Orlando Review - International Society of Hair Restoration Surgery
Transcription
Orlando Review - International Society of Hair Restoration Surgery
Volume 14, Number 2 Hair Transplant Forum International ❏ May/June 2004 Hair Transplant Forum International Volume 14, Number 3 forum May/June 2004 Regular Features Orlando Review Wednesday, March 10, 2004 Melvin L. Mayer, MD, MBBS San Diego, California summarized the anatomy of the hair he ISHRS now sponsors both follicle and then described in pictures the Annual Live Surgery both the gross and the microscopic Workshop and the Annual appearance of the many causes of Scientific Assembly. The Live Surgery scarring and non-scarring alopecias. Dr. Workshop is ten years old and one is Kudance took up where Dr. Mejia left impressed with the growth, camaradeoff and, as an internist, dermatologist, rie, organization, and educational and dermatopathologist, gave a full opportunity for all participants including the faculty. What an opportunity to discourse on this topic. The importance “rub shoulders” of the “Patient with some of the Consultation” was most welleloquently known and summarized by experienced hair Dr. Sharon transplant Keene. Careful surgeons from patient selection around the can help provide world. Friendone with satisfied ships are made patients and a for life with healthy practice. many of the Ruston, MD, Mario Marzola, MBBS (ISHRS President), Matt Leavitt, Trust and men and women Tony DO (Meeting Co-Chair), David Perez-Meza, MD (Meeting Co-Chair) confidence through we meet at the realistic options and conservative Live Workshop each year. recommendations serve as the Wednesday’s lectures and surgeries foundation of a meaningful, long were loaded with pearls. Trying to lasting patient-doctor relationship. summarize these in print does not do The humorous and articulate presentathese presentations justice. Two absolutely great presentations on tion of Dr. Ken Washenik regarding Medical Therapy emphasized the fact Hair Loss and Scarring and Nonthat, when Propecia® and Rogaine® are Scarring Alopecias were delivered by Drs. Ricardo Mejia and Donald used in conjunction, optimal results can Kudance, respectively. Dr. Mejia be maximized. continued on page 85 T President’s Message ............................... 82 Co-Editors’ Messages ............................ 83 Notes from the Editor Emeritus ............ 84 Pioneer of the Month ........................... 89 The Dissector ..................................... 100 Cyberspace Chat ................................. 101 Surgeon of the Month ......................... 104 Pearls from Providence ....................... 107 Once Upon a Time ............................. 110 Surgical Assistants Corner .................. 115 Feature Articles A Statistical Approach for Comparing Hair Populations ................................ 91 Reducing the Female Forehead without Hair Transplantation .......................... 93 A Method for Removing Scabs in the Post-operative Stage in Hair Restoration Surgery ............................ 95 FUE Megasessions—Evolution of a Technique ........................................... 97 Stereomicroscopes for Hair Transplantation ................................ 105 HIPAA and the Surgeon: Protecting Patient Privacy .................................. 111 Hair Restoration at TransPel/Sandoval in Mexico City, Mexico ..................... 115 Registration now open for the 12th Annual Scientific Meeting, Vancouver Official publication of the International Society of Hair Restoration Surgery 81 Hair Transplant Forum International ❏ May/June 2004 Hair Transplant Forum International Volume 14, Number 3 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: Mario Marzola, MBBS Executive Director: Victoria Ceh, MPA Editors: Michael L. Beehner, MD, and William M. Parsley, MD Surgical Assistants Corner Editor: TBA Managing Editor & Graphic Design: Cheryl Duckler, [email protected] Advertising Sales: Cheryl Duckler, 847-444-0489; [email protected] Copyright © 2004 by the International Society of Hair Restoration Surgery, 13 South 2nd Street, Geneva, IL 60134. Printed in the USA. The International Society of Hair Restoration Surgery (ISHRS) does not guarantee, warrant, or endorse any product or service advertised in this publication, nor does it guarantee any claim made by the manufacturer of such product or service. All views and opinions expressed in articles, editorials, comments, and letters to the Editors are those of the individual authors and not necessarily those of the ISHRS. Views and opinions are made available for educational purposes only. The material is not intended to represent the only, or necessarily the best, method or procedure appropriate for the medical situations discussed, but rather is intended to present an approach, view, statement, or opinion of the author that may be helpful to others who face similar situations. The ISHRS disclaims any and all liability for all claims that may arise out of the use of the techniques discussed. Hair Transplant Forum International is a privately published newsletter of the International Society of Hair Restoration Surgeons. Its contents are solely the opinions of the authors and are not formally “peer reviewed” before publication. To facilitate the free exchange of information, a less stringent standard is employed to evaluate the scientific accuracy of the letters and articles published in the Forum. The standard of proof required for letters and articles is not to be compared with that of formal medical journals. The newsletter was designed to be and continues to be a printed forum where specialists and beginners in hair restoration techniques can exchange thoughts, experiences, opinions, and pilot studies on all matters relating to hair restoration. The contents of this publication are not to be quoted without the above disclaimer. 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 14, Number 2 President’s Message Our house is gradually getting into order. Sometimes it’s two steps forward and one step back, but progress abounds on many fronts. Our membership Mario Marzola, MBBS is steady at over Adelaide, Australia 700 Physician & Surgical Assistant members. We continue to have successful Annual Scientific Meetings as well as Live Surgery Workshops all backed up with a hard-working committee structure and strong leadership from the head office. Financially we are making solid progress, prudently building our reserves to equal one and a half years’ expenses, after which we can party! Seriously though, that’s what is considered good management, that’s where other successful societies are, so that’s where we’re headed. It is at times like these that we should look to lift our sights and see if we can raise the service to our patients to a new level. I’m happy to say that in a small way this has already happened. “Operation Restore,” the Pro Bono Founda- tion of the ISHRS, is up and running. I encourage you to fill in the application to become a volunteer physician when you receive it. On a much larger scale there is an enormous amount of work still to be done. Our membership consists of USA, 336; Canada, 56; Korea, 24; Brazil, 21; Australia, Japan, and Mexico, 15 each; France and Italy, 14 each; UK, 12; and Germany, 10, plus many other countries with a few members only. We have no members in China, 5 in India, and only 1 in Russia, just to mention some big countries. Our penetration outside the Americas and Western Europe is superficial to nonexistent. So ladies and gentlemen, if we are true to our name, we must address this imbalance in the next 10 years. It’s taken us this long to steady our home base, now let’s really become INTERNATIONAL. Imagine 200 members each from China, India, Russia, etc.—it will be an enormous administrative workload for Victoria Ceh and her team, but I’m sure they will welcome the task. Please let us have your ideas for workshops in far away places so we can spread the good word.✧ Cheers, Mario Marzola, MBBS To Submit an Article or Letter to the Forum Editors Please send submissions via a 3½" disk or e-mail, Remember to include all photos and figures referred to in your article as separate attachments (JPEG, Tiff, or Bitmap). For email submissions, be sure to ATTACH your file(s)—DO NOT embed it in the e-mail itself. We prefer e-mail submissions with the appropriate attachments. Any person submitting content to be published in the Forum agrees to the following: 1. The materials, including photographs, used in this submission do not identify, by name or otherwise, suggest the identity of, or present a recognizable likeness of any patient or others; or, if they do, I have obtained all necessary consents from patients and others for the further use, distribution, and publication of such materials. 2. The author indemnifies and holds harmless the ISHRS from any breach of the above. Send to: William M. Parsley, MD 310 East Broadway, Suite 100 • Louisville, Kentucky 40202-1745 E-mail: [email protected] Submission deadlines: September/October, August 10 • November/December, October 10 82 Volume 14, Number 2 Hair Transplant Forum International ❏ May/June 2004 Co-Editors’ Messages Like many of you, I often pinch myself as I go off to work and reflect on my good fortune to be able to earn my living being a hair transplant surgeon. I am Michael L. Beehner, MD often asked by my Saratoga Springs, New York patients or friends what part of my job I enjoy the most. And I always reply that, without a doubt, the best part is seeing the patients return whom I have operated on. When I see the smiles on their faces and hear them tell me what a difference it has made in their self-esteem and self-image, it is truly gratifying. Because most of my patients do come three or four times to complete their transplant, I get to see this effect build over time. I am always amazed that those around them, even family members sometimes, don’t even know that a transplant has taken place. ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ Orlando Highlights The 10th Annual Live Surgery Workshop was held in Orlando, March 10–13. Dr. David PerezMeza has been William M. Parsley, MD taking a graduLouisville, Kentucky ally more prominent role in orchestrating the meeting, and this year’s meeting was one of the best, in spite of a policy change that did not allow surgeons without a Florida medical license to operate. While we are assured that visiting doctors will again be allowed to operate next year, the problem was only a minor one this year. Kudos to Dr. Perez-Meza, Dr. Matt Leavitt, Valerie Montalbano, and the rest of the staff who worked so hard to make this meeting meaningful. It was interesting to watch Dr. Alan special views I want and arranging for the payment of the photos. Obviously, if you know that a particular patient or one of his family members is particularly adept at photography, you could always ask them to take the photos themselves and send them to you, but, by and large, I find that “homemade” photos are usually almost worthless. If you do have them take their own photos, be sure and insist that a macrolens camera be used. The role of photography in a hair transplant practice cannot be overemphasized, in my opinion. When someone starting out visits my office and asks me what is most important in getting started in hair transplantation, I always answer two things: Do good work, and take good pictures! You could be the best hair surgeon in your state, but if your photos are of poor quality—with glare, shadows, poor lighting, or “red eye”—then no one will ever know you do great work, except perhaps the patient who received the Another benefit to having your patients return to see you, whether it is for a last–perhaps even unnecessary— ”touch up” transplant session or their last scheduled session, is that it gives me a great opportunity to take some good “after” photos to go with my preoperative ones. I usually am so busy that I forget to later contact many of these men and women I have completed, and miss out on the opportunity for obtaining their final photos and also for getting feedback on how they viewed the whole transplant process. This is fairly easy with patients living nearby, but is more difficult with those patients who live far away, as approximately half of my patients do. One approach I have used with regard to these distant patients, is to ask them if they would be willing to go to a nearby professional photo studio for such photos. I make this more attractive by treating them to a family photo at the same time. I obtain the name and number of the studio and then call the photographer, letting him know what ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ Bauman performing follicular unit extraction (FUE). Of the 7 consecutive grafts that I checked microscopically, he had only 3 transections out of the 19 hairs present. In those 3, the shafts were transected at mid-hair, so I expect that the remaining hair shafts would regrow. Dr. Bauman states that he goes by “feel,” not millimeters, in determining the depth, and his technique was quite impressive. Rock-hard tumescence was necessary to obtain good results, and an electrical tumescence infusion machine seemed to work nicely. It appears that with proper technique the transection rate with FUE can be very acceptable in the proper candidates. Additionally, Dr. Bauman has solved the problem of buzzcutting large amounts of the donor area by punching right thru the hair shafts, thus requiring no trimming at all. This still leaves some major obstacles to overcome—length of the procedure and expense of the procedure. Also, thus far, the final results of FUE seem to be less continued on page 96 ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ impressive than with strip procedures, but this may change. Perhaps the ideal situations for the procedure will be for body hair transplants, small procedures, patients with a history of poor healing, or patients with nearly depleted donor hair. It will be interesting to follow its development. Without question, progress is being made. A special section on handling a young (roughly 22 years old) patient was presented in Orlando. Experienced, caring doctors are very divided on how to approach such young patients, and opinions in this meeting mirrored that diversity. A NW 6 patient in his late 40s was also presented and was found to talk comfortably and openly to the attendees. Following this patient, a 20year-old was presented. He was wearing a cap and was very reluctant to remove it. His head was down and his emotional devastation was obvious. When his cap was finally removed, surprisingly continued on page 96 83 Hair Transplant Forum International ❏ May/June 2004 Volume 14, Number 2 Notes from the Editor Emeritus Comments on ISHRS Directory The annual ISHRS Membership Directory is a source of great interest to me, and I have been collecting Richard C. Shiell, MBBS and tabulating Melbourne, Australia the statistics for a number of years. The membership now remains pretty steady at 702 (598 Physicians and 104 Assistants). Although the total ISHRS membership reached a high of 830 in the year 2000, it fell to 712 by 2002 and has only varied by 3% over the past 2 years. This is perturbing, as each year we vote in many new members at our Annual Meeting, so the Society should be growing steadily. These new members are obviously being balanced by resignations—probably from doctors who thought that HT would be “a great little earner” and who later found that there was more to it than they originally thought. The physician membership is distributed widely and unevenly throughout the world with North America at 392; Mexico and Central America combined at 28; South America, 30; Western Europe, 84; Poland, Russia, and Eastern Europe, 8; Middle East, 17; North Africa and Saudi Arabia, 9; India/ Pakistan, 11; China and S.E. Asia, 13; and Australia 16. Nationally, the physician membership rankings remain much the same as last year with the United States in first place with 336 members, Canada 2nd (56); Korea 3rd (24); Brazil 4th (21); Australia, Japan, and Mexico sharing 5th spot with 15 members each; France and Italy share 6th place (14 each); the UK is 7th with 12 members; and Germany 8th with 10. One may be sure that there are many more doctors performing hair transplants in Russia, China, Africa, India, and Pakistan than indicated by our 84 ISHRS membership. Together, these countries hold ¾ of the world’s population, yet doctors from these countries make up only 1% of our membership. Lack of familiarity with the English language obviously inhibits many physicians from joining the ISHRS, and the huge differences in monetary exchange rates inhibit many others, with very adequate English, from coming to our meetings. Forthcoming Meetings By the time you read this, the Orlando meeting will be over, but details of its outstanding program will hopefully be filling some of the pages of this current edition of the Forum. The ESHRS meeting has been cancelled and the DHI meeting postponed until October, but the Italian Society meeting will be held as scheduled in Turin. Please consult the back page of this edition for details. If you would prefer to go somewhere more exotic, then perhaps Brazil will suit you more than Europe. The Brazilian Hair Transplant Society, led by ex ISHRS President, Marcelo Gandelman, will be holding a meeting in Recife, Northern Brazil, on June 16–19. I can vouch for the hospitality of the Brazilians, having been to a wonderful HT meeting there in 1992. Research Grants It is coming up to that time of the year when applications for Research Grants should be submitted to the ISHRS head office. Do not be bashful; if you have a good idea and would like to test it, you may like to apply for some financial support from the Grants Committee. Apart from the cash and considerable prestige attached to these Grants, there is a certificate that you can frame for your wall. Even better, you get to shake the ISHRS President’s hand on Presentation Night. Awards It is also time to start submitting names for the Gold and Platinum Awards and for the newly initiated Surgical Assistant’s Award. Remember to carefully list your reasons why you think that your candidate is deserving of consideration by the Committee. It is not sufficient that he or she be a great hunting and fishing partner or drinking buddy!! Comments on the March Forum Forum 2, 2004, was one of the best yet; I know I have said this before, but congratulations to our Editors, production staff, and to you the contributors for continuing to make our newsletter such an interesting and instructive read. I particularly enjoyed the articles on ISHRS members Drs. Shelly Friedman and Joerg Hugeneck. I have known both gentlemen for over fifteen years and it is good to be reminded of the all-round abilities of some of our quieter members. Both have made major contributions to our craft in their own way. The article by Bernie Nusbaum on Diffuse Alopecia Areata should be photocopied and kept in an office drawer for quick reference. In 38 years I have never personally diagnosed a case, so I must have missed many in my thousands of consultations. It is only when one becomes aware of these conditions that we can make a