Forum 4 - International Society of Hair Restoration Surgery

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Volume 16, Number 4
COLUMNS
113 President’s Message
115 Co-Editors’ Messages
117 Notes from the Editor
Emeritus
124 Once Upon a Time
July/August 2006
Preview Long-Hair Follicular Unit
Transplantation: An Immediate Temporary
Vision of the Best Possible Final Result
Marcelo Pitchon, MD Belo Horizonte, Brazil
135 Pearls of Wisdom
137 Surgeon of the Month
141 Cyberspace Chat
144 Message from the 2006
Program Chair
146 Book Review
147 Letters to the Editors
148 Surgical Assistants Editor’s
Message
149 Message from the Surgical
Assistants Program Chair
150 Classified Ads
FEATURE ARTICLES
P
review long-hair follicular unit transplantation is a concept and a technique in which the
patients submitted to a hair transplant can see, at the end of the procedure, a temporary
preview of the final definitive result. This preview causes such a positive emotional impact on
patients that it strengthens their connection to the procedure with favorable repercussions for the
whole treatment.
In order to perform long-hair follicular unit transplantation (LH-FUT), the donor hair is not
shaved or shortly trimmed, but kept long, to generate grafts, dissected under microscope vision,
that contain long hair.
We have found that the hair could be any size, but should preferably be left no less than 5cm
long to provide a suitable visual result. These long hair grafts are transplanted to the recipient
area, that, at the end, shows a preview of the future new look of the patient after the hair
transplant. This preview is temporary, because just like in traditional shaved hair transplantation,
the hair transplanted, long or short, will gradually fall out in one to four weeks after the procedure. The final definitive result will be the same as the preview result, in numbers of hairs, if the
long-hair grafts transplanted regrow in their totality.
120 ISHRS Represented in the
AMA
121 Eyebrow Transplantation
125 Review of ISHR 11th Annual
Congress
127 Review of ESHRS 9th
Annual Congress & Live
Surgery Workshop
131 Review of ISHRS Regional
Workshop: Follicular Unit
Extraction: State-of-theArt Methodology and
Instrumentation
133 Graft Site Depth Control
Sleeves for Needles
139 In Memory of Dr. Noel
Digby and Valerie MitchellChambers, RN
143 The Hair Foundation Update
149 Something to Think About
REGISTER NOW
for the ISHRS
14th Annual Meeting
Hotel del Coronado
San Diego, California
October 18–22, 2006
Figure 1. Long-hair follicular unit transplantation provides the patient an immediate preview of the final result.
Technical and artistic excellence in all the steps of a hair transplantation procedure, along with
individual patient factors, will define the final percentage of definitive growth, just like it happens in
every traditional shaved hair graft transplant. If the percentage of the definitive hair growth is close
to 100% of the hair transplanted, the final result can look even slightly fuller than the preview
temporary result. This may occur because there may be a very small percentage of shaved or
shortly trimmed hair grafts and telogen hair among the long-hair grafts. These short hair grafts
and the telogens are obviously also transplanted with the long-hair grafts, but they do not add
visible density to the preview result.
continued on page 118
Official publication of the International Society of Hair Restoration Surgery
Hair T
ransplant F
orum International
Transplant
Forum
Hair Transplant Forum International
Volume 16, Number 4
Hair Transplant Forum International is published bimonthly by the International Society of Hair
Restoration Surgery, 13 South 2nd Street, Geneva,
IL 60134. First class postage paid at Chicago, IL
and additional mailing offices. POSTMASTER:
Send address changes to Hair Transplant Forum
International, International Society of Hair
Restoration Surgery, 13 South 2nd Street, Geneva,
IL 60134. Telephone: 630-262-5399, U.S. Domestic
Toll Free: 800-444-2737; Fax: 630-262-1520.
President: Paul T. Rose, MD, JD
Executive Director: Victoria Ceh, MPA
Editors: Jerry E. Cooley, MD, and
Robert S. Haber, MD
new
Managing Editor & Graphic Design:
info.
Cheryl Duckler, [email protected]
Advertising Sales: Cheryl Duckler,
262-643-4212; [email protected]
Copyright © 2006 by the International Society of
Hair Restoration Surgery, 13 South 2nd Street,
Geneva, IL 60134. Printed in the USA.
The International Society of Hair Restoration
Surgery (ISHRS) does not guarantee, warrant, or
endorse any product or service advertised in this
publication, nor does it guarantee any claim made
by the manufacturer of such product or service.
All views and opinions expressed in articles,
editorials, comments, and letters to the Editors
are those of the individual authors and not
necessarily those of the ISHRS. Views and opinions
are made available for educational purposes only.
The material is not intended to represent the only, or
necessarily the best, method or procedure appropriate
for the medical situations discussed, but rather is
intended to present an approach, view, statement,
or opinion of the author that may be helpful to others
who face similar situations. The ISHRS disclaims
any and all liability for all claims that may arise out
of the use of the techniques discussed.
Hair Transplant Forum International is a privately
published newsletter of the International Society of
Hair Restoration 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).
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President’s Message
Paul T. Rose, MD, JD Tampa, Florida
What’s in a name—your name? Your name is your reputation, and if you are proud of it, you want it protected. You
have worked diligently to provide patients with the best care
available and develop your reputation amongst patients and
colleagues.
Your name is something that you need to protect and defend. Companies spend millions of dollars “branding” their
products and company names. They do this to build a presence in the marketplace and provide consumers with the confidence that if they purchase the product they can be assured Paul T. Rose, MD, JD
of the quality. They defend it against any type of infringement and they are quick to
take whatever legal means are available to defend against fraud, misrepresentation, slander, libel, or other abuse. If you care about your reputation, you must act
in similar fashion.
How does this all make sense in the context of the President’s message? Let me
provide you the relevant facts.
I recently learned that an individual who hosts various websites purchased a
domain with my name, Paul Rose, and created paulrose.com. This person had the
audacity to use my name to attract to his website potential clients and other physicians that he represented. He did this without notifying me, and obviously without
my permission.
This information should prompt you to ascertain whether someone has taken
your name and wishes to misuse your name or perhaps attempt to extort or blackmail you to purchase your own name. If this has occurred, you may have recourse. Legally the use of your name may constitute unjust enrichment and common law copyright infringement. A resource for resolution of these types of cases
can be the World Intellectual Property Organization (WIPO). This international agency
oversees domain names and can revoke the name from someone who is utilizing
your name illegally.
The situation that I am embroiled in must cause one to wonder how someone
could be so unethical as to acquire a person’s name. To me, it is an indication of the
perverse entrepreneurial side of the web and the many who utilize the web to line
their pockets at the expense of others.
The Internet can be a marvelous resource, yet at the same time, it is a place
where sleaze can flourish. Much of the information is educational and very helpful,
but some of the information, especially in the chat rooms, lends itself to abuse.
Staying on message, it is important that you recognize the value of your name
and that you initiate measures to protect it. I would suggest that you acquire if you
can, your name and various permutations of your name.
Many physicians feel that they are too busy to monitor their websites and be
involved in monitoring sites they may belong to. Physicians may operate out of fear
because they are unfamiliar with the workings of the Internet and may worry that
their businesses can be sabotaged by the webmasters and even other doctors.
These fears are real and you must either monitor the sites yourself or have people
you trust in place to monitor and manage sites that you possess or participate in.
Spencer Kobren, who is well known to many of us through The Bald Truth.com
as well as his radio show, spoke with me about my domain name experience. In
discussing my predicament, Kobren was quick to point out that “whoever controls
your domain and your website controls your business.” He added that the person
controlling the website can even do things such as “send e-mails that appear to be
from you.” The person in control can “collect the leads and download e–mails.” He
suggests that if a physician belongs to the various websites that garner patients, he
or she should have the consult go directly to the physician rather than come through
the website consultation.
These words are very true, and it is again evident that we must be secure with
continued on page 116
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Co-Editors’ Messages
Jerry E. Cooley, MD Charlotte, North Carolina
One of the interesting quirks about
golf is how great golfers, both past and
present, differed greatly in their golf swing
and yet achieved similar results. Usually
these famous golfers have such a
uniquely identifiable swing, almost like a
fingerprint, that they can be identified by
watching them hit a golf ball, even if you
can’t see their face. Different styles can
Jerry E. Cooley, MD
produce the same great results.
Furthermore, if famous golfer A were to suddenly drop
their swing, and take up that of famous golfer B, the results
would probably be disastrous. Each has evolved a unique
swing that best suits them. The corollary of this is that this
same swing may not work well for someone else.
Even though great golfers often have very different
swings, closer analysis shows that they usually look very
similar the moment they make contact with the ball. And
despite obvious differences in golf swings, there are certain
swing fundamentals that always apply and no one can ignore and still play consistently well.
Hair surgeons, of course, have very different styles too.
Whether it’s a different approach to hairline design, or something more mundane, like a preference for harvesting while
the patient is sitting (vs. prone), each of us has a unique
approach, a unique “swing,” that can identify us. Have you
ever known two surgeons who did everything exactly the
same? Of course not.
Is the message here, “Do your own thing, and don’t
worry about anyone else”? Definitely not. The champion
golfer attentively watches their competitor’s swing, and
works closely with one or more coaches and instructors, to
further refine and improve their own swing. Likewise, we
have to constantly be aware of what our colleagues are doing and ideally have a couple of trusted friends and mentors
to turn to when needed for specific advice.
Reading journals, going to meetings, observing others
perform surgery, and seeing live patients provide crucial feedback to us, and help us to further optimize our own unique
style. Some of the new things we learn will work well for us,
others will work well when we modify them, and others
won’t work well in our hands no matter how hard we try.
Despite the many ways we can differ and still achieve great
results, there are certain “hair restoration fundamentals” that
have to be respected by everyone. Whether it’s the progressive
nature of pattern hair loss, or the need for careful graft handling during transplants, these fundamentals apply to all of us,
beginning or advanced. Identifying and optimizing our unique
style, with constant input from others, is the surest way to
succeed and perfect our own “swing.” See you in San Diego!
Jerry Cooley, MD
Robert S. Haber, MD Cleveland, Ohio
Some physicians view the concept of
continuing medical education as an annoyance. Something to be done simply to
keep their medical license up to date or
meet other criteria. Those are unfortunate souls indeed. There are “expert” hair
surgeons in my region who have never
attended a meeting of the ISHRS, and others who haven’t been seen for over 8
Robert S. Haber, MD
years. I’ve spoken to surgeons to ask why
they are no longer attending ISHRS meetings, and have many
times been told “there is nothing new to learn.” Perhaps they
are gifted surgically beyond my wildest dreams, but I cannot
imagine that they are providing surgical results to their patients that meet the current standard of care. I have never
attended a meeting, or even stood around chatting with colleagues, and not learned something new that I went home,
tried, and tinkered with to make even better.
I recently had the opportunity, along with several colleagues, to visit the office of my co-editor, Jerry Cooley. At a
small surgical meeting sponsored by the Hair Transplant Network, we observed Jerry’s technique from start to finish, and
were able to evaluate hairline design, donor preparation, donor harvesting, slivering, cutting, site preparation, graft storage solutions, graft planting, and post-operative care. I found
the visit very informative, and confirmed firsthand my impression of Jerry as a world-class surgeon. I easily learned a
half dozen things that I will adapt for use in my office in my
own never-ending quest for perfection. But what struck me
was that although several dozen surgeons were invited to this
gathering, only a small handful elected to attend. And among
that handful were some of the best in the world. Why would
world-class surgeons take time away from their offices and
homes, while less-experienced physicians stayed away?
Is there really anything new that Bill Parsley can learn?
Or Ron Shapiro? I suspect that many of our readers would
think the answer is “no,” but certainly these surgeons would
disagree. The sight of Bill videotaping graft planting (as I
was doing myself) suggested that even one of the best planters I’ve ever watched thinks he can become even better.
Dow Stough taught me by example over a decade ago
that the best surgeons are constantly making changes and
refinements, until sometimes there is little resemblance to
the original procedure. Walter Unger periodically reminds
us that we are always either growing or dying; we cannot
stay the same. And so long as we take up a scalpel and
press it to a trusting patient’s flesh, we have a duty to be
certain that we are the very best we can be. That demands
that we expose ourselves to new ideas, and be willing to
discard current techniques and beliefs.
What’s my take-home message? If your goal is to be
among the best, then try to attend every didactic or surgical
meeting you can, even those not sponsored by the ISHRS.
There’s plenty of room at the top, but you can’t get there by
yourself.
Bob Haber, MD
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President’s Message
continued from page 114
the control that we have of our respective sites and sites owned
by others that we may belong to. It is crucial that if you have
developed a website through someone else that you have control of the URL. You must be free to move the site to another
web host without fear of reprisal. It would be ideal to have in
writing that you can move the site at will, and have a limit on
the time of any contractual relationship with the web host.
I hope that the account of my unfortunate experience will
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prove constructive for you and help you protect your name
and reputation.
On a more positive note, I would like to apprise you of
the recent AMA meeting and the first ever participation of the
ISHRS. Dr. Tony Mangubat and Ms. Victoria Ceh represented
the ISHRS and were welcomed into the fold. This is a significant achievement for the ISHRS membership and gives us a
voice in an important organization. It also lends further credence to our efforts to become an ABMS recognized specialty.
Please see the article on page 120 of this issue of the Forum.
Paul T. Rose, MD, JD
ISHRS R
egional W
orkshops P
am
Regional
Workshops
Prro gr
gra
Consider hosting a local Live Surgery Workshop in 2007!
There are various opportunities to work with the ISHRS to provide valuable educational workshops for members.
The purpose of this program is to allow for the host facility of a small workshop with a limited enrollment to
share in the meeting profits with the ISHRS and for the ISHRS to aid in content development. This is an excellent
opportunity for members to “partner” with the ISHRS to offer a Live Surgery Workshop in their region. All ISHRS
Physician members in good standing are eligible to submit an application.
The CME Committee and Live Surgery Workshop Committee oversee the process and the Board of Governors
approves applications. The annual application submission deadline is June 1, for a workshop to take place the
following year. Go to www.ISHRS.org, Members Only section, to review the guidelines and obtain an application.
2005–2006 Board of Governors
2005–2006 Chairs of Committees
President: Paul T. Rose, MD, JD*
Vice President: Paul C. Cotterill, MD*
Secretary: Bessam K. Farjo, MD*
Treasurer: William M. Parsley, MD*
Immediate Past-President: E. Antonio Mangubat, MD*
Michael L. Beehner, MD
Jerry E. Cooley, MD
Edwin S. Epstein, MD
Jung Chul Kim, MD
Jerzy R. Kolasinski, MD, PhD
Melike Kuelahci, MD
Matt L. Leavitt, DO
Robert T. Leonard, Jr., DO
David J. Seager, MD
Paul M. Straub, MD
Surgical Assistants Representative:
Cheryl J. Pomerantz, RN
2006 Annual Scientific Meeting Committee: Bernard P. Nusbaum, MD
American Medical Association (AMA) Specialty & Service Society (SSS)
Representative: E. Antonio Mangubat, MD
Audit Committee: Robert S. Haber, MD
Bylaws and Ethics Committee: Robert T. Leonard, Jr., DO
CME Committee: Paul C. Cotterill, MD
Core Curriculum Committee: Carlos J. Puig, DO
Corporate Support Liaison: E. Antonio Mangubat, MD
Fellowship Training Committee: Carlos J. Puig, DO
Finance Committee: Paul C. Cotterill, MD
Hair Foundation Liaison: E. Antonio Mangubat, MD
Live Surgery Workshop Committee: Matt L. Leavitt, DO
Media Relations Committee: Robert T. Leonard, Jr., DO
Membership Committee: Marc A. Pomerantz, MD
Nominating Committee: Bessam K. Farjo, MD
Past-Presidents Committee: Mario Marzola, MBBS
Pro Bono Foundation Committee: Paul T. Rose, MD, JD
Scientific Research, Grants, & Awards Committee: Marcelo Gandelman, MD
Surgical Assistants Executive Committee: MaryAnn Parsley, RN
Task Force on Hair Transplant CPT Codes: Robert S. Haber, MD
Website Committee: Ivan S. Cohen, MD
Ad Hoc Committee on ABMS: William M. Parsley, MD
Ad Hoc Committee on Hair Council: Paul C. Cotterill, MD
Ad Hoc Committee on Low Level Laser Therapy: Marc R. Avram, MD
Ad Hoc Committee on Practice Diversification: Neil S. Sadick, MD
Ad Hoc Committee on Regional Chapters: Bessam K. Farjo, MD
Ad Hoc Committee on Residency Programs: Robert S. Haber, MD
Strategic Task Force on Awareness and Perception Initiative: E. Antonio Mangubat, MD
Strategic Task Force on Training Initiative: Carlos J. Puig, DO
Sub Task Force on Physicians Curriculum: Carlos J. Puig, DO
Sub Task Force on Assistants Curriculum: Sharon A. Keene, MD &
Cheryl J. Pomerantz, RN
Strategic Task Force on Practice Guidelines and Physician Recognition:
William M. Parsley, MD
Strategic Task Force on Financial Security Initiative: Matt L. Leavitt, DO
*Executive Committee
116
To Submit to the Forum
Please send all submissions and author consent
release forms electronically via e-mail. Remember to
include all photos and figures referred to in your
article as separate attachments (JPEG,Tiff, or Bitmap).
Be sure to ATTACH your file(s)—DO NOT embed
them in the e-mail itself.
An Author Consent Release
Form must accompany ALL
submissions.
The form can be obtained in the Members Only section of the ISHRS website, under the section “Forum
Newsletter,” at http://www.ishrs.org/members/
member-index.php.
