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Official publication of the International Society of Hair Restoration Surgery

Volume 25 Number 2

March/April2015

Inside this issue

President’s Message .......................54Co-editors’ Messages ......................55Notes from the Editor Emeritus: Richard C. Shiell, MBBS ..................57Cyberspace Chat: The Treatment of Men with Finasteride: Scientific and Anecdotal Evidence .....................61How I Do It: Designing the Hairline: The Role of the Thumb ......................64Complications & Difficult Cases: A Close Call with Donor Area Harvesting on a Patient with Irradiated Scalp .............................65 Ask the Fellows ...............................68Introduction to UK Hair Restoration Surgery Clinical Standards ............73Hair’s the Question ..........................76Review of the Literature ...................79Regional Societies Profiles: Society of German Hair Surgeons ................................80

Letters to the Editor ........................81Meetings & Studies: Review of the 6th Annual Hair Transplant 360 Workshop ............... 84 Review of the Japan Society of Clinical Hair Restoration 19th ASM & Live Surgery Workshop ...... 85ISHRS Annual Giving Fund Year-End Report .............................. 86Messages from the 2015 ASM Program Chair ....................................88 Surgical Assistants Chair ...............89 Classified Ads ..................................90

HAIR TRANSPLANTforumI N T E R N A T I O N A L

www.ishrs.org/AnnualMeeting.html

PLAN TO ATTEND!

Update on Efficacy of Generic FinasterideEdwin S. Epstein, MD, FISHRS Richmond, VA, USA [email protected]

Finasteride 5mg was approved by the U.S. Food and Drug Administration (FDA) in 1992 for the treatment of benign prostatic hyperplasia, and in 1997 for male pattern hair loss (MPHL) in the 1mg dose. For many years, because of cost and availability issues of finasteride 1mg, physicians, especially outside of North America, have suggested that patients divide brand or generic 5mg finasteride into quarters. Recently, numerous hair transplant physicians have commented on anecdotal reports by their patients of increased shedding and progressive hair loss noted after changing from brand to generic finasteride 1mg. This raises several questions about generic medi-cations: how does the efficacy compare to brand, how are generic drugs regulated, are there variations among generic manufacturers, and is the active ingredient evenly distributed in the tablet?

Using bioequivalence as the basis for approving generic copies of drug products was established by the “Drug Price Competition and Patent Term Restoration Act of 1984,” also known as the Hatch-Waxman Act. This Act expedites the availability of less costly generic drugs by permitting the FDA to approve applications to market generic versions of brand-name drugs without conducting costly and duplicative clinical trials. At the same time, the brand-name companies can apply for up to five additional years longer patent protection for the new medicines they developed to make up for time lost while their products were going through the FDA’s approval process. Brand-name drugs are subject to the same bioequivalence tests as generics upon reformulation.

According to the FDA website, a generic drug is identical or bioequivalent to a brand-name drug, and must follow the same standards as the innovator drug:

• Contain the same active ingredients as the innovator drug (inactive ingredients may vary).• Be identical in strength, dosage form, and route of administration.• Have the same use indications. • Be bioequivalent.• Meet the same batch requirements for identity, strength, purity, and quality.• Be manufactured under the same strict standards of FDA’s good manufacturing practice regulations

required for innovator products.

In order to obtain FDA approval to market a generic drug, companies must submit an abbreviated new drug application (ANDA). The ANDA process does not require the drug sponsored to repeat preclinical (animal) and clinical (human) research on ingredients or dosage forms already approved for safety and effectiveness. Instead, generic applicants must scientifically demonstrate that their product is bioequivalent (i.e., performs in the same manner as the innovator drug). Bioequivalence is often demonstrated by studies measuring the time it takes the generic drug to reach the bloodstream in 24-36 healthy volunteers. This determines the rate of absorption, or bioavailability, of the generic drug, which is then compared to that of the innovator drug. The generic version must deliver the same amount of active ingredients into a patient's bloodstream in the same amount of time as the innovator drug. Bioavailability is usually assessed by measuring the area under the plasma concentration–time curve (AUC).1

For FDA approval, a generic manufacturer must demonstrate that the 90% confidence interval for the ratio of the mean responses (usually of AUC and the maximum concentration, Cmax) of its product to that of the brand-name drug is within the limits of 80% to 125%. While AUC refers to the extent of bioavailability, Cmax refers to the rate of bioavailability.2

The 80-125% criterion is used to compare two treatments to evaluate bioequivalence. The bioequivalence test states that we can conclude that two treatments are not different from one another if the 90% confidence interval falls completely within the range 80-125%. The 80-125% criterion cannot conclude that the drugs are the “same,” only that they are not “different.” For drugs with a narrow therapeutic index range, small differences in dose or serum concentration may have therapeutic failures or adverse events, and the acceptance range of 80-125% may need to be smaller.3

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Hair Transplant Forum International March/April 2015www.ISHRS.org

President’s MessageSharon A. Keene, MD, FISHRS Tucson, Arizona, USA [email protected]

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Hair Transplant Forum International Volume 25, Number 2

Hair Transplant Forum International is published bi-monthly by the International Society of Hair Restoration Surgery, 303 West State Street, Geneva, IL 60134 USA. First class postage paid at Chicago, IL and additional mailing offices. POSTMASTER: Send address changes to Hair Transplant Forum International, International Society of Hair Restoration Surgery, 303 West State Street, Geneva, IL 60134 USA. Telephone: 1-630-262-5399, U.S. Domestic Toll Free: 1-800-444-2737; Fax: 1-630-262-1520.

President: Sharon A. Keene, MD, FISHRS [email protected]

Executive Director: Victoria Ceh, MPA [email protected]

Editors: Mario Marzola, MBBS Robert H. True, MD, MPH, FISHRS [email protected]

Managing Editor, Graphic Design, & Advertising Sales: Cheryl Duckler, 1-262-643-4212 [email protected]

