forum - International Society of Hair Restoration Surgery

Transcription

f orum
HAIR
TRANSPLANT
Volume 24
Number 3
May/June
2014
I N T E R N A T I O N A L
Inside this issue
President’s Message........................82
Co-editors’ Messages.......................83
Notes from the Editor Emeritus:
Bernard Nusbaum, MD.......................85
The ISHRS Achieves ACCME
Accreditation with Commendation
for Educational Activities.................89
The Combined Technique (FUE +
FUT) Without Fully Shaving Hair:
Executive Untouched Strip.............90
FUE Research Committee:
Standardization of the Terminology
Used in FUE: Part III.......................93
To Better “Serve” Your Patient’s
Comfort...........................................94
Robotic Recipient Site Creation
in Hair Transplantation....................95
Complications & Difficult Cases:
Scalp Cellulitis in the Recipient
Area Following a Hair Transplant
Procedure.......................................98
Cyberspace Chat: Surgical
Hair Loss .....................................102
How I Do It: Direct Non-Shaven
FUE Technique.............................103
Meetings & Studies: St. Louis to
Tokyo................................................. 106
Regional Societies Profiles:
BAHRS.........................................108
Hair’s the Question: PRP................ 111
Letters to the Editor ....................... 114
Review of the Literature.................. 115
Messages from the 2014 ASM
Program Chair & SA Program Chair.... 116
Classified Ads................................. 118
2014 Anuual Scientific
Meeting
NEW VENUE & DATE!
Medical Therapy for Female Pattern Hair Loss (FPHL)
Nicole E. Rogers, MD Metairie, Louisiana, USA [email protected]
Female pattern hair loss…to treat or not to treat? And with what? Does anything really work for women?
Many in our field would argue that it’s not worth even treating women, citing concerns about donor area, the
paucity of effective treatments, or how it can be difficult or impossible to achieve patient satisfaction. But these
concerns should not prompt us to give up. Rather, women can be some of the most rewarding patients to treat,
and using simple things like handouts, dermoscopy, and photography can help increase understanding, reduce
confusion, increase compliance, and dramatically improve their response to treatment.
Women often undergo an extensive workup before arriving at a diagnosis of FPHL. They may start by seeing
their internist, then their OB/GYN, then their endocrinologist, and even a naturopath before seeing a dermatologist or hair loss specialist. Along the way, they may get told that the hair loss is due to stress, adrenal fatigue,
or “low-normal” thyroid function, all of which when corrected fails to stop the hair loss—until they find YOU!
In a matter of seconds, you recognize the presence of miniaturized hairs either on clinical examination or with
the use of dermoscopy. Finally, they get the diagnosis they have been dreading: female pattern hair loss. They
believe nothing can be done for them…or can it?
Although there is only one FDA-approved medication for hair loss in women (topical minoxidil), there are
other off-label options such as oral spironolactone, oral finasteride, and certain birth control pills that can be
tried before or in addition to hair transplantation. Women may also benefit from low level light therapy (LLLT),
which has 510K FDA clearance as a medical device. Depending on how advanced their degree of hair loss, they
may benefit from one or more therapies. The physician should consider their comorbidities, lifestyle, family
planning, and personal preferences.
Topical Minoxidil
The only FDA-approved medication for hair loss in
women is topical minoxidil or Rogaine®. There is new evidence that use of topical minoxidil can improve the quality
of life with FPHL.1 The drug is recommended for twice
daily usage as a 2% solution for women and as a 5% foam
and solution for men. The 2% solution has been shown to
be effective at arresting hair loss in 60% of cases,2 and
even better results have been seen with the 5%.3 Excellent
results can be achieved with consistent usage (Figure 1).
Recently, one study showed that the 5% foam worked just
as well, used once daily in women, as the 2% worked twice
daily.4 There also were fewer complaints about pruritus
Figure 1. Before (left) and after (right) use of topical 5% minoxidil for 6
and dandruff. Many physicians already recommend using months.
the 5% foam once daily at bedtime as a way to increase
compliance and simplify the morning grooming routine. This has since prompted the FDA to approve a women’s
5% Rogaine foam formulation for once daily usage.5 The risk of hypertrichosis should still be discussed as it has
been reported in 8.9% of patients using this regimen.6
Perhaps the most difficult thing about getting women
to use topical minoxidil is helping them to understand
that it works. They often believe that because it is over
the counter, it can’t possibly work. Or, they believe that
if they stop it, ALL of their hair will fall out. Or that they
have to use it forever. OR ELSE! These misconceptions
can be addressed by drawing a simple diagram for your
patients, using an x-y axis to demonstrate the natural pro- Figure 2. Diagram to increase patient compliance with medical therapy.
gression of hair loss over time (Figure 2). By drawing a
[ page 86
Official publication of the International Society of Hair Restoration Surgery
Hair Transplant Forum International
Volume 24, Number 3
Hair Transplant Forum International is published bi-monthly by
the International Society of Hair Restoration Surgery, 303 West
State Street, Geneva, IL 60134 USA. First class postage paid
at Chicago, IL and additional mailing offices. POSTMASTER:
Send address changes to Hair Transplant Forum International,
International Society of Hair Restoration Surgery, 303 West State
Street, Geneva, IL 60134 USA. Telephone: 1-630-262-5399,
U.S. Domestic Toll Free: 1-800-444-2737; Fax: 1-630-262-1520.
President: Vincenzo Gambino, MD
[email protected]
Executive Director: Victoria Ceh, MPA
[email protected]
Editors:
Mario Marzola, MD
Robert H. True, MD, MPH
[email protected]
Managing Editor, Graphic Design, & Advertising Sales:
Cheryl Duckler, 1-262-643-4212
[email protected]
Controversies: Russell Knudsen, MBBS
Cyberspace Chat: John Cole, MD; Bradley R. Wolf, MD
Difficult Cases/Complications: Marco Barusco, MD
Hair Sciences: Jerry Cooley, MD
Hair’s the Question: Sara M. Wasserbauer, MD
How I Do It: Timothy Carman, MD
Meeting Reviews and Studies: David Perez-Meza, MD
Regional Society Profiles:
Mario Marzola, MBBS; Robert H. True, MD, MPH
Review of Literature:
Nicole E. Rogers, MD; Jeffrey Donovan, MD, PhD
Copyright © 2014 by the International Society of Hair Restoration
Surgery, 303 West State Street, Geneva, IL 60134 USA. Printed
in the USA.
The views expressed herein are those of the individual author
and are not necessarily those of the International Society of Hair
Restoration Surgery (ISHRS), its officers, directors, or staff.
Information included herein is not medical advice and is not
intended to replace the considered judgment of a practitioner
with respect to particular patients, procedures, or practices. All
authors have been asked to disclose any and all interests they
have in an instrument, pharmaceutical, cosmeceutical, or similar
device referenced in, or otherwise potentially impacted by, an
article. ISHRS makes no attempt to validate the sufficiency of
such disclosures and makes no warranty, guarantee, or other
representation, express or implied, with respect to the accuracy or
sufficiency of any information provided. To the extent permissible
under applicable laws, ISHRS specifically disclaims responsibility
for any injury and/or damage to persons or property as a result of
an author’s statements or materials or the use or operation of any
ideas, instructions, procedures, products, methods, or dosages
contained herein. Moreover, the publication of an advertisement
does not constitute on the part of ISHRS a guaranty or endorsement
of the quality or value of the advertised product or service or of any
of the representations or claims made by the advertiser.
Hair Transplant Forum International is a privately published
newsletter of the International Society of Hair Restoration Surgery.
Its contents are solely the opinions of the authors and are not
formally “peer reviewed” before publication. To facilitate the free
exchange of information, a less stringent standard is employed to
evaluate the scientific accuracy of the letters and articles published
in the Forum. The standard of proof required for letters and articles
is not to be compared with that of formal medical journals. The
newsletter was designed to be and continues to be a printed forum
where specialists and beginners in hair restoration techniques can
exchange thoughts, experiences, opinions, and pilot studies on all
matters relating to hair restoration. The contents of this publication
are not to be quoted without the above disclaimer.
The material published in the Forum is copyrighted and may
not be utilized in any form without the express written consent
of the Editor(s).
82
www.ISHRS.org
May/June 2014
President’s Message
Vincenzo Gambino, MD Milan, Italy
[email protected]
I’m addressing this message more to the newer members
of our Society and profession. Some simple principles are
worth repeating. We all use different calendars. For many,
January 1 starts the New Year. Some measure their year by
the start of school.
My calendar year began in San Francisco with the ISHRS
Annual Scientific Meeting. This year, as president, I made a promise to attend as
many “Hair” meetings as possible. A friend once related to me that a hair surgeon
she had a consultation with for her son told her proudly: “I don’t waste time going
to meetings.” When she asked him how he kept current, he said the medical supply
salesmen were his source of information. I was stunned. I’ve been doing only hair
in my practice for 25 years and I find going to meetings invaluable. There is always
something new to learn and apply to your patients. I have never walked away from
a meeting empty handed. No doubt, attending a meeting is expensive. Travel, hotel,
registration fees, and, most of all, the money you aren’t making while away from
your practice is considerable. We all have to make decisions based on cost/benefit.
Attending meetings has so many benefits professionally, and in the long run, it’s
money well spent if you maximize your participation. This is your chance to get to know
and exchange information with peers one-on-one. These meetings give you an opportunity
to become active by offering to serve on committees and help organizing workshops.
The ISHRS and the national and regional societies need your involvement if they
are to stay relevant and vital. It’s not a numbers game. Unfortunately a family situation
caused me to miss the 20th anniversary of the Orlando Live Surgery Workshop in
April. My congratulations go to Drs. Matt L. Leavitt and David Perez-Meza for organizing this successful meeting. I was told more than 100 doctors participated. Bravo!!
I am looking forward to the 5th meeting of the Brazilian Association of Hair Restoration Surgery (ABCRC) in São Paulo, Brazil, this May 21-24. Program Chair, Dr.
Arthur Tykocinski, is a respected member of the ISHRS. South America, especially
Brazil, has always been on the cutting edge of new techniques in aesthetic medicine.
I expect to see innovative approaches to hair restoration there.
From June 13-15, I’ll be in Brussels, Belgium, for the ISHRS European Hair
Transplant Workshop that will focus on complementary approaches of FUE and FUT.
Dr. Jean M. Devroye is a talented physician and experienced meeting organizer who
has put together a first-rate international faculty of experts in the field.
From June 26-29, the Italian Society for Hair Restoration (ISHR) is holding their
15th biannual meeting in Siracusa, Sicily. Present and past ISHR presidents, Drs.
Franco Buttafarro and Pietro Lorenzetti, are hosting this meeting. The meeting, with its
blend of Italian and international faculty, is themed “Advancing in Hair Restoration.”
From September 19-29, I’ll be in Goa, India, for the Association of Hair Restoration Surgeons (AHRS)–India 6th annual meeting chaired by Drs. Rajesh Raiput, Anil
Garg, and Kapil Dua. India is known for innovation in instrumentation and for the
first time the meeting will include a cadaver workshop.
Unfortunately, I am not able to attend the 5th Annual Hair Restoration Surgery
Cadaver Workshop in St. Louis, Missouri, from October 23-26. Having taught at
cadaver workshops in Nice, France, I can tell you it’s a good way to get hands-on
experience for a beginner in our field.
My year highlights with the ISHRS 22nd Annual Scientific Meeting being held in
Kuala Lumpur. I’ve already told you that the hard decision to move the meeting from
Bangkok was made after much deliberation. I am heartened by the large number of
abstracts we’re receiving, the number of committed exhibitors, and the outstanding
preliminary program Dr. Damkerng Pathomvanich has put together.
I am confident that this will be a record-breaking meeting.
My presidency over, I’ll be attending the Japan Society of Clinical Hair Restoration (JSCHR) meeting from November 23-24. The program, which is chaired by Dr.
Shinsaku Kawada, will be a fine way to end a very special year.u
www.ISHRS.org
May/June 2014
Co-editors’ Messages
Mario Marzola, MBBS Adelaide, South Australia [email protected]
In this issue, we have two articles on female pattern hair
loss. Drs. Nicole Rogers and Bernard Nusbaum bring together
in a concise and readable manner the current thinking on the
diagnosis and treatment of this frustratingly difficult condition.
Why is it different from male pattern hair loss? Is it truly androgen dependent? Why is there inflammation around the follicles?
Why is female pattern hair loss so sensitive to shock loss (anagen
effluvium) after hair transplants? Who hasn’t seen the unhappy
female patient a month after the operation with so much more
hair loss than before? What a tragedy that is, more so because
some of the hairs lost will not re-grow. I know of some doctors
who tell their female patients up front that large numbers of grafts
need to be planted as none of the existing hair can be relied upon
to stay. I can understand how they have come to that conclusion.
What is the best way to handle female hair loss? Certainly,
we should do all the blood tests to eliminate polycystic ovaries,
thyroid conditions, low iron, or anything else that can cause hair
loss. If we are not sure of the diagnosis, it can almost always be
established accurately with a biopsy. Considering that the diagnosis will be a lifetime sentence, the inconvenience of a biopsy
may well be worthwhile. Medical treatment to stabilize the loss
then can be determined and, if we are lucky, re-grow some hair.
There are many things we can try as can be seen in these articles,
but it will take time and patience, maybe a year or two or three.
Can you or your patient wait that long? Females with hair loss
will book for a transplant immediately, but it does pay to go
slow. There needs to be sufficient donor material with minimal
miniaturization and there needs to be reasonable expectations.
Small operations will minimize the risk of
shock loss but to achieve enough coverage a number of sittings will be needed.
Finally, the stabilization effort will need to
continue indefinitely as all hair loss, male
or female, is progressive.
There is so much more to write on this
subject again. We have not touched on mesotherapy, which is
very popular in some countries, and we have not explored PRP,
ATP, or cell-based therapies sufficiently, and we could know
more about the best and safest way to transplant hairs in females.
On another subject, the development of robotic abilities in
hair restoration surgery never ceases to amaze me. Dr. Bernstein
and colleagues have developed a recipient site making technology to add to the donor harvesting ability of the ARTAS robot.
It’s the early days yet and much more brainstorming will be
required before they can offer a complete and safe graft planting
system. For those of us interested in technology, it’s going to be
a fascinating journey.
I hope you are enjoying reading the Forum, our bimonthly
newsletter on all things hair. I’m sure this field of hair restoration
attracts more than its fair share of ingenious and lateral thinking
practitioners. Bringing you some brain stretching information,
news, and cheer every two months is our plan. For my part, I
must thank my co-editor, Dr. Bob True, and our managing editor, Cheryl Duckler, for their help and patience for without it my
editing learning curve would be much steeper.u
Robert H. True, MD, MPH New York, New York, USA [email protected]
Last week I participated in the last ISHRS CME committee meeting and have been part of the abstract review process.
After listening to Dr. Damkerng Pathomvanich’s meeting plans
and Victoria Ceh’s description of potential activities, I am getting very excited about our upcoming annual meeting in Kuala
Lumpur. It will be innovative, engaging, and fun!
The Cyberchat column is short this time, but you shouldn’t
miss it. The concept of iatrogenic, or “surgical,” hair loss as an
important concern for all of us is outlined very clearly by Dr.
Wolf.
We don’t see post-operative infections very often, but they
do occur, even with unusual causes as described by Drs. Scott
Boden and Marco Barusco in the Complications column. No
matter how much experience you have as a surgeon, you are still
going to see things you have never seen before.
Drs. Nicole Rogers and Bernard Nusbaum have given us
precise and thorough outlines of the state of the art in treatment
of FPHL. Of course, we need even better therapies, but, I do feel
that this unified approach to therapy provides the best potential
outcomes for our female patients at this time.
Thanks to Dr. Ricardo Lemos for sharing the story of the
Brazilian Association of Hair Restoration
Surgery. I have a lot of respect for the
abilities of our Brazilian colleagues and
I am looking forward to attending their
May 2014 meeting.
Learning how to do FUE without
shaving is very challenging. Dr. Timothy
Carman’s “How I do It” column by Dr.
Jae Park and the associated commentaries provide some good
practical suggestions.
Have fun with Dr. Wasserbauer’s quiz; you will probably
learn something about PRP you didn’t know before.
Frontal Fibrosing Alopecia (FFA) is a hot topic these days.
In this issue Dr. Donovan reviews a well-designed study on
therapy of this condition.
Kudos to Victoria Ceh, Dr. Cotterill, and the CME committee
for achieving ACCME Accreditation with Commendation for
Educational Activities. See their article for more detail.
And finally, all readers will be intrigued to read about the
application of robotics to recipient site creation in an excellent
article in this issue by Drs. Bernstein, Wolfeld, and Zingaretti.u
83
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May/June 2014
INTERNATIONAL SOCIETY OF HAIR RESTORATION SURGERY
Vision: To establish the ISHRS as a leading unbiased authority in medical and surgical hair restoration.
Mission: To achieve excellence in medical and surgical outcomes by promoting member education, international collegiality, research, ethics, and public awareness.
2013–14 Chairs of Committees
American Medical Association (AMA) House of Delegates (HOD) and
Specialty & Service Society (SSS) Representative: Carlos J. Puig, DO
(Delegate) and Robert H. True, MD, MPH (Alternate Delegate)
Annual Giving Fund Chair: John D.N. Gillespie, MD
Annual Scientific Meeting Committee: Damkerng Pathomvanich, MD
Audit Committee: Robert H. True, MD, MPH
Bylaws and Ethics Committee: Robert T. Leonard, Jr., DO
Communications & Public Education Committee: Robert T. Leonard, Jr., DO
CME Committee: Paul C. Cotterill, MD
Regional Workshops Subcommittee: Matt L. Leavitt, DO (Chair) &
David Perez-Meza, MD (Co-Chair)
Subcommittee on EBM and Research Resources: Marco N. Barusco, MD
Subcommittee Expert Panel: Paul C. Cotterill, MD
Subcommittee on Webinars: James A. Harris, MD
Core Curriculum Committee: Anthony J. Mollura, MD
Fellowship Training Committee: Robert P. Niedbalski, DO
Finance Committee: Ken Washenik, MD, PhD
FUE Research Committee: Parsa Mohebi, MD
Hair Foundation Liaison: E. Antonio Mangubat, MD
International Relations Committee: Bessam K. Farjo, MBChB
Membership Committee: Michael W. Vories, MD
Nominating Committee: Kuniyoshi Yagyu, MD
Past-Presidents Committee: Jennifer H. Martinick, MBBS
Pro Bono Committee: David Perez-Meza, MD
Scientific Research, Grants, & Awards Committee: Michael L. Beehner, MD
Surgical Assistants Committee: Aileen Ullrich
Surgical Assistants Awards Committee: Tina Lardner
Ad Hoc Committee on Database of Transplantation Results on Patients
with Cicatricial Alopecia: Jeff Donovan, MD, PhD
Ad Hoc Committee on FUE Issues: Carlos J. Puig, DO
Ad Hoc Committee on Regulatory Issues: Paul T. Rose, MD, JD
Subcommittee on European Standards: Jean Devroye, MD,
ISHRS Representative to CEN/TC 403
Subcommittee on Alberta, Canada Standards: Vance Elliott, MD
Task Force on Physician Resources to Train New Surgical Assistants:
Jennifer H. Martinick, MBBS
Task Force on Finasteride Adverse Event Controversies: Edwin S. Epstein, MD
2013–14 Board of Governors
President: Vincenzo Gambino, MD*
Vice President: Sharon A. Keene, MD*
Secretary: Kuniyoshi Yagyu, MD*
Treasurer: Ken Washenik, MD, PhD*
Immediate Past-President: Carlos J. Puig, DO*
Alex Ginzburg, MD
James A. Harris, MD
Sungjoo Tommy Hwang, MD, PhD
Francisco Jimenez, MD
Melvin L. Mayer, MD
Paul J. McAndrews, MD
David Perez-Meza, MD
Arthur Tykocinski, MD
Bessam K. Farjo, MBChB
Robert S. Haber, MD
*Executive Committee
Editorial Guidelines for Submission and
Acceptance of Articles for the Forum Publication
Bernard Nusbaum, MD
1.
