Improving the Revascularization of Transplanted Hair Follicles

Transcription

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HAIR TRANSPLANT
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Volume 17, Number 4
COLUMNS
118 President’s Message
119 Co-Editors’ Messages
121 Notes from the Editor
Emeritus
139 Message from the Program
Chair of the 2007 Annual
Scientific Meeting
140 Message from the Chair of
the Pro Bono Committee
142 From the Literature
143 Surgeon of the Month
148 Cyberspace Chat
152 Surgical Assistants
Co-Editors’ Messages
152 Message from the 2007
Surgical Assistants Chair
154 Classified Ads
FEATURE ARTICLES
127 Long Hair Grafts: 20 Years
of Experience
129 Translated Reprint:
Regarding the Implantation
of Live Hairs to
Create Eyelashes
131 Preliminary Experience and
Extended Applications
for the Use of Autologous
Platelet-Rich Plasma in Hair
Transplantation Surgery
133 Survey Finds Popularity of
Hair Restoration Is
Growing
144 Review of ESHRS 10th
Annual Congress & Live
Workshop
146 Review of ISHR XII
International Congress
153 Deep Vein Thrombosis: Are
Our Patients at Risk?
You can’t lose
at the
ISHRS 15th Annual
Scientific Meeting.
September 26–30, 2007
✦
Las Vegas, Nevada
July/August 2007
Improving the Revascularization of
Transplanted Hair Follicles Through UpRegulation of Angiogenic Growth Factors
Fabio Rinaldi, MD, Elisabetta Sorbellini, MD, Paola Bezzola, MD Milan, Italy
H
air follicles are avascular, like the interfollicular epidermis, and their growth is surrounded by
perifollicular blood vessels arising from a deep plexus (the “fascial network”) into subcutaneous adipose tissue and deep dermis. The capillary loops around the hair follicle nourish the hair
bulb and dermal papilla cells through a rich blood supply.
Many studies have shown that hair growth depends on the induction of angiogenesis to meet
the increased nutritional needs of the rapid cell division of hair follicle during the anagen phase,
and that the number and diameter of perifollicular vessels significantly decrease during catagen
and telogen (with more than fourfold reduction in perifollicular vessel size). It has been demonstrated that the hair follicle provides its own angiogenic stimulus, and that the angiogenic activities are related to the different phases of the hair cycle.
The real molecular mechanism of vascular control is not yet well known. Vascular endothelial
growth factor (VEGF) plays an essential role in mediating angiogenesis during development of the
hair cycle. VEGF enhances angiogenesis as well as microvascular permeability increasing the
vessels’ size during anagen. These changes coincide with the increasing size of hair follicles.
The enhancement of perifollicular vessels is mediated by the up-regulation of VEGF mRNA by
cells of the dermal papilla and outer root sheath keratinocytes, with the consequent growth of
hair follicles and hair shafts.
The hair growth depends also on the up-regulation of other growth factors such as fibroblast
growth factor-7, insulin growth factor-1, and the direct stimulation of specific receptors of taurine and ornithine in the outer root sheath.
Transplanted hair follicles are avascular immediately after transplantation. One
of the critical moments of hair transplantation can be the risk of an ischemia
reperfusion injury of the hair grafts because of poor revascularization, and nonspecific inflammatory response.
Transplanted hair follicles must find the
best condition in the scalp to start their lifelong cyclic transformation. To survive,
transplanted follicles need to avoid ischemia
reperfusion injury, to meet the increased
nutritional need to stimulate the rapid proliferation of follicular keratinocytes and the
1. Adenosine sulphate directly stimulates the up-regulation of
elongation and thickening of the hair shaft. Figure
VEGF in dermal papilla cells in vivo, and the up-regulation of FGF-7 gene
Many of the transplanted hair follicles slip expression in DPC via specific receptor AdoR A2b.
into the resting phase (telogen) before passing to the growth phase (anagen): active and resting follicles differ remarkably in the metabolism
and control mechanism. Adachi et al. showed that in active follicles, compared with resting ones,
glucose utilization is increased by 200%, glycolysis by 200%, activity of the pentose cycle by
continued on page 125
Official publication of the International Society of Hair Restoration Surgery
Hair T
ransplant F
orum International
Transplant
Forum
Hair Transplant Forum International
Volume 17, 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 C. Cotterill, MD
Executive Director: Victoria Ceh, MPA
Editors: Jerry E. Cooley, MD, and
Robert S. Haber, MD
Managing Editor & Graphic Design:
Cheryl Duckler, [email protected]
Advertising Sales: Cheryl Duckler,
262-643-4212; [email protected]
Copyright © 2007 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.
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President’s Message
Paul C. Cotterill, MD Toronto, Ontario, Canada
I was in Japan recently to participate at the ISHRS Asian
Hair Surgery Workshop. At the end of the meeting, Dr.
Kenichiro Imagawa, who did such a beautiful job of organizing the workshop, took the faculty on a very special 2-day
tour of Kyoto and Nara, Japan. At one of the temples we
visited, Dr. Imagawa pointed out a little-known fact, at least
by the Western world. In Kyoto, there is a temple, established
in 1150, that tells the story of what may be one of the very
first transplants, even predating the work of Dr. Dieffenbach
Paul C. Cotterill, MD
from Germany in 1822. According to the Shoren-in Temple’s
records, the temple was established in 1150 to protect the priests Honen and
Shinran, who were developers of new Buddhist sects in the 13th Century. Contemporary followers of these sects regard the temple as a particularly sacred place.
Dr. Imagawa tells me that the hair transplant story starts when Saint Shinran
(1173–1262) entered the field of religion and shaved his hair in 1181. His mother
saved the hair and implanted it on to a papier-mâché statue of Shinran and always kept it near her.
After she died, the papier-mâché statue was kept in the Shoren-in Temple for
a long time.
Gradually, Saint Shinran’s reputation was enhanced with more and more people
wanting to worship the statue. As a result, the people of the temple made a
wooden statue of Saint Shinran and put on a canonical robe, and transplanted his
hair from the papier-mâché statue to his wooden statue and enshrined it near the
temple or Annex, so everyone was able to worship it.
A believer built another temple in 1759 and worshiped three Amida divinities
images with this statue by their side, which people called “Shoku Hatsu Do.”
Now people pray at this temple or Annex for the purposes of “memorial services for scalp hair,” “to have a large practice or prosperity,” and “the advancement of the techniques.” Dr. Imagawa tells me that these temples are especially
good for people working as barbers and at hair salons. However, it wouldn’t
surprise me to see the odd hair restoration surgeon, now that word is out, making
pilgrimages to the Shoren-in Temple to promote and grow their own practices.
During my trip to Japan for the regional workshop I also had the honor, along
with Dr. Jim Arnold and his wife Betty, of having a very memorable dinner with the
executive council of the Japanese Society of Clinical Hair Restoration (JSCHR): Drs.
Takeshi T. Hirayama, Kuniyoshi Yagyu, Sotaro Kurata, Akio Sato, Yoshinori Ishii,
and Tetuo Ezaki. Creating ties and friendships with members of local hair societies,
such as the JSCHR, is a very important part of being able to reach out to internacontinued on page 120
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).
Drs. Wen-Yi Wu, Kenichiro Imagawa, Damkerng Pathomvanich, Jerry Wong, and Paul Cotterill are
seen worshipping at the Shoren-in Hair Temple of Saint Shinran.
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Co-Editors’ Messages
Jerry E. Cooley, MD Charlotte, North Carolina
Where do we go from here? With our
ability to densely transplant thousands
of finely dissected follicular units, is there
really much room for improvement until
that day when cloning is here? In fact, I
think the answer is yes and that we may
be on the verge of a paradigm shift.
Paradigm shifts, according to Thomas Kuhn who coined the term, occur
Jerry E. Cooley, MD
when “normal science” runs into “anomalies” that cannot be explained with the current way of thinking.
The anomaly in our current paradigm is the variability in results we see among different patients. Why do some patients
get better results if we do the same careful technique from case
to case? Some of it, of course, is variability in hair characteristics, but that only explains some of it.
I’m not sure what this change in thinking should be called.
Something to the effect of “wound healing and graft optimization.” It would cover ideas and innovations such as new
graft holding solutions, platelet rich plasma (PRP), hyperbaric
oxygen, peri-operative use of low level laser therapy, and
topical agents to promote angiogenesis. I’m not saying all of
these ideas will ultimately prove useful. But I definitely think
some of them will.
The current paradigm is that a structurally intact graft placed
into an incision that doesn’t stress the blood supply should in
fact grow. In this model, grafting is a rather two-dimensional
process. Emphasis on quantitative aspects of the process prevail: # of grafts, # of hairs, # of hairs/FU, # of grafts/cm2, etc.
The actual process of graft survival is a black box.
The new paradigm will certainly hold high respect for the
intact graft and minimally disruptive incisions, but these will
be seen as necessary but not sufficient for graft survival. The
grafting process is viewed as a dynamic, organic three-dimensional process. Awareness of basic hair research and the
surgical literature will inform this new view of hair transplantation. Graft survival will be seen as a small miracle that involves ex vivo storage, ischemia-reperfusion injury, passive
oxygen absorption, and ultimately successful angiogenesis.
It is patient “micro-variability” in these steps that explains
the “macro-variability” in results in my opinion.
In this issue of the Forum, the new paradigm comes into
our consciousness a little more. Rinaldi describes preliminary results with “Atodine,” an agent that reportedly stimulates angiogenesis. It seems reasonable to me that anything that speeds up and augments the process whereby a
new capillary network is established around our grafts
would be beneficial.
Joseph Greco, PhD, describes his positive experience coating grafts with PRP as well as placing the gel into recipient
sites and the donor area. In a personal communication, Greco
told me that he recently saw two patients in whom PRP was
used in their transplant 6 months prior. “My first impression
was that they looked as though they were at 9 to 10 months
rather than 6 months. The transplanted hair appeared more
mature, with more aesthetic density than most patients do at
that time.” Of course, this is anecdotal data but from someone with as much as experience as Joe, I have to put some
stock in that.
Jerry Cooley, MD
Robert S. Haber, MD Cleveland, Ohio
It has been a busy few months. Two
weeks in Europe for the ESHRS and ISHR
meetings, with a side trip to Dublin. One
week vacationing with my kids. Ten
days camping out West. And soon another week in New York City and more
camping. More time out of the office
for me than I’ve taken in years, and yet
I don’t seem at risk of declaring bankRobert S. Haber, MD
ruptcy any time soon. How easy it is
for us to put our lives outside of medicine on hold for “lack
of time,” knowing all the while how ever more precious that
aspect of our lives becomes with time. I hope all of you have
taken enough time for yourselves this summer.
Both the ESHRS meeting in Paris and the ISHR meeting in
Milan were successful by any measure, and are fully covered elsewhere in this issue. Dr. Patrick Frechet organized a
thorough didactic program and an incomparable social program that made us feel like royalty. There was also a live
surgical program successfully beamed by satellite from
Patrick’s surgical center to the auditorium. I had the pleasure of demonstrating my Spreader during this program,
but learned just before harvesting that my patient had undergone a scalp reduction just a month before. This can
alter the vascularity of the donor area, and much to my
consternation, the donor harvest was, shall I say, somewhat more sanguinous than desired while cameras were
rolling. All turned out well though, and I enjoyed the subsequent opportunity to closely observe Drs. Ron Shapiro and
Jerry Wong demonstrate their respective skills.
The ISHR meeting was organized by Dr. Vincenzo
Gambino, and was well attended and very informative. The
location was elegant, the meals were superb, and the gala
dinner was one of the most special evenings ever, particularly for those who stayed until the wee hours.
In between, I visited with Dr. Maurice Collins in Dublin.
Still relatively new to our field, he has many years of surgical experience, and has demonstrated himself to be meticulous, skilled, creative, and both gracious and generous. I
feel fortunate to be able to consider him a friend.
As always, the recent meetings and office visit managed
to bring new ideas into focus, and I’ve changed my practice
yet again, always hoping to tweak my way to an elusive
perfection.
As I now enter the crepuscule of my tenure as co-editor
of the Forum, I begin to reflect on the concepts that have
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continued from page 118
tional members and potential international members for the
purposes of spreading the latest techniques in hair restoration, and also, as a by-product, through reaching out to
these doctors with regional workshops and good relationships via the local societies, we can build and grow the membership of the ISHRS. Recently, the Italian Society of Hair
Restoration (ISHR) also held its annual congress, hosted by
Dr. Vincenzo Gambino, which was a great success. Next
year in Rome there is an application to the ISHRS to have,
for the first time, a joint ISHRS-Italian meeting hosted by
Dott. Piero Schiavazzi of the Istituto Dermopatico
dell’Immacolata (IDI) along with Dr. Ciro De Sio as the ISHR
President as well as begin the Program Director with Dr.
Bob Leonard. I am also delighted to report that Dr. Tommy
Haber Message
appeared within its pages over the past few years, and how
they have changed me. I value the Forum partly for its permanence and luxury of time it grants for learning. While
Guidelines for Submitting an Article to the Forum
9 Send submission AND Author Consent Release Form
electronically via e-mail to Robert Haber, MD, at
[email protected]
9 Include all photos and figures referred to in your article as
separate attachments in JPEG, TIFF, or BMP format. Be sure to
attach your files to your e-mail. Do NOT embed your files in the
e-mail itself.
9 An Author Consent Release Form must accompany your
submission. The form can be obtained in the Members Only
section of the website at www.ishrs.org.
9 Financial conflicts of interest with devices, pharmaceuticals,
cosmeceuticals, etc. discussed in your paper must be disclosed at
the beginning of your submission.
9 Trademarked names should not be used to refer to devices or
techniques, when possible.
Submission deadlines: June 10 for July/August issue; August 10,
September/October; October 10, November/December
2006–07 Board of Governors
President: Paul C. Cotterill, MD*
Vice President: Bessam K. Farjo, MD*
Secretary: Edwin S. Epstein, MD*
Treasurer: William M. Parsley, MD*
Immediate Past-President: Paul T. Rose, MD, JD*
Michael L. Beehner, MD
Jerry E. Cooley, MD
John D. N. Gillespie, MD
Jerzy R. Kolasinski, MD, PhD
Matt L. Leavitt, DO
Robert T. Leonard, Jr., DO
Jennifer H. Martinick, MBBS
Damkerng Pathomvanich, MD
Carlos J. Puig, DO
Paul M. Straub, MD
Surgical Assistants Representative: MaryAnn W. Parsley, RN
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Hwang has submitted an application to hold an ISHRS Regional Workshop in Seoul, Korea, next year. There is also
further interest from international locations such as Mumbai,
Tehran, Tokyo, and Sao Paulo.
The next Global Council meeting set for when the ISHRS
meets in Las Vegas this September will be another chance
for all the leaders of the local hair societies to sit down and
discuss, among other things, the prospect of creating more
regional workshops through the assistance of the ISHRS. I
am very excited by this as I see the future success and growth
of the ISHRS to be closely linked to the desire for our members to want to hold regional workshops, either on their
own or in association with their local societies. If anyone
else has this interest, please contact me and I will assist you
in submitting an application.
Paul C. Cotterill, MD
[email protected]
concepts conveyed in a 7-minute presentation or great ideas
fleetingly discussed in a hallway do not always “take root,”
I can take time to absorb the ideas in an article and refer
back to it as often as needed. I do hope the Forum is as
gratifying for you to read as it is to create.
Bob Haber, MD
2006–07 Chairs of Committees
2007 Annual Scientific Meeting Committee: Sharon A. Keene, 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: Edwin S. Epstein, MD
Fellowship Training Committee: Vance W. Elliott, MD
Finance Committee: William M. Parsley, 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: Edwin S. Epstein, MD
Past-Presidents Committee: E. Antonio Mangubat, MD
Physician Training Committee: Carlos J. Puig, DO
Pro Bono Committee: David Perez-Meza, MD
Scientific Research, Grants, & Awards Committee: Marcelo Gandelman, MD
Surgical Assistants Executive Committee: Ailene Russell, NCMA
Task Force on Hair Transplant CPT Codes: Robert S. Haber, MD
Website Committee: Ivan S. Cohen, MD
Ad Hoc Committee on HRS Journal: Marc R. Avram, MD
Ad Hoc Committee on Practice Diversification: Neil S. Sadick, MD
Ad Hoc Committee on Residency Programs: Robert S. Haber, MD
Evidence Based Medicine (EBM) Task Force: Jerry Shapiro, MD &
Andreas Finner, MD (Vice Chair)
Joint Task Force on ABHRS/ISHRS: William M. Parsley, MD
Joint Task Force on HF/ISHRS: E. Antonio Mangubat, MD
Sub Task Force on Assistants Curriculum: Marcelo Gandelman, 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
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Notes from the Editor Emeritus
Michael L. Beehner, MD Saratoga Springs, New York (Forum Editor 2002–2004)
As I look back on the past five years
and the differences in my own practice
regarding how I transplant my patients,
the following stick out as having been the
biggest improvements for us (not listed
in order of importance necessarily):
Use of custom-cut micro blades for
dense packing of FU grafts. These have
Michael L. Beehner, MD been most helpful to us when making
temple, hairline, and vertex sites with FUs, especially in patients where these areas are basically hairless. I still prefer
the small solid-core needles when transplanting between
existing hair without dense packing.
