Orlando Review - International Society of Hair Restoration Surgery

Transcription

Volume 14, Number 2
Hair Transplant Forum International
❏
May/June 2004
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
❏
May/June 2004
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
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
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:
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
❏
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.
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Orlando
Highlights
The 10th
Annual Live
Surgery Workshop was held in
Orlando, March
10–13. Dr.
David PerezMeza has been
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
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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
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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
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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
Volume 14, Number 2
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
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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
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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
❏
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
87
❏
May/June 2004
Orlando Review
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
❏
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
89
❏
May/June 2004
Pioneer of the Month
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
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NOMINATIONS!
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90
Volume 14, Number 2
❏
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
91
❏
May/June 2004
Comparing Hair Populations
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
❏
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
93
❏
May/June 2004
Female Forehead
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
❏
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
❏
May/June 2004
Beehner Message
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
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?✧
Volume 14, Number 2
❏
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
97
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May/June 2004
FUE Megasessions
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
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
❏
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
❏
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
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
101
❏
May/June 2004
Cyberspace Chat
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
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
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
FUE looks like a useful, but infrequently needed, tool. Very few of my
Editor Emeritus
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
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the patient’s remaining hairs to give the undetectable appearance of a fuller head of hair.
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103
❏
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.
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104
Volume 14, Number 2
❏
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
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May/June 2004
Stereomicroscopes
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.
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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
❏
May/June 2004
PEARLS from PROVIDENCE
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Robert T. Leonard, Jr., DO, FAACS, Past President, ISHRS Cranston, Rhode Island
H
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Figure 1
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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
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(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.✧
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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
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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.
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Remember, if you prescribed such
medications and did not plan for the
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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!
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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
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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
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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
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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
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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.
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“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.
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“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)
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Volume 14, Number 2
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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
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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
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May/June 2004
HIPPA and the Surgeon
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.
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May/June 2004
Volume 14, Number 2
Stop b
y
our bo
o
t
h
in Van
couver
.
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Volume 14, Number 2
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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
❏
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
❏
May/June 2004
117
118
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May/June 2004
Volume 14, Number 2
Volume 14, Number 2
❏
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
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
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August 15–22, 2004
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ISHRS Post-Meeting Alaskan Cruise
Royal Caribbean Cruise Line
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2004 Aegean Masters FUE Meeting
Oct. 3 Live Surgery
Oct. 4–8 Aegean Cruise
The Aegean Islands, Greece
HAIR TRANSPLANT FORUM INTERNATIONAL
13 South 2nd Street
Geneva, IL 60134
Forwarding and Return Postage Guaranteed
120
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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
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post-M uise
Cr
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October 3–8, 2004
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through UNIGLOBE Advance Travel
FIRST CLASS
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PAID
CHICAGO, IL
PERMIT NO. 6784

Orlando Review - International Society of Hair Restoration Surgery

Transcription

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