Send article AND release form to:
Robert Haber, MD
E-mail: [email protected]
Submission deadline:
September/October, August 10
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Notes from the Editor Emeritus
William M. Parsley, MD Louisville, Kentucky (Forum Editor 2002–2004)
For those attending this year’s
While our passion and innovation appear to be unlimmeeting in San Diego, be prepared for
ited, unfortunately, our funds are not. In an effort to keep
a big surprise. This meeting will be
our progress moving at the present speed, the ISHRS is exlike no other. The ISHRS has conploring the concept of a Giving Fund for committed memtracted for at least 14 cadaver scalps
bers who are willing to donate extra funds in order to mainfor the Wednesday courses and for
tain existing programs and help develop and implement new
several hands-on workshops. For the
programs. The ISHRS prefers to keep the annual dues and
first time, we will be working with
meeting registration fees as low as possible. A successful
human scalp. A cadaver scalp was
Giving Fund and Estate Planning Program will certainly help
William M. Parsley, MD
tested at the Live Surgery Workshop
us in this regard. There are a number of programs that a
in Orlando this March and it was found to be nearly idenGiving Fund will enhance. Live surgery at the annual meettical to the live tissue in our day-to-day hair transplants.
ing has limited tickets, but is in great demand. This year we
After years of trying to find a useful model, it appears to
plan to have video feeds to the meeting with audience interhave been found. The doors are now open for the ISHRS
action. Donated funds will help the ISHRS expand these feeds
to train both doctors and assistants in an intensive manand create even more interaction. Translators are still dener without having patients be involved in the early part
sired for those whose language discourages them from comof the learning curve. ISHRS meeting attendees can now
ing to the meeting or from fully receiving the maximum our
practice donor harvesting and repair, graft preparation,
meeting has to offer, but they are quite expensive. Coordisite creation, and graft placement with human tissue. With
nated research and its funding are critical if we are to conDr. Bernie Nusbaum as the Program Chair, much thought
tinue as a progressive scientific field. Plans for offshore meethas gone into how to use the cadaver scalps for maxiings could be carried out without much concern of a slight
mum advantage.
loss. Funds can
Dr. Carlos Puig
also help defend
orking with human
wee will bbee w
working
For the ffirst
irst time, w
will be using
ISHRS members
these scalps exwho encounter
scalp.…ISHRS meeting attendees can now practice
tensively in the
regional political
donor har
epair
af
epar
ation, sit
harvvesting and rrepair
epair,, gr
graf
aftt pr
prepar
eparation,
sitee
Basics Course
situations where
and my wife,
their right to
creation, and graft placement with human tissue.
Mary Ann Parspractice hair resley, RN, will use
toration is being
some in the Surgical Assistants Cutting/Placing Workjeopardized. Turkey is such an example. Additionally, a
shop. Those bringing their assistants will be rewarded
campaign to increase public education about hair loss and
with a very valuable program and hands-on activities that
awareness of the ISHRS would certainly help stimulate our
are geared to benefit both beginners and those with exfield. ISHRS-owned equipment, such as instruments, miperience. The Workshop Co-Chairs, Drs. Francisco
croscopes, and anatomic models will help promote teaching
Jiménez-Acosta and Sharon Keene, then plan to use the
and save us rental fees.
scalps in several of the morning and afternoon workshops.
Some of our members are early in their careers and
All this will be followed by an excellent live surgery worksacrifice just to pay the dues and registration fees. The ISHRS
shop chaired by Drs. Mel Mayer and Matt Leavitt, this
certainly wants to make it easier for them to stay involved.
year adding a video feed to the meeting. For years, many
Many have benefited greatly from the educational programs
attendees have requested more hands-on activities and
at the ISHRS and have gone on to successful careers. Hopelive surgery. This is the year it begins.
fully, some funds will be available for supporting the field
The ISHRS has been blessed with enthusiastic and inthat helped with their success and for supporting the younger
novative leaders since its beginning 14 years ago. Those
members.
who have been involved throughout these years could not
This year there will be a silent auction on Saturday
possibly have envisioned the progress that has been made
evening immediately before the Gala Dinner. They are a lot
in our knowledge and techniques. This year will represent
of fun and some great values will be available. Even if your
another major step forward. In addition to fueling technique
bids are not successful, Dr. Russell Knudsen will be enterimprovements, the ISHRS has an excellent website, ACCME
taining as the auctioneer for several of the bigger-ticket items.
approval, and a seat on the AMA Specialty and Service SoIt will be for a good cause, as the purpose is to raise money
ciety. These activities have taken us from a loose, unorgafor OPERATION RESTORE.
nized group of hair restoration surgeons to a growing influOn a final note, if you haven’t yet made plans to come
ence in medicine. We have worked diligently and should be
to San Diego, start making them now. It is one of the most
proud of our stewardship and accomplishments in the area
beautiful cities in the United States, and this will certainly be
of medicine over which we preside.
a landmark meeting.✧
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sult are temporary, the small period of presence of the long
hair dramatically changes the perception of the procedure
continued from front page
by the patient, his involvement in it, and his positive attachment to it. By seeing the best possible result during or after
The preview result will look more exuberant depending on
surgery in his scalp, eyebrow, or any other area, the patient
the length of the hair shaft used on the grafts and other hair
achieves a level of connection to the procedure, to the staff,
shaft characteristics (diameter, colour, waviness, etc.), which
and to himself that is rarely achieved in traditional noninfluence cosmetic result in all transplants. The longer the hair
preview hair transplantation.
length of the graft, the denser the preview result will look.
Some patients submitted to traditional shaved hair transWhen the donor hair is excessively long it can make the
plantation feel happy after surgery because they can see
cutting of the grafts and the insertion technically more difficult.
where the new hair will grow, or, sometimes, just because
In these situations the donor hair can be cut to a specific dethey made their dream of doing the hair transplant come
sired length that is technically more comfortable to work and
true. In preview LH-FUT they are often much happier, some
also produces a beautiful preview result (approximately 7cm).
times effusive, because they see actual hair, actual results,
In order to perform preview LH-FUT, the donor hair
even though they know it is temporary and that the final
removal technique must be one that preserves the total length
definitive hair may not grow completely and will grow only
of the hair, even in the short-hair patients.
months after.
To this date, the best way to harvest
In order to take advantage of all the
the donor hair for LH-FUT is through single
benefits provided by preview LH-FUT,
ellipse excision. Microscopically-assisted
patients must be very well informed about
dissection of long-hair follicular units, to
this concept during their preparation to
avoid transection, and obsessive hydration/
surgery. As in traditional shaved hair transpreservation are mandatory for the necesplantation, patient expectations must be
sary maximum equivalence between the
created only to the extent of the results
temporary and the definitive result.
that can really be realistically achieved.
For the creation of the recipient sites
They must know that in order to achieve
and the insertion of the long-hair grafts,
a definitive final result that is the same as
virtually any refined and gentle care techthe preview result we depend not only on
nique can be used.
excellent technique but also on patients’
Attention must be directed to the fact
personal factors that influence growth,
that preview LH-FUT shows, immediately
Figure 2. Immediate post-operative appearance
some of them which may not be totally
after the procedure, the aesthetic quality of long hair grafts in place.
understood or completely predictable.
of the work. An outstandingly beautiful
Every patient must know that, although we always strive
result will be shown and seen in “real time.” Poor refinefor and expect maximum growth, we may have final results
ment technique, that evolves to unaesthetic results in tradivarying from 0% to 100% of the immediate preview result.
tional shaved hair transplantation, will show, immediately
Surgeons, as well as patients, must be very prepared for
after surgery, a poor aesthetic look in preview LH-FUT. Poor
this new concept/procedure too, technically and artistically.
preservation technique with a high level of transection and
The surgeon must be very familiar with the vast variety of
desiccation may show excellent immediate results after prehair types (color, coarseness, curliness, density) and hair
view LH-FUT, but will show very poor growth in the final
transplantation techniques in order to plan to achieve a reresult, also like in traditional shaved hair transplantation.
sult that closely matches what was predicted to the patient.
The development of the preview LH-FUT technique was
Preview LH-FUT enables the surgeon to select the best
possible only because of the consistent and predictable costechnical strategy for every patient and even make changes
metic results of traditional follicular unit transplantation, alduring surgery, because the surgeon also has the advantage
lowing us to permit patients to see and anticipate their fuof a visual preview “monitorization” of future results. The
ture immediately after surgery.
vision of the “result” in real time gives directions and clues
Preview LH-FUT generates a whole new positive enviof how the work must continue after the first groups of grafts
ronment in the hair transplantation universe. Patients can
are inserted. Immediate adjustments on angling, direction,
see and feel immediately after surgery the aesthetic and
density, and regional/geographical distribution of the grafts,
emotional improvements that can be achieved with hair transwhich would not be perceived as necessary with traditional
plantation. This fact changes completely one of the most
shaved hair transplantation, can now be seen and done with
problematic factors of hair transplantation: the long wait to
the advent of preview LH-FUT.
see the final result.
Seeing the future look of what is being planted assists even
The final definitive result will still take the same time to be
a very experienced doctor, not to mention a beginner. “Seeing”
seen in preview LH-FUT as in traditional hair transplantation,
is also an important pedagogic advantage that helps the surbut the possibility of seeing in advance a preview of the best
geon to always improve his technique. By seeing the preview
possible final result, inserts the hair transplantation field into
result when preforming LH-FUT, the surgeon can optimize dena different category of procedures. This category is the same
sity, avoiding unnecessary waste of hair, or the opposite, inas of other aesthetic procedures, in which an immediate visucrease density, when the preview of the result shows that what
alization of the result provokes an extremely positive aura of
is being done will not produce an ideal density.
satisfaction, happiness, and good commentary.
With LH-FUT there is virtually no chance of “piggyAlthough the long hair transplanted and the preview re-
Preview LH-FUT
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backing” or burying grafts. White hairs kept long facilitate
dissection and identification for avoidance of transection.
Individual unaesthetic hair units like “pili torti” or one kinky
hair among totally straight hair can be strategically separated and placed away from the hairline.
The visibility of the crusting period is virtually eliminated by the natural camouflage provided by the long hair.
Patients feel motivated to resume their professional and social activities earlier, reducing the downtime, because they
are not worried anymore about showing the crusts, a very
common concern to hair transplantation patients.
LH-FUT can still somehow help wig-user patients in their
transition phase toward hair transplantation.
It is very interesting that when a patient is seen with his
new temporary preview result, he is not perceived to have
had hair transplantation, even in advanced baldness Norwood
types, but especially those that still keep some residual original hair. This is a very common situation also with traditional shaved hair transplantation, but only in the final definitive period.
Patients get so much satisfaction with preview LH-FUT
that almost all of them wish that the long hair would not fall
out in one to four weeks and they would not go back to their
previous appearance. Despite that, they accept well the fact
that the new hair will shed before regrowth.
Preview LH-FUT seems to diminish patients’ anxiety of
waiting for the final result, so common in traditional shaved
hair transplantation. The fact that they have already seen
how much better they may look with more hair, and that the
transplant looks like normal, beautiful non-pluggy hair, seems
to make them wait much more patiently for the final result.
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The chronological time between surgery and the final definitive result is the same in both methods, though the psychological time is different. Preview LH-FUT changes hair transplantation from a “wait and see” to a “see and wait” concept.
By seeing the preview result, patients give more value to
the surgeon’s and staff’s efforts than when they see only
shaved grafts or crusts of traditional hair transplantation.
Probably the habit of shaving donor hair came from the
hair transplantation modern era primordials when the use
of biopsy punches for donor hair removal would make longhair transplantation virtually impossible. When elliptical donor excisions came up, long-hair transplantation could be
performed, but the additional ability and dexterity required
to deal with long-hair grafts during the insertion phase and
the visibility of the pluggy look have probably discouraged
the consistent use of this concept.
Although technically slightly more laborious than shaved
hair transplantation, the extraordinary positive reaction of
patients to preview LH-FUT greatly encourages the investment and the use of this method.
Even with the advent of LH-FUT, patients can still choose
the traditional shaved hair transplantation, if they prefer,
which still did not happen in our experience.
Preview LH-FUT, by showing the immediate beautiful artistic result and by predicting this result as definitive, months in
advance, functions as a proof of the quality of the art and
science of hair transplantation as performed worldwide today.✧
Long-hair FUT is a fascinating concept. To my knowledge, this
idea was first described by Dr. Pierre Bouhanna (Greffes a cheveux
longs immediats, Nouv Dermatol (1989) 8(4):418-20). —JEC
Correction on Long-term Evaluation of Hair Transplantation
into Various Recipient Sites
Sungjoo “Tommy” Hwang, MD, PhD Seoul, South Korea
We apologize to Dr. Hwang for a misprint in Table 3 (page 44) of his article that appeared in the March/April 2006
issue of the Forum, front page (Vol. 16, No. 2). The corrected (in bold) table follows.
Table 3.
Growth Rate and Shaft Diameter of Transplanted Hairs on the Palm, Hand
Dorsum, Lower Back, and Occipital Scalp Hair at 20 Months and 4 Years after
Transplantation
Growth rate (mm/month)
Shaft diameter (mm)
Area
20 months
4 years
20 months
4 years
Palm
7.2±1.3
7.3±1.5
0.086±0.009
0.087±0.012
Hand dorsum
8.1±1.3
6.8±1.4
0.087±0.010
0.086±0.014
Lower back
8.8±1.2
8.9±1.3
0.085±0.009
0.087±0.012
Occipital scalp
15.9±0.9
15.6±1.1
0.087±0.010
0.088±0.016
Wrist*
7.6±1.4
—
0.089±0.011
—
Occipital scalp* 12.8±1.0
—
0.088±0.010
—
*Volunteer’s hair
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ISHRS Represented in the AMA
E. Antonio Mangubat, MD Seattle, Washington
June 10, 2006, marks a major milestone in ISHRS hison “Member Center.” Help keep our voice in mainstream
tory as the ISHRS was formally represented in the American
medicine alive.
Medical Association (AMA), the largest medical organizaBecause I am also a member of the American Academy
tion in the world. Traditional representation in the AMA is by
of Cosmetic Surgery (AACS), I had the opportunity to sit in
individual state medical associations. California and New
the AACS’s seat in the House of Delegates and cast votes on
York are large states with large physician populations and
behalf of the Academy. The experience was the most valuthus have the greatest number of delegates.
able education I got at the meeting. The procedural complexThe ISHRS was accepted to the Specialty Services Sociity of the AMA became clearer as I experienced this responsiety (SSS) of the
bility, and I hope
AMA where spethat the ISHRS will
I bbelie
elie
s rrole
ole in the AMA will bbee the
elievv e the ISHRS’
ISHRS’s
cialties, such as
be a voting memvic
es that no other or
gaabilit
o of
abilityy tto
offf er HRS ser
servic
vices
orgafamily practice,
ber of the House of
cosmetic surgery,
Delegates in the
nization ccan
an of
o patients in need. OPER
ATION
offfer tto
OPERA
pediatrics, etc.,
near future.
are represented in
Several weeks
ent
erpiec
or that
REST
ORE will bbee an ex
RESTORE
excc ellent ccent
enterpiec
erpiecee ffor
the house of
in advance of the
medicine. The
meeting we reeffort.
larger the speceived a huge delcialty, the greater the number of representatives in the House
egate agenda handbook that was over 4 inches thick. It
of Delegates. The AMA House of Delegates is massive. There
contained hundreds of proposed resolutions being put forth
are over 500 voting delegates plus several hundred more
to the House of Delegates. Resolutions come from differalternate delegates and guests. At this meeting there were
ent caucuses and individual societies. The SSS reviews and
well over 1,000 people in attendance. This was a particudiscusses resolutions that are applicable to the specialties.
larly exciting time because HRS is at the beginning of being
The resolutions are sorted through and assigned to 1 of 6
noticed as a recognized specialty. The SSS is the ISHRS’s
reference committees that meet in a forum open to all atfirst step; we hope to be granted a voting seat in the House
tendees, and they discuss the resolutions. Members can
of Delegates in the next few years.
provide testimony and discussion prior to the vote. The
When I first introduced myself as a representative of
reference committees then determine what recommendathe ISHRS, many reactions were, “Why are you interested in
tion they will make to the House. The House then reconbeing a part of this?” My explanation was simple: We want
venes and the delegates of the House vote on the reference
our peer physicommittee recomcians to undermendations of the
If yyou
ou ar
er of the AMA, I ur
ge yyou
ou tto
o
aree not a memb
member
urge
stand that HRS is
resolutions. Evjoin. It is as simple as going to the AMA website at
a mature discierything is done by
pline, we want a
strict parliamenhttp://www
.ama-as
sn.or
g/ and clicking on “Memb
er
http://www.ama-as
.ama-assn.or
sn.org/
“Member
voice in maintary procedure.
stream medicine,
Resolutions
C ent
entee rr.. ”
and we are ready
are on a huge vaand willing to contribute our share of effort to advance the
riety of topics and concerns. Many resolutions at this parcause of all of medicine today.
ticular meeting had to do with the U.S. Medicare reimburseIt should be noted that 50% of our membership is not
ment system and reforming the national health care system.
from North America. The ISHRS did pursue membership in
There were resolutions that applied directly to the ISHRS,
other national organizations around the world, but no other
for example, exposing and countering nurse doctoral proorganization that we are aware of offered membership to
grams misrepresentation, expediting the immigrant visa
outside associations like the ISHRS.
process for physicians, incentives for physicians who volWe expect our contributions to the SSS will expand in the
unteer without remuneration, issues surrounding specialty
years to come as long as the ISHRS’s members maintain
board certification and recertification, and a call for a study
their individual memberships in the AMA. We currently have
regarding copyright and patent issues of surgical ideas.
37% of our North American members who are also members
I believe the ISHRS’s role in the AMA will be the ability
of the AMA. The AMA requires that a minimum of 35% of the
to offer HRS services that no other organization can offer to
ISHRS’s North American membership maintain their individual
patients in need. OPERATION RESTORE will be an excellent
membership in the AMA. Our 2% margin is thin so I encourcenterpiece for that effort. As we get to be better known
age all ISHRS members to help us increase our percentage
over the years, this task will become easier. The ISHRS has
and give us a reasonable safety buffer. If you are not a mema part to play in the future of medicine, and being accepted
ber of the AMA, I urge you to join. It is as simple as going to
to the AMA is a major step in the right direction.✧
the AMA website at http://www.ama-assn.org/ and clicking
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Eyebrow Transplantation
Jeffrey S. Epstein, MD Miami, Florida
The refinement in follicular unit micrografting techniques
has enhanced the ability to restore hair to non-scalp areas.
Next to eyelash restoration, a procedure I limit to those with
a complete absence of all or a section of eyelashes, no procedure has benefited more from these technical advancements than eyebrow restoration. Using all 1- and 2-hair
grafts, it is possible to restore essentially natural appearing
eyebrows to patients who are, as a whole, the most grateful
of my patients, as they no longer have to live with the psychological toll due to thinning or absent eyebrows. Eyebrows,
of course, play an essential role in facial aesthetics, serving
to complement the most important component of the face—
the eyes—that serves as a vital non-verbal communicator
of emotions, intelligence, and, especially, beauty.