Increased number of FUs in the front hairline zone. A
couple of years go we averaged 350 FUs each session in the
hairline zone, and it now averages 450 and occasionally
reaches 500–600. The biggest result of this increase is that
more patients are now content to stop after two procedures,
whereas in the past 3–4 were almost always necessary. Our
numbers in the rear border zone and the creases have also
gone up proportionately during this time.
Use of Micro-VID magnifying hand-held camera with
computer screen. We use this now in the majority of our
consultations to help more accurately evaluate the strength
or vulnerability of the donor hair and also the recipient area.
(See Figure 1.) This is most helpful in women, young males,
and patients with borderline Body Dysmorphic Disorder. It
can also be used in annual checkups on young men being
treated medically with finasteride and/or minoxidil.
Figure 1. Using Micro-VID Video Loupe to show patient donor hair at 30×
magnification.
Routine use of “finger spoons” to hold grafts during planting to keep them moist. We got this idea from Dr. Jerry Wong
and have custom modified the devices. (See Figure 2.) We
have a local metal shop make them out of stainless steel.
Almost everyone in our office prefers the small spoon coming
off of the non-planting index finger at a lateral angle rather
than sitting atop the finger as Dr. Wong’s device does.
Figure 2. Two lateral finger spoons for keeping FU grafts moist during placement.
Use of FUE to camouflage old wide donor scars. If there
is sufficient laxity, I will usually first try a 5mm wide excision
of some of the scar tissue. I find if you go over this width and
get greedy, the “rubber band effect” takes over and you end
up with the same width scar. If this does succeed and you
hold 90% of your gains, which happens frequently for us,
then another 5mm can be excised if it needs to. I find that
often simply just reducing the width of the scar by that 5mm
makes all the difference in the world and the patient is happy
to do no more. But, if the laxity is not there or myself or someone else has already made one excision attempt, I now routinely go to FUE. Typically, I’ll place around 200 FUs in this
manner, if it is a long scar. You can’t dense-pack in this type of
tissue, and can always come back several months later and
repeat it to attain a higher density of camouflaging FUs.
Use of “focal dense packing” in key areas. In many
men and women whose main complaint is a lack of framing
of the face up through the “frontal core” area, we will draw
in a small circular or semi-oval area. (See Figure 3.) After I
have made all the recipient sites elsewhere, I then perform
“stick-and-place” with 2-hair FUs into 20g needle sites,
usually at a density of 40–50/cm2. We use this strategy in
virtually every female patient, less often in males. In males
whose main thinning and area of concern is in the frontotemporal recessions, I will draw in a somewhat narrow oval
area on each side just behind the front hairline zone and will
use stick-and-place to put 120–150 FUs on each side at the
same planting density as above. For this purpose, the assistants pick out what we call “tight twos,” which means that
the two hairs in the FU have to be virtually parallel and close
together, rather than in a “teepee” relationship to each other.
They also cannot contain a hair with any degree of miniaturization. When I first started using this technique, I used
all 3-hair FUs and performed stick-and-place also, but had
to use slightly larger needles, often 18g ones in coarse-haired
patients, and the growth was not satisfactory. I firmly believe that the size of the recipient hole is very important when
dense packing. Because 90% of my patients come to me
with thinning or baldness throughout the entire top of the
head, I still depend on MFUs (cut under scopes) in the form
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Figure 3. Small frontal core zone for dense packing with stick-and-place method in
female patient.
of mostly DFUs and occasionally TFUs for filling in the large
central areas of the frontal and midscalp areas, all of which
I discussed at length in my last Editor Emeritus column.
Slightly more conservative policy in selecting female
surgery candidates. As noted above, using the 30× power
Micro-VID device has helped us to even better screen out
those female patients who have a fair amount of miniaturization in the occipital donor area. If 15% or more of the best
donor areas are miniaturized, I now discourage the woman
from proceeding with surgery and greatly reduce the promised expectations for results. In those women who do have
good occipital donor hair, I now divide these into those whose
recipient area is just a little thinned out and those in whom it
is markedly thin. In the latter more deprived group, I still like
placing 270–300 slit-MFUs averaging 4–6 hairs apiece in the
large central area, with another 1,000–1,200 FUs placed in
the temple, hairline, and inter-MFU spaces. But in the women
with very early thinning who aren’t that bad off, I now use
FUs exclusively, as I have a hunch there might be less chance
for “shocking.” I place approximately 1,500–1,700 FUs in
20-, 19-, and 18-gauge sites.
Incorporating temple hair restoration into the transplant plan. (See Figures 4–7.) When I sat down to write this
column, I was originally going to confine the article to temple
transplantation, but got carried away up above as you can
see. But I will go into this topic in a little more detail than
with the other topics. I reviewed all of the surgical cases for
the past two years and found that, looking at all my male
patients over 35, I now include side temple transplants for
31% of the patients. This adds around 300–500 FUs to the
overall number of grafts needed (150–250 per side range).
In some men with borderline donor reserves, this will not be
offered in the plan, as usually every graft is needed for some
sort of forelock type pattern.
1. We recommend including this area whenever we envision ahead that the frontal area will not be adequately
supported by the amount of side temple hair that is present.
As Drs. Mel Mayer and David Perez-Mesa have pointed
out with their rating scale of this area, a flat front temple
line often appears incomplete. Other men, who have already been transplanted in the frontal region, will have a
very acute angle of bald skin coming under the lateral
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edge of the front hairline, and in these men, simply “blunting” this angle with a few grafts does wonders to increase its natural appearance. Re-creating the anterior
temple points goes a long ways toward re-creating a
youthful look, not to mention the fact that most of the
donor hair comes from the usually darker, more melanized hairs in the occipital region, and sprinkling them in
among the white/gray hairs in the temple makes that
area appear more prominent and youthful in both fullness and color.
2. It is terribly important to make these recipient sites extremely acute, which is why the Hasson/Wong customcut blades are so ideal in this area. We orient our recipient sites in a “perpendicular” fashion when there is
no hair around, but will change the sites to more “oblique” or “parallel” if there is a fair number of preexisting hairs in the area being transplanted, so as to minimize damage to these follicles. Usually two sessions
takes care of the temples and, if the patient needs a
third session for the top area, the temples can be left
out at that final session. It is also important to take
care with the “curl” of the anterior-most FUs on the
front temple border and make sure that they all hug the
skin and curl posteriorly. Occasionally, on inspection
after the temple hairs have grown out, one of the hairs
at the front edge will appear too kinky or “corkscrew”
like, in which case it should be cored out and removed.
It should be obvious that only 1-hair FUs should be
used at the anterior-most border, but, once you get past
the first 3mm, one should quickly switch to putting all
2-hair FUs into the sites. We generally save the 3-hair
FUs for other areas of the scalp and don’t use them in
the temple.
Figure 4. 48-year-old male; before temple restoration.
Figure 5. After 3 sessions.
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Figure 6. 51-year-old male; before.
Figure 7. After 2 sessions; note darkening effect of darker occipital donor hair in
temple.
3. For the most part, I try not to create hair in a large, totally
bare area in front of the existing temple hairs, but prefer
rather to simply strengthen and augment what already
exists, with the temporal points usually being the only
area that is newly created into bare skin often.
sultation evaluation process, I see that indeed there have
been changes. They come mostly from attending meetings
and exchanging messages with colleagues. They seem to
slip into my “modus operandi” without my being aware I’m
doing something different. As I look over how I do things
today and how far the field has come, I tend to want to
assume that we have reached the acme and there are no
new frontiers to reach, but I know deep down that three
years from now, there will be another list of ten things I’m
doing totally differently.✧
It seems virtually every patient who comes back for a
subsequent surgery or a later consultation about possible
future work asks the question: “What’s new?” At first I’m
thinking “nothing much,” but then, if I look at a chart from
2-3 years back and even look at how I approached the con-
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Improving the Revascularization
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800%, and ATP production via the respiratory chains by 270%.
It is logical to think that the transplanted follicle undergoes an
important metabolic “shock,” with high apoptotic risk and
slower cellular respiration rate.
Although grafts are normally revascularized in an adequate time, it is uncertain whether the revascularization
produces significant oxygenation of the implanted grafts.
We have used reflectance confocal microscopy (RCM) to
evaluate the angiogenesis around the transplanted hair follicles (appearance of perifollicular capillary loops and increase of vessel’s size) from the first day after hair transplant, 5 days a week in the first month, once a week for the
next 6 months, in 50 hair transplant patients. RCM is a novel,
noninvasive imaging tool that can produce high-resolution
imaging in vivo in real time. We could show that the first
evidence of revascularization around the new follicle is evident after 2–3 weeks following transplantation, and that the
development of definitive capillary loops and transplanted
perifollicular vessels is evident after 10–12 weeks. Scalp connective tissue probably nourishes transplanted grafts during
the first few days after a transplant.
It is worth noting that small grafts (micrografts and FUs)
revascularized faster than bigger grafts (minigrafts).
Recently, some studies have shown that adenosine sulphate directly stimulates the up-regulation of VEGF in dermal papilla cells in vivo, and the up-regulation of FGF-7
gene expression in DPC via specific receptor AdoR A2b (Figure 1). It has also been shown that up-regulation of taurine
and ornithine receptors in outer root sheath increases the
hair growth.
Therefore, the stimulation of vessels’ size and permeability resulting in hair fiber elongation, anagen prolongation, and the reduction of apoptotic mechanism might improve the surgical result of hair transplantation, reducing
revascularization time, increasing nutritional support, and
speeding up wound healing time.
Therefore, we performed a study to evaluate the effect of
up regulating the adenosine-, ornithine-, and taurine-mediated signal transduction pathways. We studied the effect of
a topical solution: adenosine sulphate 0.1%, taurine 1%,
and ornithine chloride 1% in a lyposomal vehicle (called 13-Atodine) versus placebo (hydro-alcoholic solution alone)
applied to the recipient area twice daily post-operatively. A
double-blinded, randomized clinical trial was conducted on
104 subjects (70 women, 34 men) who underwent hair transplantation (micro-/minigrafts, FUs) in androgenic alopecia
from March 2005 to July 2006.
We have used the same evaluation protocol with RCM,
and the in vivo images showed a faster revascularization in
subjects treated with active solution compared to placebo.
In particular, we noted a vessel’s size increase after 1–2
weeks in the 1-3-Atodine group (versus 3–4 weeks in the
placebo group), and the development of perifollicular vessels after 4–6 weeks (versus 10–12 weeks in the placebo
group) (Figure 2).
The RCM evaluation in the next 6 months revealed a significant change in the average vessel’s size in the 1-3-Atodine
group compared to the placebo group (Figure 3).
Figure 2.
Figure 3.
Figure 4.
The growth rate of transplanted follicles was larger in
the active group compared to the placebo group (Figure 4).
It is worth noting, too, that we had not seen any side
effects using the active solution.
The diameter of perifollicular vessels is significantly bigger 1 month after the hair transplant in the 1-3-Atodine
group (650 µm2) versus placebo group (95 µm2) (Figure 5)
The diameter of the hair follicle is bigger, too. The skin around
the hair follicle in the active group shows a strong stimulation of skin dermal papillae. Abundant perifollicular capillary loops were evident after up regulation of VEGF using
the treatment solution (Figure 6).
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Conclusion
It is well known that the up regulation of VEGF and FGF7 via cAMP signalling, and the up-regulation of specific amino
acids receptors in DPC and ORS can stimulate perifollicular
vessel permeability, the anagen phase, the hair follicle growth
rate, and hair follicle diameter.
Furthermore, we think that a post-operative topical treatment that can stimulate the up-regulation of VEGF, FGF-7,
ornithine, and taurine receptors in ORS after a hair transplant can improve surgical results, reducing ischemia
reperfusion injury, increasing the rate of hair growth, and
stimulating anagen phase in transplanted hair.✧
REFERENCES
1. Kiichiro Yano, Lawrence F. Brown, and Michael Detmar.
“Control of hair growth and follicle size by VEGF-mediated angiogenesis.” The Journal of Clinical Investigation
(February 2001); 107(4):409–17.
2. Fabio M. Rinaldi. “The role of growth factors in hair transplantation: improvement of hair growth mediated by angiogenesis.” ISHRS 14th Annual Scientific Meeting (October 18–22, 2006), San Diego, California, USA.
3. Kiichiro Yano, et al. “Thrombospondin-1 plays a critical
role in the induction of hair follicle involution and vascular regression during the catagen phase.” Journal Invest.
Dermatol (January 2003); 120(1): 14–19.
4. K. Adachi, et al. “Some metabolic profiles of human hair
follicles.” In: Montagna W., Dobson R.L., eds. Advances
in Biology of Skin, Vol IX: Hair Growth. Oxford:
Pergamon, 1969: 511–34.
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Figure 5. The diameter of perifollicular vessels is significantly bigger 1 month after the
hair transplant in the 1-3-Atodine group (650 ìm2) versus placebo group (95 ìm2). The
diameter of the hair follicle is bigger, too.
Figure 6. Perifollicular capillary loops after up regulation of VEGF: The white spots
inside the vessels are circulating red blood cells.
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Long Hair Grafts: 20 Years of Experience
Pierre Bouhanna, MD Paris, France
Twenty years ago, we set out the technique of long hair
grafting based on a logical approach supported by repetitive
observations and the discovery of new surgical techniques.
This technique was developed in combination with the use
of peri-operative use of minoxidil.
A study was conducted on 16 male subjects aged between 25 and 52, displaying a male androgenetic alopecia,
type III–VI, according to Hamilton’s classification. These
patients were candidates for a 4mm in diameter cylindrical
autograft transplantation and applied 1ml of 2% minoxidil
solution twice a day, one month before and three months
after the surgery. This hair counts technique, using the
phototrichogram I published, allowed me to do a practical
approach and an objective follow-up of hair graft evolution
whether spontaneously or after the application of minoxidil
2% solution.
This treatment was momentarily interrupted over a 3week period following the hair transplant surgery.
Typically, scabs fell off between 2–4 weeks after the surgery, along with shafts of the grafted hairs being of a dystrophic, anagen type instead of a telogen type, as was previously mentioned in the literature. This hair loss, although
transitory and followed by a regrowth within 3 months, was
aesthetically embarrassing. A macrophotographic control of
64 grafts, taken in a group of 4 from each patient and
marked with a tattoo, was done over 3 months. It showed a
continuous growth of part of or the whole hair graft 4 weeks
after transplantation for 71% of the patients. Moreover, hair
loss was less than 50% for 31% of the grafts. This study
suggests that minoxidil treatment helps to maintain the transplanted hairs in the anagen stage.
In 1986, our intent was to take advantage of minoxidil’s
efficiency on grafts in order to set up a technique using long
hair grafts. A 2% minoxidil lotion is applied over the grafts
as mentioned above. A strip of scalp containing long hairs
was carefully harvested from the occipital donor area and
was then cut into different size segments, some not larger
than 1- to 2-haired micrografts or 3- to 4-haired minigrafts,
others measuring up to 4mm wide. We called this procedure
“long hair grafting” and believed it had numerous benefits.
Even if the persistent growth of hair grafted in conjunction
with the application of minoxidil did not always succeed, it
nevertheless helped the patient to momentarily hide for 3
weeks the scabs formed over the grafts.
The 2% topical minoxidil solution applied before and after surgery helped to avoid, in most of the cases, the postoperative hair effluvium. Combining this local treatment and
grafts with long hairs, we were able to develop a methodology to achieve an immediate reconstruction of baldness.
In 1993, the long hair graft technique was described and
fully detailed in the chapter “Newer techniques in hair replacement,” in Roenigk’s textbook Surgical Dermatology
(Dunitz, ed., pp. 527–533). It is also described in my book
“Hair Replacement Surgery,” (Springer Verlag, eds., 1996;
pp. 106–114).
