Our hats off to you, as we bid you a fond adieu…

forum
HAIR
TRANSPLANT
I N T E R N A T I O N A L
Volume 20, Number 4
July/August 2010
COLUMNS
110 President’s Message
111 Co-editors’ Messages
113 Editor Emeritus: Russell
Knudsen, MBBS
124 Hair Sciences: Centre for
Skin Sciences launched
126 How I Do It: Use of intact
“pillars” in donor harvesting
131 Hair’s the Question
133 Surgeon of the Month:
Fernando Basto, MD
141 Surgical Assistants Editor’s
Message
142 Classified Ads
FEATURE ARTICLES
116 A comparison between the
preview long hair technique
and the classic hair
transplant technique
121 Expanding graft numbers
combining strip and FUE in
the same session: effect on
linear wound closure forces
125 One step closer: report on
the AMA House of Delegates
127 Multiracial variations in
anatomical location of
the occipital artery and
nerve complex: a key to
avoiding injury prior to strip
harvesting
133 Newly formed Asian
Association of Hair
Restoration Surgeons
(AAHRS)
134 ABHRS holds exam in
Capri, Italy
137 Auditing within a hair
transplant setting
Don’t Forget to
Register!
RED C0 M100 Y100 K10 PMS 661C
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Our hats off to you,
as we bid you a fond adieu…
Cheryl Pomerantz, RN
1949–2010
T
hose of us who knew her were shocked
and saddened to hear of the sudden
death of Cheryl Pomerantz, RN on July
3, 2010. She and her husband Marc were
both Foundation Members of the ISHRS
in 1993 and they took an active role in
the formation of our Society.
With her homemade hats and feather
boa, Cheryl always seemed larger than
life and was great company. She was editor of the Forum’s Surgical Assistants Corner from 1998 to 2001 and again in 2004.
In addition, she organized the Surgical
Assistants Program at several meetings. I
was delighted when she received the very
first Assistants Award in 2003. She was
still serving on the Awards Committee at
the time of her death.
Always happy and utterly fearless,
Cheryl would tackle any challenge and
usually be successful. We will miss her
greatly and I am sure that fellow ISHRS
members will join me in offering heartfelt condolences to husband Marc and
Cheryl’s son, Justin.
Richard Shiell, MBBS
I met Cheryl ten years ago thanks to
the wonderful “family” of the ISHRS. We
hit it off instantly as neither of us takes
ourselves too seriously and enjoy having
fun to the point that others may see it
as ridiculous. Our meetings through the
years have been peppered with amazing
hats, feather boas, singing and dancing,
and all in good fun.
Marc, you have been blessed with a
wonderful and creative wife, not to men page 114
Official publication of the International Society of Hair Restoration Surgery
Hair Transplant Forum International
Hair Transplant Forum International
Volume 20, Number 4
Hair Transplant Forum International is published bi-monthly by the
International Society of Hair Restoration Surgery, 303 West State
Street, Geneva, IL 60134. First class postage paid at Chicago, IL and
additional mailing offices. POSTMASTER: Send address changes
to Hair Transplant Forum International, International Society of Hair
Restoration Surgery, 303 West State Street, Geneva, IL 60134.
Telephone: 630-262-5399, U.S. Domestic Toll Free: 800-444-2737;
Fax: 630-262-1520.
President:
Edwin S. Epstein, MD
Executive Director:
Victoria Ceh, MPA
Editors:
Francisco Jimenez, MD
[email protected]
Bernard P. Nusbaum, MD
[email protected]
Managing Editor, Graphic Design, & Advertising Sales:
Cheryl Duckler, 262-643-4212
[email protected]
Scientific Section:
Nilofer P. Farjo, MBChB
Surgeon of the Month: Samuel M. Lam, MD;
Maurice P. Collins, MBBch
Cyberspace Chat:
Sharon A. Keene, MD
The Dissector:
Russell Knudsen, MBBS
How I Do It:
Bertram Ng, MBBS
Hair’s the Question:
Sara M. Wasserbauer, MD
Surgical Assistants Corner Editor:
Laurie Gorham, RN
[email protected]
Basic Science:
International Sections:
Asia:
Australia:
Europe:
South America:
Review of Literature:
Dermatology:
Plastic Surgery:
Satoshi Itami, MD
Andrew Messenger, MBBS, MD
Ralf Paus, MD
Mike Philpott, PhD
Valerie A. Randall, PhD
Rodney Sinclair, MBBS
David Whiting, MD
Sungjoo Tommy Hwang, MD, PhD
Jennifer H. Martinick, MBBS
Fabio Rinaldi, MD
Marcelo Pitchon, MD
Marc R. Avram, MD
Nicole E. Rogers, MD
Sheldon S. Kabaker, MD
Copyright © 2010 by the International Society of Hair Restoration
Surgery, 303 West State Street, Geneva, IL 60134. Printed in the
USA.
The views expressed herein are those of the individual author and are
not necessarily those of the International Society of Hair Restoration
Surgery (ISHRS), its officers, directors, or staff. Information included
herein is not medical advice and is not intended to replace the considered
judgment of a practitioner with respect to particular patients, procedures,
or practices. All authors have been asked to disclose any and all interests
they have in an instrument, pharmaceutical, cosmeceutical, or similar
device referenced in, or otherwise potentially impacted by, an article.
ISHRS makes no attempt to validate the sufficiency of such disclosures
and makes no warranty, guarantee, or other representation, express or
implied, with respect to the accuracy or sufficiency of any information
provided. To the extent permissible under applicable laws, ISHRS
specifically disclaims responsibility for any injury and/or damage to
persons or property as a result of an author’s statements or materials
or the use or operation of any ideas, instructions, procedures, products,
methods, or dosages contained herein. Moreover, the publication of an
advertisement does not constitute on the part of ISHRS a guaranty or
endorsement of the quality or value of the advertised product or service
or of any of the representations or claims made by the advertiser.
Hair Transplant Forum International is a privately published newsletter
of the International Society of Hair Restoration Surgery. Its contents are
solely the opinions of the authors and are not formally “peer reviewed”
before publication. To facilitate the free exchange of information, a less
stringent standard is employed to evaluate the scientific accuracy of
the letters and articles published in the Forum. The standard of proof
required for letters and articles is not to be compared with that of formal
medical journals. The newsletter was designed to be and continues to
be a printed forum where specialists and beginners in hair restoration
techniques can exchange thoughts, experiences, opinions, and pilot
studies on all matters relating to hair restoration. The contents of this
publication are not to be quoted without the above disclaimer.
The material published in the Forum is copyrighted and may
not be utilized in any form without the express written consent of
the Editor(s).
July/August 2010
President’s Message
Edwin S. Epstein, MD Virginia Beach, Virginia [email protected]
Who is qualified to perform scalp surgery? The kneejerk and obvious answer seems simple: the physician,
of course. Can and should scalp procedure be delegated
to surgical assistants? The legal answer resides within
interpretation of local regulations, but the philosophical
decision rests within each physician’s practice. So why
do these seemingly simple questions evoke so many
emotional responses?
First, we should define scalp surgery. A scalp reduction or flap procedure easily falls into the category, and
so should strip harvesting. But what about a 4mm punch
biopsy, and does that differ from a 0.7-1.0mm punch biopsy? Is removing tissue,
that is, extracting a follicular unit, surgery? How about simply cutting or incising
the scalp? Should we consider incision sites in recipient areas scalp surgery?
Does this differ from the phlebotomist’s needle insertion to draw blood?
The ISHRS is at the forefront of hair restoration surgery and should set the
guidelines and standards for best practice. In May 2010 I convened an ad hoc
committee composed of past presidents with the directive to develop a position
statement as to who should perform follicular unit extraction. Dr. Dow Stough
headed the committee, which also included Drs. Robert Leonard, Robert Haber,
Tony Mangubat, and Paul Rose. The Board of Governors has accepted the following position statement:
“The position of the International Society of Hair Restoration Surgery is that
any tissue removal from the scalp or body, by any means, must be performed
by a licensed physician in the field of medicine. Physicians who perform hair
restoration surgery must possess the education, training, and current competency in the field of hair restoration surgery. It is beyond the scope of practice
for non-licensed personnel to perform surgery. Surgical removal of tissue by
non-licensed medical personnel may be considered practicing medicine without
a license by state, federal, or local governing boards of medicine. The Society
supports the scope of practice of medicine as defined by a physician’s state,
country, or local legally governing board of medicine.”
Local medical boards review most regulations, and changes are made in
response to complaints by patients or serious surgical complications. Most
regulations that address whether physicians may delegate procedural responsibility to surgical assistants, licensed or otherwise, are vague, leaving both the
decision and the potential risks to one’s medical license to the physician. The
ISHRS leadership contends that this position statement provides clarity for our
members and, ultimately, for their patients.
On a lighter note, I recently returned from the Italian Hair Society meeting
in Capri, Italy, and would like to congratulate Dr. Piero Tesauro and his staff
for a well-run and excellent academic congress. Boston is almost here and Dr.
Paul McAndrews and the entire committee have put together a great program.
Please make plans to attend!
Edwin S. Epstein, MD
110
Hair Transplant Forum International
July/August 2010
Co-editors’ Messages
Bernard Nusbaum, MD Coral Gables, Florida
[email protected]
Paco Jimenez, MD Las Palmas, Spain
[email protected]
A new model for the pathogenesis
of cicatricial alopecia has emerged
in which the main protagonist is the
lipid metabolism of the pilosebaceous
unit. As strange as it may sound, a
recent article discovered that genes
required for lipid metabolism and
peroxisome biogenesis are decreased
in patients with lichen planopilaris
(LPP). Specifically, the initial trigger of
inflammation in LPP could be an abnormal functioning of the peroxisome proliferatior-activated
receptor gamma (PPAR-gamma). A loss of PPAR-gamma
function leads to a decreased peroxisome biogenesis and to
an aberrant lipid metabolism in the sebaceous gland, a toxic
buildup of lipids, and a subsequent inflammatory response.
As a result, the dense inflammatory infiltrate would destroy
the portion of the follicle where stem cells are located, resulting in a permanent scarring alopecia.
It is encouraging to note that pioglitazone hydrochloride,
15 mg/d orally, a medication used in the treatment of type 2
diabetes mellitus that increases the activity of PPAR-gamma,
has shown clinical improvement in LPP according to one
recent publication (Arch Dermatol. 2009; 145:1363).
After reading this paper, I wondered whether this medication would work in frontal fibrosing alopecia (FFA), a very
interesting disease that shares a similar or identical histopathologic pattern with LPP. At least in my area (Canary
Islands), the most common cicatricial alopecia that I see in
my practice nowadays is FFA. It has such a typical clinical
pattern that most of the time a diagnosis can be made while
the patient is entering through the consultation door. This
The ISHRS is synonymous with
education, networking, and the industry of hair restoration, but the
Society would not exist without
people like Cheryl Pomerantz, RN
whose recent passing we mourn,
and whose friendship and dedication
are remembered in this issue’s cover
story. While it is difficult to discuss
the scientific articles that comprise
this issue in the same message that
remembers Cheryl’s influence on our Society, it seems proper,
because Cheryl stood for improving patient care and providing aesthetic and safe hair restoration surgery—goals that
are advanced by this Forum issue.
One of the hot topics in our field is that of the “long hair”
transplantation technique and, in this issue, Dr. Crisóstomo
presents his quantitative comparison of the key components
of the hair restoration procedure comparing the long hair
technique to the classic shaved hair technique. In an interesting note from the foremost expert on this technique, Dr.
Marcelo Pitchon comments on the technical aspects as well
as the subjective, artistic advantages that are provided by
this technique for both the patient and the surgeon.
While FUE continues to evolve, Dr. Akaki Tsilosani presents his work on expanding the number of follicular units
transplanted in one session by combining strip excision and
FUE. He presents a novel concept comparing strip wound
closure tension before and after FUE is performed above and
below the linear incision. In a format that Dr. Jimenez and
I have tried to implement for the Forum, we have elicited an
editorial comment from one of the experts in the field, Dr.
 page 112
 page 112
Editorial Guidelines for Submission and Acceptance of Articles for the Forum Publication:
1.
2.
3.
4.
5.
6.
Articles should be written with the intent of sharing scientific
information with the purpose of progressing the art and science of hair restoration and benefiting patient outcomes.
If results are presented, the medical regimen or surgical
techniques that were used to obtain the results should be
disclosed in detail.
Articles submitted with the sole purpose of promotion or
marketing will not be accepted.
Authors should acknowledge all funding sources that supported
their work as well as any relevant corporate affiliation.
Trademarked names should not be used to refer to devices
or techniques, when possible.
Although we encourage submission of articles that may only
contain the author’s opinion for the purpose of stimulating
thought, the editors may present such articles to colleagues
who are experts in the particular area in question, for the
purpose of obtaining rebuttal opinions to be published alongside the original article. Occasionally, a manuscript might be
sent to an external reviewer, who will judge the manuscript
in a blinded fashion to make recommendations about its
acceptance, further revision, or rejection.
7.
Once the manuscript is accepted, it will be published as soon
as possible, depending on space availability.
8. All manuscripts should be submitted to both drnusbaum@yahoo.
com and [email protected].
9. A completed Author Authorization and Release form—sent
as a Word document (not a fax)—must accompany your
submission. The form can be obtained in the Members Only
section of the Society website at www.ishrs.org.
10. All photos and figures referred to in your article should be
sent as separate attachments in JPEG or TIFF format. Be sure
to attach your files to the email. Do NOT embed your files
in the email or in the document itself (other than to show
placement within the article).
11. We CANNOT accept photos taken on cell phones.
Submission deadlines:
August 5 for September/October 2010 issue
October 5 for November/December 2010 issue
December 5 for January/February 2011 issue
111
Hair Transplant Forum International
July/August 2010
Dr. Jimenez’s Message
 from page 111
disease is very frustrating for women affected by it, since
most medical therapies do not work and hair transplantation does not seem to be an option because it does not stop
the progression of the disease and the chance for long-term
auto-destruction of the implanted grafts is very high. So why
does this occur almost exclusively in women, most of them
postmenopausal and older than 55 years old, and why we are
seeing so many cases now when 20 years ago this disease
had not even been described? Could it be that we are facing
a new toxic, environmental disease? These are but a few of
the unsolved questions for this mysterious disease.