diagnosis. I remember presenting a lecture on Triagular Alopecia several years back and predicting that it would be seen more frequently as ISHRS members became aware of its existence. This certainly happened, and several times each year I now receive e-mail photos of cases sent to me by those who heard my talk. Bill Parsley’s editorial contained a splendid segment on the 10 Myths of Hair Transplant Surgery. It should be compulsory reading for all hair transplanters. This brings me to the sad realization that Bill and Mike will complete their 3year term as joint editors early next year (January/February 2005 will be their last issue) and are now considering candidates for their replacement. If you have a continued on page 103 Volume 14, Number 2 Hair Transplant Forum International Orlando Review continued from front page Dr. Cam Simmons made us all take a hard look at the advantages of using less anesthesia drugs overall when supraorbital and supratrochlear nerve blocks are performed. In a series of 100 patients, successful nerve blocks were achieved in 98% of the cases. Minimal complications, most commonly a small area of ecchymosis, occurred less than 3% of the time. Instrumentation was covered thoroughly by Dr. Arthur Tykocinski. His talk included those used at various stages of hair transplantation, including the donor site, graft preparation, and recipient site preparation. He also covered the various modes of using automation in preparing the grafts. Dr. Mel Mayer presented “MayerPauls Scalp Elasticity Scale Used to Maximize Donor Tissue with Minimal Scarring.” Realizing that scalp elasticity can vary from about 10% to 50%, one can use this information to help determine the maximum width of donor tissue to remove and still get a closure with minimal tension and scarring. As usual, the natural simplicity and efficiency of Dr. Tony Mangubat’s graft cutter continues to prove that there are many ways to achieve excellent results when done correctly. With all the fuss over pure follicular units and the best type of magnification needed to avoid transection, Dr. Mangubat, who may use up to ten blades in the multi-blade knife, continues to prove that one does not always have to follow the crowd and be influenced by peer pressure. It is not wrong to think outside the box. In fact, this type of thinking is refreshing and progressive. Dr. Antonio Ruston presented the topic “Hairline” with great insight and artistry. Excellent pictures and supportive illustrations were most helpful for those learning the skills of a hair transplant surgeon. “Four-Hand Stick-and-Place Technique of Hair Transplantation” was thought-provoking as presented by Dr. Jerzy Kolasinski. Dr. Kolasinski reminded us that in 1986 Dr. Carlos Uebel was the first to break the 1,000 graft barrier, and it was with the stickand-place technique. Advantages pointed out include improved density, reduction in bleeding, precise size matching of incisions and grafts, reduced risk of placing one graft on top of another, shortened surgery time, and an increased comfort level for the patient. Dr. Keene, in her presentation “Ergonometrics,” demonstrated her improved multi-blade instrument for site creation, which can reduce the hand movements of the surgeon by 75%, speed up the procedure, and decrease the risk of carpal tunnel syndrome. Her video-scope also makes life more comfortable for the surgical techs, who thereby have marked improvement in movement of their head, neck, and shoulders. “Pre- and Post-Operative Instructions,” as presented by Dr. Glenn Charles, was all-inclusive, from the initial goals to be thoroughly understood to the final post-op instructions regarding emergency contact numbers and information. The fascinating topic “Minimal Automated Techniques for Maximal Results” was presented by Dr. Yves ❏ May/June 2004 Crassas. Harvesting 6,000–8,000 hairs with limited transection, pressing grafts with the microtome, and recipient site preparation, with results assessed by the Capillicare device, were all covered in this lecture. Dr. David Perez-Meza, the CoDirector of this 10th Annual Live Surgery, presented the topic “A New Beginning for the Beginners—A Guide.” He gave more information in seven minutes than most mortal humans could absorb. Fortunately, he had prepared an excellent abstract with his key points. He also hinted that a new “Beginners Text” may be in the works called “Hair Transplantation for Dummies.” As a successful, independent, fulltime hair transplant surgeon, Dr. Alan Bauman shared many of his successful ideas in the presentation “Essentials of Media Communications.” Personal experiences that lead to news stories in USA Today and on CNN were discussed. Use of press kits and press releases was shared. Few bring more experience and wisdom to the topics “Ethics” and “Marketing in HT” than Dr. Carlos Puig. If we could all follow his advice and insights, what an improved image there would be for our practices and the whole industry of hair transplantation. Many faculty members participated in the Mentor Program at the surgery center during the afternoon. Four surgeries were conducted by various combinations of faculty. Dr. Matt Leavitt was the surgical coordinator. After such an intense day, it was a delight to relax with the participants at the Wyndham Palace Resort poolside for the welcome cocktail reception. Thursday, March 11, 2004 Carlos J. Puig, DO Houston, Texas Day 2 presented participants with a refreshing new format; that being a short synopsis or “my way” presentations on a topic followed by time for audience participation and patientfocused panel discussions. The day opened with two very nice presentations on the diagnosis and management of female hair loss by Drs. Matt Leavitt and Robert Leonard. Dr. Leonard shared his positive experience with incorporating the Luce LDS 100 low level laser therapy in the treatment of female pattern hair loss. Dr. Tony Mangubat next moderated a panel on “Creating a Hair Transplant Office” with Drs. Alan Bauman, and Carlos Puig. Dr. Mangubat offered many suggestions on how to incorporate hair restoration surgery procedures into a general cosmetic surgery practice. Dr. Bauman pointed out the need to carry the concept of a clear “mission statement” for the practice into the design of every area of the office, emphasizing the engineering principle continued on page 86 85 Hair Transplant Forum International ❏ May/June 2004 Orlando Review continued from page 85 of “form follows function.” Dr. Puig shared several cost-effective tips concerning equipment, office lay-out, and room design, pointing out that adequate space, ventilation, and lighting, combined with the adjustability of equipment and fixtures, are essential to the prevention of repetitive-motion injuries on the part of the staff. Dr. David Perez-Meza coordinated a panel on donor harvesting techniques with Drs. Michael Beehner, Alan Bauman, and Yves Crassas. Dr. Beehner presented his experience with and the strength and weaknesses of using sub-mental beard hair for donor. He recommended that it only be used in men with coarse hair and in those who intend to wear a beard for the rest of their lives. Dr. Bauman provided the most balanced review of the new Follicular Unit Extraction harvesting this reviewer has ever had the opportunity to witness. His presentation was very insightful and contained many tips on how to successfully extract these very small grafts. Dr. Crassas described the use of the Calvitron with a 1mm punch to extract hair from the temporal regions of the scalp, thereby saving the occipital zone for future grafting. Dr. William Parsley chaired a panel with Drs. Ron Shapiro, Arthur Tykocinski, and Matt Leavitt, on “Management of the Recipient Area.” These presentations centered on the theoretical and practical advantages and disadvantages of surgical vs. coronal recipient sites, the need for proper hair direction and steep exit angle, and a properly spaced hair-line transition zone with a cross hatching pattern. Dr. Shapiro pointed out that increased density is needed to achieve a natural look in the central-frontal forelock zone, which lies just behind the frontal transition zone. He recommended that this could be accomplished by using two follicular units in one recipient site. The discussions pointed out that this technique is very similar to using 3- or 4-hair micrografts in this zone. Dr. Tykocinski presented a beautiful video 86 demonstrating the stick-and-place method in the coronal plane using 0.7– 0.8mm incisions. The balance of the morning was spent in discussion panels, with specific patient presentations. Dr. Ed Epstein chaired a panel on Hairline Design with Drs. Melvin Mayer, Ron Shapiro, and Sharon Keene. Using one patient, they each demonstrated how they would design the hairline and counsel the patient for their design. Dr. Keene provided an excellent summary of the principles of hairline design. A similar case presentation and panel discussion on managing the very young male patient was masterfully coordinated by Dr. Mario Marzola, with the participation of Drs. Jerry Cooley, Matt Leavitt and William Parsley. The entire panel focused on medical therapy, delaying surgery, providing hope, and—most importantly–establishing a strong supportive relationship with the patient. Dr. Alan Bauman demonstrates his FU extraction technique. The morning ended with Dr. Robert Cattani chairing a case study panel consisting of Drs. Carlos Puig, Robert Leonard, and Melike Kuelahci on the consultation process. Discussions revolved around the pros and cons of the use of patient educators or non-physician consultants and the integration of the individual patient’s consultation with the general information presented by the practice. The patient for this panel was a woman who had a rather complex hair loss problem related to radiation treatment of an occipital brain tumor, and her husband was present also. Drs. Marzola and Cattani’s panel discussions brought, for the first time in the author’s recollection, a real demonstration of the emotional impact of hair loss in the very young, female patient. Volume 14, Number 2 Although often spoken of in presentations, these particular patients provided the novice hair restoration surgeons in the audience with possibly their first insights into the therapeutic, and not just cosmetic, aspects of a hair restoration surgery practice. The highlights of the afternoon surgeries included Dr. Shapiro’s densepacking follicular unit hair transplant and the use of follicular unit paring in one site to improve forelock density behind the transition zone. Dr. Arthur Katona’s eyebrow transplant clearly demonstrated how to achieve a very steep hair exit angle, and the complex inter-digitated web-foot hair recipient site direction needed to create a natural lateral brow. Dr. Sharon Keene demonstrated how randomness of recipient site placement can be achieved when using the multiple blade recipient knives she has designed. She also shared her digital video microscope, an excellent, ergonometrically sound dissection tool. Dr. Leavitt, under Dr. Mangubat’s supervision, was pleasantly surprised at how efficient the multiple-blade knife proved to be at harvesting strips with minimal transection. Dr. Mangubat then used those strips in the Impulse Graft Cutter (“Manguwacker”) to create 1mm grafts. Dr Bruce Marko demonstrated the design of a transplantation treatment plan for a female with Ludwig II patterned hair loss. Dr. Bauman provided a very insightful demonstration of Follicular Unit Extraction. Of the 16 grafts that Dr. Bauman extracted, 3 had a damaged morphology when examined by Dr. Parsley under the microscope, or about an 18% transection rate. Dr. Bauman did an excellent job of putting the FUE procedure into perspective relative to its indications, contra-indications, and use. Dr. Parsley pointed out the subtle differences between sagittal and coronal recipient sites. He demonstrated a very efficient technique for lifting the up edge of a CAG slit with a small skin hook, to facilitate in the atraumatic placing of grafts. Volume 14, Number 2 Hair Transplant Forum International ❏ May/June 2004 Friday, March 12, 2004 Alex Ginzburg, MD Raamana, Israel We awake in Orlando with another beautiful day. Friday’s first session concerned research. Dr. Ken Washenik, this session’s moderator, gave an update on the subject of hair cloning and talked about the possibility of creating new hair follicles (folliculoneogenesis) that will likely serve to augment the density achieved from traditional follicle-based transplants. Dr. Matt Leavitt presented a study that looked at the effects of finasteride (1mg) on hair transplantation. It was a randomized, double-blind, placebocontrolled study in which 79 men with androgenetic alopecia were treated with finasteride (40) or placebo (39) from 4 weeks before until 48 weeks after hair transplantation. The study showed that the group who received finasteride had improved growth of the non-transplanted hair, and overall improved hair density. Dr. Jerry Cooley talked about ischemia-reperfusion injury (IRI) and graft storage solutions. Seven patients participated in his study, in which the grafts were stored in chilled normal saline (control) versus Hypothermosol (a solution containing buffers, nutrients, and antioxidants). He found that the grafts with Hypothermosol showed less free- radical injury and were associated with a 47% decrease in IRI damage. Dr. Washenik also gave us an update on finasteride and minoxidil. He reported that the principal cause of irritation with minoxidil therapy is propolene glycol. He noted that the combination of finasteride plus minoxidil was statistically superior to finasteride or minoxidil alone. He also reported a randomized study of 18,882 men that found that finasteride decreases the incidence of prostate cancer 25%. The panel of special cases was moderated by Dr. Beehner. He talked about the “frontal forelock concept,” and showed four designs that he thinks work best. He described the concept of the “mirror image,” which is created on the lateral aspect of the forelock by transplanting a “gradient” of thinning off of the forelock body and off of the fringe beneath it, using different size grafts and FUs with different numbers of hairs. Dr. Arturo Sandoval talked about the “shingling points,” and Dr. Mel Mayer discussed his temporal points classification system. Dr. Marcelo Gandelman reported his wonderful experience in reconstruction of the eyebrow and his new technique to reconstruct eyelashes. In harvesting the hairs to be used for eyelash transplants, he uses the 4mm manual punch to take out several fulllength hairs with attached roots, which are then inserted at the correct eyelid angle, making it an easy 10-minute office surgery. In this session, Dr. Edwin Epstein (the program chairman at the ISHRS meeting in Vancouver) presented his technique to improve Dr. Ron Shapiro demonstrates a follicular unit transplantation case. wide donor scars using a standard 6-0 punch, or smaller. The session of ethnic and female cases was moderated by Dr. Paul Cotterill. Dr. Craig Ziering opened the session by giving a wide review of the medical and treatment aspects in female pattern alopecia. Dr. Valerie Callender presented a review of traction alopecia and central centrifugal scarring alopecia in African-American women, and described the medical management and the hair transplant techniques to be used in these cases. She recommends to only consider the surgical correction of these patients with HT after the hair loss has first been stabilized medically. Dr. David Seager discussed the advantages and disadvantages of “dense packing.” He considers the following most important: keeping the grafts moist, making recipient sites appropriate in side, and using the correct technique in dissecting the grafts. Dr. Mayer presented a new instrument for hair preparation, the KMP Digital Scope. This scope, which has been evaluated in multiple centers by both surgical techs and surgeons, is a high resolution video camera and telescoping lens that allows the tech to adjust the magnification between 8–12 power. The high resolution 8½ inch LFT screen is adjustable in three dimensions for the comfort of the technician. Dr. Ron Shapiro gave a talk on hairline aesthetics, emphasizing the angle and the direction of the hairs. He recommends that the anterior border be 4 fingers-breadths above the glabella, and he recommends creating a “framework” in the transition zone. The next session was the Orlando 2003 studies. Dr. Mayer presented the graft density production curve with dense packing; the objective was to determine the ideal density with which to place grafts. The rate of hair growth was 95%, 76%, 70%, and 82% in FU grafts transplanted to a density of 30, 40, 50, and 60 per cm2, respectively. Dr. Alex Ginzburg presented the 9-month results of FU survival after 24 hours outside the body. Among the study grafts, 20 FU grafts were implanted immediately after the harvesting, and the other 20 FUs were stored with telfa in saline solution at 4oC for 24 hours before being transplanted into the scalp. Only 7 grafts grew in the box that was implanted after 24 hours; this was compared to 19 out of 20 FUs transplanted immediately that were growing after 9 months. Dr. Ginzburg thinks that this difference occurred because the grafts were placed inside wet telfas and not directly in saline solution. Dr. Beehner presented his study of synchronization and unsynchronization of hair growth over time. The rate of growth of hairs transplanted 9 months continued on page 88 87 Hair Transplant Forum International ❏ May/June 2004 Orlando Review continued from page 87 earlier was 90%. These hairs will be followed for the next 5–8 years to see if hair growth cycles become randomized over time, with a drop in the number of hairs present in this transplanted “biosphere.” Dr. Jerzy Kolasinski presented the clinical and histological evaluation of Volume 14, Number 2 transplant debris tissue during HT surgery. His conclusion was that there was no significant hair growth to be gained from this tissue in this particular study. The next of the day’s activities took place at the Metro West Surgery Center. Four surgeries were demonstrated to all the physicians present, some of whom viewed the surgery in the operating theater, while the majority watched in the comfortable TV viewing rooms, in which there was an able faculty member to serve as the coordinator for the group feeding questions into the operating room as they came up. In the evening everyone went to Planet Hollywood for a cocktail party. We had time to drink, eat, and talk with old friends. It was a long and hard day, but we enjoyed ourselves very much. Saturday, March 13, 2004 Jerzy Kolasinski, MD, PhD Swarzedz, Poland Despite a great time at Planet Hollywood the previous night, all the participants arrived bright and early to take part in the morning sessions. First, Dr. David Perez-Meza called for a minute’s silence to pay tribute to the people who had died in the Madrid bomb attack two days before, those who have died from terrorist attacks and for “Peace in the World.” We are not only doctors but also sensitive people from all over the world. What happened in Spain could happen