Controversies: Russell G. Knudsen, MBBS, FISHRS

Cyberspace Chat: John Cole, MD; Bradley R. Wolf, MD, FISHRS

Difficult Cases/Complications: Marco Barusco, MD

Hair Sciences: Jerry E. Cooley, MD

Hair’s the Question: Sara M. Wasserbauer, MD, FISHRS

How I Do It: Timothy Carman, MD, FISHRS

Meeting Reviews and Studies: Henrique Radwanski, MD

Regional Society Profiles: Mario Marzola, MBBS; Robert H. True, MD, MPH, FISHRS

Review of Literature: Nicole E. Rogers, MD; Jeffrey Donovan, MD, PhD

Copyright © 2015 by the International Society of Hair Restoration Surgery, 303 West State Street, Geneva, IL 60134 USA. Printed in the USA. The views expressed herein are those of the individual author and are not necessarily those of the International Society of Hair Restoration Surgery (ISHRS), its officers, directors, or staff. Information included herein is not medical advice and is not intended to replace the considered judgment of a practitioner with respect to particular patients, procedures, or practices. All authors have been asked to disclose any and all interests they have in an instrument, pharmaceutical, cosmeceutical, or similar device referenced in, or otherwise potentially impacted by, an article. ISHRS makes no attempt to validate the sufficiency of such disclosures and makes no warranty, guarantee, or other representation, express or implied, with respect to the accuracy or sufficiency of any information provided. To the extent permissible under applicable laws, ISHRS specifically disclaims responsibility for any injury and/or damage to persons or property as a result of an author’s statements or materials or the use or operation of any ideas, instructions, procedures, products, methods, or dosages contained herein. Moreover, the publication of an advertisement does not constitute on the part of ISHRS a guaranty or endorsement of the quality or value of the advertised product or service or of any of the representations or claims made by the advertiser. Hair Transplant Forum International is a privately published newsletter of the International Society of Hair Restoration Surgery. Its contents are solely the opinions of the authors and are not formally “peer reviewed” before publication. To facilitate the free exchange of information, a less stringent standard is employed to evaluate the scientific accuracy of the letters and articles published in the Forum. The standard of proof required for letters and articles is not to be compared with that of formal medical journals. The newsletter was designed to be and continues to be a printed forum where specialists and beginners in hair restoration techniques can exchange thoughts, experiences, opinions, and pilot studies on all matters relating to hair restoration. The contents of this publication are not to be quoted without the above disclaimer. The material published in the Forum is copyrighted and may not be utilized in any form without the express written consent of the Editor(s).

I am pleased to share with you that ISHRS member re-sponse to the new affidavit, confirming our members’ com-mitment to performing “critical to quality” aspects of surgery themselves, has been a success. Current membership renewals remain at the same high percentage rate, and overall member-ship continues to grow. I would like to express my personal appreciation to all those who have shown their support for this important policy.

There have been occasions where respected peers have had to re-think their practice management approach, understanding there is no way to allow unlicensed technicians to perform surgery “under their watchful eye” without contributing to the growing problem of unlicensed medical practice, and violating the ISHRS position that unlicensed personnel should not be making incisions or excisions on any patient. Patients who seek hair restoration surgery deserve and expect to have a hair restoration doctor perform their surgery. But just as importantly, we have yet to identify a legal governing body in any country that supports unlicensed medical personnel performing incisions/excisions on a patient.

Recently, there have been questions raised regarding robotic operations in hair restoration surgery (HRS). This issue has been discussed with several of our members who have been operating robots. In particular, Past President and Follicle Award recipient Dr. Paul Rose has been a strong supporter of the ISHRS position to curtail the activity of unlicensed technicians in HRS. He has recently clarified his support for the ISHRS policy that requires all incisions and excisions be under the control of a licensed medical professional practicing within their legal capacity. He made clear he supports a paradigm where only licensed medical providers would operate the controls of this sophisticated and complex machine. It is the case that just because unlicensed personnel could be trained, doesn’t mean they should be trained to do this. Past experience has shown that allowing this type of behavior fostered improper activity where some technicians actually performed surgery for doctors who did not know how to do it themselves. As was shared previously, HRS embodies more than the technical aspects of surgery—appropriate diagnosis, pre-operative care, intra-operative management of medical issues, and post-operative care depend on appropriate medi-cal education and training. In other fields where complex machines are used, such as radiology, technicians are required to have education, certification, and licensure as well as continuing medical education requirements.

While many hair restoration surgeons feel they have talented and loyal staff—individuals who could “learn anything”—that is not how medical licensure works. Patients and governments do not allow us to legally “lend our license”—even to those who we think are skilled and intelligent—if they haven’t earned the right to practice medicine. Most doctors could teach a patient with high blood pressure what medica-tions to use to control their blood pressure or how to treat their asthma, but we do not allow patients to prescribe to themselves. The same is true for many minor surgeries; a trained patient could do it themselves, but we don’t allow that. Governments grant medical licensure to individuals who have the ability to integrate complex medical information because they have completed necessary education, testing, and training, and have promised a commitment to continuous medical education, ethical devotion to a patient’s best interests, and are subject to medical board oversight.

Increasingly, fewer members recall the “old days” of punch and plug surgery. When done poorly it could be very disfiguring; when done with mediocrity, it could still be unsightly. Today, with follicular unit grafting, even some of the most mediocre trans-plant results do not result in disfigurement—just disappointing cosmesis for patients who are learning to have high expectations, and sometimes a waste of donor hair. Nevertheless, despite innovations in surgical techniques, devastating consequences remain possible with improperly performed surgery or poor patient selection. One of the planned sessions at our annual meeting will review surgical complications—some

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Co-editors’ MessagesMario Marzola, MBBS Adelaide, South Australia [email protected]

Robert H. True, MD, MPH, FISHRS New York, New York, USA [email protected]

Professor Rodney Sinclair was a featured speaker at our Kuala Lumpur conference last year. Currently, I have been helping him to add surgical hair restoration to his well-established practice of general dermatology and medical hair restoration in Melbourne, Australia. What a stark reminder this has been of just how many little things are needed to get it going. So much has to fall into place before we can perform an operation with any degree of comfort, let alone to any great standard. The Operating Room table, the chairs, the lights, the microscopes and their lights, all the instruments, disposables, drugs, drapes, feeding and water-ing the patient and staff, the music for ambience, and of course, good coffee! Staff? Yes, staff is the most important and most difficult. Good, experienced, reliable, caring, and professional staff is gold. Thankfully, Dr. Russell Knudsen, who also prac-tices in Melbourne, has allowed us to use some of his surgical technicians when they are not needed in his office. Together with my staff we are gradually building local knowledge from the ground up. Don’t let anyone tell us that hair restoration surgery is a simple procedure. To achieve anywhere near high standard results takes an enormous amount of organization without too many compromises. So many things can conspire to diminish the experience and outcome for us and the patient. As Murphy said… if it can go wrong, it will go wrong.