Articles should be written with the intent of sharing scientific
information with the purpose of progressing the art and science
of hair restoration and benefiting patient outcomes.
2. If results are presented, the medical regimen or surgical techniques that were used to obtain the results should be disclosed
in detail.
3. Articles submitted with the sole purpose of promotion or
marketing will not be accepted.
4. Authors should acknowledge all funding sources that supported
their work as well as any relevant corporate affiliation.
5. Trademarked names should not be used to refer to devices or
techniques, when possible.
6. Although we encourage submission of articles that may only
contain the author’s opinion for the purpose of stimulating
thought, the editors may present such articles to colleagues
who are experts in the particular area in question, for the purpose of obtaining rebuttal opinions to be published alongside
the original article. Occasionally, a manuscript might be sent
to an external reviewer, who will judge the manuscript in a
blinded fashion to make recommendations about its acceptance, further revision, or rejection.
7. Once the manuscript is accepted, it will be published as soon
as possible, depending on space availability.
8. All manuscripts should be submitted to [email protected].
9. A completed Author Authorization and Release form—sent as
a Word document (not a fax)—must accompany your submission. The form can be obtained in the Members Only section
of the Society website at www.ishrs.org.
10. All photos and figures referred to in your article should be sent
as separate attachments in JPEG or TIFF format. Be sure to
attach your files to the email. Do NOT embed your files in the
email or in the document itself (other than to show placement
within the article).
11. We CANNOT accept photos taken on cell phones.
12. Please include a contact email address to be published with
your article.
Submission deadlines:
June 5 for July/August 2014 issue
August 5 for September/October 2014 issue
Kuala
NEW VENUE!
Lumpur
Oct. 8-11
2014
NEW DATES!
Mark Your Calendar!
84
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May/June 2014
Notes from the Editor Emeritus
Bernard Nusbaum, MD Coral Gables, Florida [email protected]
Female hair loss diagnosis is a time-consuming yet extremely
rewarding endeavor for the physician. It encompasses the detective skills of taking an inquisitive, detailed medical history
and requires an in-depth scalp examination looking for clues to
derive at a diagnosis. I would like to make note of some of the
current trends relevant to this field and hope not much overlap
occurs with Dr. Roger’s lead article.
Scalp dermoscopy has emerged as an invaluable tool in recognizing features of various alopecias not appreciable with the
naked eye. Dermoscopy is particularly helpful in differentiating
non-scarring alopecias, such as chronic telogen effluvium, in which
abnormal miniaturization is absent, contrasted to female pattern hair
loss (FPHL) where the ratio of terminal to vellus hairs is decreased
and miniaturization results in hair diameter diversity. Alopecia
areata, meanwhile, shows yellow brown dots at the follicular orifice
(also seen in some cases of FPHL), but it also shows black dots and
dystrophic hairs with a monomorphic population of miniaturized
hairs rather than the variation in diameter seen with FPHL.
With regards to therapeutic assessment, I prefer coupling
global photography with hair bundle cross-section measurements
using the HairCheck® device to follow a patient’s response. As
I presented in San Francisco, these two modalities show a high
degree of correlation, and combining them enhances a physician’s ability to determine the patient’s progress. Cross-section
hair bundle measurements compensate for the many limitations
of photography, such as changes in hair length, color, or hairstyle at different visits. Patients like the HairCheck and are very
receptive to having a numerical value assigned to their hair, to
be compared on subsequent visits.
An important finding that, in my opinion, has helped us design
more effective therapies for FPHL is the recognition of an indolent inflammation, which is a pathologic feature of this condition.1 There is empiric evidence that therapy targeted to attenuate
this inflammatory component results in enhanced efficacy.2 For
example, I have found that compounding topical corticosteroids
along with minoxidil improves our results in FPHL as compared
to minoxidil alone. In the hope of achieving even better results,
we add low level laser therapy (LLLT) to this topical regimen
and my impression is that results are further enhanced with the
combination. This “shotgun” type of approach does not allow
us to evaluate the contribution of each treatment component, yet
patients don’t seem to care about that, and generally only concern
themselves with achieving improvement.
Although evidence-based data has been limited demonstrating
the efficacy of LLLT, a recent multicenter, randomized, doubleblind study compared the laser comb to a sham device in 128
men and 141 women for 26 weeks of treatment. The laser comb
was shown to achieve a statistically significant increase in mean
terminal hair as compared to the sham device, and no adverse
effects were reported.3 Certainly, we need additional studies to
see if the benefits of LLLT can be maintained over the long term
and to determine if, in fact, the effects are additive or synergistic
with minoxidil or other topical treatments. We also have not yet
defined the preferred wavelength, power, treatment frequency,
or duration to achieve optimal results with this modality.
Evaluating female hair loss patients generally encompasses
doing some laboratory blood work and, in the past couple of
years, I have added a vitamin D level to this panel. Vitamin D
deficiency is increasingly common in the general population and
I have seen patients in whom vitamin D deficiency was probably related to telogen effluvium that resolved with adequate
replacement. The vitamin D receptor is intimately involved with
activating hair growth and mice genetically
deficient in a vitamin D receptor antagonist
generate more hair than controls. Moreover,
molecules that activate the vitamin D receptor
promote differentiation of skin cells into hair
follicle cells. Vitamin D toxicity can result
in systemic adverse effects, so the hope is to
develop topical agents that selectively manipulate the vitamin D
receptor in the scalp and hair follicles. It should be noted that while
our focus is generally to look for dietary or other deficiencies as
contributory to female hair loss (such as zinc, vitamin B12, and
folate), we need to remember that toxicity due to environmental
agents such as copper, arsenic, cadmium, or mercury can also be
associated with hair loss.4 The recent popularity of eating sushi
in the United States has prompted me to question patients about
excessive dietary intake of fish containing high mercury levels
(such as tuna, swordfish, or Chilean sea bass), and I have found
abnormally high blood levels of mercury in some patients presenting with telogen effluvium. Obviously, it is impossible to determine
if mercury was in fact the causative agent.
Lastly, knowledge of hair cosmetics is extremely helpful
when treating female hair patients and, in the past couple of
years, I have seen several women who presented with acute
onset of hair loss following Brazilian keratin hair-straightening
treatments. The hair loss appears to be secondary to both hair
breakage and a form of effluvium with the most likely culprit
being the formaldehyde in these products. Interestingly, a recent
study measured the formaldehyde concentration in seven Brazilian keratin products and found that six had formaldehyde levels
approximately 5 times higher than the level recommended by
the United States Cosmetic Ingredient Review Panel. Some of
these brands were, in fact, labeled as being “formaldehyde free.”5
I have tried to touch upon a few of the topics that I feel are of
current interest, but I wish to stress that empathy and bedside manner are extremely important for physicians to embrace when treating
these patients, as female hair loss has been demonstrated to impact
quality of life (QOL). An improvement of QOL was achieved in
those individuals with successful hair treatment outcomes.6
References
1. Magro, C.M., et al. The role of inflammation and immunity in the pathogenesis of androgenetic alopecia. JDD.
2011(Dec); 10(12):1404-1411.
2. Yuko, O., et al. Coactivator MED1 ablation in keratinocytes
results in hair-cycling defects and epidermal alterations. J
Invest Dermatol. 2012:132:1075-1083.
3. Jimenez, J.J., et al. Efficacy and safety of a low-level laser
device in the treatment of male and female pattern hair loss: a
multicenter, randomized, sham device-controlled, double-blind
study. Am J Clin Dermatol. 2014(Jan 29). Epub: http://link.
springer.com/article/10.1007/s40257-013-0060-6/fulltext.html
4. Pierard, G.E. Toxic effects of metals from the environment
on hair growth and structure. J Cutan Pathol. 1979(Aug);
6(4):237-242.
5. Maneli, M.H., P. Smith, and N.P. Khumalo. Elevated
formaldehyde concentration in “Brazilian keratin type”
hair-straightening products: a cross-sectional study. J Am
Acad Dermatol. 2014(Feb); 70(2):276-80.
6. Zhuang, X.S., et al. Quality of life in women with female
pattern hair loss and the impact of topical minoxidil treatment on quality of life in these patients. Exp Ther Med.
2013(Aug); 6(2):542-546.u
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FPHL from front page
new (green) line, women can understand what will happen if they
use medical therapy. And if they stop, they will just trend back
to their natural course of thinning. By restarting, they will trend
up again (purple line). They will not end up below this line (X),
which is worse off than if they had never used the medication.
Minoxidil can still be a hard sell. Some women of Middle
Eastern or Hispanic ancestry (or with polycystic ovary syndrome)
may already suffer from significant hirsutism and do not want
to worsen it with topical minoxidil. Other women in their 50s
or 60s do not wash their hair more often than once a week, and
dislike the idea of putting a product on the scalp every day and
then not washing it out until they return to the salon. These
women can benefit from off-label options like birth control pills,
spironolactone, or finasteride.
Spironolactone
Spironolactone is a diuretic with anti-androgen properties. It
can be helpful to explain to women that they have both estrogens
(girl hormones) and androgens (boy hormones), and that in most
women with FPHL these levels are NORMAL.7 However, their
follicles are genetically more sensitive to circulating levels of
androgens, specifically in the frontal 1/3-2/3 of the scalp (or on
the sides). Thus, spironolactone helps to block these androgen
receptors and can help prevent the miniaturization process on
the follicle.8,9 Figure 3 shows an excellent response to 100mg/
day over a 6-month period. The patient was an otherwise healthy
19-year-old female with a strong family history of thinning
(father balded in his 20s). The patient was also advised to use
topical minoxidil but admitted to using it only intermittently
(once weekly).
Figure 3. Before (left) and after (right) oral spironolactone 100mg/day
for 6 months.
Spironolactone can be an excellent choice for women with
polycystic ovary syndrome, who already have signs of hirsutism
or acne. The anti-androgen effects of spironolactone are already
used widely in the field of dermatology to successfully treat
both conditions. Women who are already on HCTZ or another
diuretic for hypertension/fluid retention may be switched to
spironolactone as a single agent to treat both conditions. This
should obviously be done with the involvement of their internist.
With rising health care costs, and an already complex health care
system, such women are usually grateful for a drug that addresses
two or more conditions. The data supporting the link between
hair thinning and heart disease might imply that we should place
all our FPHL patients on spironolactone!10
In order to slow down early thinning, patients may start
at doses of 100mg/day. In order to achieve regrowth, higher
doses of 200mg/day are generally required.11 The drug is a
potassium-sparing aldosterone antagonist, so patients should
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May/June 2014
avoid additional potassium supplements and make sure not to
consume a lot of bananas. It also can potentiate sodium wasting (syndrome of inappropriate antidiuretic hormone, SIADH)
secondary to selective serotonin re-uptake inhibitors (SSRIs).
This should be discussed if patients are already on a drug such
as fluoxetine or paroxetine. They can either take the full dose at
once or spread it out over the course of the day (100mg twice
a day). Their preference will generally be affected by whether
the diuretic effect wakes them up at night. These patients may
prefer to take it all as a single morning dose.
Other side effects can include breast tenderness, mid-cycle
spotting, a diminution or disappearance of the menses altogether,
or light-headedness. These can be reasons to gradually escalate
the dose over a 4-6 week period. The author frequently writes for
50mg daily × 2 weeks, 100mg daily × 2 weeks, and 150mg daily
× 2 weeks, and then has the patient come back to check potassium and sodium. If all is within normal limits and the patient
is tolerating the drug well, their dosage may be upped to 200mg
daily. Electrolytes should be checked every 3-6 months, increasing to every 12 months the longer the patient stays on the drug.
Due to the anti-androgen effect, women should not get
pregnant on this drug. It is helpful to explain that the same antiandrogen effect that this has on the hair follicle it may also have
on a male fetus. The author does not require all patients to be
on birth control pills, but advises them to stop it immediately if
they get pregnant.
Finasteride
Early data investigating the use of 1mg daily finasteride in
women failed to show any improvement over placebo.12 One of
the study’s authors (VP) suggests that this was likely due to the
inclusion of women with senescent alopecia, which may not
respond to any drug therapy. Subsequently, other studies done in
the United States and around the world using higher daily doses
of 2.5-5mg finasteride showed some significant results.13-15 The
largest of these came from South Korea, showing that 70/86
(81.4%) of normoandrogenic women treated with 5mg finasteride for 12 months had improvement in global photographs.
There were statistically significant improvements in hair caliber
and hair density using scalp tattooing with microscopic scalp
analysis.16
Widespread implementation for FPHL has been limited by
concerns about breast changes or breast cancer. In the Propecia®
post-marketing reports, there were reports of breast tenderness
and enlargement in men. However, new data published in the
Journal of Urology showed no statistically significant connection between breast cancer and the use of 5-alpha reductase
inhibitors.17 Although this study was limited to men, it can
make us more comfortable prescribing the drug in women.
Recommending annual mammograms can help protect us as
prescribers. Women with a strong personal or family history of
breast cancer may still choose not to use this drug. Ultimately,
the decision should be made by the patient and physician together. In the author’s experience, women are seldom put off by
this potential risk and are grateful for another treatment option.
Figure 4 demonstrates results before and 6 months after daily
use of 5mg finasteride.
Finasteride can be a good alternative for women who have
no cardiovascular risk factors (hence would not need spironolactone) or who already have a very complicated medical history
www.ISHRS.org
May/June 2014
anti-inflammatory, anti-fungal, or anti-androgen mechanisms.
Larger controlled studies are needed. In the meantime, it is an
easy addition to the medical therapy since most patients have
to shampoo anyway.
Topical Estrone Cream
Figure 4. Before (left) and after (right) oral finasteride 5mg/day for 6 months.
(and you don’t want to interfere with their drug regimen). The
physician should explain that it is metabolized by the liver but
that there are no real drug interactions. It should only be offered
to women who are not able to or are planning to conceive in the
near future. These women should have undergone a hysterectomy, had their tubes tied, or be on 1-2 forms of long-term and
reliable birth control. They must stop the drug IMMEDIATELY
if they get pregnant. They also should not donate blood while
they are taking the drug.
The medical literature supports the use of 2.5-5mg daily for
FPHL. In the author’s experience, most women report no side
effects. Insurance coverage varies: first, because it is approved
for prostate enlargement in MEN, not WOMEN, and second,
because insurance may consider hair loss cosmetic. Patients with
access to Walmart may find finasteride on the “$9 list” for a 30day supply of 5mg pills. Ninety days will cost them $24. Men
taking finasteride may also benefit from this discount.
Dutasteride
Dutasteride blocks both type II and type I 5-alpha reductase
enzyme, decreasing the levels of serum DHT by 90% versus 70%
with finasteride. It has been successfully proven to help treat
MPHL, but its widespread implementation has been limited by
concerns about a long-term reduction in sperm counts. There is
evidence that it can be very helpful in addressing FPHL, however,
it tends to be more expensive than finasteride and we have fewer
studies in women.18
Birth Control Pills and Other Anti-Androgens
Certain birth control pills may benefit women with hair loss.
In particular, the brands Yaz® and Yasmin® (which contain both
estradiol and drospirenone) appear to have the most efficacy.
Drospirenone is a cousin to spironolactone, and can exert similar
anti-androgen effects. Diane 35 is a birth control pill available
in Canada containing cyproterone acetate. This ingredient is not
US FDA approved. Although there is evidence that cyproterone
acetate and flutamide, another systemic anti-androgen used
to treat prostate cancer, can improve FPHL, their widespread
implementation is limited by concerns about hepatotoxicity.19
Ketoconazole Shampoo
Given the observation that an inflammatory infiltrate rich
in lymphocytes has been seen in areas of hair loss or balding,
and that exacerbations of AGA have been seen with seborrheic dermatitis, a study was done to see if 2% ketoconazole
shampoo could exert an effect on the thinning process. After 6
months in this small trial (39 patients total), the ketoconazole
group demonstrated 18% improvement in hair density versus
11% improvement in the minoxidil + non-medicated shampoo
group.20 It is still unclear whether the hair growth effect is through
There was a report in Greece using topical estrogen cream
applied to the scalp of women with FPHL. In a study of 75
post-menopausal females, it demonstrated improvement (via
decreased telogen rate and/or increased anagen rate) in 60-65%
of patients applying a lotion with estradiol valerate .03% over
12-24 weeks. The side effects included postmenopausal uterine
bleeding in 2 patients and breast cancer in one patient.21 An
important concern would be the development of an estrogendependent tumor, especially in a person with family history of
breast or uterine cancer. Dr. Bobby Limmer reports recent use of
this compound, and has been seeing quite impressive results. His
data is forthcoming. In the meantime prescribers should balance
the risks with the benefits for all possible patients.
Pregnancy and Lactation
If a patient is planning to get pregnant in the near future, she
should not be prescribed either spironolactone or finasteride,
given the risk of birth defects. Patients can continue with topical minoxidil right up until they get pregnant; however, they
should stop when they get pregnant because there are isolated
reports of birth defects. Patients can be reassured that the hair
will thicken during the course of their pregnancy. The hairs will
enter a resting telogen phase and won’t shed until 3-6 months
after the baby is delivered.
Patient Satisfaction
Although it can be time-consuming, patient photography is
essential to motivating patients. The author takes standard photos at the initial visit, with the hair parted down the middle and
pinned to the sides. The chin should be turned slightly down so
that the anterior and posterior aspects of the part are equidistant
from the camera lens. Similar lighting, backdrop, and distance
to camera are ideal. Patients should return for follow-up at 6-12
month intervals to assess their results. The author uses an iPad
with photos uploaded from their previous visit. Many patients
think there is no improvement until they see their old images
and cannot believe their eyes!
Hair Thickening vs. Hair Growth Products
There are a large number of products on the market that
claim to “instantly increase density” of hair. Such products are
usually in the form of shampoos, conditioners, or serums applied
to the hair. These products can be very effective at coating the
hair shaft so that it feels thicker. However, the results will only
last until the next hair washing. Patients should understand the
difference between these products and those that actually can
make the hair GROW thicker!
Conclusion
While the medical treatment of FPHL can be challenging, it
can also be extremely rewarding. Patients are relieved to know
they have options, and thrilled when they see results. In advanced
cases, this may require some trial and error, or a combination of
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FPHL from page 87
16.
17.
18.
Figure 5. Before (left) and after (right) combination treatment with 5%
minoxidil, oral spironolactone, and oral finasteride for 3 months.
19.
20.
therapies (Figure 5). Successful treatment of young women can
be especially satisfying because we are improving their sense
of confidence for a lifetime ahead.