in our countries. We join the victims’ families in their pain. The minute silence was a meaningful expression of what all the participants felt, protest against violence aimed at innocent people. The subject of the session was treatment of scars in the scalp. Dr. Jerzy Kolasiñski outlined the problem, suggesting at the same time the classification of scars as linear and area, single and multiple, small, medium, large and vast, planned, and emergency. To treat them the following approaches can be applied: simple excision, “Z” plasty, hair transplantation, or skin flaps. In the treatment of vast scars, the best results are achieved with the use of expanders. Dr. Kolasinski presented an algorithm of skin defect treatment depending on its type. Next, Dr. Marcelo Gandelman pointed out the factors that may increase the risk for developing bad scars. In his opinion, the best way for managing hypertrophic scars and keloids on the scalp is their prevention. Thus, the following should be avoided: closing under tension, cauterization; additionally, disinfectants should be 88 used with great care to avoid damaging the hair follicles. It is advisable to excise scars with the use of “W” plasty (zigzag plasty), “Z” plasty, and two-layer closure. Placement of grafts in between the wound edges may be beneficial for the final cosmetic effect. In some cases, tattooing over scars may help conceal them. Dr. Ricardo Mejia pointed out the risk of incidence of skin cancers and melanomas in the scalp. Prior to treatment with hair transplants, the scalp should be carefully examined. In case any suspicious lesions exist, a frozen section biopsy should be carried out. The most common method of neoplasm treatment in the scalp is vast excision. Hair transplants should be performed only as a secondary procedure after such lesions are treated. Dr. Humayun Mohmand presented his results of using the FUE technique in reconstructive moustache treatment. The need for such treatment usually arises following split upper lip surgery. The FUE technique is a perfect procedure in such cases, because it does not result in any more scars. The operative technique and the results fully corroborate this. The session was finished with a warm applause for Drs. Matt Leavitt and David Perez-Meza in recognition of the perfect preparation of the workshop. Thank you Matt! Thank you David! Thank you Mel! Thank you Valerie! Thanks to the entire team at MetroWest Surgery Center! Dr. Patrick Frechet Paris, France and Mel Mayer San Diego, California Among that day’s afternoon surgeries, two research projects were performed on Norwood Class VI males. On the first patient, Drs. Mel Mayer and Sharon Keene analyzed correlation between hair growth and dense packing. They drew four boxes, each 1cm2 in area, and in each of them placed 20, 30, 40, and 50 two-hair FU grafts. Partial results will be presented in Vancouver. In the second research patient by Dr. Perez-Meza, comparison of different instruments to make recipient sites was carried out, using both needles and blades. To demonstrate this, he marked 6 boxes (1cm2 each) in which he performed incisions using 18-, 19-, and 20-gauge needles, and also blades 22 Sp, 1,3 LM, and PEMA (custom made blades). The preliminary results are also to be presented at Vancouver. The 10th Annual Live Surgery Workshop proved that there is an enormous need for this type of meeting. They are very useful for the beginner, intermediate, as well as for the expert surgeons. Everybody returned to their practices, motivated to do their job better and with the latest techniques.✧ Volume 14, Number 2 Hair Transplant Forum International ❏ May/June 2004 Pioneer of the Month Ronald Lawrence Shapiro, MD William M. Parsley, MD Louisville, Kentucky Dr. Ron Shapiro is known worldwide for his innovative work and artistry in the field of hair restoration. Not many know the unlikely series of events that luckily drew him into our field and now have brought him to be honored as a Pioneer. Ron was born and raised in Washington, D.C. His mother performed modern dance and remains fit to this day by going to the health club regularly. His father was captain of the George Washington University basketball team and later pursued a career as an attorney, gave it up to be a farmer in Florida, and finally went into real estate investing. He passed away two years ago. Interestingly, Ron’s father is famous for his daring undercover role, working with the District Attorney of New York, to expose a mob gambling ring in basketball. This earned his father the nickname “Honest Dave,” and he has been written about in many basketball history books. Ron has endeavored to emulate his father’s honesty and integrity in all aspects of life, including his approach to hair restoration surgery patients. Ron grew up with three brothers— Adam, Paul, and Bob. Bob was Ron’s non-identical twin brother and later an unwitting participant in Ron’s decision to enter hair restoration. At Walter Johnson High School, Ron excelled at sports and was captain of the gymnastics, wrestling, and track teams—and still holds his school’s record for the pole vault (14 feet). He also placed in the state for wrestling and gymnastics in 1972. Ron attended Emory University from 1971–75 where he was a Phi Beta Kappa, then entered Emory University School of Medicine, graduating in 1979. While in medical school he worked at the National Institutes of Health (NIH) performing research on Feedback Inhibition of Cholesterol Metabolism in Atherosclerotic Plaques. He then left for Ron Shapiro, MD Bloomington, Minnesotta Emanuel Hospital in Portland, Oregon, where he did his internship and residency in Internal Medicine, becoming Board Certified in 1982. However, after receiving this Board Certification, he switched into the then new field of Emergency Medicine, and after receiving a second Board Certification in Emergency Medicine, practiced Emergency Medicine in Tampa, Florida. The turning point of his career was in 1991 when three major events occurred in his life. His twin brother Bob, after a difficult bout with stomach cancer, passed away; his marriage ended; and he developed atrial fibrillation while doing all-night shifts in the ER. After spending a month trekking around the Himalayas in Nepal and reevaluating his life, Ron decided to make a career change to cardiology and was accepted for an Emory University fellowship; however, he had to wait a year before the position was open. While waiting, his close friend Dr. Paul Rose encouraged him to try hair transplantation with Professional Hair Institute (PHI), as they had a position open in Minneapolis. He accepted but after only two months was disappointed and disillusioned by what he considered poor techniques. Then something happened that changed his life forever. He heard about a private Hair Transplantation Conference in Rio de Janeiro in 1992. He decided to attend and there met people such as Drs. Walter Unger, Richard Shiell, Mario Marzola, O’Tar Norwood, Arturo Sandoval, David Seager, and, most importantly for him, Claudia Prawitz from the Moser Clinic in Vienna. Ron was amazed at the encouragement and help given to him by the faculty. It was at that meeting that Claudia presented their then eyecatching technique for performing over 1,000 grafts in one surgery. As were many others, Ron was fascinated. He sensed that the field was about to change and was excited to be at the forefront of innovative and groundbreaking techniques. In the month after the meeting, he visited the Moser Clinic in Vienna. While there, Richard Shiell also visited, and recommended him to Walter Unger in Toronto, Canada. After visiting Walter, he was hooked and forfeited his Cardiology residency to make a career in hair restoration. In 1993, he joined Dr. Bill Rassman at the New Hair Institute (NHI) and helped him open his clinic in New York, but also kept working part-time for PHI in Minneapolis. In that same year, he was performing 1,800-2,000 mega-graft sessions. At the ISHRS Conference in Las Vegas in 1995, he performed the first Live Surgery, demonstrating a micrografting megasession. This prompted Dr. O’Tar Norwood to write in the September/ October 1995 issue of the Forum: “Overheard…Ron Shapiro may be the best technician in the business. I have suspected this for some time.” This statement was made about a person who had only been in the field for 3 years! In 1997, PHI disbanded and Ron had an opportunity to own the practice in continued on page 90 89 Hair Transplant Forum International ❏ May/June 2004 Pioneer of the Month continued from page 89 Minneapolis, so he took it and left NHI, naming his new practice Shapiro Advanced Hair Restoration Surgery. At the same time he opened a satellite office in Tampa, where he still had some roots. Before leaving NHI, he was asking a local dermatologist, whom he respected, to be a dermatology consultant and to cover his patients while he was out of town. This doctor, who at the time was not doing transplants and tended to be negative toward them, was Dr. Bob Bernstein. Seeing that transplant results were vastly improved, Bob took over the position with NHI when Ron left and hair restoration gained a great ambassador. Early in his career, Ron focused his lectures on the art of placing grafts. He possibly was the first to utilize the “Buddy System” for placing grafts, using one person to open the already created site while another places the graft. Over the past few years, he has been presenting his ideas on hairline design, follicular unit pairing, and the creation of parietal humps, techniques that have been copied by hair restoration surgeons around the world. To see Ron and his team work is a must for any transplant surgeon. The gentleness and precision with which he and his team handle the grafts and tissue Volume 14, Number 2 certainly play a major part in his outstanding results. Ron has published numerous papers and lectured all over the world. Perhaps his greatest honor was being invited by Dr. Walter Unger to coauthor the 4th Edition of Hair Transplantation, a major textbook that finally was made available in March this year after 4 years of effort. For all his achievements, Ron has remained shy but accessible, not being much of a self promoter. Never complacent, Ron is constantly improving his technique, keeping an open mind to any new concepts and advances. He has more than earned his status as Pioneer.✧ LAST C ALL FOR NOMINA TIONS! CALL NOMINATIONS! 2004 G olden FFollicle ollicle A w ar d • 2004 P latinum FFollicle ollicle A w ar d • 2004 Distinguished A s sistant A w ar d Golden Aw ard Platinum Aw ard As Aw ard P lease e-mail yyour our nominations with the rreason eason the pperson erson is deser ving tto o inf [email protected] g. deserving [email protected] [email protected]. 90 Volume 14, Number 2 Hair Transplant Forum International ❏ May/June 2004 A Statistical Approach for Comparing Hair Populations William H. Reed II, MD La Jolla, California The evaluation and comparison of surgical techniques require being able to employ concrete parameters. Transplanted hair growth rates (THGR) is a commonly used parameter. The quality of this parameter is impaired by the imprecision introduced by the invisible donor follicles in exogen (telogen without the hair fiber present). Exogen probably accounts for the studies with growth rates exceeding 100%. Adding to the imprecision of THGR is that the percentage of telogen and exogen vary in response to many factors, such as seasonal, emotional, and nutritional factors. These issues are likely factors in the studies showing growth rates in excess of 100%. Another parameter to measure transplant outcomes that may circumvent these exogen issues is the miniaturization of growth of the transplanted follicle. The underlying hypothesis of this parameter is that transplanted hair growth is not “digital”, that is, the hair grows or does not grow, but rather “analog,” that is, perhaps the hair diameter is determined by the number of mesenchymal stem cells surviving the duress of the surgical technique of the transplantation process. Hence, there is a spectrum of growth from no growth to the completely non-miniaturized. Researchers vary in their opinions of the accuracy of the micrometer. There may be significant variation between different measurers’ results. Additionally, the hair fiber may be “out of round” and have other diameter irregularities. This study attempts to assess the accuracy of the handheld micrometer in view of these limitations and to propose a statistical methodology to compensate for these variables. Materials and Methods Six people from two hair transplant practices made micrometric measurements of 15 hairs from 15 different patients. Two Mitutoya micrometers were employed. Each hair was transected to make two identical, though independently ordered, sets of hair. The transected junction was the protruding end Intra-Observer Deviation by Hair 1D 2N 30 4A 5K 6I 7L 8B 9F 10C 11H 12J 13G 14E 15M R 0 2 0 -1 -2 2 -1 3 2 -3 5 0 0 -5 -8 A 1 8 0 -1 -7 0 -5 4 -3 -1 6 -3 5 -6 -3 J 0 0 -8 0 10 0 0 0 -2 -12 5 0 0 -10 0 B -5 6 1 8 7 9 0 0 -20 -8 22 -10 5 13 -32 J 0 0 8 8 10 12 -10 4 -10 20 19 6 -15 4 -22 and was measured for each of the 30 sample fragments. The observers are thereby blinded to which hair fragment of one set matched which from the other. The difference in the measurements was determined for each of the 15 hairs. The mean was determined for the hair fiber diameter. The mean, standard deviations, and confidence intervals were determined on the difference of the two measurements for each hair for each of the 6 observers. Results The mean diameter for the hair samples measured by the six individuals ranged from 55 to 86 microns. Depending on the individual performing the measurements, an interval of 1.6 to 6.8 microns was necessary on each side of the mean to achieve a 95% confidence interval for the mean of the hair sample. (A confidence interval is the range on either side of a mean that is necessary to have an X% chance of containing the true mean. It is related to the sample size from which the mean is determined and the standard deviation of the sample.) Discussion M -5 -7 -5 8 -3 5 0 -2 3 0 18 -8 -5 0 -28 Table 1. The green column represents the two hair samples where, for example, hair #1’s match in the other sample is “D”. The black columns represent the measurements of the six observers. The results (Table 1) show that the mean hair fiber diameters and the confidence interval were too disparate among the individuals doing the measurements to allow inter-observer conclusions about the data. The data show this deviation appears to be introduced by the skill employed for the measurement (e.g., Hair 7L) as well as, in some instances, by the inherent irregularities in the diameters of some of the hair. (See the wide range of readings of the two fragments of hair 11H that all six of the observers obtained.) These two elements, that is, observer variability and inherent variations of some hair fiber, make conclusions about measurements of a single or even a small number of hairs continued on page 92 91 Hair Transplant Forum International ❏ May/June 2004 Comparing Hair Populations continued from page 91 unreliable. A sample size of 30 is generally regarded as adequate from the statistical point of view if one assumes a normal distribution. Such an assumption is open to criticism in some populations and, accordingly, a larger sample size would be necessary. However, the non-normal distribution is more likely in the non-donor samples and, hence, the difference of the donor vs. recipient situation would be underestimated by the assumption of a normal distribution. There are several problems facing the analysis of hair diameter. One is, of course, achieving an accurate determination of the hair fiber being measured. Another problem is the possibility of transient variations of hair fiber diameter in the post-transplant setting induced by elements of the healing mode as is perhaps seen with hypertrophy near scarring. From the statistical point of view, there is the problem of determining whether the two samples are from the same or different populations. For example, an investigator may wish to know whether the hair growing in the transplanted area has a statistically significant different diameter than the donor hair from which it was extracted. This determination is done with the “ttest” analysis of the measurements of the two hair samples. If the t-test results are obscure, yet another problem is gaining an understanding of whether an error was introduced by the person doing the measurements. The following method considers these issues and is recommended to assess whether the means of the two samples of hair are from the same or different populations, that is, whether or not miniaturization and a difference in hair mass exist in the two populations: Volume 14, Number 2 1. A two-sample mean t-test (twotailed) is run (for example by using Excel) on the means and standard deviations of the two samples (which can also be calculated with Excel) to see if they are from different populations of hair. The sample size for each should be 30 or greater. The two samples do not need to be of the same size. 2. If t > 1.96 or < -1.96, then the two samples are from different populations and the difference in hair mass can then be calculated using the radius (mean/2) squared times 3.14. 3. If t < 1.96 or > -1.96 then the means cannot be said to represent different populations. An increase of sample size will make the standard deviation smaller and may clarify that the two samples are indeed from different populations when the t-test is repeated. Such manipulation of the data can be subject to criticism. 4. The error introduced by the tool or the tool’s use might also be evaluated at this time. This would be done by repeating the measurements and determining the standard deviation and mean of difference of measurement #1 from measurement #2 for each hair. If there is a large difference in the two readings, a second person might do the measurements to see if more reproducible values result. 5. To get an idea of the necessary sample size to increase the likelihood that t-test analysis will yield values noted in #2, one should determine the 95% confidence intervals of the two samples (also calculated using Excel) and then should increase the sample size of each group until there is no overlap of the confidence intervals of the two samples. If increasing sample size can result in no overlap of confidence intervals, there will almost certainly be a subsequent t value that reflects the presence of two different populations. 