It’s been a big challenge and still is, so why do it? Well quite simply the ethos in Professor Sinclair’s office of con-

How would you reply to this question from a patient? “Doc-tor, after my surgery, can I shave my head without there being any way for others to see that I had a hair transplant?” I have to answer this question based on my own experience with both FUT and FUE by answering, “Probably not. Most, if not all, patients will have to leave their hair 2–3 mm or longer to conceal signs of harvesting by either method.” I think many of us do have patients in our practices who heal so well with trichophytic scars and with well dispersed small punch FUE that it is truly difficult to see the scars when the head is shaved. However, I do not see how any of us could answer this patient question with an unequivocal “Yes.” If you disagree, and can show evidence to the contrary, please write to us.

Related to this question, is the promise of “scarless surgery.” Unfortunately, the advertisement of FUE as scarless surgery has become relatively commonplace. There are even some who advertise and promote FUE as a “non-surgical” treatment. On an objective level, such claims are just medically false. Biopsies of extraction sites do show scarring. Therefore, such advertising is misleading and unethical. I see many young men in my practice who come to me for an opinion about their “unsightly scarring” from FUE procedures performed elsewhere. For many of these patients, I do not see scarring and spotty hairless areas beyond the norm with well-performed FUE, however, they feel they were mislead because they had been told there would be no scar even with their head shaved.

tinual questioning, teaching, and learning is addictive. Post graduate students and researchers abound, so brain stretching conversations happen every day.

Your editors are very happy with our new column, “Ask the Fellows.” What a brilliant way of checking something that may have concerned us recently. All available with a quick scan over the subjects that we can pass or home into depending on our interest. They are well written and concise and showcase the depth of knowledge we have in the ISHRS, which is also freely shared. A warm thank-you to all our con-tributing Fellows.

Because our patients need to take finasteride over a long time, it is understandable that they seek the most economical way of sourcing the drug. In our lead article, Dr. Edwin Epstein describes all the problems that may arise with the use of generic finasteride and in tablet splitting. This is good basic knowledge that will guide us in our directions to our patients. We’ve been taught to look for counterfeit dollar notes but now counterfeiting drugs may also become a problem.

We hope you enjoy reading our second issue for 2015, packed as usual with news and views.u

I have also had some patients in my practice, despite my telling them there are scars with FUE, who also feel that they have to wear their hair longer than they want to conceal the extraction sites.

As physicians who seek to be ethi-cal practitioners, we all owe it to our patients and to the public perception of the integrity of our profession to be fully honest and forthcoming in describing and promoting our services. I believe the ISHRS can and will take a stand on this issue, something I will welcome. But it also is incumbent for each of us individually to assure our own practices measure up in ethical advertising and also to challenge those practitioners who are in clear violation, whether they be members of the Society or not.

I hope and expect you will enjoy this issue of the Forum. Thanks to our excellent contributors, there are some very in-teresting articles. Remember this is the Forum, which means we depend on you and our membership to share opinions and experiences. Please consider making a submission.u

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Bernard Nusbaum, MDEditorial Guidelines for Submission and

Acceptance of Articles for the Forum Publication

1. Articles should be written with the intent of sharing scientific information with the purpose of progressing the art and science of hair restoration and benefiting patient outcomes.

2. If results are presented, the medical regimen or surgical tech-niques that were used to obtain the results should be disclosed in detail.

3. Articles submitted with the sole purpose of promotion or marketing will not be accepted.

4. Authors should acknowledge all funding sources that supported their work as well as any relevant corporate affiliation.

5. Trademarked names should not be used to refer to devices or techniques, when possible.

6. Although we encourage submission of articles that may only contain the author’s opinion for the purpose of stimulating thought, the editors may present such articles to colleagues who are experts in the particular area in question, for the pur-pose of obtaining rebuttal opinions to be published alongside the original article. Occasionally, a manuscript might be sent to an external reviewer, who will judge the manuscript in a blinded fashion to make recommendations about its accep-tance, further revision, or rejection.

7. Once the manuscript is accepted, it will be published as soon as possible, depending on space availability.

8. All manuscripts should be submitted to [email protected]. A completed Author Authorization and Release form—sent as

a Word document (not a fax)—must accompany your submis-sion. The form can be obtained in the Members Only section of the Society website at www.ishrs.org.

10. All photos and figures referred to in your article should be sent as separate attachments in JPEG or TIFF format. Be sure to attach your files to the email. Do NOT embed your files in the email or in the document itself (other than to show placement within the article).

11. We CANNOT accept photos taken on cell phones.12. Please include a contact email address to be published with

your article.Submission deadlines:

April 5 for May/June 2015 issueJune 5 for July/August 2015 issue

August 5 for September/October 2015 issueOctober 5 for November/December 2015 issue

2014–15 Chairs of CommitteesAmerican Medical Association (AMA) House of Delegates (HOD) and Specialty & Service Society (SSS) Representative: Carlos J. Puig, DO, FISHRS (Delegate), Paul T. Rose, MD, JD (Alternate Delegate)Annual Giving Fund Chair: John D.N. Gillespie, MD, FISHRSAnnual Scientific Meeting Committee: Nilofer P. Farjo, MBChB, FISHRSAudit Committee: Robert H. True, MD, MPH, FISHRSBylaws and Ethics Committee: David Perez-Meza, MD, FISHRSCommunications & Public Education Committee: Robert T. Leonard, Jr., DO, FISHRSCME Committee: Paul C. Cotterill, MD, FISHRSRegional Workshops Subcommittee: Matt L. Leavitt, DO (Chair) & David Perez-Meza, MD, FISHRS (Co-Chair)Subcommittee on EBM and Research Resources: Marco N. Barusco, MDSubcommittee Expert Panel: Paul C. Cotterill, MD, FISHRSCore Curriculum Committee: Anthony J. Mollura, MDFellowship Training Committee: Robert P. Niedbalski, DOFinance Committee: Ken Washenik, MD, PhDFUE Research Committee: James A. Harris, MD, FISHRSHair Foundation Liaison: E. Antonio Mangubat, MDInternational Relations Committee: Bessam K. Farjo, MBChB, FISHRSMembership Committee: Michael W. Vories, MDNominating Committee: Sungjoo Tommy Hwang, MD, PhD, FISHRSPast-Presidents Committee: Carlos J. Puig, DO, FISHRSPro Bono Committee: Edwin S. Epstein, MD, FISHRSScientific Research, Grants, & Awards Committee: Carlos J. Puig, DO, FISHRSSurgical Assistants Committee: Janna ShaferSurgical Assistants Awards Committee: Tina LardnerAd Hoc Committee on Database of Transplantation Results on Patients with Cicatricial Alopecia: Jeff Donovan, MD, PhD Ad Hoc Committee on Issues Pertaining to the Unlicensed Practice of Medicine: Carlos J. Puig, DO, FISHRSAd Hoc Committee on Regulatory Issues: Paul T. Rose, MD, JDSubcommittee on European Standards: Jean Devroye, MD, FISHRS ISHRS Representative to CEN/TC 403Subcommittee on Alberta, Canada Standards: Vance Elliott, MD, FISHRS Task Force on Finasteride Adverse Event Controversies: Edwin S. Epstein, MD, FISHRS