Today, the present technique of long hair grafts consists
of obtaining a strip of scalp with long hairs, whose length
varies from 10–25cm according to the numbers of needed
grafts (Figure 1), that is harvested on the occipital donor
area, which will be closed with sutures or staples. The strip
is then thoroughly cut into 1–3 long hair micrografts or long
hair follicular units grafts under a stereomicroscope to preserve the integrity of the harvested hairs (Figures 2 and 3).
Figure 1. Strip of scalp is first obtained with long hairs.
Figure 2. Strip is cut into 1–3 long hair micrografts or long hair FUGs.
Figure 3. Long hair grafts are placed on moistened pads prior to placement.
The long hair graft technique achieves an aesthetic natural look of hairs due to:
1. A fine implantation on the balding area with surgical
needles and jewelers forceps allowing the good choice of
hair emergence angle, hair orientation, and obliquity.
2. The performance of a fine and irregular “one-by-one”
frontal hairline.
3. A good implantation of 2,000–3,000 hairs in each session.
4. A homogeneous distribution of many more micrografts
and follicular units grafts.
Indications for Long Hair Micrografts
➤ In male androgenetic alopecia (MAGA): In MAGA, hair
thinning appears to follow and evolve according to a particular pattern.
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Micrograft transplantation may be associated with
either a local anti-hairloss treatment, 5% minoxidil solution alone, a systemic treatment with oral finasteride
1mg tablets, or the association of both. The aim of these
treatments is to preserve the persisting remaining hairs
between the grafts, to prevent the transitory hair loss of
the long transplanted hairs, and to initiate the regrowth
of grafted and non-grafted hairs (see Figure 4).
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ommend to stop any kind of traction for at least 6 months
before attempting any hair implantation.
Scars Due to Face Lifting
Hair loss due to facial lift scars, which are sometimes
unsightful, may justify a pre-temporal and a frontal hairline
restoration. A fine-hair implantation using the natural obliquity of hairs must be done to restore the alopecia caused by
facial lift scars.
Scalp, Beard, Moustache, and Eyebrows Scars
Cicatricial alopecia, like pseudopelade or the post-traumatic alopecia in men, can be treated with long hair grafts.
In male patients, beard and moustache alopecia are mostly
due to scars related to trauma (burns, car injury), surgery
(cleft palate reconstruction) or acne. Cicatricial alopecia of
the eyebrows is more often of traumatic, surgical, or infectious origin. Micrograft transplantation should always
be adapted to the characteristics of scars and hairs to be
restored. Orientation and obliquity are better defined using
long hair micrografts.
Pubic Hair Alopecia
The aesthetic restoration of the pubis obeys several parameters such as etiology, age, ethnic origin, hair color, and
hair shape. Schematically, we must combine the fineness of
a “one-by-one-hair” implantation and the densification created by follicular unit grafts. Here again, the obliquity and
the orientation of hair grafts are very important to obtain a
natural appearance and it is easier with the use of long hair
micrografts.
Conclusion
Figure 4. Before (A) and four months after (B) 250 long hair follicular units transplanted
to the right frontal recession.
➤ In female androgenetic alopecia (FAGA): The thinning
level of FAGA can be estimated with a static classification
or can be accurately evaluated with the dynamic multifactorial classification.
➤ For the young female: A thinning of the medial frontal
area and the vertex, beginning at the age of 18, may
justify the use of micrograft transplantation combined
with the ingestion of oral cyproterone acetate, oestrogens,
and the local application of 2% minoxidil solution.
➤ For the menopausal women: We can advocate for a
micrograft transplantation in combination with the local
application of 2% minoxidil solution and perhaps a hormonal treatment in case of no contraindication. One session is mostly sufficient, but 2–3 sessions may be needed
for Ludwig III female patients.
➤ For transsexuals: The surgeon must restore the frontotemporal recessions and define a female type frontal
hairline.
Permanent Traction Alopecia
Repeated tractions due to brushings, hair uncurling, and
braids may induce a permanent fronto-temporal alopecia,
especially in African American female patients. One must
check for the absence of hair regrowth despite the local
application of 2% minoxidil solution, and we should rec-
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We are still using in our daily practice the long hair grafting
technique. However, if the basics have remained unchanged
for the past 20 years, a great improvement was made due
to the amelioration of graft preparation techniques and the
insertion of follicular graft units.✧
REFERENCES
1. Bouhanna P. The phototrichogram. A technique for the
objective evaluation of the diagnosis and course of diffuse alopecia. In Montagna, et al.: Proceedings of the
1st International Multidisciplinary Colloquium of Cosmetology, Salus Edit, Roma, 1983; 277–80.
2. Bouhanna P. Topical minoxidil used before and after
hair transplantation. J. Dermatol. Surg. Oncol. 1989;
15(1):50–53.
3. Bouhanna P. New aspects of minoxidil. Nouv. Dermatol.
1991; 10(1):24–34.
4. Bouhanna P. Greffes à cheveux longs immédiats. Nouv.
Dermatol. 1989; 8(4):418–20.
5. Bouhanna P. Newer techniques in hair replacement. In
Roenigk, R.K., Roenigk, H.: Surgical Dermatology, Advances in Current Practice. Martin Dunitz Publishers,
Londres, 1993; 51:527–33.
6. Bouhanna P. Dardour J. C. Hair Replacement Surgery.
Textbook and Atlas. Editions Springer-Verlag, Berlin
Heidelberg, 1996, 236 pages.
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Translated Reprint
Regarding the Implantation of Live Hairs to
Create Eyelashes
By Prof. Dr. Franz F. Krusius, Ophthalmologist in Berlin
Deutsche Medizinische Wochenschrift, N. 19, Berlin, den 7. Mai 1914
Translated by Marcelo Gandelman, MD São Paulo, Brazil
From the point of view of Dermatology, there has been a
lively interest on grafting of hair of the scalp. I refer here to
the names of Schweninger, Kromayer, Menahem Hodara,
Kapp, Havas und Székely.
All these experiments, at least those dealing with implantation of live hairs, have shown that success may happen only when a small area and a restricted number of hairs
is considered. Surprisingly, however, the application of these
experiments towards Ophthalmology has taken, up to now,
less interest, although these limiting conditions apply well to
the eyebrows and eyelashes. This might result from the special localization of these hairs, particularly those of the eyelids requiring the development of new techniques very different from those customary in Dermatology, in order to
allow technically successful grafts. Next will be described a
method and instrument devised by me to be used for the
replacement of eyelashes in partial or complete madarosis,
both as a cosmetic and a therapeutic procedure.
Hairs to be used to replace eyelashes should ideally be
obtained from the own patient, from the eyebrows, scalp,
armpits or pubic hairs. The hairs, strong but not single and
old, are to be cut to the length of 4–5 cm and cleaned with
benzine. This specimen together with its roots and sebaceous glands is punched out according to the well known
method of Kromayer. Alternatively it may be obtained with
any tubular trephine with an inner diameter of 1½ mm.
Local freezing of the skin facilitates very much the punching. The hairs are rinsed with warm saline solution, smoothened and then immediately inserted into the hollow needle1
whose picture is shown here, tip of the hair first until it barely
appears at the end of the shaft sufficiently to be held with a
very fine forceps. The needle inside is equivalent to the inner
diameter of the trepan used to punch the hair and is bent to
match the curvature of a growing eyelash. The eyelid that
will receive the graft is prepared with local anesthesia and is
supported and separated from the eyeball by an eyelid plate.
The needle containing the punched hairs should pierce the
skin of the eyelid at about 2–3 cm from its border, advance
toward the eyelid border and exit at the line of eyelashes.
With the needled so positioned, the tip of the hair is delicately pulled with forceps until the bulb appears at the lid
border. The needle is then carefully pulled back and out of
the eyelid while the tip of the eyelash is still hold with the
forceps.
Through this procedure a live and prone to survival hair
is grafted as an eyelid with minimal trauma and without
hemorrhage and tissue loss. At total loss of eyelashes, 50 of
these grafts suffice to result in reconstitution with a good
density of eyelashes. It is suggested to graft no more than
20 hairs per session (one lid per session). In case of use of
armpit, pubic and scalp specimens, as these hairs grow much
longer, they need to be trimmed regularly to be used at a
length appropriated to the self feeling of beauty. When eyebrows are used to grafting, due to the shorter length of these
hairs, the introduction of the hairs in the needle should be
helped with a very fine bent wire.
As the graft is done with own hairs the take is most
favorable, the cosmetic effect is excellent and the trauma
aggression is minimal. As the objective is not only cosmetic,
pursuing also the protection of the eyeball by the repopulation
of eyelashes, this procedure can be indicated in all cases of
reduction of the population of eyelashes. The presentation
of the appropriate literature and of the casuistic will be the
object of a future complete article.
_________________________
1
This instrument was prepared according to my directions by the company R. Wurach, Berlin C, Neue Promenade, and is sold under the name “Eyelash needle.”✧
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We would love to hear from your surgical
assistants. There are many ways they can
contribute:
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➤ Help in the planning of our
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Preliminary Experience and Extended Applications
for the Use of Autologous Platelet-Rich Plasma in
Hair Transplantation Surgery
Joseph Greco, PhD, PA/C, Robert J. Brandt Siesta Key, Florida
Joe Greco has indicated no financial interest relevant to this article; Robert Brandt is president of Blood Recovery Systems.
The use of platelet rich plasma (PRP) in hair restoration
surgery reported increased yield when utilized as a graft
storage medium (Uebel, 2005).1 When grafts are bathed in
activated PRP, there appears to be higher graft survival and
quicker healing.
Based on five months of experience involving more than
30 cases, the authors suggest expanding the use of PRP in
hair restoration surgery for the following reasons: (1) to
enhance donor site wound healing, (2) to decrease the incidence of infection, (3) to reduce donor scarring, (4) to increase donor scar tensile strength, (5) to enhance recipient
site healing, and (6) to be utilized as an effective treatment
protocol in severe cases of wound dehiscence or infection.
In addition to the PRP, platelet poor plasma (PPP) also has
potent sealant properties that can be utilized for hemostasis
during the procedure.
Platelet-derived growth factor (PDGF) is the evolutionary
sentinel growth factor that initiates all wound healing. Platelet
rich plasma (PRP) contains several growth factors, including
PDGF and transforming growth factor-beta (TGF-beta 1) at
high levels and vascular endothelial growth factor (VEGF).
PDGF’s main function is to stimulate cell replication (mitogenesis) of healing capable stem cells. It also stimulates
cell replication of endothelial cells. This will cause budding
of new capillaries into the wound (angiogenesis), a fundamental part of all wound healing. In addition, PDGF seems
to promote the migration of perivascular healing capable
cells into a wound and to modulate the effects of other growth
factors. Numerous studies and practical applications have
also demonstrated how growth factors are essential for regulating the cellular events involved in wound healing by attracting cells to the wound, stimulating proliferation, and
significantly influencing matrix deposition (Declair, 1999).2
TGF-beta is extremely important because it affects most
aspects of tissue wound repair, namely initiation and termination, and also promotes differentiation and proliferation
(Choi and Fuchs, 1990).3 PDGF improves dermal regeneration, acts locally to promote protein and collagen synthesis,
causes endothelial migration or angiogenesis (Ross, 1987),4
and induces the expression of TGF-beta (Pierce, et al., 1989).5
It was further established that wounds treated with PRP
gel exhibited not only enhanced wound repair compared to
control, but possess more organized collagen than control tissues, without excessive deposition of connective tissue or scar
formation (Carter, et al., 2002).6 This equine study by Carter,
et al. demonstrated biopsy wounds treated with PRP gel to
be densely organized, tightly packed fiber bundles parallel
to the overlying epidermis suggesting the dense collagen lattice had increased tensile strength in the repaired wound.
The use of PDGF in surgery is widely documented and
has become standard intra-operative and post-operative
protocol to promote hemostasis, accelerate wound healing,
and decrease the incidence of wound infection.
It is therefore suggested that PRP gel is an excellent protocol in hair transplantation for donor wound closures. Preoperatively, 50cc of blood is drawn from the patient and processed according to the established protocol to create the PRP
gel. After the donor strip is harvested, the subcuticular layer
is closed with 3.0 Monocryl, activated PRP gel is injected into
the wound from end to end (Figure 1), and the second layer is
approximated with a running 3.0 Prolene suture. After utilizing PRP gel in the donor site, wounds appear to bleed less
post-operatively than those not treated with PRP.
Figure 1. Gel injected into the wound, from end to end.
Fear of linear donor scaring is a major concern in our
patients today. In our experience, the use of platelet-rich
plasma during donor closure results in better healing and
less scarring.
After the follicular units are dissected, they are bathed in
activated PRP gel (PRP can be activated with calcium chloride/thrombin or fibrinogen and becomes a gel-like substance)
approximately 15 minutes prior to implantation (Figure 2).
Figure 2. FUs are bathed in
activated PRP gel prior to
implantation.
While dissection is ongoing and the graft design pattern is
completed, the PRP is then injected into the recipient scalp
area after the graft pattern is completed to maximize the
multiple effects of growth factors. The PRP provides an encontinued on page 132
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riched environment of concentrated growth factors to accelerate the wound response, thus promoting healing and angiogenesis for the newly implanted follicular units (Figure 3).
Injecting PRP into the recipient area may have other advantages for the non-transplanted hairs because PRP contains several growth factors, including PDGF and VEGF.
Takakura, et al. (1996)7 demonstrated that PDGF signals
are involved in both epidermis-follicle interaction and the
dermal mesenchyme interaction required for hair canal formation and the growth of dermal mesenchyme, respectively.
In 2001, Yano, et al.8 identified VEGF as a major mediator of
hair follicle growth and cycling providing the first direct evidence that the improved follicle vascularization promotes
hair growth and increases follicle and hair size.
Figure 3. PRP promotes healing and angiogenesis in newly implanted FUs.
This author has observed a more rapid healing after injecting PRP into the recipient site in hair transplantation. Based
on the previously mentioned studies regarding the effects
growth factors have on hair growth, studies are planned to
test the effects PRP and growth factors have on the nontransplanted hair.
In 2003, one of us demonstrated rapid healing and hair
regrowth utilizing PRP on a severely traumatized wound in
an equine model. While it generally takes nine months for a
wound such as this to heal, if the animal survives at all, in
this PRP-treated animal, rapid healing of the wound occurred.
At one month, complete wound closure and hair regrowth
was evident, which never occurs in these cases. Enlarged
photos of this case can be seen at the website http://
bloodrecovery.com/wound_ba2.htm.9
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This equine case is a significant example of the extraordinary effects that PRP has on rapid wound repair and hair
regrowth in especially difficult cases. It illustrates yet another very valuable use for PRP, especially, in cases of severe infection or wound dehiscence. Rapid use of PRP in this
instance cannot only promote healing of the infected wound,
but will also promote the regrowth of hair, thus avoiding
possible impending scarring traumatic alopecia.
In conclusion, we are seeing encouraging results with
these expanded applications for PRP. Further experience will
help delineate the role for this exciting technology in our
specialty.✧
REFERENCES
1. Uebel, C. O. Presented at the Annual Scientific Meeting of
the American Society of Plastic Surgeons in Philadelphia,
Pennsylvania, Oct. 9–13, 2004.
2. Declair, V. (1999). The importance of growth factors in
wound healing. Ostomy Wound Manage. 45; 64–68.
3. Choi, Y., Fuchs, E. (1990). TGF-beta and retnoic acid
regulation of growth and modifiers of differentiation human epidermal cells. Crell regal. 1; 791–809
4. Ross, R. (1986). Platelet-derived growth factor. Am. Rev.
Med. 38; 71–79.
5. Pierce, G. F., et al. (1989). Transforming growth factor B
reverses the glucocorticoid-induced wound healing defect
in rats: possible regulation in microphages by plateletderived growth factor. Proc. Natl. Acad. Sci. 86; 2229–233.
6. Carter, C. A., et al. (2003). Platelet-rich plasma gel promotes differentiation and regeneration during equine wound
healing. Experimental and Molecular Pathology 74; 244–55.
7. Takakura, N., et al. (1996). Involvement of platelet-derived growth factor receptor-a in hair canal formation.
Journal of Investigative Dermatology 107; 770–77.
8. Yano, K., Brown, L., and Detmar, M. (February 2001).
Control of hair growth and follicle size by VEGF-mediated angiogenesis. J Clin Invest 107(4); 409–17.