Loss of eyebrows may be due to several factors. For many
patients, the condition may have been self-inflicted, as a result of voluntary plucking when tapered fine eyebrows were
in fashion, or it may be attributed to trichotillomania. Other
causes of loss of eyebrow hair include trauma, medical conditions, and genetics. When due to trauma, such as burns,
skin avulsion, or prior surgery, the loss of hair is made more
noticeable because of the typical hypopigmentation of the skin.
Approximately one-third of patients I see attribute the thin
eyebrows to their heredity. While important to identify any
potentially treatable etiologies so as to slow down or stop the
further progression of hair loss, nearly all patients with an
absence or thinness of the eyebrows can be successfully
treated with transplants.
Demographically, approximately two-thirds of my patients are women and one-third men. Asians, who make up
almost 15% of my patients, tend to have hair that grows
very straight and is somewhat more difficult to transplant,
because the lack of curl to the hair makes it even more important that the recipient sites have an acute angle to the
skin. While a slight curl of the scalp hairs is desirable, an
extensive amount of curl can be a contraindication. While
reluctant at first due to the extreme curl of the hair, I have
now performed procedures on several African-American
patients, and have achieved good results, especially for those
with a soft curl of the hair.
The following is a description of my technique for eyebrow restoration. It is based upon performing over 104 of
these procedures over the past 3 years. Assisted by my “eyebrow team,” I have developed a technique of single procedure eyebrow restoration where as many as 375 grafts, but
most commonly 225 to 250 grafts, are transplanted into
each eyebrow.
Technique
In consultation, patients are evaluated to determine if they
are candidates and then educated about the pluses and minuses of the procedure. It is explained that the goal of the
procedure is not to create “perfect” eyebrows, but rather to
significantly improve their appearance, making the pluses
greater than the negatives. Typically, of the hairs transplanted,
70% will grow, and of these hairs that grow, 10–15% of them
will grow in an aberrant direction (either too vertical or not
flat enough to the skin) despite being planted in an aesthetic
direction. These “rogue” hairs can be either cut short or simply plucked out, and have not been enough of a deterrent to
having the transplant for my patients. Because the hairs usually come from the scalp, they will need to be trimmed monthly.
Sometimes the application of hair gel may also be of benefit
to control the direction of hair growth.
Prior permanent makeup is not a contraindication to
the procedure (Figure 1). If the patient plans on having the
dye removed, it should be performed prior to the transplants.
In several patients who had permanent tattoo placed in an
unaesthetic position, I have done a direct excision and primary closure of the tattooed skin, resulting in a fine line that
can be easily concealed with transplants six months later.
In young men in whom there is a risk of the development of male pattern hair loss, it is explained that, although
quite small in number and obtained from a small donor strip,
fewer hairs will be available for potential future scalp transplants, and that there will be a small donor scar. When
trauma was the etiology of the hair loss, a waiting period of
at least 12 months before transplanting is recommended to
both ensure that no further original hairs will grow, and to
attain reasonably mature scar tissue into which to transplant (Figure 2).
A
B
Figure 1. Before (A) and 10 months after (B) 450 grafts to eyebrows in a female with
a prior history of permanent eyeliner.
Marking Out the Eyebrows
Because most patients, especially females, have a definite idea of what they are looking for, I find it useful to have
them pencil in their eyebrows to demonstrate what they want.
Any original hairs can serve as a guide to the natural shape,
as well as the direction of hair growth. While the skin where
the eyebrows once existed typically appears slightly thicker
and more porous than the surrounding skin, it must be recognized that, especially in older patients, a slightly higher
(more cephalic) location is desirable to overcome the effect of
brow ptosis with aging. Because the transplanted hairs will
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extend beyond the borders of the markings, I
have found it beneficial
to draw the superior,
and sometimes the inferior, borders slightly
closer together than
intended.
The eyebrow can
be divided into three
parts: medially is the
head, centrally the
body, and laterally the
tail. While subtle
variations exist, especially between women
and men, certain generalities can be made
about the shape and Figure 2. Before and after grafting into eyebrow
size of each part. In scar.
general, the eyebrow is 4.5–5.5cm in length, arcing to some
degree in women, minimally or not at all in men. Aesthetic
guidelines dictate that in women, the peak of the arch (which
correlates to the junction of the body and tail portions) occurs along a vertical line drawn somewhere between the
lateral limbus and lateral canthus, with some women desiring the tail to continue in a horizontal direction at the same
height as the peak of the arch (Figure 1).
The head portion is perhaps the most critically defining
portion of the eyebrows. Measuring 0.5–1cm in length, it generally has a square to somewhat rounded medial border located 1–1.5cm lateral and cephalic to the central glabella. A
more medial border creates an “older” appearance, and with
aging, the action of the corrugator muscles will tend to pull
the eyebrows even closer together. The approximately 2.5cmlong body is the area of maximal density and, for the most
prominent appearance, is usually the widest portion of the
eyebrows. A heavier and more dramatic appearance is provided by a flat horizontal caudal border along
the medial half of the
body (along with the
lateral half of the
head), which then
changes to a slightly
cephalic direction correlating with the narrowing of width that
typically occurs, especially in women. Note
that, in some men, this
narrowing of the lateral half of the body
and along the medial
aspect of the tail does
not occur, and in fact,
in some men, this area Figure 3. Before and immediately after 550 grafts
is the widest portion to male eyebrows that were previously tattooed.
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(Figure 3). Finally, the approximately 1cm-long tail is the narrowest portion, and has the lowest density of hairs, especially extending laterally. It usually extends in a slightly downward, caudal direction as it descends from the peak of the
arch, but as mentioned earlier, some patients prefer it to continue on a flatter, horizontal position.
Harvesting and Dissecting the Grafts
Most procedures are performed under mild oral sedation and local anesthesia. Once anesthetized, the donor strip
is excised and the defect reapproximated, which recently
has involved the use of the trichophytic technique whereby
the lower edge of the donor site defect is deepithelialized to
promote hair growth through the scar. A donor strip 1cm in
width by 3–4cm in length can usually provide 350–450 1
and 2-hair grafts, while allowing for the discarding of any
gray or less than perfect hairs. Larger procedures of as many
as 700 grafts require a longer donor strip. The donor area
usually extends from above one ear to the lateral occipital
region, because the hairs in this area tend to be the last to
turn gray, and they tend to provide variation in their caliber
and curl that allows for the achievement of subtle variations
along different portions of the brows, as explained below.
I have experimented using body hair for donor grafts,
including from the toes and legs. In the three cases to date I
have performed, the hairs seem to grow, and do not need to
be trimmed. However, the small number of cases does not
afford enough feedback to allow me to recommend this yet.
The grafts are dissected under binocular microscopic
visualization. The majority consists of single hairs, but 2hair grafts are used for patients with medium to finer hairs
to achieve greater density when desired, especially in the
central aspect of the body.
Recipient Site Creation
In the medial-most aspect of the approximately 1cmlong head, the hairs tend to grow vertically, and the grafts are
placed sparsely to accentuate the “feathering” for the most
natural appearance. The hairs then rapidly change from a
vertical to a horizontal direction of growth as one proceeds
laterally along the head into the body. Along the entire length
of the body, the cephalic-most hairs tend to grow at a slightly
downward, caudal angle, while the caudal-most hairs tend to
grow at a slightly upward, cephalic angle, resulting in a crosshatching, thus enhancing the density (Figure 4).
The direction of hair growth tends to be horizontal to a
slightly caudal direction. In the lateral-most portion of the
tail, a second “feathering” zone is created by the use of the
finest single-hair grafts placed in a progressively sparse distribution. Finer single-hair grafts are also placed all along
the cephalic border of the entire portion of the brows to
produce a soft natural appearance.
Meticulous attention to the three-dimensional direction
of natural hair growth is essential. In addition to the vertical
and horizontal axes, the angle of the recipient sites should
be as shallow to the skin as possible to allow for the hairs to
grow in a flat position relative to the forehead, so the grafted
hairs do not “stick out.” The recipient sites are made using
Personna® blades cut to 0.5mm in size, with a 0.6mm blade
required in those occasional patients with extremely thick
hairs. These tiny blades have several advantages: they al-
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low for the closest
possible placement of
the hairs to each
other; they minimize
the risk of damage to
already existing hairs;
and they allow for
greater control of the
direction and angle of
hair growth. The sites
are made in a “sagittal” orientation (parallel to the direction of
natural hair growth).
This allows for a
slightly wider opening
to place the grafts.
Placing the Grafts
Figure 4. Before and immediately after 425 grafts
Because of the placed into eyebrows.
small size of the recipient sites, the grafts can sometimes be difficult to place,
and good counter-traction facilitates graft placement. Because of the relatively small number of grafts typically placed,
every hair counts, so the emphasis must be on minimizing
trauma to ensure the highest percentage of hair growth.
The finest single-hair grafts are placed along the periphery,
with any 2-hair grafts going in the central areas when indicated. This achieves a peripheral thinning, as well as greater
central density, for what is usually the most aesthetic appearance. It is in achieving the ideal direction of hair growth
that the natural curl of the transplanted hairs can be used to
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their advantage. While trimmed short to the length of natural eyebrow hairs, the curl of the donor hairs should be
assessed, then the grafts placed so that the direction of curl
complements the direction of the recipient site, so that the
hairs curl into the skin as well as in the slight cephalic or
caudal direction as desired.
At the end of the initial placing of grafts into all of the
recipient sites, every patient is provided the opportunity to
look at the eyebrows and provide feedback. In all but a few
cases, some revisions are required, typically the placing of
more grafts in certain areas. Several patients have required
four or five revisions prior to leaving the procedure area to
achieve that “perfect” appearance.
Post-procedure Care
Post procedure care is quite simple. Using GraftCyte®
spray, the transplanted area is kept moist for the first 72
hours with hourly spraying. Careful face washing is permitted on the third post-procedure day, and normal face washing as well as full resumption of exercise, is permitted on the
fifth day. Crusting in the area is usually gone by the fourth
day, leaving only mild pinkness and the short transplanted
hairs. Like scalp hairs, these hairs will fall out, starting to
regrow in as soon as two months when minoxidil is applied.
Conclusion
Eyebrow transplantation has become one of the most
challenging yet rewarding parts of my practice. These patients are amongst the most grateful of my transplant patients. Having patients thank me for allowing them to “wake
up without having to run to the mirror to make up their
eyebrows” makes this a wonderful part of my practice.✧
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nce Upon a Time…
Fifteen Years Ago…
Most procedures last 80 to 100 minutes and involve either 60 to 80 grafts or 100 to 140 grafts. Scalp reductions take 40 to 90
minutes, depending on the type that is used. The surgeon commonly performs four to six procedures a day.
Russell Knudsen, MBBS (Vol. 1, No. 6, p. 2; July 1991)
Ten Years Ago…
New patients now seem to be averaging between 1,000 and 2,500 micrografts per session. One year ago it was 500 to 600 grafts
per session on average. I do all micrograft megasessions for patients who want a more perfect look and are content to have a
relatively thin look over a smaller area.
David Seager, MD (Vol. 6, No. 4, p. 5; July/August 1996)
Five Years Ago…
Few surgeons provide 2,000—3,000 grafts in a session. In fact, few surgeons provide 20 or more FU grafts/cm2 in any session.
“Megasession” transplants with “close-packing” require numerous, well-qualified and experienced team members. It is sobering to
do the calculations and acknowledge the real density we are offering in a single session of FU/micrografts.
Dow Stough, MD, & Russell Knudsen, MBBS (Vol. 11, No. 4, p. 99; July/August 2001)
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Italian Society of Hair Restoration
11th Annual Congress • Bari, Italy
May 29–31, 2006
Vincenzo Gambino, MD Milan, Italy; Piero Tesauro, MD Milan, Italy; Marco Toscani, MD Rome, Italy
The XI International Congress of the ISHR was located
in Bari, an ancient city on Italy’s southern Adriatic coastline.
The meeting was held at the prestigious Villa Romanazzi
Carducci Hotel. Upon their arrival each of the participants
were given a splendid book of black-and-white photographs
of fascinating and often hidden images of Bari taken by Dr.
Michele Roberto, president of the ISHR—one of whose many
passions is photography.
The welcome reception ended with a wonderful alfresco
dinner of regional specialties under the stars in the hotel’s
garden restaurant.
There were 60 or so participants, 15 of whom came
from other countries including Japan, Australia, Poland,
Austria, Switzerland, Argentina, and the United States.
The symposium opened with remarks by Salvatore
Barbuti, Dean of the Bari Medical School, followed by President Michele Roberto, on
behalf of the ISHR, welcoming all the attendees.
Dr. Roberto spoke of the
close relationship between
the International and Italian Societies and how the
Italian Society has raised
public awareness and acceptance of hair restoration surgery; one study giving a statistic of 5,000
surgeries performed in
Italy in 2005.
Michele Pascone, Director of Plastic Surgery–Bari Medical School, spoke about the increase in hair restoration surgery in Italy and how hair restoration is approached by the
various disciplines, commenting that the meeting was attended by surgeons, dermatologists, endocrinologists, nutritionists, and people in medical law.
Dr. Ron Shapiro, Tuesday’s keynote speaker, gave a
presentation on the importance of creating a natural hairline. He spoke about techniques to achieve the most natural
result and addressed the concept of the “extended hairline”
region, which includes a transition zone, defined zone, and
frontal tuft area. He also spoke about temporal points, frontal temporal angle, lateral hump, cowlicks, and female hairlines.
Dr. Peter Nyberg, who presented “The Frontal Hairline:
The Business Card of the Surgeon,” spoke about the hairline
being the most important factor in patient satisfaction and
his techniques for achieving the most natural results.
Dr. M. Nagal spoke on an innovative method of creating
natural hairlines by placing FU grafts using a combination
of slit incisions and Choi needle placement. He divides the
recipient area into 1×1 centimeter grids and achieves a bet-
ter density. Dr. Nagal recommends a combination approach
of Propecia® and surgery for his patients.
Dr. Kuniyoshi Yagyu did a study of 100 non-bald men
to analyze microscopically the orientation of multi-hair follicles in the whole scalp area. The major orientation of these
natural follicles were perpendicular to the radial line from
the crown swirl—arranged in concentric circles with the
crown swirl centered in the middle and peripheral scalp area.
By following the natural occurring model of follicle orientation, a more natural result will be achieved.
Dr. A. Jenke spoke about the difficulties a doctor entering
the field of hair restoration surgery encounters and solutions to these problems. His recommendations included education, reading all available material on the topic, workshops, and symposiums, starting with small cases and using
friends, without charge, as early patients.
Dr. Piero Tesauro presented some interesting
theories on the formation,
training, and organization
of the surgeon’s staff. Using the “learning cycle”
method within his work
group, this new concept
stresses the staff’s importance and clarifies that
professional
growth
comes not only from external learning but mostly
from a continuous and internal learning experience. He
concluded that the question asked shouldn’t be, “What can
we do to grow?” but rather, “How can we grow learning
from what we do?”
Dr. N. Cassano submitted a paper co-authored with Drs.
R. Ovidio and Gino Antonio Vena entitled “Nutriceutici in
Trocologia.” The term “nutriceutici” should be used synonymously with a nutritional product or a component of
this product that has a health benefit. They wrote that nutritional supplements, with their precise ingredients, are a better way of monitoring dosage and therapy than diet.
Dr. R. D’Ovidio expressed his theory that female alopecia is not inherited from the mother, which is in contradiction to the Norwood hypothesis. He also disputes that
anabolic steroids cause male pattern baldness in females,
stating the protective action of aromatase remains. According to Dr. D’Ovidio, the 5-alpha reductase inhibitor
works in selective cases. He states that ciproterone acetate works better than minoxidil if there is a hormonal
problem and vice versa. He concludes that we should use
the term female androgenic alopecia instead of female pattern alopecia.
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Dr. M. Grandolfo presented a paper, co-authored with
Dr. M. Pipoli, on androgenic alopecia and insulin resistance.
He stated that insulin resistance causes a hyperinsulin condition that increases androgenetic hormones. The purpose
of this study was to evaluate the relationship between androgenetic alopecia and insulin resistance. Thirty-five patients with androgenetic alopecia were studied and 9 were
insulin resistant. Two accepted to be
treated with corrective therapy with
metformin and both showed improvement.
Dr. N. Nagai spoke about the effects of “Etdoctor,” a new machine using magnetic fields and LED light to
stimulate hair growth. A study with 22
patients showed good results in 15
cases. There were very good before and
after pictures. More studies are planned.
Dr. Jerzy Kolasinski presented a paper on hair restoration surgery in women
that recommends, based on his 20 years
of experience, a very conservative surgical approach that may require more than one surgery.
Dr. Paul Straub presented a very favorable 1-year
study on trichophytic closures, the procedure in which a
thin border of tissue is removed from the upper edge of
the inferior wall so that the hairs can grow through the
scar acting as nails anchoring the scar margins. Sutures
are removed after 14 days. In cases of excessive tension
a triple suture closing produces a better result.
Dr. Vincenzo
Gambino presented
his opinion that
crown transplantation can be successful with young
patients if a very
conservative approach is taken that
leaves donor hair
for future restoration and the crown
is only treated
once.
Dr. F. Sisto did a study of the analysis and count of
follicular units in different parts of the scalp. He concluded
that it is very important to do a thorough anatomic evaluation prior to any surgery.
The last speaker, Dr. S. Smeraglia, presented a
supermegasession case where he removed a donor strip
temple to temple of 5,000 follicles that were transplanted
with a density of 24–30 FUs per square centimeter. He reported complete graft survival and patient satisfaction.
The day ended with the Gala Dinner and dancing at
Masseria Di Torrelongo—a magnificent villa in the countryside where awards were presented and local celebrities entertained.
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Day 2
The following day, Dr. A.M. Carboni spoke about his
experience with FU extraction (FUE), noting that it is not a
replacement for strip harvesting but has advantages in cases
where the patient has already undergone surgeries and
doesn’t want additional scars, requires only a staff of two,
and eliminates donor-site suturing.
Dr. M. Toscani’s paper, co-authored by Dr. A. Rossi,
Dr. G. Curinga, Dr. N. Scuderi, Dr. F. Francescangeli, Dr. A.