2014–15 Board of GovernorsPresident: Sharon A. Keene, MD, FISHRS*Vice President: Kuniyoshi Yagyu, MD, FISHRS*Secretary: Sungjoo Tommy Hwang, MD, PhD, FISHRS*Treasurer: Ken Washenik, MD, PhD, FISHRS*Immediate Past-President: Vincenzo Gambino, MD, FISHRS*Alex Ginzburg, MDRobert S. Haber, MD, FISHRSJames A. Harris, MD, FISHRSFrancisco Jimenez, MD, FISHRSMelvin L. Mayer, MD, FISHRSPaul J. McAndrews, MD, FISHRSWilliam M. Parsley, MDDavid Perez-Meza, MD, FISHRSRobert H. True, MD, MPH, FISHRSArthur Tykocinski, MD, FISHRS

*Executive Committee

INTERNATIONAL SOCIETY OF HAIR RESTORATION SURGERYVision: To establish the ISHRS as a leading unbiased authority in medical and surgical hair restoration.

Mission: To achieve excellence in medical and surgical outcomes by promoting member education, international collegiality, research, ethics, and public awareness.

Global Council of Hair Restoration Surgery SocietiesMembership proudly includes:American Board of Hair Restoration SurgeryAsian Association of Hair Restoration SurgeonsAssociation of Hair Restoration Surgeons-IndiaAustralasian Society of Hair Restoration SurgeryBrazilian Society of Hair Restoration Surgery (Associação Brasileira de Cirurgia de Restauração Capilar – ABCRC)British Association of Hair Restoration SurgeryFrench Hair Restoration Surgery SocietyIbero Latin American Society of Hair Transplantation (Sociedad Iberolatinoamericana de Trasplante de Cabello – SILATC)International Society of Hair Restoration SurgeryItalian Society for Hair RestorationJapanese Society of Clinical Hair RestorationKorean Society of Hair Restoration SurgeryPolish Society of Hair Restoration SurgerySociedad Iberolatinoamericana de Trasplante de Cabello

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Richard C. Shiell, MBBS Melbourne, Australia [email protected]

Notes from the Editor Emeritus

Don’t throw the past awayYou might need it some rainy day

Dreams can come true againWhen everything old is new again

So goes the 1974 song penned by my fellow countryman Peter Allen in conjunction with American singer Carole Bayer Sager. So it is also with hand-operated biopsy punches and scalp reductions. I thought I had demonstrated the superiority of mo-torized punches as far back as the 1970s when I introduced our ultra-sharp carbon steel Australian punches to the Hot Springs meetings in 1975 and 1979. I did not bother to take out a patent and they were copied extensively throughout the world.

At around the same time, many of us agreed that around 3.5mm was the smallest size punch that could be reliably cut without causing follicular damage. Pierre Pouteau, the celebrated and vastly experienced Parisian transplanter, was using 2.0mm punches, which certainly gave a less tufted effect, but his growth rate per graft seemed unacceptably low to me. I was wrong again, and the “top guns” of today are using dull punches of 0.8mm diameter and a claimed transection rate as low as 3%. I notice that they do not claim it is easy, and I wonder how the average HT surgeon scores with this meticulous procedure?

Now let us turn our attention to the scalp reduction or alopecia reduction operation, which has been virtually “dead” since 1996. This was introduced to the hair transplant world by the Blanchard Brothers of Montreal and Dr. Martin Unger of Toronto almost simultaneously in 1978. A more widely read paper on the same subject by surgeons at the Bosley Clinic in Beverly Hills served to further promote this procedure. Around 1980, it took off with patients and surgeons alike and within 2 years the Transform Clinic in the UK, of which I was Director of Surgery, had done 2,000 cases. By 1983, I was regrettably able to coauthor a paper on the complications we had seen.

The big attraction was that within 30 minutes the patient could rise from the operating chair minus about 35cm2 of his baldness. This procedure could be repeated at intervals of 3-6 months. Like most miracles, there were drawbacks and the residual scalp could stretch back some 30-50% in this period. Note that this stretch was in the adjacent scalp, not the central scar, which was generally less than 1mm wide. Thus, to remove a 10cm bald area was not possible in 3 procedures of 3.5cm each, but because of the stretchback and increasing tension within the scalp, it could take 4, 5, or even 6 operations to close the bald area (typically 3.5 + 3.0 + 2.5 + 2.0 + 1.5cm).

Dr. Patrick Frechet later introduced an ingenious Scalp Extender, which was inserted under the scalp to speed up the process by increasing the advancement of the hairy sides and preventing stretchback. This enabled him to remove a 10-12cm bald area within 3 surgical procedures.

The other problem was that the more one tried to close the bald area, the more the hair direction appeared to be abnormal and, with a central scar, the patient looked as if he had been struck on the head with a meat cleaver. A variety of different

surgical approaches were introduced. C, J, Y, U, and M shape excisions were the most popular, but each had its drawbacks and one was still left with a detectible scar. Z-plasty only seemed to make the scar worse so the ever-inventive Dr. Frechet developed his ingenious Triple Flap procedure and received our 1st Annual Golden Follicle Award for his efforts in 1994. The only drawback was that although the procedure worked well in the hands of Dr. Frechet, very few had his touch and experience, scalp reductions were becoming unpopular, and the method gained very few adherents. More would have tried had it not been that “mini- grafting” from scalp strips was slowly creeping onto the scene and was being refined by microscopic dissection of the actual follicular units. While labor-intensive, it was safe and much of the work could be delegated to trained staff. Furthermore, the final results were extraordinarily natural in appearance.

This is the situation we have reached in 2015. Although experiments continue with attempts to prevent temporary loss of transplanted hair and speed up the procedure with robotic machines, there seems to be no move to return to reductions and flaps.

Should we be doing more scalp reductions and flaps?I put this question to former AR guru and ISHRS Past Presi-

dent Mario Marzola and in part his reply was: “I don’t think the routine alopecia reductions will ever make

a comeback! The same applies to flaps and 4mm grafts. In ac-cidents or burns or large excisable areas of scarring alopecia, maybe there is still a place, and certainly in hairline lowering where, associated with scalp expansion, it still has a role.”

