop meeting. He has personally been
invited on more than one occasion,
and the Workshop Committee would
embrace his attendance and participation this year. In addition, the ISHRS
Live Workshop Committee strongly
encourages all ideas and participation
from members who seek to improve
the Live Workshop learning experience.
To properly address Dr. Swinehart’s
comments, the history of the Workshop from past to present should be
reviewed. The Live Workshop started
as a concept developed by Drs. Patrick
Frechet, Marcelo Gandelman, and
operating rooms, and competent hair
transplant surgeons in Chicago, as in
any major city.
Science? The cast is distinguished,
but true studies must be performed
on multiple patients over a long
period of time with respect to hair
growth.
The chain director claims that he
receives little or no publicity from this
annual event. If this is the case, he
surely will voluntarily relinquish his
ISHRS sponsorship of this meeting.
Let’s see if the Board of Governors
can rule with an even hand, treating
all dues paying members fairly and
equally.
Sincerely,
write-up by the ISHRS. They were
done with my own money and
promotional mailings. No publicity
was given by the organization.
This is America, the land of entrepreneurs, and anyone certainly can
give his own surgical course. However,
the selective promotion of one clinic
works to the detriment of small
individual practitioners who cannot
afford national advertising. Unfortunately, I am asked to pay the same
dues as the owner of the chain, and
have done so for nine years!
The devotion of nearly an entire
issue of the journal to glowing testimonials of a surgical course best
appreciated in person only contributes
to this selectivity and favoritism. I feel
that the course should be entirely
independent of the ISHRS. Surely
there are plenty of bald patients,
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myself. I had been asked by Dr. Jules
Newman, the President of the North
American Academy of Aesthetic and
Reconstructive Surgery ten years ago
to form a hair transplant arm of that
group and subsequently to develop
hair transplant meetings. Although
the ISHRS was in its infancy, we saw
no logic in duplicating the ISHRS
efforts to deliver a quality didactic
meeting. Drs. Frechet, Gandelman,
and myself, along with many others,
were frequently hosts in our practices
to visitors seeking observation of hair
transplantation. The idea of a workshop where doctors of all levels could
come together to learn from each
other and to teach beginners seemed
promising. Orlando was chosen for its
universal appeal as a travel destination
over other sites that were considered.
The original workshops were only
moderately well-attended and lost
money, but allowed the teaching
faculty to formulate new ideas each
year on how to better the educational
experience. The Workshop gradually
grew in stature driven by the enthusiastic response of attendees. The ISHRS
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James M. Swinehart, MD
Denver, Colorado
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leadership of Drs. Dow Stough,
Russell Knudsen, Shelly Kabaker, and
Danny Rousso, amongst others, had
the foresight to try to marry the Live
Workshop experience with the didactic experience of the ISHRS meetings
to provide the best of both learning
experiences.
The goal of the Workshop is not
promotion of any one individual or
group name. In fact, the brochure
does not discuss or promote any
group, and my name is only listed as
program director in the faculty listing
and with a picture in the program
mission statement. (The ISHRS
Board of Governors and the Live
Workshop Committee are very sensitive to this issue.) The goal of the
Workshop is education, science,
camaraderie amongst fellow surgeons,
and the promotion of hair restoration
as a field unto itself.
The faculty of the ISHRS Live
Workshop is selfless in their participation at the Workshop. The 30–40
faculty doctors not only pay to be at
the Workshop but also take up to a
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❏
Volume 13, Number 1
nce Upon a Time…
“No matter what method is used (grafts, flaps, reductions, scalp lifts, expanders),
the best results are due to patient selection, as much as to surgical expertise.”
—Shelly Kabaker, MD (Vol. 5, No. 6, November/December 1995, p. 19)
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“The only mega thing you should do is be mega-careful!”
(On his “Tips for New Players”—advising surgeons new to hair transplantation)
—Russell Knudsen, MBBS (Vol. 5, No. 3, May/June 1995, p. 17)
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“I believe dense packing is foolhardy. One may get away with it in a number of patients,
but I think it is a percentage game; the closer one packs grafts together, the greater the percentage of cases of poor growth.”
(In an article titled “Megasessions and Dense Packing May Be Counter-productive.)
—David Seager, MD (Vol. 5, No. 2, March/April 1995, p. 14)
276
Volume 13, Number 1
❏
The Internet—Curse or Godsend
for Surgeons?