References
1. Zhuang, X.S., et al. Quality of life in women with female
pattern hair loss and the impact of topical minoxidil treatment. Exp and Ther Med. 2013; 6:542-546.
2. De Villez, R.L., et al. Androgenetic alopecia in the female.
Treatment with 2% topical minoxidil solutions. Arch Dermatol. 1994; 130:303-307.
3. Lucky, A.W., et al. A randomized placebo controlled trial
of 2% and 5% topical minoxidil solutions in the treatment
of female pattern hair loss. J Am Acad Dermatol. 2004;
50:541-553.
4. Blume-Peytavi, U., et al. A randomized, single-blind trial
of 5% minoxidil foam once daily versus 2% minoxidil solution twice daily in the treatment of androgenetic alopecia in
women. J Am Acad Dermatol. 2011; 65:1126-1134.
5. Online: Drugs@FDA: FDA Approved Drug Products.
(NDA) 021812. Approved 2/28/14.
6. Peluso, A.M., et al. Diffuse hypertrichosis during treatment
with 5% topical minoxidil. Br J Dermatol. 1997; 136:118120.
7. Schmidt, J.B., et al. Hormone studies in females with
androgenetic hair loss. Gynecol Obstet Invest. 1991; 31:235239.
8. Sinclair, R., M. Wewerinke, and D. Jolley. Treatment of
female pattern hair loss with oral antiandrogens. Br J Dermatol. 2005; 152:466-473.
9. Rathnayake, D., and R. Sinclair. Innovative use of spironolactone as an antiandrogen in the treatment of female pattern
hair loss. Dermatol Clin.
10. Su, L.H., et al. Association of androgenetic alopecia with
mortality from diabetes mellitus and heart disease. JAMA
Dermatol. 2013; 149:601-606.
11. Redmond, G. It’s Your Hormones. New York: Harper Collins, 2006.
12. Price, V.H., et al. Lack of efficacy of finasteride in postmenopausal women with androgenetic alopecia. J Am Acad
Dermatol. 2000; 43:768-776.
13. Lorizzo, M., et al. Finasteride treatment of female pattern
hair loss. Arch Dermatol. 2006; 142:298-302.
14. Stout, S.M., and J.L. Stumpf. Finasteride treatment of hair
loss in women. Annals of Pharmacol. 2010; 44:1090-1097.
15. Trueb, R.M. Finasteride treatment of patterned hair loss in
88
21.
May/June 2014
normoandrogenic postmenopausal women. Dermatol. 2004;
209:202-207.
Yeon, J.H., et al. 5mg/day finasteride treatment for normoandrogenic Asian women with female pattern hair loss.
JEADV. 2011; 25:211-214.
Bird, S.T., et al. Male breast cancer and 5-alpha-reductase
inhibitors finasteride and dutasteride. J Urology. 2013;
190:1811-1814.
Olszewska, M., and L. Rudnicka. Effective treatment of
female androgenetic alopecia with dutasteride. J Drugs
Dermatol. 2005; 4:637-640.
Hassani, M., et al. Treatment of female pattern hair loss.
Skinmed. 2012; 10:218-227.
Pierard-Franchimont, C., et al. Ketoconazole shampoo: effect of long-term use in androgenetic alopecia. Dermatol.
1998; 196:474-477.
Georgala, S., et al. Topical estrogen therapy for androgenetic
alopecia in menopausal females. Dermatol. 2004; 208:178179.u
Editor’s Note: We are indebted to Dr. Nicole Rogers
and to Dr. Bernard Nusbaum (see Editor Emeritus) for
their articles on female pattern hair loss (FPHL) in this
issue of the Forum. They bring the current thinking on the
medical treatment of this difficult condition into focus. Hair
transplantation is often also available for these patients, but
it’s more difficult than in males and would make a suitable
subject for another time. While we can currently make
some difference for female hair loss sufferers, most of us
working in this field would be happier if we could do more.
We hope that something better will come along and soon.
Already there are many doctors using PRP in hair loss but
scientific studies are few. Anecdotally, the reports, however,
are encouraging.
As in so many difficult to treat conditions there is an inverse relationship between the number of therapies and the
likelihood that any will be of great benefit. Thus, the plethora
of treatments for FPHL, noted our esteemed colleague, Dr.
Bob Haber, in a recent communication.
Understanding the pathogenesis of FPHL is the first step,
then therapy should be made easier. We are getting closer
but not there yet. —MMu
www.ISHRS.org
May/June 2014
The ISHRS Achieves ACCME Accreditation with
Commendation for Educational Activities
Victoria Ceh, MPA, Executive Director, and Paul C. Cotterill, MD, CME Chair Geneva, Illinois, USA
[email protected]
On behalf of your CME Committee, we are pleased to report that the International Society of Hair Restoration Surgery
achieved the coveted Accreditation with Commendation by the
Accreditation Council for Continuing Medical Education (ACCME) for a six-year period as a provider of continuing medical
education for physicians. Accreditation with Commendation is
the highest level a provider can achieve and represents excellence
in medical education.
This March 2014 decision from the ACCME was based on the
ISHRS’s recent re-accreditation, a rigorous, multilevel process
employed by the ACCME for evaluating institutions’ continuing
medical education programs according to the high accreditation
standards by all seven ACCME member organizations. These
organizations of medicine in the U.S. are the American Board
of Medical Specialties, the American Hospital Association, the
American Medical Association, the Association for Hospital
Medical Education, the Association of American Medical
Colleges, the Council of Medical Specialty Societies, and the
Federation of State Medical Boards of the U.S., Inc.
ACCME accreditation seeks to assure the medical community
and the public that ISHRS provides physicians with relevant,
effective, practice-based continuing medical education that supports U.S. health care quality improvement.
An achievement of this magnitude would not be possible
without the steadfast dedication of ISHRS staff and members
who work hand-in-hand to provide physicians with unmatched
educational offerings in the ever-evolving field of hair restoration. Each year, the ISHRS hosts a number of continuing medical education activities for physicians around the world that are
sanctioned for AMA PRA Category 1 Credits™, including the
Annual Scientific Meeting, the Orlando Live Surgery Workshop,
regional workshops, and many enduring educational products
such as On-Demand Webinars and the Basics Lecture Series
in Hair Restoration Surgery. Ultimately, our commitment to
education means patients can expect high-quality patient care
and enhanced treatment outcomes.u
89
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May/June 2014
The Combined Technique (FUE + FUT) Without Fully Shaving Hair:
Executive Untouched Strip
Márcio Crisóstomo, MD, MS Fortaleza, Brazil [email protected]
Intoduction
In advanced degrees of baldness (e.g., Norwood Class V,
VA, VI), the patient needs more than one surgery to achieve
his goals of coverage and density. In order to maximize the
number of grafts in one surgery, a combination of the two most
important harvesting methodsStrip and Follicular Unit Extraction
(FUE)—is proposed by some authors.1-4
To perform the combined technique while preserving an area
for future strip harvesting, this author proposed the Untouched
Strip Technique, in which an area of 1.0-1.5cm below the suture of the strips is “untouched,” without undermining or FUE
harvesting, thereby retaining its anatomical features for future
harvesting and improved yield of follicular units (FUs).3,4 With
this technique, an increase of 30% to more than 50% more hair
is obtained in one surgical procedure, allowing the surgeon to
cover more areas and with more density, as widely presented by
the author (Figure 1).5-12
B
A
C
D
Executive Untouched Strip: Surgical Technique
The surgical technique is the same as previously described
by the author;3,4 the difference is in preparation of the donor
area. Patients are required to leave their hair at least 4-5cm long.
Donor area demarcation. First, the safe donor area (SDA)
is estimated. Then the strip to be excised is defined inside the
SDA. From the lower border of the strip to the upper border of
the SDA, the hair is shaved, but 1-2cm in the upper limit is left
unshaved. The preserved hair will cover the FUE area. Below the
strip demarcation, an area of 1.0-1.5cm is preserved for future
strip harvesting in accordance with the “Untouched Strip” principle. In this area, the hair is not shaved and will cover the lower
FUE area, joining the unshaved hair below the SDA (Figure 3).
A
B
C
D
E
Figure 1. A: Demarcation of the Untouched Strip technique with the strip to be excised,
the strip to be preserved (untouched strip), and the FUE area above and below, inside the
SDA; B: donor area on post-op day 1; C: pre-op view; D: Post-op day 1 (4,747 FUs); E:
7 months post-op view.
One limitation of this technique is the requirement for shaving
the hair to perform FUE. Many patients complain about aesthetic
appearance in the post-operative period, reducing the recommendations of the procedure, even in cases of advanced baldness (Figure
2). In some cases, more than 1 month is required for full recovery
of donor area aesthetics and, differently from FUE, in this technique
both the stitches and the scar are apparent during this period of time.
The aim of A
B
this paper is to
demonstrate a
methodology
for applying
the Untouched
Strip Technique, with
the benefit of Figure 2. A: Donor area on post-op day 1; B: donor area on day 15.
90
increasing the number of grafts in one surgery, but without the
inconvenience of shaving the hair completely.
Figure 3. A: Demarcation of the SDA, the Strip to be excised, the
upper and lower FUE area shaved, and the Untouched Strip to be
preserved unshaven; B: demarcation continues in the back, until
the opposite side of the head, in the entire SDA; C: hair from the
Untouched Strip covering the lower FUE area; D: hair around the
upper SDA combed, covering all the shaven area.
Intra-operative. During the surgery, first the strip is excised,
avoiding tension, and closed with trichophytic closure without
undermining.14 After the implantation of all strip FUs, FUE is
carried out above the strip suture and below the untouched strip
(Figure 4). The FUE FUs are implanted in the location deemed
most appropriate by the surgeon in order to cover more areas
and/or to improve density.
Discussion
For all patients with advanced baldness, the amount of hair
transplanted is a major concern as it is directly related to the final
result. The combination of FUE and strip can increase the number
of grafts achieved and meet the patient’s and surgeon’s goal.1-4
Clearly, a natural result does not depend solely on the number
of grafts; all of the other aspects of a good hair transplant, such
as hairline design, natural implantation, proper indication and
www.ISHRS.org
B
A
C
Figure 4. A: Before surgery; B: strip excision; C: strip sutured with trichophytic closure
and no tension; D: FUE harvesting above the strip suture and below the untouched strip; E:
first day after implantation in a Norwood VI patient (total = 3,832 Fus: 2,927 Strip FUs +
905 FUE FUs, an increase of 30.9%).
surgical technique, must be observed, but this article will discuss
only how to treat the donor area.
The Untouched Strip principle is based on the fact that FUE
scars are hardly noticeable, but they do exist and do bring about
certain alterations to the donor area, such as local fibrosis, density
reduction, and anatomical alteration.15,16 This way, a second strip
harvesting is more difficult due to the fibrosis and the strip will
yield fewer FUs. As patients with advanced degrees of baldness
usually require a second surgery, if the surgeon preserves a strip
without any surgical intervention, anatomical alterations will be
minimal and a second strip harvesting will be more productive.
In the methodology presented in this paper, the hair of the
untouched strip preserved at its natural length will help to cover
part of the FUE area while joining the unshaven hair around
the SDA. The longer the hair, the better the coverage achieved.
Conducting the surgery with the entire head shaved facilitates
the procedure, not only in harvesting, but in the implantation
process as well. However, the requirement to shave all the hair
is a major concern in most patients and a limitation to recommendation of the Untouched Strip Technique, even when the
patient needs more extensive surgery.
The name “Executive Untouched Strip” was given by some
patients operated on by this methodology and is based on the
fact that the patient can have a combined procedure and retain
reasonable appearance of the donor area in the post-operative
period—the area being covered by the unshaven hair—resulting
in minimal time away from social and professional activities
(Figures 5 and 6).
Some physicians consider that the combination of strip and
FUE has a future role to increase the potential SDA and increase the total number of grafts, but usually recommend these
A
B
B
C
Figure 6. A: Post-op showing hair concealing sutures and two extraction zones; B: upper
extraction zone and suture line; C: lower extraction zone.
E
D
A
May/June 2014
C
Figure 5. A: Post-op day 1 showing the FUE area with shaved hair; B: preserved hair of the
untouched strip covering the lower FUE area; C: hair preserved around the SDA combed
and hiding the whole shaven area.
two methods separately with the FUE performed after one or a
number of strip sessions are completed.17 We believe that, as
both procedures are well established in the hair restoration field
to treat alopecia with good individual results, this combination
can be safely applied in the same surgical time, giving patients
with advanced baldness an option to potentialize their donor area
and to achieve more hairs in one procedure.
References
1. True, R. Combining FUE and strip harvesting in the same
procedure. Oral presentation at the 17th Annual Scientific
Meeting of International Society of Hair Restoration Surgery. Amsterdam, The Netherlands, July 22-26, 2009.
2. Tsilosani, A. Expanding graft numbers combining strip and
FUE in the same session: effect on linear wound closure
forces. Hair Transplant Forum Int’l. 2010; 20(4):121-123.
3. Crisóstomo, M.R., et a;. Untouched Strip: a technique to
increase the number of follicular units in hair transplants
while preserving an untouched area for future surgery. Surg
Cosmet Dermatol. 2011; 3(4):361-364.
4. Crisóstomo, M. Untouched Strip: FUE combined with strip
surgery to improve the FU number harvested in one session,
preserving an untouched area for a possible future transplant.
Hair Transplant Forum Int’l. 2012; 22(1):12-14.
5. Crisóstomo, M. FUE versus Elipse em área doadora - prós
e contras: O papel das técnicas combinadas de retirada de
unidades foliculares. 5th Workshop of the Brazilian Association of Hair Restoration Surgery. July 5-7, 2012, São
Paulo, Brazil.
6. Crisóstomo, M. Untouched Strip: technique combining FUE
and FUT to improve the number of follicular units harvested
in a safe way. Presented at the XIV International Congress
Italian Society of Hair Restoration. May 24-27, 2012, Rome,
Italy.
7. Crisóstomo, M. Untouched Strip: nova técnica de transplante capilar para aumentar o número de fios em uma única
cirurgia. Oral presentation at the 19th Scientific Meeting of
Prof. Ivo Pitanguy. Ex-Alumini Association. October 4-6,
2012, Lisbon, Portugal.
8. Crisóstomo, M. Untouched Strip: A New Technique to Improve the Amount of Hair Transplanted in a Hair Restoration
Surgery. Video presentation at the 21st Congress of International Society of Aesthetic Plastic Surgery. September 4-8,
2012, Geneva, Switzerland.
9. Crisóstomo, M. Combining Follicular unit Extraction and
Strips. Oral presentation at the International Hair Surgery
Master Course. October 13, 2012, Paris, France.
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Combined Technique from page 91
10. Crisóstomo, M. The Untouched Strip Technique: A Procedure Combining FUE and Strip Surgery to Improve the
Number of FUs Harvested While Preserving an Area for a
Future Transplant. Video presented at the Advanced Surgical
Video session at the 20th Annual Scientific Meeting of the
International Society of Hair Restoration Surgery. October
17-20, 2012, Nassau, Bahamas.
11. Crisóstomo, M. Transplante Capilar—Técnica Untouched
Strip. Oral presentation at the Brazilian Congress of Plastic
Surgery. November 14-18, 2012, Porto Alegre, Brazil.
12. Crisóstomo, M. Combination of Strip and FUE—The
Untouched Strip Technique. Oral presentation at the 19th
Annual Orlando Live Surgery Workshop. April 17-20, 2013,
Orlando, Florida, United States.
13. Crisóstomo, M. Combining FUE and FUT in Hair Restoration: The Untouched Strip Technique. In: A. Barrera and C.
May/June 2014
Uebel, eds. Hair Transplantation: The Art of Micrografting
and Minigrafting, 2nd Edition. Quality Medical Publishing:
St. Louis, Missouri, USA, 2013. Chapter 10
14. Marzola, M. Trichophytic closure of the donor area. Hair
Transplant Forum Int’l. 2005; 15(4) 113-116.
15. Crisóstomo, M. Combining Extraction and Transplantation:
Untouched Strip Technique. In: A. Barrera and C. Uebel,
eds. Hair Transplantation: The Art of Micrografting and
Minigrafting, 2nd Edition. Quality Medical Publishing: St.
Louis, Missouri, USA, 2013. Chapter 10, pp. 237-261.
16. Bernstein, R.M, W.R. Rassman, and K.W. Anderson. FUE
megasessions—evolution of a technique. Hair Transplant
Forum Int’l. 2004; 14(3):97-99.
17. Unger, W.P., R.H. Unger, and C.K. Wesley. Estimating the
number of lifetime follicular units: a survey and comments
of experienced hair trasnplant surgeons. Dermatol Surg.
2013; 39:755-760.u
Wireless Follicular Dermatoscope
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May/June 2014
FUE Research Committee Chair’s Message
Parsa Mohebi, MD Los Angeles, California, USA [email protected]
I am pleased to present the last part of the FUE Terminology on behalf of FRC (FUE Research Committee) members. Parts I and II can be found in the September/October 2013 and November/December
2013 issues, respectively. The FUE Terminology subcommittee is one of the three subcommittees of the
FRC primarily focused on defining the language and terminology for FUE hair transplantation.
The members of the FUE Terminology subcommittee include Drs. Jose Lorenzo (Chair), John Cole,
Jean Devroye, and Robert True, who have contributed their hard work and time to this document. It was
also reviewed, re-examined, and approved by the entire FRC committee before its publication.
We are grateful for the recommendations, comments, and even criticisms of other colleagues after the publication of the
first two parts; this helped us better prepare this final document. We would like to extend our invitation to the pioneers in this
field, and to those who perform FUE transplants on a regular basis, to help us continually improve FUE terminology. We look
forward to your comments about the content of the prepared FUE terminology. Please send your messages directly to Dr. Jose
Lorenzo at [email protected].
Standardization of the Terminology Used in FUE: Part III
Introduction
The terms in this part of FUE standard terminology focus
on the measurement of quality in extraction. Utilizing these
measurements in daily practice allows the practitioner to fully
assess the quality of his or her technique. In order to perform
these calculations, the following must be observed, counted, and
recorded in all surgeries: 1) the number of punch insertions; 2)
all pieces of tissue removed regardless of appearance; 3) the
number of partially and completely transected follicles in all
removed tissue; 4) the number of follicles intact and transected
per graft, and 5) pre-operative densitometry.
Results
Intact Graft: This graft is comprised of the entire structure of a
healthy terminal follicular unit, including intact structures of the infundibulum, isthmus, and bulbar structures, and
has not suffered any trauma during the
Figure 1. Intact graft
process of extraction.
Partially Transected Graft: Refers
to a graft that contains one or more follicles that have been transversally cut,
but which still contains intact follicles.
Completely Transected Graft: Refers to the amputation of all the follicles
within a graft so that there are no intact
Figure 2. Partially transected
follicles in the extracted tissue.
graft
Buried Graft: A graft that is pushed
and remains under the skin surface during an attempt to cut and isolate with a
circular punch.
Empty Graft: A graft of skin lacking hair follicles resulting from the
Figure 3. Completely transected
insertion of a punch into bald skin.
graft
Missing Graft (MG): Any graft
(intact, complete or partial transection, capped, buried, or empty)
that cannot be located because it is misplaced during the surgery.
It’s the difference between the total number of punch insertions
and the total number of grafts available for hair transplant, plus
the number of grafts unavailable for transplantation: MG = total
number of punch insertions – (grafts available for HT + graft
unavailable for HT).