It is a fact that undesirably high hairlines in females can be easily moved a centimeter or two by a frontal advancement procedure (even more with prior insertion of an inflatable tis-sue expander). The residual scar is barely detectible and seldom requires improvement. Unwanted transplants or frontal scars in men can similarly be removed with one or two easy procedures.

Another former Forum Editor and ISHRS Past-President Russell Knudsen commented:

“I think that AR is now a repair procedure for those who know its value and have been trained in how to do it correctly. Lateral AR can ‘lift’ the balding margin to the previous grafts or remove cicatricial alopecia. Not much other value I am afraid. If used in extensive male pattern baldness to ‘reduce’ the bald area, it must have widely spaced galeal sutures to minimize stretchback as described by the late Dr. Gerard Seery in 1997. I don’t know of anyone doing this today. Of course, strip surgeons doing 3,000+ grafts practice the same technique in the donor area. Can we call this ‘donor reduction’?”

Lateral, posterior, and U-shaped reductions are still employed to help bridge an area of baldness that has appeared since the first transplants some decades earlier. Hopefully, the use of finasteride

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President’s Message from page 54

Editor Emeritus from page 57

over the past 15 years has minimized this baldness progression, but there are probably a vast number of former patients who have not used the drug or who even know about it.

Should Reduction techniques be taught at ISHRS teaching courses?

I believe that this should be occurring regularly, rather than adventurous young surgeons working alone without the benefit of our vast collective experience. As far as I know, I was the only person to perform a scalp reduction at a hair meeting within the past 20 years (Sydney, 2005). Drs. Marzola, Martin Unger, and I did three to packed operating rooms and temperatures of 90+ degrees at a meeting in Rio de Janiero in 1992. The procedure was not made easier by large video cameras lenses almost at the wound margins and massive bleeding due to the heat. Although a relatively simple surgical procedure, there are the usual traps for young players and valuable tips can be passed on by those of us who have learned from experience. I have seen more serious flap and reduction problems caused by overconfident Plastic Surgeons without specific training than by members of the more cautious and trained hair transplant fraternity.

Medico-Legal BarriersA recent barrier to the use of alopecia reduction and ad-

vancement and pedicle flaps has been instituted by our Medical Insurers. Many modern policies will only permit Board-certified surgeons to perform these procedures or alternatively they charge a much higher annual premium for others who plan to do them. The fact that strip removal and any associated undermining prior to closure is almost identical to a scalp reduction seems to have “slipped under the radar.” Perhaps this is why all hair transplan-tation in places like France and Singapore is now restricted to Plastic Surgeons.

BibliographySee the excellent book chapters listed below for detailed

accounts of past and present ancillary procedures and many references.

1. Marzola, M., et al. Ancillary Surgical Procedures. Chapter 18. In: W. Unger, Ed. Hair Transplantation, 5th Edition. Informa Health Care Press, 2010. (with accompanying DVD)

2. Marzola, M. Surgical Female Hairline Lowering.I In: S.M. Lam, Ed. Hair Transplant 360. JayPee Press, 2014. (with accompanying DVD)u

caused by unlicensed technicians performing hair restoration surgery. Unlicensed technicians generally do not see patients in follow-up to know when they make an error. In contrast, we as doctors are accountable and must learn from our mistakes. I would like to encourage all members to gather any cases they feel will assist in this learning process and submit them for the planned Complications Panel at the annual meeting in Chicago.

Despite our ongoing efforts to eliminate the unlicensed practice of medicine among former doctors’ assistants—most of whom were at one time employed by hair restoration doctors, the ISHRS recognizes the majority of our staff are honest, loyal, and respected team members. We continue to reward them with special recognition at our meetings, and to encourage their par-ticipation in training fellow assistants at sponsored workshops. It is with great pride that the ISHRS in conjunction with Dr. James Harris is sponsoring the first “stand alone” Surgical Assistants

Workshop. I encourage anyone who has recently hired new staff to utilize this valuable training opportunity.

Finally, for those who have been reading the series on low level laser therapy (LLLT), the third and final part has been completed, but for space constraints will not be included until our next edition. I do not promote or critique any one device. My intention with this series was to educate and elicit a critical look at the science as well as the devices that apply it, in order to assist members in making their own decisions and recom-mendations to patients. Hopefully, every doctor will be able to determine whether a particular device may be helpful to treat hair loss for their particular patient. What I can say for certain, questions remain about the optimal device and dosing schedules, and like clothing—no matter what the tag may say—there is no such thing as “One size fits all”!u

On a biannual basis, the ISHRS collects practice data from members in an effort to analyze trends and properly report to media on the state of Hair Restoration Surgery. The 2015 Practice Census Survey will be e-mailed to ISHRS Physician Members in April. We ask that you please complete the survey. It is very important to get a solid response rate.

It is shorter in length this year, and we are offering several incentives for participation. The data report will be released to all members and published on the ISHRS website.

Thanks in advance!

ISHRS 2015 PRACTICE CENSUS

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Generic Finasteride from front page

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The Federal Food, Drug and Cosmetic Act (FFDCA) es-tablished the “180-day exclusivity” period, during which the FDA will not approve other ANDAs for the same product. Dr. Reddy’s, an international generic pharmaceutical company based in India, was awarded a 180-day period of marketing exclusiv-ity for finasteride 1mg on January 2, 2013, which expired on July 1, 2013. Since then, the following generic manufacturers also produce finasteride 1mg and 5mg: Accord Healthcare Inc., Actavis, Aurobindo, Camber, Hetero Labs, Mylan, Sun Pharma, Teva, and Zydus (5mg).

Increasingly, generic pharmaceutical active ingredients are made outside of the United States. This has raised concerns about drug quality and regulation in various countries, and the potential for counterfeit drugs. The FDA reported that 40% of finished generic drugs, and 80% of active ingredients, are com-ing into the United States from overseas sources.4 In July 2012, Congress passed the Food and Drug Administration Safety and Innovation Act (FDASIA). In summary, it allows the FDA to inspect foreign facilities, to increase penalties for adulterated or counterfeit products, and to collect user fees from industry to fund the reviews of innovator and generic drugs, medical devices, and bio-similar products, and to expedite the develop-ment, review, and approval of “breakthrough therapies.” On February 14, 2014, The New York Times published an article titled “Medicines Made in India Set Off Safety Worries,” which noted that “India is the second-largest exporter of generic and OTC drugs to the U.S., supplying 40% of the US market.” They reported that the FDA has increased inspection of Indian plants, with new penalties and warning letters, and expressed concerns about potential counterfeit operations in China, and frustration with their efforts to increase inspections.