Patrick Hennessey, Publisher of the Hair Transplant Network
Because Internet sites were a hot topic for debate at the Chicago meeting, as Forum editors, throughout the coming year we will try to print articles
from lay and physician sources, giving different viewpoints on the subject. These articles do not necessarily in any way reflect the viewpoints or
endorsement of the editors or the ISHRS. —MB/WP
During the past year in particular, the
Internet has gained recognition as a
powerful medium for finding and
educating patients. As an open and
interactive medium with multiple
viewpoints, it has become widely used
by prospective patients who want more
credible information than brochures or
scripted TV ads. It also empowers
people to do in-depth research that is
convenient yet private.
Our online community has grown
popular over the past three years in
large part because it helps prospective
patients sort through the many
competing claims and the general
clutter of the Internet.
It is different from online physician
directories, which list any and all
physicians by area based solely on their
willingness to pay. The criteria for
inclusion on the Hair Transplant
Network is a proven track record of
excellent patient results and a demonstrated competence and commitment
to doing microscopically dissected
FUTs. This selective sponsorship,
based on qualitative standards, is why
this online community has grown in
popularity and usage.
However, this selective inclusion has
also created controversy among hair
transplant surgeons who are not yet
recommended on our online community. These surgeons may see another
surgeon in their area recommended
while they are not. It is understandable
that this would concern them.
As the publisher of the Hair Transplant Network and a very satisfied
patient, I strive to maintain these
qualitative standards, while making our
community inclusive of all surgeons
who meet these standards.
However, none of us are omniscient.
There are, no doubt, numerous
excellent surgeons who are not yet
represented on our community. To
claim to have definitive information
about all quality surgeons would be
arrogant and insulting to physicians
and patients alike.
I’m careful to explicitly spell out the
limitations of this selection process.
These caveats are at the Hair Transplant Network site at www.hair
transplantnetwork.com on a page
called “How Surgeons Are Selected for this
Site.” One of the paragraphs states:
“The surgeons recommended on this
site are not a definitive list of all excellent surgeons. But these recommended clinics will give you a quality
benchmark by which to judge all
other clinics you choose to consult
with. I encourage everyone visiting
this site to look as far and wide as
they feel necessary before selecting a
hair transplant clinic (see below for
tips on evaluating clinics).”
Those surgeons who are carefully
reviewed and chosen for recommendation on this site contribute a
modest monthly fee to co-sponsor
this online community and display
their before and after photos and
contact information.
None of us have perfect information.
But with lay people and physicians
openly exchanging information online,
our individual and collective knowledge is enhanced.
Patients and surgeons are also encouraged to fill out an online questionnaire
to recommend a particular clinic. This
detailed questionnaire is the starting
point for researching and reviewing a
clinic for inclusion in our online
community. Surgeon sponsors of our
community are then welcome to review
these questionnaires/applications.
Over time, I hope that our online
community will represent at least the
majority of surgeons who are commit-
ted to doing microscopically dissected
FUTs at the highest level of patient
satisfaction. Such inclusiveness is only
fair to the patients and the surgeons
who have made this commitment to
quality.
In the meantime, I do not indulge in
disparaging remarks about those
surgeons who are not recommended on
our community, despite hearing all the
“horror stories.” I also continue to be
an enthusiastic supporter and defender
of the ISHRS, as I believe this professional organization has been the most
important catalyst for the advancement
of the entire hair restoration profession.
I believe that our online community
has played a supporting role in cultivating a positive perception of hair
restoration among the public. It has
demonstrated to thousands of people
each week that hair restoration can
naturally restore not only their hair,
but also often their self-esteem, if they
choose an experienced surgeon.
Ultimately, the prospective patient
must make their own decision about a
particular physician and his or her
procedure. Ideally, they will make this
judgment only after exploring all their
options and gathering information
from both qualified physicians and
patients who have gone before them.
Our organization strives to help
them gather this information from
both physicians and patients by
providing resources, on and offline, for
doing so. Prospective patients appreciate these resources and that surgeons
care enough about educating and
empowering them to provide it.