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We proudly announce we have
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Paco Jimenez, MD
Advanced FUE Handpiece:
Dr. Nusbaum’s Message
• Autoclavable
• Cordless
• Oscillating tip
 from page 111
Robert True, which I think is certainly thought-provoking
and which I know you will enjoy reading. We are fortunate
to have received yet another article from Dr. Damkerng
Pathomvanich’s group in which lead author Dr. Theresa
Cacas and associates present their “quick reference” method
for identifying what I consider the most important anatomical structure in hair restoration: the location of the occipital
neurovascular bundle. In “How I Do It,” Dr. Michael Beehner
presents an interesting technique for avoiding the nemesis
area for strip excision: the mastoid region.
I hope you find this issue to be informative and enjoyable.
Visit our website for our other
newly designed products:
www.atozsurgical.com
The leader in instruments and accessories
for Hair Restoration Surgery
Bernard Nusbaum, MD
2009–10 Board of Governors
2009–10 Chairs of Committees
2010 Annual Scientific Meeting Committee: Paul J. McAndrews, MD
American Medical Association (AMA) House of Delegates (HOD) and
Specialty & Service Society (SSS) Representative: Carlos J. Puig, DO
(Delegate)
Annual Giving Fund Chair: Matt L. Leavitt, DO
Audit Committee: Robert H. True, MD, MPH
Bylaws and Ethics Committee: Robert T. Leonard, Jr., DO
CME Committee: Paul C. Cotterill, MD
Core Curriculum Committee: Edwin S. Epstein, MD
Fellowship Training Committee: Nilofer P. Farjo, MBChB
Finance Committee: Carlos J. Puig, DO
Hair Foundation Liaison: E. Antonio Mangubat, MD
Live Surgery Workshop Committee: Matt L. Leavitt, DO
Media Relations Committee: Robert T. Leonard, Jr., DO
Membership Committee: Marc A. Pomerantz, MD
Nominating Committee: Jennifer H. Martinick, MBBS
Past-Presidents Committee: Bessam K. Farjo, MBChB
Pro Bono Committee: David Perez-Meza MD
Scientific Research, Grants, & Awards Committee:
Michael L. Beehner, MD
Surgical Assistants Executive Committee: Laureen Gorham, RN
Surgical Assistants Awards Committee: Cheryl J. Pomerantz, RN
Task Force on Hair Transplant CPT Codes: Robert S. Haber, MD
Website Committee: Cam Simmons, MD
Ad Hoc Committee on Database of Transplantation Results on Patients
with Cicatricial Alopecia: Nina Otberg, MD
Ad Hoc Committee on Regulatory Issues: Paul T. Rose, MD, JD
Evidence Based Medicine (EBM) Task Force: Sharon A. Keene, MD
Strategic Task Force (#3) on Increasing Physician Membership:
Edwin S. Epstein, MD
Strategic Task Force (#5) on Resources for Training Assistants:
Jennifer H. Martinick, MBBS
President: Edwin S. Epstein, MD *
Vice President: Jerry E. Cooley, MD*
Secretary: Jennifer H. Martinick, MBBS*
Treasurer: Carlos J. Puig, DO*
Immediate Past-President: William M. Parsley, MD*
Michael L. Beehner, MD
Vincenzo Gambino, MD
John D. N. Gillespie, MD
Alex Ginzburg, MD
Robert S. Haber, MD
Sharon A. Keene, MD
Jerzy R. Kolasinski, MD, PhD
Robert T. Leonard, Jr., DO
Bernard P. Nusbaum, MD
Arthur Tykocinski, MD
Surgical Assistants Representative:
Emina Karamanovski
*Executive Committee
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Hair Transplant Forum International
July/August 2010
Notes from the Editor Emeritus
Russell Knudsen, MBBS Sydney, Australia [email protected]
Doesn’t it still strike you as ironic
that, in 2010, while achieving the best,
most natural hair transplant (HT) results via FU grafting that have ever been
seen, we, as a medical specialty field,
still attract such low regard in the online
blogosphere?
Why is this so? I will contend that a
significant factor is that many practitioners
in our field confuse the product with the service.
The product in our field is the FU graft (produced by
either strip excision or FUE).
The service is the design and execution of the movement
of the FU grafts from the donor to the recipient areas to
achieve the patient’s goals in the most natural manner.
When you market a product, the consumers (our patients)
expect uniform quality of the branded product, wherever the
product is purchased. This allows the consumer to judge a
purchase decision around pricing. A GE toaster is still a GE
toaster wherever you make the purchase.
When you market a service, the consumer is critically
aware it matters who is providing the service as to expectations regarding the quality of the service. Consumers accept
that differential pricing is appropriate and will make decisions based on a value judgment of the service offered.
So, how does this impact on the HT industry? It has long
been my view that competitive advertising utilizing pricing
is self-defeating as it persuades the potential consumer (patient) that judging the product (FUT/FUE) by pricing alone
is appropriate, as the service is equivalent among different
practitioners. Competition in the marketplace is generally
good as it helps lift standards. Competition that belittles the
service (the “race to the bottom” of ever cheaper advertised
graft prices) is likely to lower standards as doctors and
clinics seek ways to make the diminishing financial returns
remain profitable.
This, in some cases, means that the doctor’s involvement
in the procedure is minimized and the assistants input is
maximized.
I believe successful marketing revolves around perceived
value, which can be seen as a combination of the product
and the service. Perceived value, while influenced by pricing,
isn’t solely decided by pricing.
What influences perceived value? A combination of
factors: choice of surgeon (or clinic) based on reputation,
experience, personal involvement in the operation, demonstrated outcomes in other patients, etc. The analogy I prefer
is that performing a hair transplant is like hand-building
a car. It might be cheaper to mass-produce the “car” (the
Model T Ford production line approach), but the perceived
value of the hand-built vehicle (Rolls Royce, Ferrari, Lamborghini, Aston Martin, etc.) justifies the extra expense as it
is recognized as a luxury service. You can still price as you
wish, but you are not selling to the cheapest-option sector
of the marketplace. Let’s remember that every outcome of
our procedure is unique. There is no general equivalence
as to the result as it depends upon both the design and the
execution of the procedure.
If we take these factors into consideration, how do we
increase the perceived value of our product/service?
First, we doctors must reclaim the operation. Stick-andplace by assistants can have a role but, for most of us, we
need to be seen to be performing the operation. For purely
philosophical reasons, I am the only person allowed to cut
the patient. It is then MY operation and I will take FULL
responsibility for the result.
Clinics that pretend that a doctor oversees the procedure while having little to no role do us a disservice. As our
president, Dr. Ed Epstein, discusses in his Forum column, the
oncoming mechanization of FUE harvesting might make it
attractive for doctors to divest the harvesting to their staff or,
far worse, encourage non-medical “independent contractors”
to market their FUE services to largely uninvolved doctors
seeking a quick secondary source of income.
Success in our field is not solely based upon quality
outcomes. It is also based upon patient satisfaction with
our quality outcomes. For this, we need to develop good
relationships with our patients that will lead to trust and
respect.
If we don’t respect ourselves and our procedure, how can
we expect prospective patients to do so?✧
113
Hair Transplant Forum International
tion hard working and dedicated to the development of the
Surgical Assistants Program.
As Chair of the Committee on developing a Staff Training
Program for doctors, which has been a year in completion, and
in which Cheryl was an instigator, it saddened me to learn of
her death on the same day as the program was finalised.
Cheryl will live on in my heart, although she will be
greatly missed.
Marc, may it comfort you to know that my friendship is
always there. All I can offer you is tender compassion and
understanding.
Saying goodbye is the hardest thing I’ve ever had to do.
I’ll miss you Cheryl, forever.
Jennifer Martinick, MBBS
There are no words that can accurately depict Cheryl’s
dedication and influence on the ISHRS. She was selfless in her
efforts to build awareness of the importance of assistants in
the field and develop meaningful educational forums to raise
our standards. From a personal perspective, Cheryl was a
genuine, warm and caring friend. I will miss her.
Matt Leavitt, DO
It was with profound sadness to learn from Marc of
Cheryl’s sudden death. It truly was a shock not only to me,
but to our entire profession.
There are three things that come to mind when I think
of this lovely lady. First, were the many talks we had about
how we each felt that the profession of medicine has become
so less professional. We discussed (and lamented) how,
especially in our field, that underhanded business practices
and unethical behavior have too often overshadowed the
doctor-patient relationship. We talked about how doctors—colleagues—so often denigrated one another simply
to “make a sale” of patients who visited various offices in
their due diligence in deciding who to choose to perform
their procedure. We usually talked about too much of taking
the low road instead of the high road….
Secondly, I have such high respect for Cheryl’s continuous hard work to make our procedures more safe, efficient,
and comfortable for our patients. She taught hair transplant
assistants and physicians alike on these topics. In addition,
because I sincerely love our Society, I always did and continue to thank her for all the work she had done to make the
ISHRS what it is today. For this I am eternally grateful.
Lastly, what a stylish diva Cheryl was! She provided
panache and fun and elegance to all of our meetings! Her
signature headgear will never be forgotten. As a husband, I
also observed how very much she loved Marc—how fortunate he has been to have her as a partner and wife.
HATS OFF TO YOU, CHERYL! May your memory be
eternal!
Robert Leonard, DO
Truly a shock. She was a gift of God to all of us. Always
something to contribute, and willing to help in any way she
could. We will all miss her.
Carlos J. Puig, DO
July/August 2010
A few years ago I had the pleasure of working with Cheryl
as a member of a task force chaired by Carlos Puig, in the
early phases of designing the core curriculum for the CDbased assistants program. My participation was brief as I
left to take on the role of Scientific Chairman for our annual
meeting. Truthfully, I really wasn’t needed since I found in
our first conversations she had already written and organized
comprehensively all the core points that I would have recommended! In particular, I recall the conversations Cheryl and
I had about OR etiquette and staff professionalism. I was
amazed to learn we abhorred similar stories from patients
who recounted their experiences with some clinics where
operating staff didn’t seem to understand that even though
hair restoration is elective, cosmetic surgery, it was surgery,
and rules of operating room etiquette still applied.
It was clear to me that Cheryl and I shared common values
for rules of safety and appropriate behavior when it came to
caring for patients. It was easy for me to see that she was an
“old school” nurse, and if you don’t know what that means,
my best description is, it’s like having a second “mom” in
the OR who takes care of you (the surgeon) as well as she
does the patient—determined to limit frustration, and provide
maximal organization so the surgeon never has to go looking
for tools or medication etc…. I knew from our conversations
that she would run a seamless operating room, and could
discern that “responsibility” was her coat of arms. We even
spoke a little bit about how she met Marc as a surgical nurse,
when he was still a general surgeon. Nurses like Cheryl are
not easy to find today, and I knew Dr. Marc Pomerantz was
a lucky surgeon to have her. But as we know, she was much
more than an OR nurse for Marc, and I am profoundly saddened for his loss. I admired her determination to make a
difference in the education of assistant staff, I admired her
flair and sense of self…only Cheryl could pull off those hats
and look fabulous in them! I will very much miss seeing her
at our meetings, and miss the intelligence and leadership
she showed for excellence in the education and training of
nurses and assistants. I am deeply saddened that she will
not be present any longer at our meetings, but her contribution will live on in all that she has done to promote quality
education and patient care.
Sharon A. Keene, MD
Cheryl was active with her husband, Marc, in the ISHRS
even before the by-laws were written and approved. When
the by-laws included an Assistants Ancillary she took action
and, with the help of her friends, organized the first meetings. For a decade or more the highly successful meetings
of the assistants group were largely the efforts of Cheryl.
She represented the assistants at the Board of Governors
meetings and strongly championed their cause.
The ISHRS meant a lot to Cheryl and Cheryl meant a lot
to the ISHRS. We will deeply miss her.
Paul Straub, MD
I felt so sad to hear that Cheryl had passed away. I will
miss her but her spirit may be with us in the assistant
workshop in Boston.
Damkerng Pathomvanich, MD
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Hair Transplant Forum International
July/August 2010
Cheryl always had a big presence when she entered a
room, as demonstrated from her big voice, big hats, big ideas
that she wasn’t timid to share, and her big heart. I got to
know Cheryl when I was Chair of the Washington meeting
and she was the Surgical Assistants Chair. Cheryl always had
novel ideas on ways of teaching the assistants, and getting
people involved, from auctions to cookbooks. Cheryl always
stood up for those she worked with and always spoke her
mind. She deserved and was given a lot of respect from those
around her. I will miss Cheryl, from her grand entrances to
her grand concern for others.
Paul Cotterill, MD
In 1996, I didn’t know Cheryl
Pomerantz very well. She wore crazy
hats, and I assumed she was just an
eccentric lady. I was the program
chairman for the ISHRS meeting in
Barcelona, and the program included
a live surgery session that I was expecting to be a highlight. The evening
before the session, I met with several individuals involved, and Cheryl
joined us, uninvited. She proceeded to
ask me question after question. How
was I prepared for various scenarios?
What steps had I taken to assure
safety? Questions about instruments,
traffic flow, and more. As she asked
these questions, my heart sank, as
my responses were ill prepared, and I
saw disaster looming ahead. However,
after identifying many deficiencies,
Cheryl then cheerfully offered to solve
them, and off she went. In less than
12 hours, she managed to reorganize
the entire live surgery program, and it
ran as smooth as silk. From that moment on, Cheryl was my
heroine. It’s easy to find fault in a plan. It’s not all that difficult
to know how to solve those faults. But it’s quite extraordinary
to actually volunteer to solve a myriad of problems, in a foreign
country, at a moment’s notice, and succeed. And why did she
do it? Patient care. Her involvement wasn’t about making the
doctor’s experience better, but rather about making sure that
nothing diminished the care that the patients were to receive.
And in the fourteen years since that meeting, her focus on and
devotion to the patient never wavered. I miss her already.
Cheryl had a wonderfully creative side to her life and she
loved to surprise us with her latest hats and beautiful gowns;
all of which she designed and sewed herself.
We all loved Cheryl and recognized her many contributions.
We all mourn together across the miles that separate us.
Marilynne Gillespie, RN
I was shocked when I learned of Cheryl’s unexpected
death. She passed away peacefully in her sleep over the
Independence Day holiday weekend
here in the U.S. As her son Justin
said at the funeral, this was fitting
for Cheryl’s death to be timed to a
celebration, because she was a celebration of life. For those who knew
her, Cheryl was smart, outspoken,
passionate about her field, and very
energetic. She liked things done her
way and let those of us who worked
with her know it. (smile) Cheryl
was my friend, and I felt a special
closeness with her because we are
both from the Chicagoland area.
Cheryl made an entrance and could
not be missed at the annual Galas.
I was looking forward to seeing her
again at the Boston meeting. Now
we will only have her memory. Rest
in peace, Cheryl. We will miss you
very much.