6. The investigator repeats the experiment using this larger sample size (i.e., number of hairs). If the t value is as described in #2, then hair mass is calculated using the means of the two samples. Conclusion Though individual measurements of hair may be unreliable and difficult to interpret with the micrometer, this instrument can be used to accurately compare different populations of hair. A two-sample mean t-test (two-tailed) can be utilized in the manner described to achieve this comparison. The magnitude of difference in the means of the samples being compared, the regularity and roundness of the fiber being measured, and the skill employed in using the micrometer determine the size of the sample needed. The difference in hair mass of the two populations can subsequently be determined. The assessment of the mean of the hair fiber of different populations of hair may prove of value in assessing components of surgical techniques and their impact on grafted hair growth. Such components include the dense packing of grafts, skinny vs. chubby grafts, follicular units obtained by follicular unit extraction and other aspects of the transplant process such as the use of copper peptide or selenium post-operatively. Regardless of the ultimate utility of hair diameter assessment, a statistically sound approach to the use of the hand-held micrometer in the assessment of hair fiber diameter has been needed. Addressing such a need is the intent of the above study and proposed methodology.✧ “The difference between the right word and almost the right word is the difference between lightning bug and lightning.” —Mark Twain 92 Volume 14, Number 2 Hair Transplant Forum International ❏ May/June 2004 Reducing the Female Forehead without Hair Transplantation Alexander L. Ramirez, MD, Sheldon S. Kabaker, MD Oakland, California The female hairline is variable in position. In the ideal situation, the hairline is 5 to 6.5cm above the brows and begins at the trichion, the point where the scalp slopes from a more horizontal to a more vertical position. At this location, the hair exits the scalp at an acute angle in relation to the ground and is directed caudally. This allows for versatility with hairstyling and the face can be split into vertical thirds, a characteristic of faces that are well-balanced and attractive.1 In contrast, there are a number of women who have hereditary high hairlines. These patients have a hairline that is usually stable after puberty and have normal density and volume behind it; however, these patients are often distressed about their situation. The appearance of a high hairline makes them look older than their years, the associated large forehead is less attractive, and their hair styling, often limited to combing downward for camouflage, is irritating.1 Occasionally, the hairline is so high (greater than 8cm from the brow) and posterior to the trichion that the hair will exit the scalp parallel to the ground or even at an obtuse angle to the ground. Hair does not fall effectively and the upper third of the face is so disproportionate that patients appear to have hair on only the posterior half of the scalp. These women with high hairlines will often present to the transplant surgeon requesting lowering of the hairline. Hair transplantation can be used to treat these patients. Follicular unit grafting is an effective treatment that has a low incidence of complications and is certainly the gold standard for hair work. However, this technique is labor intensive, time consuming, and can be expensive, especially because these patients would require multiple sessions to achieve the 2–4cm of hairline lowering required with adequate density. In addition, patients will protects the supratrochlear nerve and have to wait 2–4 years to see the full result after transplantation. For the past the superficial branch of the supraorbital nerve—nerves responsible for 20 years, the senior author has used an sensation in the forehead. Although alternative technique to address this patients may complain of some numbsituation without the use of grafts. It ness in their forehead after the proceproduces outstanding results rapidly, is dure, it is always temporary and resolves readily acceptable to patients, and has if the proper plane of dissection is little complications. maintained. After the scalp and foreOur preferred method for lowering head are mobilized, the scalp is adthe female hairline consists of an irregularly irregular trichophytic incision vanced anteriorly and the excess non-hair-bearing forehead skin is made within the fine hairs of the anterior hairline. Two points are critical excised with an incision that is parallel to the success of this incision. First, the to the trichyophytic incision. The wound is closed in two layers. incision should not be placed pretrichial (e.g., at the junction of the hair- The galeal is closed for strength and to approximate the wound edges. The skin bearing and non-hair-bearing skin). Future disguise of this incision depends closure concentrates on wound eversion. To ensure a good cosmetic result, on hair growing through the scar. To ensure this occurs, the incision is placed there should be no tension on the within the fine hairs of the hairline and wound. If necessary, serial galeotomies may be made on the scalp flap in a it is beveled perpendicular to the hair. This incision will then transect the hair direction parallel to the incision.1 This shafts but leave the bulb of the hair allows adequate advancement of the follicle intact within the superior hairline and wound closure without wound edge of the proximal flap. This tension. However, these must be done allows hair growth through the distal with great caution because the scalp’s 2 flap virtually concealing the incision. blood supply lies immediately superficial to the galeal and may be comproSecond, this incision should not be mised. A light dressing is placed and linear and it should not be in any removed on the first post-operative day. predictable pattern. It may match the A cosmetic result is appreciated immeexisting irregular hairline but must be diately because the hair may be combed irregularly irregular to avoid attention by the discriminating eye. The incision downward and there is minimal creates a similar transition zone seen in bruising and edema. Sutures are removed in 7 to 10 days (Figure 1). the hairline created by follicular unit grafting. It appears natural and undetectable. After the incision, the scalp and Pre-operative 9 months post surgery forehead are undermined in Figure 1. Hairline lowering alone the subgaleal plane, freeing attachments to the There are two variations with this periosteum, to allow advancement. This procedure that have proved useful. First, dissection is rapid and bloodless. In the if the hairline needs to be advanced a forehead, dissection in this plane continued on page 94 93 Hair Transplant Forum International ❏ May/June 2004 Female Forehead continued from page 93 large distance or if the scalp is tight, a tissue expander may be required. This is done as a staged procedure, with placement of the expander as the first stage and advancement of the hairline as the second stage. Typically, the balloon is expanded over a 6-week period (e.g., 75– 100cc per week) to stretch the scalp sufficiently to allow for 4–6cm of advancement (Figure 2). This is well tolerated by patients aside from the Figure 2. Hairline lowering using scalp expander cosmetic inconvenience during the last three weeks of the expansion and the only complication over a 10-year period has been the occasional case of temporary hairloss, called telogen effluvium. The second variation of this procedure is to combine the hairline adPre-operative Figure 3. Hairline lowering alone 94 2 days post surgery vancement with a browlift. This is particularly useful for older patients who have had inferior descent of the brows with aging. These patients complain of a heavy or tired appearance in combination with their large foreheads. As a result, at the same time the forehead is advanced, the brows can be raised to a more youthful position. This adds minimal time to the procedure and the recovery is the same (Figure 3). The most important disadvantage to this technique for hairline advancement is the possibility of a noticeable or unsightly scar. The two mentioned technical points are critical in avoiding this complication. The trichophytic hairline incision must be non-linear; it is an irregular non-repeating pattern that by itself makes the scar less noticeable. And, it is critical to bevel the incision perpendicular to the direction of the hair as described. This allows the hair growth through the scar to further enhance its disguise. As the 9 months post surgery hair grows and the wound matures, the incision will become virtually nonexistent.4 Aside from the temporary forehead Volume 14, Number 2 numbness previously described, patients tolerate this procedure very well. Other complications have been extremely rare. Female patients with high hairlines have treatment options available. Although hair transplantation with follicular unit grafts is an option, we recommend an alternative technique. This technique has been used by the senior author for over 20 years and has proved to be almost immediately effective, well tolerated by patients, and associated with minimal complications. Although it is associated with an incision, the presented techniques can be used to make the scar virtually invisible, making patient satisfaction extremely high. ✧ REFERENCES 1. Marten T. Hairline Lowering during foreheadplasty. Plastic and Reconstructive Surgery. January 1999. Vol. 103(1):224–236. 2. Camirand A, Doucet J. A comparison between parallel hairline incisions and perpendicular incision when performing a face-lift. Plastic and Reconstructive Surgery. January 1997. Vol. 99(1):10–15. 3. Knize D. Limited incision foreheadplasty. Plastic and Reconstructive Surgery. January 1999. Vol. 103(1):271–287. 4. Camirand A. Why I no longer use short incisions in facial rejuvenation. Aesthetic Surgery Journal. January/ February 2001. Vol. 21(1):65–67. Volume 14, Number 2 Hair Transplant Forum International ❏ May/June 2004 A Method for Removing Scabs in the Postoperative Stage in Hair Restoration Surgery Nicolas A. Lusicic, MD; Alejandra Susacasa, MD; Sebastián Abalo Araujo, MD Buenos Aires Argentina Introduction In the post-grafting period, three aesthetic problems limit our patients’ reintegration into society and their workplace, which sometimes causes them to put off the decision to undergo surgery: 1. Possibility of frontal swelling 2. Likelihood of anagen effluvium 3. In all cases, the presence of scabs. Objective Therefore, our objective is to speed up scab detachment by applying an oily solution. Photo 1. Patient from Control Group I 7 days after surgery; note many scabs still present. Photo 2. Patient in “special oil solution” treatment Experimental Group II. same fashion until all scabs had been removed. After being washed, the recipient area was dampened with gauze soaked in the solution so that it would work for 12 hours. As of the fourth day, check–ups were carried out every 48 hours until scabs had become detached. Photos were taken before and after treatment. In each group the following items were analyzed: degrees of baldness, age, number of grafts, sex, and personal medical history. It can be seen that in the placebo group most of the patients were Norwood 5 and in the experimental group the distribution was more homogeneous. The average age in Control Group I was 43 and in Experimental Group II, 42. There was a range between 27–67 for Group I and 27–54 for Group II. The number of grafts transplanted averaged 1,018 for Control Group I and 1,050 for the oil solution group. treatment with our new solution (Photos 1 and 2). Concerning the statistics, 77% of the patients in the control group still had scabs on the seventh day versus 20% in the solution group. Thus, there was a significant difference after using the square chi test. It can be seen that we succeeded in lowering the number of scabs by 57% by the seventh post-operative day. There is, however, a slight chance of scabs persisting when using the solution, by analyzing relative risk. No complications resulting from the use of the solution were observed in the sample analyzed. Only one patient presented slight erythema in the area treated with the solution The prevalence of scabs on the seventh day was reduced by 57.14%. Only 20% of the patients treated with the solution still presented scabs, although less than 25% of the grafted area was affected. The solution has proved to be very effective in speeding up scab detachment, thus allowing the patient’s rapid reintegration into society and work and, as a result of this, a higher number of patients deciding on surgery.✧ Methods and Materials The first step was to analyze scab composition, and we found out that among its components there were hydrophilic and lipophilic substances. We know there is a chemical principle stating that both lipophilic and hydrophilic substances attract or drag substances bearing their same features. Following this principle, we came up with a solution based on substances bearing both properties, but using a mordant substance so that they will be miscible. The components of this substance are Liquid Vaseline 80, Marigold oil, and Polysorbate 80. For this purpose we designed a cohort, randomized, prospective, open trial, comprising 45 patients. Two groups were formed: Group I Control, which consisted of 35 patients, was included and their results were analyzed as the study proceeded. This group received the usual standard care. Experimental Group II with 10 patients was also studied and analyzed with the standard care plus our new special solution to help remove scabs sooner. Experimental Group II The solution was first applied twice on the fourth day and used daily in the Results It can be seen that there is a difference in the amount of scabs on a patient on the fourth post-operating day and the seventh day after 3 days of 95 Hair Transplant Forum International ❏ May/June 2004 Beehner Message continued from page 83 transplant. You will discredit your past fine work in the eyes of the prospective patients coming to you in consultation. Then there’s the patient who comes for his first surgery and, out of an extreme sense of privacy, tells you that he will not allow any photos to be taken. First of all, I refuse to transplant such a patient, as I then have no legal documented record of what the patient looked like before surgery. In truth, I have never had to turn someone away on this account because, after I explain the above to them, I can almost always get them to agree to have “eyebrows and up” photos taken, which they usually allow me to show to others. I add a little humor to the situation by appealing to their wish for a great transplant result by telling them: “You should want me to do such a great job that I’d want to show your photos to someone.” Miscellaneous Notes The fourth edition of Hair Transplantation, edited by Walter Unger and Ron Shapiro, is now available. We urge every hair surgeon, experienced and novice alike, to purchase and read this text, as it is the first major text in more than seven years and will be the standard in our field for some years to come. Volume 14, Number 2 I was impressed that 11 men and women sat for the ABHRS exams in Orlando this past March. Even more impressive was the unselfish giving of time and talent by some of our Board’s Exam Committee members in helping administer the exam. Fourteen diplomates were needed to properly administer the exam, and, although the majority of them were already in Orlando attending the workshop, I have to tip my hat in special thanks to Drs. Walter Unger, Tom Rosanelli, Mike Elliott, and Dan DiDocha, all of whom got on a plane and came all the way to Orlando just to help us out.✧ Michael Beehner, MD Parsley Message continued from page 83 he was found to have only modest loss (early NW 3 at worst). Dr. Mario Marzola, the moderator, astutely picked up on this emotional difference and emphasized how very different the approach must be between a young and a mature patient presenting at one’s office. The self-esteem of a young patient and his hair loss are nearly inseparable, and the doctor’s judgment and compassion are called to task in a demanding way. Stick-and-Place Stick-and-place techniques started sometime around 1988, with Drs. Carlos Uebel and Bobby Limmer independently developing their own respective techniques—Dr. Uebel with a #15 scalpel blade and Dr. Limmer with hypodermic needles. Now it seems that more and more of the top surgeons are adding some stick-and-place (S&P) to their hair transplant regimen. Drs. Limmer, Seager, Sandoval, and others have been performing individual S&P follicular unit grafting (FUG) for 8–16 years. Most of the newer surgeons are using a 2-person S&P for FUG and for double follicular units (DFUs). Among these are Drs. Ron Shapiro and Arthur Tykocinski. Dr. Jerzy Kolasinski has been using a similar technique with mini-grafts. Some are even making the 96 sites first, then planting with a “buddy team,” one assistant opening the site and blotting while the other assistant plants the grafts. While watching their techniques, one is impressed with their gentleness in handling the grafts, and the results are impressive. I expect to see more surgeons utilizing this technique for at least part of their procedure over the next few years. One of the most interesting lectures came from Dr. Arturo Sandoval. He discussed a “shingling zone” on the frontal hairline. This is the zone where the scalp transitions from vertical to horizontal, much like the vertex transition zone more posterior. This can be found by pushing the fingers against the forehead in a posterior direction and running them vertically; the point at which the fingers actually start sliding posteriorly is the shingling zone. Grafts placed anterior to this zone will tend to have a sparse look for the same reasons that it is difficult to create cosmetic density over the lower vertex; that is, the more perpendicular the line of sight to the skin the more the hair appears to be sparse. It is an interesting concept and certainly has merit. August Vancouver Meeting It seems like the New York ISHRS meeting just ended, but the ISHRS Annual Meeting in Vancouver is coming up soon. This year’s meeting is August 11–15, a departure from the customary October date; so it is urgent that you make plans now if you haven’t done so already. Dr. Ed Epstein is the Program Chairman and has been working very hard to ensure that the meeting reaches an educational level that surpasses anything we have had previously. Vancouver is one of the most beautiful cities in the world, and there are wonderful destinations a short drive or ferry boat away. Victoria, on Vancouver Island, is accessed by a quick ferry boat ride, and nearby Butchart Gardens is a “don’t miss” location. Whistler Ski Resort is less than a 2-hour drive away. It is located in the middle of snow-capped mountains and has great hiking and sight seeing. After the meeting, consider the Alaskan cruise, during which one can become better acquainted with other members of our field while navigating through one of nature’s masterpieces—the Inland Passage. Learning doesn’t get any more sugar-coated than this. And take some of your assistants with you. Don’t they deserve it?