9. Brandt, R. (2003). Internet website posting. http://
bloodrecovery.com/wound_ba2.htm
Editor’s note: This preliminary information takes the work
of Uebel one step further, suggesting that PRP may be of
use not only for “basting” grafts but also when injected
into recipient sites and in the donor wound. It will be interesting to see if this anecdotal data can be repeated by
others and followed with convincing clinical studies. —JC
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Survey Finds Popularity of Hair Restoration Is Growing:
Number of Procedures Performed Worldwide
Increased 34% Since 2004
Robert T. Leonard, Jr., DO, Chair, ISHRS Media Relations Committee Cranston, Rhode Island
Karen Sideris, ISHRS PR Consultant Highland, Indiana
The results of the ISHRS’s 2007 Practice Census survey
out surgical patients in their 40s (by a hair!) for the title of
are in…and the numbers show impressive increases in hair
the age group with the largest number of patients undergorestoration surgery since the first
ing hair restoration surgery.
Practice Census was conducted in
The data also show that the num2005. Most importantly, approxi- ® Since 2004, the percent of female
ber of younger men undergoing hair
surgical hair restoration patients
mately 225,800 hair restoration
restoration surgery has increased
has risen by 2.4%—from 11.4% in
procedures were performed worldfrom 2004 to 2006. For example,
wide in 2006, up 34% from 2004.
in 2006, 17% of men aged 20 to 29
2004 to 13.8% in 2006.
This significant increase coinsought surgical treatment for their
cides with the soaring number of Ö More than half (57.9%) of your
hair loss compared to 15% in 2004.
hair restoration patients treated
Similarly, the number of male surpatients fell between the ages of
around the world—from 361,077
gical patients between the ages of
30 to 49 years old.
patients in 2004 to 645,281 patients
30 to 39 years old also increased,
in 2006. Specifically, the extrapowith 31.6% seeking treatment in
lated worldwide number of hair res- ° The average number of procedures 2006 versus 28.7% in 2004.
administered to achieve the desired
toration patients treated in 2006 included 216,547 surgical patients
results dropped slightly—from 2.2 Which Procedures Are
and 428,734 nonsurgical patients.
Gaining Popularity?
procedures in 2004 to 1.8 proceBreaking down the extrapolated
As expected, hair transplant
dures in 2006.
worldwide volume of hair restoraprocedures targeting the scalp action procedures performed in 2006 by
counted for the vast majority
specific countries or regions, almost every area experienced a
(92.9%) of all hair restoration procedures. But the survey
boost. Of the estimated 225,800 hair restoration procedures
found that the demand for procedures targeting nonscalp
performed, the United States accounted for 100,445 proceareas seems to be increasing. Of the 7.1% of hair restoradures (a 14.2% increase from 2004); Canada, 12,625 (a 42.5%
tion procedures performed on nonscalp areas of the body,
increase); Mexico/Central & South America, 10,668 (a 35.5%
the most notable standouts include:
decrease, which represents the only area that saw a decrease
Ö Eyebrows (3.4% in 2006 vs. 3% in 2004)
in procedures); Europe, 29,818 (a 6.3% increase); Asia, 57,542
Ö Eyelashes (1.4% in 2006 vs. 0.35% in 2004)
(a 178.3% increase); Australia, 2,394 (a 27.7% increase);
Ö Face/moustache/beard (1.5% in 2006 vs. 1% in 2004)
and the Middle East, 12,287 (a 194.2% increase, which represents the highest increase in procedures by region).
The total number of eyelash, eyebrow, and facial hair
transplant procedures was the highest in the United States,
Does the Typical Patient Still Exist?
with the Middle East boasting the highest number of chest
While men continue to dominate our patient base—comhair transplants and Asia the most pubic hair transplants.
prising 86.2% of hair restoration surgical patients and 71.8%
of nonsurgical patients—there are some noticeable changes
2006 estimated worldwide market for hair
in who is seeking treatment and at what age.
restoration procedures (by currencies):
For starters, we’re treating more women than we did in
Þ $1,238,162,024 USD (U.S. Dollars)
2004. Since 2004, the percent of female surgical hair restoÞ €914,692,195 (Euros)
ration patients has risen by 2.4%—from 11.4% in 2004 to
Þ $1,376,043,747 CAD (Canadian Dollars)
13.8% in 2006. The number of female nonsurgical hair resÞ $1,488,753,637 AUD (Australian Dollars)
toration patients has remained constant since 2004, with
female patients accounting for 28.2% of nonsurgical paWhat’s New in Your Practices?
tients in 2006 versus 28.3% in 2004.
When asked what percent of your practices are devoted
In addition, it appears from survey results that our pato hair restoration surgery, the survey found that about twotients are getting younger. When you were asked to provide
thirds (65%) devoted the majority (76% or more) of your
percentages of your male and female surgical patients treated
practices to hair restoration surgery. On average, ISHRS
by age category, you collectively indicated that more than
members reported devoting nearly three-fourths (74%) of
half (57.9%) of your patients fell between the ages of 30 to
their practice to hair restoration.
49 years old. Interestingly, surgical patients in their 30s edged
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Survey Results
In 2006, the average number of hair restoration procedures performed by an ISHRS member was 203, with members performing an average of 17 hair restoration procedures per month. The majority of hair restoration surgical
procedures were performed using the hair transplant strip/
linear harvesting technique (90.8%), with 38.3% of members reported having used tricho-closure in addition to hair
transplant with strip/linear harvesting.
Lastly, the survey found that the average number of
procedures administered to achieve the desired results
dropped slightly—from 2.2 procedures in 2004 to 1.8 procedures in 2006.
How Will the Data Be Used?
A big thank-you to everyone who completed this year’s
Practice Census. Through our joint efforts, we ended up with
a 26% response rate—an impressive number that certainly
adds credence to our findings.
As you know, we have been working hard to raise aware-
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ness of our specialty through multifaceted public relations
efforts for more than a year now. We are confident that
data such as these will only enhance our visibility among
the media and the public as the world’s premier medical
authority on hair loss and hair restoration.
To that end, we have developed a press release that was
distributed nationwide in the United States and in Europe
(England, France, and Germany, with translations in French
and German) in late June. A fact sheet that included additional statistics also was developed, and both documents
are posted in the media center of the ISHRS website with the
complete 2007 Practice Census report at www.ishrs.org/
ishrs-media-center.htm.
In order for you to use these findings in your local markets, in the next few months you will be receiving a press
release template and sample pitch letter that includes survey
highlights and information that you can tailor to your individual practice. We encourage you to share these statistics
with your local media to help us raise awareness of the
ISHRS—while at the same time promoting yourself as a local hair loss expert. Based on our findings, we certainly have
plenty of good news to share!✧
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Have you seen this before?
Dow Stough, MD Hot Springs, Arkansas OFFERS:
The patient is a 35-year-old Caucasian male who displays a beautiful frontal double whorl. What is interesting
is the fact that his father has the same exact hair pattern. We have spoken of these whorls as being autosomal
dominant in the past, but this reinforces our assumptions. Of particular interest is that the hair direction in the right
swirl is opposite from that of the left. Note the changes in hair direction. The center of each whorl is marked with
a red X.
This is a wild one. It looks to me like the whorls are butting up against each other at the mid frontal point where
there is the line of high density. They appear to encroach on half of each whorl, forming two half whorls. I think that
all peaks are formed by whorls, particularly when you note that they usually are accompanied by follicles at an
acute angle that take off 90 degrees to the rest of the hair. Commonly a person with a widows peak will have hair
on one side of the frontal border angling posteriorly. This patient takes it to another level.
William Parsley, MD Louisville, Kentucky
I have seen plenty of frontal single whorls or “cow-licks” but never a “double” in my 40 years. It must be
exceedingly rare. Double whorls on the crown are reasonably common as we all know.
Richard Shiell, MBBS Melbourne, Australia
ABHRS Recertification Exam*
Tuesday, September 25, 2007, 7:00PM
The Venetian Resort Hotel Casino • Room: Murano 3203
Las Vegas, Nevada, USA
For those whom certification expires in 1997, you are encouraged to register for the Recertification Exam. For those
interested in first-time certification, the next primary exam will take place Saturday, January 19, 2008, in Houston, Texas.
For further information and to register, contact:
Peter B. Canalia, JD, Executive Director
American Board of Hair Restoration Surgery
18525 South Torrence Avenue
Lansing, IL 60438
Tel: 708-474-2600 • Fax:708-474-6260
E-mail: [email protected] • www.abhrs.org
*Note: To take place at the ISHRS 15th Annual Scientific Meeting
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Doctors:
Bring Your Assistants
to the Las Vegas Meeting!
Assistants are welcome and encouraged to attend the general sessions Thursday–
Sunday. In addition, a special Surgical Assistants Program is being planned for
Wednesday.
Surgical Assistants Program
Date: Wednesday/September 26, 2007
Time: 8:00AM–3:00PM (includes luncheon)
Fee: Included in price of overall registration fee
Surgical Assistants Chair: Ailene Russell, NCMA
This year’s Assistants Program is a one-day meeting. The morning session will consist of lectures on the basic science of hair
transplantation as it pertains to assistants. This will reflect the upcoming core curriculum for surgical assistants. This program will cover
basic anatomy and physiology, medical and surgical treatments, graft preparation, care and handling of tissue, instrumentation, ergonomics,
complications during procedures, and helpful teaching aids in training staff. In the afternoon session, experienced assistants from
several offices will share how their office operates. In addition, there will be a networking luncheon along with the Surgical Assistants
Auxiliary Annual Business Meeting. You don’t want to miss this valuable program!
Target Audience:
Î Surgical assistants and technicians new to the field of HRS
Î Experienced HRS surgical assistants.
Î Consultants and office managers.
Learner Objectives:
Upon completion of this program, you will be able to:
9 Identify basic anatomy & physiology of the scalp and hair.
9 Define standard vocabulary specific to hair restoration surgery.
9 Identify types of hair transplantation techniques.
9 Recognize various techniques in the preparation of grafts.
9 Identify tools and techniques that improve ergonomics during graft dissection and placing.
9 Identify common medications used in hair transplantation surgery.
9 Discuss the basic concepts of emergency management; recognize common complications of hair transplantation surgery
and gain knowledge on how to handle them.
9 Discuss the relevance of marketing and the potential impact on one’s HRS practice.
9 List the Assistants Core Competencies and stages of assistant training.
Surgical Assistants Cutting/Placing Workshop
Date: Wednesday/September 26, 2007
Time: 6:00PM–8:00PM
Fee: $245.00 additional
We anticipate this workshop
to sell out, so register
as soon as possible!
Taught at the surgical assistant level. Open to assistants and physicians, however, only surgical
assistants may advance register for this workshop.
Back by popular demand! Learn to cut and place grafts of various sizes utilizing a variety of instruments and
techniques. The Surgical Assistants Cutting/Placing Workshop is 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 share helpful teaching aids for training staff. Enrollment is limited
to purposely maintain a low student-to-faculty ratio. Instruments will be provided and shared. Students may
bring their own personal favorite instruments for their use during the course, if they wish.
Learner Objectives:
Upon completion of this program, you will be able to:
9 Compare various instruments used for the preparation of the grafts and the placing of the
grafts.
9 Identify tools and techniques that improve ergonomics during graft dissection and placing.
9 Identify helpful teaching aids in training staff.
9 Demonstrate preparation of slivers and grafts with human cadaver scalp tissue and planting of follicular unit grafts into
cadaver scalp.
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Message from the Program Chair
of the 2007 Annual Scientific Meeting
Sharon A. Keene, MD, Chair, ISHRS Annual Scientific Committee 2007
Sharon A. Keene, MD
Tucson, Arizona
Dear Colleagues,
Through the efforts of many of our own members and the contribution of esteemed researchers from around
the globe, our Annual Meeting is shaping into what promises to be a phenomenal and unsurpassed learning
experience for those involved or who wish to be involved with hair restoration surgery. As always, attendees will
be educated on the latest scientific breakthroughs, but specifically there is exciting news to share with advances
in the areas of stem cell research and folliculoneogenesis, potentially new medical treatments for hair loss, and
the latest research on animals that suggests it may be possible to perform scalp allografting with a minimal
period of immune suppression! Imagine being able to harvest your grafts from a different patient with a full
head of hair with no need for medical immunosupression after a few weeks?! You will also find out about the
results of the first human trials with robots to assist in performing surgery, and continue the discussion on
automation to include tools that may help us be more efficient until the robots are here.
If you are just putting together your first surgery rooms, or wanting to update yours with the best methods
for infection control, assistant training, and scientific ways to assess your outcomes, you will not want to miss
our panel on Quality Control as well as an introduction to the Six Sigma technique for continuous quality
improvement. Included in this discussion will be all processes and mechanisms, including emergency protocols,
that will maximize patient safety and satisfaction. Not to be left out of this discussion is a report from our first
task force on Evidence Based Medicine to answer the calls for scientifically designed studies to evaluate our
techniques and outcomes.
We all share in the quest for the best techniques and methods to achieve the optimum cosmetic outcome for
our patients. Panels of experts in the field will discuss various approaches, depending on whether we are dealing
with minimal hair loss patterns or advanced hair loss patterns, and will delve into the affect that age, hair
characteristics, and economics can play on finding the optimal approach for your patient. Live patients will be
presented during these panels to illustrate various approaches.
Our program includes the latest surgical techniques for eyelash restoration, follicular unit extraction, and an
update on the “long hair transplant” technique. The Saturday afternoon live patient viewing panel will give you
the opportunity to see in person the results of each of these techniques with access to the doctors who perform
them to answer your questions. Videos of live surgeries will be included in the associated panels to offer a bird’s
eye view on “how to” perform these techniques safely.
As always, we are an international, collegial group of physicians, who enjoy sharing our knowledge with
each other for the benefit of our patients, and we welcome new attendees who have an interest in what we do
either as a future career or to educate themselves or their patients. Who knows, you may learn something that
will make you the next great innovator in our field!
Register today!
Come one, come all and join us
for the “Big One” in Las Vegas!
www.ISHRS.org/15thAnnualMeeting.html
Register now so you can reserve
your place at the Venetian, and
enjoy your first choice among our
outstanding, expertly organized
workshops to be held prior to the
start of the General Session!
I look forward to seeing you in
Vegas.
Best regards,
Sharon Keene, MD
Chairman Annual Scientific
Committee 2007
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Message from the Chair
of the Pro Bono Committee
David Perez-Meza, MD, Chair, ISHRS Pro Bono Committee
David Perez, Meza, MD
Maitland, Florida
Dear ISHRS Member,
As the newly appointed Chair of the International Society of Hair Restoration Surgery’s
(ISHRS) Pro Bono Committee, I would like to bring your attention to an important mission close to my heart called OPERATION RESTORE (O.R.).
See Cindy’s story
OPERATION RESTORE is the ISHRS’s pro bono program, designed to match
prospective hair restoration patients with ISHRS physicians willing to help people
on opposite
who lack the resources to obtain treatment on their own. Since its inception in
page!
2004, OPERATION RESTORE has provided nearly $100,000 worth of free hair
transplant services and expenses for a dozen patients suffering from hair loss
due to disease or trauma.
We are 650 ISHRS physician members and only 50 are volunteer physicians of the program. One of my
goals as Chairman of the committee is to enroll more volunteers in the program. I know that each of us knows at
least one patient that is a good candidate for the program; if all the members join the program, we can help a
minimum of 650 patients all over the world in a one-year period; that will be a great satisfaction for all the
members to help patients suffering hair loss after trauma or disease.
Patients suffering from hair loss due to disease or trauma who cannot afford hair restoration surgery are
encouraged to apply to the ISHRS’s OPERATION RESTORE program. Selected patients are matched with an ISHRS
physician volunteer who is most skilled with the hair restoration procedure that is required, and every effort is
made to match patients with physicians in their geographic area. But in cases where travel is necessary, the
program covers these expenses for the patient.
Hair loss due to injury, trauma, or disease is not uncommon and typically occurs from such things as burns,
dog bites, or certain types of cancer. Unfortunately, hair loss that results from injury, trauma, or a medical
condition is usually permanent. An obstacle these patients face is that hair restoration surgery is generally not
covered by health insurance because it is considered a “cosmetic” procedure.