Angeloni, and Dr. C. Marchese, presented an important study
done at the University of Rome “La
Sapienza,” observing 40 patients successfully transplanted with duplicated follicles
in the frontal hairline. They attempted to
locate in vitro the exact position of stem
cells in the bulge and papilla, and found
the molecular selective marker that exactly locates the position of these stem
cells.
Dr. Anthony Mollura gave a paper on
micro-follicular unit transplantation for
the repair of post–face lift scars and hair
loss showing excellent results and reported on increased patient self-esteem.
Dr. Kenichiro Imagawa presented an interesting case of
successful FU transplantation on the thin scar tissue of a
severely burned patient and discussed techniques used for
cicatricial alopecia.
Dr. V. Bucaria gave a paper co-authored by Dr. M.
Pascone reporting on their experience with patients with
post-accident or cancer surgery loss of scalp. They use
vascularized flaps
and expanders in
their reconstruction
and always keep in
mind the vascular
anatomy.
Dr. M. Clemente
gave a paper coauthored by Dr. C.
De Sio that described a case using expansion and
an occipital flap after the excision of a
frontal midline,
congenital nevus in
reconstruction of a class 4–5 patient. They then removed
the dog ear and performed a three flap rotation using the
Frechet technique.
Dr. F. Sisto spoke about the use of skin expanders in the
removal of large scars and tumors. He stressed the importance of using the correct type of incision, the right shape
expander, and the correct placement of the valve.
Dr. F. Capitali spoke about a rare case of pilomatricoma,
or mummified and calcified epithelioma of Malerbe, in a
healthy 40-year-old adult.
It was a very interesting and informative meeting for all
attendees.✧
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European Society of Hair Restoration Surgery:
9th Annual Congress and Live Surgery
Workshop,
Zurich, Switzerland • May 25–28, 2006
Thursday, May 25, 2006
Melvin L. Mayer, MD San Diego, California
The ESHRS 9th Annual Congress and Live Surgery Workshop presented a very unique format. The first two days
consisted of solid live workshop, no lectures or didactic presentations.
The charming, hospitable host for the meeting was the
Swiss native Dr. Beatrice Banholzer. She along with the Board
of Directors of the ESHRS showed off the beautiful historic
city of Zurich in an unforgettable manner.
The lakefront Asthetische Plastische Chirurgie Utoquai
served as the center for the Live Surgery Workshop, providing three spacious operative suites and a meeting hall to
accommodate the theater-sized video screen and excellent
communications with the moderators and surgeons.
Four surgeries were conducted with multiple surgeons
demonstrating special techniques. Dr. Robert Haber showed
the Haber Spreader, which seems to be very “user friendly”
and a step forward in decreasing donor harvesting transection rate. Dr. Patrick Frechet followed with his trichophytic
closure technique to produce a minimal scar. He trims off
the lower edge about 1–2mm, and undermines about 5mm
under the upper and lower edge. One of the most faithful
participants with the ESHRS, Dr. Ron Shapiro, described his
approach to the frontal hairline design and organizing the
density variations of the frontal zone.
Dr. Brad Wolf used his newly developed gold suture to
minimize widening of scars closed under tension. His 22ctgold suture is 99.9+% pure, which makes it essentially inert
and, of course, it does not dissolve. He has had to reinforce
the suture needle junction to avoid breakage. The temporal
points were augmented by Dr. Mel Mayer who demonstrated
two additional helpful hints, including placing a dot on the tip
of the nose and measuring equal distances to the tip of the
points and also using a string from a mask tie stretched horizontally between the points to ensure that they are level. On a
patient who had been in an auto accident, Dr. Carlos Velasco
de Aliaga demonstrated his exceptional surgical skills on a
beard scar correction with a creative modified W-plasty.
Dr. Jim Harris with his FUE system showed how chest
hair can be used to augment density in donor depleted patients. Despite his expertise in FUE, only about 10% of his
cases are done with this technique. He believes that the hair
retains the donor characteristics and shows very little adaptation to the appearance of the hair of the recipient area. He
explained that he believes hair from other parts of the body
is best used as “filler hair.”
Few can duplicate the surgical skills of Dr. Frechet who
again demonstrated the Frechet triple flap procedure to correct a slot deformity from previous midline scalp reductions.
Friday, May 26, 2006
James A. Harris, MD Greenwood Village, Colorado
The second day of the ESHRS workshop featured a
variety of cases. In operating room number one the patient
had a previously placed Frechet extender and was to have
an alopecia reduction, placement of a second extender, and
follicular unit transplantation. Dr. Damkerng Pathomvanich
demonstrated his technique for minimal transection donor
harvesting utilizing traction with small skin hooks. The keys
seem to be minimal bleeding of the incision to improve visualization of the follicles and utilizing only the blade tip to
cut the skin. The donor incision was closed by Dr. Paul
Straub utilizing a trichophytic technique. Dr. Patrick Frechet
performed a scalp reduction following the removal of an
extender and demonstrated the placement of a second extender.
Drs. Michael Beehner and Matt Leavitt then discussed
their approach to making recipient incisions. Included in the
discussion was the theory of minimal depth incisions, parallel versus perpendicular, the use of “oblique” incisions, and
pearls for successful graft placement.
In operating room number two, I performed a follicular
unit extraction case on a patient who had one previous surgery and desired additional density. I utilized the FUE technique I developed that involves a 1mm sharp Miltex punch
and a 1mm blunt dissecting punch (the “Scribe”). There was
fairly prominent tethering of the follicular units, which allowed the demonstration of the “double grasp” or “handover-hand” technique for removing the units. In spite of the
degree of tethering, the follicle transection rate was minimal. I also demonstrated the 1mm serrated punch (which
Dr. Bill Rassman refers to as the “crown” punch).
Finally, in operating room number three, a patient who
was to undergo a slot correction with a Frechet triple-flap
correction had instead a scar revision of a widened scar
using a trichophytic closure performed by Dr. Ciro De Sio.
Saturday, May 27, 2006
Michael L. Beehner, MD Saratoga Springs, New York
Dr. Ron Shapiro opened this session speaking on hairline design. He emphasized that the hair surgeon needs to
be artistic as well as technically competent. He described
the various ways to incorporate “macro-contouring” and
“micro-contouring” into the hairline. He stressed the importance of a few “sentinel hairs” out away from the hairline to
increase the naturalness.
Dr. Mel Mayer spoke on the subject of “mega-sessions,”
which he defined as being over 2,500 FUs, with 4,250 having been his own personal largest one to date. Using the
custom-made lateral slit blades, most of his sites range from
0.7–1.0mm in width. He stressed the importance of leaving
the grafts out of the body no longer than 8 hours, to ensure
a high percentage of survival. The density and laxity of the
donor scalp dictates how large the session can be. He also
advised against cutting up 2- or 3-hair FUs into smaller
segments to fulfill numerical goals.
Dr. Mike Beehner spoke on the subject of the “frontal
forelock,” more properly a frontal-midscalp forelock, which
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is used in 15% of his surgical cases and emphasizes the framing of the face along with a “mirror-image” construction at
the sides with a thinning area between the fringe and the
body of the forelock itself. Staying out of the vertex and avoiding
any temple reconstruction is important in young men, whose
eventual balding pattern is uncertain. Multi-FU grafts in the
central areas make it easier to create a gradient of density.
Dr. Mayer again spoke on “temporal peaks,” and reviewed his classification system, which is: N = “normal”; T
= “thinning,” some mild recession, and thinning of the temporal points; P = “parallel,” the temporal hair is set back
some and is parallel to a vertical line; and R = “receded,”
actually recedes backwards behind the vertical line down from
the fronto-temporal corner point. He usually transplants at a
density of 30/cm2 in this area using either a 19g needle or an
88 Spearpoint blade, and first marks out the location of the
temporal artery to avoid cutting into it. Tumescence and a
very acute angle with the bevel flat are important.
Dr. Patrick Frechet reviewed his approach to extensively
bald men, most of them Norwood VI and who want an aggressive approach used, in whom he is able within 2 months
to remove the entire bald vertex and accomplish his triple
flap closure. He said that the new silastic extenders can extend several times their original length. He showed numerous impressive examples of this in several very bald men.
Dr. Ken Washenik spoke on medical therapy for hair
loss. He said minoxidil is a direct stimulator of follicular
growth, working as an upregulator of vascular endothelial
growth factor. It peaks in its effect at around 16 months.
Two studies (1992, 2002) show that combining it with oral
finasteride therapy obtains a synergistic effect greater than
the sums of what each would accomplish individually. Several investigators have reported significant hair loss when
finasteride was continued but the minoxidil was stopped after 9 months. Irritant topical dermatitis has been a big problem due to the propylene glycol vehicle it is in, but a new
foam with glycerine has promise of reducing this. There are
no new studies on finasteride results. Speaking on its use in
females, he reported a report by Tosti, in which 37 premenopausal women with female pattern hair loss were given
2.5mg finasteride daily and had significant improvement.
However, no controls were used and it was based on global
photography. Dr. Vera Price in her studies found no benefit
after 12 months with females using finasteride.
Dr. Damkerng Pathomvanich spoke on “harvesting with
a low transection rate.” He uses tiny skin hooks and a 15
blade to gradually incise down along the hairs and avoid
transection. He pushes the blade forward rather than back
to him. He emphasized the importance of keeping blood out
of the field with a tiny suction tip and also keeping constant
tension with the hooks while cutting.
Dr. Beehner next spoke on a new harvesting technique,
called the “Free Hand Bridge Technique,” in which he leaves
intact “bridges” of uncut scalp at the mid-occipital point
and at the lateral corners to provide stability for a third cut
down the center, which then produces two manageable strips
of 5mm width each. He said the keys to producing two strips
with very minimal transection are sharp blades, lateral traction by the surgeon and assistant, and frequent checks for
cutting angle.
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Dr. Robert Haber next described the use of his “Haber
Spreader,” which is now available commercially after some
engineering “bugs” were worked out. He makes a superior
and inferior superficial 1.5–2mm cut in the donor wound
and then uses the spreader to carefully pull the wound apart,
resulting in almost no transection. He stated there are occasional patients in whom the hairs will tear or scar tissue
prevents its use, but one can tell this by observing closely
during the initial use of the instrument. Its use is particularly
valuable in black patients with their curly hair and follicles.
Dr. Mohammad Mohmand then described his experience with a trichophytic closure, removing a small “wedge”
of tissue from the wound edge of approximately 1mm
(1.5mm in low-density patients). He uses a simple one-layer
closure with 3-0 Prolene.
Dr. Frechet described his “invisible scar,” using the lower
edge trichophytic closure, with excision of a small wedge of
tissue off the lower edge. He limits his strips to 10mm in
width and undermines just above the galea a short distance.
Dr. Karen Leonhardt, who works with Dr. Frank Keidel
in Germany, next spoke of their clinic’s randomized, doubleblind study of 27 patients, with 13 donor wounds closed in
the usual oppositional method and 14 with the inferior Frechet
trichophytic trimming and closure. Their conclusion was that
in the patients with the trichophytic closure, there was “some
increase” in natural appearance in most of them, especially
in women and those patients with gray hair.
Dr. Paul Straub described his experience with the Frechet
trichophytic closure in 185 patients. His strips are 1–1.5cm
wide and sutures are left 14 days. He uses a custom-made
scissors, with the tips cut off. If there is any tension, he
undermines under the galea, and then closes with 3 layers,
using 3-0 Maxon sutures in the deep closure.
Dr. Brad Wolf spoke on treating wide, tense donor closures with metal sutures, which remain permanently in the
tissues. He is developing a gold thread of 24 carat, which is
heated to be malleable. The suture is placed at the dermal
level. A patent is pending and it is not FDA approved yet. He
states its use is a “last resort” for tense closures and only if
another strip is not planned. Patients coming from a long
distance and those with low body fat probably should not
receive this suture.
Dr. Kuniyoshi Yagyu of Japan next spoke of his study
of the natural orientation of follicular units in the frontal
area. He divided all men into those with clockwise and counterclockwise orientation of the whorl in the vertex, and
stated the direction in the rest of the scalp evolves off of
this. He broke the top of the scalp into several marked off
regions and studied the percentage of parallel and perpendicular oriented FUs in each zone. In general, in the peripheral and mid-frontal areas, the majority of the FUs
were aligned in a perpendicular orientation relative to the
direction of the hair angulation.
Dr. Shapiro shared some pearls on placing grafts and
compared various placing techniques. Keeping the grafts
in the field of vision without looking away greatly helps
the efficiency of the placer. Tumescence helps the needles
avoid the deep scalp vessels. Minimizing trauma, dehydration, and time out of the body for the grafts are all of
prime importance. With all sites pre-made, a person can
place them singly or use a “buddy technique.” Then, with
“stick-and-place,” again this can be done by a single person or in a “buddy” manner with 2 persons. Having a
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separate person to apply saline spray frequently to the
With a full day of lectures having been presented, the
grafts is very helpful.
100-plus attendees enjoyed a wonderful gala dinner and
Dr. Pyra Haglund of Sweden showed a remarkable case
dance at the 300-year-old Zunfthaus Zur Meisen.
in which FUE-obtained grafts from the lower neck nape and
chest were used to treat a patient deformed after 7 reducSunday, May 28, 2006
tions and 5 transplant procedures. She pointed out that the
Kenneth J. Washenik, MD, PhD Beverly Hills, California
medial chest hair is better and not as soft.
Following Saturday night’s spectacular gala at the elDr. Ken Imagawa from Japan demonstrated a case in
egant 18th century Zunfthauf zur Meisen, the tricho-obsessed
which he used FU transplants under a split-thickness graft
reassembled in the theater on the lake to devour the last
in a burn patient to fill in the hair on the entire right lateral
series of tidbits offered from the podium.
aspect of the face and head. He decreased the density of the
The first session was led by Dr. Frank Neidel (president
incisions, used topical minoxidil to help, kept the angles acute,
of the ESHRS and co-host of the meeting) and consisted of
and used tumescent solution.
important topics that did not fit into one of the other formal
Dr. Jim Harris again spoke of his FUE technique. The
categories at the Congress. Dr. Gholamali Abbasi from Iran
initial sharp incision is only 0.3–0.5mm deep and then the
discussed his thoughts on decreasing the patient’s pain and
dull punch, which is 4.36mm deep, is used to free up the
anxiety during the procedure. He pointed
remainder of the FU. He currently expeout that pain and anxiety can increase
riences around a 5.6% transection rate
catecholamine release, which can lead to
and can harvest 200–350 FUs per hour
further anxiety, increased pulse and
maximally. He considers 100% of the
blood pressure, and, ultimately, increased
patients viable candidates for FUE. In his
popping and bleeding. He reported the
own practice, somewhat less than 10%
data from a 1996 ISHRS study that
of his patients elect this method. He does
showed that the majority of hair transnot use tumescence. He is also working
plant physicians responding to the surwith different designs for the second, dull
vey used either midazolam or diazepam
punching maneuver, most recently with
as a pre-medication. He pointed out the
a “crown” punch with a serrated tip. He
benefits of buffering the lidocaine soluhas the patient prone during the procetion with sodium bicarbonate (9:1
dure and uses more sedation than for a
lidocaine to bicarb stock), warming the
strip patient. The maximum he has been
lidocaine solution before injecting, and
able to harvest from both sides of the
using mechanical distractions such as vihead and the occiput is 3,000 FUs in one
bration to decrease the discomfort assurgery with shaving.
sociated with the infiltration of the anesDr. Jean Devroye of Belgium showed
thetic solution. Dr. Abbasi also reviewed
patients from his practice in whom he
the formula he uses to incorporate trirepaired wide donor scars with FUE. He
amcinolone into the tumescent solution
stated that, if you do enough FUE
used in the recipient site (1cc of 40mg/
punches, you will often get a “white dotcc, 1cc of 1:1000 epinephrine and enough
ted” appearance to the donor area on
Patrick Frechet, MD, addressing the audience.
saline to make a total of 100cc).
close examination.
The next two presentations focused on hair transplanDr. Bijan Feriduni, also from Belgium, showed his methtation for eyebrow reconstruction. Dr. Cordula Kerner from
ods for using FUE and FUT. He uses a Versi handle to hold
Germany discussed the utility of using FUE to obtain the
a 0.9 and a 1.0mm punch. He emphasized that the FUE
donor hair to be placed into the eyebrows. She pointed out
takes a much longer time than the simple strip FU transthe need for a thorough consent process, stressing the poplanting.
tential difference in texture and even color between the scalp
Dr. Sang Lee from South Korea spoke about the use of
donor hair and the patient’s native eyebrow hair as well as
the Calvitron to accomplish FUE. Operative time is greatly
the chronic post-operative need to trim the transplanted hair.
decreased, but in the early going the transection rate is higher
She recommended only taking fine, straight 1- and 2-hair
until one becomes adept at the procedure. FUs are around
(at the most) grafts from the lower occiput. Dr. Kerner
6mm long in many Asians, which requires a deeper incision.
stressed the need to ensure a very acute angle for the grafts
They term their grafts obtained in this fashion “omnigrafts.”
and suggested drawing a line from the tip of the nose over
Dr. Ana Trius of Spain showed examples of FUE being
the lateral border of the iris to determine the highest point of
used to treat young and older patients. She also finds FUE
the reconstructed brow. Dr. Mustafa El Sombaty from Egypt
much more time-intensive, that there is a higher incidence
also discussed eyebrow reconstruction. He reviewed the use
of “cysts,” and that the older patients are not as concerned
of composite full-thickness skin grafts and island pedicle
with donor scars.
grafting in addition to the use of 1- and 2-hair micrografting.
Dr. Mark DiStefano shared his development of a new
The island grafts require tunneling of a pedicle attached to
device for performing the second step of the FUE procedure.
its superficial temporal artery into its new position on the
It is a bi-level needle and he is able to obtain 300 grafts per
brow. He favors composite grafts over island grafting behour using it. He uses a lubricant such as KY jelly or Vaseline
cause the island grafts require a second modifying surgery
on the skin. He said the best candidates are those with coarse
and the orientation of the hair follicle direction is often inhair and very realistic expectations. He is conducting hair
correct. He also finds merit in micrografting but points out
growth studies presently.
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that more than surgery is required in his hands to get the
desired density.