✧ William M. Parsley, MD Volume 14, Number 2 Hair Transplant Forum International ❏ May/June 2004 FUE Megasessions—Evolution of a Technique Robert M. Bernstein, MD New York, New York; William R. Rassman, MD Los Angeles, California; Kenneth W. Anderson, MD Los Angeles, California The ability to complete the hair restoration process in just a few sessions had long been an elusive goal for patients seeing treatment for their hair loss. This goal was eventually achieved with extensive micrografting1 and then with the more refined technique of Follicular Unit Transplantation.2 The natural evolution is to be able to accomplish this task with Follicular Unit Extraction.3 This time has arrived! The purpose of this writing is to identify the special organizational and technical skills required for FUE Megasessions, describe its advantage over other FUE techniques, and to discuss some of the long-term implications of FUE, particularly with respect to the effects of FUE on the donor scalp. The Fox Test In spite of significant improvements in techniques over the past several years, we still believe that each patient is different enough, with respect to the ease of extraction, that testing prior to the actual FUE procedure is warranted. This may not be necessary when treating triangular alopecia, restoring eyebrows, adding hair to donor scars, or in other cases where there is a limited demand for hair. However, in situations where the longterm demand for hair is large, performing a Fox Test is important for long-term planning. We particularly stress “longterm” for this information is probably more important in treating early recession in a person in their late 20s, than it is for the Norwood Class 6 patient in his late 50s. In the latter case, if extraction proves to be difficult, (i.e., the grafts shred or fragment on extraction), the yield may be lower than expected or the procedure may take longer than anticipated. In the worse case, a strip incision can be used to achieve the desired number of follicular units. However, in the younger person who plans on wearing his hair very short on the sides, having to abort FUE is a disaster, since this patient may have opted out of the hair restoration process altogether if he had known in advance he were a poor candidate for the procedure. To make matters more complicated, Fox Testing (Follicular Unit Extraction) is not black and white. It varies from patient to patient and can decrease in the same patient over time (as the same areas are accessed more than once). We use a subjective scale of 1 to 5 for the assessment, assigning a score of 1 (now accounting for over 90% of patients) when intact follicular units literally pop out of the scalp or when there is only occasional transection of individual hairs in the unit. For Fox grade 2 patients, extraction may be relatively easy in the first session, but in subsequent procedures (when the donor area is slightly scarred) it becomes more problematic and the yield starts to decline. In these patients, the long-term yield can be compromised and planning extremely difficult. With Fox grade 3–5 patients, where large numbers of grafts are needed, the yield is too low for the FUE procedure to be successful. Here the decision not to use FUE is straightforward. Unfortunately, the physician cannot make this decision without prior knowledge of the Fox results. As a consequence, the patient may have inadvertently been started on a course of treatment that cannot be completed. Factors in Transitioning from 500–600 Graft Cases into FUE Megasessions For this discussion, we arbitrarily define an FUE Megasession as a single session of 1,500 or more FU grafts, cognizant of the fact that traditional transplant sessions were first called “megasessions” when they exceeded 1,000 grafts. The bar, of course was soon raised to 1,500 and then 2,000 grafts as skills improved, with sessions greater than 2,500 now being routine in some clinics. The key to successful FUE Mega- sessions is the economy of movement during the extraction process. At the “micro” level, this demands: ➥ Excellent lighting. ➥ Adequate magnification for the surgeon and staff. ➥ Determining the angle of the hair below the surface of the skin. In almost all instances, the angle of the emergent hair is more acute than the angle of follicle in the dermis. The incision must obviously anticipate this and be oriented in the direction of the follicle rather than the visible hair. ➥ Using a single, short twisting motion of the punch (<180°) with the hand perfectly stable. We find that clockwise rotation (for the right-handed person) generally provides more stability than twisting in the other direction. A back-and-forth motion causes unnecessary transection and is incompatible with successful FUE, as is a 360° rotation of the punch. In some cases of Fox grade 1 cases, direct pressure alone (without any twisting) may be sufficient to extract the grafts. ➥ Sharp punches. These are critical to minimize the amount of twisting needed to cut into the dermis. In addition, they allow the surgeon to feel the “release” as the punch progresses from tougher dermis into the subcutaneous tissue. ➥ Punch size of 0.9–1.0mm in diameter. This size is large enough to encompass the width of the follicular unit, yet small enough to minimize wound size and scarring. At the team organization level, this entails: ➥ Batching the incision (and dissection when necessary) phase of the procedure and separating it from the actual extraction phase. This is a critical aspect in the organization of the procedure. Batching greatly speeds up the process, but doesn’t continued on page 98 97 Hair Transplant Forum International ❏ May/June 2004 FUE Megasessions continued from page 97 provide immediate feedback to the surgeon with respect to transection. ➥ It is important, particularly at the beginning of the session, to examine every graft as it is incised and extracted so that adjustments can me made with respect to angling the punch. This is also important as new areas of the scalp are accessed. It is important to note that hair does not always exit from the donor scalp in exactly the same direction, even with adjacent follicular units. The need for constant adjustment of the hair angle is critical to an efficient extraction. ➥ In cases where the angle is consistent and easy to determine, a surgeon can easily batch up to 50, or more, grafts at time. However, in more difficult cases, or in more difficult areas of the scalp, checking for transection should be done every few grafts throughout the duration of the procedure. This must also be done if the grafts have any tendency to fall into the fat. These grafts can be extruded by putting pressure on the surrounding skin, or by using jeweler’s forceps to pull them out, and prevented by making the initial incision more superficial. With batching, however, there is no way to keep track of the grafts that may have inadvertently entered the subcutaneous space. The continuous checking for transection (necessary in all cases that are not Fox 1) and for grafts that may have Volume 14, Number 2 slipped into the fat, greatly decreases the efficiency of the procedure and increases the operating time. ➥ Positioning the holding solution close to the area being operated on so that the extracted grafts can be immediately placed into the solution after extraction. This will minimize excess movements and also avoid desiccation of grafts. ➥ Working with two parallel teams, if practical, for both harvesting and placing. ➥ Shaving the back and sides of the scalp to 1mm will provide access to the largest surface to harvesting the grafts. For smaller FUE sessions, clipping horizontal strips of hair allows for an undetectable donor area, but it is impractical for large FUE sessions. Case Studies Patient 1. The patient is a 35-yearold male. His goal was to attempt to complete the restoration in a single session and he was absolutely determined not to have it done with strip harvesting. He had average hair weight with good body and white in color. His donor density was 2 hairs/mm2 and his Fox Test was classified as 1. This case is important for a number of technical reasons. The almost clear white hair is very difficult to see, so we dyed his hair black the morning of the surgery. The FOX procedure is very intense so we made sure that there were no interruptions for the day to disturb our concentration. The staff consisted of one surgeon (KWA) and three medical assistants. The procedure took 12 hours to extract and plant 1,901 follicular unit grafts. The grafts were trimmed of excess skin and hair counts were performed. The grafts were sorted in Petri-dishes of cold Ringer’s solution and refrigerated at 36°F. All of the grafts were removed by the doctor with 91.5% yield of intact units. (Photos 1–3.) Patient 2. This patient had two FUE procedures 1 and 2 years earlier totaling 1,195 grafts. The FUE procedures left small pinhole scars that were hard to see with the hair at a normal length (photo 4). As the hair was clipped very short or shaved (photos 4 and 5), the scars were visible. Obviously these scars will impact future extraction. In our fairly extensive experience, the scarring shown here is typical for the FUE procedure. Photo 1. Donor area for 1901 grafts one day post-op Photo 2. Frontal recipient area of approximately 1,000 FUs Photo 3. Crown recipient area of approximately 901 FUs Photo 4. View of FUE donor site one year after surgery (~1,600 grafts in two sessions) Photo 5. Hair clipped view of FUE donor site one year after surgery (~1,600 grafts in two sessions) Photo 6. Head shaved view of FUE donor site one year after surgery (~1,600 grafts in two sessions) 98 Volume 14, Number 2 Other issues: ➥ Microscopic evaluation and, when needed, trimming the grafts of excess tissue. This is particularly important at the frontal hairline to ensure that the follicular units used in this location are only single-hair grafts. ➥ Sorting and recording the follicular unit grafts by the numbers of hairs they contain. This is important so that there will be enough grafts to create a frontal hairline or other areas that require single-hair grafts. There is a tendency to remove only the largest units, resulting in too few 1hair follicular unit grafts. By giving the physician feedback, smaller units can be extracted to fill this need. ➥ Tumescence is critical, but it is most effective when injected superficially into the dermis. Normal saline should be injected into the dermal layer in small areas at a time, as the saline diffuses away quickly and the turgid effect is rapidly lost. Tumescence into the subcutaneous space offers little benefit. Advantages of Performing an FUE Megasession Over Staged FUE Sessions Various schedules for performing FUE have been devised. These include daily, weekly, and monthly sessions. Daily sessions have the advantage of using post-op edema as a form of built-in tumescence, and aggregating the sessions for patients that travel a distance for the procedure. Weekly sessions have an advantage over monthly sessions in that the latter makes identification of recipient grafts difficult. However, FUE Megasessions have advantages over both. The single session avoids the post-op crusting (and associated bacterial buildup) from daily sessions that can alter the visual field and it allows for easiest placement of recipient grafts, since all the follicular units are “at hand” when making judgments as to the density and distribution of grafts. In addition, anesthesia does not have to be placed into an edematous recipient area filled with 1-day-old grafts that are tenuously anchored, nor do additional sites have to be made. Most importantly, the patient does not have to suffer the Hair Transplant Forum International inconvenience of daily trips to the operating room. In the future, is it hoped that extraction and implantation can be carried out simultaneously, significantly decreasing the duration of the procedure. Donor Scarring ❏ May/June 2004 same area for additional grafts in future sessions is not eliminated. The difficulty in extracting intact follicular unit grafts from previously harvested areas may result in decreased overall yield, making subsequent FUE sessions less productive than the first and significantly less robust than traditional strip excision for FUT. This limitation must be discussed with patients and be considered before the first follicular unit extraction session is undertaken.✧ Because the main advantage of FUE is the elimination of a linear donor incision, it is ironic that donor scarring is the major limitation to successful FUE. Although the individual scars of FUE are small, the cumulative scarring from REFERENCES hundreds to thousands of open wounds, 1. Rassman WR, Carson S. Micrografting left to heal by secondary intention, is in extensive quantities; the ideal hair significantly greater than from a linear restoration procedure. Dermatol Surg incision. The small white donor scars 1995; 21:306–311. may not be visible through normal 2. Bernstein RM, Rassman WR, length hair, but it is disingenuous to Szaniawski W, Halperin A. Follicular represent that scaring doesn’t exist. The transplantation. Intl J Aesthetic fine white scarring can be seen if the Restorative Surgery 1995; 3:119–32. scalp is clipped or shaved, a style that is 3. Rassman WR, Bernstein RM, increasingly common today. McClellan R, Jones R, et al. Follicular The major consequence of this unit extraction: Minimally invasive scarring is the decreased yield in future surgery for hair transplantation. FUE sessions. Successful FUE depends Dermatol Surg 2002; 28(8):720–7. upon tactile as well as visual cues, and scarring in the donor area significantly diminishes the sensitivity of the former. The scars in a previously harvested donor area make it significantly more difficult to extract intact follicular units without transection. The scarring process alters the angle State-of-the-art of the follicles, as well as instrumentation for hair the feel of the dermis. This can be appreciated restoration surgery! both in the vicinity of a linear scar, as well as in For more information, contact: the area of previously extracted grafts. Just as traditional 21 Cook Avenue megasessions were an Madison, New Jersey 07940 USA improvement over small Phone: 800-218-9082 • 973-593-9222 hair transplant sessions, FUE Megasessions offer Fax: 973-593-9277 many advantages over E-Mail: [email protected] small FUE sessions. However, even with www.ellisinstruments.com FUE Megasessions, the need to go back to the 99 Hair Transplant Forum International ❏ May/June 2004 Volume 14, Number 2 The Dissector Disse e ctor An article by anonymous Scene: Deathbed setting with follicle/hair named Fred, as he passes from this world, nearing the end of his final hair-cycle. Follicle neighbors of Fred’s, and even some from the “old neighborhood,” gather around him to comfort him in his last hours. Follicle A: Fred, you’ve had a full life. You’ve traveled. You’ve experienced things most hairs and follicles never see in a lifetime. You’ve done it all. Fred: Yeah, it’s been quite a journey. I started out 60 years ago on the back of Bainbridge Fudrugger’s head. When I was young, I thought I could look forward to a nice quiet and peaceful life in the shade down there on Bainbridge’s lower back scalp. But wouldn’t you know it, one day I stood up as high as I could and peered over the top of my fellow hairs and I could see he was losing all of the hairs on top of his noggin. Follicle B: Were you scared, Fred? Fred: I sure was! I thought whatever did them in was heading down in my direction and soon I’d be a goner too. But it never came that far down. The clearing out of hairs stopped just a little above where I was rooted in. Follicle A: What I don’t understand, Fred, is, if you started out on the back of Fudrugger’s head, how did you ever get up there to the front where you are now? Fred: Well, it’s a long story. I could tell early on that ole Fudrugger didn’t like the situation. It seemed every other month some new and different toxic chemical or zapping beams from all kinds of hair dryers and magic wands would rain down upon us. I would have headaches for weeks on end! Then one day I knew things would never be the same. I suspected we were in a doctor’s office, and, sure enough, I look up and see this huge, noisy, hollowed-out circular drill bit coming right at me. I started spinning wildly and, by the time I knew what hit me, I was up here on the front of Bainbridge’s head where I am now. I heard through the grapevine that the casualties were high that day, so maybe 100 I should be grateful I was one of the few survivors. Anyway, I was squished in tightly with 20 other follicles. When I looked out from my new home, I could see these rather weak hairs on all sides, and, a little past them, I could see other groups just like us. Well, this situation stayed the same for several years and then I could see the nearby weak hairs disappearing gradually, ‘til eventually there was only bare scalp between our cluster and the ones around us. I then began to notice that other people were staring at Fudrugger’s head and, occasionally, I could hear them laugh as they pointed to the top of his head. I could tell once again that ole Fudrugger wasn’t happy with his hair situation and seemed ashamed of us remaining hairs. We then entered what I call the “era of the RUG.” One day this huge, thick layer of fake hair was dropped down on top of us. We went weeks at a time without seeing any daylight. Then one day, after a couple of years, Bainbridge was standing at a bus stop and the wind was blowing like a gale. Suddenly the rug goes flying right off his head and catches on to the back tire of a bus that was going by. I’ll never forget the sight of ole Fudrugger running down the street after this bus, with his hair rug flipfloppin’ on the bus tire through the dirty street. We never again saw the rug or another one like it. One morning, a couple of months after Bainbridge lost his “piece,” we got sprayed with this can of black goop that he ordered after seeing a TV infomercial. Think black dirty stuff! Ugh! But then, after doing this routine every day for a couple of months, he stopped using it, probably because people were still staring and snickering. Then we entered another version of the “dark ages.” Every morning when the sun came out, Bainbridge would go into the bathroom, pull out his comb, and suddenly we couldn’t see a thing. These really long hairs from way over on the side of his head were pulled over our position and it would be dark all day. Ruined our view! Except for when the wind was really blowing. Then we could see a little daylight for a few moments until he pulled the hairs back over us. And, of course, the staring continued. A few months into the “comb-over” phase, one particular day I could tell we were once again in the doctor’s office. I could smell ethyl alcohol and looked out and noticed some 3-year-old magazines. A little while later, there were all kinds of crunching sounds around us and blood splattering. When it was over, I could see that some small groups of follicles with stubby hairs were planted all around us. I remember thinking: ‘There goes the neighborhood!’ But I must admit that life got better after that. Bainbridge no longer pulled that God-awful hair over our heads and all the silly sprays disappeared from the scene also. It was around this same time that I became aware that both Bainbridge and I were getting older. Over a period of several years, I lost all my color. You could see right through me! Then I started to shrink in height every few years and get thinner, ‘til I became the wispy, pale hair and follicle you see before you now. I tell you—I am not long for this world! Follicle B: Any advice to pass on to future generations of hairs and follicles, Fred? Fred: Yeah. Tell ‘em that, if they end up on the back of some guy’s head who’s unlucky enough to lose his hair, that they should hope their guy is someone who’s not as vain or nutsy as my Fudrugger was. (At that very moment a giant comb came through Bainbridge Fudrugger’s scalp and Fred was carried off, never to be seen or heard from again.)✧ Volume 14, Number 2 Editor: Jennifer H. Martinick, MBBS Perth, Western Australia Hair Transplant Forum International ❏ May/June 2004 CYBERSPACE CHAT… Please send your comments/questions to: [email protected] Marc Pomerantz MD, Hinsdale, Illinois, poses the following question: A 35-year-old man with early slight thinning in a minimal Norwood 5A pattern has a low hairline that he very much wishes to retain. He is starting Propecia®, but wants grafts as well. Do you accede to his wishes, or insist on a higher hairline, knowing that he can always find another surgeon who will be willing to reinforce his low hairline? Please e-mail your thoughts and experiences to the above address. AVOIDING DONOR SCARRING Bradley Limmer, MD San Antonio, Texas I keep the donor strip width at 1–1.2 centimeters in width. If the scalp is tight, especially over the mastoid area, I decrease the width. I never want to undermine, as it seems to increase the chances of a wide scar. Secondly, I can harvest about 15 square centimeters of donor scalp without crossing the posterior mid-line of the scalp. This leaves half of the donor area in a virgin state for the second procedure. It also typically allows you to do a series of four transplants without going to the same area more than twice. This helps to minimize the risk of tension and wide scarring. If I do go back to the same area, I prefer to locate the old scar in the midportion of the planned donor. I have found this approach helps to remove not only the visible scar, but also the wide underlying band of scar tissue within the subcutaneous fat. If this underlying scar is not removed, it keeps the scalp bound down causing a tight closure. In a small retrospective study of 20 consecutive follow-up patients, their average scar width was found to be 0.9mm. We are in the planning stages of a much larger study to evaluate donor scar outcomes. William Rassman, MD Los Angeles, California Mario Marzola, MBBS Adelaide, South Australia A few points regarding scar formation: 1. The patient’s own healing ability has much to do with the end result. Once we adhere to all surgical principles and if a scar forms, there may be nothing that we could have done. Most of the patients we have seen with scars, had a great deal of laxity, and no suture tension postop. I estimate 15% of patients will develop a scar greater than 3mm from any incision in the donor area. 2. Location of the excision area is important. Too high or too low both have a very high incidence of widened scars. 3. Type of Suture: Dr. Bernstein and I use 5/0 Monocryl and let it dissolve by itself. 4. Keep the sutures very close to the wound edge (1mm) and do not strangle the skin between the sutures. One absolute indicator of bad scarring is tension on closure. I avoid any situation that will produce a tight closure. My donor strips are long and rarely wider than 7mm. The second indicator of bad scarring is taking subsequent donor strips in the same site as the first one and excising the previous scar. Because each scar is in a new area, it heals well under no tension, so it doesn’t matter how many scars there are. James Vogel, MD Baltimore, Maryland Scars are white in Caucasians and when juxtaposed with white skin in the elderly, there is less contrast and they look very good. Also, collagen is depleted in older patients and they will develop a weaker collagen rebuilding response, thus a weaker and less intense scar. As there is less collagen, there is less visco-elastic pull on the wound edges, which will contribute to an improved scar. Michael Beehner, MD Saratoga Springs, New York Before donor harvest, I take a close look at the quality and density of the hair in the occipital area, noting the inferior and superior limits of this good dense hair. I then make a mark onethird of the way up from the bottom point of dense hair. This point becomes the inferior border of my strip I will harvest, and I then excise a strip (or two strips totaling) approximately 0.8–1.0 centimeters wide. In subsequent sessions, I take my strips superior to that scar, with the inferior border of my next strip dancing in and out of the old scar. I don’t make a conscious effort to excise the old scar. To avoid a wide donor scar at the “corners,” where the occipital scalp turns towards the parietal area, I start continued on page 102 101 Hair Transplant Forum International ❏ May/June 2004 Cyberspace Chat continued from page 101 grafts have a real advantage and cases where paired FUs have an advantage. I use DFUs if closely associated— particularly in people with fine light hair and those with say 40% single-hair follicular units. back in the mid-occiput developing a slight curve to my strip incision. Lastly, I will often delay my closure of the donor area by half-an-hour to allow the dissipation of the 40 to 50ccs of tumescent saline first, giving me a better idea of how tight the closure will be, and this makes undermining an extremely rare occurrence. I stay committed to having only one scar. I don’t like the cumulative look of thinness that serial scars, stacked above one another, can create. As long as there is an interim of 8 to 10 months between sessions, I find that the laxity of the donor scalp returns to 90% of what it was before the previous procedure. Wonderful results can be achieved by follicular unit transplantation, but it is difficult to organize a first-class team to achieve these results. It’s not just a matter of having a new tool; we must know how to use it wisely, and careful patient selection is paramount. There are no simple answers—keep an open mind on all techniques, even if you do not wish to use them yourself. In expert hands these techniques can be surprisingly effective. Paul Rose, MD Tampa, Florida Michael Beehner, MD Saratoga Springs, New York Scars in females seem to be less noticeable. Could there be less of a fibroblast response in women? Laxity in elderly skin provides a recipe for excellent wound healing. Over the past five years, I have seen quite a few patients in consultation who were transplanted exclusively with FUs, all of whom were hoping for more density than was achieved. My gut tells me that from a density standpoint, small slit and round minigrafts will contribute more visible density than individual FUs. Why? First, to make small holes over 2 to 3 sessions that are as close together as three follicles in a triple follicular unit requires very precise angulation, and the chances of the “legs” of an existing FU being cut off as the new recipient sites are made, I think would be greater as you go back a second or third time. Secondly, I am convinced that a higher percentage of the hairs transplanted in multi-FU grafts survive, probably because of the buffering protection afforded to each hair in the larger graft, with the collective connective dermal and subcutaneous tissue protecting the hair follicles from trauma and desiccation better than is possible in a slender FU. Eric Eisenberg, MD Mississauga, Ontario, Canada I do not excise the previous scar at the next surgery when there is a tendency to wider than expected scars in the donor area. Very fine serial scars are cosmetically acceptable to both surgeon and patient since they’re only detectable on close inspection. SUPPORT FOR MULTI-UNIT GRAFTING Water Unger, MD Toronto, Ontario, Canada DFUs (double follicular units) and TFUs (triple follicular units) are by definition slit grafts prepared with stereoscopic magnification to produce slivers, which in turn, contain intact follicular units. William Parsley, MD Louisville, Kentucky Like all the techniques we use, how you use them, when you use them, and where you use them is all-important. There are occasions when multi-unit 102 Richard Shiell, MBBS Melbourne, Australia Vance Elliott, MD Sherwood Park, Alberta, Canada The promotion of FUT as the “gold standard” in various marketing approaches may have had a negative effect. It has taken the focus off the skill of the doctor. There are technical parameters, Volume 14, Number 2 but the skill, style and approach of each surgeon will also exert a big effect. I think the role of skilled hands and judgment has been under-represented. The goal of hair transplantation is naturalness and coverage. There are situations where FUT will be more natural, but only on very close inspection. Good results by any method are not easy, otherwise we would never see poor results any more. FUT works, of that there is no doubt. However, it is a tool that has its strengths and weaknesses like all others. Other surgical approaches work too. A PLACE FOR FUE? Bradley Wolf, MD Cincinnati, Ohio I’ve used FUE in the following situations: 1. Moustache for 100 grafts. The patient in question had prior surgery and wanted a touch-up. 2. Female, after brow lift and facelift, with tight scalp and scarring behind the ears. 3. Marine who shaved his head. Two sessions of 500 grafts done in a Class III with temporal recessions. 4. Temporal triangular alopecia—150 grafts. 5. “Unplugging” hairlines. It is very useful in selected cases, but not for those who want more than 1,000 follicles moved at a time. It is not easy. It takes intense concentration, which can be draining for the doctor. Paul Rose, MD Tampa, Florida In certain circumstances, a patient might receive fewer 3- and 4-hair grafts due to possible transection in harvesting. There is also the question of overmanipulation if one has difficulty removing the graft from the donor area. One can become extremely good at harvesting these grafts, but the outcome will depend on the patient’s hair characteristics and donor area tissue. Patients that seek out this procedure are a niche population. There is more time involved, a significant portion of the scalp may need to be shaved, and Volume 14, Number 2 Hair Transplant Forum International sessions are smaller and significantly more expensive than strip harvesting. William Rassman, MD Los Angeles, California There are far more problems with FUE than people know about. The FOX test, which I discussed in our original article, still has a place. There is a great deal of misinformation, even within the groups that offer it. I ask: Can we be so blind? William Parsley, MD Louisville, Kentucky FUE looks like a useful, but infrequently needed, tool. Very few of my Editor Emeritus continued from page 84 yearning to take on 3 years in a timeconsuming, unpaid position, where you will get little thanks and much more criticism than praise, then here is your big chance. You probably should have at least 10 years’ experience in hair trans- patients would let me shave the back of their head. Good grafts can be obtained and I’m sure that they grow well. PHILOSOPHY OF HAIR RESTORATION SURGERY Jennifer Martinick, MBBS Perth, Western Australia Medicine and business make for uneasy bed mates, so a limited survey of ISHRS members was undertaken to understand better how we view ourselves in business and our doctorpatient relationship. What we found: ➤ Most doctors considered that the service we offer is non-essential. plantation and a willingness to put your personal life on “hold” for 3 years. You should also have a degree of familiarity with computers, some I.T. skills, and be reasonably competent in the English language in order to apply. Applicants please send your credentials to Victoria Ceh in triplicate or form a long line outside Bill’s office in Louisville. ❏ May/June 2004 ➤ The doctors considered that the public’s perception of HRS was equally divided between skeptical and unsure. ➤ Most doctors considered our industry a business. ➤ Success was defined unanimously as the quality of surgery (interestingly, not dollars earned or size of procedures). ➤ With regards to promoting ourselves, the vast majority considered we should raise our profile, but that it should be undertaken moderately.✧ Joking aside, and despite the long hours and no pay, the Forum Editorship is one of the most challenging and satisfying jobs in the entire field of hair transplantation. Our six past Editors all declare the Editorship to have been one of the highlights of their professional lives.✧ Richard Shiell, MBBS Toppik Makes Thinning Hair Look Full and Natural in 30 Seconds Toppik fibers are pure keratin, colored to match the 8 most common hair colors (black, dark brown, medium brown, light brown, auburn, blonde, gray & white). You simply hold the Toppik container over the thinning area and shake it in. In seconds, the fibers combine with the patient’s remaining hairs to give the undetectable appearance of a fuller head of hair. Toppik resists wind, rain and perspiration. It is totally compatible with all topical treatments for hair loss. And Toppik is ideal in conjunction with hair transplant surgery, as it effectively conceals any post-operative thinning. For a free tester kit containing all 8 colors, call, fax or email: Spencer Forrest, Inc. 64 Post Road West Westport, CT 06880 Before Toppik After Toppik Phone: 888-221-7171, ext. 10 • Fax: 203-226-2369 • Email: [email protected] • www.toppik.com 103 Hair Transplant Forum International ❏ May/June 2004 Volume 14, Number 2 Surgeon of the Month alute to Vance Elliott, MD Jerry E. Cooley, MD Charlotte, North Carolina USA Readers of the Forum and regular attendees at the ISHRS Annual Meeting will already be familiar with our Surgeon of the Month. Vance Elliott, MD, is the editor of the Hair Repair section of the Forum and has served on several committees of the ISHRS, where his enthusiasm and dedication to our specialty have been apparent to all. Vance was born and raised in the booming metropolis of Maidstone, Saskatchewan (pop. 1,000), where, as he recalls, he played a lot of hockey. He attended Concordia College in Edmonton, Alberta, and then received his medical education at the University of Saskatchewan College of Medicine. He trained as a family physician, but has spent the past eight years specializing in hair restoration surgery. Vance’s personal experience with hair loss led him into the field. He noticed his own hairline starting to recede when he was 18 years old, and had his first transplant at the age of 24. After this, he trained and began practicing hair restoration exclusively in 1996 with PAI Medical Group in Canada and the United States. He developed the “MultiUnit Grafting” (MUG) technique, which is still in use by that group, and he has trained more than 20 physicians Vance W. Elliott, MD Sherwood Park, Alberta, Canada and medical assistants in its use. In 2004, Vance left the PAI group to begin a private practice in hair restoration surgery in Edmonton, Alberta. Vance’s typical goal for hair restoration in the average patient is to end up with 10,000–12,000 hairs in the front two-thirds of the scalp. While use of follicular unit grafts is a critical component of any great result, according to Vance, transplanting 10,000 hairs using follicular units exclusively would require 4,500–5,000 grafts. This is possible but may result in prohibitive costs and require numerous sessions for those patients who want increased coverage and volume. Vance is a passionate advocate of the “MUG technique,” which relies on multibladed donor harvesting and cut-to-size grafts placed into slot and slit incisions. This technique allows as many as 6,000–7,000 hairs to be moved per procedure in the form of both follicular units and MUG grafts. Vance maintains that, for many patients, this is the ideal approach and still achieves a natural result while maximizing volume. Vance has refined his technique by visiting numerous other surgeons. He counts as his mentors in hair restoration Drs. Richard Shiell, Jim Arnold, and Gerard Seery, among many others. Vance received certification from the ABHRS in 2003. He is also a strong advocate for medical treatment with finasteride and minoxidil, which he himself has been using for eight years. For 13 years, Vance has been happily married to his “true love,” Chantal, who is a psychiatrist. They have a 5year-old daughter, Sophie, and a 1-yearold son, Jack. In his free time, Vance enjoys spending time with his family, running, skiing, traveling, and learning to speak French. He also collects fine wine and enjoys cooking.