Total Number of Punch Insertions (or Punch Attempts):
The total of all punch insertions made, whether the insertions
yield graft or not.
Total Number of Grafts Available for Transplant: The total
number of intact grafts or partially transected grafts available
for insertion.
Total Number of Grafts Unavailable for Hair Transplant:
The difference between the number of punch insertions and
number of grafts available for hair transplant. The sum of missing, capped, completely transected, and empty grafts equals the
total number of grafts unavailable for hair transplant.
Total Number of Grafts Extracted: The number of grafts
available for transplant plus the number of grafts unavailable
for transplant.
Missing Graft Rate (MGR): The number of missing grafts
divided by the number of punch insertions. MGR equals:
Number of missing grafts × 100
Number of punch insertions
Graft Transection Rate (GTR): The result obtained when
the number of grafts containing one or more transected follicles
is divided by the total number of grafts extracted. GTR equals:
Total number of transected grafts (partially + completely) × 100
Total number of extracted grafts
Completely Transected Graft Rate (Total Transection
Rate, TTR): The result of the total number of grafts completely
transected divided by the total number of grafts extracted. TTR
equals:
Total number of completely transected grafts × 100
[ bottom of page 94
93
www.ISHRS.org
May/June 2014
To Better “Serve” Your Patient’s Comfort
Mohammed A. Alsufyani, MD Riyadh, Saudi Arabia [email protected]
Hair restoration surgery using follicular unit transplant (FUT)
is an effective, but lengthy and tedious procedure. This article
presents a practical tip to add more to the patient’s comfort
during FUT.
Surgeons go above and beyond to ensure the best level of
comfort is provided to the patient to endure the vexation of such
a procedure. One of the advantages of using the FUT method for
hair restoration surgery is that the patients, male or female, may
leave their hair long. This helps in covering the donor and the
recipient areas from being seen, and this gives a sort of confidence
to the patient to be up and about by the second day after surgery
without being self-conscious about the appearance of the scar
of the donor area or the tiny hemorrhagic crusts of the recipient
area. But, unfortunately, no good deed goes unpunished! The
long hair, especially in females, presents an annoying problem
for the patient during the recipient site creation. While the patient
is lying on his or her back comfortably, the surgeon continuously
combs the hairs to different directions to create the recipient
sites, depending on the hair direction and angle. When the hair
falls to the front, it brushes against the patient’s face, constantly,
which can be irritating and sometimes wakes the patient from a
deep and relaxing nap!
We came up with a simple, inexpensive method to ameliorate this problem. When the patient is positioned on his or her
back for the recipient site creation, the patient is fitted with an
adjustable tennis cap. The anterior rim of the cap is placed just
above the supraorbital foramens, approximately 1.5cm above the
eyebrows, while the adjustable Velcro belt is placed just above,
below, or even on the donor wound if pressure hemostasis is
required (Figure 1). The inner surface of the tennis cap is lined
with gauze to ensure further padding of the cap for more comfort
and sterility. An additional advantage with using the tennis cap:
the brim of the cap shields the patient’s eyes from the bright
overhead lights, adding more comfort to the patient’s experience.
Opportunities are vast for improving the field of hair restoration surgery, wither it may be scientifically, medically, or
simple practicality. We as surgeons just need to be intuitive to
our patient’s needs to improve on any aspects of patient care and
comfort. The French microbiologist Louis Pasteur said it best: “In
the field of observation chance favors only the prepared mind.”1
FUE Terminology from page 93
Calculated Follicles per Graft Achieved (CFGA): The
number of intact follicles extracted divided by the number of
extracted grafts available for transplant plus the total number of
completely transected grafts. CFGA equals:
Partially Transected Graft Rate (Partial Transection Rate,
PTR): The result obtained by dividing the number of grafts
partially transected by the total number of grafts extracted. PTR
equals:
Total number of partially transected grafts × 100
Follicle Transection Rate (FTR or TR): The result obtained
when the number of transected follicles is divided by the total
number of follicles that have been extracted, both intact and
transected. FTR equals:
Total number of transected follicles × 100
Total number of extracted follicles (intact + transected)
Calculated Follicles per Graft Expected (CFGE): The number of intact follicles extracted plus the number of follicles transected divided by number of grafts available for transplant plus
the total number of completely transected grafts. CFGE equals:
Intact follicles + transected follicles extracted × 100
Total number of grafts available for transplant + completely transected grafts
94
Figure 1. Adjustable tennis cap helps keep hair off of patient’s face.
Reference
1. Louis Pasteur. Wikiquote.Org. Retrieved December 15,
2013, from http://www.wikiquote.org.u
Intact follicles × 100
Total number of grafts available for transplant + completely transected grafts
Pared Follicle Rate (CFGA): The number of follicles pared
(or de-sheathed) divided by the total number of follicles (intact
and transected) that have been extracted. PFR equals:
Total number pared follicles
Total number of extracted follicles (intact + transected)
Donor’s Area Calculated Density (Hairs per Follicular
Group): The number of follicles counted in the donor area
divided by the number of follicular units or follicular families
counted in the same donor area (typically performed with a
dermatoscope or trichoscope).u
www.ISHRS.org
May/June 2014
Robotic Recipient Site Creation in Hair Transplantation
Robert M. Bernstein, MD, Michael B. Wolfeld, MD New York, New York, USA; Gabe Zingaretti, PhD San Jose, California, USA*
[email protected]
*Dr. Bernstein is a medical consultant to Restoration Robotics, Inc. Dr. Zingaretti is head of research and development at Restoration Robotics,
Inc. Drs. Bernstein, Wolfeld, and Zingaretti have financial interests in the company.
Editor’s Perception on the Evolution of the Robot
I attended the Orlando Live Surgery Workshop in Orlando because of the stiffness of their epidermis, or as a result of other
in April 2014 and saw a demonstration of robotic recipient site characteristics that make their grafts more difficult to place. The
creation; however, it left me with a few concerns. I was very only way to detect these patients and to avoid this problem is
impressed with the sophistication of the mapping software and by testing each patient before making all of the sites.
The robot uses, I think, three sizes of needles to make sites.
in particular the ability of the robot to recognize and adjust the
At the OLSW, I asked why needles were used and not custompattern of incisions around existing hair in the recipient area.
As I watched the procedure, I noted that there was a lot cut blades that can be made to any specific size, and I was
of bleeding as the robot made sites. The robot had been set to told this is because eventually the robot will be used to place
make sites at 5mm depth. I asked why so deep. After discus- grafts through the needles. I don’t know if this is the reason
sion, during which there was a pause to extract a few test grafts the manufacturer would give, but this does make sense. The
to see their depth, the depth of insertion was reduced to 4mm. consequence, however, is that the robot, as currently configured,
As the robot then proceeded, the bleeding of the recipient sites will not be able to finesse recipient site size to the degree of
surgeons customizing their site size to each specific patient.
was much reduced.
I suspect that my concerns are unnecessary in the hands of
In the below article, the sites were made at 5.5mm deep. As
Dr. Francisco Jimenez reported, human scalp follicles average experienced surgeons, however, some who will be using the
4.2 ± 0.4mm long. In my practice, and, as so well described by robot will not be so experienced. My suggestion is that, if sites
Dr. Bradley Wolf in the March/April 2014 Forum, site depth are being premade with the robot (or by hand for that matter),
and size is determined after measuring grafts and testing sample it should be routine practice to harvest some grafts first, and
grafts for placement before proceeding with premade sites. The based on measurement and test placement adjust the robot to
most common depth I use is 3.5-4mm, so sites at 5 and 5.5mm make the sites no deeper than necessary and to a size that opseem unusually deep to me. There are many potential problems timally facilitates placement. I think this will avoid problems
with sites that are too deep, such as unnecessary vascular trauma, and promote the best results.
As it stands, at this point, in the battle between Ken Jensunken grafts with pitting, and poor growth. One other potential
problem with premade sites is that some patients just simply nings and Watson, I pick Jennings. With further evolution of
need slightly different sites because their grafts are slippery or the robot, a day might come that the balance shifts. —RHT
The initial application of the ARTAS™ robotic system (robot), released in the fall of 2011, was the separation of follicular
units from the surrounding scalp tissue, the first step in a follicular
unit extraction (FUE) procedure.1,2 Subsequent steps in FUE include removal of the follicular unit grafts from the donor scalp,
site creation, and graft placement. With its new hardware and
software capabilities, the robot can now perform one more step
in this process, making recipient sites. Preliminary observations
suggest that it can accomplish this function with greater precision
and consistency than when performed manually.
For robotic recipient site creation, the doctor first draws a hairline
and other markings directly onto the patient’s scalp to delineate the
recipient area. Next, multiple photographs are taken of the patient
and, using new software called the ARTAS Hair Studio™ (AHS),
the images and markings are converted into a 3D model of the
patient. The robot uses the inter-pupillary distance (IPD) to match
dimensions of the model with the actual dimensions of the patient.
To determine how the hair will ultimately grow, the physician uses the software to specify the angle of the recipient site
incisions (relative to the plane of the scalp), incision direction,
site depth, average density, and total number of incisions. The
site spacing can then be easily modified to create variations in
density in different parts of the scalp while the computer keeps
the total number of sites constant.
An important feature of the ARTAS system is that the robot
uses image-guided technology to avoid hairs of a specific diam-
eter when making recipient sites. In this way, the distribution of
sites that are created in the procedure can be made to complement
the distribution of existing terminal hairs (or the hair from prior
hair transplant procedures), while ignoring hair that is miniaturized or vellus. The physician can specify the cut-off diameter
based upon the diameter of the patient’s full terminal hairs.
Partially miniaturized hair may also be included in the group of
hairs to be avoided. Once this parameter is set, the robot will
proceed to create sites at a minimum distance from the selected
existing hair and do so randomly throughout the areas where the
hair is finer or the scalp is bald.
The imaging software is currently used to translate the
design the physician makes directly on the patient scalp into a
computerized algorithm that directs the creation of recipient sites
in the operating room. In the future, the system will also have
the capability of simulating, in advance of the surgery, what the
actual hair transplant will look like so that it can be used as tool
to aid the physician during the consultation.
Case Study
The 44-year-old patient is a white male with straight, fine,
brown hair and a Norwood Class VI-VII pattern of hair loss.
His donor density is 70 FU/mm2 and he has 20% donor miniaturization. After discussing the various surgical modalities for
hair restoration, the patient chose FUE in order to wear his hair
[ page 96
95
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Robotic Recipient Site Creation from page 95
relatively short. He understood that due to his extensive hair loss
and limited donor supply, the goal was to restore light coverage
to the front and top of his scalp. The ARTAS system would be
used for both follicular unit dissection and recipient site creation.
To minimize the time the grafts were outside the body, recipient
site creation would be performed before graft harvesting.3
The morning of surgery the procedure was reviewed, consent
was obtained, and five photos were taken; full-face front, top of
scalp, back of scalp, and left and right sides. The photos were
then loaded into the AHS. Using facial landmarks—eyes, nose,
mouth, forehead, and chin—as a guide, a 3D model was built
around the images and was displayed on a touch-screen monitor. The IPD measured 63.4mm. The recipient site parameters
were then specified. The recipient site depth was programmed at
5.5mm with an angle of elevation from the scalp of 45 degrees.
All of the sites were programmed to 0 degrees, meaning that
they would point in a forward direction and be parallel to each
other. The robot was programmed to avoid hairs with a diameter
of 80u or greater (Figure 1).
Figure 1. ARTAS Hair Studio showing the hair transplant design.
Vital signs were taken and a pulse oximeter was attached to
the patient’s left middle finger. The patient was sedated with oral
Valium and IM versed. Local anesthesia was administered using
a ring-block consisting of xylocaine 0.5%, bupivicane 0.25%,
and epinephrine 1:200,000.
The robotic harvest and subsequent dissection yielded 2,256
grafts consisting of 228 1-hair, 1144 2-hair, and 884 3-hair grafts.
All forty 4-hair grafts were dissected under a stereomicroscope
into smaller grafts (3-hair and 1-hair) to generate enough 1-hair
grafts for the frontal hairline and to ensure a natural appearance
in a patient with low overall density.
Using a 19-gauge hypodermic needle to make the incision,
the robot created 1,632 recipient sites. In Area 1, the frontal
region of the scalp measuring 32 cm2, 583 sites were created at
a density of 18.2 grafts/cm2. In Area 2, the mid-scalp measuring 61 cm2, 1,049 sites were created at a density of 17.2 grafts/
cm2. The remaining 624 recipient sites were made by hand; 220
for the frontal hairline and the remaining 404 for the transition
zone in the posterior aspect of the mid-scalp and to fill in gaps.
The current system uses a grid, measuring 2.5cm×13cm, that
is placed vertically on the patient’s scalp. This serves to orient
the robotic optical system (Figure 2). After the grid is filled with
recipient sites, it is moved to a new position adjacent to the first. In
the current procedure, the robot created sites at 1,500/hour. With
time for set-up and moving grids and creating the manual sites,
the total time for site creation was 1.5 hours (Figures 3 and 4).
96
May/June 2014
Discussion
As with the extraction process, the robot
eliminates the inconsistencies inherent in
creating large numbers
of recipient sites by
hand. The robot can
create sites at a rate of
up to 2,000 per hour,
although there is more Figure 2. Creating recipient sites with the ARTAS robot.
set-up time compared
to sites made manually. The
physician can specify punch
depth (3.5 mm to 7mm),
punch angle to the scalp
(35 to 60 degrees), and site
direction (forward, parallel,
lateral, etc.). Once these parameters are set, site creation
is precise and rapid.
The case described above Figure 3. Before, with marking for the
was the first time we used the procedure.
robot to create recipient sites
on the front and mid-scalp.
Cases subsequent to this
have shown that there is a
rather quick learning curve
that results in a reduction
in the time needed for data
input, set-up, and grid placement; and a shorter overall
duration for this step of the
hair transplant procedure.
Figure 4. Two days post-op.
One of the benefits of
robotic site creation is that the distribution of grafts over a fixed
area of the scalp can be exact. For example, if a physician wants to
transplant 1,000 grafts evenly over 50cm2 of area, this can be done
with great precision and with uniform site spacing. In addition,
the physician can vary the densities in select regions of the scalp
and the robot will adjust the densities in other areas (in real time)
so that the total number of sites remains the same. For example,
if you have 2,500 FUs to cover 120cm2 of scalp and you want to
create a density of 25 sites/cm2 in a 40cm2 frontal forelock and use
the remaining grafts to cover the other 80cm2 of bald scalp, the
robot will automatically calculate a second density of 18.75 sites/
cm2 for the remaining area.
Another benefit is that the robot can be programmed to avoid
existing hair and select which specific hair diameters to avoid.
The robot is programmed to keep a minimum distance from the
existing hair of at least 250 microns (or greater with lower target
densities) to ensure that the resident follicles will not be damaged
and that the distribution of new hair is even and natural. This
computerized mechanism appears to be more accurate than what
can be done by hand and does not sacrifice speed in the process.
This is an important benefit of the new technology.
Compared to manual FUE, the disadvantage of making sites
with a robot is the additional set-up time and small additional cost
(if one is already using the robot for extraction). The disadvantages of robotic site creation when performing FUT procedures
www.ISHRS.org
include cost, the need for a dedicated room, additional staff training, and set-up time. Another issue involves the preparation for
site creation. When creating recipient sites, the recipient area must
be clipped to 1mm in length. In FUE, the patient often prefers this
length to match the donor area, which has already been clipped.
Since the donor clipping is not necessary in FUT, these patients
generally prefer to keep any hair they have in the recipient area
uncut. Therefore, only FUT patients who are already bald in the
recipient area would choose to have their sites made by the robot.
Because of these constraints, robotic site creation lends itself more
to robotic FUE procedures and will probably be used less often in
FUT procedures, even if there is a robot on the premises. A final
issue is that using a robot for site creation may be impractical
for very small sessions that can easily be accomplished by hand.
At this time, the robot is not capable of making the necessary directional changes needed to reproduce the natural swirl
that occurs in the crown. In addition, although the robot can be
programmed to create a hairline, the nuanced irregularity of the
hairline lends itself to being done by hand. If the robot is used
for this part of the procedure, a change to a smaller needle is
required to accommodate the single-hair grafts.
For the physician who is skilled at follicular unit hair transplantation (either by FUE or FUT), robotic site creation adds
modest value to the procedure, as recipient site creation is perhaps
the easiest step to perform. A more significant benefit of the new
technology is in the imaging tool that can assist the physician
in showing the patient the outcome of the procedure in advance
of the actual surgery. Of course, its greatest value is that automated site creation is a necessary precursor to the final step of a
completely robotic hair transplant, automated graft insertion—a
technology that is at least several years away.
May/June 2014
Summary
In performing recipient site creation, the robot automates
another part of the hair transplant process that can be prone to
human error and variability. In addition, the new technology
will soon give the physician a consultation tool to show what the
hair restoration procedure can do and to help align the patient’s
expectations with anticipated results.
Probably the greatest significance of this new method of site
creation is that it brings the technology one step closer to the
goal of a totally automated hair transplant that can be performed
with robotic precision, speed, and reproducibility. The physician
can then focus on the critical, but more subjective, elements of
the hair restoration process, namely, patient selection, patient
education, and hair transplant design.
References
1. Canales, M.G., and D.A. Berman. The age of surgical robots.
Hair Transplant Forum Int’l. 2008; 18(3):95-96.
2. Bernstein, R.M. Integrating Robotic FUE into a hair transplant
practice. Hair Transplant Forum Int’l. 2012; 22(6):228-229.
3. Bernstein, R.M., and W.R. Rassman. Pre-making recipient
sites to increase graft survival in manual and robotic FUE
procedures. Hair Transplant Forum Int’l. 2012; 22(4):128130.u
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97
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May/June 2014
Complications and Difficult Cases
Marco N. Barusco, MD Port Orange, Florida, USA [email protected]
The Morbidity & Mortality Conference presented by the ABHRS was a great success last year during
the Annual Meeting of the ISHRS in San Francisco. In this issue, Dr. Scott Boden describes the case he
presented at the M&M Conference last year; a rare case of infection in the recipient area of a follicular
unit hair transplant procedure done on a patient with a previous history of trichotillomania. This is an
interesting case that brings attention to the controversial issue of use of antibiotics before, during, and
after hair transplant procedures. At the end of the case report, Dr. Boden provides an excellent review
of the current recommendations for antibiotic therapy as it relates to hair transplant procedures. I would like to thank Dr.
Boden for his contribution to this column and congratulate him on the management of this patient and the excellent results
obtained from the procedure.
Scalp Cellulitis in the Recipient Area Following a
Hair Transplant Procedure
Scott A. Boden, MD Wethersfield, Connecticut, USA [email protected]
The following case report illustrates a recipient area wound
infection, an uncommon complication of hair transplant surgery.
Donor area infection and wound dehiscence are seen infrequently, but under clean surgical conditions, localized infection or
cellulitis of the recipient area is a far rarer event. Scalp cellulitis
itself is a rare occurrence, and has been reported to be associated with hydradenitis suppuritiva1 and occurring as a relapsing
inflammatory disease process.2 Inflammatory tinea capitis has
been reported as a mimic of dissecting cellulitis.3
This case provides an opportunity to review current recommendations regarding appropriate
use of antibiotics in hair transplantation, and to address the
risks associated with unnecessary
prophylactic antibiotics.4
The present case concerns
a 60-year-old woman with hisFigure 1. Pre-operative
tory of Female Pattern Hair Loss
(FPHL) and trichotillomania, in
remission (Figures 1 and 2). Her
past medical history is notable for
hyperlipidemia and depression,
for which she takes atorvastatin
and escitalopram. She previously
took riluzole (off-label usage) for
trichotillomania. She notes allerFigure 2. Pre-operative
gies to latex and sulfa drugs.