It is a TEAM effort and there is so much you can do to help! I would like to encourage you to get involved in this
worthwhile mission. Here are three ways you can dramatically impact the lives of patients in need:
n Agree to become a volunteer physician with OPERATION RESTORE. All volunteer physicians must complete
and sign an O.R. application form. To download a volunteer physician application, go to: http://www.ishrs.org/
PDF/VolunteerPhysicianApp_FINAL.pdf
o Refer potential candidate patients to OPERATION RESTORE. To download a prospective patient application, go
to: http://www.ishrs.org/PDF/ProspectivePatientApp_FINAL.pdf
p Help fund the OPERATION RESTORE mission. Anyone interested in making a monetary donation or purchasing
OPERATION RESTORE apparel should visit the ISHRS Web site at www.ISHRS.org or call the ISHRS headquarters at 1-800-444-2737. All monetary donations for OPERATION RESTORE are designated as Donor Restricted, with all of the net proceeds used to fund OPERATION RESTORE activities, and are tax deductible as a
charitable donation.
Please let me know if you would like any further information on OPERATION RESTORE.
We are making a difference, one patient at a time—won’t you please join us!
Sincerely,
David Perez-Meza, MD
Chair, ISHRS Pro Bono Committee
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After HRS
Cindy’s Story
Diagnosed with dermatofibrous sarcoma, in 1986 at 26 years old Cindy had a 2-inch malignant tumor removed.
The result coupled with radiation therapy left a postcard-sized bald spot on the back of her scalp. Operation Restore
volunteer physician, Dr. Tony Mangubat, performed scalp expansion surgery in 2004.
“Dr. Mangubat and the ISHRS have changed my life.
My confidence and self-esteem have soared and I can’t stop smiling;
friends and family are amazed at the miracle, and a miracle it is.”
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From the Literature
Bessam Farjo, MD Manchester, England
Wnt-dependent de novo hair follicle regeneration in adult mouse skin after wounding.
Mayumi Ito, Zaixin Yang, Thomas Andl, Chunhua Cui, Noori Kim, Sarah E. Millar, and George
Cotsarelis. Nature (17 May 2007) 447; 316–320.
The loss of an adult follicle is considered permanent. The
possibility that hair follicles develop de novo following
wounding was raised in studies on rabbits, mice, and even
humans 50 years ago. In this study, the authors show that,
after wounding, hair follicles form de novo in genetically
normal adult mice. Analysis demonstrated that the follicles
arise from epithelial cells outside of the hair follicle stem cell
niche, suggesting that epidermal cells in the wound assume
a hair follicle stem phenotype. Regenerative capabilities of
the adult support the notion that wounding induces an embryonic phenotype in skin.
During their studies on wound healing in mice, the authors noticed structures within the centre of large healing
wounds that resemble early developing hair follicles. The
final rather than initial size of the wound seemed to correlate with hair follicle neogenesis.
Hair follicles consist of at least 10 different epithelial and
mesenchymal cell types geared toward the production of
hair. They discovered that hair follicle neogenesis following
wounding paralleled embryonic follicle development at the
molecular level.
The newly formed hair follicles also proliferated normally
and generated hair as well as sebaceous glands. They discovered that although bulge cell progeny migrated to the
centre of the larger wounds, they did not persist. Less than
3% of the new hair follicles were labelled, suggesting that
non-hair follicle bulge cells were the primary source of regenerated follicles. New follicles originated from cells outside of the hair follicle stem cell niche. The new follicles arose
from cells in the epidermis and/or upper portion of the follicle (infundibulum). Both of these areas are considered to
possess stem cells that normally undergo epidermal rather
than follicular differentiation. Their findings are the first to
indicate that non-hair follicle stem cells in genetically normal adult mice acquire competence to form hair follicles in
response to wounding.
The regenerated follicles produced hairs and cycled up to
three times within 90 days after wounding , indicating the
presence of functional stem cells. The new hairs lacked pigment and associated melanocytes, suggesting that the melanocyte stem cell niche was not reestablished or that it could
not be repopulated. In mice, melanocyte precursors localise
to the bulge.
Wnt7a has been shown to maintain the hair-follicle-inducing capacity of cultured dermal papilla cells. The over
expression of activated ß-catenin, an intracellular Wnt effector, in epidermis induces new hair follicles, and exogenous Wnt promotes formation of cysts with hair follicle
differentiation; however, to date, there has been no evidence
that extracellular Wnt ligands can promote actual hair follicle neogenesis in adult skin.
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Thus, excess Wnt in combination with wound healing
potentiates regeneration of hair follicles, perhaps by altering
cell fate and increasing the number of cells competent to
produce hair. Wnt signalling in epidermal keratinocytes is
required for hair follicle regeneration.
The authors demonstrated that a wound stimulus is sufficient to trigger regeneration of hair follicles from epithelial
cells that do not normally form hair. In their opinion, this
raises the possibility of treating acute wounds with modulators of the Wnt pathway to decrease scar formation, and
treating hair loss by regenerating follicles through wounding and Wnt pathway activation.✧
State-of-the-art
instrumentation for hair
restoration surgery!
For more information, contact:
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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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Surgeon of the Month
Nilofer Farjo, MD
Vance W. Elliott, MD Edmonton, Alberta, Canada
Nilofer Farjo was born in
Lancashire, U.K. in 1961 to an
English mother and a Pakistani
father. Her family moved to
Washington, D.C. when she
was 4, and then to Toronto,
Ontario, Canada in 1968. There
Nilofer was brought up with her
three brothers and one sister.
She participated in the usual
Canadian activities such as ice
skating and skiing. Her father
Nilofer Farjo, MD
is an allergist in Toronto and is
Manchester, England
still working full-time at age 76.
Her mother until recently ran the offices and various business ventures. Nilofer says this of her mother: “She is my
great inspiration in life, raising five kids, running a business and never a complaint. She is a person who never lets
anything stop her. I remember as a child helping her and
my granddad build a fence at my dad’s new office and
another time she put up wallpaper whilst in a cast with a
Colles fracture!”
Nilofer’s primary and secondary school education was
in Toronto. She spent summer holidays in her dad’s office
from the age of 12 helping out with administration and
eventually doing allergy testing. With a keen interest in
the sciences, it was inevitable that she was steered, not
unwillingly, toward medicine. She attended the University
of Toronto for pre-med before heading to Dublin, Ireland,
for medical school. It was there that she met her future
husband, Bessam. Her original plan was to go into pediatrics but by the time she finished medical school, she
decided on internal medicine. After graduating, Bessam
and Nilofer had planned to head to Toronto but, as fate
would have it, the Canadian regulations on foreign graduates changed the year before they graduated. They stayed
and worked in Dublin for two years before coming over
to England.
At this point, they were at a crossroads in deciding on
specialties, Bessam in surgery and Nilofer in medicine. In
1993 they contacted Dr. Larry Fremont in Toronto and spent
around three months training with him before setting up
their own clinic in Manchester. Bessam at that stage was
Norwood VII so he had a personal interest in the subject!
From a part-time practice, the couple soon enough added
a London office and now has one of the busiest clinics in
the U.K.
Since this initial training, Nilofer has attended as many
workshops, conferences, and doctors’ offices as she could.
She has been to all the ISHRS meetings except the very
first one (she had just given birth to their second child).
Currently, Bessam and Nilofer do follicular unit grafting
with average operations in the range of 2,000–2,500 grafts.
They also do occasional follicular unit extraction cases and
very rarely scalp reductions as well. A lot of their time is
spent on research projects. Nilofer first became interested
in research when she was working with her father, coauthoring a couple of papers with him. In University, she
volunteered in some of the research labs on projects such
as cervical carcinoma. Her current projects include: cell
regeneration (with Intercytex, a private U.K. biotech company), the mode of action of minoxidil (with the University
of Bradford), the behavior of balding hair follicles (with
London University), and comparison of donor suturing techniques (study grant from the ISHRS).
Nilofer describes her philosophy: “There is no such thing
as the perfect transplant so striving to constantly improve
my technique is my aim. Once I’m no longer doing this I
should throw in the scalpel. Therefore, I take a very handson approach to hair restoration. I get involved in all aspects of the surgery, including cutting and placing grafts
on almost all patients. My philosophy is that if I can’t do
all aspects of the surgery myself, then I shouldn’t be doing
it at all. This also allows me to monitor quality control of
my staff.”
Accomplishments in the past year include writing the
hair transplant module for the first recognized course in
aesthetic surgery offered by the University of London and
being awarded a Fellowship by the Institute of Trichology
(founded in 1902). Nilofer is the current president of the
British Association of Hair Restoration Surgeons.
We all know Nilofer’s spouse! Nilofer and Bessam have
two children, a daughter Aliya, aged 15, and son Janan,
aged 14, known to most people who regularly attend the
conferences. They’ve been attending since they were toddlers, and Nilofer thinks they should be due a pin by now!
Nilofer has many hobbies including Salsa dancing with
Bessam (the one with the rhythm, according to Nilofer).
She currently has a knee injury from playing netball (similar to basketball but you can’t run when you have the ball).
She also loves to cook and does so at least five nights a
week. Bessam is getting her to compile a cookbook from
her recipes.
She says: “If I gave up work, I would devote my time to
travel and art. I can’t draw so I do abstract multimedia
canvasses and objects. My dad still has some of my artwork in his offices that I did when I was about 12!”✧
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European Society of Hair Restoration Surgery:
10th Annual Congress & Live Surgery Workshop,
Paris, France • May 24–27, 2007
Thursday–Friday/May 24–25, 2007
John Gillespie, MD Calgary, Alberta, Canada
Dr. Patrick Frechet organized an excellent 10th Annual
Congress and Live Surgery Workshop. The meeting was held
at the Hotel Marriott, Champs Elysées. Dr. Frechet emphasized that he wanted the meeting to stress practical aspects
of hair restoration surgery and he certainly achieved this. The
evenings were highlighted by a black tie dinner at Maxim’s de
Paris, cocktails at the Automobile Club de France, and the
gala dinner and dance at the private club Cercle de l’Union
Interalliée. The attendees had an opportunity to visit exclusive
locales that would not normally have been accessible.
The first day started with a warm welcome from Dr.
Michael May, the current ESHRS president. The scientific
sessions started with “State of the Art” moderated by Dr.
Ron Shapiro. Dr. Shapiro discussed the creation of a natural
hairline. He emphasised how framing the face requires more
than just a frontal hairline. It requires temporal angles, temple
points, and the hairline itself. He discussed the concepts of
both micro and macro irregularities of the hairline. He feels
that macro irregularities are more important than micro irregularities and they are definitely more important when
looking at a hairline from a distance. He emphasized that
density starts a little behind the hairline and it is an error to
try to achieve a dense hairline by placing hair too anteriorly.
He used very good computer drawings to demonstrate hairlines. He stressed the need to constantly reassess the hairline throughout the procedure, and to add grafts as needed
to achieve both the micro and macro irregularities.
Dr. Shapiro spoke again on the placing of grafts, and he
feels that this is a critical step for density. He had some
pearls for placing that I think are worth repeating. He feels
that in good placing there should be but 2 touches of the
graft. He feels that magnification is essential and it’s best if
grafts are kept in the field of vision, such as on the fingertip.
Leaving the hair slightly longer will make the grafts easier to
see and will reduce the chance of missed holes or piggybacking. It is important to control bleeding with good tumescence and limited depth incisions as well as constant
spraying with saline. Frequent dabbing is essential usually
with every place. The right size holes are important and the
size of the graft should be checked to ensure the holes are
correct. Good hydration of the grafts is of course necessary
to ensure good growth, and this is very important during
the placing process. When using pre-made holes, Dr. Shapiro
thinks that the placing should average 7 grafts per minute.
This gives us a goal for our own clinics.
Dr. Jerry Wong talked of balancing the top of the hairline
to the temporal hairline. He emphasized that the frame for
the face involves both the frontal and temporal hairlines. Dr.
Wong made some interesting observations about natural hairlines. He has observed that the right temporal hairline points
more posterior and the left more inferiorly in most patients.
When transplanting temporal points, following the directions
of residual hair is very important. He has observed that the
right temples are often more receded than the left, and some
of us surmised that this may have something to do with “left
brain, right brain” or even right and left handedness. Later in
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the day he showed videos of his multiple blade holder, which
uses custom cut blades. He can make 6 lateral slits at a time,
which greatly improves one’s efficiency. The geometric pattern formed also allows easier placing.
Dr. Frechet next spoke on scalp extension and the Frechet
flap. Even after seeing Dr. Frechet’s presentations on many
occasions I am constantly amazed at the dramatic results
that he shows in just one or two months. He stated emphatically that one should not graft the vertex in any men
under the age of 50. He feels that their only treatment should
be reducing the vertex. With 1 or 2 Frechet extenders, along
with the triple flap procedure, Dr. Frechet showed impressive results of men with quite extensive hair loss. He
emphasised there is a risk of necrosis in the triple flap, particularly in those who are inexperienced, and one must be
cautious in undertaking these procedures as a beginner.
Dr. Bill Parsley discussed shapes of male frontal hairlines, and showed examples of different patterns, including
triangular, oval, and flat patterns. He discussed land marks
in drawing hairlines and emphasized that any hairline pattern that doctors design should occur in nature. Dr. Frank
Neidel moderated the session “Harvesting with Minimal
Transection and Closing the Wound with Minimal Scarring.”
Dr. Robert Haber demonstrated the use of his tissue
spreader, which is very ergonomically designed. It uses the
strong flexor muscles of the forearm. I can say from personal experience that it definitely reduces the transection
rate. He did an analysis of the transection rate using his
spreader verses the transection rate in an Orlando LSW study.
It showed that from 25% to over 50% of the hairs in danger
are transected even in good hands. In large clinics, the cost
of these transections, to either the patient or the physician,
could be $100,000 or more annually. His final point was
that “harvesting without transection is paramount.”
Dr. Paul Rose is also developing a tissue spreader based
on a Kelly haemostat. It requires a slightly deeper incision
and more hand strength. He is presently working on a reverse action model that will be more ergonomic and may
soon be available. Dr. Kuniyoshi Yagyu spoke on the prevention of donor hair transection as well. Dr. Yagyu did a study
of 100 patients to determine hair direction in relation to the
whorl. He found that in 70–80% of patients, the follicular
units oriented perpendicular to the whorl pattern. On this basis he concluded that concave incisions in concentric circles
radiating out from the whorl will result in less transection.
Dr. Paul Straub spoke on the trichophytic closure. He
uses the Frechet technique, in which a small strip of epithelium tissue is excised from the lower margin of the incision.
He cuts a 2mm triangle from the lower margin using a special pair of scissors that never quite closes. He always undermines in the fatty layer about the width of the incision
and finds it’s easier on the lower edge. He feels that undermining prevents the change in hair direction that is sometimes noted in trichophytic closures. Dr. Straub uses a very
superficial suture about 2mm from the edge of the wound.
He notes that cysts may occur and that there may be some
irritation as new hairs grow up through the acute margin.
Dr. Straub showed examples of his results including his own
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scalp, which had a trichophytic closure about 1 year ago.
His scar was virtually invisible.
Dr. Paul Rose discussed his method of trichophytic closure that he refers to as ledge closure. His horizontal incision is about 1mm deep and his vertical is about 1–2mm
from the edge. His closure allows one to go in between follicular units 1–2mm from the edge, which may yield a better
result. Dr. Rose feels he gets some undermining with his
spreader, but doesn’t otherwise undermine.
Dr. Frechet also discussed trichophytic closures and did
a study on the results of his closures. He noted inflammatory reactions for up to 6–8 months but otherwise the scars
healed very well. He feels that undermining one or both sides
of the incision is necessary to get the best results and usually undermines inferiorly for a lower incision and superiorly for an upper incision.
Dr. Jorge Gaviria did a large study on trichophytic closure verses non-trichophytic closure. He used a trichophytic
closure on one half of his incision and a superficial closure
on the other side. He de-epithelialized the inferior edge of
the wound. He concluded that the trichophytic closure has
more discomfort, more irritation, and more cysts but gives
a better long-term result.
Dr. Tseng-Kuo Shiao showed a video of a disposable
implanter that he has developed. He feels that it allows less
experienced staff to get up to speed in planting of grafts
quickly. It probably does not have a place in busy experienced clinics. Dr. Ken Washenik gave an excellent presentation on medical treatment of hair loss and cell therapy. Professor Yann Barrandon gave the feature lecture on stem cells.
Saturday/May 26, 2007
Ken Washenik, MD Beverly Hills, California
Saturday morning featured a return to the didactic portion of the agenda, after Friday’s Live Surgery Session.
ESHRS President Michael May opened the morning with a
session examining aspects of both FUT and FUE. Dr. Jean
Devroye reviewed the utility and practical differences between coronal and sagittal recipient sites. The usefulness of
long hair (untrimmed before or after the harvesting process)
follicular unit transplantation as a means to provide the patient with a “preview” of their results was discussed by Dr.