Victoria Ceh, MPA
When I first joined the ISHRS team
as designer/editor of the Forum, I had
the pleasure of communicating with
Cheryl, then the assistants editor, as we looked to build up
the Surgical Assistants Corner. When the phone would ring
and Cheryl was on the other line, my husband would hand
me the phone, grab a book, and leave the room—he knew
it would be a while.
Cheryl was a unique personality that grabbed you in.
I couldn’t help but admire her intelligence, passion, and
dedication, which shown through with every conversation.
Her sparkle will truly be missed.
Bob Haber, MD
I have always thought of Cheryl Pomerantz as “larger than
life,” so it is difficult to comprehend that she is no longer
with us. Cheryl’s loyalty and passion for our organization
knew no bounds. She was the glue that kept our Surgical
Assistants Program together as we struggled to become
established and recognized.
Cheryl was committed to welcoming and teaching newcomers and “rounding up” those of us who had been around
for awhile to help her with her many projects.
115
Cheryl Duckler
Hair Transplant Forum International
July/August 2010
A comparison between the preview long hair technique
and the classic hair transplant technique
Márcio Crisóstomo, MD Fortaleza, Brazil [email protected]
Introduction
The classic hair transplant technique involves shaving
hair from the donor area and having it transplanted while
short to the bald area. The patient must wait 6-12 months
to see the surgery’s result, which in some cases may create
great anxiety both for the patient and the surgeon.1
The long hair transplant was first mentioned by Bouhanna
in 1989.2 In 2006, Brazilian plastic surgeon Dr. Marcelo
Pitchon published the preview long hair (PLH) technique,
which involves transplanting hair in its natural length and
allows for the probable result to be visualized immediately
following the surgery (Figure 1).3 This technique has been
adopted by a number of authors since then.4,5
volved trimming the donor hair until it was 4-5 centimeters
long (Figure 2B). Follicular unit (FU) preparation, conservation, and implantation were carried out following a similar
procedure with the difference being that the hair was longer
in the PLH group (Figure 3). It is important when using the
PLH technique to exercise care not to pull implanted long
hair and to constantly wash the area in order to prevent
blood from accumulating.
The following variables were analyzed and compared: 1)
time spent removing the donor strip; 2) time spent implanting FUs; 3) total surgery time; 4) total FUs obtained per
cm2 of donor area; 5) number of implanted FUs; 6) speed
of implantation (FU/min); 7) time until crusts were shed;
Figure 1. Long hair transplant. A: Marking of anterior hairline; B: appearance
immediately after surgery.
Figure 2. A: Marking of donor area for surgery according to the classic technique; B:
marking of donor area with hair maintained in its natural length for surgery according
to the PLH technique.
In addition to seeing the immediate results, the following
are advantages mentioned by Dr. Pitchon: 1) this method
allows the surgeon to assess during the surgery whether
the amount of transplanted hair is sufficient to cover the
intended area and adjustments can be made wherever necessary; 2) the preparation of white hair is easier, so there
is less transection and a lower probability of implanting
hair in the opposite direction, which would cause inclusion
cysts; 3) thicker and non-aesthetic follicular units are more
easily avoided at the anterior hairline; and 4) the crusts are
covered by longer hair and therefore the patient stays away
from his or her usual activities for a shorter time.3
The aim of this research was to compare the classic hair
transplant technique with the PLH technique, taking into account technical aspects pertaining to the surgical procedure
as well as the post-operative period and final results.
Figure 3. A: Microscopic view of follicular units of shaved hair (10× enlarged); B:
microscopic view of follicular units of long hair (10× enlarged).
Method
A prospective study was carried out with 20 male patients
who underwent surgery between October 2008 and January
2009. Ten patients underwent the PLH technique (PLH group)
and 10 the classic technique (CT group).
Both groups had a similar average age—43.5 for the
TFL group and 40.6 for the CT group, t test (p=0.59). Both
groups had an equal distribution according to the Hamilton/Norwood baldness classification.
The classic technique involved shaving the donor area
with an electric razor (Figure 2A). The PLH technique in-
Figure 4. Surgery times for both groups (donor area harvesting, FU implant, and total
surgery time), minutes (mean±standard deviation).
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Hair Transplant Forum International
8) time until patients returned to their social activities; and
9) assessment of result after 6 months and, for the PLH
technique, a comparison of the 6-month result with the
immediate result.
Normal curves were determined for all variables; the
sample mean and standard deviation (SD) were also calculated. Student’s t test and the respective probabilities were
calculated to compare the means for both groups.
July/August 2010
was 1,663 (SD±155). This difference was not statistically
significant (p=0.66).
It took longer for crusts to shed in the PLH group (14.3
days, SD±3.5) than in the CT group (10.4 days, SD±3.1)
(p<0.05). Patients from the PLH group returned to their
social activities in less time than patients from the CT group
(Table 1).
Time to Return to Social Activities
Results
The surgery took longer for the PLH group than the CT
group, both in terms of harvesting the donor area as well as
the time spent implanting FUs and the surgery’s total duration. The difference in the three variables was statistically
significant (Figure 4). The average speed of implantation was
significantly faster for the CT group (Figure 5).
The average donor area of patients from the PLH group
was 32.1cm2 (SD±5.5), which was significantly larger than
that of the CT group of 26.3cm2 (SD±3.6) (p=0.05). The
average hair density (number of FUs produced per cm2 of
donor area) obtained in the PLH group was 54.3 FU/cm2
(SD±12.3); in the CT group it was 63.8 FU/cm2 (SD±6).
This difference was not statistically significant (p=0.08).
The average number of implanted FUs in patients of the
PLH group was 1,717 (SD±258), and in the CT group it
Preview Long Hair
Classic Technique
< 7 days
4
2
7-14 days
6
5
> 14 days
0
3
Table 1. Time elapsed after surgery until patients returned to their social activities.
The similarity between the result obtained on the first
day and that obtained after 6 months by the PLH group was
deemed to be higher than 80% by 8 patients and between
60% and 80% by the remaining patients (Figures 6 and 7).
Of the PLH group, 7 believed it was a positive thing to be
able to preview the result, 3 said they were indifferent to it,
and none believed it was a negative.
Figure 7. Male patient, aged 68, class VI baldness,
submitted to an implant of 1,856 FUs using the long
hair transplant technique. A: Preoperative; B: first
postoperative day; and C: 6 months postoperative.
The assessment of results after 6 months made by patients from both groups after analyzing the pre- and postoperative photographs was the same (Table 2).
Preview Long Hair
Classic Technique
Excellent
Good
Average
7
7
3
3
0
0
Poor
0
0
Table 2. Subjective assessment made by patients from both groups regarding the
result obtained after 6 months.
Discussion
Figure 5. A comparison between speeds of implant (FU/min) for both groups
(mean±standard deviation).
Figure 6. Male patient, aged 41, class IV baldness,
submitted to an implant of 1,289 FU using the long
hair transplant technique. A: Preoperative; B: first
postoperative day; C: 6 months post-operative.
The long hair transplant, or PLH, is a breakthrough
because it transforms hair transplant surgery, which traditionally requires patience to verify the final result, into a
procedure that allows for a preview of this result.3
In this study, 70% of patients who were submitted to
the PLH technique saw as positive the fact that they could
have an idea of what the later result would be. Eight of 10
patients from the PLH group believed that the result obtained
6 months after the surgery was over 80% of that seen on
the first day. The patients also mentioned that this preview
allowed them to have a realistic expectation of what would
be obtained from the surgery, and therefore, it was easier
to understand the need for a second procedure to increase
hair density, if necessary.
 page 118
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Preview long hair technique
 from page 117
Lowering anxiety levels would not be enough to change a
well-established surgical routine if there were any negative
consequences to the final result. Such a negative effect might
be predicted if there was a decrease in the number of FUs
implanted, or an excessive increase of surgery time that led
to a longer period of ischemia to the grafts.6
In this study, there was no decrease in the number of
hairs transplanted using the PLH technique.
The speed of implantation was significantly faster for
patients who were in the TC group (p<0.002). The PLH
technique, however, requires greater care at implantation so
that hairs do not get tangled with those already implanted
and to avoid pulling them accidentally and consequently
extruding the FU from its recipient site.4,5 The hair must be
washed with saline solution and combed to remove blood
several times during the PLH procedure. Such care aims to
prevent hairs from being stuck together because of clots,
which makes it easier for them to get pulled accidentally,
and this may have contributed to the increased surgery time
seen in our study.
The time spent implanting FUs for the PLH group was
significantly longer than for the CT group. Time spent removing the FUs was also longer. As a result, the PLH group’s
total duration was significantly longer (p<0.0006); however,
a 6-hour time limit was never exceeded.
In the post-operative period, the formation of inclusion
cysts was determined less for patients who were in the PLH
group since visualizing the long hair practically excludes
the possibility of implanting hairs backwards, which is one
of the causes of such cysts.3
The visibility during the period in which crusts appear is
lower when using the PLH technique because the long hair
offers a natural camouflage. This makes that period less
perceptible (Figures 6 and 7).3 Although it took longer for
crusts to shed for patients in the PLH group, it was noted
that patients in this group returned sooner to their usual
activities. This was probably due to the above-mentioned
camouflage effect.
An important piece of information obtained was that the
patients’ assessment of the result achieved with both techniques was the same. This shows that the final result was
not affected by the choice of surgical technique and that the
choice between using the classic technique or the preview
long hair technique can be made by the surgeon and patient
without any consequence to the final result.
July/August 2010
References
1. Uebel, C.O., ed. Hair restoration: micrografts and flaps. São
Paulo, Brazil: OESP Grafica; 2001.
2. Bouhanna, P. Greffes a cheveux longs immediats. Nouv
Dermatol. 1989; 8(4):418-420.
3. Pitchon, M. Preview long-hair follicular unit transplantation: an immediate temporary vision of the best possible
final result. Hair Transplant Forum Int’l. 2006; 16(4):113115.
4. Bertram, N.G. A simple do it yourself tool to prevent
tangling of grafts in long hair transplantation. Hair
Transplant Forum Int’l. 2009; 19(4):133-134.
5. Crisóstomo, M.R., et al. Comparação entre a técnica
clássica de transplante de unidades foliculares e o
transplante de fios longos (preview long hair). Rev Bras
Cir Plast. 2010; 25(1):117-126.
6. Greco, J.F., R.D. Kramer, and G.D. Reynolds. A “crush
study” review of micrograft survival. Dermatol Surg.
1997; 23(9):752-755.✧
A note from Dr. Marcelo Pitchon
Belo Horizonte, Brazil
Dr. Crisóstomo deserves compliments for his beautiful
study comparing the preview long hair (PLH) technique
and the classic technique. Many other Brazilian and nonBrazilian surgeons have learned the long hair technique
and are now performing it in 100% of their cases, as I have
been doing since my very first patient in 2004. Every new
surgeon performing the PLH technique is adding personal
experience from his or her own background with the conventional technique. Variations include stick-and-place;
pre-made incisions; mixed styles; four- or two-handed
insertion; local anesthesia or sedation; small, medium, or
large sessions; coronal or sagittal, etc. The personal comparison that each surgeon perceives between PLH and the
classic conventional technique will be different from that of
others according to experience, ability, and the efficacy of
personal style to achieve the main objectives of this technique, which are fascination of the patient and enhancing
patients’ perception of the type of quality hair transplant
surgery achieved by our field. (I am considering here objectives evaluated from the patients’ perspective and not the
technical advantages that patients cannot compare, such
as the visual definition by the surgeon of the ideal density
and hence optimization of the donor resource.) Issues like
the incidence of tangling and extrusion of grafts caused by
bleeding, clots, and other factors may vary considerably
from surgeon to surgeon being influenced by his particular
way of working. The increased duration of procedure issues has always been present in every significant scientific
advance in our field (e.g., microscopic dissection) and, with
time, has ceased to be an issue. Technical individual differences between surgeons’ styles can make the comparison
between two techniques in any study’s specific surgical
environment valid, yet almost impossible to generalize to
a broader universe of surgeons utilizing the PLH concepts
or to the PLH methodology itself. Although Dr. Crisóstomo
has reinforced and correctly alerted us to some important
details regarding the care necessary to deal with long hair
grafts, his study confirms many, if not all, the findings
Conclusion
Surgery time was longer for the PLH group due to a
longer time spent harvesting the donor area, but mainly
from a longer time spent implanting the follicular units. The
surgery’s total duration did not exceed 6 hours for any of
the patients, and the number of follicular units was similar
for both groups. The anxiety of waiting to see the result
was lower for patients in the PLH group, and the assessment of the final aesthetic result was considered equal for
both techniques.
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July/August 2010
reported in the 2006 article, “Preview long hair follicular
unit transplantation: an immediate temporary vision of the
best possible final result” (Pitchon, M. Hair Transplant Forum
Int’l. 2006; 16(4):113) and stimulates other surgeons to experience for themselves the pleasure of giving patients the
PLH technique. I am sure that if, in a future study, we could
include a group of patients who were previously submitted
to the conventional technique and would now be submitted
to the PLH technique, we would probably have this group
totally or almost totally in favor of the PLH method.
The PLH concept and technique were developed in order
to show the current state of hair transplantation excellence.
It was originally conceived to show, but not only show;
to show immediately, how beautiful, emotional, artistic
and fascinating today’s hair transplantation is. It is very
difficult to compare the PLH technique with the classic
one because objective comparisons do not take the above
main subjective elements into account in a measurable
way. To perform PLH in the totality of its conception, these
and other subjective elements are essential, and obviously associated with the objective and scientific ones.
As an example, in order to show results on the same day
of surgery (without a dressing to hide them), you must
have a beautiful bloodless post-operative field (also intraoperative, if possible) and incisions that perfectly fit the
grafts so that they do not bleed easily and stay firm and
difficult to remove, no matter if the PLH or CT technique
was used. After surgery the hair should always be well
cleaned and parted the way the patient likes because it
provokes patients’ positive reactions and emotions. So if
the surgeon performing the conventional technique makes
incisions too big for the grafts, he will first have to make
a move into customized incisions in order to step toward
PLH. The PLH technique has a learning curve that started
for me before its conception in 2004, I am referring to a
curve focused on improving the classic technique as much
as possible before a novice to PLH starts performing it.
Thus, I think that the extra time spent at the beginning of
the PLH learning curve is also due to details that are not
exclusively inherent to PLH, but rather to the improvement
of the classic technique itself. Just leaving the hair longer,
without an extremely refined technique, does not mean
that you can show and provide to the patient an artistic
preview, ending in the patient’s fascination. That could be
a disaster. One can leave longer hair even in gigantic old
grafts inserted into big incisions or punch holes, but this
is not something you can show to patients in order to fascinate them and promote the perception of quality in our
field, two of the most essential elements of the creation of
preview long hair follicular unit transplantation.