I welcome your suggestions, comments, or questions regarding our
educational efforts this year. And thank
you for enabling me as a patient and
layperson to play an active role in
educating prospective patients.✧
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Volume 13, Number 1
Letters to the Editors
week from their practices, fly staff in
to work with them, and teach their
hearts out. The fact that the Workshop receives so many positive testimonials is a credit to all of them. The
Workshop is an exhausting four days
of early mornings to late nights of hair
transplant utopia. Beginners, intermediate, and the most advanced surgeons rub elbows with the goal of
learning. The coordination of 22 live
surgeries coupled together with
scientific lectures, studies, social
events, etc. is not easy. In addition,
there is a huge responsibility to the
patients both in the now and the
future for satisfactory outcome of their
hair restoration process with subsequent liability.
Accolades for the Live Workshop are
not solicited. Participants and faculty
write about their experiences and
lectures, studies and different surgeries are highlighted. Dr. Jim Arnold for
years was the sole reporter on the
Workshop and simply wrote what he
witnessed. The ISHRS Live Workshop
Committee is pleased with the
response from participants in the
Workshop, both published and
unpublished, but strives to improve
the experience every year. The Workshop faculty actively solicits constructive comments to try to improve all
aspects of the meeting.
Medical Hair Restoration should
not be derided for its venue or financial tie to the Workshop. All MHR
doctors, including myself, are paying
participants! The Workshop is profitable because of Dr. Bobby Limmer’s
edict to have all participants—no
exceptions—pay. If MHR doctors and
key faculty members did not pay, the
workshop would once again lose
money or be marginally profitable. In
addition, the loss of revenue for
shutting down my personal surgery
center and removing all MHR doctors
from their own surgery schedules
shoulders a huge financial burden
that the entire faculty also shares.
The Live Workshop Committee
fully agrees with Dr. Swinehart that
true studies must be performed on
multiple patients over a long period of
time. The goals of the studies at the
Workshop are to stimulate further
work outside the workshop venue.
I appreciate Dr. Swinehart’s forthright comments and hope that he will
accept the offer to participate in this
year’s Workshop. In addition, if Dr.
Swinehart or anyone else would
personally like to be put on an ISHRS
Live Workshop, we would welcome
his proposal. There is always room for
more quality education.
Respectfully submitted,
Matt L. Leavitt, DO
Heathrow, Florida
First IBHRS Exam Scheduled
June 1, 2003 • Berlin, Germany
(2-Hour Oral Prep Course May 30, 2003)
The newly formed International Board of Hair Restoration Committee has announced that the first examination for
certification for Board Diplomate status or for the Certificate of Added Qualification (CAQ) will be given in Berlin on
Sunday, June 1, 2003, on the final day of the European Society meeting. The Board plans to have a two-hour
evening session on Friday, May 30, to help prepare candidates for the format of the oral portion of the exam. The
other part of the examination will be a 200-question written examination. All hair transplant surgeons from Europe,
Australia, Asia, and Africa are encouraged to sit for this examination, providing they meet the qualifications.
278
Volume 13, Number 1
❏
Surgical Assistants Corner
“The best leader is the one who has sense enough to pick good men
to do what he wants done, and self-restraint enough to keep from
meddling with them while they do it.”
—Theodore Roosevelt
Techniques in Training… Retraining
Dear
Surgical Assistants:
We have a lot to cover in this issue! First is news about the ISHRS Annual Meeting. For
those of you who attended, you benefited from lots of stimulating ideas and discussion. For those of you who were
not fortunate enough to make it, hopefully we can outline some of what we experienced. We always learn so much
when we are together and it’s always fun to put faces to names.
This issue introduces the all-encompassing subject of training. It is a very complex subject because everyone has
different techniques in training and I’m sure you have found what works and what doesn’t work in your office.
Through all training techniques, however, a theme runs consistently: Success. We all want our teams to succeed.
The success of the team is the success of the practice. So training is critical… and so is retraining. I’m always
amazed at the time and effort it takes to keep the training going. Because I am a bottom-line type of manager, I
like stating something once and then not having to repeat myself. Well, that isn’t necessarily practical. I have
noticed that employees learn in such different ways and what you trained in the early days has to be restated
again around the third month, and sometimes even a year later. I think it has to do with the fact that there is so
much to learn in the first six months that there are things that just didn’t “stick.” Do you ever hear that statement, “No one ever told me that before!” Well, that’s what I mean. It’s not that you didn’t tell the new employee,
it’s that they could only hear so much, and then it was gone.
Thus, retraining is a part of the process. The One Minute Manager is a great tool. It has such practical steps in
training. Putting the One Minute Manager to work is also a great follow-up. I have included a few tips for your
perusal:
TIPS FROM THE ONE MINUTE MANAGER
➩ If a person can’t do something—go back to goal setting (training issue).