The last speaker in this session was Dr. Colin Westwood
from the United Kingdom. He gave a detailed history of his
personal journey of the past few years from a NorwoodHamilton class VI–VII to his current state through the use of
topical minoxidil, 3 hair transplant procedures, and the systemic off-label use of the dual 5-alpha reductase inhibitor,
dutasteride. Particularly interesting was his review of the
history behind the development of 5-alpha reductase inhibitors and his development of frontal hair growth well anterior to the location of his transplanted grafts.
The second scientific session consisted of Drs. Fernando
Basto and Matt Leavitt discussing female baldness. Dr. Basto
from Brazil, the moderator of the session, reviewed the
current classification systems used to grade degrees of female pattern hair loss including those developed by Drs.
Hamilton, Ludwig, and Olsen. He proposed a new system
that he has developed that incorporates aspects of each of
these scales and is intended to be more inclusive of the all
the patterns that women present with. The Basto classification includes six stages and, additionally, accommodates
frontal (class IV), vertex (class V), and combination frontal and vertex (class VI) involvement as well as the loss of
the hairline. Dr. Basto indicated that he transplants as many
as 2,000 grafts in the frontal area in one procedure in some
female patients. Dr. Leavitt gave a very thorough review of
the algorithm that a physician should work through when
evaluating a woman with hair loss. This algorithm (from
his recent textbook on the subject) covers all types of hair
loss as it is not restricted to female pattern hair loss. He
also spent time stressing that not all types of hair loss seen
in women, as in men, are appropriately treated with hair
transplantation, thus reinforcing the need for accurate diagnosing. Lastly, Dr. Leavitt reviewed an additional classification system used for female pattern hair loss, the Savin
scale, which was utilized during the early minoxidil clinical
studies.
Dr. Melvin Mayer moderated the next session where he
and Dr. Leavitt reviewed some of the research studies that
have been conducted at the Orlando Live Surgery Workshop. One study compared transection rates when harvesting a single-blade ellipse (Dr. Glenn Charles) compared to
multi-blade strips (Dr. Vance Elliott using a 3-blade knife).
The data seemed to indicate that with the increased ease
with which staff can prepare grafts from the multi-blade
strips, there ultimately may be less graft transection when
strips are created by multi-blade knives than when an ellipse is created with a single knife. Obviously this result is
very user dependent, both as to who excises the strip as
well as the staff trimming the grafts.
A study done by Drs. Jennifer Martinick and Bill Parsley
looked at the influence of placing grafts in sagittal versus
coronal recipient sites. Dr. Martinick felt that the coronally
placed grafts looked better, and Dr. Parsley opined with caution that the coronal sites are more damaging to the blood
supply. Hair counts in coronal sites were better than or equal
to the counts obtained with sagittally placed grafts. Both
sagittally and coronally placed grafts were demonstrated to
maintain their orientation as they grew.
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The next session contained a number of important presentations on scarring alopecia. The first speaker was one
of the most respected academic physicians in the field of
hair, Professor Ralph Trüeb of Switzerland. His presentation
was an encyclopedic, thorough discussion of the cicatricial
alopecias, their causes, differential diagnosis, and treatments.
He pointed out that the cicatricial alopecias are relatively
rare, accounting for only 1–5% of dermatology consults for
hair loss.
Dr. Trüeb stressed the importance of taking an appropriate biopsy and of submitting the specimen for both horizontal
and vertical sectioning. He recommends staining the sections
for H and E as well as PAS, elastin, mucin, and direct
immunoflurescence. Concerning the treatment of folliculitis
decalvans, Professor Trüeb pointed out the effectiveness of
using the “British regimen” of clindamycin and rifampin for
10 weeks, and he stated that areas of persistent disease should
be excised as they represent depots of disease.
Dr. Richard Rogers, of the United Kingdom, spoke next
on the surgical treatment of a patient with radiotherapy-induced alopecia secondary to treatment for an astrocytoma.
He stressed the need to minimize the use of epinephrine and
to use the smallest possible recipient sites given the inherent
compromised vascular status in the cicatrized recipient bed.
Dr. Pyra Haglund of Sweden reviewed a number of cases
of hair transplantation in patients with a variety of types of
hair loss. She candidly discussed examples of transplant
outcomes that, in retrospect, did not meet her pre-operative
expectations. Her conclusions and recommendations resonated well with her Sunday morning audience: be sure of
the diagnosis prior to proceeding with transplantation and
carefully evaluate the quality of the donor hair. Dr. Hasan
Hamzepur from Iran described a new hair transplantation
chair that has been developed by Dr. Abbasi.
Wrapping up the morning, Dr. Conradin von Albertini from
the host country of Switzerland presented a well received review on the status of the routine use of antibiotic prophylaxis
peri-operatively in hair transplantation. He pointed out that
most of the literature that is usually quoted comes from the
dermatologic literature, and it indicates that there is no need
for routine antibiotic prophylaxis during uncomplicated skin
surgery. However, he was quick to point out that the cutaneous surgeries on which those conclusions are based are different from hair transplantation in a number of important
ways: hair transplantation surgeries are much longer in duration than the referenced procedures, there are thousands of
wounds involved in hair transplantation, there is more handling of the tissue, and more support staff are involved in hair
transplantation procedures cases. He quoted one hair transplantation-specific study in the medical literature, a Georgian
study by Drs. Tsilosani and Gugava, where they studied 542
hair transplant cases and were unable to find any benefit to
the use routine peri-operative antibiotics. He stressed that these
findings do not pertain to those patients for whom prophylactic antibiotics are strongly suggested such as patients with
prosthetic valves or endocarditis. His presentation sparked a
lively discussion from the floor concerning the pro’s and con’s
of peri-operative antibiotic use, which ended with the sage
suggestion that more formal and randomized study is warranted before definite recommendations can be finalized.
Dr. Patrick Frechet closed the 9th ESHRS Congress and
Live Surgery Workshop with parting remarks that left us all
looking forward to next year’s meeting.✧
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ISHRS Regional Workshop
Follicular Unit Extraction:
State-of-the-Art Methodology and Instrumentation
Denver, Colorado • April 21, 2006
Mark S. DiStefano, MD Worcester, Massachusetts
The first modern-day ISHRS Regional Workshop took
(those with no fat at all) as this is about 40–45% of the
place in Denver, Colorado, April 21, 2006. Dr. James Harris
grafts that he gets. There is a question as to the viability of
hosted the event, which brought together some of the leadthese grafts and he has started a study to see how these
ing experts in Follicular Unit Extraction (FUE) techniques from
grafts will do compared to grafts with more surrounding
around the world. The event was a real hands-on workshop
fat. Dr. DiStefano mainly utilizes his punch to extract body
to learn, evaluate, and teach the art and science of FUE.
hair. He states that he is trying to make more total hair
There were 25 doctors from 10 different nations, ranging
available for transplantation.
from beginners to experts. The faculty included Drs. James
Following Dr. DiStefano’s session, a lively discussion
Harris, William Rassman, Paul Rose, and Mark DiStefano.
about the viability of body hair transplants ensued. Dr.
The workshop was held in Dr. Harris’ office in Denver.
Rassman was concerned about the ethics of using body hair,
We had a beautiful view of the Rockies as we started our
which has a much different growth cycle, and then charging
morning session. Friday morning gave us a history of the
for a graft that we know little about. The group seemed to
methods that led up to the FUE process. Dr. Rassman took
agree that if there was full disclosure to the patient in all
us through the evolution of FUE ofregards, this should not be an issue.
fering some of his thoughts and opinThere were many prominent surions. I remember fondly the discusgeons at the conference, such as Drs.
sions and debates on the floor of
Brad Wolf and Ron Shapiro. It was
recent annual meetings with many
fun to see Dr. Shapiro out of his elecommenting that we have come full
ment; you could see the wheels turncircle from plugs to plugs again, aling as he watched and took in all of
beit smaller plugs. This conference
the information. The international conshowed that there has been much
tingent was replete with its experienced
thought and design going into this part
FUE surgeons. Dr. Mark DuBois from
of hair restoration.
Belgium ONLY performs FUE and reDr. Harris discussed his own spefers all strip transplants out to other
cial tools and techniques, telling us
surgeons. Dr. Pyra Haglund from
about their development and how he
Sweden performs a significant numdesigned them to be both fast and safe.
ber of FUE cases in her practice as
Dr. Harris has the speed to do 1,000
well.
Dr. James Harris demonstrates FUE using chest hair as the
grafts in 5–6 hours from start to fin- donor source.
From here we went upstairs to the
ish. He has very few buried grafts and
ORs, where there were two patients.
has developed a method to get them out quickly. If he can’t
First, the instructors would show their instruments and techget them quickly, he will leave them in because his experiniques and then each of the students would try their hand at
ence has shown no significant complications with this method.
it. It was fascinating to watch, all hands-on and no holds
His transection rate is below 2%. He has presented this
barred. Each participant was able to try each method until
method and instrumentation at the Live Surgery Workshop
they felt like they had a feel for it. Unlike some “live surgery
in Orlando and has demonstrated it at numerous ISHRS conworkshops” where there is almost no hands-on experience,
ferences. His focus is on trying to decrease the number of
this workshop covered a few specific procedures and was
steps involved in punching and removing the grafts. He hopes
all hands-on for everyone attending.
to automate this process in the future.
The next morning it was back to the classroom. DisDr. Rose showed and described his modified slit lamp
cussions of patient selection made for an interesting converstation to hold the patient’s head stable and comfortably.
sation. Dr. Rassman discussed his pre-op test used to deThis seemed to position the patient in a very comfortable
termine who was a candidate, while Dr. Harris said that
position, which was secure and easily adjustable from paeveryone was a candidate with his method. Dr. Rose distient to patient.
cussed complications that may arise. We all heard new terms,
Dr. DiStefano brought his own newly developed punch.
such as:
Capping: While attempting to remove the follicular unit,
This bi-beveled device has two points that are off set as the
when you pull on the epidermis, the top pulls off, leaving the
device slips over the top of the follicular unit. It is inserted
hair shaft and follicle in place.
3mm or so and then the follicular unit is removed using a
pair of sharp forceps. He has some issue with naked grafts
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of ideas that we shared. A special thanks also to Dr. Harris’
incredibly helpful and knowledgeable staff, who helped to
put on this wonderful conference.✧
Tethering: When you try to pull out the follicular unit and
the base is attached at the sides and base, it is “tethered.”
One needs to cut it using a sharp edge of some kind.
There were discussions of transected and buried grafts,
and surgical planning and donor management were very
important discussions as well, such as the need to not take
too many follicular units from the same area to avoid the
moth-eaten appearance. There were several patterns demonstrated to avoid this pitfall. For example, Dr. Rose maps
out his area, punches out on one side of the head, and then
has his technician remove the follicular units as he moves to
the other side and punches out more follicular units, thereby
ensuring better time management.
Emphasis was placed on the time needs of this procedure. For every second saved in a 1,000-graft procedure
there will be 16 minutes saved. All acknowledged that this
was very labor intensive for the physician and therefore more
expensive for the patient.
Patient positioning varied by physician. It was felt that
you needed to learn about all of the positions available to
determine which one fit you, your patient, and your office
the best. It was obvious that all of the faculty felt that you
needed to have as many weapons in your armamentarium
as you could to fight the war on balding On Friday night, we
all went out to a wonderful Italian dinner hosted by Dr. Harris and his wife, Monique. It was a fun way to exchange
ideas. The food was good, the wine free-flowing, and, as
usual, the camaraderie was outstanding. It is as much about
friendship as it is about the exchange of ideas. This conference was a success in the new friends that we all made, the
relationships that we solidified, and the wonderful exchange
132
State-of-the-art
instrumentation for hair
restoration surgery!
For more information, contact:
21 Cook Avenue
Madison, New Jersey 07940 USA
Phone: 800-218-9082 • 973-593-9222
Fax: 973-593-9277
E-Mail: [email protected]
www.ellisinstruments.com
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Graft Site Depth Control Sleeves for Needles
Tseng-Kuo Shiao, MD Overland Park, Kansas; I-Sen Shiao, MD Taipei, Taiwan
For creating graft recipient sites, 18- to 20-gauge disposable needles continue to be popular because of their low
cost, convenience, and minimal scalp damage. Lacking depth
control, however, remains a disadvantage when compared
to many graft-site-making instruments designed for hair
restoration surgery.
By accident, we discovered that our custom-made
polypropylene (pp) plastic tubes with 18- to 20-gauge inside
diameter make excellent depth control devices by cutting the
tubes into sections that are 5mm shorter than the needles and
threading the needles through the tubes (photo 1). Subsequently, we found tubes made of silicon rubber work as well
or better. Ethylene dioxide gas sterilizes both pp plastic and
silicon rubber tubes. Heat can sterilize silicon rubber tubes.
This simple sleeve allows us to create 5mm-deep graft
sites faster and more uniformly. Thus, we hope to introduce
it to our colleagues who use needles for graft sites. If anyone wishes to obtain some free samples, please e-mail
[email protected].
Photo 1. Disposable needles with their respective depth control sleeves.
f orum
HAIR TRANSPLANT
I N T E R N AT I O N A L
Now
le!
Availab The
Bound Collection (2001–2005)
Limited Edition
The Bound Collection (2001–2005) includes copies of all Forum issues from January/
February 2001–November/December 2005. This limited edition publication is enclosed in
a beautiful royal blue faux leather hard cover with silver inlay lettering, a complement to
any library. This compilation of the Hair Transplant Forum International publication has a
limited number of available copies. Purchase yours today!
The Bound Collection is now available to current members in good standing.
For an order form, access the “Members Only” section of the ISHRS website at www.ishrs.org
Pricing Information: ISHRS Member Cost — $125.00 (plus shipping and handling)
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ISHRS Regional Workshop, Hosted by Paul M. Straub, MD
Eyelash Surgery Workshop for Hair Restoration Surgeons
Straub Medical Center & Torrance Marriott • October 23, 2006 • Torrance, California, USA
Don’t miss this unique opportunity to collaborate about the latest developments in eyelash surgery.
This workshop is expected to sell out quickly, so register early!
OVERVIEW: This one-day educational workshop will include lectures by leaders in the area of eyelash transplantation surgery and live surgery
demonstrations.
EXPECTED RESULTS AND LEARNING OBJECTIVES
1. Improve results by using the latest, optimal surgical techniques for transplanting eyelashes on the upper and lower lids for restorative and/or
cosmetic purposes.
Learning objectives
9 Discuss the various methods, pros and cons, of eyelash restoration following trauma and/or for cosmetic surgery so that you can offer the most
appropriate procedure to your patient.
9 Compare and contrast the techniques and instruments available for eyelash surgery so optimal selections are made to ensure the best outcome
for your patient.
2. Improve results to achieve fine scars from donor strip removal.
Learning objective
9 Identify the latest techniques and instruments to perform trichophytic donor closure so that you can produce the best donor closure for your
patient
INVITED FACULTY: The following have been invited and have accepted the invitation.
¾ Dr. Jennifer Martinick: The main presenter. She will demonstrate several cases. TV monitors will allow everyone to follow all the surgery.
¾ Dr. Marcelo Gandelman: The originator of eyelash transplantations.
¾ Dr. Alan Bauman: Has performed many eyelash transplants for purely cosmetic reasons.
¾ Dr. Paul Straub: Will demonstrate trichophytic donor site closures.
CME CREDITS: The International Society of Hair Restoration Surgery is accredited by the ACCME to provide continuing medical education for physicians.
The International Society of Hair Restoration Surgery designates this educational activity for a maximum of 8 AMA PRA Category 1 Credits™. Physicians
should only claim credit commensurate with the extent of their participation in the activity.
COST: $900 USD for ISHRS member physicians, $1,100 USD for non-member physicians, $500 USD for
technicians. Enrollment is limited.
REGISTRATION: You may access the brochure and registration form at http://www.ishrs.org/
EyelashRegionalWrkshp.htm, or write, call, or fax: Straub Medical Center, 23326 Hawthorne Boulevard, Torrance,
California 90505; Phone: 800-258-8881 or 310-373-8622; Fax: 310-375-5016.
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Robert T. Leonard, Jr., DO Cranston, Rhode Island
“Doc, can I have a hair transplant now because I don’t like that my hairline is going back in the corners?”
or “Look, can’t you see how my hairline isn’t flat across like it was in my high school picture three years
ago? I need it to be the way it was again, so I want a hair transplant to fix it.”
How often have you heard questions and comments like these from young men who are just starting to notice a
slight recession of their hairlines? What about the man in his early twenties who you examine and note that he has not
only frontal recession, but also progressive baldness throughout the top of his head? And how about the guy with a
clearly developed bald area in the vertex—and he’s 26 years of age?
Our questions in this issue’s column revolve around treating (or not treating) the young hair loss patient. There is
often disagreement among experienced surgeons about the approach to hair restoration in young men, such as those
under age 30. Some surgeons use a specific cutoff, such as age 23 or 25, before they will consider doing a transplant;
some are even more conservative. On the other hand, some are proponents of doing a surgery in the young because
of the effect hair loss has on these patients. Some make a big distinction between considering transplants to the frontal
scalp versus the crown in the young. What is your approach? Do you have a specific age requirement before you will
consider a transplant for a patient? How do you design the hairline and plan the distribution of grafts in a young man?
Below is just a small sampling of practice “pearls” from members throughout the world. Don’t wait another
minute to book your travel and to register for our Annual Scientific Meeting in San Diego!
I look forward to seeing you there!
Bob
Dr.Viroj Vong of Bangkok,THAILAND, indicates:
This is my approach to a young patient (18–28 years
old). Generally I will do a hair transplant on a young patient
if he meets all of these criteria:
1. Moderate to severe baldness: Norwood Grade 3-7 (ideally with no more progression, which is almost impossible).
2. Moderate desire to have more hair. If he strongly desires this, then it is more difficult to really satisfy him.
3. Low expectations and a 30-plus-year-old hairline. I tell
him I can improve his look but I cannot give him as
much hair as a wig. If he understands and agrees, then
I shall perform the transplant. When I do, I concentrate
on the front and hairline. With some, I even add a high
widow’s peak if he has triangular skull and face.
Dr. Kenichiro Imagawa of Yokohama, JAPAN, writes:
We should respect the recommended guidelines as indicated in Dr. Cohen’s excellent article (Forum, September/
October 2001), but I don’t have a minimum age for hair
transplantation.
I have one case of transplantation of a 16-year-old boy
with a Norwood 6 classification requested by his father. The
boy was depressed and couldn’t go to school because of
classmates’ teasing. Several months after his procedure, his
father let us know that his son could return to school and
was very happy. I know this was a very rare exception.