One last point: In my opinion, for a case to qualify as a
“preview” long hair transplant the donor hair needs to be
any length longer than shaved, whether 5mm or 15mm;
any length longer than the height or diameter of the crusts
(if they exist), since the surgeon’s objective is to produce
a preview for the patient. The expression “long hair” was
used in the original paper so that the medical community
could differentiate it from shaved hair, the current technique at that time, in 2004. The main idea centers around
the “preview” concept, and the length of the hair is just a
means of achieving that preview.
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Hair Sciences
 from page 83
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Expanding graft numbers combining strip and FUE in the
same session: effect on linear wound closure forces
Akaki Tsilosani, MD, PhD Tbilisi, Georgia [email protected]
Introduction
To achieve 5,000 follicular units (FUs) in a case of high
donor density (80-90 FUs per cm²), it is necessary to harvest
a strip of not less than 60cm². When strip length is limited
to 25-30cm, the width of the strip in the center has to be
increased up to 3cm. This is only possible when there is
very good scalp flexibility. Donor zone closure under such
tension increases the risk of wide donor scar formation.
Though scalp exercises before surgery can improve laxity
and increase yield by anywhere from 500-1,500 FUs,1 often
this is not sufficient.
In order to reduce strip width without decreasing the
number of grafts transplanted during an operation, in 2006
we decided to combine FU strip excision (FUS) with FU extraction (FUE). Conducting the operation using the combined
techniques of FUE and strip excision is very simple. First,
the strip edges subject to excision are marked. Strip width in
such cases seldom exceeds 2cm (the length usually ranges
from 20-28cm). Above and below the strip edges, 500-1,500
grafts are harvested using the FUE method followed by a strip
excision; this generates from 2,500 up to 3,500 additional
grafts depending on the density. As a result, 3,000-5,000
follicular units are obtained for transplantation (Figure 1).
expanding the area by 10-15%). Strip average width varied
from 1.2-2.0cm (after the excision, the average strip width
shrank to 1.0-1.6cm). The maximum width of a strip to be
excised was determined based on the clinical estimation of
scalp mobility of a particular patient, though all widths were
extremely large for these patients.
In all subjects, scalp tension during donor wound closure
was measured. To achieve this, retention sutures involving
the dermis at equidistant points 5-8cm from the wound
center were placed. Retention sutures placed on the upper
wall of the wound were attached to one dynamometer, and
sutures put on the lower wall of the wound were attached
to another (Figure 2). Next, the assistant accurately moved
the dynamometers in one plane at right angles to the wound
in different directions, stretching the wound edges until the
moment of contact. Readings of both dynamometers were
registered. The sutures were then removed.
Figure 2. Scalp tension
forces measurement
after strip excision.
This method not only provides the ability to harvest the
necessary quantity of grafts, but also substantially decreases
tension on the donor wound closure.
The purpose of this study was to compare and analyze
scalp tension forces while closing donor wounds immediately following strip excision and before and after additional
FUE extraction in patients with low donor density and poor
laxity.
Scalp tension forces during donor wound closure were
determined as the sum of forces applied to the upper and
lower ends of the wound necessary for adjoining its edges.
The obtained data was statistically processed.
The wound was then temporarily packed and we proceeded with the FUE extraction of grafts above and below
the strip donor area to try to obtain at least 30% additional
grafts than was generated through strip excision. We used
0.75 and 1.0mm punches for graft extraction. The quantity of
grafts obtained with FUE varied from 450-1,500 FUs (Figure
3). At the completion of the FUE procedure, scalp tension
was measured a second time as described above (Figure 4).
Next, a lower edge trichophytic closure of the wound with
one-layer continuous 5-0 monocryl was performed.
Materials and Methods
Results
Figure 1. Donor area
after 1,500 FUs extracted
and strip excision giving
3,520 FUs—total of 5,020
grafts.
Twenty patients aged 25-55 with poor scalp laxity and
with low or average donor density underwent hair transplantation with the purpose of correcting male pattern alopecia
of high degree (Norwood IV-VII). The quantity of grafts
obtained via a strip varied from 2,500 up to 3,500 follicular
units. Using a single-blade scalpel, an 18-28cm–long ellipse
shape was excised from the donor area under local anesthesia. The maximum width in the occipital prominence was
1.8-2.8cm (the measurement was taken following anesthesia
The power required to approximate the donor wound
edges (scalp tension power) without the additional FUE
procedure varied from 3.4-8.8 kg-f depending on scalp
flexibility and the number of obtained grafts (strip width).
The average tension power in cases of transplantation of
2,505-3,544 FUs was 4.92±0.09kg-f. After FUE extraction
of 450-1,500 FUs, the necessary power for approximation
was 2.1-5.3kg-f, average 2.95kg-f, p<0.001% (Table 1).
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Expanding graft numbers
 from page 121
Figure 3. Donor area
immediately after strip
excision and 1,200 FUs
extracted.
Figure 4. Scalp tension
forces measurement after
strip excision and 1,200
FUs extracted.
It was observed that if, through FUE, at least 30% additional grafts are generated, then compression forces
decreased by half during wound closure. For example, if a
patient had 1,200 FUs extracted above and below the excised
strip (which generated 3,306 grafts), this would decrease
scalp tension power from 6.4kg-f to 3.1kg-f. If FUE would
generate less than 30% of the quantity of strip grafts (e.g.,
450 FUs per 2,512-graft strip), then
the compression force during wound
Number of
closure did not decrease significantly.
transplanted
N
grafts
On average, after FUE, scalp tension
power varied from 4.92-2.95kg-f,
which accounts for a 40% decrease.
1
3,306
Donor wounds in all patients healed
2
2,568
3
2,540
as cosmetically acceptable scars
4
2,500
(Figure 5).
Discussion
If there is a possibility of transplanting the needed amount of grafts
in one session, the patient only benefits for the following reasons:
1. The optimal cosmetic benefit of
the hair transplant surgery is obtained earlier (1 year after the first
session, instead of 1 year after the
subsequent, or last, session).
2. All the inconveniences related to
the surgery are experienced only
one time.
3. As long as one large session is
offered at a discounted cost per
graft, the patient benefits economically.
Figure 5. One of the observed
patient’s donor area after 8
months.
Large sessions have additional advantages. In our opinion, there is a better final donor scar (even with the donor
strip being wider, the final result will be better than after 2
or 3 incisions in the same place). There is no previous scar
deforming the anatomy, so there is less risk of damage to the
nerves and arteries. In many cases, the first session grows
best,2 maybe because of the hypothesis of less recipient
area scarring leading to better growth or because of some
other reason, based on the fact that growth is much better
on the virgin scalp.
Many surgeons, however, believe that performing large
sessions is associated with lots of difficulties. After analyzing these problems, we can list three possible complicating
factors:
1. Placement of large numbers of grafts close to each other
may compromise the vascularity of the recipient area,
which can lead to decreased graft survival.
2. Long operative time (8-12 hours) increases the risk of time
out of body and graft dehydration, and tires the patient
and staff, which can affect the quality of the work.
Maximum
width
of donor
strip (cm)
2.60
2.20
2.00
1.90
2.40
2.00
2.30
2.40
2.00
2.30
2.50
2.20
2.20
2.60
2.50
2.40
2.00
1.80
2.20
2.40
2.36
5
3,544
6
2,525
7
2,580
8
3,032
9
2,600
10
2,860
11
2,910
12
2,772
13
2,545
14
2,622
15
3,520
16
3,152
17
2,622
18
2,512
19
2,705
20
2,510
M
2,943
m
t=22.23
p<0.001
Number of
additional
FU grafts
1,200
800
1,000
600
1,200
600
800
1,000
800
1,000
1,000
1,000
700
700
1,500
450
600
450
800
500
Table 1.
122
Tension forces applied to the upper and
lower edges of the wound necessary for
their adjoining kg-f
After strip excision
After strip excision
and FUE
3.2+3.2=6.4
2.0+2.0=4.0
2.5+2.5=5.0
2.5+2.5=5.0
3.0+3.2=6.2
2.2+2.3=4.5
1.9+2.0=3.9
2.7+2.7=5.4
2.3+2.2=4.5
2.6+2.5=5.1
1.9+2.0=3.9
2.8+3.0=5.8
2.2+2.4=4.6
4.6+4.2=8.8
2.8+2.9=5.7
2.4+2.1=4.5
1.8+1.6=3.4
1.7+1.7=3.4
2.3+2.4=4.7
1.8+1.7=3.5
4.92
0.09
1.6+1.5=3.1
1.4+1.5=2.9
1.5+1.0=2.5
1.5+1.6=3.1
1.8+2.0=3.8
1.5+1.5=3.0
1.1+1.0=2.1
1.5+1.8=3.3
1.2+1.2=2.4
1.2+1.2=2.4
1.2+1.2=2.4
1.2+1.4=2.6
1.5+1.5=3.0
2.6+2.7=5.3
1.5+1.5=3.0
1.4+1.5=2.9
1.4+1.6=3.0
1.2+1.6=2.8
1.2+1.2=2.4
1.4+1.5=2.9
2.95
0.02
Hair Transplant Forum International
July/August 2010
3. Wide strip excision in patients with low donor density
and poor scalp flexibility causes an unacceptable scar.
4. Tsilosani, A. One hundred follicular units transplanted
into 1cm² can achieve a survival rate greater than 90%.
Hair Transplant Forum Int’l. 2009; (19)1:1.✧
On the other hand, large sessions are performed on
Norwood classes IV-VII, in whom the recipient area exceeds
100cm². Transplanting even 4,000-6,000 FUs results in an
average density of less than 50 FU/cm². Recent research has
shown that small (less than 1mm), sharp instruments used
for recipient site creation do not compromise blood supply
and do not decrease graft survival, even with densities of 70
FU/cm.2-4 Today, 40-50 FUs per cm² is considered safe.
We think that large sessions are impossible without a
very large staff. While performing them, we always pre-make
recipient sites and work in three teams:
I – surgeon and 1-2 nurses
II – cutters (1 leading cutter for slivering and 8 other
cutters)
III – implanters (3 experienced implanters and 1-2 assistants for cleaning and drying recipient sites)
A note from Dr. Robert H.True
New York, New York
FUE and strip donor excision (FUT) are increasingly
being seen as complementary techniques. At the 2009
ISHRS Annual Meeting in Amsterdam, I presented several
models in which FUE and FUT are both performed in the
same procedure. One of the models is to do as described
in this paper; that is, to perform FUE immediately adjacent to the sutured FUT incision. While this approach
can significantly add to the graft harvest, I have come
to prefer the approach where the FUE zone is separate
and placed 1-2cm above the FUT zone. In my hands, this
yields the greatest additional harvest. In all cases, I remove
the strip first and suture the incision before commencing
FUE. I think this is the most efficient approach because
I am making grafts at the same time as others are being
dissected from the strip.
As to the effect of FUE on diminishing strip wound
closure tension, I would be hesitant to infer causality. Dr.
Mike Beehner and others have observed that waiting 4560 minutes before closure reduces wound tension due to
reabsorption of tumescent solution. Dr. Tsilosani notes
that with smaller FUE harvests the reduction of wound
tension was less. Presumably, these smaller harvests took
less time and the wounds were closed sooner, whereas
the time interval with larger harvests being longer may
have allowed for the reabsorption effect to fully develop.
One way to evaluate this would be to delay closure 45-60
minutes and perform FUE above and below the incision
to only half of the wound. If there was no difference in
reduction of closure tension between the two sides, any
effect due to FUE could be excluded.
In our office, transplanting 5,000 grafts, on average, takes
less than 6 hours, so we think that the only problem with
performing large sessions is poor donor supply in the patient
with low donor density and poor flexibility. The combination
of strip surgery and FUE increases the duration and the cost
of the operation; nevertheless, we believe this is the optimal
option to perform large sessions in patients with poor donor
laxity and density.
References
1. Wong, J. Preoperative care for super mega-sessions. In:
D. Pathomvanich and K. Imagawa, eds. Hair Restoration
Surgery in Asians. Springer. 2010; 81-82.
2. Seager, D.J. The “one-pass hair transplant”—a six-year
perspective. Hair Transplant Forum Int’l. 2002; 12(5):1-6.
3. Nakatsui, T., J. Wong, and D. Groot. Survival of densely
packed follicular unit grafts using the lateral slit technique. Dermatol Surg. 2008; 34(8):1016-1025.
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Hair Transplant Forum International
July/August 2010
Hair Sciences
Nilofer P. Farjo, MBChB Manchester, United Kingdom [email protected]
Centre for Skin Sciences launched
On May 11, 2010, the U.K.’s largest academic research lectures (Figure 3). Some of the research
centre in skin sciences was officially launched by an invita- projects of recent interest in the media that were presented
tion-only event at the University of Bradford. This was a at the meeting are summarized below.
poignant day for Bradford, a town in the
north of England, as it was the 25th anStem Cells
niversary of a devastating fire at Bradford
Dr. Cotsarelis spoke on epithelial
City Football (soccer) Club stadium in
stem cells and skin regeneration. His
which 56 people died and over 200 were
group at the University of Pennsylvania
injured. In the wake of the 1985 tragedy,
School of Medicine originally proposed
the University, together with plastic surthat quiescent keratinocytes at the bulge
were epithelial stem cells involved in
geon Dr. David Sharpe, set up its Plastic
hair follicle cycling, epidermal renewal,
Surgery and Burns Research Unit, which
wound healing, and carcinogenesis.
has provided a cutting-edge research
They went on to identify cytokeratin 15
facility to support the research training
of some of the most eminent plastic sur- Figure 1. Nilofer and Bessam Farjo with Prof. (K15) expression as a marker for these
geons in the U.K.—several of whom have Valarie Randall and Dr. David Woodward (Allergan, cells. Through mouse models and gene
USA) at VIP dinner
analysis they showed that bulge cells
gone on to take this experience worldwide
generate all epithelial lines within the
during their placements.
lower anagen follicle. Destroying the
Over the years, research at the Univerbulge cells resulted in permanent hair
sity has expanded to cover all areas of skin
loss but survival of the epidermis. In
science such as pigmentation, hormone
response to wounding, bulge stem cells
regulation of the skin and its appendages,
move into the wound area to assist in
hair growth, skin cancer and renewal,
re-epithelialization but these cells do
wound healing, skin lipids, transdermal
not persist. Recent work by this group
delivery, percutaneous absorption, and
showed that in mouse models, wounded
biochemistry. The University’s reputaskin regenerated hair follicles. These
tion in the field has attracted leading
hair follicles arose from non-hair follicle
researchers to Bradford from around the
Figure 2. Lecture Hall
stem cells as bulge labeled cells were not
world to create the largest group of acapresent in the wound. Furthermore, they
demic researchers working on skin and
showed that when wnt7A was over exhair in the U.K. The new Centre for Skin
Sciences, with the Plastic Surgery and
pressed, there was a three-fold increase
Burns Research Unit as an integral part,
in hair follicles.
will bring together expertise from multiple
disciplines. Professor Desmond Tobin, the
Lhx2
new Centre’s director, said of the launch:
Professor Vladimir Botchkarev of the
“This is a very exciting time to bring toCentre for Skin Science spoke about the
gether our wide range of scientific and
Lhx2 family of transcription factors that
clinical disciplines under one umbrella
control the activity of epithelial stem
Figure 3. Keynote lecturers (l to r): George Cotsarelis,
centre structure. Now more than ever Angela Christiano, Julia Newton-Bishop, Vladimir cells in the hair follicle in development
Botchkarev, Desmond Tobin
progress in the skin sciences demands
and in cycling. They demonstrated that
such a multidisciplinary approach, which
they are also involved in the control of
will help us find skin and hair health soluwound healing. In response to woundtions in partnership with colleagues in the
ing, it was shown that Lhx2+ cells in the
academic, health care, pharmaceutical,
bulge proliferated and that expression of
and personal care sectors.”