➩ If a person won’t do something—reprimand (attitude issue).
➩ People who feel good about themselves produce good results!
➩ Help people reach their full potential.
➩ Catch them doing something right (it adjusts the attitude).
➩ Everyone is a potential winner. Some people are disguised as losers; don’t let their appearances fool you.
➩ Feedback is the breakfast of champions!
In my office, I use my quality assurance audits as a tool to give feedback (good and bad). I have also used my
staff meetings as a forum to restate the goals of the team, and to cover small issues that we still need to work on.
Of course, everyone responds to positive, forward thinking. So how this feedback is stated makes a huge impact on
how criticism is received. As Norman Vincent Peale said, “The trouble with most of us is that we would rather be
ruined by praise than saved by criticism.” But criticism (feedback) is a part of training! Without feedback, we
would never achieve the results that make us successful.
Criticism also impacts team communication. Each member of the team should be encouraging to each other.
Find what works and polish that. Then when a challenge presents itself, work on it as a team. A team that competes within itself becomes a group and not a team. The dynamics and the success of groups versus teams are
huge. And if there is confusion in a team, retraining is imperative so that consistency is reestablished. All of this
takes time. Time is a commodity that a lot of us don’t have. But to get a team to be successful, training and
retraining, feedback and then retraining, is part of the journey.
On the next page is an outline submitted by Rebecca Brady, who works for Dr. Mike Beehner. It is delightful
because it is concise and to the point, very well-organized, and helpful. I especially like her points about not
279
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Volume 13, Number 1
Surgical Assistants Corner
overwhelming the new assistant.
In the next issue, we will be discussing Holding a Team Together: Motivating, Morale Boosters, and Mentoring. What
things do you do in your team to support each other? Do you plan social times? How do you motivate each other to
do your best? Who is your mentor? Why? What do you consider morale boosters? Is money all that you want or is it
something else? Recognition for a job well done? I need lots of help for this issue, so please contact me. In the May/
June issue, I plan to cover OR Etiquette: Emphasizing Professionalism. That one should be fun, too!
Shanee Courtney, RN
Summary of Assistants Business Meeting
10th Annual Meeting of the ISHRS • Chicago, Illinois
First order of business was expanding the Assistants Committee from three people to:
✧ Chairperson or Co-Chairpeople
✧ Vice Chairperson
✧ Secretary
✧ 2 Committee Members
The group approved this at large by a vote. Each position was then nominated, seconded, and voted upon as
follows:
Co-Chairpersons
Vice Chairperson
Carole Limmer, SA
Marilynne Gillespie, RN
Cheryl Pomerantz, RN
Secretary
Members
Betsy Einzig, LPN
MaryAnn Parsley, RN
Shanee Courtney, RN
The second order of business was forming a sub-committee for the Assistants Award. This position was nominated,
seconded, and voted with approval for Helen Marzola, RN, to head up this committee.
Dr. Konstantinos Minotakis’s “Training of Hair Transplant Assistants”
Cheryl Pomeranz, RN Hinsdale, Illinois
I found this lecture to be very informative and to the point. Dr. Minotakis stressed the importance of the Surgical
Assistant’s knowledge and expertise in the surgical procedure, clinical operations, patient care and follow-up, and
administration.
I also believe that constant observation and instruction for the beginning assistant is important. We use the buddy
system in our practice. The new assistant is teamed up with an experienced assistant. We try to give feedback throughout the day. I have not used formal evaluation forms, though it may be something I may start to do. It is important for
the new assistant to know his or her weaknesses and strengths. Using formal evaluation forms will help to illustrate this
and can be used to evaluate the new assistant’s learning process, and can be referred to on an ongoing basis.
280
○
○
Fax: 303-694-9373
○
○
○
○
○
○
Cell phone: 303-694-9381 x 0
○
○
○
○
Office phone: 303-694-9381
○
Shanee Courtney, RN
James A. Harris, MD
5445 DTC Parkway, #1015
Englewood, CO 80111 USA
○
All correspondence for Surgical Assistants Corner should be directed to Shanee Courtney, RN, at:
Volume 13, Number 1
❏
Training and Developing New Assistants
Rebecca Brady, LPN Saratoga Springs, New York
This is a fast-paced area of medicine and many people are not cut out for this field. We have found that it takes a
strong will and a lot of perseverance to make it here. If an assistant does not love this job from day one, he or she probably won’t make it. Training is very quick and concentrated. A new assistant will be slow at first, but don’t worry, speed
comes with time. Once the job is learned, it’s all repetition.