Procedure
Follicular unit hair transplantation to the hairline, forelock,
and mid-scalp was undertaken, and the surgery proceeded uneventfully. There were 2,568 FUs implanted, and the patient
tolerated the procedure well. The grafts were packed densely in
the frontal forelock, and less dense coverage was provided in
the vertex (Figure 3).
Following the procedure, the patient felt fine, with no significant discomfort and no fever, chills, nausea, or vomiting on
post-operative day 1.
98
On post-operative day 3, she
reported increasing discomfort
in both the donor and recipient
areas, with no systemic signs
or symptoms of infection. She
was seen in the office on postoperative day 4, and she reported
increasing tenderness. The donor
area was well-healing, with scant Figure 3. Immediately post-operative
erythema and minimal tenderness. The recipient area, however,
revealed pustules, tenderness, and slight diffuse fluctuance. Initial management involved thorough cleansing with antibacterial
soap and treatment with doxycycline 100mg by mouth twice
daily for 10 days.
Symptoms worsened over the following two days, and she
was admitted to the hospital with a diagnosis of scalp cellulitis,
and treated with intravenous vancomycin. Unfortunately, wound
cultures failed to identify a specific bacterial pathogen. She was
discharged on the third day on
oral minocycline, cephalexin, and
florastor probiotic (contains yeast
[saccharomyces boulardii] and
bacteria [such as lactobacillus
and bifidobacterium]).
During post-operative days
7-10, she showed continued improvement and was monitored
closely. Sutures were removed on Figure 4. Post-operative day 7; diffuse
cellulitis with erythema, pustules,
day 10 without difficulty, and at scalp
and tenderness
that time, the donor wound was
clean, dry, and intact without exudate or lymphadenopathy. The
recipient area showed improving
erythema and minimal fluctuance
(Figures 4 and 5).
Three weeks post-procedure,
she showed continued improvement (Figure 6), with contin5. Post-operative day 10;
ued improvement and excellent Figure
improving erythema and reduced
growth of the transplanted hair fluctuance
www.ISHRS.org
over subsequent months (Figures
7 and 8).
•
Discussion
This case raises several clinical questions: Was anything
different or unusual about this
case? Would debridement or
other surgical intervention have Figure 6. Three weeks post-operative;
changed the outcome? Should note continued improvement
anything different have been
done? What were the correct
antibiotic choice(s)?
In addition, was there an
unrecognized risk for infection?
The patient denied active trichotillomania. Precautions were
taken to account for her latex
sensitivity. The patient works
as dental hygienist—did this
increase her risk of carrier status
Figure 7. Five months post-operative
for MRSA or other pathogen?
Most importantly, I questioned and evaluated the available literature regarding antibiotic use in hair transplant surgery,
both for treatment of active
infection and if there is a role for
prophylactic antibiotics.
Antibiotic resistance is a major problem associated with the
overuse of antibiotics:
• Each year in the United Figure 8. Ten months post-operative
States, at least 2 million
people acquire serious infections with bacteria that are
resistant to one or more of the antibiotics designed to
treat those infections.4
• At least 23,000 people die each year as a direct result of
these antibiotic-resistant infections. Many more die from
other conditions that were complicated by an antibiotic
resistant infection.4
•
Judicious use of antibiotics for the treatment of infection and
prophylactic antibiotic use is recommended only in select patient
populations. Hair transplantation is considered a Class 1 (clean)
cutaneous surgical wound, and as such, there is no documented
benefit for routine prophylactic antibiotic use. Furthermore, there
is no documented benefit of antibiotics after wound closure in
the reduction of surgical site infections. Prophylactic topical
antibiotic creams and ointments (e.g., bacitracin or Neosporin)
have not been shown to prevent wound infections better than
white petrolatum.5
Specific recommendations for use of prophylactic antibiotics
include only those patients at high risk for infective endocarditis
or hematogenous joint infections.6 Indications for prophylactic
antibiotics in hair transplantation surgery include the following:
• THERE IS NO DOCUMENTED BENEFIT FOR ROUTINE PROPHYLACTIC ANTIBIOTIC USE IN HAIR
TRANSPLANTATION (Considered Class 1 [clean]
cutaneous surgical wound).
•
•
•
•
May/June 2014
THERE IS NO DOCUMENTED BENEFIT OF ANTIBIOTICS AFTER WOUND CLOSURE IN THE
REDUCTION OF SURGICAL SITE INFECTIONS.
IF ANTIBIOTICS ARE TO BE CONSIDERED FOR
THE PREVENTION OF INFECTIVE ENDOCARDITIS (IE) or HEMATOGENOUS JOINT INFECTION
(HJI), USE IN HIGH-RISK PATIENTS ONLY.
HIGH RISK FOR IE: Prosthetic heart valve; history
of IE; cardiac transplant with valvulopathy; unrepaired
coronary heart disease; valve repair within past 6 months
with synthetic material.
HIGH RISK FOR HJI: Surgery within 2 years of joint
replacement; history of prosthetic joint infection; immune compromised.
IF APPROPRIATE TO USE ANTIBIOTICS TREAT
WITH ONE DOSE 30-60 MINUTES PRIOR TO PROCEDURE AND DO NOT EXCEED 24 HOURS OF
TREATMENT.
CHOOSE ANTIBIOTIC APPROPRIATE FOR SKIN
FLORA (typically cephalexin or dicloxacillin; clindamycin or azithromycin in penicillin-allergic patients).
If prophylactic antibiotics are indicated, one dose should
be initiated within 30-60 minutes prior to the procedure, and
antibiotics should not be continued for more than 24 hours.7
Antibiotic Selection in Hair Transplantation Surgery
There should be no prophylactic antibiotics, except as noted
above. In the case of suspected infection, obtaining a wound culture
is optimal. Unfortunately, wound culture was not revealing in this
patient’s case. Likely skin pathogens to be considered in the case of
infection include Staphylococcus aureus (both community acquiredMRSA and MSSA) and Group A, B, C, or G Streptococcus.
If localized infection is noted (<5cm diameter lesion), incision and drainage alone may be sufficient rather than systemic
antibiotics. Antibiotic selection guidelines for infection (systemic
or localized but >5cm lesion) in hair transplant surgery include:8
• I & D alone for localized infection (lesion <5 cm)
• Abscess without fever treat with one of the following:
TMP/SMX 1DS by mouth twice daily; Doxycycline
100mg by mouth twice daily; Clindamycin 300-450mg
by mouth three times daily; Minocycline 100mg by
mouth twice daily
• Abscess with fever add rifampin; no minocycline
• Duration: 5-10 days
Physicians should have a low threshold to suspect community-acquired Methicillin-resistant Staphylococcus aureus (CAMRSA). If abscess(es) are seen without fever, treat with one of
the following: TMP/SMX (Bactrim, Septra) double strength
one tablet by mouth twice daily; doxycycline 100mg by mouth
twice daily; clindamycin 300-450mg by mouth three times daily;
minocycline 100mg by mouth twice daily. If fever, consider
adding rifampin and do not use minocycline. Duration of treatment should be for 5-10 days. For hospitalized (septic) patient:
vancomycin 1g intravenous every 12 hours or daptomycin are
appropriate therapies.
For an infected wound or a subcutaneous abscess, the following are recommended: Check gram stain of exudate—if gram
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Complications from page 99
negative bacilli, add beta-lactam inhibitor (e.g., amp/clavulanic
acid) to TMP/SMX or clindamycin. Note that TMP/SMX has
uncertain activity against strep.
In low-risk surgical procedures, including clean dermatologic
procedures, antibiotic-associated adverse effects exceed the
benefits of prophylaxis. In hair transplant procedures, antibiotics
have a place for the treatment of infection, but the practice of
routine prophylactic use of antibiotics should be abandoned.
The patient discussed in
this case recently underwent
a second FU hair transplant
procedure with me to increase
density and add coverage to the
vertex. Clean surgical precautions were undertaken; she had
no post-operative complications, and is showing excellent
progress (see Figure 9).
Figure 9. Seven months after second hair
transplant
References
1. Koshelev, M.V., P.A. Garrison, and T.S. Wright. Concurrent
hidradenitis suppurativa, inflammatory acne, dissecting cellulitis of the scalp, and pyoderma gangrenosum in a 16-yearold boy. Pediatr Dermatol. 2014(Jan-Feb); 31(1):e20-1.
2. Mundi, J.P., et al. Dissecting cellulitis of the scalp. Dermatol
Online J. 2012(Dec 15); 18(12):8.
3. Stein, L.L., E.G. Adams, and K.Z. Holcomb. Inflammatory
tinea capitis mimicking dissecting cellulitis in a postpubertal
male: a case report and review of the literature. Mycoses.
2013(Sep); 56(5):596-600.
100
May/June 2014
4. Centers for Disease Control and Prevention. Antibiotic
resistance threats in the United States, 2013. Sept 16, 2013.
http://www.cdc.gov/drugresistance/threat-report-2013/
5. Smack, D.P., et al. Infection and allergy incidence in ambulatory surgery patients using white petrolatum vs bacitracin
ointment. A randomized controlled trial. JAMA. 1996;
276:972-977.
6. Wilson, W., et al. Prevention of infective endocarditis:
guidelines from the American Heart Association. Circulation. 2007; 116:1736-54.
7. Classen, D.C., et al. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection.
N Engl J Med. 1992; 326(5):281-286.
8. Gilbert, D.N., et al. The Sanford Guide to Antimicrobial
Therapy 2012.
Bibliography
1. Bratzler, et al. Clinical practice guidelines for antimicrobial
prophylaxis in surgery. Am J Health-Syst Pharm. 2013;
70:195-283.
2. Edwards, F.H., et al. The Society of Thoracic Surgeons
practice guideline series: antibioic prophylaxis in cardiac
surgery, part I: duration. Ann Thorac Surg. 2006; 81(1):397404.
3. Fennessy, B.G., et al. Antimicrobial prophylaxis in otorhinolaryngology/head and neck surgery. Clin Otolaryngol.
2007(Jun); 32(3):204-207.
4. Halpern, A.C., et al. The incidence of bacteremia in skin
surgery of the head and neck. J Am Acad Dermatol. 1988;
19:112-116.u
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101
www.ISHRS.org
May/June 2014
Cyberspace Chat
John P. Cole, MD Alpharetta, Georgia, USA [email protected], and
Bradley R. Wolf, MD Cincinnati, Ohio, USA [email protected]
Surgical Hair Loss
John P. Cole
The question was asked by Dr. Bradley Wolf: “Would anyone
want to guesstimate the second most common form of hair loss
in men, after androgenetic alopecia (AGA)?” The responses were
varied and included (number of responses): alopecia areata (6),
senile alopecia (2), anabolic steroids (1), traction alopecia (1),
diffuse unpatterened alopecia (DUPA) (1), postpartum alopecia
(1), dietary insufficiencies (iron), impure water, microbial infections (1), hair transplant surgery (1, from Dr. John Cole).
According to the ISHRS, 35 million men in the United States
are experiencing noticeable hair loss. The cause in more than
95% of those men is androgenetic alopecia.1 The lifetime risk
of developing alopecia areata is 1.7 percent, with a prevalence
of 0.1 percent.2,3 An estimated 310,624 surgical hair restoration
procedures were performed worldwide in 2012.4 In the United
States, 88,304 hair restoration procedures were performed in
2012.4 Those are the available statistics. Millions of hair restoration surgery procedures have been performed since the 1960s,
many using outdated, inefficient techniques.
After receiving responses, Dr. Wolf replied: Recently, I've
seen quite a few patients who were misled and had terrible results that negatively affected their lives. That got me to thinking
about all the scarring I see, especially in the donor area. Figure 1
shows a patient who had
one strip at 26 years old
done about 3 years ago.
He has excellent density
and laxity. There is nothing wrong with his scalp
except this wide scar. I
see this ALL the time.
Consider the death of
follicles from bad strip Figure 1. 26-year-old, approximately 3 years
dissection, FUE transec- post-strip
tion, poor graft placement, unnecessary surgery, reductions, flaps,
lifts, and horrible donor
scarring past and present
and you have “Surgical
Hair Loss.”
Figure 2 is of a
patient who, prior to
seeing me, was seen
Figure 2. Patient with minimal loss but a lot of
in consultation by an miniaturization at consult
ISHRS member doctor (in good standing) who wanted to do 2,500 grafts in his
hairline, by strip excision. He actually has very little hair
loss but a lot of miniaturization. How much Surgical Hair
Loss would he have had? Surgical Hair Loss is not just a
phenomenon of the past.
102
Bradley R. Wolf
Jerry Cooley responded: No, hair transplant surgery is not
the second most common form of hair loss. It might be in your
practice. That’s no more accurate than the African American
female hair restoration surgeon who claims traction and CCCA
are the most common forms of hair loss or the medical dermatologist who claims its telogen effluvium or the rheumatologist
who claims its lupus. We are all biased by the patients who
come to see us.
John Cole added: In reality this could be true. Every time
you remove a strip, you kill some follicles. Even your needle can
cause needle point areas of hair loss. Every time you do FUE,
you are going to get some transection and we have to assume this
kills at least some follicles. There is not a single patient who has
undergone a hair transplant procedure who has not lost hair. It
may not be much in many instances, but it is always something.
I agree with Jerry and John. While we will never know the
incidence of “Surgical Hair Loss,” it bears consideration due
to past inefficient hair restoration surgeries and the increased
number of surgeries being performed today. Worldwide, from
2004 to 2012, there has been an increase in the number of hair
restoration surgeries by 85% (168,155 to 310,624).4
“Primum non nocere” is a Latin phrase that means “First,
do no harm.” Another way to state it is that, given an existing
problem, it may be better to not do something, or even to do
nothing, than to risk causing more harm than good. It reminds
the physicians that they must consider the possible harm that
any intervention might cause. Current techniques have evolved
in an effort to preserve follicles by causing as little damage to
existing follicles as possible. The potential for surgical hair loss
is real and in every patient should be taken into consideration
prior to surgery.
References
1. Statistic Brain: Hair Loss Statistics. http://www.statisticbrain.com/hair-loss-statistics/ (source: Relevant Research
Inc.).
2. Safavi, K.H., et al. Incidence of alopecia areata in Olmsted
County, Minnesota, 1975 through 1989. Mayo Clin Proc.
1995; 70:628-633.
3. Shellow, W.V., J.E. Edwards, and J.Y. Koo. Profile of alopecia areata: a questionnaire analysis of patient and family.
Int J Dermatol. 1992; 31(3):186-189.
4. International Society of Hair Restoration Surgery (ISHRS)
2013 Practice Census Facts and Figures. Retrieved from:
http://www.ishrs.org/statistics-research.htm.u
www.ISHRS.org
May/June 2014
How I Do It
Timothy Carman, MD, FISHRS La Jolla, California, USA [email protected]
The issue of removing donor hair via the traditional strip vs. the FUE method is an evolving discussion
among hair transplant surgeons. Regardless of differences of opinion over the nuances that indicate or
contraindicate FUE’s use, it is generally agreed that it is a more labor intensive and time consuming process
compared to strip excision harvesting. FUE can also have additional disadvantages as well, one of which
is the need to shave large areas for harvest. Below, Dr. Jae Hyun Park shares his method for an alternate
method of FUE harvest without shaving the donor area. As we surgeons of the ISHRS continue to evolve
in our procedures and practices, observations and innovations such as Dr. Park’s can be valuable to us all.
Direct Non-Shaven FUE Technique
Jae Hyun Park, MD Seoul, Korea [email protected]
Ever since Rassman and Bernstein first introduced the follicular unit extraction (FUE) method in 2002,1 the FUE has developed
remarkably and is now being practiced even by robots.2,3,4 The
FUE procedure has several advantages. It does not leave a linear
donor scar, it causes less post-operative pain, and it enables a
larger amount of hair to be harvested and transplanted in cases
where the donor scalp may not have enough laxity to yield that
same amount via the traditional strip method. However, there are
also some disadvantages. FUE demands a relatively long learning
curve and possibly shows a high transection rate in cases of low
surgical proficiency. Also, the FUE may reach up to the unsafe
zone in procedures where large numbers of grafts are sought and,
furthermore, it typically requires that the patients’ hair be shaved
quite short. Among those disadvantages mentioned above, the fact
that patients are required to have their hair shaved is frequently
the main objection that makes them unwilling to have the FUE
procedure. Particularly in South Korea, where I practice, the
short-shaved hairstyle may trigger associations with criminals,
gangsters, or prisoners due to existing prejudices and stereotypes
in the Korean society.
For this reason, the FUT procedure can be an alternative.
However, it still cannot be chosen if patients do not wish to be left
with a linear donor scar, if they have a serious phobia of pain, or
if the donor scalp laxity is not sufficiently lax. In such cases, FUE
can be chosen through wide variations, such as partial-shaving
or microstrip shaving, so that the top hair can cover the shaved
donor site. I perform different types of FUE procedures based on
the shaving patterns described below. (See Figure 1).
Microstrip shaving may lead to an appearance of multiple
linear scars if more than 400-600 grafts are extracted. In both
partial shaving and microstrip shaving patterns, there may be
less possibility to selectively harvest 2- to 3-hair follicular units
primarily with thick anagen hairs in the wide donor area. In addition, both patterns may so severely decrease the hair density in
these specific small areas such that it looks vacant, presenting as
a moth-eaten or see-through appearance of the scalp. Also, it is
not possible for patients with a crew-cut to have partial shaving.
Therefore, in our opinion, a non-shaving technique is sometimes
a better choice in these cases.
Literally, non-shaven FUE means that the FUE procedure
is performed with the natural state of the patient’s long hair,
without shaving. Some expert FUE hair surgeons perform nonshaven FUE while many other surgeons are not able to because
of the particularly long learning curve, extremely long operating
A
B
C
C
D
D
D
Figure 1. Comparison of various shaving patterns in FUE. A: Total shaving (post-op day
1); B: partial shaving (post-op day 1); C: microstrip shaving (pre-op—after shaving (left)
and immediate post-op day 1 (right)); D: non-shaving—800 grafts (post-op day 3).
time, and the high transection rate due to physician fatigue. The
non-shaven FUE procedure is mostly carried out in a two-step
procedure. The first step is for a surgeon or an assistant to cut the
target hair short, using scissors. In the second step, the surgeon
punches out the follicular units that were cut in the first step.
In addition, there are two main sub-patterns in the 2-step
non-shaven FUE procedure. The first is that follicular units for
extraction are cut short in advance in each prearranged section
in the donor area, followed by the surgeon locating these units
and performing FUE punch/extraction. The second method is
that as the assistant cuts the follicular units, the surgeon immediately performs the follicular unit punch/extraction, alternately
working with each other. Both patterns take a great deal of
time, and in that sense have a lower efficiency rate. In order
to shorten the time of the procedure, and increase efficiency,
I perform the so-called, “1-step non-shaven FUE,” or “direct
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How I Do It from page 103
non-shaven FUE.” This procedure involves punching and cutting hair simultaneously rather than cutting hair in advance for
extraction. The process is as follows:
1. Selection: Long hairs are combed and hairs to extract
are chosen mainly from anagen hairs.