Sox9 and Tcf3&4 (markers of epithelial
The official launch included a VIP dinstem cells) increased. Their data provides
ner (Figure 1) followed by a 1-day symevidence that Lhx2 is involved in controlposium (Figure 2) that included a poster
ling the supply of the hair follicle derived
session on wound-healing research, stem
progenitor cells to the wound epithelium
cells, and pigmentation. We were honored
and also suggests that this may be a
to be invited to attend these events along
potential target for the development of
with such world-renowned speakers as
new approaches to modulation of stem
Professor Angela Christiano and Profes- Figure 4. Professor Desmond Tobin with Lord Mayor cell activity.
and Lady Mayoress of Bradford
 bottom page 125
sor George Cotsarelis who gave keynote
124
Hair Transplant Forum International
July/August 2010
One step closer: report on the AMA House of Delegates
Carlos J. Puig, DO Houston, Texas [email protected]
In June the ISHRS and all of its member physicians were of participation to be acknowledged as a mature, independent
formally recognized as an independent medical specialty by specialty by our professional colleagues.
We come to the House of Delegates at a rather fortuitous
organized medicine when it was given a seat in the American
Medical Association’s House of Delegates. With over 500 time, a time when the health care debate is on the mind of
voting delegates, the American Medical Association (AMA) virtually every American in addition to many others around
House of Delegates is one of the largest representative de- the world who are interested in how our critical issues will
mocracies in the world, and functions to provide health care be resolved. It is a time when the free market model of health
policy assessment, recommendations, and guidance to the care delivery is being challenged; indeed, it has already
medical profession as well as to state and federal govern- been severely eroded into a complex system that few can
understand. Our colleagues in “sick
ments. Being afforded a seat in this
patient medicine” are seeking indemocratic “House of Medicine”
It is the uniqueness of our
affirms the medical profession’s
novative ways to retain quality and
recognition that hair restoration
efficiency, while at the same time
multi-disciplinary evolution that expanding the service capabilisurgery is a complex, unique medical discipline that functions as an
ties of their practices and untanincreases our potential value to gling the Gregorian knot that has
independent medical specialty,
and strengthens the credential of
captured the health care industry
the ISHRS member and ABHRS
over the last 40 years. History has
mainstream medicine.
Diplomate.
proven that the best way to achieve
This is the first step, and just as
all of these goals is to provide the
an expansion of a teenager’s liberty is accompanied by addi- services in a free market environment. Because this is the
tional responsibility, this recognition brings unique additional very business environment in which we hair restoration
responsibilities to the ISHRS, that being to participate in the surgeons are most familiar, we have a unique opportunity
process that sets the standards for medical practice, profes- to share with our colleagues the wisdom we have gained by
sional interactions, and governmental regulation of the entire developing our specialty in an open-minded, patient-focused,
health care system. Recognizing that most of us have limited multi-disciplinary, free market environment.
It is exciting to see our specialty grow and be recognized.
our practices to elective cosmetic surgery to avoid these very
complexities, we find ourselves somewhat conflicted as to the Indeed, it is the uniqueness of our multi-disciplinary evolution
degree our Society should engage in these activities. I submit that increases our potential value to mainstream medicine. I
that just as the teenage driver must accept the responsibili- believe we have a lot to contribute, and we are being given a
ties of safe driving behaviors in order to be trusted with the unique opportunity to pass on our experience and to develop
family car, so too the ISHRS must accept the responsibilities a leadership position within the medical profession.✧
SWAMP
Recently the journal Nature published a study co-authored by Dr. Angela Christiano, director of basic science
research in the Department of Dermatology at Columbia
University. A mutation in the SWAMP/Apcdd1 gene on
chromosome 18 was found to produce the autosomal
dominant condition hereditary hypotrichosis simplex. Dr.
Christiano and her colleagues examined the genetic makeup
of members of two Pakistani families and one Italian family whose members have inherited the condition. The gene
they discovered inhibits a signaling pathway that has long
been shown to control hair growth in mice and along with
other genes is linked to human hair growth. SWAMP, which
comes from cell surface-tethered wnt antagonist mutated in
hypotrichosis, was found to be a novel inhibitor of wnt/bcatenin signaling.
In a recent media report, Dr. Christiano was quoted: “In
addition to providing more insight into hereditary hypotrichosis simplex, the gene research ‘gives us an inroad into
understanding male pattern baldness’ because the conditions
are similar. It may be a matter of reprogramming the hair
software because the hardware is still there.”
A long-range goal of her research is to develop genetic
and cell-based therapies for skin and hair diseases through
understanding disease pathogenesis. Much of this work has
looked at alopecia areata (AA) first with linkage studies looking
at pedigrees but more recently with association studies looking
at the whole population to look for shifts in allele percentages.
Eight genes have been found to underlie AA with increased
numbers of alleles associated with increased severity of the
condition. Gene associations with AA have been found with
rheumatoid arthritis, coeliac disease, and type I diabetes.
Other speakers from the Centre spoke on such topics as
the effect of estrogen on wound healing, the beneficial effect
of maggots on wound healing in burn patients, micro-RNAs
in hair follicle gene regulation, androgens and prostaglandins
in regulating hair growth (Professor Valarie Randall), sun
exposure and melanoma risk (Professor Newton-Bishop),
and the mechanism of melanin transfer in human skin cells
(Professor Desmond Tobin). ✧
125
Hair Transplant Forum International
How I do it
July/August 2010
Bertram Ng, MD Hong Kong, China [email protected]
Following is an excellent article from Dr. Mike Beehner. Personally, I think this approach gives the
best yield in patients with advanced MPB when the occipital rim of donor hair is narrow and way
down, while the parietal donor hair is strong and high up. Because the deep vessels are not disturbed
in routine strip harvesting, I wonder if it is possible to start the lateral strips 1cm directly above the
edges of the occipital strip to maximize the number of grafts. Your opinion is welcomed.
Use of intact “pillars” in donor harvesting
Michael L. Beehner, MD Saratoga Springs, New York [email protected]
There are situations in which taking a long, continuous,
curvilinear donor strip extending from one side to the other
may lead to a tight closure, a wide scar, or further widening of
an existing scar. A method I have been using for a few years is
to leave intact gaps of scalp at the rear parietal corners, which
I call “pillars.” A horizontal donor strip is harvested across
the occipital region for a length of around 10cm, and two additional strips are harvested from the lateral scalp, leaving a
1-2cm–long space of intact scalp between the end of the occipital wound and the posterior edges of the lateral strips.
Leaving this small segment of intact scalp at these rear,
parietal corners serves as a buttress to hold the scalp together
and thereby results in less tension on the closure of the open
donor areas. The area behind the mastoid, where the donor
strip curves around from the occipital to the parietal area, can
present with tension upon closure resulting in a wide scar and,
occasionally, anagen effluvium with permanent hair loss.
The following patients would be ideal candidates for this
approach:
1. The patient having his first transplant who has a tight
scalp, as these corners are the hardest to close.
2. The patient who already has a relatively wide scar, yet
still wants more hair transplanted. In my practice, this is
the most common indication for using these pillars. It’s
impossible to remove a reasonably large amount of donor
hair, plus cut out the old scar, because it creates too much
tension and the scar will heal wider than before. Leaving
these corners intact, as I mentioned above, keeps the
corner areas themselves from getting any worse and, in
my opinion, helps to minimize the stretch on the closure
of the three adjacent harvesting areas (the occipital and
the two lateral areas) (Figure 1, A-C).
3. Another indication is when the best hair to harvest in
the occipital region is a lot lower than in the lateral area.
Instead of sweeping a steeply curved donor strip upward
A
at each corner, the occipital hair can be harvested with
its own horizontal strip, and the two lateral strips can
be started higher, and ideally at a point at least 1-2cm
further anterior to a vertical line drawn up from the end
of the occipital donor strip edge. An example of such a
patient is shown in Figure 2. Whenever a donor strip is
angled fairly steeply, say at 45 degrees for example, the
real, actual width of the strip being removed per horizontal
1cm of scalp is much wider than what is being excised. For
example, if a 10mm-wide donor strip is taken all around
and is horizontal in the back but angles up acutely at the
corner and laterally, the width of scalp being excised per
horizontal 1cm of the patient’s head is probably 15mm or
more. This can often lead to a wound that will not close under normal tension and is best
left partly open
to granulate in
over time, rather than to yank
them together
with brute force
and suture them
together under
extreme ten- Figure 2. Intact pillar is shown at the parietal corner
with adjacent strips at different heights.
sion.
The obvious negative to using the pillars is that it deprives
the hair surgeon of 2-3cm of horizontal length of donor hair
that will not be harvested on that particular day. However,
I think that, when indicated, leaving these intact pillars is
still preferable and additional donor hair can be obtained by
extending the lateral strip further anterior than usual and
also by taking a slightly wider strip in the occipital area that
usually comes together without undue tension.✧
B
C
Figure 1. This patient had transplants many years earlier at another clinic with a resultant wide scar, yet wanted a large transplant session. A: The drawing plan with the
“pillar” left alone; B: a post-excision view; and C: after the suture closure of the occipital portion.
126
Hair Transplant Forum International
July/August 2010
Multiracial variations in anatomical location of the
occipital artery and nerve complex: a key to avoiding
injury prior to strip harvesting
Theresa Marie R. Cacas, MD, Damkerng Pathomvanich, MD, Kulakarn Amonpattana, MD Bangkok, Thailand
[email protected]
Introduction
The occipital artery and nerve complex is an important anatomical structure that must be considered in hair
transplantation. Every effort should be made to identify its
location since trauma to these vital structures can cause
significant patient morbidity. Most hair transplant surgeons
often do not pay much attention to the occipital artery and
nerve, which can lead to complications such as bleeding,
hematoma, the possibility of post-surgical anagen effluvium,
hypo-/hyperesthesia, neuromas, and neuralgias.1,2
In hair transplantation, both the nerve and artery become
susceptible to trauma with donor dissection at the posterior
occipital scalp. Chances of transection are even higher if
tumescent anaesthesia is not administered appropriately,3,4
and if anatomical landmarks for these structures are not considered during the overall planning of donor harvesting.
Current studies available to identify these structures use
palpable bony landmarks as reference points.5-8 These landmarks, however, vary among patients and multiracial groups,
and may even be absent in some individuals.5,7 This study
aims to show how the reflection of the skin of the external
ear and scalp is easily identifiable and is a useful landmark
in identification of the occipital artery–nerve complex.
measured with a ruler in centimeters and recorded (Figure
1). The distances between the right and left pulsations were
recorded as well (Figure 2). Identification of occipital artery
pulsations, marking with gentian violet, and measurements
were done by a single observer. Data was analyzed by taking
the mean and range of recorded measurements on the right
and on the left, and the distance between pulsations. These
recorded means were compared among different sexes and
racial groups.
Figure 1. Measuring horizontal
distance in centimeters from the
superior reflection of skin of the
external ear and scalp until the
point of maximal occipital artery
pulsation as marked with gentian
violet.
Objectives
The three objectives of this study were:
1. To measure the distance from the reflection of the skin
of the external ear and scalp to the point of maximal occipital artery pulsations on the right and left side.
2. To measure the distance between the points of maximal
occipital artery pulsations on the right and left side.
3. To compare the means of the above measurements among
males, females, and different racial groups.
Materials and Methods
This study included a total of 100 patients and female
staff volunteers at the DHT clinic in Bangkok, Thailand, from
August to November 2009.
The safe donor area was selected using the occipital protuberance as a reference point. All patients were placed in
the prone position and the occipital artery pulsations were
located on both sides by starting palpation from behind the
ears. The fingertips were used to feel for occipital artery pulsations moving toward the midline, and running superiorly and
inferiorly, until the maximal point of occipital artery pulsation
was felt. This spot was marked using gentian violet with a
vertical line in the sagittal plane. A horizontal line measuring
the distance from reflection of the skin of the external ear and
scalp, beginning at the uppermost point of the ear and crossing the vertical mark at 90 degrees or perpendicularly, was
Figure 2. Measuring the distance
between occipital artery pulsations.
Results
Out of the 100 patients included in the study, 86 were
male and 14 were female. The mean age was 33.23 with
a range of 20–70 years. There were 63 Asian patients, 36
Caucasian patients, and 1 patient of African descent. Of the
Asian patients, 46 were Oriental, 6 were Middle Eastern, and
11 were Indian. Symmetrical measurements of the distance
between the reflection of the skin of the external ear and the
occipital artery pulsations bilaterally were obtained in 55
patients, while 45 had asymmetrical distances (Table 1).
It was observed that in the majority of patients, the maximal point of occipital artery pulsations can be felt at the level
of the nuchal ridge. Pulsations can still be felt superior to
this point, but they become weaker.
For the entire study population, average measurements
of the distance between the reflection of the skin of the external ear and scalp to the occipital artery pulsations was
8.44cm (range 6.5–10.5cm) on the right side and 8.42cm
(range 7–10cm) on the left. The average distance between
the right and left occipital artery pulsations was 10.54cm
(range 8–13.5cm) (Table 2).