Marcello Pitchon. Drs. Demir Ilter, Ekrem Civas, and Mark
DiStefano each discussed the utility of and specific technical
aspects of FUE before Dr. Brian Feriduni wrapped up the
session with a helpful comparison of both techniques.
Dr. Bill Parsley moderated the next session that focused on
female patients. Dr. Fernando Basto proposed a new classification system for female pattern hair loss, noting the clinical
gaps in the commonly used classifications. Drs. Karin Leonhard
and Kyle Seo each addressed different aspects of creating aesthetically appropriate hairlines in female patients. The session
was completed by Dr. Bob Leonard who gave his perspective
on the unique aspects involved in caring for female patients. Dr.
Walter Unger presented a thorough treatise on the merits of
transplantation in carefully selected younger patients.
A highlight of the ESHRS meeting was the live patient viewing
after lunch. Participants had an opportunity to examine and
discuss patients who had had surgery the day before, as well
as a number of patients operated on years and even decades
before, representing a variety of techniques.
The day culminated with presentations moderated by Dr.
Kenichiro Imagawa who also spoke on the topic of problematic hairlines in young patients. Also presented in this
session was a talk on the relationship between the structure
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of the patient’s face and the design of the constructed hairline. Dr. Kuniyoshi Yagyu gave a quantitative and clear analysis of the native concentric, circular orientation of follicular
units in different areas of the scalp.
Sunday/May 27, 2007
William M. Parsley, MD Louisville, Kentucky
Sunday’s first session was moderated by Drs. Ramon Vila
Rovira and Carlos Velasco de Aliaga. Dr. Kenichiro Imagawa
spoke on the pitting and tenting of grafts, noting that pitting
occurs when the graft sinks below the skin surface and tenting
occurs when papules develop at the follicular orifice, giving a
“goose bump” appearance. He presented several reasonable
theories as to their cause. Dr. Kyle Ki Seo next spoke on hairline
modification using hair removal laser. To solve the problem of
obtaining finer hairs for the hairline, he transplanted single hairs
and later treated with a laser, trying to stay between the level of
no effect and hair destruction, thus obtaining finer hair shafts.
He would treat the hairs 6–10 months after surgery. At treatment, he would shave the first 2–3 rows of hairs. He found that
he needed 1–3 sessions at an interval of 3–4 months to get
good results, which were impressive. Dr. Velasco de Aliaga
showed a 30-year-old man with an inappropriately low hairline made worse by the use of large round grafts. His repair
consisted of a surgical excision of the hairline, requiring a
17×1.5cm strip using a W-plasty. This was followed by follicular unit transplantation using 2,500 grafts, giving a much
improved cosmetic result. Dr. Ahmed Abel Noreldin next spoke
on FUT for the management of cicatricial alopecia. He discussed burns on scalps of children, with minor burns defined
as less than 15% of the scalp and moderate burns involving
15–40%. In treating scalp burns, partial and full thickness grafts
are very helpful along with serial excisions, flaps, and grafts.
He suggested waiting 6 months after grafting before transplantation. Dr. Ramon Vila Rovira discussed his experience in
reconstruction. He may use Vallis strips, free flaps, and excisions using either the Frechet Extender or expanders. His favorite tool for creating graft sites in burns is the SharpPoint.
The next session was moderated by Dr. Pyra Haglund.
Dr. Thomas Nakatsui presented his survival results with
densely packed follicular units placed into lateral slits. Grafts
placed at densities of 23, 29, 41, and 72 FUs/cm2 were all
found to have survival rates of approximately 98%. Surrounding grafts were placed at a density of 40 FUs/cm2. Dr. Haglund
spoke on combination therapy using surgery and lasers. She
presented a patient who, after laser therapy, had more hairs/
FU and had an increased diameter of her hairs on top and on
the vertex. She stated low level laser light (LLLT) increases
intracellular energy levels, blood supply, and wound healing
while being anti-inflammatory. Dr. Haglund cautioned against
using LLLT on donor scars as this could potentially increase
the chance of a hypertrophic scar. Finally, Dr. Colin Westwood
finished the meeting with a talk on the 5-alpha reductase
blockers finasteride and dutasteride. He reminded us that this
work began with a village in the Dominican Republic that had
a number of people they called “guevedoces” (meaning “testicles/penis at 12”). They were missing the alpha reductase
type II enzyme and thus had a 65% reduction of their DHT.
At puberty it became obvious that they were males, not females. Also, it was found that they didn’t go bald and didn’t
develop an enlarged prostate.
Everyone agreed that this was a productive, well-organized meeting. Kudos to Dr. Michael May, Dr. Patrick Frechet,
and all those integral in putting this meeting together.✧
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Italian Society of Hair Restoration:
XII International Congress
Milan, Italy • May 31–June 2, 2007
This year’s ISHR meeting was held in Milan, home of Program Chair and ISHR President Dr. Vincenzo Gambino. The
program’s theme was “Crowning Achievement in Hair Restoration” with the image of Julius Caesar. Friends of Dr. Gambino
will know that he is a history buff interested in all things related to Julius Caesar. The program that Dr. Gambino put on
this year would have made Caesar very proud indeed.
Friday Morning/June 1, 2007
Jerry Cooley, MD Charlotte, North Carolina
The meeting began with opening remarks from Honorary
Congress President Dr. Martin Unger, followed by Dr. Gambino.
As in previous years, many of the presentations were in Italian and attendees were able to listen to simultaneous English
translations via headsets, which worked extremely well.
The first segment was a media panel with several prominent Italian journalists. Television journalist Osvaldo Bevilacqua
spoke on the role of the Internet, which he referred to as the
“infernet,” likening this information medium to Dante’s inferno. The issue of the impact of inaccurate health information and the damage this can cause the public was discussed.
Science journalist Luciando Onder pointed out that in Italy
there are about 3,000 sports journalists and only 100 medical
journalists, a ratio that is likely similar in the rest of the world.
The next segment focused on hairline design. Dr. Ron
Shapiro spoke on how he approaches hairline and frontal
restoration. Dr. Paul Rose presented a simple technique for
creating symmetrical hairlines using moldable templates. He
uses flexible screens available at arts and crafts stores and
cuts out various hairline designs. These screens can then be
bent to conform to the patient’s head, allowing a perfectly
symmetric hairline to be drawn on. Dr. Antonio Ruston gave
an excellent presentation on “ultrafine single hairs” to create
the finest possible hairlines. One of the audience members
expressed concern that “ultrafine” singles may be miniaturizing hairs that will subsequently be lost.
The next series of lectures focused on science and research.
Dr. Maurice Collins gave an excellent presentation on wound
healing and hair transplantation. His opinion is that wound
healing is a prerequisite step before hair can grow, therefore,
the sooner the former occurs, the sooner the latter will occur.
For example, Dr. Collins emphasizes the importance of moisture in healing, and he gets his patients to vigorously spray
their scalps with saline continuously in the immediate post-op
period. Having recently visited Dr. Collins in his Dublin clinic, I
can attest to how good his patients look the day after surgery.
Dr. Bessam Farjo provided a nice review of Intercytex’s
cell therapy research, discussing in particular the incorporation of robotics into the cell culturing process, which holds the
promise of making large-scale commercial production feasible and cost effective. Clinical trials have recently been initiated in the United Kingdom at the Farjo Clinic that will test the
efficacy of cultured follicular cell implants.
Dr. Sotaro Kurata discussed the importance of hair matrix
structure for survival of transplanted follicles. He discussed
his own research that shows that extended storage of grafts
in Hank’s culture media results in better subsequent survival
compared to normal saline. Dr. Jerry Cooley provided pre-
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liminary results of new research he has been conducting using visible light spectroscopy to determine surface scalp oxygen levels. Several surprising findings emerged in his studies
that he plans to present at the ISHRS Annual Scientific Meeting this September in Las Vegas.
Dr. Fabio Rinaldi presented the results of his research showing that post-op treatment with topical adenosine solution stimulates angiogenesis and appears to have clinical benefit in terms
of growth of transplants (see cover story this issue). He also
discussed the critical role of growth factors (e.g., IGF, FGF).
Friday Afternoon/June 1, 2007
Ricardo Mejia, MD Jupiter, Florida
The afternoon was greeted by Dr. Martin Unger discussing
low level laser therapy (LLLT) for hair restoration therapy. Dr.
Unger reviewed much of the clinical data regarding the benefits
of LLLT. He stressed the safety and biological effects for hair
restoration surgery. Based on the FDA studies, his viewpoint is
that LLLT is better than Propecia® and/or minoxidil and should
therefore be regarded as a standard of care for treatment. Dr.
Alan Bauman also discussed the multitherapy approach to LLLT
utilizing the combination therapy approach of laser transplant,
Propecia®, and Rogaine® to give the maximum benefits to patients. Dr. Alfredo Rossi discussed long-term treatment of androgenetic alopecia. He reviewed the 10-year data clinical trial
of minoxidil 5% vs. 2%. They utilized the 10-year global photography of finasteride and minoxidil to evaluate patients. The
session was moderated by Dr. Ronald Shapiro.
Next, we moved to body hair transplantation moderated
by Dr. Yves Crassas. Dr. Mario Marzola showed a nice video
regarding safe administration of tumescent anesthesia for
anesthetizing large areas in body hair transplantation. Dr.
Robert True presented on torso hair transplantation. He recommended starting with test sessions of 200–300 grafts. He
uses a torso to donor hair index score based on density, texture, 2- to 3-hair follicular units, and hair length. He uses his
scoring system to help determine who is a candidate for torso
hair transplantation. Dr. Vincenzo Gambino then played a
video showing chest to scalp transplantation. Dr. Masahisa
Nagai also discussed body hair transplantation. He noted the
differences in density and orientation from the body to the
hairs and related a 7.4% transection rate related to the different angles in body hair transplantation from body to hair.
Drs. Crassas and Marzola stressed avoiding the sternum to
avoid hypertrophic scars in this area.
The session moved to Dr. Paul Rose moderating implantation techniques and devices. Dr. Alex Ginzburg discussed utilizing different orientations for the incision to help hair technicians determine the sizes of grafts to be placed. He alternates
incisions coronal to sagittal to indicate to the technicians the
different sizes of blades for the different hairs per follicular unit.
Dr. Robert Elliot showed a video showing the side-by-side comparison of the Shiao implanter vs. traditional manual placers.
Overall, the manual placing method was faster than the Shiao
implanters when tested in Dr. Elliot’s clinic. Dr. Silvio Smeraglia
presented a criss-crossing technique for the crown area. He
felt a criss-crossing pattern would provide better coverage in
the crown area as opposed to the traditional vortex design.
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Dr. Jerzy Kolasinski then moderated the session on thinking out of the box, new approaches through hair transplantation surgery. Dr. Carlos Puig presented the philosophy of
introducing Six Sigma technologies for hair restoration surgery. This is the system by which you must apply protocols
to minimize errors in hair transplantation surgery and to
improve the quality of our workflow. Dr. Puig will be providing a more in-depth, thorough analysis of this process and
workflow at the ISHRS Annual Scientific Meeting this September in Las Vegas. Dr. Marcello Pitchon then presented
his technique on transplanting with long hair follicular units.
This impressive technique allows one to immediately visualize the results of the hair restoration procedure as opposed
to waiting for the regrowth of the hair. Dr. Marco Toscani
discussed the transplantation of the eyebrows stressing the
aesthetic importance of the proper directional angles for
proper placement of the hair follicles.
Saturday Morning/June 2, 2007
Nilofer Farjo, MD Manchester, England
The day began with FUE presentations. Dr. Yves Crassas
discussed his use of the modified Calvitron. As he feels that
the manual technique is too time consuming, he uses the automated system at low speed to cut the superficial layer and
then top push deeper manually. The follicular units are then
aspirated and placed. With this method he can harvest and
place 600–1,000 grafts per hour. Dr. Paul Rose next showed
the development of a new punch for FUE that has a slot to
decrease the surface area and limit the depth. He finds that
this method will allow you to follow the direction of the hair
follicles. Dr. Ezio Nicodemi also presented an automated system using an auto punch with aspiration. A study he performed over 3 months showed an initial transection rate of
40% decreasing to 18% after 3 months. The final speaker,
Dr. Silvio Smeralgia, described his experience with FUE using
chest and pubic hair FUE.
The next session was about large and mega sessions. Dr.
Russell Knudsen gave a comprehensive overview of the principles behind single pass grafting. Suitable candidates are those
with moderate to severe balding, older, and with good donor
hair characteristics. Dr. Piero Tesauro described his method
for large sessions including the need to dye white-haired donor hair 2–3 days prior to surgery. He talked about the importance of exercises for staff to prevent eye strain during
long procedures.
Dr. Bob Leonard gave a presentation on the general approaches to hair loss in women including the use of minoxidil
(including the newly release foam), LLLT, and camouflage
agents. Dermatologist Dr. Andrea Marliani discussed whether
“androgenetic alopecia” in women really exists. He postulated that low local estrone and peripheral resistance may be
the cause of hair loss in women. Dr. Paul Struab showed
videos of surgery from the eyelash workshop in October 2006.
He compared the techniques used by Drs. Jennifer Martinick,
Marcelo Gandelman, and Alan Bauman. Dr. Straub recommends that older patients with atrophied eyelashes are suitable candidates for this procedure, not young women who
want thicker/longer eyelashes.
Next were difficult and unusual cases. Dr. Tony Mangubat
outlined flaps and extender and expander techniques with
examples. Dr. Paul Cotterill showed an example of hair transplantation in a male to female transgender patient. He describes the biggest concern to be that of expectations. Dr.
Ricardo Mejia showed examples of his experience with skin
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cancer of the scalp. He demonstrated the importance of careful scalp examination to avoid missing skin tumours in their
early stages. Dr. Jerzy Kolasinski described his treatment
plan for difficult cases whether it be conservative or surgical
and the options available. Dr. Kenichiro Imagawa showed
the pitting and tenting side effects that can occur. Pitting can
occur if grafts are too big for the incision and are placed too
deep; tenting (“goose skin” effect) is rare and is due to elevation of the grafts and can’t be predicted. Advice on treatment includes: dermabrasion, CO2 laser resurfacing, or hypertrophic scar gel. Dr. Ciro De Sio desribed the use of the
Frechet extender for the vertex baldness and the use of extenders and expanders in cases such as accidents, burns, or
artificial hair scars. The patients suitable for use of these
devises are nonsmokers and those with realistic expectations and willingness. Dr. Yoshinori Ishii showed a case that
came to see him 1 year following bilateral flap surgery to
his hairline who was unhappy with the scar along the hairline. Dr. Ishii made a comparison of the differences between
Orientals and Caucasians in terms of scalp and hair characteristics. He then showed how he managed this case with
FU grafting in front of the flap.
Saturday Afternoon/June 2, 2007
Bessam Farjo, MD Manchester, England
The short session started with Dr. Tony Ruston presenting
his method of correcting unaesthetic transplants by using a
combination of 0.75mm punch followed by laser therapy epilation prior to regular transplantation. This helped to reduce
surface irregularities and enabled reuse of the hair.
Dr. Ricardo Mejia touched on the importance of proper
planning before surgery from consultation and patient communication down to recipient slit size to match the graft. Prof.
Torello Lotti from University of Florence gave a rundown on
the classification and differential diagnosis of cicatricial
alopecias and medical treatments, showing they form 10%
of all alopecias. Dr. Nilofer Farjo demonstrated applying hair
transplant techniques to treat a variety of cicatricial (“burntout” cases), non-MPB and other unusual alopecias, and general principles in these cases. (Generally wise to do less grafts
per sq. cm. and if in doubt do a test procedure.)
Dr. Bob Haber presented his study using his tissue spreader
that showed a 80–96% reduction in donor transection rate
and that the spreader is not suitable in about 10% of patients.
Dr. Jerzy Kolasinski lectured on his method of measuring the
vertical elasticity of the donor site concluding that 2cm of
vertical elasticity should enable 1–1.5cm wide donor strip.
Less than 1.5cm elasticity means sticking to a strip of less
than 1cm. Dr. Kuniyoshi Yagyu presented his concept of staying
parallel to concentric lines around the scalp when harvesting
the donor to minimize transection rate. He makes the donor
incision concave-shaped and also believes that horizontal slivering would better than vertical.
The day’s final panel was hosted by Dr. Mario Marzola
on donor scar pearls. The general agreement was that minimal tension was key. Most doctors used trichophytic closure
routinely. Another consensus was that doctors can consider
themselves doing state-of-the-art surgery if routinely performing 2,000 FU graft operations using 4–6 assistants with
total microscopic dissection. This way the scars are almost
always guaranteed to be minimal.