2. Targeting: The punch is positioned above the hair to be
punched.
3. Punching: The foot switch pedal is stepped on in advance.
When the punch starts spinning, hairs are cut by the sharp
punch tip and punched at the same time.
4. Extraction: The punched grafts are extracted.
Using a motorized FUE machine with a 1mm sharp punch, I
carry out harvesting in the sitting position as an operator along
with an assistant in charge of graft extraction to my right. I sort
out the follicles to extract and conduct punching, and then the
assistant performs the extraction. ATOE forceps (Cole Instruments, USA) are used for extraction. In this way, it is possible
to extract about 400-500 follicles per hour. In our practice, graft
implantation is done in the supine position.
Non-shaven FUE takes a long time for extraction. Therefore,
I prefer the two methods for implantation in order to shorten the
operation time as below.
In the first method, a pre-made slit creation is done before
donor FUE punching and then the transplant follows with an
implanter using a “No-Touch Technique” or “Chubby No-Touch
Technique.”4,5 Almost all the follicles without trimming are
implanted by the Chubby No-Touch Technique. Pre-made slit
creation is mostly performed in cases of relatively tough skin
type or bleeding tendency.
In the second method, follicles are implanted only with an
implanter without pre-made slits.6
I retrospectively reviewed the medical records of 40 patients
who had a hair transplant in the manner outlined above. Out of
the 40 patients, there was 1 female atrichia, 34 with male pattern baldness (MPB), 4 with female pattern hair loss (FPHL),
and 1 female hairline correction case. Two MPB patients were
Caucasian and 38 were Korean with black hair. On average, 782
grafts were extracted per patient. The lowest number of grafts
was 320 and the highest was 1,492. The average number of follicles harvested per hour was 412 grafts.
In the 2 Caucasian patients, the transection rate (TR) was
7.2%. The extraction procedure for them was much easier than for
the Korean patients because of their soft scalp tissue with a loose
collagen bonding force and a shallow follicle depth.7 Overall,
the TR was 11.8%. For reference, in my case, the TR is generally recorded at about 5% and the average number of follicles
harvested per hour is 800-1,000 when the donor site is shaven.
The most salient weakness of the non-shaven FUE procedure
method is that, on average, it requires a longer operating time. In
general, it takes 2-4 times as long as the standard FUE procedure
method and thus may be a source for increased fatigue for the surgeon along with their operating teams. It may also lead to follicle
transection and/or capping in the harvesting process. In addition,
a loupe of at least 5× magnifications must be worn during the operation. Therefore, it is desirable for a surgeon to first attempt the
non-shaven FUE in a smaller case setting, such as a touch-up procedure, if he or she is accustomed to the total shaven FUE method.
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May/June 2014
It is anticipated that a growing number of patients will wish
to have non-shaven FUE and, therefore, I hope a diversity of
techniques will be developed.
Conclusion
Direct non-shaven FUE can be a good choice among hair
transplantation methods. The direct non-shaven FUE surgical video is available on YouTube: http://www.youtube.com/
watch?v=mQBoS-ZVhms.
References
1. Rassman, W.R., and R.M. BernsteinM. Follicular unit extraction: minimally invasive surgery for hair transplantation.
Dermatol Surg. 2002; 28(8):720-727.
2. Bernstein, R.M. Integrating robotic FUE into a hair
transplant practice. Hair Transplant Forum Int’l. 2012;
22(6):228-229.
3. Bernstein, R.M., and W.R. Rassman. Pre-making recipient
sites to increase graft survival in manual and robotic FUE
procedures. Hair Transplant Forum Int'l. 2012; 22(4):128130.
4. Park, J.H. My hair transplant procedure with ARTAS
robotic system and “Chubby No-Touch Technique.” Hair
Transplant Forum Int'l. 2013; 23(5):173-174.
5. Konstantinos, J.M., and R. Shapiro. The No-Touch Technique. Chapter 16. In: Hair Transplantation, 4th Edition.
Marcel Decker. 2006; 657-662
6. Lorenzo, J., et al. Introduction to the use of implanters. Hair Transplant Forum Int'l. 2011; 21(4):121-122.
2011;21(5):170-171
7. Bertram, N. Idiopathic occipital fibrosis: what the FUE
surgeon should be aware of. Hair Transplant Forum Int’l.
2012; 22(6):230-231.u
Commentary on Dr. Park’s Unshaven FUE
John Cole, MD Alpharetta, Georgia, USA [email protected]
Non-shaven FUE is the future for hair transplant surgery.
As Dr. Park states, there are many who want FUE to avoid a
strip scar, however, they also are unable to shave their head.
For this reason, I introduced non-shaven FUE in 2003. I introduced the totally non-shaven technique in Korea in 2008.
Initially, we offered shaven patches, which is the same
thing as Dr. Park’s shaven strips. We discovered within the
first year that shaven patches limited the number of grafts
we could obtain, as much of the donor area was non-shaven.
The chief complication of shaven patches was linear areas
of thinner density, which resulted in linear patches having a
moth-eaten appearance. The result was as bad as a strip scar in
the author’s opinion. Therefore, I believe that shaven patches
or shaven strips should NEVER be performed.
If a physician is going to shave a portion of the donor area,
while leaving the remainder of the hair long, the preferred
method is to shave the entire safe donor area while leaving
the surrounding hair long. Of course this requires long hair,
which is more common in women. Grafts should then be
harvested in an irregular, diffuse manner so that there is no
resulting extraction pattern.
We prefer the totally non-shaven approach. We require
approximately 1 hour to prepare a donor area for a 3,000-graft
www.ISHRS.org
May/June 2014
non-shaven procedure. We do our best to trim only the grafts
that we intend to remove, however, we always seem to over trim.
Over trimming is preferable to under trimming only because
under trimming decreases the desired graft count. We harvest
grafts nearly as fast as if the donor area is not shaven. My speed
is higher because of the experience I have of performing over
1,000 cases of non-shaven FUE already. We also find that, with
practice, the follicle transection rate is nearly the same as with
a shaven procedure. It simply takes time and practice.
It is always nice to find ways to cut corners. Using the
punch to cut hair as you proceed is one way, though there are
problems resulting from this method. Hair follicles are hard.
When you use the punch to cut the hair shaft, the hair follicles
will accelerate the dulling of your punch. Asian hair is often
coarse and the dulling affect is greater with coarser hair. It
is far easier to use this technique with fine hair. The second
problem is that it is more difficult to approximate the hair shaft
exit angle when you leave the hair long. Hair grows along a
curve angled down toward the skin. With longer hair, this curve
will make the hair appear to exit more acutely from the skin
than it actually does. The physician must guess the true angle
with longer hair. The coarse nature of the hair requires greater
axial force from the physician to cut the hair follicles. This
greater axial force displaces the hair follicle and thus further
complicates the extraction process while increasing the risk
of follicle transection needlessly. The preferred method of
non-shaven FUE is to pre-cut the hair shafts so that these
risks and complications are avoided. The author feels that
saving time is not acceptable when it carries greater risk to
hair follicles.
There are many different types of skin. Some are hard,
some are soft, and some are rubbery. It is impossible to make
generalizations from a limited number of Caucasian cases. One
can assume that Asian skin will be firmer and the follicles will
be deeper and coarser. There are Caucasians with deep follicles
and firm skin, however. In general, I like the firm skin of the
Asian patient. I feel it helps limit follicle displacement while
excising the graft.
Editors Note: One of the problems when doing unshaven
FUE with a rotating punch is that the adjacent long hair can
get caught and wrapped around the punch. This slows the
procedure. Dr. Park overcomes this problem by using a hand
punch without rotation, but at the sacrifice of speed. In discussing this with Dr. Cole, holding the hair flat with the opposite
hand and minimizing the length of punch protruding from the
motor helps to reduce but not eliminate this problem.—RHTu
105
www.ISHRS.org
Meetings and Studies
David Perez-Meza, MD Mexico City, Mexico [email protected]
COuRSES
Below Dr. Carlos Puig reviews the 5th Annual St. Louis workshop that was held at the excellent facilities
of the Saint Louis University School of Medicine and hosted by Dr. Sam Lam. The workshop included the
latest High Definition Live 3D lectures and surgery dissection and an extensive, hands-on Cadaver Workshop. In addition, Dr. Puig summarizes the annual Japanese Society of clinical hair restoration meeting.
This was an excellent and very interesting meeting that included several papers on cutting-edge technologies
and stem cell research.
Thank you to Dr. Carlos Puig for his excellent summaries.
FEE:
$895
May/June
2014
LEVEL:
Beginner
BASICS COURSE CH
David Perez-Me
Marco N. Barus
David Perez-Meza, MD
St. Louis to Tokyo: From the Basics to the Cutting Edge
Carlos Puig, DO, FISHRS Houston, Texas, USA [email protected]
Last year I was indeed honored to be invited to participate as faculty at both the Saint
Louis Hair Transplant 360 Workshop and at
the annual meeting of the Japanese Society
of Clinical Hair Restoration. The St. Louis
meeting, organized and run by Dr. Sam Lam
from Dallas, focused on training physicians
in the basics of hair restoration surgery. The
cadaver labs were utilized to train on donor
harvesting both FUE and strip techniques,
recipient site creation, and treatment planning.
The Japanese society meeting, held in Tokyo
and organized by Dr. Akira Takeda, focused
on cutting-edge technologies that included the
use of ACell, tissue culturing, and stem cell
and growth factor research.
Dr. Sam Lam reviewing course objectives.
5th Annual St. Louis Hair Transplant
360 Hands-on Cadaver Workshop
Dr. James Harris leading a workgroup station in
The St. Louis meeting was organized by the cadaver lab.
Dr. Sam Lam and was held at the St. Louis
University School of medicine's practical
anatomy and surgical education center, November 14-17, 2013. This beautiful facility
was designed specifically for post-doctorate
training of physicians and surgical techniques
utilizing cadavers and houses the Zeiss dissecting microscope laboratory, which has
about 15 dissecting microscope teaching stations. Each station has not only a dissecting
microscope, but also a video display panel, so Tina Lardner presenting to the Surgical Assistants.
the instructor can see exactly what the student
is doing and make immediate recommendations. This creates a very unique and efficient
teaching environment.
Dr. Lam has managed this course for the
last for five years, and has developed a very fine
faculty, including Drs. Michael Beehner, Bob
Niedbalski, Brad Wolf, Jim Harris, and Ken
Williams. He has also recruited hair restora- Emina Karamonvoski showing proper positioning
to a student.
tion surgery technicians. The technician team
was led by Emina Karamanovski, and included Brandi Burgess,
Tina Lardner, Aileen Ullrich, and Shellie Henderson. This year's
meeting was attended by about 70 attendees, some from as far
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supplies necessary
course.
Participants
may bring their ow
formal lecture format, panel
discussions,
and
own personal
use during the course, if t
questions from the audience.
It was remarkPRECAUTION
This course will utilize hum
able to see how similar the
strategicNOTE:
thinking
Although all tissue is pre-screened for contaminan
was among the faculty. There
were
very
few
Universal Precautions must be observed for the en
the Attendee Agreement on the registration fo
differences of opinion as see
to you
how
towear
apply
the
but
may
scrubs
for this course if you cho
coverings will besurgery.
provided, including standard dis
basic strategies of hair restoration
an allergy to latex or glove powder, please bring s
Because the program was focused in helping
physicians to get started, the faculty seem to
spend extra time in providing the registrants
with information about technological surgical
 2011
18 ANCHORAGE
skills and medical therapies,
as well as help
with practice building that included information on such topics as office design, staffing,
and practice management.
I believe Dr. Lam and the staff at the St.
Louis University School of Medicine Practical
Anatomy Education Center have once again
delivered a well-designed program for beginning hair restoration surgeons.
www.ISHRS.org
May/June 2014
inhibitors in the treatment of alopecia areata.
18th Annual Scientific Meeting of
Both of these discoveries are made even more
the Japan Society of Clinical Hair
clinically applicable because many of these
Restoration
compounds are already on the market for
I returned to Houston from St. Louis,
other diseases.
unpacked, and then repacked, grabbed my
Dr. Robert Hoffman, Department of
lovely wife, Cheri and boarded the plane
Surgery, University of California San Diego,
bound for Tokyo to attend the November
presented a number of papers about hair fol23-24 meeting. We crossed the International
licle stem cells that express Nestin, and their
Date Line and lost a day arriving in Tokyo
about three in the afternoon on Tuesday. The Faculty of the Japanese Meeting (left to right): Drs. potential impact on regeneration of injured
Japanese society meetings were not sched- Ken Wahenik, Marwan Safi, Akira Takeda, Carlos nerves. Nestin-expressing hair follicle stem
cells of the mouse can differentiate into neuuled to start until Friday, and Cheri and I had Puig, John Cole, and Kuniyoshi Yagu
rons, keratinocytes, smooth muscle cells, and
taken a few extra days before the meeting to
melanocytes in vitro. They appear to enhance
spend time with Dr. Kuniyoshi Yagyu and his
nerve regeneration and restoration of nerve
lovely wife, Wakako. On Wednesday we took
function in mouse injured nerve models.
a bullet train to Kyoto and spent two beautiThis is exciting as Nestin-expressing stem
ful days there under Sensei Yagyu’s tutelage
cells are readily available in hair follicles.
visiting temples, shrines, and samurai castles,
These hair follicle stem cells may be an eassome of which were nearly 1,000 years old.
ily accessible source of safe, autologous stem
Indeed Cheri and I will always be grateful
cells for clinical use in treating neurological
to the Yagyu's teaching us about Japanese
injury or disease.
culture, food, and history.
Attendees of the Japanese Meeting
Attending these meetings just before
The Japanese Society of clinical hair restoration is unique among the hair restoration surgery societies the Christmas holiday season made the last quarter of the year
around the world in that several years ago the surgical group rather hectic, but also an exciting time to learn from both new
elected to expand its membership to include both physicians and old friends, many new and exciting things about hair and
and PhD biological science researchers interested in hair follicle hair restoration.u
physiology and pathophysiology. Nearly half the membership
consists of researchers who are looking at hair follicle stem cells
and the growth factors and cytokines that influence hair follicle
cycling. The papers presented at this meeting were some of the
most cutting-edge presentations in stem cell research available
today. Unfortunately, only about half of the meeting was supported by translation, so those of us on the faculty who do not
speak Japanese were often relegated to interpreting the slides
as best we could.
Once again, I was honored to be invited by Dr Akira Takeda,
president of the Japanese Society, to participate in their annual
meeting as part of an outstanding faculty that included Drs. John
Cole, Ken Washenik, Marwan Saifi, Robert Hoffman, and Drs.
Tsuji and Itami.
Dr. Tsuji is one of the world’s foremost authorities on hair
follicle neogenesis from dissociated cells. He has successfully
grown hairs in the mouse kidney and transplanted them into the
mouse scalp where they established normal anatomical development including developing erector pili attachments, growth
and cycling.
Dr. John Cole presented a very nice overview of his experiFor more information, contact:
ence with the use of ACell and follicular unit extraction hair
restoration surgery. As he often does, Dr. Cole left the attendees
with as many questions about the new technologies as there were
21 Cook Avenue
answers in his presentation.
Madison, New Jersey 07940 USA
Dr. Ken Washenik presented a nicely organized overview
of the current status of hair follicle stem cell tissue culturing,
Phone: 800-218-9082 • 973-593-9222
and therapies that may be coming down the road in the future,
Fax: 973-593-9277
whose origins came from this research. He also discussed the
paradoxical role of different prostaglandins in the regulation
E-mail: [email protected]
of hair growth and loss, and the possible use of prostaglandin
www.ellisinstruments.com
stimulators or inhibitors in the treatment of hair loss. Dr. Washenik shared the exciting discovery of potential use of JAK kinase
State-of-the-art
instrumentation for hair
restoration surgery!
107
www.ISHRS.org
May/June 2014
Regional Societies Profiles
In this issue, it is our pleasure to highlight the Brazilian Association of Hair Restoration Surgery (BAHRS). ISHRS members
have had a great time with our Brazilian friends over many years enjoying both professional and personal interactions. They are
amongst the most gracious hosts in the world when we visit, and hopefully many of us will make the journey for their upcoming
conference scheduled for May 21-24 in São Paulo.
Dr. Ricardo Lemos is generous with his praise of the help that the ISHRS has given to Brazil, but we know that the exchange
goes both ways and we certainly appreciate the insights we have received over the years from our Brazilian colleagues. May
it long continue.
All the best Dr. Lemos for your conference, keep up the educational work. —MM
Brazilian Association of Hair Restoration Surgery
MM: What is the name of your society and
when was it founded?
RL: The ABCRC - Associação Brasileira de
Cirurgia da Restauração Capilar (BAHRS - Brazilian Association of Hair Restoration Surgery)
was founded on March 1, 2003.
MM: Who are the founding members?
RL: Marcelo Gandelman, MD; Fernando
Teixeira Basto Jr., MD; José Candido Muricy,
MD; Carlos Eduardo Leão, MD; Maria Angélica
Muricy, MD
MM: Do you have regular meetings, conferences, or workshops?
RL: Yes, we have a bi-annual meeting and one workshop
per year. The previous one took place last November at the
Ruston Clinic (ABCRC Live Surgery Workshop—Long Hair
Transplant & FUE).
MM: Who are the office bearers?
RL: The Board of Directors until March 2015 includes: President, Ricardo Lemos, MD; Vice President, Francisco Le Voci,
MD; Executive Secretary, Luiz Alberto Pimentel, MD; Deputy
Secretary, Alonso Aymoré, MD; Treasurer, Sandro Salanitri,
MD; Deputy Treasurer, José Rogério Régis, MD.
The Scientific Committee includes: Arthur Tykocinski, MD;
Antonio Ruston, MD; Mauro Speranzini, MD.
MM: How many hair practitioners are there in your country
and what proportion are members of your society?
RL: At present, there are not formal statistics of how many
hair transplant practitioners we have in Brazil. In our association,
we have 144 members.
MM: How many are members of ISHRS?
RL: There are 55 who are also members of the ISHRS.
MM: Are there any medico-political problems in your
country?
RL: Now-a-days we are facing a lack of doctors in our
country. As Brazil is a huge country, there are many regions
that don't have enough of doctors. In response, our president,
Dilma Rousseff, launched a program called MAIS MÉDICOS
108
(More Doctors) to solve
this problem. In this program, President Rousseff
made a partnership with
a Cuban Government and
Dr. Ricardo Lemos
the Cuban Medical Association to send Cuban doctors to these areas.
However, those doctors didn't undertake any
evaluation to practice these specialties in Brazil,
which caused a problem in the medical area.
MM: Is advertising allowed and are there different rules for
medical advertising?
RL: There are many rules for medical advertising in our
country and these rules are rigorous. The Federal Council of
Medicine does not allow the advertisement of pre- and post-op
photos. For example, the only permitted advertisement is educational, and even in this case you may not provide your address
and phone number.
MM: Has the general public embraced hair restoration or is
it still in its infancy?