Counterfeiting occurs throughout the world, but it is most common in countries where there are few or no rules about mak-ing drugs. An estimated 10-30% of medicines sold in developing countries are counterfeit. In the industrialized world (countries such as the United States, Australia, Japan, Canada, New Zea-land, and those in the European Union), estimates suggest that less than 1% of medicines sold are counterfeit.5 The only way to know if a drug is counterfeit is through chemical analysis done in a laboratory. Counterfeit drugs may look strange or be in poor-quality packaging, but they often seem identical to the real thing. In March 2013, the FDA formed a new Cyber Crimes Investigation Unit, a special team within their Office of Criminal Investigations (OCI), devoted to combating rogue Internet phar-macies. This unit works with other domestic and international agencies to track down the operators and suppliers of websites that illegally sell prescription drugs.

Tablet splitting is a widespread practice to allow for dose flexibility and cost advantages for consumers. On July 21, 2009, the FDA posted “Tablet Splitting: A Risky Business” on its consumer site (www.FDA.gov), which noted: “FDA does not encourage the practice of tablet splitting unless it’s specified in the drug’s professional prescribing information. If a patient is considering splitting a tablet, FDA recommends that the patient gets advice directly from his or her doctor or pharmacist to de-termine whether it is appropriate or not for a particular drug.” Possible risks to consumers include confusion over the dose, as people may forget to split them, and tablets may be difficult to

split evenly due to size, shape, and technique. Several studies have shown weight variability of unscored split tablets, even those split by pharmacists.6 These concerns are especially rel-evant in drugs with a narrow therapeutic index.

Concerning the practice of splitting finasteride 5mg, two is-sues come into question: How evenly distributed is the drug in half or quarter fragments, and does splitting affect the clinical outcome? The U.S. Pharmacopeial Convention (USP) sets the standards for identity, strength, quality, and purity of medica-tions, which are enforced by the FDA. The amount of active drug is never 100% evenly distributed in any tablet. One study looking at the uniformity of distribution of finasteride in 5mg halves and quarters showed a high mean average content in both (2.88, 1.33).7 Another study concluded that drug content variation in half-tablets appeared to be attributable primarily to weight variation during the splitting process, highly determined by the ability of patients to split tablets perfectly in half.8 A Veterans Affairs study noted that 4/12 products that failed the weight-uniformity test when split in halves, varied in tablet shape and hardness.9 Splitting devices also vary in quality and design. Among various manufacturers, finasteride 5mg tablets vary in size and shape; thus fragmentation, powdering, and fragment loss may occur with splitting. In addition, patients should be advised not to split more than one pill at a time to be stored for later use as exposure to heat, moisture, humidity, and other factors could affect drug efficacy.

A review of the clinical pharmacology of finasteride is rel-evant to its therapeutic index range. Finasteride is a competitive and specific inhibitor of Type II 5α-reductase with preferential inhibition of the Type II isozyme, and is 100× selective for the Type II 5α-reductase over Type I isozyme. For both isozymes, the inhibition by finasteride is accompanied by a reduction of the inhibitor to dihydrofinasteride and adduct formation with NADP+. The turnover for the enzyme complex is slow (t1/2 approximately 30 days for the Type II enzyme complex and 14 days for the Type I complex). This may explain its long relative clinical effect on hair loss. In terms of absorption, Merck’s original study in 15 healthy young male subjects, the mean bioavailability of finasteride 1mg tablets was 65% (range 26-170%), based on the ratio of area under the curve (AUC) relative to an intravenous (IV) reference dose. Relative to an

The many different pill shapes and sizes.

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Generic Finasteride from page 61

intravenous reference dose, the oral bioavailability of finasteride is approximately 80%. The bioavailability is not affected by food. Maximum finasteride plasma concentrations are reached approximately two hours after dosing and the absorption is complete after 6-8 hours. The mean terminal half-life is ap-proximately 5-6 hours in men 18-60 years of age and 8 hours in men more than 70 years of age.10

The concerns of adverse events and post-finasteride syn-drome have initiated discussions among physicians in terms of titration of dose to potentially reduce symptoms, or patient concerns over potential side effects, yet still maintain efficacy for hair loss. In the original dose ranging study with finasteride for male pattern hair loss,11 efficacy was demonstrated at 0.2mg for all end points including hair count, investigator and patient self-assessment of hair growth, and global photography. Efficacy results were similar at 1mg and 5mg doses, which were superior to the 0.2mg dose. Some suggested regimens are ¼ tablet every other day, ¼ three times per week, and a “titration” program of 1mg per week for 1 month, 1mg twice a week for 1 month, then 1mg every other day. Fewer side effects and better patient compliance, without reduced efficacy, have been observed.12

However, controlled clinical trials using 1mg, 5mg, and placebo arms have not shown a dose-dependency relationship for sexual side effects in both androgentic alopecia and benign prostatic hyperplasia age groups.13,14

Several hair transplant surgeons anecdotally report comments from patients that shedding occurred after switching from brand to generic finasteride, or the generic seemed less effective. Ex-planations for this might include placebo effect, counterfeit drug, or quality control differences in batches or processing. Based on my research of FDA requirements for generic approval, and the relative long effective half-life of finasteride Type II isozyme complex, the splitting of generic finasteride 5mg should be an equally effective alternative to the 1mg generic, or to the brand-name drug, despite the potential for fragment loss during splitting.

References1. Merck Manual; http://www.merckmanuals.com/profes-

sional/clinical_pharmacology/pharmacokinetics/drug_bio-availability.html

2. Wikipedia3. www.fda.gov4. www.fda.gov5. “Counterfeit Drugs: Fighting Illegal Supply Chains.” How-

ard Sklamberg testimony before Congressional Committee of Energy and Commerce, February 27, 2014.

6. Rosenberg, J.M., J.P. Nathan, and F. Plakogiannis. Weight variability of pharmacist dispensed split tablets. J Am Pharm Assoc. 2002; 42:200-205. doi: 10.1331/108658002763508498.

7. Al-Haddab, M. Drug content and uniformity in com-monly split tablets in dermatology. J Am Acad Dermatol. 2014(May); 70(5): Supplement 1, AB151.

8. Hill, S.W., et al. Analysis of drug content and weight uni-formity for half-tablets of 6 commonly split medications. J Manag Care Pharm. 2009(Apr); 15(3):253-261.