❖ We begin by helping new assistants to be:
✦ Comfortable with their surroundings
✦ Familiar with the equipment by using teaching tools:
✧ A card file that explains most set-ups
✧ A picture of a set-up tray next to our autoclave
✧ Written instructions on assistant duties
✧ Currently working on a training video
❖ Over the course of the first week, the assistant will:
✦ Assist the doctor in:
✧ Taking pictures
✧ Administering medications
✧ Taking donor strip
✧ Suturing donor area closed
✦ Learn to cut grafts
✦ Learn to place grafts
✦ Assist in cleaning operating room
✦ Assist in set up for next case
✦ Begin charting medications
❖ By the end of the first month the assistant will, without assistance:
✦ Draw up medications
✦ Set up operating room
✦ Run autoclave
✦ Chart medications
✦ Give patient consent forms and countersign them
✦ Clean operating room
✦ Cut grafts
✦ Place grafts
✦ Apply dressings
✦ Remove sutures
✦ Perform patient hair washes
❖ It’s very important not to overwhelm new assistants:
✦ We have one nurse do most of the training.
✦ In order to be efficient, we must all complete tasks in the same manner.
✦ A former assistant comes in to train in cutting and placing, therefore not slowing us down during the
training process.
✦ We always encourage asking questions.
✦ If it seems the new person is starting to “burn out,” then we slow the pace (everyone learns at a different pace).
✦ Don’t expect each assistant to learn in the same manner.
✦ We learn from our mistakes (just be sure they can be fixed).
✦ Always be willing to adapt or you may lose a perfectly good assistant.
In conclusion, remember the golden rule: “Do unto other assistants as you would have another assistant do unto you.”
In other words, treat them with respect and don’t expect them to do anything you would not be willing to do yourself.
(A good sense of humor never hurts either!)✧
281
❏
Volume 13, Number 1
2002 Surgical Assistants Meeting
Cheryl Pomerantz, RN Hinsdale, Illinois
It was a pleasure to serve as your chairperson for the 2002 Annual Meeting in Chicago. I would like to take
this opportunity to thank all the doctors who brought their staff and office personnel. We had a great
turnout for our meetings and workshops. We tried a few new things in our program, and all went very well.
A special thank-you goes to the faculty for their hard work and presentations:
➤
➤
➤
➤
➤
➤
Julie Stuart, RN: “Training and Development of New Staff ”
Dr. Konstantinos Minotakis: “Management and Quality Control in Hair Restoration”
Dr. Paul Cotterill: “What the Doctor Needs, Wants, and Expects from His Staff ”
Dr. Daniel Didocha: “Complications During Surgery and Immediately Post-Op”
Dr. Marc Pomerantz: “Pre-Op Teaching and Communication”
Helen Marzola, RN: “Stick and Place: Freeing the Doctor from the
O.R.”
➤ Justin Koehler, MA in Counseling Psychology (two lunchtime
workshops): “Stress, Burn-Out and Coping” and “Communication
Skills”
I appreciated the sharing of information from the audience that added
to the speakers’ presentations. Thank you to the audience for sharing
and caring about the whole group. I felt that we were united as one.
This was a truly positive experience.
Thanks also to Marilynne Gillespie, RN, and to Mary Ann Parsley,
RN, for their support and hard work for the 2002 Surgical Assistants
Meeting.
Sincerely,
Cheryl Pomerantz, RN
2003 11th Annual Meeting
We ❤
❤ NYC
Empire State Building/Chrysler Building
I hope that all of you are making your plans now
to meet in New York City. Our Surgical Assistants
Committee has been hard at work making plans since
October. We are very fortunate to have Marilynne
Gillespie, RN, and Carole
Limmer Co-Chairing this
meeting. We are sure to have
an outstanding meeting with
these two women in charge.
Be sure to watch for meeting
updates in the Surgical AssisPhoto from www.nycvisit.com
tants Corner of the Forum.