The conference ended with a gala dinner and dance and
included a birthday celebration for Vincenzo’s wife, Irene,
with a spectacular cake enjoyed by all.✧
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Cyberspace Chat
Jennifer H. Martinick, MBBS Perth Australia
[email protected]
HOLDING SOLUTIONS
William M. Parsley, MD Louisville, Kentucky ASKS:
Jerry, could you attempt to list the relative importance of
the following characteristics of a holding solution for follicular grafts (best being #1)?
1. Osmolarity; 2. pH; 3. Presence of glucose; 4. Temperature-chilled versus saline; 5. Other minerals (magnesium,
potassium); 6. Antioxidants; 7. Buffers (lactate, gluconate); 8. Immersion versus air/fluid interface; 9. Light
People seem to do well with putting grafts at the air/fluid
interface (versus immersion), but I worry about the build up
of minerals on the grafts with evaporation. Thoughts?
Is there any evidence that <10°C is more damaging for
grafts in standard holding solutions? My Petri dishes on the
coolers run between 2–8°C. And what about pH?
Jerry’s REPLY:
My guess, in decreasing order of importance: osmolarity, pH, buffers, antioxidants, temperature, glucose, minerals, air-liquid interface. I don’t think light plays a factor. I
too worry about evaporation, which is why we have a humidifier running. We cover any full graft dishes that aren’t
being used to prevent dehydration.
In my opinion, chilled saline is the accepted standard
and there is not enough evidence to prove a switch should
be made. There are, however, ample good reasons to think
that something else might work better. Limmer’s study (and
common sense) tells us there is a decline in graft survival
with increasing ex vivo storage times. The bottom line is that
for short cases (e.g., <4 hours) it may not matter what we
use. The solution becomes more important as the case gets
longer. Just like they don’t culture cells and tissue in saline,
and they don’t generally transport organs for transplantation in saline, perhaps we shouldn’t have our grafts sitting
in saline for 8–12 hours.
Chilled saline or Ringer’s Lactate is what most people use,
and 12°C is probably less damaging than <10°C. If you’re
routinely doing cases over 2,000 and don’t take serial strips,
consider putting the strips and slivers in HypoThermosol at
4–10°C, prior to dissection. HypoThermosol at 12°C is probably OK, but the higher the temp, the more chance of damaging osmolarity imbalance. Coolers thaw out over the course
of several hours, which is why we change ours after 2–3
hours and keep our strips in the fridge at 4°C.
Dr. Jung Chul Kim did studies with 800 grafts and showed
that for times less than 6 hours, chilling had no positive or
negative effect. At 24 and 48 hours ex vivo, chilling definitely
helped. Somewhere between 6 and 24 hours, the benefits of
chilling become apparent. Dr. Kim does not chill his grafts
when he does transplants.
I am referring to theoretical “cooling injury” for non-hypothermic solutions like saline and Ringer’s Lactate. I’m not
aware of any actual evidence that there is poorer growth.
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¤
The literature is clear that lower temperatures induce membrane pump dysfunction, making the cell take on water, and
with increased calcium, sets off cell death cascades. So 2–
8°C would theoretically be worse than 12°C in this regard.
Hair follicles are remarkably resilient to all the insults we
hit them with. In the absence of well-done clinical studies, I
base what I do on Dr. Kim’s study (no benefit to chilled
saline) and Krugluger (DMEM seems better than saline), and
the large body of research that shows the rationale for hypothermic solutions when chilling is used.
My current practice is as follows (for cases over 1,500
grafts): We keep a mini-fridge in the OR and place unslivered
strips in HypoThermosol there; slivers are also in
HypoThermosol on coolers. It is important to keep
HypoThermosol cold and we switch out our coolers at lunch;
we’ve tested it and we can keep the solution at 10°C or less.
This way, all tissue has soaked in antioxidants for theoretical protection against ischemia reperfusion injury.
In Orlando last year, I showed that grafts kept in 4°C for
one week showed signs of viability if stored in HypoThermosol
(unlike saline or LR). Trypan Blue staining (for dead tissue) is
much greater on saline stored grafts. Also, 40% of grafts
stored in HypoThermosol for 1 week at 4°C yielded viable
dermal papilla cultures (compared to 0% for saline).
The dissected grafts are kept on DMEM/HEPES culture
media. This has glucose, vitamins, and a buffer to keep pH
steady. We keep them on DMEM soaked Reston foam at the
air-liquid interface as opposed to immersion. We do not chill
them. Both the HypoThermosol and our DMEM have HEPES
buffer in them, which keeps pH steady.
To put all this in perspective, I think transplanting intact
follicles with minimal vascular disruption is more important
than which holding solution is used. But I do think that there is
a benefit to using optimized holding solutions for larger cases.
FUTURE CLASS VIII
Ron Shapiro, MD, Bloomington, Minnesota ASKS:
I have a case that I would like to get your thoughts on.
This patient is 24 and he looks like he is going to be a
type VIII. He is not on Rogaine or Propecia® because he
doesn’t want to take medication. He is not super concerned
if he loses his hair. He would like to keep the frontal tuft a
little thicker for the next 10 years and maybe have a residual
about the same as it is now when he loses the rest.
I told him he is so young and has so much loss that he
might be what I call a type VIII with just see-through thin
fringe hair, but he said he knew this. He said he is fine with
just having a small isolated thin frontal forelock…slightly
less than what he has now. He wants to make sure he does
keep this little tuft of hair.
My gut feeling is not to do him; however, if we put a little
hair in the isolated forelock that looked normal even if he
went bald, have we done him harm?
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Your REPLIES:
Like all of us, you want to help this patient. My main
concern is the donor scar showing with age, especially if he
is the one in a hundred who has a wide donor scar. We all
cringe when we see older men who have literally no donor
hair left. I think we have established that this is rare. He
could be one in which this occurs. Humor him, tell him you
see younger men with more loss, give him Propecia samples,
tell him to shave his head and buy some time. I’m sure you
know all this, but I wouldn’t do him. Medications could help
him more than we could with transplants.
Bradley R.Wolf, MD Cincinnati, Ohio
A huge factor in my decision whether or not to do him
would be my 30-power (Micro-VID) exam of his best occipital donor hair area. If this area showed significant miniaturization (10–20% or greater), I would probably not want
to do him, as the chance the scar would be very visible someday would be higher.
With the availability of instruments such as the Micro-VID
handpiece attached to a computer screen, you can get a fairly
accurate mathematic percentage of miniaturized hairs in several areas on a patient and even follow it over time with medical treatment or with the passage of time without treatment.
The three instances in which I really find it valuable in the
consultation is in 1) all female patients, 2) all young males,
and 3) people who are somewhat “body dysmorphic” and
don’t look that bad at all.
My inclination would be to do him, but with a couple of
caveats: I would try and do only ONE session. That way you
have the best chance at a nearly invisible scar, as successive
cuts at the same donor scar do inevitably raise the risk for a
slightly wider scar, which perhaps in his future would not be
cosmetically desirable. I would pretty much do exactly what
you are proposing, namely a small/small-medium frontal forelock area that frames his face for the rest of his life. I would use
only FUs and make it definitely “thinnish” in density, but even
with a thin look you can still create a gradient (e.g., thin to
thinner, to thinnest). A very small number of FUs (usually 1and 2-hair ones, not 3-hair ones) off laterally in a triangular
configuration off to the side of the small forelock does wonders
to create a natural effect, even with the fringe sides dropping
off the side of head later in life. If someone had real coarse,
dark hair or short, curly hair that did not “flow” well with
styling, I would not do such a project. Lastly, his light colored
hair is a “plus” for him, as I think it will make the result look
much more natural and undetectable, and even a scar more
undetectable, as I think light hair over light skin makes it hard
to pick up detectable things like thin donor scars or even slight
“puckering” around the grafts, as occasionally occurs. As long
as his expectations are way down low, and the goal is simply
a thinnish frame to the face to avoid the huge “ski hill” of bald
skin in front, I would accommodate him. It would obviously be
a little nicer if he were 34 instead of 24.
Michael L. Beehner, MD Saratoga Springs, New York
Why not do what Mike is suggesting in 3 years’ time so
the patient is really sure what he wants to do and so you
can get a little better handle on the rapidity of his hair loss.
One procedure may just leave him with too thin a look for a
young person—remember, he is only 24. And a 10-inch scar,
albeit fine, can still be a huge problem if he wants to buzz
his head in the future.
I would be concerned that when he becomes a class VIII
the donor scar will be visible. He already has see-through
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temples. I don’t think he will be good for 10 years. I think that
he would be much better served by trying to convince him
again to at least “try” finasteride for a while. Once patients
take it they often find that it isn’t so bad. Even if he doesn’t
want the medication, I would not operate now. From my experience, most patients that become very bald at a young age
would have preferred not to have had a hair transplant rather
than be left with a frontal forelock and thin strands of hair on
the sides—trying desperately to hide a scar that shows when
they swim or get out of the shower. Many patients hate this
look when they are young and there is no turning back if they
don’t like it. In any event, he may change his mind in a year
or two. I would not transplant him now. Encourage him by
telling him he has very strong facial features, light hair, and
will look cool with a buzz cut when the time comes.
Robert M. Bernstein, MD New York, New York
In addition to the donor scars that will be seen through
the sparse side hair, you might actually speed up the loss of
his remaining top hair.
Ron Shapiro, MD Bloomington, Minnesota
This cause and effect is difficult to prove in a guy who is
already in rapid decline but I have had to be an Expert Witness in a couple of legal cases where the patients claimed
that the surgery caused a rapid speed-up. (The cases were
settled before trial in the patient’s favor. This does not prove
the relationship but shows that you would have a difficult
time defending the negative position.)
Richard Shiell, MBBS, Melbourne, Australia
I would also encourage him to shave his head, but most
young guys will have already tried this and rejected it, which is
why they’re in your office. I frequently encounter men reluctant to take finasteride. I always prescribe it every other day
and for those especially reluctant, I try to convince them to
take it just twice a week, along with nightly 5% minoxidil. The
pharmacokinetics of the drug are such that serum DHT is suppressed for a week after a single dose, with the trough being
about 2–3 days. I tell them what a simple regimen this is and
that after 6–12 months of doing this, we might consider a transplant. If he follows this and returns in a year, and restates that
an isolated forelock would make him happy, and that he doesn’t
like the shaved head look, and he understands the risk of donor scar, then I would consider what Mike recommended.
Many of these young patients will be “lost to follow-up,”
which is fine because it shows they weren’t that motivated
or realistic, which disqualifies them for surgery.
Whether the finasteride works or not is not really the
point. What matters most is that the patient has at least a
year to consider the procedure and his options, and is better
able to come to grips with the fact that he may not have a
full head of hair again—even with surgery—and can make
the best long-term decision.
I think everyone is acting on what they feel is the best interest of the patient; it’s just that we disagree on what is in their
best interest. Time will tell. Certainly there are many patients
who are cosmetic cripples from the plug grafts and the minigrafts as well. With FUT and FUE has this situation been corrected? I believe that it has improved but is still a potential
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problem. I turn down 20–30 patients a year who I feel aren’t
good candidates. Nearly all were balding at a young age.
It is hard to measure the impact on poor work and judgment both on the patient and on the field in general. I have
patients ask why more people don’t have transplants, realizing that the techniques today are so improved. The answer is pretty clear: They are seriously worried about having the outcome of the patients that they have seen. Are the
young men receiving transplants today going to end the
public’s worries or create many more years of hesitant patients? We simply don’t know. But I am hesitant to be too
critical of doctors following their conscience. Who knows—
they may be right, but the answer will, unfortunately, come
after most of our careers are over.
William M. Parsley, MD Louisville, Kentucky
I am emphatic about his commitment, i.e., the patient
must use finasteride for one year before I will consider HT,
unless the patient is already a class V or VI with end stage
miniaturization and mature expectations.
Edwin Epstein, MD Richmond,Virginia
I was reading Dr. Cooley’s excellent commentary on “offering surgery to young men” (in a previous Forum) and he
cautioned that we should not become artificially polarized in
this debate. I think the debate should be centered on setting
up some guidelines before operating on the young. These
might include:
9 More than one consult with the physician before scheduling surgery.
9 Attempting to have a family member or some other significant other involved in the decision making.
9 Unless not indicated, trying medical therapy for at least
one year.
9 Having psychological counseling for those deeply depressed about their hair loss (as hair loss may not be the
problem or at least not the only problem).
9 Have a printed explanation of the possible long-term consequences of performing surgery at an early age to
complement the consult.
9 Get a second opinion from a colleague.
I certainly agree with Walter that one should not automatically deny young patients a hair transplant. I have
done hundreds of such patients over my 40-year career
and have seldom regretted it. I emphasize that I do not
rush into these cases but bring the patient back several
times with his parents and really make sure that they understand the many negative aspects as well as the shortterm benefits. The patients have to EARN a hair transplant
from me by their positive attitude and absence of signs of
Body Dysmorphic Syndrome.
The biggest problem is deciding whether a guy has BDS
or is just an anxious guy. It is not a simple diagnosis.
Never say “NEVER,” but on the other hand, we should
always PROCEED WITH CAUTION in such cases.
Richard Shiell, MBBS Melbourne, Australia
1. We have a technology that in the proper hands will produce
natural-looking and good density coverage of the frontal
and at least part of the midscalp areas in two sessions of
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1,500–2,500 FUs each, obtained from two 8–10mm-wide
strips and leaving one fine donor area scar in its wake.
2. In my experience, there is a very, very small percentage
of men whose alopecia will evolve over their lifetime to
such an extent that two such sessions should not have
been done because the donor area becomes so sparse
and narrow that the scar will show and/or most of the
transplanted hair will have been lost.
3. In the recipient area, at worst an Isolated Frontal Forelock composed of FUs will result from an overly optimistic prognosis and the patient will have been forewarned of this. Even in that group, for most of a young
man’s emotionally critical 20s and probably 30s, he
will have hair from both frontal and lateral viewing.
(Hopefully Propecia® with or without minoxidil will have
at least preserved much of his hair in the vertex area
and perhaps the midscalp area.)
I believe that a fully informed young man and his family
have the right to have the above told to them with the caveat
that nobody can foretell the future perfectly and that, therefore, medical treatment should be tried first. However, if the
emotional stress on the patient is severe enough, he should
not be forced to delay the surgical treatment.
When I interview these young men and their families, I
really push the medical treatment first, but I am also very
positive about the surgical approach because of what I’ve
seen and the reaction of the patients I have treated. I have
also insisted young patients now try Propecia®/minoxidil for
1 year before we seriously consider surgery.
We each must choose how much cold logic and how much
compassion should be allocated to each patient we see.
I follow the precautions summarized below and believe I
am appropriately balancing both logic and compassion when
I do that for patients who are being emotionally devastated
by their hair loss. I would much prefer such patients would
never come to see me because, of course, the absolutely
safest thing for me is to not operate on any of them. We all
agree on that. We only disagree on a) how much emotional
pain they should be forced to accept because we have no
magic crystal ball, and b) whether or not their fully informed
opinion should ever outweigh our fears about the unknown
and probably 10- to 30-year future.
I believe “early” HT is reasonable when the following six
qualifications are applied:
1. The physical exam and family history should be appropriate.
2. All aspects of surgical technique are good enough to consistently obtain good hair survival and good donor area scars.
3. Given the impossibility of a 100% accurate prognosis for
the ultimate donor/recipient area ratio in any individual,
the physician does his/her best to convince the patient to
leave at least one session (two if the patient is particularly young) in reserve for the unknown future.
4. With rare exceptions, no more than a single session of
FUT is employed in each area of present or future alopecia until the individual is at least 35 years old; and with
rare exception, only frontal and mid-scalp areas are
treated.
5. No more than a single scar through the densest area of
hair is created, no matter how many sessions are carried out.
6. The hair density goal should be no more than 25–30 FU/
cm2 except perhaps in very limited areas.
Walter P. Unger, MD Toronto, Ontario, Canada
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N
Reg EW!
istra
t
now ion
ope
n!
The ISHRS is pleased to announce the
development of web-based seminars, or
“Webinars,” to meet our commitment to
educating members on the latest advancements in hair restoration. These Webinars
will be devoted to topics identified by physician members and/or the ISHRS Core
Curriculum in Hair Restoration Surgery as
necessary to professional enhancement
or patient care and will be taught at an
advanced level. Each Webinar will be led
James A. Harris, MD
by a recognized leader in the field of hair
transplantation and when appropriate will have adjunct faculty
that are renowned for their work in a particular area. Each Webinar
will offer up to 3 hours of AMA PRA Category 1 CreditTM. For those
unable to attend the live Webinar session, it is planned that it
will be available in archival form (not eligible for CME) for later
review. Go to the Advanced Webinars website for further information, technical requirements for participation, and to register.