127
 page 128
Hair Transplant Forum International
July/August 2010
Multiracial variations
 from page 127
No. of Patients
100
Sex
Male
86
Female
14
Age
Mean
33.23 years
Range
20–71 years
Race
Asian
63
Caucasian
36
African descent
1
Asian population
Oriental
46
Middle East
6
Indian
11
Measurements between ROA and LOA
Symmetrical
55
Asymmetrical
45
•
•
Discussion
Table 1. Data of patients Included in the study.
Population
7–10.5cm) for the right and 8.64 (range 7–10.5cm)
for the left; mean distance between arterial pulsations
was 9.67cm (range 8–13.5cm).
The Caucasian population showed a mean distance
of 8.70cm for the right side (range 6.5–10.5cm) and
8.61cm (range 7–10cm) for the left; mean distance between pulsations was 11.04cm (range 7.5–14cm).
The patient of African descent showed a distance of
8cm on the right, 8cm on the left, and 11.5cm between
arterial pulsations.
ROA (cm)
LOA (cm)
BET (cm)
Total population
8.44
8.42
10.54
Asian
Oriental
Middle East
Indian
8.57
8.66
7.18
8.51
8.50
7.22
10.52
10.50
10.04
Caucasian
8.70
8.61
11.04
African descent
8.00
8.00
11.50
Asian Female
8.39
8.64
9.67
ROA—distance from reflection of skin of the external ear and scalp to
maximal point of occipital artery pulsation at the right side
LOA—distance from reflection of skin of the external ear and scalp to
maximal point of occipital artery pulsation at the left side
BET—distance between occipital artery pulsations
Table 2. Mean measurements of distance from reflection of skin of the external ear
and scalp to right and left maximal occipital artery pulsations, and mean distance
between pulsations.
The mean distance of occipital artery measurements
was also identified and compared for the different racial
groups:
• The Asian Oriental population showed a mean distance of 8.57cm for the right side (range 7–10.5cm)
and 8.51cm (7–10cm) for the left; mean distance
between pulsations was 10.52cm (range 8.5–
13.5cm).
• The Asian Middle East population showed a mean
distance of 8.66cm for the right (range 8–9cm) and
8.5cm (range 7–9.5cm) for the left; mean distance between pulsations was 10.5cm (range 9.5–12.5cm).
• The Asian Indian population showed a mean distance of 7.18cm for the right (range 7.5–9cm) and
7.22cm (range 8–9cm) for the left; mean distance
between the artery pulsations was 10.04cm (range
9.5–12.5cm).
• All female patients were Asian Oriental and mean
measurements showed an average of 8.39cm (range
In hair transplantation surgery, one important anatomical
structure that has to be considered in donor harvesting and
closure is the occipital artery and nerve complex. The course
of the occipital artery can be divided into three segments.9
The first, or digastric, segment shows that the occipital artery
originates from the external carotid opposite the facial artery
at the inferior margin of the digastric muscle. It ascends
to the interval between the transverse process of the atlas
and the mastoid process of the temporal bone, and passes
horizontally backward, grooving the surface of the latter
bone. At this course, the artery is being covered by the sternocleidomastoid, splenius capitis, longissimus capitis, and
digastricus, and is resting upon the rectus capitis lateralis,
obliquus superior, and semispinalis capitis. The second,
or suboccipital, segment extends from the occipital groove
where it then changes its course and runs vertically upward
piercing the fascia connecting the cranial attachment of the
trapezius with the sternocleidomastoideus to the superior
nuchal line. The third, or terminal, segment corresponds to
the subgaleal segment just above the superior nuchal line
and ascends in a tortuous course in the superficial fascia
of the scalp, where it divides into numerous branches. It
divides into an ascending branch, a descending branch, and
a transverse branch at the nuchal border of the splenius capitis and sternocleidomastoid attachments.10 Some branches
reach as high as the vertex of the skull and anastomose with
the posterior auricular and superficial temporal arteries.
This artery supplies blood to the back of the scalp and to
the sternomastoid muscles.
The greater occipital nerve has been described as the
largest purely sensory nerve in the body. It arises from the
dorsal ramus of C2 deep to the inferior oblique muscle where
it branches. The medial branch is the greater occipital nerve,
which runs transversely along the inferior oblique and is
covered by the splenius capitis, the longissimus, and the
semispinalis muscles. The nerve then turns upward to pierce
the semispinalis capitis. Here, the nerve runs rostrolaterally
before emerging into the scalp by piercing the aponeurotic
fibrous attachment of the trapezius and sternocleidomastoid
to the superior nuchal line. Immediately below the superior
nuchal line, the nerve divides into several terminal branches;
medial branches innervate occipital skin and the lateral
branches pass into the region behind the pinna.11
The point after which the nerve traverses the trapezius
muscle aponeurosis to travel within the subcutaneous tissue at the superior nuchal line is the segment of greatest
concern during donor harvesting and closure. It is within this
area that the occipital nerve is intimately associated to the
128
Hair Transplant Forum International
July/August 2010
occipital artery and pulsations of the occipital artery can be
felt at this point as well.5,12 The occipital nerve was shown
to always lie superior to the artery and its width increasing
in size from a mean of 2.3mm at the midline to 3mm at the
periphery,8 again increasing the chances of trauma.
The safe donor area lies within and around the superior
nuchal ridge where the occipital artery–nerve complex passes through. A lack of proper visualization and inadequate
attention to the depth of incision while donor harvesting
may result in injury to the occipital nerve and artery or any
one of its branches.10,11
Complications such as bleeding, hematoma, the possibility of post surgical anagen effluvium, hypo-/hyperesthesia,
neuromas, and neuralgias have been described.1,2
One of the most bothersome and irritating complications to these structures is occipital neuralgia. Treatment
of this condition is difficult,6,11,13,14 therefore, the surgeon’s
knowledge of the anatomical course and landmarks for the
identification of these structures is vital in preventing such
complications.
There are several studies in the literature that address
the location of the occipital artery–nerve complex. It has
been shown that the nerve pierces the fascia of the trapezius
muscle 37.8±4.6mm from the occipital protuberance (range,
24–49mm).5 In cadaveric studies, the distance between the
midline and the point where the greater occipital nerve
pierces the trapezius muscle aponeurosis (TMA) showed the
right side having a mean of 35.4mm and the left a mean of
33.9mm. A significant difference in the vertical distance from
the occiput to the point at which the greater occipital nerve
pierced the TMA was observed between male and female cadavers (male: mean, 11.4mm; range, 8.1–14.0; female: mean,
7.9mm; range, 3.9–11.3mm; SD, 1.9 mm; p=0.004).4
These studies, however, mostly used bony landmarks as
reference points.
Particular attention has been given to take into account
existing anthropometric variations of the skull.8 In fact,
reported failures of treating occipital neuralgia have been
linked to these variations in skull anatomy.10 The occipital
protuberance is a palpable bony landmark, not an exact spot,
and this is even poorly established in some individuals.5
To eliminate this factor of skull variations, some studies
have used two bony landmarks to locate the artery nerve
complex. They have observed that the greater occipital nerve
emerged from the aponeurosis of the trapezius muscle at
22% of the distance from the external occipital protuberance
to the tip of the mastoid process or at 41% of the length of
the intermastoid line.7 Locating the greater occipital nerve
just medial to the palpated occipital artery and directing
the injection needle 90° towards the bony endpoint of the
occiput for anaesthesia was proposed.7,13
In this study, we used the reflection of the skin of the
external ear and scalp as our reference point because it is
easily identifiable and more often than not present in all
individuals. The maximal point of the occipital artery pulsations was usually felt at the level of the nuchal ridge corresponding to the area where the artery and nerve traverses
the trapezius muscle aponeurosis. Pulsations can still be felt
as the fingers are run superior to this point but are much
weaker. This corresponds to the anatomic description of the
ascending branches of the occipital artery where they can
be found to run as high as the vertex of the scalp.10
In the general study population, the mean distance from
the reflection of the skin of the external ear and scalp to the
point of maximal occipital artery pulsations was 8.44cm
on the right and 8.42cm on the left. The range from these
mean measurements is 1.5–2cm and indeed, upon donor
harvesting in study patients, we did observe some arterial
branches running right underneath the mark we had made
or about 1–2cm from the mark.
The Indian population showed the shortest distance at
7.18cm on the right and 7.22cm on the left. The farthest
point of maximal occipital artery pulsations was recorded
in Caucasians at 8.70cm on the right and 8.61cm on the left.
The female population showed the shortest distance between
occipital artery pulsations at 9.67cm. The longest distance
between occipital artery pulsations was found in the patient
of African descent at 11.50cm followed by Caucasian patients
at 11.04cm. It is important to keep in mind that only one
patient of African descent was included in the study. The
asymmetry in location of the right and left occipital artery
pulsations was seen in 45% of the study population and
was similar to studies showing 40% asymmetry between the
right and left side as the occipital nerve exits the trapezius
muscle aponeurosis.5
Conclusion
The findings reported in this study aim to enhance identification of the occipital nerve–artery complex using an easily
identifiable reference point. Prior to donor harvesting and
closure, it is advisable to always locate the occipital artery
and nerve by the method of palpation used in this study.
If pulsations are weak, it is difficult to palpate, or if some
inconvenience is felt in finding its location, we recommend
marking the area with a vertical line in the sagittal plane
based on the mean measurements we report for the particular population. It is advised that within 1.5–2cm from
this point, dissection and undermining be very meticulously
done since the occipital neurovascular bundle can be found
to run underneath this vertical zone. We also recommend
avoiding placement of deep or retention sutures within and
surrounding this area. This can decrease chances of trauma
to these structures and thus minimize complications.
It would be important to note and is likewise recommended that future studies include equal numbers of patients
for each racial group, include measurements of total scalp
circumference, and employ statistical analysis of data. It
is hoped that the results from this study can offer a useful
guide for hair transplant surgeons dealing with patients
of multiracial groups to decrease chances of injury to the
occipital artery and nerve complex during strip harvesting
and donor closure.
References
1. Cooley, J. Complications of hair transplantation. In: W.
Unger and R. Shapiro, eds. Hair Transplantation. New
York: Marcel Dekker. 2004; 568-573.
129
 page 130
Hair Transplant Forum International
Multiracial variations
 from page 129
2. Marzola, M., and Vogel, J. Complications. In: D. Stough
and R. Haber, eds. Hair Transplantation. Philadelphia:
Elsevier Saunders. 2006; 175-176.
3. Wolf, B. Anesthesia. In: W. Unger and R. Shapiro, eds.
Hair Transplantation. New York: Marcel Dekker. 2004;
243.
4. Khan, S., and S. Khan. Nerve block and local anesthesia.
In: D. Stough and R. Haber, eds. Hair Transplantation.
Philadelphia: Elsevier Saunders. 2006; 80.
5. Ducic, I., M. Moriarty, and A. Al-Attar. Anatomical
variations of the occipital nerves: implications for the
treatment of chronic headaches. Plastic and Reconstruct
Surg. 2009; 123:859-863.
6. Taylor, M., S. Silva, and C. Cottrell. Botulinum toxin-A
in the treatment of occipital neuralgia: a pilot study.
Headache. 2008; 48:1476-1481.
7. Loukas, M., et al. Identification of greater occipital nerve
landmarks for the treatment of occipital neuralgia. Folia
Morphol. 2006; 65:337-342.
8. Natsis, K., et al. The course of the greater occipital nerve
in the suboccipital region. Clinical Anat. 2006; 19:332336.
July/August 2010
9. Alvernia, J., et al. The occipital artery: a microanatomical
study. Neurosurg. 2006; 58: 114-122.
10. Rose, P., R. Shapiro, and M. Morgan. Basic science. In:
W. Unger and R. Shapiro, eds. Hair Transplantation, 4th
ed. Chapter 2, p. 35.
11. Ducic, I., E. Hartmann, and E. Larson. Indications and
outcomes for surgical treatment of patients with chronic
migraine headaches caused by occipital neuralgia. Plastic
and Reconstruct Surg. 2009; 123:1453-1461.
12. Shimizu, S., et al. Can proximity of the occipital artery
to the greater occipital nerve act as a cause of idiopathic
greater occipital neuralgia? An anatomical and histologic
evaluation of the artery–nerve relationship. Plastic and
Reconstruct Surg. 2007; 119:2029-2033.
13. Andrychowski, J., et al. Occipital neuralgia: possible
failure of surgical treatment–case report. Folia Neuropathologica. 2009; 47:69-74.
14. Kapural, L., et al. Botulinum toxin occipital nerve block
for the treatment of severe occipital neuralgia: a case
series. Pain Practice. 2007; 7:337-340.✧
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130
Hair Transplant Forum International
July/August 2010
“?”
Hair’s the Question
Sara Wasserbauer, MD Walnut Creek, California [email protected]
The first time I was taught about the vertex (sometimes interchangeably referred to as the crown),
I heard it referred to as the “black hole” for hair. This is true not only for the numbers of grafts it can
take to fill it in, but also for the hours spent educating patients regarding realistic expectations. It
may also be an area that new physicians find themselves sucked into transplanting without understanding the longterm consequences, particularly for young and eager patients. With all these pitfalls in mind, here are a few refresher
questions about the area we all wish we could make magically disappear.
The vertex
1. According to the Ziering and Krenitsky study of vertex
hair patterns,1 which is the most common among men?
A. ZZ double whorl
B. Z Pattern
C. Diffusion Pattern
D. S Pattern
2. According to the Ziering and Krenitsky study of vertex hair
patterns,1 which is the most common among women?
A. ZZ double whorl
B. Z Pattern
C. Diffusion Pattern
D. S Pattern
3. Statistically speaking, in a male with no hair at the “bald
spot” to suggest what previous whorl pattern naturally
existed, what would be the most likely pattern for a surgeon to re-create in an attempt to reproduce nature?
A. An S pattern on the left side or in the center
B. A Z pattern on the right side
C. An S pattern on the right side
D. A diffuse pattern centered on the right
4. A 21-year-old patient presents with vertex loss but no
appreciable frontal hair loss. His father was a Norwood
Class VI at age 45. He does not want to take finasteride
or use minoxidil. He has adequate donor (70 FU/cm2 and
30% elasticity) and wants to put as many grafts as possible in the back so that the bald spot “goes away.” What
is the least appropriate course of action at this point?
A. Advise him that future procedures may be necessary
for the frontal area and discuss the risks and benefits
of finasteride and minoxidil therapy only
B. Advise him to wait until he needs frontal/hairline
restoration in addition to the vertex coverage
C. Refuse to do the surgery unless he starts on finasteride for at least a year
D. Proceed with surgery for the vertex
5. At what age is it appropriate to transplant a vertex?
A. Any age as long as the patient agrees to take finasteride long term for vertex fringe protection
B. Over age 50
C. Over 35 as long as the patient realizes he or she may
require additional surgery and is counseled regarding
use of finasteride
D. Any age older than 25 with adequate donor area
6. Regarding the vertex, which of the following is true?
A. Trichotillomaniacs often have a predilection for this
area.