RL: I have the impression that in the last few years there has
been an increase in acquiring knowledge on the part of doctors
due to participation in the ISHRS and our association, ABCRC,
and consequently improvement in the HT results. As such, there
has been an increase in acceptance of this procedure. So, HT
surgery is neither in its infancy in Brazil nor have we reached
full acceptance. In fact, one important obstacle is the lack of
knowledge about the technique on the part of potential patients
given that advertisement is so restricted here.
MM: Are most hair doctors busy? Are there lots of new doctors joining and, if so, are there too many complications?
RL: There are some HT surgeons who are very busy, but this
is not the case for all doctors in this area. Regarding the doctors
who are new to this area, most have acquired current knowledge
about the technique but face the complications of gaining experience and also building the surgical team necessary for FUT and
as such may have complications in their results. There are also
doctors who have more years of experience, but they have not
sought to update their techniques (potentially therefore having
complications in their results.)
www.ISHRS.org
MM: Is the surgery mostly FUE or FUT?
RL: The majority of surgeries are FUT (more than 90%). FUE
is just beginning to become popular in Brazil now.
MM: Are there any robots in Brazil?
RL: No, there are no robots in Brazil. ARTAS is trying to
obtain approval for the robot with ANVISA (Health Department). Probably in the second semester of this year, we will
have robots in Brazil.
MM: Is anybody investigating cell-based therapies?
RL: As far as I know, no.
MM: Who are the doctors that are active in education in your
country and outside your country?
RL: Active doctors include: Alessandra Juliano; Alonso
Aymoré; Antonio Ruston; Arthur Tykocinski; Carlos Alberto
Calixto; Carlos Eduardo Leão; Carolina Marçon; Cristine Graf;
Clerisvaldo Almeida Souza; Denise Steiner; Dirlene Roth; Fabio Bongiovani; Fernando Basto; Francisco Le Voci; Henrique
Radwanski; Ival Peres Rosa; Izelda Maria Costa; Jório Santana
Filho; José Candido Muricy; José Rogério Régis; Luiz Alberto
Pimentel; Marcelo Gandelman; Marcelo Pitchon; Marcio Crisóstomo; Maria Angélica Muricy; Maria Gabriela Crisóstomo;
Mauro Speranzini; Ricardo Lemos; Sandro Salanitri
MM: Where is hair restoration headed in your country?
RL: As noted above, we believe FUE will become more
popular in the next few years, otherwise, it should be business
as usual. A gradual overall improvement in results is expected
with the increased availability of our conferences and workshops.
May/June 2014
About Dr. Lemos…
Dr. Ricardo Lemos received his degree in Medicine in
1985 from the University of São Paulo, School of Medicine.
Upon graduating, he received the Professor Edmundo Vasconcelos Award for best student surgeon in his class. In the
five years that followed, Dr. Lemos completed his residencies in General Surgery and Plastic Surgery at the Hospital
Das Clinicas of the University of São Paulo.
Dr. Lemos is a full member of the Brazilian Society of
Plastic Surgery, the International Society of Hair Restoration
Surgery, and the Brazilian Association of Hair restoration
Surgery, for which he is currently president, and actively
participates in national and international conferences.
During his career, he has dedicated himself to perfecting the art and efficiency in the field of hair restoration,
particularly with Long Hair Transplantation, and is now a
devotee of this technique. Over the last 18 years, Dr. Lemos
has performed over 5,000 hair transplant surgeries, of which
one-third were long hair transplants.
MM: What would you say are the strengths of your society?
RL: The promotion of educational programs and ethical
control of medical practice in our area in Brazil.
MM: What can the ISHRS do to help you?
RL: The ISHRS is already helping us with the promotion of
continuing education by way of the annual meetings and workshops and by supporting our local meetings during which various
foreign doctors come to give classes. Otherwise, I believe that
holding an ISHRS Annual Meeting in Brazil would be of great
value to the Brazilian HT doctors as well as an honor.u
MM: When and where is your next scheduled meeting?
RL: The V Brazilian Congress of Hair Restoration will be on
May 21-24, 2014, in Maresias Beach, São Sebastiao, São Paulo.
Announcing ISHRS Online Video Library
Dear ISHRS Members:
There is a new valuable member-benefit now available!
We have compiled with authors’ permissions the ISHRS Online Video Library containing surgical videos. Access is exclusive to ISHRS Members with no additional charge.
Over the years, the CME Committee envisioned this offering. We are happy to see it
come to fruition. We will continue to add videos. All videos are educational in nature and
non-commercial. Most are 5 minutes in length. Thus far, inclusion of videos has been by invitation only. There
are many excellent videos and I encourage you to check it out.
We thank those physicians who created and allowed us to post their videos. The Society has always been about
sharing education so our members can be better practitioners and our patients can receive the best treatments.
If you feel you have a worthwhile educational surgical video showing a particular technique or pearl and it
meets these parameters, please e-mail our Executive Director Victoria Ceh with a link and description of the
video at [email protected] and the Committee will review it.
To access the ISHRS Online Video Library, login to the Members Only section at www.ISHRS.org. On the
upper navigational bar, click “Members Only” and then Video Library. If you have trouble logging in, please
contact ISHRS Headquarters and one of our staff can walk you through it.
109
www.ISHRS.org
May/June 2014
ISHRS Cheryl Pomerantz
Surgical Assistants Training Resources Center
This online resource center contains materials to help physicians
train new hair transplant surgical assistants/technicians.
The training resources have been developed by a
task force composed of ISHRS physician and surgical
assistant members who are devoted to the education
and quality training of other professionals in the field.
The format of this resource center includes PowerPoint
presentations, video files, images, sample PowerPoint
slides for you to tailor so you can teach your surgical
assistants, and Word documents with references and tips.
TR AInIng ToPICS
1. Introduction and
Acknowledgements
2. Job Description
3. Basic Science for the Beginner
Technician
4. Instrumentation
5. Dissection: Slivering and Graft
Preparation
6. Graft Placement
7. Trainer Placer Board
8. Quality and ‘H’ factors
(human factors)
9. Efficiency Standards
10. Surgical Assistant
Resource Manual
CoST
ISHRS PHySICIAn membeRS
monthly lease (30 days): $750 USD
Quarterly lease (90 days): $2,000 USD
ISHRS PHySICIAn membeR-PenDIngS
monthly lease (30 days): $900 USD
Quarterly lease rate not available to
Physician member-Pendings.
FoR moRe InFoRmATIon
and to lease the Surgical Assistant Training
Resources, go to:
http://www.ishrs.org/content/
educational-offerings
110
HoW To ACCeSS THe
TRAInIng ReSoURCeS CenTeR
The Training Resources Center is
available for lease via our online gateway.
Visa, masterCard, and American express
payments are accepted. A confidential
URL and password will be emailed to you
after your payment has been processed
via the online gateway. your password
will automatically expire after your 30/90
day usage.
you may lease subsequent months by
repeating the online lease process or
by contacting the ISHRS Headquarters:
telephone 1-630-262-5399 or
1-800-444-2737, or [email protected].
DeDICATIon
This Resource
Center is fondly
dedicated to the
memor y of
Cher yl Pomerant z , RN
(19 4 9 -2 010).
Che r yl was a fou nd i ng su rg ic al
assistant me mbe r of the
Soc iet y and devote d cou ntle ss
hou r s towards deve lopme nt of
assistant e duc ation, g row th, and
re cog ni tion. She was passionate
abou t the f ie ld of hai r re stor ation
su rg e r y and provid i ng qual i t y c are
to patie nts.
We honor he r me mor y wi th the
de d ic ation of this R e sou rce
Ce nte r.
www.ISHRS.org
May/June 2014
Hair’s the Question*
Sara Wasserbauer, MD Walnut Creek, California, USA [email protected]
*The questions presented by the author are not taken from the ABHRS item pool and accordingly will not be found on the ABHRS Certifying Examination.
Platelet Rich Plasma (PRP, also termed autologous platelet gel, plasma rich in growth factors
(PRGF), and platelet concentrate (PC)), while not a new technology, is a “new kid on the block” in hair
transplant. What is PRP and how does it affect the hair follicle? Test your knowledge of this “new”
adjunctive treatment for hair loss. You can bet your patients are going to know some of these answers.
PRP Questions
1. Mouse dermal papilla cells and epidermal cells mixed with
activated PRP (10% and 15%) resulted in which of the following?
A. No change in hair follicle growth after grafting
B. Shortened the time of hair formation after grafting only
C. Increased the time of hair formation after grafting but
more hair follicles being formed
D. Both shortened the time of hair formation and increased
the number of newly formed follicles after grafting
7. The process to produce PRP (without a dedicated PRP-making machine!) involves collecting several vials of a patient’s
blood and:
A. Centrifugation once only
B. Centrifugation twice only
C. Centrifugation twice and addition of dermal papilla cells
(DPCs) or competent epidermal cells
D. Centrifugation twice and addition of a platelet activator
(thrombin, calcium chloride, or even collagen)
2. All of the following are basic growth factors in Platelet Rich
Plasma, EXCEPT which of the following?
A. Dermal papilla cells (DPCs)
B. Platelet derived growth factor (PDGF)
C. Transforming growth factor (TGF)
D. Vascular endothelial growth factor (VEGF)
8. Which of the following would be an appropriate and expected
use of PRP in a medical setting?
A. Accelerated wound healing and reduction of scar formation
B. Enhanced revascularization and bone/tissue regeneration
C. Follicular neogenesis, improved graft survival rates, and
improvement of existing hair growth (including both
numbers of hairs growing and diameters of the individual
hairs)
D. All of the above
3. The Platelet Rich Plasma (PRP) commonly used in hair
restoration is:
A. Porcine derived or bovine derived
B. Acellular (e.g., ACell or Matristem)
C. Heterologous
D. Autologous
[ Answers on page 112
4. Other possible actions of PRP include:
A. Stimulation of apoptosis and proliferation
B. Stimulation of angiogenesis
C. Differentiation and proliferation of leukocytes
D. Reversal of the hair miniaturization cycle (i.e., miniaturization ceases)
5. The concentration of platelets in Platelet Rich Plasma (PRP)
is:
A. 1-2× that of native plasma
B. 2-3× that of native plasma
C. 3-5× that of native plasma
D. 5-10× that of native plasma
6. Which of the following most accurately characterizes the
morphology of PRP?
A. A dense mix of various growth factors, RBCs, and leukocytes
B. A loose acellular matrix that impedes bacterial migration
and proliferation
C. A fibrin framework over platelets that has the potential
to support regenerative matrix
D. A platelet pellet
111
www.ISHRS.org
Hair’s the Question from page 111
1. D. Both of these are results according to multiple studies
including (most recently) the latest Derm Surg article from
Yong et al. (reference #3). Exciting, right? I mean even if
this is only in a mouse model, shortening the time to hair
formation AND increasing the number of follicles is like
the “holy grail” of hair science. No wonder everyone gets
excited at the thought of this stuff working for human scalp
hair!
2. A. The dermal papilla cell is NOT one of the basic growth
factors in PRP, which means, if you picked A, you are
CORRECT! (The fact that the answer did not include the
words “growth factor” was likely a dead giveaway.) I almost
never write a question this way (i.e., “all of the following
EXCEPT”), because it is poor testing technique, but I wanted
to make the point that PRP has several important and easily
recognizable growth factors (IGF and PDAF are two others). Dermal papilla cells ARE induced to proliferate by
the action of PRP, but the question asked for the names of
growth factors.
3. D. “Advantages of using an autologous PRP include no risk
of cross reactivity, immune reaction or disease transmission.”2 Some people like to mix ACell (Matristem) with
PRP, but it is not the same thing. Sometimes the thrombin
used to activate PRP is bovine derived, hence answer A,
but the blood used to create the PRP comes from the patient
themselves.
4. B. It is hypothesized that programmed cell death (apoptosis)
may be REDUCED by the use of PRP, so A is incorrect.
Differentiation, proliferation, and angiogenesis are, in general, up-regulated! However, white blood cells (leukocytes)
do not proliferate due to the action of PRP (answer C) and
the process of miniaturization has not been shown to cease
completely (answer D). This last point is a fine one, since
even though hair formation post treatment is thicker in some
studies, no one knows how long these effects will last so it
is too early to call PRP treatment a “reversal.”
5. C is correct.2
6. C is correct.1
7. D. According to a few dental journals I read, the whole
process takes only 12 minutes!3 I would love to hear from
hair transplant colleagues out there as to how long it takes
in their offices, but I have never made it that fast. True
“cookbook medicine,” right? Answer C is the mix used in
the Miao et al. article.3
8. D. D is of course true! (HINT: When taking my quizzes,
ALWAYS choose “D. All of the above”). A quick scan of
the literature reveals that PRP is being tried for multiple uses
throughout medicine. For those who are interested, I have
included a suggested reading list below that might provide
an educational start. Enjoy!
References
1. Fernandez-Barbero, J.E., et al. Flow cytometric and morphological characterization of platelet-rich plasma gel. Clin
Oral Implants Res. 2006; 17:687-693.
2. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2609914/
3. Miao, Y., et al. Promotional effect of PRP on hair follicle
reconstitution in vivo. Derm Surg. 2013; 39:1868-1876.
112
May/June 2014
Suggested Reading
1. Stenn, K.S., and G. Cotsarelis. Bioengineering the hair
follicle: fringe benefits of stem cell technology. Curr Opin
Biotechnol. 2005; 16:493-497.
2. Miteva, M., and A. Tosti. Treatment options for alopecia: an
update, looking to the future. Expert Opin Pharmacother.
2012; 13:1271-1281.
3. Eppley, B.L., W.S. Pietrzak, and M. Blanton. Platelet-rich
plasma: a review of biology and applications in plastic
surgery. Plast Reconstr Surg. 2006; 118:147e-159e.
4. Uebel, C.O., et al. The role of platelet plasma growth factors in male pattern baldness surgery. Plast Reconstr Surg.
2006; 118:1458-1466.
5. Li, Z.J., et al. Autologous platelet-rich plasma: a potential
therapeutic tool for promoting hair growth. Derm Surg.
2012; 38:1-7.
6. Weinberg, W.C., et al. Reconstitution of hair follicle development in vivo: determination of follicle formation, hair
growth, and hair quality by dermal cells. J Invest Dermatol.
1993; 100:229-239.
7. Perez-Meza, D. Part II: The use of autologous rich and poor
plasma to enhance the wound healing and hair growth in
hair restoration. In: Programs and Abstracts. 13th Annual
ISHRS Scientific Meeting; Sydney, Australia 2005.
8. Uebel, C. A new advance in baldness surgery using plateletderived growth factor. Hair Transplant Forum Int’l. 2005;
15:77-84.
9. Perez-Meza, D., M. Leavitt, and M. Mayer. The growth
factors Part 1: clinical and histological evaluation of the
wound healing and revascularization of the hair graft after
hair transplant surgery. Hair Transplant Forum Int’l. 2007;
17:173-175.
10. Greco, J., and R. Brandt. Preliminary experience and extended applications for the use of autologous platelet rich
plasma in hair transplantation surgery. Hair Transplant
Forum Int’l. 2007; 17:131-132.
11. Greco, J., and R. Brandt. The effects of autologous platelet
rich plasma and various growth factors on non-transplanted
miniaturized hair. Hair Transplant Forum Int’l. 2009; 19:4950.
12. Zheng, Y., et al. Organogenesis from dissociated cells:
generation of mature cycling hair follicles from skin-derived
cells. J Invest Dermatol. 2005; 124:867-876.
13. Jahoda, C.A., K.A. Horne, and R.F. Oliver. Induction of
hair growth by implantation of cultured dermal papilla cells.
Nature. 1984; 311:560-562.
14. Takakura, N., et al. Involvement of platelet derived growth
factor receptor-a in hair canal formation. J Invest Dermatol.
1996; 107:770-777.
15. Yano, K., L. Brown, and M. Detmar. Control of hair growth
and follicle size by VEGF-mediated angiogenesis. J Clin
Invest. 2001; 107:409-417.u
www.ISHRS.org
May/June 2014
ISHRS Educational Webinars Enduring Material, On‐Demand, Online Format The International Society of Hair Restoration Surgery (ISHRS) is pleased to present its On‐Demand Webinars. Recorded webinars are 60 to 120 minutes in length. Because they are recorded and available at all times, you may watch the webinars whenever it is convenient for you! CME Credit may be earned for many of the webinars by passing a short post‐test with 70% or higher correct answers. Pricing: ISHRS Members: $40 per credit hour; ISHRS Pending Members: $45 per credit hour; Non‐Members: $50 per credit hour Grow Hair Grow! Minimizing Poor Growth in Hair Transplants and New Ways to Max It Out Faculty: Mario Marzola, MBBS, Michael L. Beehner, MD, John P. Cole, MD, and William M. Parsley, MD 120 Minutes; 2.0 CME Credits This webinar shares insights on how to minimize poor growth outcomes in FUT and FUE procedures. Case studies illustrate the best practices in maximizing hair growth, lessons learned, and how to confront patients with poor growth. The faculty also discusses new ways to maximize growth in the use of vasodilators, angiogenesis stimulators, PRP, Lipophilic ATP, ACell, and other growth maximizer treatments. Intro to Biostatistics & Evidence Based Medicine Faculty: Jamie Reiter, PhD and Jerry E. Cooley, MD 90 Minutes; 1.5 CME Credit This webinar provides basic information regarding proper research design and statistics for investigators in hair restoration surgery through didactic lecture and dialogue between presenters. It covers the importance of proper design and analysis, typical research questions asked by ISHRS members, research design, statistical analysis, and resources. Being Discovered by Google and Prospective Patients Faculty: Matt Batt (Moderator), ISHRS Integrated Communications Manager; Matthew Jackson, Search Engine Optimization (SEO) Manager, Lingo24; Bessam Farjo, MBChB 60 Minutes; 0 CME Credit (No CME) Cost: No charge. Available only to ISHRS Members. (member benefit) Being discovered by prospective patients online includes optimizing your website and “Playing by Google’s Rules.” Keeping up with all of Google’s changes can be challenging, even to marketers focusing their attention on this subject. This webinar, which was recorded on February 27, 2014, highlighted Google’s most recent changes, including the Hummingbird update, and shared strategies and tips to help practices be discovered by existing and prospective patients. Sign up and watch today! http://www.ishrs.org/content/demand‐ishrs‐webinars International Society of Hair Restoration Surgery Headquarters | 303 West State Street, Geneva, IL 60134 USA | Tel: 1‐630‐262‐5399 | Fax: 1‐630‐262‐1520 | [email protected] | www.ISHRS.org EDUCATION – RESEARCH – COLLEGIALITY
113
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May/June 2014
Letters to the Editors
Re: Laxometer II: Instruction to use
Parsa Mohebi, MD, FISHRS Encino, California, USA*
[email protected]*
*COI Disclosure: Dr. Parsa Mohebi is the inventor of the
Laxometer and receives royalty from its proceeds.
I read the interesting article by Dr. Jae Hyun Park about
the Laxometer in the November/December 2013 issue of Hair
Transplant Forum International (23(6):208-209) and thought
it would be best to write a note describing the proper use of the
Laxometer.
Dr. Park noted that the Laxometer only measures the downward mobility or laxity of the scalp and not the upward laxity.
He then described an alternative solution that measures the mobility of the scalp in both directions in two stages. I absolutely
agree that scalp laxity is important in both superior and inferior
directions since it directly affects the final traction forces on the
closed wound edges.