The Japanese FDA approved Propecia® only last December, so we couldn’t provide another option (the use of medical therapy) to this boy at that time.
Also, what would be thought if I made a medical decision not to do the transplant, and another doctor was to
make a business decision to perform the surgery? Most of
the doctors working in franchise clinics (and there are many
in Japan) are performing hair transplants on young patients.
In my opinion, these patients must be more depressed when
procedures are done by less-experienced doctors.
Dr. John Frank of New York, New York, USA, provides:
Men under the age of 25 are typically the most eager
and captive patient of any age group and may, therefore,
present the greatest challenge. It’s important to include another family member or close friend in the consultation process. I will test their understanding and commitment to hair
retention by trying finasteride or another potential remedy. I
try to get some clues from the family history. Rather than
rejecting a young patient, it is more important to accept him
into your practice, give him good advice, and stay with him
as he understands more clearly the implications of poorly
placed grafts at a young age.
Biologic age and maturity seem to be more important
than chronological age. It’s key to take all factors into consideration before either denying or offering somebody in their
early twenties a transplant.
Dr. Robert McClellan of Houston,Texas, USA, submits:
I do not have a specific age requirement for hair transplants. I believe that one must discover whether the young
man has a family history of class 7 baldness and would
modify my approach if the history were positive.
I only do the frontal and top regions and would only
consider an adult location for a hairline. My goal would be
to establish, at most, a class 5 Vertex pattern. I would insist
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on the man being committed to a life-long use of Propecia. I
would also require that his parents be present and agree to
the procedure. Lastly, I would give very strong informed
consent that the results would be limited.
Dr. Gary Hitzig of Rockville Centre, New York, USA, states:
I do not have a specific age distinction, but instead approach the young patient using the following parameters.
1. I will create or re-enforce a higher hairline, letting the patient clearly know that young patients with hair loss often
progress the quickest and reach a more advanced pattern
of baldness more often than their older counterparts.
2. I will not touch the crown but will create a rear curved
“natural” hairline mid-scalp.
3. I encourage the combination of transplant in front and
Propecia for the mid and crown areas.
4. In the case of a Propecia failure, I will do the periphery of
the crown first to limit any additional donor I might need in
the future anticipating for the rapid progression to class 7
in the early balding young patient.
5. I introduce the cosmetics Hair-So-Real or Toppik to the
patient early to cosmetically fill in thinning areas and
reduce the anxiety of a patient needing a “Quick Fix”
and thereby making a bad decision.
Dr. Antonio Pistorale of Bologna, ITALY, states:
I do not use any rigid age cutoff in my practice. Specific
parameters are considered and age is an important one. I
usually evaluate specifically a young patient’s clinical situation and initial expectations, “purifying” them by frequent
parent’s influence. I try to predict in my mind possible longterm prognosis of baldness, both for recipient areas and
precious donor area.
I follow the patient conservatively for months, starting
medical treatment using minoxidil and finasteride.
In the meanwhile, I take care of psychological aspects
with periodical interviews, trying to guide the patient’s expectations to realistic surgical possibilities if, in my opinion,
there are any.
If the situation progresses favorably from a psychological and clinical point of view, the first hair transplantation can be done. I usually do not transplant the crown in
very young patients, believing that medical therapy will work
more in the vertex, as reported by the literature. Frontal
hairline planning is not so different in young patients; I used
to be very conservative in advancing the hairline, grafting
only single and fine follicular units in the first lines.
In very young patients, I select for first lines grafts from
the more cranial and upper part of the donor strip, in order
to have an eventual long–term, natural frontal recession as
a possible consequence of donor area progressive baldness.
Leaving intact donor area, without wasting any millimeter for the future sessions, and letting the young patient
know that future sessions will be surely necessary are additional keys to guide him through the future decades, thus
avoiding him to ever be a true bald man!
Dr. M. Humayun Mohmand of Islamabad, PAKISTAN, relays:
We all do agree that young patients are a bit of a challenge. I have certain parameters to fulfill in order to decide
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whether I would do a surgery on a young patient or not.
I do not consider age a limit to do a surgery, so I will do
surgery for any age group; however, I will have to be cautious about the long-term results. In order to make sure
that my results can stand the test of time, I will do the following evaluation.
Hair transplant have moved on from punch grafts to
follicular units. The bad or good job done back in 80s is no
more a problem. So even if person loses hair he will not look
unnatural. So I think the myth of not treating young patients
should not be there anymore, provided if the doctor knows
what he is doing.
First I do not take patients who are thinning and not
bald, not because the surgery cannot be done, but because
it is difficult to make them happy. In such cases, I put them
on medical therapy in the combination of Propecia, minoxidil,
low-dose laser, some anti- oxidants, essential amino acids,
iron, and some herbal homeopathic medicine, which have
given me good results.
On the other end, if the patient is bald, then I will see
these things:
1. I will have to see the family history; if there is no extensive balding then I will treat him like any other of my
patients.
2. I should be confident enough to get at least 4,000 to
5,000 follicular units from a viable donor area and I
would do at least 2,300 to 2,600 follicular units during
the first surgery.
3. I look for miniaturizing hair, and not the donor area as
such. This will give me an idea how far down he will
proceed with baldness. In my opinion, everyone will be
type VII unless proven otherwise.
4. Good counseling and postoperative pictures of my patients
will be a good way to give them a realistic approach.
It is usually in the second surgery that I will treat them as
I do like any of my other patients; that is, to bring the hairline
down and also to create the temporal peaks. The time difference is about 1 to 2 years between these two surgeries.
I do not understand the rationale of treating a 25 year
old and not a 19 year old; if I know the science of hair loss
and the possible amount that he will lose (give or take a
5% error), then I will treat everyone alike, and be just a bit
cautious.
He will be shown some pictures where some thinness is
visible and he will be explained the limitation of the procedure. If and when he agrees to all this, only then will I do the
surgery.
Generally speaking, in my experience, every young patient I have refused has been to someone who does not understand the concept of hair loss and did a bad job. So I feel
that since the young patient is so traumatized with his thinning hair, he will go to any extent to get the job done. I
believe I can help him in such a way that no matter what, he
will not look unnatural in the end.
I believe hair transplantation is not about hair on scalp,
but about the naturalness even if less hair...so I will do a
surgery on a YOUNG person.
So far and by far, almost everyone of my young patients is very satisfied and happy.✧
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Surgeon of the Month
Alan J. Bauman, MD
Vance W. Elliott, MD Edmonton, Alberta, Canada
Alan Bauman was born and
raised in New Jersey. At an early
age, Alan was exposed to health
care through his father’s dental
practice and his uncle’s gastroenterology practice. He was also influenced by his mother, who was
interested in art and music, as well
as his grandfather, who was an
author, inventor, and college
chemistry professor.
From a young age, Alan remembers his own father’s struggle
Alan J. Bauman, MD
Boca Raton, Florida
with hair loss and eventual hairpiece
use. While in college, he had the opportunity to spend time
with a plastic surgeon in New York City who was a close
friend of the family. This sparked his initial interest in the
more aesthetic side of surgery. After Alan graduated from the
University of California—Riverside with a B.S. in Psychobiology, he attended New York Medical College. While there, he
continued to gravitate toward the surgical side of medicine,
spending more time with his mentor and observing more plastic
surgery and reconstructive procedures. After medical school,
Alan spent two years in a general surgery internship and residency at Beth Israel Medical Center and Mt. Sinai Medical
Center in New York City. During his general surgery residency, Alan met the love of his life, his wife, Karen.
It was also at that time that Alan first learned about
hair transplantation from his father-in-law, who had had
several hair transplant procedures over the years. Encouraged by his father-in-law’s natural looking hair transplant
results, Alan decided to pursue this further. The more he
observed and researched the field of hair restoration, the
more it became clear to Alan that hair transplantation would
satisfy both his surgical and artistic interests. At the end of
his second year of surgical residency, Alan began working
full-time with a hair restoration physician on Long Island
and traveling to hair restoration conferences and workshops.
In 1997, he and his wife moved to Boca Raton, Florida,
where he started a practice exclusively dedicated to treating
patients with hair loss. Amongst the hundreds of surgical
procedures Alan performs each year, he has performed
several sessions of transplantation to restore his father’s
hair (and help him eliminate his hairpiece) as well as his
father-in-law (who needed some minor hairline refinement and densification). Alan advocates a holistic, multitherapy approach to hair loss, using medical and surgical techniques to help his patients maintain and/or restore
their hair.
Currently, Alan performs one or two procedures daily,
using primarily follicular unit micrografting sessions. With
an average of five technicians per case, he and his team use
microscopic magnification (with stereo- and video-microscopes) for dissection, minimal depth incisions that average
from 0.7 to 1.5mm widths (of both parallel and perpendicular orientation), and follicular unit session sizes over 3,000
but averaging 2,400 grafts. For several years, Alan has also
performed FUE (for which he designed his own instruments),
and eyelash and eyebrow transplantation as a smaller, but
routine part of his practice. Currently, about one-third of his
consultations are with female patients, who represent the
fastest growing segment of his practice. His practice extends nationally as well as internationally, having operated
on patients from around the United States, as well as Europe, Asia, and South America. Alan meets with each patient in consultation personally rather than use consultants.
Within the past several years, his practice has received
local and national media attention from such prominent outlets as CNN, NBC, USA TODAY, The New York Times, Men’s
Health magazine, and Woman’s World magazine. Most notably, Alan was recently chosen to appear on NBC’s Dateline
on two separate occasions last year. In NBC’s hair restoration “challenge” called “The Follicle Five: Battle Against Baldness,” Dateline featured the emotional impact of male pattern hair loss and hair restoration while comparing the
effectiveness of popular hair growth treatments and procedures including Propecia®, minoxidil, low-level laser therapy,
nutritional modification, and follicular unit micrografting
performed by Dr. Bauman. Alan’s hair transplant patient
had the most substantial growth and was judged by an independent physician as the official “winner” of the challenge. Alan believes hair loss sufferers worldwide were the
real winners, as each of Dateline’s “Follicle Five” episodes
was seen by well over 9 million television viewers.
Alan is an active member of the ISHRS and has sat on
its Ethics and Bylaws Committee, Website Committee, the
Media Center Subcommittee, the Ad Hoc Committee on Media Relations, as well as the Strategic Task Force for Hair
Restoration Awareness and Perception. While on the Website
committee, Alan spearheaded the creation of the ISHRS
web-based Media Center, where members of the media and
general public can gather and view reliable, accurate information regarding the field of hair restoration and the
treatment of hair loss. Along with his co-chair and rest of
the committee, Alan helped develop the ISHRS Annual Census Survey, designed to capture and analyze data submitted by ISHRS members that form the foundation of the
ISHRS Media Center. At the Annual Meetings and Live Surgery Workshops, he is an annual participant and lecturer.
Alan frequently writes about current hair loss treatments
for the general public and physician readers. He also
authored the “Hair Loss” chapter in the latest edition of the
textbook Cosmetic Dermatology by Leslie Baumann, MD.
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Dr. Bauman and his wife Karen have two sons, Ross
and Spencer. In his spare time, Alan enjoys playing the electric bass guitar and has been active on the board of the
Players Club, the Boca Raton support group for the Florida
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Philharmonic Orchestra. Dr. Bauman and his wife have also
been avid supporters of the local chapter of the American
Cancer Society, and recently, Karen planned and co-chaired
a local “Think Pink” luncheon, supporting the Susan G.
Komen Breast Cancer Foundation, in honor of her mother
who is a breast cancer survivor.✧
Something New—Pro Bono Stories
Soon there will be a new feature on the ISHRS website called Pro Bono Patient Stories. This is
a way for the ISHRS to recognize the generous pro bono work done by its members outside of
the OPERATION RESTORE program. ISHRS member physicians will be able to submit their
Pro Bono Patient Stories with photos using the form that will be available on the website at
www.ishrs.org.
2006 Basics in Hair Restoration Surgery Lecture Series
1st ISHRS educational
activity to receive
AMA PRA Category 1 Credit!
The first activity that will be designated
with AMA PRA Category 1 Credit is the
2006 Basics in HRS Lecture Series. This is an enduring material
currently in development. It will be in CD-ROM format for computers and consist of 14 prerecorded lectures with PowerPoint,
handouts, and bibliographies. Each lecture is 30–50 minutes in
length. Total length of all lectures combined is 9.0 hours. A posttest will be included that must be completed, returned to ISHRS
headquarters, and earn a passing grade of at least 70% in order
to earn a CME credit certificate. This Lecture Series will be included with the Basics Course to be held at the 2006 Annual Scientific Meeting. It will also be available for purchase on its own. It
is expected to be available in August of 2006.
Lectures on the CD-ROM
Contents and faculty include:
1. History of HRS & ISHRS Course Overview, Carlos J. Puig, DO
2. Anatomy & Physiology of Hair Growth, William M. Parsley, MD
3. Physiology & Medical Treatment of Hair Loss, Kenneth J. Washenik, MD, PhD
4. Identification of Non-Androgenetic Pathological Hair Loss, Bernard P. Nusbaum, MD
5. HRS Patient Consultation: Ethics, Expectations, and Patient Selection, Matt L. Leavitt, DO
6. Hairline & Crown Whorl Design, Michael L. Beehner, MD
7. HRS Anesthesia & Hemostasis, Vance W. Elliott, MD
8. Donor Harvesting & Closure, Marcelo Gandelman, MD
9. Graft Preparation and Storage, Jerry E. Cooley, MD
10. Recipient Site Preparation & Graft Placement, Robert P. Niedbalski, DO
11. Flaps, Reductions, and Lifts, E. Antonio Mangubat, MD
12. Office Emergency Preparedness, Edwin S. Suddleson, MD
13. Office Design and Ergonomic Work Stations, Carlos J. Puig, DO
14. Basic Principals of Staff Training, Carlos J. Puig, DO
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In Memory...
Noel Kenelm Digby
Digby,, MD
I am sad to announce the loss of one our friends and colleagues, Dr. Noel Digby. He passed
away May 21, 2006, after a valiant battle with brain cancer. He died peacefully at his home in
London, surrounded by his loving wife and 4 children.
Dr. Digby was a fellow Seattle hair restoration surgeon working for Bosley. I was fortunate to
get to know him as a warm and compassionate physician who was also a brilliant surgeon. The
highlights of his extraordinary surgical career include a vascular surgery fellowship with Dr.
Michael DeBakey in 1985, acceptance as a fellow in prestigious organizations like the Royal
College of Physicians and Surgeons (Glasgow 1979), Royal Australasian College of Suregons
(1987), and the American College of Surgeons (1990), and finally joining Bosley in 1995 where he
thrived practicing hair restoration surgery.
Dr. Digby used his considerable surgical skills to make his patients extremely happy, and we
had the opportunity to collaborate on several difficult cases. This just emphasizes what a loss he is to our specialty; he
always put his patients first.
When he first told me of his disease, I was stunned but he assured me he would beat it and come back to work. His
dedication to our specialty was supreme; he even registered for the ISHRS Annual Meeting in Sydney but, sadly, his condition
kept him from being with us.
As a person, Noel was always a delight at our local Seattle cosmetic surgery meetings, and his personality always
infected everyone around him with smiles and laughter. He will be sorely missed by his colleagues, patients, staff, and most
of all, his family.
Dr. Digby is survived by his wife of 13 years, Helen, along with their children Aleisha, 11; Mikaela, 10; Sophie, 8; and
Harrison, 4. Funeral services were held on Thursday, June 1, 2006, at St. Mary’s Church in Essex, England.
In lieu of flowers, donations are being accepted in his name by:
Royal Marsden Brain Tumour Research Fund
The Royal Marsden Cancer Campaign
Downs Road
Sutton, Surrey SM2 5PT
Great Britain
With deepest sympathy, Tony Mangubat, MD
Valerie MitchellChambers, RN
Mitchell-Chambers,
It is with deep sadness that I write this letter regarding a great co-worker and dear friend.
Valerie Mitchell-Chambers passed away recently after courageously battling ovarian cancer.
I first met Valerie in 1981 when she assisted Walter Unger on my first transplant. I
remember being panicked about the thought of having my scalp cut open.
Valerie, as always, was a beacon of bubbly enthusiasm, making me feel more relaxed
and less terrified.
Many of you who have visited the offices of Walter Unger over the years will remember
Valerie. She’s the one that looked like Cher!
Valerie started in the field of hair restoration in 1977 assisting Walter. From 1989 until a
year and a half ago, when she left, she acted as Walter’s Head Nurse and Office Manager,
adeptly organizing the Toronto and New York offices, and everything in between.
Valerie played a big part in my training when I joined Walter in 1983, eventually becoming my head nurse with Walter,
until I went out on my own 6 years ago.
I am sure that many of you reading this letter will remember Val from the many ISHRS conferences she attended and
spoke at, as well as through her travels to many locals in a teaching capacity with Walter, including Brazil, Hong Kong,
Rome, and Bologna. I remember Val as always being a really “up” person who took a genuine interest in others. She had
many, many interests outside of hair restoration. Val and I like to think of ourselves as amateur gardeners and would swap
our prize perennial cuttings with each other.
Val had a beautiful memorial service recently where many of her friends and family were there to laugh and cry. Nancy,
Robin, and Judy, from Walter’s office, gave a wonderful rendition of some of their experiences and exploits together as
friends and co-workers.
It is always difficult to lose someone you have worked with for many years. It is that much more difficult to lose
someone who has been a close friend and confidante over the years.
Val, we miss your love of life and spirit.
Paul Cotterill, MD
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Cyberspace Chat
Jennifer H. Martinick, MBBS Perth Australia
CATAGEN, ANAGEN, AND ASYNCHRONY
Richard Shiell, MBBS Melbourne, Australia ASKS:
How do you separate catagen and anagen follicles under the
microscope? Do you use the depth of the bulb as presumably both
types of follicle are still producing hairs?
Ken Washenik, MD, PhD Beverly Hills, California
On the scalp, you recognize the anagen majority (90–
95%), and the telogen hairs (5–10%), therefore you see one
for 20 anagen follicles, but finding a catagen follicle is like a
needle in a hay stack. Telogen shafts are the same size as
anagen shafts. They are shorter above the skin if they have
been recently cut (because they don’t grow) and below the
epidermis, because their bulb has risen up from the fat into
the dermis as it progresses from anagen through catagen
into telogen.