B. Miniaturized hairs may be masked by the pattern of
the whorl here.
C. Finasteride will not slow or stabilize posterior fringe
loss in most cases.
D. Loss in this area bothers patients less if they are tall.
7. You are examining a 60-year-old male patient’s bald vertex
for transplant when you note a scar shaped like a 3-pointed
star (Mercedes-Benz symbol). His donor area is intact and
there are no other scars on his scalp. He denies previous
hair transplant. Which of the following is most likely?
A. This patient has an old Juri flap and care should be
taken with the blood supply in the area since it may
be reduced.
B. This patient has had a brain tumor removed and you
should not transplant in case further brain surgery
becomes necessary.
C. This patient has had a scalp reduction.
D. This patient was in a car accident and that is the
likely cause for his hair loss.
8. In the vertex, which of the following is a common patient
misperception?
A. There is no natural pattern with a central hair tuft
surrounded by loss.
B. Vertex loss will stabilize on its own.
C. The vertex zone will continually expand over time.
D. Transplantation in the vertex gives little cosmetic
benefit.
9. A 61-year-old male presents to you after two previous hair replacement surgeries in his frontal area. He
is pleased with his results and wears his hair combed
straight back. He realizes he has limited donor supply
but wants to “do something” about the vertex area since
he is an avid boater and the wind is constantly revealing
his bald spot. After discussing finasteride therapy options, which of the following would be the best and most
reasonable course of action?
A. No further surgery and consider obtaining a clip-on
non-surgical hairpiece for the vertex
B. Surgery to add additional frontal density
C. Surgery to add “tackers” to the vertex area to help
anchor the longer hair
D. Surgery to remove the old scars and “raise” the inferior edge of the crown
 page 132
131
Hair Transplant Forum International
July/August 2010
Hair’s the Question
 from page 131
Answers
1. D. The S pattern was seen in roughly 75%. The ZZ
double whorl was not seen at all. Note that the Z pattern
and the Diffusion pattern were both seen about 10% of
the time.
2. C. About 78% show the Diffusion pattern. Even though
the number of women was much smaller in this study,
and thus had less power statistically, the only other pattern seen with some frequency (at about 17%) was the
S pattern—which is the most common pattern among
males!
3. C. An S pattern on the right is most likely. Note that there
are very few patients who would be unable to be categorized using vellus hairs or previous photographs, so every
attempt should be made to reproduce nature if possible.
4. D. It would not be appropriate to proceed with surgery
for the vertex without discussion of the risks of progression or other therapies for this young patient.
5. C. There is not a clear-cut answer to this question, but
answer C seems to be the answer with which most of
the published opinions from hair surgeons generally
agree. Obviously, this is an area of ongoing debate with
many experienced surgeons choosing not to transplant
anyone younger than 45-50 years old. However, the key
points of the question are that an arbitrary age limit is
less important than giving the patient the hard truth
®
6.
7.
8.
9.
about the relentless progression of hair loss and setting
reasonable expectations. Additionally, many physicians
would agree that ongoing finasteride treatment, while
not a foolproof safety net, should be strongly considered
in these patients, if not a prerequisite for surgery.
A. This is the correct answer.
C. Care should be taken with the directionality of the
hair (as with all vertex surgeries) and realize that the
anatomy of this area has been altered, which may affect
blood supply, depth of incisions for receptor sites, and
growth, among other things.
B. The Merck 5-year data and physician experience
clearly demonstrates relentless progression, but the
number one reason that patients do not seek treatment is
that they believe their hair loss will not get any worse.
C. A would also be a good option but not optimal in this
patient who is an “avid boater” and out in the wind all
the time (or so my patient on whom this question is
modeled told me).
References
1. Ziering, C., and G. Krenitsky. The Ziering whorl classification of scalp hair. Derm Surg. 2003; 29:817-821.
2. Marritt, E. The overwhelming responsibility. Hair Transplant Forum Int’l. Special Edition, 1993; p. 4.
3. Stough, D. The paradox of crown transplantation. Hair
Transplant Forum Int’l. 2005.
4. Unger, W.P. Basic principles and organization. In: W.P.
Unger, Ed. Hair Transplantation, 4th ed. Chapter 5.✧
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Hair Transplant Forum International
July/August 2010
Newly formed Asian Association of Hair Restoration
Surgeons (AAHRS)
Damkerng Pathomvanich, MD, FACS Bangkok, Thailand [email protected]
A new Asian society—Asian Association of Hair Restoration Surgeons (AAHRS)—was organized and founded in
Bangkok, Thailand, during the ISHRS Asian Regional Live
Surgery Workshop that ran June 25-27, 2010.
The word “Asian” includes many countries in the continent, each of which has its own set of cultures, as well
as distinct differences in facial features and skin and hair
characteristics. Thus, even if the basic principles of surgery
remain the same, there are striking differences in Asian hair
transplantation compared with that of Caucasian.
At the annual ISHRS scientific meetings, there is minimal
contribution among doctors regarding Asian hair transplantation. With the increasing number of Asian doctors practicing hair restoration surgery throughout the world, and
likewise an increasing number of Asian patients seeking hair
transplantation, we felt that this was the appropriate time
to organize a society of our own. Many have attempted to
form an Asian hair society in the past ten years, but failed
due to conflicts of interest and politics.
The ISHRS is the largest and most successful hair transplant society in the world, and I envision that the Asian
Association of Hair Restoration Surgeons will someday follow in its footsteps. I am not claiming to be a hero riding a
white horse, but rather, a physician who foresees the need
of building an Asian hair society of our own. The exchange
of knowledge within each Asian country through joining the
AAHRS will promote education within Asia as well as help
to spread this knowledge throughout the world.
For the past 6 months, I have been in touch with the president, past president, and executive director of the ISHRS to obtain their input on forming the Asian society. I have personally
invited many reputable hair transplant surgeons from different
Asians countries, but with minimal response, and some have
sent their regrets to attend the workshop and business meeting.
To give this society a head-start, and after discussions with
many reputable hair transplant colleagues from the East and
West, I have committed myself to the task of being the first
president for a two-year term, and have appointed Dr. Sunjoo
“Tommy” Hwang to be secretary and treasurer. He will automatically move to become president for the two years following
my term as I become immediate past president.
I am in the process of approaching reputable hair surgeons from different Asian countries to become officers of the
AAHRS assigned for the first two years under my term. Anyone can become a member of the AAHRS. I highly encourage
everyone, whether Asian or Caucasian, who practices hair
restoration surgery to join us in our vision of improving hair
transplantation through the exchange of knowledge, education, and research. The dues are only $200USD for 3 years.
After July 31, 2010 the dues will increase to $300USD for 3
years. For your membership application, please contact Dr.
Hwang at [email protected].
I still remember when Dr. Dow Stough first organized the
ISHRS; there were about 100 members and today it is nearing
1,000. With your support, I am hopeful this new Asian society will start the same and rapidly expand in the future.✧
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133
Hair Transplant Forum International
July/August 2010
ABHRS holds exam in Capri, Italy
Robert H. True, MD New York, New York [email protected]
The American Board of Hair Restoration Surgery (which in hair restoration surgery. The ABHRS/IBHRS is the only
is also the International Board of Hair Restoration Sur- certification recognized by the International Society of Hair
gery) for the first time held a certification examination Restoration Surgery.
outside of the United States. The examination was held in
Physicians who are eligible to apply for ABHRS/IBHRS cerCapri, Italy, and was sponsored by the Italian society of tification have demonstrated the accumulation of significant
Hair Restoration, under the
experience in the field of
leadership of its president,
hair restoration surgery and
Dr. Piero Tesauro, and in
have shown a commitment
conjunction with its Annual
to high standards of training
Meeting, which ran May
and education. Those who
20-21, 2010. Dr. Tesauro
have achieved certification
and the ISHR members
have demonstrated adextended gracious supvanced knowledge in the art
port and assistance. We
and science of hair restoracan’t thank them enough
tion through peer-reviewed
for their professionalism,
examination.
Those who are interestunparalleled hospitality,
ed in pursuing certification
and the opportunity to
or who may be interested
visit such a beautiful loABHRS examiners in Capri (L to R): Drs. Bessam Farjo, Michael Vories,
cale. In particular, we will
in setting up a certifying
Dan Didocha, Robert Reese, Robert True, and Robin Unger.
remember the wonderful
exam through their regional
reception Dr. Tesauro and his lovely wife Gabriela held for society should visit www.abhrs.org for an application and
examiners and examinees at their Capri villa overlooking contact details.✧
the Mediterranean.
The ABHRS was founded in 1997 and has grown to 150
certified diplomates, 35 of whom come from outside of North
America. The annual certifying examination is held every
year in January in Houston, Texas. Over recent years, the
Board has been hearing from increasing numbers of hair
RECERTIFICATION EXAM
transplant surgeons who reside outside of North America
that they are very interested in pursuing certification but find
Date:
Wednesday, October 20, 2010
traveling to Houston in January to be very difficult. It was
Time:
5:30PM–8:30PM
in response to this need that the ABHRS decided to offer the
Location: Back Bay Complex, on the mezzanine
exam outside of the United States.
level of the World Trade Center
Eight hair restoration surgeons from eight countries in
the Middle East, Asia, and South America came to Capri to
take the examination. The written portion was given in the
For those ABHRS Diplomates who were board certified
morning and the three oral examination cases were in the
in 1999 or 2000, in order to maintain certification you
afternoon. Board president, Dr. Robert H. True, was joined
must register/apply for the Recertification Exam.
by Drs. Robin Unger, Bessam Farjo, Michael Vories, Dan
The Recertification Exam is also being offered on
Didocha, and Robert Reese as the examiners. All examiners
January 22, 2011, from 2:00PM–5:00PM, in Houston,
are volunteers and travel at their own expense.
Texas. For those interested in first time certification,
Based on the success of this experience and the continthe next primary exam will take place on January 22,
ued high level of interest, the ABHRS Board of Directors is
2011, in Houston, Texas.
considering holding additional certifying exams outside of
North America. The model of holding them in conjunction
For further information and to register, contact:
with regional society meetings seems to offer many advantages both for examinees and examiners.
Peter B. Canalia, JD, Executive Director
The mission of the ABHRS/IBHRS is to act for the
American Board of Hair Restoration Surgery (ABHRS)
benefit of the public, to establish specialty standards,
419 Ridge Road, Suite C, Munster, IN 46321, USA
and to examine surgeons’ skill, knowledge, and aesthetic
judgment in the field of hair restoration surgery. It is the
Tel: 219-836-5858; Fax: 219-836-5525
largest worldwide entity to have established standards
Email: [email protected] • www.abhrs.org
for certification for education, training, and experience
134
Hair Transplant Forum International
July/August 2010
Surgeon of the Month: Fernando Basto, MD
Samuel M. Lam, MD Plano, Texas
Citing divine inspiration, Fernando
Basto recalls: “I wanted to be a plastic
surgeon ever since I was 15 years
old.” With that revelation, Fernando,
founder of the Brazilian Society of
Hair Restoration Surgery, has become
both an amazing thinker and a doer in
the ISHRS. He has contributed numerous publications both in our journals
as well as in his own country, Brazil, where he has practiced
hair restoration since 1988.
Born on August 16, 1957, in Recife, State of Pernambuco
(in northeast Brazil), Fernando is the last of 11 children with 4
brothers and 6 sisters. His father worked on the dock until he
retired, after which he then started an insurance agency, and
his mother was a housewife. Fernando recalls: “My parents
were good to us. Both had a simple, hard life, very modest,
but they made the impossible possible to create better opportunities for their children. Both were devout Catholics and
our education was based on these Catholic philosophies.”
Fernando began his primary education in public school
and completed high school at Colégio Nóbrega, a private
school. He went on to the Universidade de PernambucoCiências Médicas, graduating in 1981, followed by a residency in General Surgery in Federal University finishing in
1982. Studying under Dr. Perseu Lemos from 1983 to 1986,
Fernando underwent a residency in Plastic Surgery at the
Federal University of Pernambuco. Shortly thereafter in 1988,
he began his career in hair restoration.
Fernando was attracted to hair transplants after he saw
some of the results. However, he explains: “I decided that
perhaps the technique could be improved on. As I carried out
more and more surgeries, I found that this really interested
me, and with each surgery I tried to improve on tactics and
techniques that I developed and carried out.” Having now
completed 3,600 surgeries, he originally started with punch
grafts and Juri flaps but has evolved his method to modern
follicular unit technique with strip harvest and occasional
follicular unit extraction.
His publications in the field of hair restoration are diverse, including his 2005 Forum article, “Irregular and sinuous anterior hairline: prior technique refinement in male
and female trace parameters.” He has also developed and
published his own classification system for female pattern
baldness.
Fernando has been married to his wife, Élida, since 1986,
with whom he has three children: 19-year-old Amanda, who
is at university studying her second year of law; 15-yearold Caio, a high school student; and 12-year-old Gabriel,
also a student. He notes that both of his sons are interested
in entering medicine. At 52 years of age, Fernando’s other
passion is playing guitar in the company of his friends and
family. He also loves wine and viticulture, and has a large
wine cellar at home. After a long, demanding week of hair
restoration surgeries, Fernando’s ideal way of relaxing and
unwinding on weekends is with a glass of good wine, his
guitar, and his family at his side.
We are very happy to award Fernando Basto the distinction of Surgeon of the Month for his outstanding scientific
contributions and for his lifelong achievement in the practice
of hair transplantation.✧
Dr. Basto and his family enjoy the incredible views offered by Bariloche, Argentina.
135
State-of-the-art
instrumentation for hair
restoration surgery!
For more information, contact:
21 Cook Avenue
Madison, New Jersey 07940 USA
Phone: 800-218-9082 • 973-593-9222
Fax: 973-593-9277
E-mail: [email protected]
www.ellisinstruments.com
Hair Transplant Forum International
July/August 2010
Are you new to the field or looking for a refresher?
2010
Basics In Hair Restoration Surgery
Lecture Series
The 2010 Basics in Hair
Restoration Surgery
Lecture Series is an enduring
material created by the International
Society of Hair Restoration Surgery (ISHRS).