9. Polli, J.E., S. Kim, and B.R. Martin. Weight uniformity of split tablets required by a Veterans Affairs policy. J Man-aged Care Pharm. 2003; 9(5):401-407.

10. Merck & CO., INC.11. Roberts, J., et al. Clinical dose ranging studies with finas-

teride, a type 2 5α-reductase inhibitor, in men with male pattern hair loss. J Am Acad Dermatol. 1999; 555-563.

12. Email communication with Drs. Michael Beehner, Ron Shapiro, and Russell Knudsen.

13. Gormley, G., et al. The effect of finasteride in men with benign prostatic hyperplasia. N Eng J Med. 1992; 327:1185-1191.

14. Roberts, J., et al. Clinical dose ranging studies with finas-teride, a type 2 5α-reductase inhibitor, in men with male pattern hair loss. J Am Acad Dermatol. 1999; 555-563.u

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[ page 62

Cyberspace ChatJohn P. Cole, MD Alpharetta, Georgia, USA [email protected], and Bradley R. Wolf, MD, FISHRS Cincinnati, Ohio, USA [email protected]

John P. Cole Bradley R. Wolf

The Treatment of Men with Finasteride: Scientific and Anecdotal Evidence

(JC) How do we manage the very young patient with a strong family history of andro-genic alopecia, who is advancing to a NW 5 at a young age? In such individuals, hair trans-plant surgery is not an optimal option. Medical therapy is the obvious answer, but what should we consider when medi-cal therapy fails? We all know the clinical studies, but what is our personal experience and how does personal expe-rience govern our deci-sion making progress?

(BW) Edwin Epstein presents a well-written and well-referenced lead article in this issue, “Update on Efficacy of Generic Finasteride,” that explores scientific evidence concerning finasteride. But does our knowledge end there? Of course not. Physicians have been prescribing finasteride in one form or another for 23 years during which time much anecdotal evidence has accumulated. Anecdotal evidence (information passed along by word-of-mouth but not documented scientifically) leaves verification dependent on the credibility of the party or parties presenting the evidence. We leave it to you to assess the credibility of the information based on those presenting the evidence.

The Scientific Evidence(BW) From the original Merck studies: Investigator assess-

ment was based on a 7-point scale evaluating increases or de-creases in scalp hair at each patient visit. This assessment showed significantly greater increases in hair growth in men treated with Propecia® compared with placebo as early as 3 months (p<0.001). At 12 months, the investigators rated 65% of men treated with Propecia as having increased hair growth compared with 37% in the placebo group. At 2 years, the investigators rated 80% of men treated with Propecia as having increased hair growth compared with 47% of men treated with placebo. At 5 years, the investiga-tors rated 77% of men treated with Propecia as having increased hair growth, compared with 15% of men treated with placebo.¹

If women were told that there is a medica-tion that 65-80% of the time could stop the ag-ing of their faces for at least 5 years with minor side effects, how popu-lar would that drug be? The scientific evidence suggests that finaste-ride is a miracle drug that prevents most men from prematurely losing hair that is genetically programmed to die. Our patients should be en-couraged not to outlive their hair! (See Figures 1-4.)

(JC) With this in mind, Jim Vogel re-cently presented the case of a 22-year-old male who lost hair fol-lowing an 11-month course of generic 1mg finasteride (Figure 5).

What would you do and which questions would you ask? What percentage of men are non-responders to finasteride? What would your next course of action be? These questions triggered an interesting debate.

The Anecdotal Evidence Ed Epstein pointed out that his experience with finasteride

was similar to the Merck study mentioned above. This seems to be a similar experience for Jerry Wong, Jim Vogel, and Bill Parsley. Ron Shapiro feels that 70-80% respond with no progression or more hair. Bob Haber feels that at the very least finasteride slows down the progression of hair loss. Personally, a large percentage of my patients refuse to take any form of medication. In those men who take Propecia, I (JC) see about an 80% response.

Years ago, Bill Parsley studied his patients’ response to Rogaine®. He was unable to find a single patient who had dem-onstrated clinical improvement on Rogaine alone. Vance Elliott points out that Rogaine is very beneficial in his female patients. Personal experience (anecdotal evidence) indeed seems to govern our treatment protocols. Dr. Parsley states that “the true gold standard is how it works in your hands and in your office.”

Figure 1. Pre-treatment (left) and after 7 years of Propecia (right).

Figure 2. Pre-treatment (left) and after 8 years of Propecia

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Cyberspace Chat from page 61

Bill Parsley, Ron Shapiro, Brad Wolf, and Bob Haber pointed out a concern we are seeing with the generic finasteride. Vance Elliott stated that he’s had only one patient who has NOT lost hair when switched to generic finasteride, so he strongly advocates the brand name (Propecia). Men who did respond to Propecia at times fail on the generic version of finasteride. Therefore, if a patient fails to respond to finasteride, make sure you give him a trial of name-brand Propecia or quartered 5mg finasteride. Bill Parsley points out that, while he has seen no problems with 5mg generic finasteride, he would not start a patient on generic 1mg finasteride or generic minoxidil in the first year. Bill and many others have found that the combination of minoxidil and finasteride is much better than finasteride alone.

In his article, Ed Epstein lists the manufacturers of generic fi-nasteride and reminds us that we should report finasteride failures to the FDA. Is this an industry-wide issue or company specific? John Gillespie notes that many widely prescribed drugs includ-ing metformin, Synthroid, Norvasc, and Amoxil are dispensed in generic form, so it does not make sense when men are failing on generic finasteride. Ed points out that generic manufacturer applications are required to show 80-125% bioavailability. The question remaining is what percentage of counterfeit generics has filtered into the marketplace.

Then there is the concern about compliance. How frequently did they take the medication? Many men stop suddenly because they see no improvement. Others may take the product sporadi-cally because they see little improvement. It is also possible that finasteride slows the progression of hair loss in some who appear to be non-responders. Russell Knudsen pointed out that there is an “aggressiveness index” in some patients who will not have a complete cessation in balding while on finasteride when they are experiencing significant and rapid balding. Bill Parsley noted that some young male patients really want a hair transplant so they will pretend to take the medication, appear to fail treatment, and then seek a hair transplant. Some physicians recommend that patients start on finasteride 3-4 months prior to surgery to improve the donor area. Why, when there are supposedly no receptors for DHT in the donor area?

Editor’s note (RHT): Yes, it appears to make no sense to prescribe finasteride for the donor area. But I can think of one reason: if you know you are harvesting from an area that you

think will probably be affected by progression of balding, put-ting such patients on finasteride helps to promote the longevity of follicles transplanted from outside the “safe zone.”