Carlos Puig, DO Houston,Texas
Hairs grow in follicular units of 1–4. Does the entire FU
go into telogen or just one of its hairs? I always thought it
was just one of its hairs, and that one of the advantages to
FU transplantation is that intact anatomy should save the
telogen follicles. Is this correct?
Francisco Jiménez-Acosta, MD Las Palmas, Spain
You find in the same follicular unit hair follicles in different phases of the cycle, because the cycle of human hair
follicles is characterized by asynchronization, meaning that
each follicle cycles independently.
Paul Rose, MD, JD Tampa, Florida
A hair in a follicular unit can be miniaturizing while others are not, and similarly one can be losing pigment when
the others are not. This may suggest that the hairs are derived from different clones. Embryologically there appear to
be waves of hair growth. After one group starts, another
group may arise in between the other hairs and at a later
time the follicular unit with the recognized attachments may
form. If one were to be able to perform DNA analysis on the
individual hairs in an FU, one might find differences in the
basic arrangements from one hair to the next.
BULGE
Ken Washenik, MD, PHD Beverly Hills, California
We often discuss the “bulge” region of epithelial stem
cells. I use slides pointing out the location of the bulge in my
lectures. I have listened to a good number of our best scholars discuss avoiding the bulge when grasping the follicle
¤
during placing or when suturing the donor site. While I believe that these representations and discussions are well intentioned, the bulge is a structure present in mouse follicles.
There is no bulge in human hair follicles. It is more of a
diffuse sheath in the human follicle.
Francisco Jiménez-Acosta, MD Las Palmas, Spain
I have read most of the literature concerning the bulge
zone and have worked with immunomarkers that label the
bulge area (for example with antibodies antiCK15).
On microscopic observation, human adult hair follicles
do not have a distinctive bulge. The bulge is an anatomic
term that has been used to define the region of the hair
follicle that coincides with the attachment zone of the arrector pili muscle.
The term bulge was initially misused by George Cotsarelis,
MD, defining the zone of the follicle where stem cells are
located. This pseudobulge zone (I would call it “stem cell
zone”) is larger than the true anatomic bulge zone.
In a strict sense, the niche of follicular stem cells is not
the bulge, but a wider zone of the external root sheath at the
level of the isthmus, specifically between the sebaceous gland
and the insertion point of the arrector pili muscles. This has
been clearly shown in the paper Ohyama et al. (J Clin Invest
2006; 116:249–60) and can be seen with anti CK15 antibodies and others (such as CD200).
BURNING SCALP
Marc Avram, MD New York, New York ASKS:
Sometimes patients complain of “burning” but not pain in
the scalp while planting. Any tricks or suggestions to limit it?
Bernard P. Nusbaum, MD Miami, Florida
From my experience as a patient, that is the first manifestation of recipient site pain. I tell patients to report burning as soon as it occurs so we can re-anesthetize quickly.
Vance Elliott, MD Sherwood Park, Alberta
Sometimes I will re-infiltrate a superficial “bead” of
lidocaine in the high dermis along the central third of the
hairline if I have already repeated subcutaneous lidocaine
without effect.
Carlos Puig, DO Houston,Texas
I found that using Kline’s Lipsosuction solution for tumescence nearly eliminates this problem. I do my primary
blocks with a 50/50 mixture of Lidocaine 2% and Marcaine
0.5%. The combination of the two provides very good ancontinued on page 142
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esthesia with a minimal number of patients experiencing
breakthrough pain.
MIDAZOLAM
Francisco Jiménez-Acosta, MD Las Palmas, Spain ASKS:
I do not have any experience on the use of midazolam, and
would like to know more about it. Your insight?
Richard Shiell, MBBS Melbourne, Australia
From 1975–1985 we used intravenous Valium in dose
of 5–10mg. Valium has a long half-life so patients were often still very “groggy” at the end of the short 30–90 minute
procedures of those days, so I switched to midazolam in
mid-1985.
Midazolam has a very short half life and so it is quite
possible for a patient to drive quite safely within 3–4 hours
of administration. The other advantage over IV Valium is
that it is water soluble and there is no residual pain after
tissue spillage and none of the phlebitis that we occasionally
saw with Valium.
If there are no obvious veins available we use 5mg IM.
It works just as well but takes 10 minutes for sedation to
commence.
The sedation is not suitable for those patients sitting
upright during the procedure. We have always had our patients in the lateral position for donor removal and semireclining for graft insertion, so the state of awakeness or
otherwise has never been a problem.
I have been using this for 21 years and can assure you
all that it is quite safe as long as you follow some simple
rules:
1. Always use a pulse oximeter. The only common sideeffect is respiratory depression. Under the effects of
midazolam some patients do not breathe as deeply as
necessary to maintain optimum blood oxygen levels.
The treatment is to tell the patient to “breathe –up” until
the PO2 returns to normal.
2. Respiratory depression is much more troublesome if
midazolam is combined with opiates so I prefer to use it
alone.
3. Take extra care if the patient is older than 60 or has
obstructive lung disease. (One should always give the
drug in small increments).
4. Some patients will ask for a “top-up” dose during surgery. We try to discourage this unless they have a driver
as they certainly cannot be allowed to drive home after
surgery.
Ron Shapiro, MD Bloomington, Minnesota
I would much prefer to use midazolam. My feeling is
that it is much safer and predictable than PO valium. I think
the IV route is actually safer than larger doses of PO medication and it is totally predictable, titratable, and you see
the affect within minutes and don’t have to worry about
different absorption rates from the GI tract or IM, which can
sneak up on you.
The main reason I have not used it yet is that I have
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been looking for a small IV butterfly that can be put in easily
and that is not painful. I have not wanted to do IV push
because of the slight risk of tissue infiltration if not in the
vein, although midazolam is water soluble and safer in that
respect. Also, if I was going to do the IV route, I liked having
IV access because I could:
1. More easily start with a smaller dose like 2mg and then
in a few minutes add the rest if I did not get my effect
2. Give more later in a titratable manner if I needed it
3. Have access to the antidote if needed.
I had not considered the IM route because, like the GI
route, I was not as sure about predictability and titratablity,
but that may be that I am just unfamiliar with the IM route.
Russell Knudsen, MBBS Sydney, Australia
I have changed to IM midazolam over the last 2 years.
The onset of sedation is slower than IV (4–10 minutes) but it
is a smoother effect (not as obvious a first-pass effect) and
the patient drifts off nicely during the donor excision.
Top-ups mean they cannot drive but can be useful in
the longer cases as they can get fidgety during prolonged
planting mid-afternoon.
The amnesia is profound, which is probably the main
reason I give it.
The dosage of IM midazolam I normally use is 5mg IM
for males, 3.75–5mg for females depending upon body
weight.
I inject it in the deltoid muscle when they first lie in the
chair. I take the BP, O2, pulse; wait 5 minutes before giving
lidocaine.
The patient lies on their side and I take approximately
half the required donor before suturing. I await a graft count
before doing the second half of the donor strip and continuing the suture. Grafts from the first half of the donor are
placed in cups and marked as the first half. They will be
planted first.
Tony Mangubat, MD Tukwila,Washington
The standard of care in the USA is monitoring any patient with IV sedation as it CAN significantly alter level of
consciousness. It requires monitoring with at least pulse/
oximetry (that is an ASA standard according to my anesthetist). Also, you are required to have the necessary equipment to resuscitate a patient if they have a respiratory arrest. Although uncommon, there are people who are
exquisitely sensitive to IV medications and even 2mg of
midazolam can cause problems. I have seen these patients
in my practice.
RESPIRATORY DEPRESSION
Marc Avram, MD New York, New York ASKS:
If someone gets respiratory depression what is the treatment?
Carlos Puig, DO Houston,Texas
Airway control, Bag Valve Mask breathing, and
flumazenil IV.
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The Hair Foundation Update
E. Antonio Mangubat, MD Seattle, Washington
I announced the formation of
18, 2006, in which bylaws were
The Hair Foundation at the ISHRS
adopted, the budget and time line
2005 Annual Meeting in Sydney,
were approved, the administrative inAustralia. In the 10 months since
frastructure discussed, and the conthis announcement, the Foundation
cepts for the website confirmed.
has made significant progress.
The funds that have been colTo quickly review, The Hair
lected from these sponsor organizations are currently being used to
Foundation is a worldwide nonestablish The Foundation’s infraprofit organization that believes that
structure, which includes incorpohair is important to everybody and
ration and establishing an adminhas the MISSION to develop the gloistrative support system. The
bal concept of hair health, educate
Foundation’s Executive Director
the public, promote the importance
Search Committee met with strong
of hair health, support hair-related
March 18, 2006, Orlando, FL. The first Hair Foundation Board of Trustees
research, and coordinate the tal- meeting. Standing: Jim O’Connell (Guest, P&G), Dow B. Stough, MD (Treasurer), and qualified candidates in Chicago
ents of each member organization Paul T. Rose, MD, JD, Matt L. Leavitt, DO (Secretary), E. Antonio Mangubat, in mid-June 2006, and we are close
(President and Chair), William M. Parsley, MD
to offering a contract for that poto serve this mission with an unbi- MD
Sitting: Russell Knudsen, MBBS, Angela Begley (Guest, P&G), Victoria Ceh, MPA
ased and unbranded approach. The (Interim Executive Director), and Kenneth J. Washenik, MD, PhD (Vice Chair) sition.
The relationship between the
member organizations are those
ISHRS and the Foundation is close and will continue to evolve
that provide hair-related products, education, and services;
to serve the needs of our patients and to meet the significant
these organizations will fund the Foundation’s educational
challenges ahead. Education is the critical mission of the Founand philanthropic activities. The largest effort will be on
dation, and the ISHRS is well suited to this task. The ISHRS is
fundraising. Those funds will be used for the purposes above,
currently expanding
notably, to increase
T he Hair FFoundation
oundation MISSION: tto
o de
devv elop the gloits educational obpublic and media
jectives and offerawareness about all
bal concept of hair health, educate the public, proings, and I believe
aspects of hair, inwe are ready to
cluding HRS.
mote the importance of hair health, support hairtake on the task as
The Hair Founwe look forward to
dation was officially
ch, and cco
o o rrdinat
dinat
r elat
ed rresear
esear
dinatee the talents of
elated
esearch,
future educational
incorporated on
each memb
er or
ganization tto
o ser
sion
organization
member
servv e this mis
mission
grants from the
March 10, 2006.
Foundation.
The founding orgawith an unbiased and unbranded approach.
It is exciting to
nizations are the
see a concept come to reality, especially with a vision such
ISHRS and Procter & Gamble (P&G) Corporation, makers of
as this that has been shared by so many ISHRS members.
multiple hair products and significant supporters of hair reThis is a major building year for The Hair Foundation, and I
search. Other organizations that have contributed financially
look forward to reporting more significant developments in
to the Foundation are Bosley and Hair Club for Men.
the coming year.✧
The first Board of Trustees meeting took place on March
Cyberspace Chat
continued from page 142
Jim Harris, MD Englewood, Colorado
If it is severe enough that stimulation by voice/pain is
not enough to keep the patient breathing, then flumenazil
0.2mg IV and repeat after 1 minute until the sedation is
reversed (1mg maximum). I don’t know if it works via IM
route. The result is dramatic.
I start IVs on all my patients for this reason. I think if
you’re using IV sedation, then you need rapid access.
Michael Beehner, MD Saratoga Springs, New York
When we are using parenteral midazolam and demerol
(which is virtually every case), we always have the pulse
oximetry on. We do take it off with around 1–1.5 hours to
go, while the girls are placing and the patient is obviously
starting to be more alert, etc. We use intermittent BP and
EKG monitoring only in specific high-risk patients.
Jennifer Martinick, MBBS Perth, Australia
Drug Reversal Protocol
Midazolam (and other benzodiazepines)—Flumenazil
0.2mg IV in 15 seconds. Give 0.1mg after 60 seconds. May
repeat as necessary.
Fentanyl—Naloxone 400mcg to 2mg IV. Repeat at 2–3
minute intervals. Can use up to 10mg. Must use airway and
oxygen.
Epinephrine—Phentolamine 2–5mg IV. Monitor BP.✧
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Dear Colleagues:
Some of you may still be deliberating whether to attend the 14th Annual Scientific
Meeting. I would like to point out some of the reasons why you cannot afford to miss
“The Big One” in San Diego.
New Developments: As you know, the field of Hair Restoration is constantly evolving, and the San Diego meeting is set to be the showcase for unveiling the latest developments. From featured speaker lectures to roundtable discussions in the newly developed
Biotechnology Workshop, you will be among the first to hear about the latest advances
Bernard P. Nusbaum, MD from Hair Biology to Cloning-Cell Therapy. With the current trend toward Super MegaSessions and the achievement of the highest graft densities ever reported, you will not want to miss the indepth discussions and critical analysis that will be debated by the most prominent members of our industry.
Certainly, the “buzz” about Follicular Unit Extraction and Body Hair Transplants has been heard around the
world and, for the first time, live patients with results of these techniques will be available for your close
inspection at the ever-popular Live Patient Viewing Session.
Hands-on Experience: Another “first” for our meeting is the use of cadaveric scalps for technique
demonstration as well as hands-on training. This learning tool will provide an unprecedented learning
experience in several of the Workshops that have been shifted to a “hands-on” interactive format. You will
be able to observe the faculty performing their unique methods on the cadaver scalps and then have an
opportunity to practice these techniques in a small group setting with world experts at your side.
Cadaver scalps will also be utilized in the practical stations of the Basics Course and in the Surgical
Assistants Program, which is featuring a completely new Cutting/Placing Workshop where attendees will
hone their skills in cutting and placing grafts while the faculty shares their pearls in a low student-to-faculty
ratio environment.
Observing Live Surgery: Probably the most effective method for incorporating new techniques into
your practice, live surgery observation is being taken to the next level at the San Diego meeting. The always
popular Live Surgery Observational Workshop will once again take place. Three procedures will be demonstrated with close interaction with faculty. For those not attending the Live Surgery Observational Workshop, the first ever Live Surgery via Satellite Session will be presented on Saturday afternoon and will feature
a Dense Packing case with Trichophytic Closure and an FUE case televised live from the workshop into the
General Session Hall. The lecture hall will be equipped for live audio communication with the operating room
surgeons, and attendees will be able to ask questions as the surgery takes place. A panel of experts will be
present at the lecture hall for discussion and commentary of every surgical step. This session represents an
exciting upgrade for our meeting and is an event not to be missed.
Networking: Those of you who have attended past meetings know quite well the spirit of hospitality
and camaraderie that is the trademark of our Society. You will be pleasantly surprised at the warm, friendly
atmosphere that permeates every aspect of our annual meeting. Whether it is with a “Who’s Who” of Hair
Restoration, past presidents of the Society, or renowned colleagues from around the world, you will be
made to feel “at home” and part of this wonderful “family” that makes up the ISHRS. Society members
are known for sharing their knowledge in an unselfish manner to all who approach them, and it is
at this meeting that you will make contacts that will be rewarding not only professionally,
but also with the creation of lifelong friendships.
The above reasons are only a small sampling of the stimulating learning experiences that the San Diego meeting has to offer for newcomers as well as the
most experienced members within our ranks. I encourage you to make
your plans to attend now, and bring your family and staff members.
We are looking forward to a fantastic meeting.
With warm regards,
Bernard P. Nusbaum, MD
Chair, 2006 Annual Scientific Meeting
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MAKE YOUR HOTEL RESERVATIONS NOW FOR SAN DIEGO
Make your reservations early, as our room block is limited!
Call the Hotel del Coronado directly at 1-619-522-8000 or toll-free at 1-800-468-3533, and request to make a
reservation in the ISHRS block. Our special group rate is $248.00 (USD) single/double for run of the house rooms, plus
applicable taxes—the resort fee is already included in our group rate. (Note that a limited number of Victorian Guest
Rooms are available at $225.00 single/double, and limited Ocean View Rooms at $310.00 single/double). You may
also make your hotel reservations on-line. For a link to the appropriate site,
go to the ISHRS meeting page at www.ISHRS.org/14thAnnualMeeting.html.
These group rates are available through September 26, 2006, or while
the block lasts, so make your reservation early!
NEW
DOCTORS: BRING YOUR ASSISTANTS TO THE SAN DIEGO ANNUAL MEETING!
S ur
gic
al A
s sistants C
utting/P
lacing W
orkshop
urgic
gical
As
Cutting/P
utting/Placing
Workshop
Wednesday/O
er 18
ic Meeting
18,, 2006—at the Annual Scientif
Scientific
ednesday/Occ t o bber
Learn to cut and place grafts of various sizes utilizing a variety of instruments and techniques. The Surgical Assistants Cutting/Placing
Workshop will be a hands-on environment using human cadaver scalp. Students will be assigned to small groups and will formally rotate
among several stations. The workshop is geared toward novice-level assistants and techs, however, experienced assistants will also find
the workshop interesting and useful. Faculty and students will share their pearls and personal techniques in slivering, cutting, and placing
as well as sharing helpful teaching aides for training staff. Enrollment is limited to purposely maintain a low student to faculty ratio.
Learner objectives:
9 Compare various instruments used for the preparation of the grafts and the placing of the grafts.
9 Identify helpful teaching aides in training staff.
9 Demonstrate preparation of slivers and grafts with human cadaver scalp tissue and planting of follicular unit grafts into cadaver
scalp.
L ab
or
a ttor
or
ee: The registration fee for this course includes a Surgical Assistants Kit. The Kit includes necessary supplies
abor
ora
oryy FFee:
and instruments to participate in the course (e.g., variety of blades and forceps). Students will take home their Kit. In addition,
students may bring their own personal favorite instruments for their use during the course, if they wish.
NEW
At the Annual Scientific Meeting in San Diego this October 2006
The International Society of Hair Restoration Surgery presents:
Liv
ur
ger
at
ellit
ivee S
Sur
urger
geryy via S
Sat
atellit
ellitee
featuring
Dense-packing with trichophytic closure
&
FUE
Moderators: Robert S. Haber, MD, and Jennifer H. Martinick, MBBS
With a discussion panel of experts
A Live Surgery via Satellite session is being planned in the General Session at the hotel. Two of the surgeries taking place at the
Live Surgery Workshop will be broadcast live via satellite to the hotel. Moderators and audience members will have the
opportunity to ask questions of the operating surgeons. The head table in the General Session room will include a panel of
experts for continuous discussion, commentary, and debate. It is sure to be an exciting event not to be missed!