The Series can be taken alone or paired
Sponsored by the International Society of Hair Restoration Surgery
with the Basics Hands-On Course at the ISHRS
Annual Scientific Meeting. The Series provides the
To order your copy, go to:
didactic information and the Hands-On Course teaches
the core skills. When paired with the Hands-On Course,
http://www.ishrs.org/2010-HRS-Basics.html
students are expected to complete the Series prior to the
Hands-On Course. Together the overall emphasis is to provide basic
and core skills essential for the practice of safe, esthetically sound
hair restoration surgery. It is intended for use by those new to the
field as well as those who are interested in a refresher. This enduring
Anagen (Growth)
material was developed as a result of the need for the consistent
• Varies from species to
and comprehensive presentation of the core basic topics. A faculty
species
• Varies from region to region
of well-known and distinguished experts in the field developed
within the same species
• Varies from season to
the materials and content based on the pre-determined learning
season
• Varies with age
objectives and with the guidance of the CME Committee.
ENDURING MATERIAL, ONLINE FORMAT
Lichen Planopilaris
• 6 sub stages
• In humans, the growth rate
is 0.35mm per day
B
A
LECTURES IN THE SERIES:
1. Introduction: Course Overview and History of HRS,
Matt L. Leavitt, DO 26:59
2. Anatomy & Physiology of Hair Growth,
William M. Parsley, MD 38:16
3. Contemporary Insights into Hair Cycle Physiology and the Genetics
of Hair Loss, Bessam K. Farjo, MBChB 26:23
4. Physiology & Medical Treatment of Hair Loss,
Ken Washenik, MD, PhD 58:28
5. Identification of Non-Androgenetic Pathological Hair Loss,
Bernard P. Nusbaum, MD 42:13
6.
HRS Patient Consult: Ethics, Expectations, and Pt Selection,
Matt L. Leavitt, DO 51:24
7. Hairline & Crown Whorl Design, Michael L. Beehner, MD 40:11
8. HRS Anesthesia & Hemostasis, Vance W. Elliott, MD 38:24
9. Donor Harvesting & Closure, Melvin L. Mayer, MD 45:45
10. Graft Preparation and Storage, Jerry E. Cooley, MD 31:09
11. Recipient Site Preparation & Graft Placement,
Robert P. Niedbalski, DO 35:09
12. Flaps, Reductions, and Lifts, E. Antonio Mangubat, MD 1:03:01
13. Office Emergency Preparedness, Edwin S. Suddleson, MD 25:53
14. Office Design and Ergonomic Work Stations, Carlos J. Puig, DO
19:26
15. Basic Principles of Staff Training, Carlos J. Puig, DO 30:15
Orientation
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theincoronal
Emergency conditions which may arise
our office and require immediate action
plane)
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Lidocaine Toxicity
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Shock
Bleeding Diathesis
Slip and Fall
Hair Growth Direction
Emergency Preparedness
International Society of Hair Restoration Surgery
303 West State Street, Geneva, IL 60134 USA
Tel: 630-262-5399 Fax: 630-262-1520 E-mail: [email protected]
FORMAT Internet/online, computer.
The following is a list of user/system
requirements in order to participate in
this enduring material:
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speed of 1000 kilobytes per second.
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higher, Firefox 2.0 or higher,
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CONTINUING MEDICAL EDUCATION (CME) CREDIT
Sponsored by the International Society of Hair Restoration Surgery. The
International Society of Hair Restoration Surgery is accredited by the ACCME
to provide continuing medial education for physicians.
The International Society of Hair Restoration Surgery designates this
educational activity for a maximum of 9.5 AMA PRA Category 1 CreditsTM .
Physicians should only claim credit commensurate with the extent of their
participation in the activity.
To receive CME credit participants must participate in the activity, complete
the post-test, and achieve a passing grade (70% or higher). Instructions are
included on the webpage.
136
Hair Transplant Forum International
July/August 2010
Surgical Assistants Editor’s Message
Laurie Gorham, RN Boston, Massachusetts [email protected]
We were all saddened to hear of the passing of Cheryl Pomerantz. I had the privilege of working
with her during the assistants meetings. She was a delightful person who will be sorely missed
by her ISHRS family.
Rest in peace, Cheryl. I will personally cherish the time we had working side by side.
Laurie Gorham, RN
Editor, Surgical Assistant’s Corner; Surgical Assistants Program Chair
Auditing within a hair transplant setting
Sara Roberts, RN Farjo Medical Centre, Manchester, United Kingdom
The definition of audit is an evaluation of a person, organization, system, process, project, or product. The purpose of
any audit is to ascertain efficacy and effectiveness of internal
systems, and as with any organization the importance of how
our systems and protocols work within the hair transplant
clinic are crucial not only for patient safety but for patient
and staff appeasement. This article will illustrate how we
implemented a very basic evaluation system within the clinic
that allowed the main goals of auditing to be achieved.
The initial aim was to make all systems for checking and
examining our practices uniform, so we devised a simple
format that everyone could understand and follow as a tool
and guide to make the audit procedure clear. This format
took the following structure: purpose, method, results, conclusion, and action plan.
For each evaluation, the auditor needs to make clear the
purpose of completing and evaluating the particular process.
For example, when auditing emergency procedures within
the clinic, the purpose would include current procedures and
reasons why these measures may need modifying.
The method of evaluation of a particular process needs
to be designed to be straightforward to those taking part and
to be effective in producing results that are easily evaluated.
For instance, when reviewing emergency procedures a simple
test paper was completed by surgical staff to ascertain their
levels of knowledge regarding emergency situations.
Results are then correlated into a table format so that it
is clear to see any areas that may need improvement.
The conclusion is a short summary of all the above with
any new measures to be implemented in an action plan. At
this point, an annual review date is set so that each audit
gets properly followed up.
Staff is instructed on how to complete audits and all are
encouraged to regularly examine their practices.
An end of year audit summary report is completed by the
head nurse that can be used as a quick reference guide to all
areas evaluated that year. It also serves as a training instrument and to see how techniques have evolved. Some areas
that we have audited include infection control, health and
safety procedure, single-use instruments, patient care, stock
control, surgery forms, end of day procedures. (Please see
the example of a past audit that demonstrates the structure
discussed in this article.)
137
Audit of Health and Safety Procedures
June/July 2009
Purpose: To manage the ongoing health and safety of staff, patients,
and visitors.
Method
•
All current health and safety documentation and policies
were reviewed, including risk assessments, practice and
procedures, and accident log.
•
Surgery staff was given an infection control assessment paper
that included questions regarding the procedures for needle
stick injury (see also infection control audit).
Results Summary
•
Conditions within the clinic change regularly so risk assessment needs to be an ongoing process (i.e., under constant
update rather than annual).
•
Some areas of documentation and reporting need to be
monitored more closely but no areas of danger or high risk
were identified.
•
No accidents or incidences were recorded that require any
follow-up.
•
Staff has demonstrated awareness of Health and Safety
procedures and how to report any incidences. They also
know who to ask for any further information.
•
Flow of visitors within the clinic needs to be monitored.
•
Some documentation (e.g., health and safety folder not being
replaced after use)
Conclusion
•
Health and Safety is an on going concept and all areas within
the clinic are constantly monitored and measures are in place
to facilitate this.
Plan
•
Following last year’s report in conjunction with the current evaluation and discussion with Office Manager, Nurse
Manager, and Surgery Technicians it was decided that we do
need a more comprehensive guide to managing the health
and safety of visitors to the clinic. Nurse Manager to compile
an action plan to be completed by the end of June 2009.
•
As per last year’s audit, some new members of staff need to
attend Health and Safety courses.
•
Memo to be sent to all staff regarding the importance of
returning files and information to their place of storage.
Hair Transplant Forum International
July/August 2010
Classified Ads
Hair Transplant Physician Wanted
30+ year old Hair Transplant Practice in L. I. / NYC looking for experienced physician to join/possibly acquire
14,000+ active patient practice. Great Opportunity, would consider training right person.
Email contact information [email protected] or Fax to 516-764-5702
Hair Restoration Technician Wanted
Experienced Hair Restoration Technician wanted for multi-office practice locations in
Worcester, MA; Providence, RI; and Hartford, CT.
Expanding practice hiring well-trained and experienced technicians.
Opportunity for advancement to head technician for the right person.
Will be based in one office but must be willing to travel between offices occasionally.
Pay based on experience. $15-$20 per hour plus full health insurance, 401K, vacation.
Respond to DiStefano Hair Restoration Centers at [email protected]
Hair Transplant Technician Wanted
Experienced Hair Transplant Tech needed for an established Hair Transplant Surgeon in the Raleigh, NC area.
Also needed to manage a new anti-aging medical practice.
Great opportunity and salary, flexible hours. IRA, health insurance benefits.
Fax résume to 919-362-0071
To Place a Classified Ad
To place a Classified Ad in the Forum, simply e-mail [email protected]. In your email, please
include the text of what you’d like your ad to read—include both a heading, such as “Tech Wanted,”
and the specifics of the ad, such as what you offer, the qualities you’re looking for, and how to
respond to you. In addition, please include your billing address.
Classified Ads cost $60 plus 60 cents per word per insertion. You will be invoiced for each issue
in which your ad runs.
138
Hair Transplant Forum International
July/August 2010
REGISTER TODAY!
To obtain the complete program with registration materials, go
to: www.ishrs.org/18thAnnualMeeting.html
Advances in Hair Restoration: Revolutionary Concepts and Evolutionary Techniques
Revolution & Evolution
There are many exciting
formats and topics that will
take place at the 18th Annual
Scientific Meeting, including
a Live Surgery Observational
Workshop aimed at beginners
in the field, a full day, handson Basics Course in Hair Restoration Surgery
utilizing cadaver scalp, a full day Board Review
Course, a full day Surgical Assistants Program,
several morning workshop on specific topics,
a Surgical Assistant Dissecting & Implanting
Workshop utilizing cadaver scalp, lunch
symposiums, “breakfast with the experts”
table discussion groups, Live Patient Viewing,
a controversy panel, a high definition surgical
video theater, a hairline design panel, use of an
audience response system to keep the sessions
exciting and dynamic, a full exhibits program,
and many opportunities for socializing and
networking.
NEWCOMERS ARE WELCOME!
As a result of the positive feedback from the
2009 annual meeting, we will again offer a
“Meeting Newcomers Program” to orient those
who are new to the ISHRS annual meeting.
Newcomers will be paired with hosts. We
want to welcome you, introduce you to other
colleagues, and be sure you get the most out of
this meeting.
Sincerely,
Paul J. McAndrews, MD, Chair
2010 Annual Scientific Meeting
FEATURED GUEST SPEAKERS
Bruno A. Bernard, PhD,
Dr.ès Sci.
Head of the Hair Biology Research
Group, L’Oréal Advanced Research,
Life Science Department, at the
C.Zviak Research Center of L’Oréal,
in Clichy, France
Dr. Bernard will speak on,
“New Insights into Human Hair Growth,
Shape, and Whitening.”
Kurt S. Stenn, MD
David Whiting, MD
Aderans Research
Institute, Inc, Philadelphia,
Pennsylvania, USA
Clinical Professor of Dermatology and
Pediatrics, University of Texas Southwest
University, Dallas, Texas; and Medical
Director, The Hair and Skin Research
and Treatment Center, Baylor University
Medical Center, Dallas, Texas, USA.
Dr. Stenn will speak on “Perspectives Dr. Whiting will speak on,
of Bioengineering of the Hair Follicle.” “Senescent Alopecia: Fact or Fiction?”
International Society of Hair Restoration Surgery
303 West State Street ´ Geneva, IL 60134, USA ´ Tel: 630 -262-5399 or 80 0 -444 -2737 ´ Fax: 630 -262-1520
[email protected] ´ w w w.ISHRS.org
139
A d va n c i n g t h e a r t a n d
science of hair restoration
Upcoming Events
Date(s)
Event/Venue
Sponsoring Organization(s)
Contact Information
July 23-25, 2010
2nd Annual Hair Restoration Surgery
Cadaver Workshop
St. Louis, Missouri, USA
Practical Anatomy & Surgical Education, Center for Anatomical
Science and Education, Saint Louis University School of Medicine
http://pa.slu.edu
in collaboration with the International Society of
Hair Restoration Surgery
http://pa.slu.edu
August 18-21, 2010
4th Scientific Meeting of the
Brazilian Association of Hair Restoration Surgery
Belo Horizonte/Ouro Preto, Minas Gerais, Brazil
Brazilian Association of Hair Restoration Surgery
[email protected]
September 10-12, 2010
2nd Annual Meeting of the Indian Association of
Hair Restoration Surgeons
Rajasthan, India
Indian Association of Hair Restoration Surgeons
www.ahrsindia.com
www.ahrsindia.com
October 20-24, 2010
18th Annual Scientific Meeting
of the International Society of Hair Restoration Surgery
Boston, Massachusetts, USA
International Society of Hair Restoration Surgery
www.ISHRS.org/18thAnnualMeeting.html
Tel: 630-262-5399
Fax: 630-262-1520
Japan Society of Clinical Hair Restoration (JSCHR)
www.jschr.org
Hosted by Akio Sato, MD
Tel: +81-3-5351-0309
Fax: +81-3-5351-1395
[email protected]
Diploma of Scalp Pathology & Surgery
U.F.R. de Stomatologie et de
Chirurgie Maxillo-faciale; Paris, France
Coordinator: Pr. P. Goudot
Directors: P. Bouhanna, MD, and
M. Divaris, MD
Tel: 33 +(0)1+42 16 13 09
Fax: 33 + (0) 1 45 86 20 44
[email protected]
International European Diploma for
Hair Restoration Surgery
Coordinator: Y. Crassas, MD, University Claude Bernard of
Lyon, Paris, Dijon (France), Torino (Italy), Barcelona
(Spain). Department of Plastic Surgery
www.univ-lyon1.fr
For instructions to make an
inscription or for questions:
Yves Crassas, MD
[email protected]
16th Annual Scientific Meeting and
Live Surgery Workshop
Okinawa, Japan
February 24-25, 2011
DIPLOMAS
Academic Year
2010–2011
January 2011
HAIR TRANSPLANT FORUM INTERNATIONAL
International Society of Hair Restoration Surgery
303 West State Street
Geneva, IL 60134 USA
Forwarding and Return Postage Guaranteed
Dates and locations for future ISHRS
Annual Scientific Meetings (ASMs)
2010: 18th ASM, October 20-24, 2010
Boston, Massachusetts, USA
2011: 19th ASM, September 14-18, 2011
Anchorage, Alaska, USA
2012: 20th ASM, October 17-21, 2012
Paradise Island, Bahamas
2013: 21st ASM, October 23-27, 2013
San Francisco, California, USA
FIRST CLASS
US POSTAGE
PAID
CHICAGO, IL
PERMIT NO. 6784