282
(L to R)
Rebecca
Brady,
LPN &
Cheryl P
om
erantz, R
N
A Musical Evening
to Be Remembered
I can’t remember having as good a time as I did at
the Musical Evening, given in honor of Dr. Richard Shiell’s birthday. It was really a night to remember. I had never played with a band before,
but I did that night. I played the maracas with enthusiasm. I don’t know how good I was, but it was
great fun. I hope that we can do this again. Music
is the universal language and the language of love.
Thank you, Dr. Seery, for planning this event and
thanks to Medicap for sponsoring the event.
Volume 13, Number 1
❏
Guidelines for
Submitting Articles to
the Forum
All submissions to the Forum must be in electronic format: e-mail, 3.5" PCformatted disk, or PC-formatted Iomega Zip 100 disk. We prefer Microsoft
Word documents, however, WordPerfect and ASCII text files are also acceptable. Please adhere to the following additional guidelines when submitting
your article(s):
✔ E-mail submissions will only be accepted with an ATTACHED
document file—do not embed the file in your e-mail as we will be
unable to use it. Your e-mail program should have an option to attach a
file. When e-mailing an article, also be sure to attach any graphic files as
well. Artwork (images) must be separate attachments (see bullet #3).
✔ If you are mailing your article, please submit both a hard copy of the
article(s) AND a disk with the article and any graphic files (TIFF,
JPEG) copied onto it. Before mailing, please be sure that your article
did in fact copy onto the disk.
✔ Any artwork, photos, or figures that are referenced in your article
must be enclosed with your mailed submission or saved on the disk in
either TIFF or JPEG format. Any graphics that are submitted for
scanning must be clean, original copies. When scanning photos for
submission, please scan in black and white at a minimum of 150 dpi;
for best output, scan at 300 dpi. Keep in mind that most figures
appear no larger than 3 inches (width) in the publication, so size
accordingly. (This will also reduce the size of your TIFF/JPEG file
and keep it manageable.)
✔ Please submit clean originals and clear photos. If you need artwork,
graphics, or photos returned, please supply a self-addressed, stamped
envelope with your submission and they will be returned promptly.
Send your submissions to:
310 East Broadway, Suite 100
Louisville, Kentucky 40202-1745
*Please Note: All entries will be returned if incomplete or
not adhering to guidelines.
283
Upcoming Events
❏
Volume 13, Number 1
Following is a guide to upcoming meetings and workshops related to hair restoration. For more information, contact the appropriate sponsoring
organization at the number listed. Meeting organizers are reminded that it is their responsibility to provide the Forum Editors with advance notice of
meeting dates.
Date(s)
Venue
Sponsoring Organization(s)
Contact Information
March 5–8, 2003
9th Annual Live Surgery Workshop
Orlando, Florida USA
ISHRS/Medical Hair Restoration, Inc.
Valarie Montalbano
Tel: 407-333-4200, ext. 141
Fax: 407-333-9464
May 31–June 2, 2003
Annual Meeting of the European
Society of Hair Restoration Surgery
Berlin, Germany
European Society of Hair Restoration Surgery
Tel: +49 - 30 - 885 10 27
Fax: +49 - 30 - 885 10 29
June 1, 2003
IBHRS Board Examination
Berlin, Germany
International Board of Hair Restoration Surgery
Peter Canalia
Tel: 708-474-2600
June 2–7, 2003
Aegean Cruise H.T. Meeting
Athens, Greece
DHI Medical Group
John Cole, MD
Tel: 800-368-4247
October 15–19, 2003
11th Annual Meeting of the ISHRS
New York, New York USA
International Society of Hair Restoration Surgery
Tel: 630-262-5399;
800-444-2737
Fax: 630-262-1520
CORRECTION
The Editors would like apologize for a Reference error that appeared in the November/December 2002 Forum in the
article entitled “Propecia® Use in Patients Receiving Hair Transplantation” (Krenitsky G, Ziering C: Vol. 12, No. 6, p.
215). The correct authors for Reference #3 should be: RINALDI F., SORBELLINI E., BEZZOLA P. (Propecia® can
help improve hair transplantation. ESHRS 2001; Autumn 4–5).
HAIR TRANSPLANT FORUM INTERNATIONAL
International Society of Hair Restoration Surgery
13 South 2nd Street
Geneva, IL 60134
Forwarding and Return Postage Guaranteed
284
FIRST CLASS
US POSTAGE
PAID
CHICAGO, IL
PERMIT NO. 6784

The Hair Loss Profile and Index: A New Classification System for

Transcription

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