Make sure to sign up for this session when you register for the meeting!
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Book Review
Richard C. Shiell, MBBS Melbourne, Australia
HAIR TRANSPLANTATION by Robert S. Haber, MD, and Dowling B. Stough, MD (Elsevier 2006).
There have now been many textbooks written on the
subject of hair restoration surgery. Some are by nature of
their size and layout, encyclopedic. Although they can be
used as “how-to-do-it” manuals, they are more difficult to
use for this purpose. Others, while commendable in many
aspects, do not have the all-round attributes of this current
book.
In an age when textbooks are routinely growing larger
with each edition, Haber & Stough’s book, by careful topic
selection and rigorous editing, has actually shrunk by 50%
from the 1996 work by the same authors.1 It now comes
in at a very readable 200 pages, and is a most admirable
production with attractive layout, clear type, good quality paper and binding, and helpful color illustrations and
charts. As a novel feature, the book comes with an accompanying DVD covering a number of common operative procedures.
Edited by two experts who have both been editors of
the Hair Transplant Forum and presidents of the ISHRS, and
with contributions by 24 other eminent authors, this book
is outstanding in every respect. The editors have wisely
limited the scope of the book to tried-and-true hair transplant techniques, and avoided more controversial topics
such as reduction, extension, and scalp flap techniques.
There is no outright criticism of these techniques, which
are known to work well in the hands of some experts, but
they have been omitted from this text for other authors to
discuss as they wish.
Contents
This edition provides a concise coverage of everything a
new surgeon needs to know to get started in this specialty,
and is a great “refresher” for the experienced surgeon. Topics include the Pathogenesis and Medical Treatment of Male
and Female Hair Loss, Anatomy, Terminology in Hair Transplant Surgery, The Consultation, Legal Consent, Hairline
Design, Anesthesia, Donor Harvesting, Microscopic Slivering and Dissection, Implantation Techniques, and Dense
Packing to name but a few of the 26 chapters. There are
also chapters on specialty topics such as hair transplantation in Women, Asians, African-Americans, Transsexuals,
and Renovation of Previous Transplants.
Some new techniques, such as Follicular Unit Extraction, have been included in this text. While FUE does not yet
have a definite place in every surgeon’s armamentarium, it
appears to be a technique that is on the rise and may be
useful for patients who have specific problems and requirements. You will not find entries on Frechet Flaps or Juri Flaps,
alopecia areata, folliculitis decalvans, lichen planopilaris, or
triangular alopecia in the index. If you require this type of
information, I recommend the great work by Unger &
Shapiro2 or one of the specialty dermatology or surgical texts
on hair loss.3,4
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A Few Downsides
The index, while comprehensive, gives the impression
of having been compiled by computer rather than by the
mind of man. For instance, if you are looking for the entry
“folliculitis,” you’ll be directed to page 180, and there it is—
one word in the heading Cysts, pustules, pimples, and folliculitis—but with no further information whatever on this common and important subject. (Ah well, one can always look
in Elise Olsen’s textbook.3) Curiously, follicular degenerative
syndrome, seen almost exclusively and then only very rarely
in African-American women, scores 10 lines on page 143.
A check on the word “alopecia” produced 10 pages dealing exclusively with the male and female androgenetic variety of this diverse group of diseases, but nothing at all on
the common alopecia areata and its more extensive variants. Now, I have already said that this book is not pretending to double as a dermatology text, but as this is primarily
a text for beginners, I would have expected some mention of
the more common and important hair problems that turn up
during the preliminary consultation.
There are 12 pages on The Consultation and Informed
Consent, yet one has to turn to page 173 to find 8 lines on
the very important subject of Body Dysmorphic Disorder, which
is the most likely underlying cause of serious legal problems
for both the beginner and the expert. Certainly, there are no
tips for the tyro on how to identify this psychological condition in advance.
The other most frequent cause of patient discontent is a
wide and unsightly donor scar. This issue is touched upon
briefly in the chapters on Donor Excision and later in Complications, but such is the importance of scar formation and its
subsequent management that it probably deserves a separate chapter.
In spite of these several points and omissions, the book
is outstanding and should certainly be in the library of every
physician with an interest in hair transplantation.✧
References
1. Hair Replacement—Surgical and Medical, Dow B. Stough &
Robert S. Haber, eds. (Mosby Year Book, 1996)
2. Hair Transplantation, Walter P. Unger & Ronald Shapiro,
eds. (Dekker, 2004).
3. Disorders of Hair Growth, Elise A. Olsen, ed. (McGrawHill, 1994).
4. Handbook of Diseases of the Hair and Scalp, R. Sinclair, C.
Banfield, & R. Dawber (Blackwell Science, 1999).
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Letters to the Editors
RE: THE BUSINESS OF HAIR TRANSPLANTATION
In his article on this subject in the March/April 2006
Forum (Vol. 16, No. 2), Dr. William Rassman raised some
very good points. Let me summarize these and add some
further comments:
1. The number of hair transplant operations is not increasing
in most Western countries, and the number of new patients may even be decreasing.
2. The work is increasingly in the hands of large, established clinics, and it is increasingly difficult for even the
most dedicated and enthusiastic new practitioners to
get established from scratch.
3. The financial returns from conventional advertising in
the Yellow Pages, television, and print media have fallen
from 4:1 to less than 1:1 in the past decade.
4. Most patients these days come via the Internet, but this
source has become increasingly clogged with claims and
counter-claims and more confusion for the patient.
ily available and really works. It is rare to find a popular
magazine without something on cosmetic surgery, and yet
one can search through hundreds of magazines without finding even the briefest mention of hair transplantation.
It is true that poor results from earlier decades are still
around to give the procedure a bad reputation, but the same
applies to other very “visible” cosmetic procedures such as
nasal correction and facelifts. The vast majority of those
with poor results have had follow-up work to correct the
problems. When the ISHRS first commenced having meetings in 1994, it was embarrassing to see some of the work
on the heads of leading transplant doctors. Hotel staff would
comment to me, “If that is the best you guys can do for your
colleagues then I don’t want any.” These days most of the
same doctors have had corrective procedures performed and
their transplants are virtually undetectable.
What is the solution?
There is no simple solution. We need constant, ongoing,
favorable public relations in hundreds of different states and
Many of us have viewed these trends for a number of
countries, but how do you achieve it and who is going to pay
years with growing alarm. Very few new doctors have enfor it? Should the national bodies or the ISHRS become more
tered the field and survived in the past decade, and many
involved in public relations? These are questions for the curolder doctors are retiring. Some just close their doors berent generation of hair restoration surgeons and must be adcause of increasing overheads and decreasing patient numdressed promptly if our specialty is to survive and grow. Cerbers, while others have been able to sell the goodwill and
tainly we need more favorable articles on hair transplantation
fixtures of their practices. To buy into an active practice should
in the popular press and on TV.
be a golden opportunity for an enterprising young doctor as
We need more high-profile patients to go public with
the goodwill prices are surprisingly modest compared with
their transplant as has happened with face and breast surthe potential income and compared with the figures that are
gery. The proceasked for most nonE v e rryy time yyou
ou criticize another sur
geon’
s w
ork
surgeon’
geon’s
wo
dure is already
medical businesses.
sound and reliable
Unfortunately, docfrom the past or present, you sew further seeds
but this will help
tors are not good
make hair transbusinessmen and
of uncertainty in the psyche of the patient who may
plantation “resome who buy into
spectable.” Such
thriving practices fail
already be skeptical about the procedure and about
favorable publicity
to capitalize on their
was common 30
purchase and the
doctors in general.
years ago when it
business may dewas commonly known that Senator Proxmire, singer Frank
cline under the new management.
This is most unfortunate and should not occur as the
Sinatra, and actor Burt Reynolds had all received hair transplants. These days I do not know of a single U.S. celebrity
size of the market is immense. Dr. Rassman has estimated
with a hair transplant and yet I know that there must be
that we are currently tapping only a tiny percentage of this
thousands of very successful transplants out there. The same
potential market.
applies in my own country where I have performed dozens
So what is the problem?
of transplants on well-known figures but it is only those
The problems stem largely from a marked lack of onperformed 25 or more years ago that are recognized (and
going, favorable publicity about hair restoration surgery.
whose work is often criticized) by members of the public.
Standards and results have never been better, and yet pubModern transplants are frequently undetected, even by the
licity about hair transplantation is the lowest it has been in
patient’s own hairdresser.
40 years. The long article by Burkhard Bilger about the
We must stop criticizing other surgeons and their surBosley Group in the New Yorker, January 9, 2006, was outgery from earlier decades. Every time you criticize another
standing in its style and content but it reached too few
surgeon’s work from the past or present, you sew further
people to make a significant difference around the world.
seeds of uncertainty in the psyche of the patient who may
There have been numerous but isolated mentions of hair
already be skeptical about the procedure and about doctors
transplantation in “Make-Over” and “Current Affairs” proin general. Just say to the patient: “That was great work in the
grams on TV, but they reach only a limited audience and
70s (or 80s or 90s), but we have now moved on. Modern surgical
are gone in 5–10 minutes.
results are virtually undetectable.”
Richard C. Shiell, MBBS Melbourne, Australia
No one doubts these days that cosmetic surgery is eas-
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Surgical Assistants Editor’s Message
Heather Hunter, MA Atlanta, Georgia
Hi Assistants,
Can you believe that in a few short months we will all be together again?! Seems like this year has
really flown by. We have another great article written by Kathryn at the Gillespie clinic. I also had one
response to the question of the month. Feel free to e-mail me your thoughts and comments. I have
some great articles for publishing in the coming issues, but there is always room for more.
See you very soon and remember to keep e-mailing each other!
Heather Hunter, MA
Heather Hunter, MA
Questions of the Month:
What is your standard post-op care like? Do you recommend products? etc.
E-mail the answer to [email protected].
Response to last month’s question regarding magnification for graft dissection:
Hi, Heather:
Here in Adelaide at Restoration Clinics of Australia, we always use magnification. We use the Meiji microscope. We
also have a Mantis, but everyone seems to prefer the Meiji. We also use a back light with it.
I think it is most important as the magnification can let you see a lot more than the naked eye. Particularly with
sandy or grey hair! It can also help avoid transaction of the follicles, as you can see them all quite clearly—much better
than without!
Cheers,
Tania Lee, Practice Manager
Norwood Day Surgery, Restoration Clinics of Australia
R egistr
ation is op
en!
egistration
open!
Extra courses and workshops fill quickly,
so don’t delay—register today for the 14th
Annual Scientific Meeting taking place
October 18–22, 2006 in San Diego,
California.
Go to
www
g/14thAnnualMeeting.html
w.. i s h r s . o rrg
to register online and for meeting details.
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Something to Think About!
Kathryn Lawson Calgary, Alberta, Canada
It’s a common thing. You’re out, meeting new people,
talk about is work. However, one always has to keep in
mingling at a function, talking to your friends, family memmind that brushing off questions or giving short answers
bers, etc. People begin discussing work. What you do for a
could cost you, your office, or the industry a whole lot more.
living tends to be a favorite topic. And, if you’re like me,
So many people are just too nervous or too embarthe minute you tell someone what you do, you are bomrassed to call your office and ask questions, or book a
barded with strange looks of curiosity and more than a
consultation. Some have been misinformed or heard the
few questions.
urban myths about what it is we do and how it looks;
Everyone knows someone who’s losing their hair. They
many don’t even know there are other options, such as
all immediately have someone in mind as they begin asking
medication, out there as well.
you: “You do what?
These casual
Does that really
encounters are our
Es sentially yyou
ou ar
alking, talking billb
o ar
d. E
aree a w
walking,
billbo
ard.
Evven
work? How does it
chance to inform
work?” And it seems
more important is that everything you say is a di- people on how far
they always want to
the surgery has
rect reflection of not only your clinic but the entire come from years
know more.
From that moago, that there are
industr
industryy.
ment on, you are
other options, that
their first impresit is natural, and
sion. You are the person that is going to either turn them off
that it’s nothing to be ashamed of.
or reel them in. Essentially you are a walking, talking billIn saying this, one also has to remember to always
board. Even more important is that everything you say is a
speak positively of everyone, and not get into bad mouthing
direct reflection of not only your clinic but the entire industry.
the competition. If you truly believe in what you and your
This is something you always need to consider when speakclinic does, your clinic will speak for itself later, if someone
ing to people anywhere.
chooses to visit you.
Often after a day at the office, the last thing you want to
Remember: You are always “On”!✧
MESSAGE FROM THE 2006
SURGICAL ASSISTANTS PROGRAM CHAIR
Well it is time to get into the swing of things and get registered for this year’s annual meeting in
beautiful San Diego, California. The early registration is very promising for a great turnout this year.
Don’t wait too long if you are considering attending the Surgical Assistants Cutting/Placing
Workshop because there is a limit to the number we can accommodate. It will be a great way to expose novice-level
assistants to experienced assistants and give them a chance to learn all their pearls. I have so many experienced
assistants who have graciously offered their time to come and share their expertise. This is what it is all about! We all
learn from each other!
My faculty for the morning is like no other. The experience and knowledge they will provide will be the foundation
of the core curriculum for surgical assistants. They will be presenting everything a surgical assistant needs to know. It
will be well worth anyone’s time to attend this informative program. I know I always learn something that I can take
back with me. I’m already excited!!!
So join us in San Diego for a new concept of a one-day Surgical Assistants Program. The workshop will definitely
be the first of its kind anywhere. Come see what it is all about—sign up today!
Sincerely,
MaryAnn Parsley, RN Surgical Assistant’s Program Chair
MaryAnn Parsley, RN
Background: Hotel del Coronado
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Classified Ads
Hair Transplant Practice Opportunity
30+ year old Hair Transplant Practice in N.Y.C. /L.I.
Looking for Experienced Hair Transplant Surgeon
to join/possibly acquire 14,000+ active patient practice.
Great Opportunity for the Right Person.
Fax Resume and Contact Information to 516-764-5702
Experienced Hair Technicians Needed
Connecticut Hair Restoration Institute
Located in a beautiful new state-of-the-art medical building in Farmington, CT (10 minutes from Hartford, 2 hours
from NYC and Boston). Looking for skilled hair technicians for per diem work.
Flexible work hours with competitive pay. All inquires confidential.
Email: [email protected] or call Betty Jean at (860) 676-2474
Fax: (860) 678-9119
Is Your Physician Profile on the ISHRS Website in
Compliance with the Official Criteria?
To view and/or edit your existing Physician Profile, access the Members Only section of the ISHRS website at:
www.ISHRS.org. Modify your details (if necessary).
ISHRS staff will begin editing or removing non-compliant Physician profiles on July 1, 2006.
Official ISHRS Website Physician Profile Criteria
1. No mention of media or the lay press (including mention of media appearances and awards, e.g., “best doctor”)
2. No mention of marketing-type language
3. No mention of fees
4. No superlatives (e.g., best, better than, or recognized leader)
5. No mention of web rating affiliations, or designation as “sponsor” or “preferred member” of web marketing
sites
6. Academic honors and publications, societal appointments, and awards ARE acceptable; however, it is not
necessary to describe the award.
7. If a physician identifies himself/herself as “board certified” by a non-ABMS board (e.g., the ABHRS), he/she
must have an asterisk explaining that the board is not recognized by the American Board of Medical Specialties
(ABMS).
When editing your Physician Profile, please remember:
1. Address information added here will not be reflected in the ISHRS membership database. If you have a change
of address, please notify the ISHRS at [email protected] or by phone at 630-262-5399.
2. Please use the above noted “Official ISHRS Website Physician Profile Criteria” when posting information.
3. All content is subject to review and approval by the ISHRS. Any information can be removed at any time by the
ISHRS.
Only ISHRS Physician and Emeritus members in good standing are eligible to maintain a Physician Profile page. This
is not a member benefit for Adjunct, Resident, or Surgical Assistant auxiliary members.
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Advancing the art and science of hair restoration
Upcoming Events
Date(s)
Event/Venue
Sponsoring Organization(s)
Academic Year
2006–2007
Registration before
October 20, 2006
Diploma of Scalp Pathology & Surgery
University of Paris VI—
School of Medicine
Paris, France
Coordinators: P. Bouhanna, MD, and
M. Divaris, MD
Director: Pr. J. Ch. Bertrand
Tel: 33 +(0)1+42 16 12 83
E-mail: marie-elise.
[email protected]
October 18–22, 2006
14th Annual Meeting of the ISHRS
Hotel del Coronado
San Diego, California USA
International Society of Hair Restoration Surgery
www.ishrs.org
Tel: 630-262-5399;
800-444-2737
Fax: 630-262-1520
[email protected]
Registration opens May 16.
Contact Information
October 23, 2006
ISHRS Regional Workshop
Eyelash Surgery Workshop for Hair
Restoration Surgeons
Torrance, California, USA
International Society of Hair Restoration Surgery
Hosted by Paul M. Straub, MD
http://www.ishrs.org/EyelashRegionalWrkshp.htm
Tel: 310-272-8622;
800-258-8881
Fax: 310-375-5016
[email protected]
November 11–14, 2006
43rd Annual Meeting of the SBCP
Recife, Brazil
Brazilian Society of Plastic Surgeons (SBCP)
Chairman: Oswaldo Saldanha, MD
Scientific Coordinator: José Horácio Aboudib, MD
www.cirurgiaplastica.org.br
Carlos Uebel, MD
Tel: 55-11-3826-1499
(São Paulo Brazil)
[email protected]
January 2007
International European Diploma for Hair
Restoration Surgery
www.univ-lyon1.fr
Coordinators: Y. Crassas, MD, P. Cahuzac, MD
University Claude Bernard of Lyon, Paris, Dijon
(France), Torino (Italy), Barcelona (Spain)
Department of Plastic Surgery
For instructions to make an
inscription online or for
questions:
Yves Crassas, MD
[email protected]
Future ISHRS Annual Scientific Meetings
October 18–22, 2006 — San Diego, California, USA
September 26–30, 2007 — Las Vegas, Nevada, USA
September 3–7, 2008 — Montreal, Quebec, Canada
HAIR TRANSPLANT FORUM INTERNATIONAL
International Society of Hair Restoration Surgery
13 South 2nd Street
Geneva, IL 60134 USA
Forwarding and Return Postage Guaranteed
152
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