✧ 1-800-GET HAIR Making good marketers great, and great marketers greater. • Easy to remember number keeps prospective patients out of the phone book and away from the competition. • Available to only one physician in each regional area—You’ll be kicking yourself when you see or hear it in your competitor’s ads. • Will make your phone ring more— gets prospective patients on the line; you convert them to clients. • A simple way to significantly increase the benefit of your precious advertising dollars and grow your patient base. Call 248-543-2200 to find out how to make your phone ring more and your competitor’s less. 104 Volume 14, Number 2 Hair Transplant Forum International ❏ May/June 2004 Stereomicroscopes for Hair Transplantation William M. Parsley, MD Louisville, Kentucky Since the advent of follicular unit transplantation in the early 1990s, stereomicroscopes have rapidly become standard instruments for graft preparation around the world. Early on, few transplant surgeons knew the brands, the options, or the suppliers. Gradually, our knowledge of these instruments has increased, but it is still lacking. Basically, a stereomicroscope consists of eyepieces, a body (containing observation tubes, intermediate lens elements, and objective), an illuminator, and usually a subject platform. Below are a few of the basics to consider when making a purchase. Basic Design There are two basic designs for stereoscopes: Greenough design and telescope (or parallel) design. The Greenough design, the most commonly used design for hair restoration, consists of two compound microscopes with two identical objectives aligned to their axis that forms a V down to the subject, creating approximately a 10° angle. These scopes are generally, but not always, less expensive than parallel scopes even though some have excellent optics and quality. Added accessories are limited. The telescope/parallel design has tubes that run parallel down to a common objective from where they angle down to the subject. Many accessories used in research, such as fluorescent lighting, can be added, making them more versatile and usually more expensive scopes. They are also known by the term CMO (Common Main Objective or Center Mounted Objective) scopes. The advantages of this design may not be realized in hair surgery. Greenough Design Telescope/Parallel Design (Common Main Objective) © Carl Zeiss GmbH® Printed with permission. <http://www.zeis.com> Eyepieces Magnification. Standard magnification is 10× but eyepieces with 20×, 30×, etc. can be interchanged on many scopes. Final magnification is determined by measuring the eyepiece magnification by the objective magnification. For example, if the eyepiece is set on 10× and the objective is 0.7×, then the final magnification is 7. Magnification can also be changed by adding an auxiliary lens below the objective. Observation tube (eyepiece angle). As a general rule, the steeper angles are best for smaller (shorter) scopes, while more horizontal angles are better for big research-type scopes. Observation tubes will generally vary from 30°–60° above the horizontal, with most being either 45° or 60°. Some microscopists will point out that a person reading a book in a chair on at a desk will have the viewing angle at about 60°. If someone is prone to neck strain, a lower angle may be more comfortable. Depending on the size of the scope, a 30°–45° angle may be advisable. If there is still a problem, then the eyepieceless instruments (Mantis or Lynx) should be considered. These scopes have a viewing angle close to 0°. Field number (F/N). We have found this parameter to be very important. This number represents the field of view seen through the eyepiece. It is usually printed on the eyepiece along with the magnification. Eyepieces with a larger F/ N allow the subject to be found more easily and are brighter. Usually a larger F/N is associated with a larger diameter lens opening in the eyepiece. Try to pick an eyepiece with an F/N of 21 or more. Eyepoint. This number indicates how far the eyes of the user should be from the eyepiece. Look for a higher number for eyeglass wearers. High eyepoint eyepieces are a little more expensive and are usually identified with the words “specs” or by small diagram of eyeglasses. They are highly recommended. Reticles. These are additions behind the eyepiece lens that places a micrometer or a crosshair pattern to help measure or identify the location of an area of interest on the specimen. Diopter adjustment. This is an adjustment, ideally on each of the eyepieces, that allows focusing to compensate for diopter differences between the 2 eyes. It is needed to adjust parfocal zoom scopes (keeping focus while zooming). Diopter adjustment is usually standard but is very important. To parfocalize a zoom scope, set each eyetube to 0, zoom to highest magnification and focus using the focus knob, zoom all the way back out and focus using the Diopter adjustments. Thereafter, the specimen should remain in focus throughout the zoom range. This needs to be individualized for each user. Magnification Adjustments While magnification changes are generally made by intermediate lens elements (between the eyepieces and the objective lens), they can also be made at the eyepiece. Standard eyepieces are 10×, but 20× and 30× eyepieces are available on certain scopes. As noted above, the final magnification is calculated by multiplying the eyepiece magnification by the objective magnification. Most assistants will work at 7– 12× while creating grafts. Non-continuous (step) magnification. Adjustment controls can be used to jump from one magnification to another, usually with 4 or 5 stops over the magnification range of the scope. Zoom (continuous) magnification. This adjustment allows continuous magnification changes throughout the magnification range. Zoom adjustments are very convenient and versatile. While not necessary, it would be desirable for most offices. Illumination Reflected (episcopic) versus transmitted (diascopic). Basically, reflected illumination means overhead (for more opaque objects) and transmitted means backlight (for more translucent objects). Because continued on page 106 105 Hair Transplant Forum International ❏ May/June 2004 Stereomicroscopes continued from page 105 skin is both translucent and opaque, assistants are divided over their favorite type of illumination. Most assistants tend to use only one type of illumination for everything, but some will use reflected light for slivering and transmitted light for cutting the follicular units. Reflected light can be used obliquely to aid in seeing clear or colorless objects. For transplant work, you will want a variable intensity light source. Illumination units (light sources). Listed below are some of the many types of illuminators to consider: 1. Nicholas-type Illuminators (reflected light). These illuminators are point source lights that insert into an incident light port on the microscope stand or are attached to an adjustable arm. They consist of a variable intensity box and a separate unit for the light source. Nicholas illuminators are common and are adequate for transplant surgery. Fiberoptic lighting is only slightly more expensive and is a better, more flexible option. 2. Fiberoptic lighting (reflected light). In this setup, a halogen light source is in the power unit. Fiberoptic lights run from this unit to a) a ring light or b) a single or dual arm light, also known as pipes. These are excellent light sources that produce little heat and have variable intensity, but are also more expensive. The single or dual arms can be placed at any angle and, used obliquely, may help with white hair. 3. Fluorescent ring light (reflected light). These are relatively inexpensive, cool, and convenient. Some have variable intensity and these would be recommended. Need for repair can be a problem. 4. Built-in light (reflected and transmitted light). Some scopes, such as the Zeiss Stemi DV4 and Mantis, have built-in halogen lights. They provide adequate lighting for transplant work and are inexpensive. The DV4 provides both reflected and transmitted light; however, the transmitted light may be too hot for grafts. 106 Working Distance The working distance is the distance between the subject (hair graft) and the objective lens. This represents the vertical room available for hands and instruments while preparing grafts. Adequate room is vital in our field. 100mm or more is desirable. Stands For hair restoration, consider three options: 1) plain stand—this is a simple one-piece stand that both holds the scope body and has a platform for the specimen. It is important that the platform be low and that it be wide enough to work adequately; 2) pole stand—this is a platform from which extends a single vertical pole, to which a microscope pods attaches; and 3) boom (universal) stand— this is a pole stand with an attached horizontal pole, to which a microscope pod attaches. With pole stands and boom stands, the specimen can be placed on the table top if desired or, by rotating the scope, on top of the platform. If transmitted light is desired, it would need to be added as a separate item. Some may use a thin photographic slide reading fluorescent light box for this purpose. The height of the platform is important. If too high, the hands would be at an awkward angle. Generally, the lower the better. Try to find a platform 3cm or less in height. It is important to remember that platforms and stands can be custom made. Expense Most offices will require somewhere between 3–15 microscopes, so it can be somewhat expensive to start. Most of the microscopes used in a hair restoration office will cost $1,000 to $2,000, including illumination. Excellent scopes can be found in this price range. Remember that a stereomicroscope may easily last longer than your practice. The purchase of cheap equipment is often regretted. Buy good quality— your assistants spend many hours using them and deserve good scopes. Be sure to consider buying a good teaching scope (think Motic). Brands/Models to Consider Be sure to purchase a stereomicro- Volume 14, Number 2 scope that is simple, reliable, reasonably priced, and with good optics. Know your dealer and have a good relationship. Good service is very important. The big 4 are Zeiss, Leica, Nikon, and Olympus; but Meiji scopes are probably the most widely used in our field. Leica is a conglomerate of Wild (one of the world’s best scopes), American Optical, Leitz, Cambridge, and Riechert & Jung. They recently discontinued Bausch & Lomb. Know which Leica product to order as the quality can vary greatly. Motic makes knockoffs of better known brands. They are made in China and are far less expensive than the scopes they are copying. 1. Nikon: SMZ645 2. Zeiss: Stemi DV4 3. Meiji: EMT—P stand or a KBL stand, step magnification— “T” is for Turret; sEMZ—5 on a P stand or a KBL stand—”Z” is for zoom 4. Motic: K400 (a knockoff of the legendary Wild M5), 4 step magnification; K500P, 5 step magnification; K700HI with 2112 base stand, has zoom; DSM500 Dual Viewing (for teaching)—excellent 5. Olympus: SZ40 series; SZ30 series 6. Leica: M series 7. Vision Engineering: Mantis Stereo Magnifier (hybrid between stereomicroscope and magnifier) Stereomicroscope Suppliers Hair Transplant Surgical Suppliers These companies provide a lot of support for us and stock some of the most popular scopes. Please check with them about their current stereomicroscopic equipment as their inventory changes periodically. Simply type their name into your Google search and you will be directed to their Website. A to Z (Tiemann): Meiji and Mantis Ellis Instruments: Meiji, Zeiss Stemi DV4, Mantis Mediquip: Zeiss Stemi DV4, various Robbins: Meiji Nikon Inc. Martin Microscope Company Southern Micro Instruments Olympus America, Inc. Lukas Microscopic✧ Volume 14, Number 2 Hair Transplant Forum International ❏ May/June 2004 PEARLS from PROVIDENCE ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ Robert T. Leonard, Jr., DO, FAACS, Past President, ISHRS Cranston, Rhode Island H ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ Figure 1 ○ ○ William M. Parsley, MD Louisville, Kentucky With the growing popularity in coronal (perpendicular) grafting, many hair transplant doctors are finding the benefits of razor blades cut to various widths. These blades are quite thin, particularly if using the double-edged blade. Many using the recommended blade holder have found difficulty in placing and securing the blade into the holder and have found that the blade tends to slip in the blade holder. Additionally, finding the best container for the blades has been met with difficulty in keeping the different sized blades identifiable and preventing accidental injury. We have found a small needle holder Figure 2 ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ (Figure 1) to be an excellent solution in holding the blades. It is easy to load and allows very little movement of the blade. For a holder, we use a marked cut foam pad (Greco Pad—Figure 2), which allows for the blade to be picked up and loaded by the needle holder without handling the blade and also allows blade sizes to be changed quickly. To avoid confusion, we use only one needle holder to make mistakes in blade sizing less likely.✧ ○ Making things easier, more smooth, and with less potential for danger crosses directly into the surgical suite. The next pearl depicts how the use of a simple substance can make our surgeries more controlled and safe.—RTL ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ramifications that might occur by the use of these drugs, you could put yourself in legal jeopardy; more importantly, though, you could be the unknowing cause of potential tragedy. ○ Remember, if you prescribed such medications and did not plan for the ○ ○ Robert T. Leonard, Jr., DO, FAACS Cranston, Rhode Island This pearl is about safety. If you will be medicating your patient with an anxiolytic agent such as diazepam (Valium) or midazolam (Versed), you should consider the following steps so that proper informed consent is undertaken, so that your patient is safe, so that the general public is not put in danger, and so you are protected legally: 1. If you are planning to pre-medicate your patient, it is important to have him sign your surgical consent form at the time of his booking and not on the day of surgery after he has already taken the anti-anxiety medication. His being under the influence of such mind-altering medications might make his surgical informed consent invalid. 2. It is of utmost importance that this pre-medicated patient has another person drive him to, as well as from, his surgical appointment. If he drove himself and then was to be involved in an automobile accident, he could be injured and/or might hurt others in the public. Be certain that he has a ride! ○ opefully, you are well underway in making your travel plans to go to our upcoming Vancouver meeting. The preliminary schedule looks wonderful! One of the biggest challenges we have as hair loss experts is not to just stay in our offices and do things as we always have done them. Learning what to do (and, more importantly, what not to do) from others is key. Take the time to write to me one of those little “pearls” in your practice that makes things easier for you, your staff, your patients, or your business. cr [email protected] om. [email protected]. Please e-mail your “pearl” to me at: do docr [email protected] www.ISHRS.org log on and check us out 107 Hair Transplant Forum International ❏ May/June 2004 Volume 14, Number 2 MESSAGE FROM THE PROGRAM CHAIR Dear ISHRS Members, As Program Chair for the 12th Annual Scientific Meeting of the Regist er ISHRS in Vancouver, BC, Canada, August 11–15, I am pleased to www.IS Online at HRS 12thAn inform you that the meeting is really coming together. In response to nualMe .org/ eting.h the suggestions of those attending last year’s meeting, I have tml allowed for more time for questions and answers and have organized several panels with some of the world’s leading experts on various timely topics. We will have several guest speakers on subjects including an in-depth discussion on androgen receptors, a Urologist’s evaluation of the finasteride prostate cancer study, hair follicle stem cells, and risk management concerns in hair restoration surgery. The workshop and course chairmen have put together an excellent program. Video sessions scheduled on Saturday will demonstrate techniques from around the world. Free time is scheduled on Saturday afternoon for touring and exploring Vancouver. I want to make a concerted effort to keep this meeting on time! Speakers will be limited to 7-minute presentations, which will be timed using the PowerPoint feature, such that the presentation will end after 7 minutes. Therefore, it is important for all speakers to practice their talks to stay within the time allotted. All members should have received their programs in the mail. If you have not, please contact the ISHRS headquarters office to request another program. The program is also available online in a PDF file at www.ishrs.org/ 12thAnnualMeeting.html. Make sure to register, if you have not done so already. Looking forward to a great meeting! With warm regards, Edwin S. Epstein, MD, Chair, 2004 Annual Scientific Meeting Committee Featured Guest Speakers George Cotsarelis, MD Assistant Professor, Department of Dermatology, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania; Director, University of Pennsylvania Hair and Scalp Clinic George Cotsarelis, MD, obtained his medical degree and completed his Dermatology residency at the University of Pennsylvania. He is an assistant Professor and is the Director of the University of Pennsylvania Hair and Scalp Clinic. He has authored numerous basic science publications related to the physiology of the hair follicle and hair loss. His current research projects focus on the role of hair follicle stem cells in alopecia, wound healing, and carcinogenesis. Dr. Cotsarelis will be speaking on “Hair Follicle Stem Cells.” Martin Gleave, MD Professor, Department of Surgery, University of British Columbia; Director of Clinical Research, the Prostate Center, Vancouver General Hospital Martin Gleave, MD, FRCSC, FACS, completed an Oncology Fellowship at MD Anderson Cancer Center and is 108 the recipient of numerous awards including the American and Canadian Urologic Research Awards in 1991 and 1992. His major research focus involves the study of cellular and molecular mechanisms mediating progression of prostate cancer to its lethal stage of androgen independence, and use of this information to develop integrated multimodality therapies that specifically target these mechanisms. Dr. Gleave will be speaking on “Finasteride and the Prostate Gland: What Hair Transplant Surgeons Should Know.” Michael J. McPhaul, MD Professor of Endocrinology and Metabolism, Associate Dean for Medical Student Research Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas Michael McPhaul, MD, received his medical degree from UT Southwestern Medical Center. Following a research fellowship at Stanford University, he returned to UT Southwestern joining the faculty in the Division of Endocrinology and Metabolism. His research has focused on the mechanisms by which the androgens testosterone and 5alphadihydrotestosterone exert their effects. The title of his talk is “Androgens and Their Actions.” Sharon Warning Risk Manager, Harrison Memorial Hospital, Bremerton, Washington Sharon Warning has been in healthcare risk management for over 20 years, starting as a Risk Manager for St. Mary’s Hospital in Milwaukee, Wisconsin. Her experience includes working for two physician malpractice insurance companies: Physicians Insurance, the primary physician malpractice company in Washington State, and The Doctors Company. She has conducted risk management educational presentations at the local, state, and national level as well as at universities. Volume 14, Number 2 Hair Transplant Forum International ❏ May/June 2004 Preliminary List of Panels FUE Panel Moderator: Russell Knudsen, MBBS John P. Cole, MD, Alan S. Feller, DO, Konstantine Minotakis, MD, William R. Rassman, MD, Paul T. Rose, MD Density and Graft Growth Panel Moderator: Walter P. Unger, MD Robert M. Bernstein, MD, Victor Hasson, MD, Bobby L. Limmer, MD, David J. Seager, MD, Ron Shapiro, MD Follicular Frontiers Panel Moderator: Kenneth Washenik, MD, PhD Jerry E. Cooley, MD, George Cotsarelis, MD, Bessam K. Farjo, MD, Walter Krugluger, MD Managing the Unhappy Patient Panel Moderator: James E. Vogel, MD Ivan S. Cohen, MD, Paul C. Cotterill, BSc, MD, Robert T. Leonard, Jr., DO, Carlos J. Puig, DO Complications Panel Moderator: William Rassman, MD Sheldon S. Kabaker, MD, Russell Knudsen, MBBS, James E. Vogel, MD Approach to the Young Patient Panel Moderator: Mario Marzola, MBBS James Arnold, MD, Michael L. Beehner, MD, Robert S. Haber, MD, Dow B. Stough, MD, Craig L. Ziering, DO CAG vs. SAG Panel Moderator: Dow B. Stough, MD Sharon A. Keene, MD, Jennifer H. Martinick, MBBS, William M. Parsley, MD, Arthur Tykocinski, MD, Jerry Wong, MD 109 Hair Transplant Forum International ❏ May/June 2004 Volume 14, Number 2 nce Upon a Time… “I am presently transplanting between 30,000 and 35,000 grafts per session. Using a 137 blade knife for donor strips into my Cuisinart. I’ve hired the entire nursing staff of University Hospital. Since it is difficult to get 300 nurses in the surgery room, we now have moved to a football stadium.” Manny Marritt, MD Denver, Colorado (Vol. 5, No. 1; January/February 1995, p. 9) Quoted at first meeting of ASHRS in Los Angeles, in reaction to the dawn of the “mega-session” era. ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ “At this stage I do not plan any major changes in the Forum. However, as an avid historian I would like to add a regular feature containing brief profiles on the men who have laid the foundations of our Specialty…. What of the Japanese surgeons who remain but shadows to us in the West? Plans are already afoot to procure biographical data on Okuda and others.” —Richard Shiell, MBBS Melbourne, Australia (Vol. 5, No. 6; November/December 1995, pp. 1–2). These comments were included in his first column as the new editor of the Forum. These words turned out to be prophetic, coming to fruition nine years later in the past two Forum issues. ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ “Popularity for a concept should not be construed as proof, and marketing or advertising personal claims for personal gain should be viewed with a critical eye. Less experienced transplant surgeons are easily swayed by the louder voices around them. These louder voices must recognize their potential impact on others and should exercise caution and reserve in their pronouncements; anything less would be irresponsible. Progress is built on an open-minded approach to new ideas and a willingness to share. The next step is to prove the validity of the new ideas before (and not after) they replace the current gold standard.” —Eric Eisenberg, MD Toronto, Canada (Vol. 8, No. 1; January/February 1998, p. 23) 110 Volume 14, Number 2 Hair Transplant Forum International ❏ May/June 2004 HIPAA and the Surgeon: Protecting Patient Privacy James L. Breeling (Summarized from “Medicolegal Corner session, 11th Annual Scientific Meeting) James L. Breeling, a professional medical writer and editor, is an independent consultant to the ISHRS and assisted the Forum in covering several keynote talks at the ISHRS Annual Meeting in New York. The Health Insurance Portability and Accountabilty Act (HIPAA) was passed by Congress in 1996 and came into full effect in 2003 after all of its regulatory standards were written. The Act and its implementing regulations are spelled out in more than 100,000 words that affect all physicians and hospitals in the U.S. in the effort and cost of changes required in administrative procedures and recordkeeping. Noncompliance is addressed by penalties and sanctions administered by the Department of Health and Human Services (HHS). However, the Act does not allow lawsuits by patients who claim violation of rights spelled out in HIPAA; patients must pursue such claims by filing complaints through channels provided for in the HIPAA regulations. Privacy Rule elements of HIPAA that are most important for physician hair restoration physicians specialists were summarized for ISHRS members at the 11th Annual Scientific Meeting in New York by Justin D. Kuralt, Charlotte, NC. Mr. Kuralt is a consultant to Total Medical Compliance, a firm that specializes in helping professionals, businesses and nonprofit organizations comply with the regulatory requirements of HIPAA and OSHA. HIPAA regulations cover (1) health plans, (2) health-care clearinghouses, and (3) health-care providers who conduct transactions electronically. HIPAA Privacy Rule components consist of: ➤ Regulatory standards covering uses and disclosures of patient information and minimum necessary personal information; ➤ Privacy rights of patients; ➤ Administrative practices of healthcare providers as required to comply with HIPAA regulatory standards and patient privacy rights; and, ➤ Regulations written to balance individual rights to privacy against public needs for health and safety. Mr. Kuralt stressed a point that physicians and others who must comply with HIPAA regulations should remember: ➤ Patients have rights to privacy that are specifically stated in HIPAA and HIPAA regulations. Health-care providers should always assume that patients are aware of these rights. Patient rights under the HIPAA Privacy Rule are to: ➣ Control the release and use of personal health information (PHI) ➣ Restrict the use and disclosure of their PHI ➣ Request confidential communications ➣ Inspect and copy their PHI ➣ Amend a designated record set ➣ Ask for an accounting of any disclosures of their PHI ➣ Complain about violations of privacy rights and obtain action ➣ Know the privacy policies of a chosen health-care provider HIPAA permits some uses and disclosures of PHI, but only as defined under the Privacy Rule: ➤ Disclosure to the individual patient or to a representative of the patient whose authority to receive disclosure is satisfactorily established; ➤ Disclosure for treatment, payment and operations after a Notice of Privacy Practice has been provided by the health-care provider; ➤ Disclosure to family and friends with informal approval or for emergencies; ➤ Disclosure to any entity authorized by the patient; and, ➤ Disclosure based on professional judgment of best interest. In some specific instances, disclosure of PHI is permitted with designated restrictions spelled out in regulations: ➤ When required by public health ➤ ➤ ➤ ➤ ➤ ➤ regulations—for example, (1) to a Public Health agency that has authority to collect information on disease control, but only the information defined as necessary by law should be disclosed, (2) to a person who may have been exposed to a communicable disease, as in “sharps” injuries, and (3) to an employer if the employee is a health-care provider, if the information is for regulatory reasons and the employee is informed of the disclosure; In cases of abuse; To assist law enforcement; When the patient is deceased—e.g., to funeral directors; For purposes of organ donation; In Workers’ Compensation cases; and, For judicial proceedings. Business associates of the physician or other health-care provider covered by HIPAA must also comply with HIPAA as defined under the Act and its regulations, Mr. Kuralt pointed out. Failure to obtain a contract with business associated regarding HIPAA compliance can result in a significant failure to comply, he warned. The physician may disclose PHI to a business associate if an explicit contract is written to assure safeguard of PHI— (1) to use the information only as defined in the contract, (2) to report any disclosures of PHI made in error, and (3) to be able to provide an accounting of all disclosures. If the physician becomes aware of a breach by the business associate, the physician must take steps to cure the problem, terminate the contract, or notify the HHS. In regard to physician compliance, Mr. Kuralt urged his audience to make certain they have satisfactorily addressed all administrative procedures required by HIPAA. The minimum necessary continued on page 112 111 Hair Transplant Forum International ❏ May/June 2004 HIPPA and the Surgeon continued from page 111 administrative requirements for a physician’s office include: ➤ Identify all persons who need access to PHI in order to perform their duties; ➤ Limit access and protect PHI from unauthorized access; ➤ Write procedures and policies that limit PHI for disclosures made on a routine and recurring basis; and, ➤ Handle all other requests on a caseby-case basis and limit disclosures to the minimum necessary both internally and externally. What every physician should do immediately, if not already done, Mr. Kuralt said, is to: ➤ Name a privacy officer; ➤ Prepare and disclose privacy policies (Notice of Privacy Practices) to all patients; ➤ Document privacy policies and procedures; ➤ Develop PHI security practices; ➤ Train all employees in matters pertaining to compliance; Volume 14, Number 2 ➤ Impose sanctions for violations; and, ➤ Obtain a Privacy Rule contract with business associates. Developing a Notice of Privacy Practice (NPP) should be a No. 1 priority for the physician, Mr. Kuralt said. Most physicians have probably already done so, since the NPP was required by the first day of service after April 14, 2003. The NPP must be given to patients to read and sign, and it must be posted in the office lobby and on a Website if the physician has one. The NPP given to patients should include all items required by law; it may also include telephone reminders of appointments. The physician should review a number of office policies and procedures that may impact on proper administration of the Privacy Rule, Mr. Kuralt said: ➤ Define the types of information disclosures routinely made to family and friends of patients; ➤ Design new authorization forms as needed; ➤ Determine if signed authorizations are in hand or are needed; ➤ As needed, redesign existing forms for use in requesting and disclosing PHI; and, ➤ Define operational requirements to facilitate ease of daily operations. What must be in an authorization form? Except as permitted, a provider may not use or disclose PHI without an authorization that must include: ➣ A description of the PHI ➣ The giving and receiving entity ➣ An expiration date or event ➣ Disclosures to the patient ➣ Reason or purpose for the disclosure Violations of the Privacy Rule by employees in the physician’s office requires sanctions that may range from warnings to termination. Violations of policies and procedures by employees also make the physician liable for fines and litigation. General penalties for violation are $100 per violation with a maximum of $25.000 per year for similar violations. Penalties for willfully wrongful disclosure are (1) up to $50,000 or 1 year in prison or both, (2) up to $100,000 or 5 years in prison or both for disclosure with false pretenses, and (3) up to $250,000 or 10 years in prison or both for disclosure with intent to sell or harm.✧ You can make a difference. Submit your application today to participate as a volunteer surgeon in the ISHRS Pro Bono program. Visit www.ishrs.org for details. 112 Volume 14, Number 2 Hair Transplant Forum International ❏ May/June 2004 113 Hair Transplant Forum International ❏ May/June 2004 Volume 14, Number 2 Stop b y our bo o t h in Van couver . 114 Volume 14, Number 2 Hair Transplant Forum International ❏ May/June 2004 Surgical Assistants Corner Hair Restoration at TransPel/Sandoval in Mexico City, Mexico Beatrice Quintana Pedroza, Karina Sanchez Romero, Carol Ortega Danache Mexico City, Mexico Our History After 15 years of practicing hair restoration in Guadalajara, Mexico, TransPel, the hair restoration practice founded by Dr. Arturo Sandoval, recently opened a new surgical office in Mexico City. It is headed by Dr. Hector Sandoval, who trained and worked with Dr. Arturo for over 9 years. Their new office consists of two consultation rooms and 5 operating rooms. Currently our surgical staff consists of 10 surgical assistants, 7 of whom are nurses, and 3 others who are not nurses but have worked in the medical field before as nurses’ assistants. They underwent 6 months of training in our Guadalajara clinic before the opening of our new surgical office in Mexico City in 2003. We have now been practicing hair transplantation for 6 months and despite our new assistants previous training, they will work under the strict supervision of experienced staff, who fly back and forth from our Guadalajara office, until they pick up speed without sacrificing quality. Doctors Arturo and Hector Sandoval consider that a large surgical team is essential to complete the hair transplant in the least amount of time, allowing us to offer large sessions, an essential for increasing patient comfort and hair graft survival. Technique Dr. Hector Sandoval uses only follicular unit (FU) grafts for the procedures, which usually consist of 1,500 to 3,000 FUs. Particular to our technique is the donor harvesting method, which involves the Triple SSS (Sandoval-Score- mately 3 hours and a 4,000 graft session requires about 9 hours. Assistants’ Tips TransPel surgical team with Dr. Hector Sandoval Spread) harvesting technique in a high percentage of patients. This method basically consists of scoring the epidermis of the predetermined donor strip in an elliptical shape and then separating the emerging borders down to the subcutaneous tissue using a fine-tip hemostat forceps to avoid follicular transection and damage to neural and vascular structures. Our team uses Meiji stereoscopic microscopes for dissection of the donor tissue. Depending on the number of grafts, 1 to 3 technicians may sliver the donor strip while 4 or 5 obtain the follicular units from the slivers. After Dr. Sandoval has designed the patient’s hairline, every square centimeter of bald scalp to be covered is drawn or mapped out. These centimeter boxes (described by Dr. Arturo Sandoval) are also particular to our technique and allow Dr. Hector Sandoval to determine how many grafts each square centimeter will receive, ensuring even density throughout the hair transplant. Two to 4 technicians will alternate to plant the grafts using a stick-and-place method. A 1,000 graft session requires approxi- Tip #1. Avoid re-infiltrating the recipient area. Normally, local anesthetics (lidocaine and bupivicaine with epinephrine) will maintain recipient area anesthesia for about 2 to 5 hours; however, there are patients who absorb the anesthetic very quickly and require frequent re-infiltration. This can be avoided or delayed by applying the local anesthetic very superficially until the epidermis is elevated and a blanching of the skin occurs. Tip #2. Reduce popping. Popping of hair grafts is a frequent cause of technician headaches. This can be improved on occasion by planting in the opposite direction, in other words, switching from an anterior to posterior placement to posterior-anterior. Second, test a few grafts until you find a graft that fits perfectly into the site— then place a graft at each microscope as a reminder to other techs that size and shape of new grafts should closely resemble the example graft. Tip #3. Improved hemostasis in the recipient area. In our clinic 18-, 19-, and 20-gauge needles are used for recipient sites. We bend the tips at a 90 degree angle, which will act as a stop, preventing incisions from going too deep and possibly reaching underlying blood vessels.✧ 115 Hair Transplant Forum International ❏ May/June 2004 Volume 14, Number 2 MESSAGE FROM THE SURGICAL ASSISTANTS CHAIR 12th Annual ISHRS Meeting Update Join us in beautiful Vancouver Dear Surgical Assistant Members, The time is drawing nearer to our Annual Meeting in August. The Assistants Committee has been working on a more scientific but yet meaningful program. Our format remains basically the same with a few tweaks here and there. Each day will begin with breakfast and socializing, followed by some wonderful speakers who will address such topics as: ✯ Post-op Care of Artificial Hair Fibers ✯ Microscopes—Necessary or Not ✯ How Consults Are Presented in Our Office ✯ Men Are from Mars & Women Are from Venus We will once again offer you a luncheon on the first day to be combined with our Annual Business Meeting. We have also planned a box lunch on the second day with the workshop “Work Life Balance,” presented by Dr. Roberta Neault, CCC, RRP. I urge you to come and participate. Betsy Shea, Saratoga Springs, New York Surgical Assistants Program Chair Doctors! Please bring your Assistants to the meeting. Your clinic will reap many benefits from attending a meeting together. ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ LAST CALL! We are still accepting nominations for the “2004 Distinguished Assistant Award.” Submit nominations to: ISHRS Surgical Assistants Award Committee • Fax: 630-262-1520 • E-mail: [email protected] A Call to Surgical Assistants... We Welcome Your Contributions. Surgic al This is Assistatnts: y Let’s h our Corner. ear fro m you ! As your Forum editors, we invite the surgical assistants from the various practices around the world to submit a profile of their practice along with a photo of the doctor(s) and the assistants, plus any helpful tips you would like to share with others in the transplant field. We no longer have a formal editor for this section of the Forum, but want you to know that such articles are welcome anytime and will be printed, as space allows for such. We wish to thank the staffs of those practices who have contributed in the past. —MLB/WMP “You are here not merely to make a living. You are here in order to enable the world to live more amply, with greater vision, with a finer spirit of hope and achievement. You are here to enrich the world, and you impoverish yourself if you forgot the errand.” —Woodrow Wilson 116 Volume 14, Number 2 Hair Transplant Forum International ❏ May/June 2004 117 Hair Transplant Forum International 118 ❏ May/June 2004 Volume 14, Number 2 Volume 14, Number 2 Hair Transplant Forum International ❏ May/June 2004 Classified Ad DiStefano Hair Restoration Centers Hair Transplant Technicians Hair Transplant Clinic looking for technicians in the Hartford, CT. area. Experience preferred but will train. Pay will be commensurate with experience. $15–$25 per hour. Excellent benefit package. Full-time/Part-time. Please fax resume to (508)755-5447. Experienced Hair Transplant Technician Western Mass. Part time. $40.00 hour Fax resume to 413-587-0970. 119 Upcoming Events Hair Transplant Forum International May/June 2004 ❏ Volume 14, Number 2 Following is a guide to upcoming meetings and workshops related to hair restoration. For more information, contact the appropriate sponsoring organization at the number listed. Meeting organizers are reminded that it is their responsibility to provide the Forum Editors with advance notice of meeting dates. Date(s) Venue Sponsoring Organization(s) Contact Information June 3–5, 2004 9th ISHR International Congress Torino, Italy Italian Society for Hair Restoration www.actacongress.com or www.ishr.it Organizational Bureau Tel: 39-011-591871 Fax: 39-011-590833 E-mail: [email protected] June 16–19, 2004 First Brazilian Meeting and Second Live Surgery Workshop Recife, northern Brazil Brazilian Society of Hair Restoration Surgery Fernando T. Basto, MD: [email protected] Tel: (55 81) 3427-9000 June 26–27, 2004 Hair Restoration for the Cosmetic Surgeon & Cosmetic Surgery for the Hair Restoration Surgeon Workshop Seattle, Washington American Society of Hair Restoration Surgery & American Academy of Cosmetic Surgery www.cosmeticsurgery.org Tel: 312-981-6760 Fax: 312-981-6787 [email protected] August 11–15, 2004 12th Annual Meeting of the ISHRS Vancouver, BC, Canada International Society of Hair Restoration Surgery www.ishrs.org Tel: 630-262-5399; 800-444-2737 Fax: 630-262-1520 ○ ○ ○ ○ ○ ○ ○ ○ ○ August 15–22, 2004 ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ISHRS Post-Meeting Alaskan Cruise Royal Caribbean Cruise Line ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 2004 Aegean Masters FUE Meeting Oct. 3 Live Surgery Oct. 4–8 Aegean Cruise The Aegean Islands, Greece HAIR TRANSPLANT FORUM INTERNATIONAL International Society of Hair Restoration Surgery 13 South 2nd Street Geneva, IL 60134 Forwarding and Return Postage Guaranteed 120 ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ Leisure Department at UNIGLOBE Advance Travel Tele: 604-688-5835; toll-free: 888-463-2757 e-mail: [email protected]. The DHI Clinic www.aegeanmasters.com Carolina or Olympia Tel: 30-210-9245297 Fax: 30-210-9249378 E-mail: [email protected] NOW— BOOK eting e post-M uise Cr n a k s Ala October 3–8, 2004 ○ International Society of Hair Restoration Surgery through UNIGLOBE Advance Travel FIRST CLASS US POSTAGE PAID CHICAGO, IL PERMIT NO. 6784