However, I need to correct the assumption that the Laxometer only measures the laxity of the scalp in one direction. After
reviewing the article in the Forum, I had to go back and watch
the initial instructional video that we made about the Laxometer
II (link was also provided in the article). I have to admit that the
initial video we made was not illustrative enough for someone
who wants to use the Laxometer II for the first time.
I would like to apologize for not providing a better instructional video, and to thank Dr. Park for recognizing the issue and
trying to find a solution for it. Here, I would like to present how
the Laxometer measures scalp laxity or mobility in one step:
1. The Laxometer should be held in an upright position
with its mobile part placed firmly against the scalp.
2. The tracing rubber ring should be moved to its most superior position so it is touching the ring of the mobile part.
3. While keeping a good grip of the scalp, the mobile part of
the Laxometer should pull the scalp to its most superior
position until we cannot move the scalp more.
114
Tracing Ring
Measuring Rod
Mobile Part
Figure 1: The Laxometer components
4. Then the operator should hold and stabilize the measuring
rod with the other hand and keep it in a fixed position.
5. The final step is to pull the scalp to its most inferior
position by moving the mobile part down. This motion
is done while the measuring rod is held in a fixed position with the operator’s other hand. This move pulls the
tracing rubber ring to its most inferior position on the
measuring rod. The position of the tracing rubber ring
on measuring rod shows the maximum mobility of scalp
from its most superior to most inferior position.
Measuring the mobility of the scalp from the most superior to
the most interior position is what we need to have before removing the strip in hair transplant procedures. In other words, the
Laxometer measures the maximum safe distance we can pull up
the inferior edge, and also the maximum safe distance that we
can pull down the superior edge of the donor wound.
We also have prepared an instructional video at www.
ushairrestoration.com/laxometer to make it clear to users of how
the Laxometer is intended to be used.u
www.ISHRS.org
May/June 2014
Review of the Literature
Jeff Donovan, MD, PhD Toronto, Ontario, Canada [email protected]
Frontal Fibrosing Alopecia
Vañó-Galván, et al. Frontal fibrosing alopecia: a multicenter review of 355 patients. J Am Acad Dermatol.
2014; 70:670-678.
Frontal fibrosing alopecia (FFA) is a scarring alopecia that
seems to be increasing in prevalence around the world. The
condition most commonly affects post-menopausal women and
effective treatments remain to be fully elucidated.
In one of the largest studies of FFA published to date, 12
centers in Spain reported their observations with 355 affected
patients over the period 1994 to 2013. The mean age was
61. Eighty percent of patients had eyebrow loss, and 39%
reported eyebrow loss as the very first site of their hair loss.
Body hair was lost in 24% and axillary and pubic hair was
lost in approximately 20%. Fourteen percent had eyelash loss.
Approximately 40% of patients had “severe” FFA, classified as recession of more than 3cm. Factors associated with
“severe” FFA were eyelash loss, body hair loss and presence
of facial papules.
Reported treatments included topical and intralesional
steroids (130 patients), hydroxychloroquine (54 patients),
finasteride (102 patients), and dutasteride (18 patients). Of
patients using finasteride or dutasteride, 47% had improvement
and 53% had stabilization of their disease. This was better than
intralesional steroids, which led to improvement in 34% and
stabilization in 49%, and oral hydroxychloroquine, which was
associated with improvement in 15% and stabilization in 59%.
Comment: Prior published studies hinted at a potential benefit
of 5-alpha reductase inhibitors in the treatment of FFA. This
large study provides convincing evidence that these drugs are
at the top of the list of effective drugs in the treatment of FFA.
Surgical options were not discussed in this report and more
study of how best to integrate surgery into the algorithms of
FFA management is needed.u
e
Efficacy and Safety of a Low-Level Laser Device
Jimenez, J.J., et al. Efficacy and safety of a low-level laser device in the treatment of male and female pattern hair loss: a multicenter,
randomized, sham device-controlled, double-blind study. Am J Clin Dermatol. 2014(Jan 29). Epub ahead of print.
A limited number of published studies have reported the
benefits of low level laser devices (LLLT) in the treatment of
androgenetic alopecia. Continued widespread acceptance of
these devices by the medical community requires independent
confirmation of benefits through well-designed studies.
U.S. investigators set out to determine whether treatment
with a low level laser device (the U.S. FDA-cleared HairMax®
LaserComb) increases terminal hair density in both men and
women with androgenetic alopecia. A randomized, sham devicecontrolled, double-blind clinical trial was conducted at multiple
institutional and private practices. A total of 141 female and 128
male subjects aged 25-60 were randomized to receive either a
laser comb (a 7 beam, 9 beam, or 12 beam HairMax device) or
a sham device. Treatments were delivered on the whole scalp
three times a week for 26 weeks. Patients who used any other
hair growth promoting treatment in the prior 6 months (e.g.,
minoxidil or finasteride) were excluded from the study.
Overall, hair counts at week 26 were greater in male and
female subjects using the laser comb compared to the sham
device. A meta-analyses providing an overall assessment of the
individual study results showed a difference of change in terminal
hair density of 15 per cm2 between users of the LLLT device and
the sham device, and this was highly statistically significant (p <
0.0001). The increase in terminal hair density was independent
of the age and sex of the subject and the particular HairMax
LaserComb model.
Additionally, in a self-assessment questionnaire, a greater
proportion of female patients using the 9-beam device reported
improvement in their hair loss condition compared with shamtreated subjects (84% vs. 50%, p = 0.03) as well as an improvement in the thickness and fullness of their hair (72% vs. 46%,
p = 0.03). Female patients using the 12-beam device and male
patients using the 7-, 9-, or 12-beam device did not report differences in improvement of their hair loss condition compared to the
sham device. However, male patients did report an improvement
in the thickness and fullness of their hair compared to males using
the sham device (57% vs. 36%, p = 0.01). No serious adverse
events were reported in any subject receiving the LaserComb
in any of the four trials.
Comment: This study provides further confirmation that
LLLT devices safely improve terminal hair density. Physician
assessments of global benefits (i.e., comparison of before and
after photos) were not done in this particular study. Overall, a
proportion of users of these particular LLLT devices are expected
to feel their hair is thicker and fuller and that their hair loss
condition was improved.u
115
www.ISHRS.org
May/June 2014
Message from the 2014 Annual Scientific Meeting
Program Chair
Damkerng Pathomvanich, MD Bangkok, Thailand [email protected]
The 22nd ISHRS Annual Scientific Meeting is only 5 months away. This is the premier
meeting for hair restoration surgeons who
want to be updated and in touch with major
innovations in the field of hair restoration
surgery. We are expecting many attendees
from the Asian countries, as well as those from
Europe, the Middle East, and many from the
United States, Canada, and South America.
The Annual Scientific Meeting Committee is currently
reviewing the program evaluations from the last meeting to
improve and add on new topics to fashion another exciting and
valuable program to meet the needs of the ISHRS membership.
The program sessions range from basic sciences to advances
in new technology and new instruments, videos of new techniques, the future of hair restoration surgery, and many other
pertinent topics. There is a valuable beginner’s Basics Course
on Wednesday, prior to the scientific program, that should be
attended by those new to our field. Those who want to take the
ABHRS exam or experienced surgeons who want a refresher,
should take the Advanced/Board Review Course on Wednesday;
however, all members—regardless of experience level—are
welcome to attend any courses and workshops they feel will be
beneficial. The FUE mini courses sold out quickly last year, so
if you are interested
in learning FUE,
please register and
reserve your seat
early since attendance is limited. There
will be also a didactic FUT mini course
on Wednesday that will demonstrate how
to minimize follicular transection, how to
safely excise a wide donor strip, and how
to close the donor wound to minimize scarring and realign hair
direction. This FUT course is not to be missed, even by experienced strip surgeons.
Please don’t let the mystery of the missing Malaysian airline
flight MH370 deter you from attending the meeting. Traveling by air is still by far the safest and fastest way to reach the
destination. If you attend the meeting, you will learn concepts
and techniques you can immediately apply to your practice. It’s
not only fruitful education you receive by attending the ISHRS
meeting, but you and your family can also enjoy and explore
the beautiful city of Kuala Lumpur and/or visit neighboring
countries during your trip.
Please mark your calendar today and note that the 2014 meeting has changed to October 8-11, 2014, at the Shangri-La Hotel in
Kuala Lumpur, Malaysia. Looking forward to seeing you there.u
Message from the 2014 Surgical Assistants
Program Chair
Aileen Ullrich Hillsboro, Oregon, USA [email protected]
This year’s annual scientific meeting will be held in
Kuala Lumpur, Malaysia from October 8-11, 2014. Our
Surgical Assistants Program will be held on Wednesday,
October 8, from 7:30am to 12:00noon.
During our Surgical Assistants Program, the ISHRS
physician members have asked that the important subjects
of graft survival/growth, interaction with patients, and
infection control be addressed. With these topics in mind,
our goal is to create a unique and engaging program that
will help all levels of assistants to increase their understanding of established practices within the field of hair restoration, communicate effectively with patients, and collaborate
with the surgical team.
In addition, with incorporation of FUE into the physician’s
practice on the rise, we will examine ways to manage differences in workflow, instrumentation, and handling of FUE
grafts. Knowledgeable speakers, video, small group formats,
116
and translation of handout
materials will be utilized to
increase attendee retention
and expand learning.
I encourage all ISHRS physician members to
attend this year’s annual meeting along with their
office staff. The Surgical Assistants Program will
be a valuable educational/training opportunity for
all assistants.
Like Bangkok, Kuala Lumpur is a city of rich
culture and history and I am looking forward to experiencing with
my friends and colleagues the cuisine, architecture, and people
of this amazing destination. Please join me there.
Do not hesitate to contact me with questions regarding the
program, ideas, or suggestions: [email protected]
www.ISHRS.org
May/June 2014
CALL FOR NOMINATIONS
2014 ISHRS Awards
GOLDEN FOLLICLE AWARD
Presented for outstanding and significant clinical contributions related to hair restoration surgery.
PLATINUM FOLLICLE AWARD
Presented for outstanding achievement in basic scientific or clinically related research in hair pathophysiology or anatomy as it relates to hair restoration.
DISTINGUISHED ASSISTANT AWARD
Presented to a surgical assistant for exemplary service and outstanding accomplishments in the field
of hair restoration surgery.
How to Submit a Nomination
Include the following information in an e-mail to: [email protected]
• Your name,
• The person you are nominating,
• The award you are nominating the person for, and
• An explanation of why the person is deserving; include specific information and accomplishments.
Nominating deadline: July 15, 2014
See the Member home page on the ISHRS website at www.ISHRS.org for further nomination criteria.
The awards will be presented during the Gala Dinner at the ISHRS 22nd Annual Scientific Meeting
that will be held on October 11, 2014, in Kuala Lumpur, Malaysia.
ISHRS Research Grants Available
The International Society of Hair Restoration Surgery (ISHRS) offers research grants for the
purpose of relevant clinical research directed toward the subject of hair restoration. Research
that focuses on clinical problems or has applications to clinical problems will receive preferential
consideration. There are several opportunities this year for hair-related research grant funding
through the ISHRS with typical amounts of $1,200 to $2,600 USD per grant. ISHRS members
in good standing may apply.
Grant applications deadline: July 15, 2014
Further information and a full application can be obtained on the ISHRS website at
www.ISHRS.org/member-grants.htm.
117
www.ISHRS.org
May/June 2014
Classified Ads
Hair Transplant Surgeon for NYC
Ziering Medical is searching for an experienced Hair Transplant Surgeon to join our Chicago, New York, and Dubai clinics.
Generous compensation package in an established market, with tremendous upside.
Interested candidates, please send your CV and cover letter to
[email protected].
Hair Restoration Surgeon Needed
A busy hair restoration practice in Denver, Colorado is looking for a physician willing to perform strip harvest, manual
powered FUE and ARTAS System FUE. Some experience in hair restoration is desirable but not required.
The candidate must possess great bedside manner, excellent eye-hand coordination, and an eye for the “art” of hair restoration.
If you would like to be part of rapidly expanding practice committed to excellent patient care and results and advancing
the art and science of hair restoration with a commitment to research, physician education, and social responsibility,
contact Ms. Janiece McCasky at [email protected].
Wanted: Hair Transplant Surgeon
Searching for a Hair Transplant Surgeon to assist our patients in the Fort Myers/Naples, Florida area. Must specialize in the
FUE and FUT methods, be licensed to practice in Florida and willing to travel to our clinic 1-2 weeks per month.
Compensation: Dependent on Experience
Please call: 239-963-4780
Seeking Surgical Technicians/Medical Assistants
Ziering Medical is seeking experienced surgical technicians/medical assistants to join our team.
Excellent working environment, compensation, salary and benefits.
Searching for Full Time, Part Time and Independent Contractors. Willingness to travel a plus.
Upcoming positions available in Atlanta, Beverly Hills, Chicago, Newport Beach, New York, Philadelphia, and Pittsburgh.
Please e-mail your résumé to: [email protected]
2014 Membership Directory Now
Available
The 2014 ISHRS Membership Directory is now available!
Obtain the PDF via the Members Only section of the ISHRS website.
Many members choose to keep the PDF on their laptops while others
print out and spiral-bind a copy for their office.
To access the directory, log in to the Members Only section of the
ISHRS website. On the top blue navigational bar, click “MEMBERS
ONLY.” On the main page of the Members Only section, under the
heading “Resources,” the 2014 Membership Directory is the last link
listed.
As a reminder, the Membership Directory is for your personal use only. Per the terms of use,
you may not use the information for blast emails or mailings.
118
www.ISHRS.org
Reflections for
ultimation and evaluation of the
current and new trends in
Hair Restoration Surgery
for optimum outcomes
www.iShrS.org/annualMeeting.html
May/June 2014
Plan to attend!
The ISHRS’s annual scientific meeting is THE premiere meeting of
hair transplant surgeons and their staff. You don’t want to miss it.
General SeSSionS
neWCoMerS are WelCoMe!
•
•
•
•
•
We offer a “Meeting Newcomers
Program” to orient those who are
new to the ISHRS annual meeting.
Newcomers will be paired with hosts.
We want to welcome you, introduce
you to other colleagues, and be sure
you get the most out of this meeting.
•
•
•
•
The Future of Hair Transplantation
Advances in Hair Biology
Hairline Design Panel
Unique Issues in Ethnic Transplantation
Small Group Discussion Tables on a
Variety of Topics
Storage Solutions
Non-Surgical Adjunct Therapies
Live Patient Viewing
Surgical Pearls to Achieve the
Best Results
2014 AnnuAl Scientific Meeting
coMMittee
Chair
Damker ng Pathomvanich, MD - Thail and
Advanced/B oard Review Cour se Chair
other offerinGS
i n t e R n At i o n A l S o c i e t y o f
H A i R R e S to R At i o n S u R g e Ry
303 West St ate Street
geneva , il 60134 u SA
tel 1- 630 -262-5399 or 1- 8 0 0 - 4 4 4 -2737
fa x 1- 630 -262-1520
[email protected] X w w w. i S HRS .org
• Daily Lunch Symposia and Friday
Morning Workshops
• FUE and FUT Hands-On Mini-Courses
• Basics in Hair Restoration Surger y
Course
• Advanced/Review Course
• Surgical Assistants Program
• M&M Conference
• Exhibits Program
• E-Poster Exhibits
• Social program including optional tours
and activities, Welcome Reception,
Gala Dinner/Dance
Michael W. Vor ies , MD - USa
Advanced/B oard Review Cour se Co - Chair
Scot t Boden, MD - USa
Basics Cour se Chair
Sar a M . Wasser bauer, MD - USa
Basics Cour se Co - Chair
Ken L . Williams , DO - USa
Workshops & Lunch Symposia Chair
Antonio S . Rus ton, MD - Br a zil
L ive Patient Viewing Chair
Gholamali Abbasi, MD - ir an
Newcomer s Chair
Russell G . K nudsen, MBBS - aUSTr alia
Immediate Past Chair
Rober t H . Tr ue, MD, MPH - USa
Nilofer P. Far jo, MBChB - UniTed K ingdom
Fabio R inaldi, MD - iTaly
Surgical Assistant s Chair
Aileen Ullr ich - USa
119
www.ISHRS.org
May/June 2014
HAIR TRANSPLANT FORUM INTERNATIONAL
Presorted
First Class Mail
US Postage
PAID
Mt. Prospect, IL
Permit #87
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)
2014: 22nd ASM
October 8-11, 2014
Kuala Lumpur, Malaysia
2015: 23rd ASM
September 9-13, 2015
Chicago, Illinois, USA
2016: 24th ASM
October 2016
Central America (TBC)
f orum
HAIR
TRANSPLANT
I N T E R N A T I O N A L
Advancing the art and science of hair restoration
Upcoming Events
Date(s)
Event/Venue
Sponsoring Organization(s)
Contact Information
University of Paris VI
www.hair-surgery-diploma-paris.com
Tel: 33 (0)1 + 42 16 13 09
[email protected]
5th Brazilian Meeting of Hair Restoration Surgery
Maresias Beach, Sao Paulo, Brazil
Brazilian Society of Hair Restoration Surgery (ABCRC)
www.abcrc.com.br/congresso
Arthur Tykocinski, MD, Program Chair
[email protected]
June 13-15, 2014
ISHRS European Hair Transplant Workshop
Brussels, Belgium
Hosted by Jean Devroye, MD
www.European-Hair-TransplantWorkshop.com
June 26-29, 2014
XV ISHR International Meeting:
Advancing in Hair Restoration
Siracusa (Sicily), Italy
Italian Society of Hair Restoration
Hosted by Franco Buttafarro, MD & Pietro Lorenzetti, MD
May 20-23, 2014
University Diploma of Scalp Pathology and Surgery
Paris, France
May 21-24, 2014
[email protected]
HAIRCON 2014
Association of Hair Restoration Surgeons–India
Marriott Resort & Spa, Goa, India
http://www.ahrsindia.org/index.html
http://www.ahrsindia.org/Hair%20Con%202014_Final%20Art%20Work.pdf
September 19-21, 2014
[email protected]
[email protected]
www.ishr2014.com
Dr. Sandeep Sattur, Congress President
Tel: +91 9821259300
[email protected]
Tel: 1-630-262-5399
Fax: 1-630-262-1520
www.ishrs.org
October 8-11, 2014
22nd Annual Scientific Meeting
of the International Society of Hair Restoration Surgery
Kuala Lumpur, Malaysia
October 23-26, 2014
Practical Anatomy & Surgical Education (PASE), Center for
6th Annual Hair Restoration Surgery Cadaver Workshop
Anatomical Science and Education, Saint Louis University School
St. Louis, Missouri, USA
of Medicine
In collaboration with the International Society of Hair
Restoration Surgery
http://pa.slu.edu
http://pa.slu.edu
November 23-24, 2014
19th Annual Meeting of the JSCHR
Okayama, Japan
Japan Society of Clinical Hair Restoration (JSCHR)
Hosted by Shinsaku Kawada, MD
Shinsaku Kawada, MD, Program Chair
[email protected]
www.jschr.org
December 5-6, 2015
20th Annual Meeting of the JSCHR
Kochi, Japan
Japan Society of Clinical Hair Restoration (JSCHR)
Hosted by Ryuichiro Kuwana, MD
Ryuichiro Kuwana, MD, Program Chair
[email protected]
www.jschr.org
120

forum - International Society of Hair Restoration Surgery

Transcription

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