Register online at:
http://www.registration123.com/ishrs/07WEBINARS/
Registration Fees:
Member Rate = $150.00 USD per webinar
Member Pending Rate = $165.00 USD per webinar
Non-Member Rate = $180.00 USD per webinar
James A. Harris, MD, Advanced Webinars Chair
2007-2008 Schedule
Biotechnology Update: Cell Multiplication, Gene Therapy,
and Storage Media
Saturday, July 28, 2007, 10:00AM–1:00PM (Central Time/Chicago)
Director: Kenneth J. Washenik, MD, PhD
This course will offer the attendee information on the latest research in the
area of cellular and gene therapies for hair loss. The theoretical basis of the
therapies will be reviewed and the status of the research or trials will be
discussed. The faculty will also review the basis for a critical evaluation of
current graft storage media and present alternatives that may enhance graft
survival or growth characteristics.
Learning Objectives:
• List the major areas of biotechnology research for the treatment of
hair loss.
• Describe the models for “cell based” research.
• Identify at least two genes responsible for controlling hair follicle
growth or function.
• State the rationale for utilizing a graft storage media with properties
other than moisture and refrigeration.
Special Situations in Hair Transplantation
Saturday, December 8, 2007, 10:00AM–1:00PM (Central Time/Chicago)
Director: Robert P. Niedbalski, DO
Hair transplantation is a field that has many “special situations” that require
modification of “basic” techniques of hair transplantation. These factors
include sex and race of patient; area to be transplanted (beard, lip, eyebrow,
etc.); and skin conditions (scarring, etc.). This course is designed to make the
physician aware of the patient who may require technique modifications, and
to convey the modifications necessary for a successful surgical outcome.
• Identify those patients with special requirements.
• List transplant areas that will require procedure modifications.
• Describe procedure changes for transplanting into facial areas or
into scar tissue.
Complications
Saturday, February 23, 2008, 10:00AM–1:00PM (Central Time/Chicago)
Director: James E. Vogel, MD
Hair restoration surgery, although one “procedure,” has many individual
steps that may lead to a complication. Some steps are in the direct control of
the physician, others tend to be related more to the surgical team. The intent
of this course is to outline the steps of the procedure that are at risk for
producing a complication and to provide information on how to reduce the
risks and how to manage complications should they occur.
• Identify those steps in the procedure that are at risk for complications.
• Recognize ways to convey to team members critical steps in avoiding complications.
• List common complications and strategies to avoid them.
• Describe methods to handle common complications.
• Learn how to manage a patient experiencing complications.
Quality Assurance and “Six Sigma” Strategies in Hair
Transplantation
Saturday, July 26, 2008, 10:00AM–1:00PM (Central Time/Chicago)
Director: Carlos J. Puig, DO
Quality assurance is a planned and systematic set of activities to ensure that
the critical steps in a procedure are clearly identified and assessed and measures are taken in ensure that these steps meet the benchmarks to provide the
patient with the optimal outcome. Preventable errors can lead to complications and poor patient outcomes. A strategy known as “Six Sigma,” which
reduces defects in a process to fewer than 3.4 per million, may be applicable to
hair transplantation. This course will describe the underlying causes of error
and provide suggestions for important changes that may include adopting
new educational programs, devising strategies to increase staff awareness,
and encouraging physician commitment to quality improvement.
• Describe the difference between Quality Assurance (QA) and Six
Sigma quality improvement programs.
• Define and list a “critical to quality” step in hair transplantation.
• Outline the steps in implementing a Six Sigma quality program.
• Define and contrast an internal and external customer.
• Define and contrast a stable and unstable process.
• Describe the role of variation in managing quality.
• Define profound knowledge.
Advanced Hair Transplant Principles and Planning
Saturday, November 8, 2008, 10:00AM–1:00PM (Central Time/Chicago)
Director: William M. Parsley, MD
This course is intended to provide the experienced transplant physician direction for counseling and planning when they are dealing with a patient who
has extraordinary needs or demands, such as young patients, those wanting
low hairlines, patients at risk for severe shock loss, those with body dysmorphic
disorder, or patients with class VI–VII patterns. It will also provide practical
surgical details to physicians wanting to practice at an advanced level utilizing a variety of recipient site orientations (perpendicular and parallel), transplanting at high densities, and advanced harvesting and closure techniques.
• Understand how to counsel and assess patients with a variety of
needs and desires that may be beyond the “standard” patient.
• Describe the factors critical for “high density” transplants.
• Define “parallel” and “perpendicular” recipient sites.
• Describe the theoretical advantages and disadvantages of “parallel” vs. “perpendicular” sites.
• Explain the variety of ways that donor tissue may be harvested and
list possible uses of each.
• Describe the methods for closing a strip harvest incision.
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Surgical Assistants Co-Editors’ Messages
Betsy S. Shea, LPN Saratoga Springs, New York; Laurie Gorham, RN Boston, Massachusetts
Greetings Assistants!
As I watched my youngest child
walk across the stage to accept his
high school diploma last week, I
thought of what surprises life may
hold for him. It brought back memories of my own graduation from
nursing school. If you would’ve told
Betsy S. Shea, LPN
me then that I was to become a hair
transplant surgical assistant, I would not have known what
you were talking about. That was 20+ years ago and I had
no idea that hair transplantation even existed. But alas destiny prevailed and here I am. I find this job very rewarding
and have never had an employer as kind and generous as Dr.
Beehner. I also have had the great fortune of meeting a lot of
wonderful and interesting people along the way, the majority
of which, I am happy to say, I consider my friends. I look
forward every year to the annual ISHRS meeting to get reacquainted with all of these people and make some new friends.
I encourage each and every one of you to attend this year’s
meeting in Las Vegas. It’s shaping up to be very interesting
and full of new information and opportunities. The use of
cadaver scalp has proven to be a major teaching tool that we
get to experience once again this year.
Come join in the excitement and make some new friends
along the way. I can’t wait to meet you!
Betsy S. Shea, LPN [email protected]
Hi everyone,
I’m looking forward to the
meeting in Las Vegas this year.
The exchange of information
and quality of the presentations
is so important. We spend all of
our time in our corners of the
world and it’s good to get toLaurie Gorham, RN
gether, exchange ideas, and
absorb as much as we can during our short time together. The Cadaver Workshop is a great addition to a
program that was already excellent. I’m confidant that
it will be as successful as the workshop last year because we have an incredible group of professionals who
work well as a team and work hard to make it as informative and productive as it can be. We have a knowledge base of information that has no limits.
This will be a great meeting and we can’t help but
have fun along the way.
And, please, keep those articles coming in for the
Forum!
Laurie Gorham, RN [email protected]
Message from the 2007
Surgical Assistants Program Chair
Hopefully everyone is getting excited about this year’s meeting. The Surgical Assistants Program will be held on Wednesday, September 26, followed by the hands-on workshop. As with last
Ailene Russell, NCMA
year’s program, this will allow for all surgical assistants to attend at the General Session and other
Charlotte, North Carolina
programs.
I want to thank all of you who have sent in suggestions or volunteered to assist in putting together this program.
Without your participation and the doctors’ support we would not be able to do this. There is always room for one
more! This is an invitation to get involved!
Our goal is to see this year’s program a full house and the workshop totally booked. We have evolved enormously
over the years thanks to all the hard work done by the past Chairs and active participation from assistants. We want
to continue to grow. Let’s make this the best year yet!
When I first took over the position of chair, this quote was sent to me from Kimberly at the ISHRS: “…It is also a
daring time, filled with courage you can turn ordinary plans into extra-ordinary achievements.… Your time is now, and
your adventure has just begun.” (Author unknown.) I feel this statement is talking about all of us. Our time is now. Let
the adventure begin!
Ailene Russell, NCMA, Surgical Assistants Chair
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Deep Vein Thrombosis: Are Our Patients at Risk?
Julie Edwards, Surgical Technician, Farjo Medical Centre Manchester, United Kingdom
Over the past few years, the advancement of hair restoration procedures has allowed us to transplant an increased
number of follicular units in one session. As a result, this
subjects the patient to a lengthy procedure, requiring them
to sit in one position for prolonged periods of time.
Although there have been no reported incidents in the
literature of deep vein thrombosis (DVT) during or following
hair restoration procedures, a patient’s safety and welfare
has always been paramount. This led me to research the
subject of DVT and compile a risk assessment for our patients at our clinic in the U.K.
Fortunately, DVT is a rare condition with 1 in 2,000 people
being affected in the U.K each year; it is less common in
people under the age of 40.
Deep vein thrombosis sometimes occurs in normal veins
for no apparent reason; however, the risk of DVT is increased in certain circumstances. These circumstances are
based on patients who are undertaking hair restoration procedures and who have one or more of the following:
A surgical procedure lasting more than 30 minutes
Surgical procedures carried out under general anaesthetic
Diabetes, carcinoma, obesity, or cardiovascular disease
An inherited condition that increases blood clotting
Varicose veins
Female patients who are taking the oral contraceptive pill
containing oestrogen or hormone replacement therapy
Patients who are over the age of 40 (The average age of
our patients here in the U.K is around this age.)
Patients who have travelled for four hours or more to the
clinic
Dehydration is also a contributing factor.
After researching DVT and taking into account the above
presented information, various measures have now been put
into place in our clinic to keep the risk minimal. A pre-operative risk assessment is now required for all our patients
and is acted on accordingly. The assessment is recorded on
a surgical care plan in the patient’s chart in the form of low,
medium, and high risk.
On the day of the surgical procedure, patients are as
always encouraged to stand, stretch, and change positions
regularly. Our patients are recommended to take on plenty
of fluids, such as water or fruit juices, to avoid dehydration.
Lower leg exercises are also encouraged.
As a duty of care to our patients and profession, I feel it
is necessary to take a few simple steps to identify possible
risks and act on them accordingly. Prevention has always
been an important part of good medical care.✧
We’re cooking up something special and could use your help…
CALL FOR RECIPES!
You got ‘em? The ISHRS wants ‘em!
Always bragging about your short ribs?
Does your Italian grandmother have an authentic sauce to die for?
To commemorate the 15th Anniversary of the ISHRS, the Surgical Assistants Auxiliary is creating an International Cookbook. This commemorative book will celebrate
the diversity of our membership and be filled with great recipes from around the
world that you submit. Cookbooks will be sold at the Annual Scientific Meeting and
proceeds will benefit the Annual Giving Fund.
Please submit your favorite recipe, along with a personal story or clip related to the
recipe, to the ISHRS Headquarters at [email protected] or call 630-262-5399 for more
information.
The International flavor of the ISHRS: Bringing together good friends and good food.
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Classified Ads
Seeking Surgical Assistants for Expanding Practice in
Boca Raton, Florida
Full-time Positions – Great Benefits – Beautiful Lakeside Location
Candidates must be proficient at microscopic follicular-unit graft dissection and placement in order to
assist physician with scalp, eyelash, eyebrow, F.U.E. and other hair transplant procedures.
We welcome team-oriented, highly motivated applicants who are seeking interesting new opportunities.
Please fax resume and cover letter to Tanya at (561) 394-4522 or e-mail [email protected].
All inquiries confidential.
Hair Transplant Tech Wanted
Hair Transplant tech needed per diem in Raleigh, NC to work with physician with 11 years experience.
Tech must be experienced in graft cutting and placement. Interstate travel & lodging covered.
Excellent pay and flexible days/hours. Inquires confidential.
Fax resume: 919-362-0071. Office phone: 919-362-5090.
Announcing the
2007 ISHRS Annual Giving Fund!
We need your help and support to accomplish the many
projects and initiatives of the ISHRS.
Projects and Initiatives to Be Funded
Leadership Circle: $1,000/year (5-year commitment)
✔ Only for inaugural year, access to VIP Room at the
Annual Meeting—stocked with snacks, e-mail access, a
place to relax, network
✔ 2 tickets to President’s Giving Fund reception or dinner
each year the person gives this amount
✔ Inaugural pin (for those who sign up in the inaugural year
only)
✔ Acknowledgment sticker on Annual Meeting name badge
✔ Recognition on website (name appears for duration of one
year, for each year of giving)
✔ Recognition in the Forum (once per year)
Giving Categories
Supporter’s Circle: $500/year (5-year commitment)
✔ Only for inaugural year, access to VIP Room at the
Annual Meeting—stocked with snacks, e-mail access, a
place to relax, network
only)
➥ Increase international public awareness of ISHRS activities
through website improvements and other media channels
➥ Expand educational and training programs
➥ Expand the Forum with the addition of more color photos
➥ Increase support to OPERATION RESTORE
➥ Provide additional amenities for members at meetings (e.g.,
Internet café)
➥ Attract more internationally known guest speakers
➥ Build supply of technical equipment (e.g., microscopes, mannequin heads, etc.) that can be used repeatedly at meetings
➥ Coordinate guided, better financed research programs
Trustees Circle: $2,000/year (5-year commitment)
✔ Access to VIP Room at the Annual Meeting—stocked with
snacks, e-mail access, a place to relax, network
✔ 2 tickets to President’s Giving Fund reception or dinner each
year the person gives this amount
only)
Please consider donating to the
ISHRS Annual Giving Fund.
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Contributor’s Circle: $250/year (5-year commitment)
only)
Recognition in the Forum (once per year)
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Advancing the art and science of hair restoration
Upcoming Events
Date(s)
Academic Year
2007–2008
August 24–25, 2007
for Physicians
August 26, 2007
for Surgical Assistants
Event/Venue
Diploma of Scalp Pathology & Surgery
U.F.R de Stomatologie et de
Chirurgie Maxillo-faciale
Paris, France
1st Hair Surgery Workshop
Hospital Milton Muricy
Curitiba, Parana Brazil
Sponsoring Organization(s)
Coordinators: P. Bouhanna, MD, and
M. Divaris, MD
Director: Pr. J. Ch. Bertrand
Hospital Milton Muricy and Brazilian Society HRS
Contact Information
Tel: 33 +(0)1+42 16 12 83
Fax: 33 + (0) 1 45 86 20 44
[email protected]
[email protected]
Chopin—Art&Perfection
The First PSHRS International Workshop
Poznan, Poland
Polish Society of Hair Restoration Surgery
www.bokiz.pl/HRS-Chopin
September 25, 2007
ABHRS Recertification Exam
The Venetian Hotel
www.abhrs.org
Tel: 708-474-2600
Fax: 708-474-6260
[email protected]
15th Annual Scientific Meeting
The Venetian Hotel
International Society of Hair Restoration Surgery
www.ishrs.org
Tel: 630-262-5399;
800-444-2737
Fax: 630-262-1520
[email protected]
November 24–25, 2007
13th JSCHR Congress and Live Surgery Workshop
Tokyo, Japan
Japan Society of Clinical Hair Restoration
www.jschr.org
President & Program Chair: Kuniyoshi
Yagyu, MD
Tel: +81-3-5215-5733
Fax: +81-3-5215-5722
[email protected]
Note: Simultaneous Interpretation is available at the congress.
Program Director: Jerzy Kolasinski, MD, PhD
Tel: 0048-61-8187550
Fax: 0048-61-8187551
[email protected]
January 19, 2008
ABHRS Exam
Houston, Texas, USA
www.abhrs.org
Tel: 708-474-2600
Fax: 708-474-6260
[email protected]
May 2–4, 2008
III Congress of Brazilian Association of Hair
Restoration Surgery
Rio de Janeiro, Brazil
Brazilian Association of Hair Restoration Surgery
(ASSOCIAÇ´O BRASILEIRA DE CIRURGIA DA
RESTAURAÇ´O CAPILAR - A.B.C.R.C.)
President: Marcelo Gandelman, MD
Chairman: Henrique N. Radwanski, MD
[email protected]
16th Annual Scientific Meeting
Fairmont The Queen Elizabeth
Montreal, Quebec, Canada
www.ishrs.org
Tel: 630-262-5399;
800-444-2737
Fax: 630-262-1520
[email protected]
HAIR TRANSPLANT FORUM INTERNATIONAL
13 South 2nd Street
Geneva, IL 60134 USA
Forwarding and Return Postage Guaranteed
156
FIRST CLASS
US POSTAGE
PAID
CHICAGO, IL
PERMIT NO. 6784

Improving the Revascularization of Transplanted Hair Follicles

Transcription

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