Russell Knudsen referred to a case where the patient continued to lose hair on finasteride, but he had significant recovery when dutasteride, 0.5mg per week, was added to his medical regimen. Of course, as Jim Vogel points out, another option is to switch your patient to dutasteride. Jerry Wong reflected that he has at least 3 pa-tients who did really well on dutasteride after they failed finasteride.

A Closer Look at Finasteride(BW) The potential side effects of chronic finasteride use

should be completely explained to all patients who begin treat-ment. This can be accomplished by verbal and/or written instruc-tions. Some physicians choose to have their patients read and sign a document specifying the mechanism of action and the known side effects of chronic finasteride use. Finasteride should not be administered to men who have an elevated prostate specific antigen (PSA). It is recommended that men over 49 years old have a PSA level drawn prior to starting finasteride.

Other important points to be considered when prescribing finasteride include: it takes an average of 6-12 months after starting to see results and 6-12 months to lose the effects after stopping treatment, always have the patient take photos before initiating finasteride treatment for objective comparison, and success is dependent upon the number of existing anagen and miniaturized hairs present at the time of initiation of treatment.

The following forms of finasteride are currently available: Brand finasteride 1mg (Propecia), generic finasteride 1mg, brand finasteride 5mg (Proscar), generic finasteride 5mg. Benefits and negatives are listed below:

Brand 1mg (Propecia) Benefits: The gold standard, no counterfeits, optimal results

seen as soon as possible, no pill cutting necessary for therapeutic dose, can dose in 1mg increments or less, private practice can dispense from the office.

Negatives: Most expensive alternative.

Generic 1mgBenefits: Approximately one-third of the cost of Propecia

and will decrease in price in the future, can dose in 1mg or less increments.

Negatives: Manufactured off shore by generic makers with reported poor quality control/counterfeits, difficult to dispense from physicians’ offices, many reported treatment failures.

Brand 5mg (Proscar)Benefits: NoneNegatives: Same as for generic 5mg—more expensive than

generic, no greater efficacy than generic.

Generic 5mgBenefits: Inexpensive alternative for treatment, consistent

good results, available at pharmacies in the United States for as little as $10 per prescription, no reports of treatment failure.

Negatives: Must divide for therapeutic dose, variable amount of finasteride in each fragment, loss of ingredient with cutting, smallest dose is 1.25mg, if taken every day-higher chance of side effects.

Figure 5. Dr. Vogel’s patient before (left) and 11 months after (right)

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My Anecdotal Experience(BW) Based on my experience prescribing finasteride to men

since it became available in 1992, I use the following criteria to determine which form to prescribe:

Brand name 1mg (Propecia): I prescribe this to patients who can afford it and, given the alternatives, request it to avoid the chance of treatment failure. I dispense it from my office at a reduced price compared to retail pharmacies. When starting treatment, it is the gold standard to determine the initial response to the recommended therapeutic dose (1mg/day).

Generic 1mg: This became available in 2013 and is a popular alternative due to its reduced price. As reported by others, I have seen multiple scenarios in which its use has led to treatment failure. This includes men who have been on Propecia for a long time and noticed shedding and/or thinning after taking the 1mg generic for 3-6 months. In some instances, the generic is substituted for Propecia by the pharmacist unbeknownst to the patient. They usually see a cessation of shedding/thinning with resumption of Propecia. Patients who have originated treatment with generic 1mg have seen no results and subsequently have seen results when switched to Propecia. I have a patient who had good results with one generic but was switched to another generic by his pharmacy and saw shedding/thinning. This resolved with resumption of the original 1mg generic. If patients are started on or switched to 1mg generic, I inform them that they should be aware of either no results or shedding/thinning in 3-6 months and should switch to Propecia. I do recommended generic 1mg for men who have been on brand name 1mg for 6-12 months who want reduced price. These patients are warned to look for shedding/thinning and change to brand name 1mg or ¼ generic 5mg immediately.

Finasteride 5mg: The brand name (Proscar) and generic have the same effect, so I therefore see no need to use Proscar. For some reason, generic 5mg finasteride has not suffered the same pains as generic 1mg finasteride. When originating treat-ment with quartered generic 5mg finasteride (at most 1.25 mg/day), I have never had a treatment failure or a patient complain of shedding/thinning when switched to generic 5mg. Generic 5mg finasteride would seem to be the ideal option, but when informed of all the options, some patients choose not to use generic 5mg for three reasons: 1) they prefer not to split pills, 2) they do not want to risk ineffectiveness by having the active ingredient unevenly distributed in the tablet, and 3) they don’t want to risk the increased chance of side effects by taking 0.25 mg/day more than recommended. These are patients who want the highest chance of success without regard to cost and choose to use Propecia.

Reduced DosingAnecdotal evidence has shown that doses of less than 1 mg/

day are as effective as 1mg/day. Russell Knudsen may have been the first to report dosing less than 1mg/ day, prescribing rather 1mg three times a week. Bill Parsley often starts patients on ¼ mg per day, a 1mg tablet quartered. I have been using reduced doses for a number of years. I start men who choose to use quartered 5mg finasteride on at most ¼ tab (1.25mg) every other day, which is 2.5mg every three days. If patients who are 40 years old and older choose Propecia (1mg), they are started on 1mg every other day. Any patient who is overly concerned about side effects are started on a reduced dose. I often recom-

mend that patients 50 and older take 1mg Propecia or 1.25mg generic finasteride every third day. If patients experience side effects and are concerned, it is recommended that they reduce their dosage by half or stop the medication altogether. It is puz-zling to me that the dosage reductions described above have not led to complaints of shedding or thinning in patients, some who had taken 1mg finasteride/day for 10 years or more. Why is this? If testosterone in men decreases with age, is there a concomi-tant decrease in dihydrotestosterone (DHT), making decreasing finasteride doses effective?

As patients age, the side effects from finasteride, decreased libido and/or erectile dysfunction, are common without ingesting finasteride. As men get older, their testosterone level gradually declines—typically about 1% a year after age 30. Testosterone peaks during adolescence and early adulthood. It is important to determine in older men if a low testosterone level is simply due to the decline of normal aging or if it is due to a disease (hypogonadism).²

Testosterone decline is not inevitable with age, according to Australian scientists. Older men in excellent health can maintain their hormone levels. Two study centers in Australia recruited 325 men over the age of 40 (median age 60) who had self-reported excellent health and no symptom complaints. To test blood testosterone levels, the researchers took blood samples from the men nine times over three months. They excluded men from the study who took medications that affect testosterone. Age had no effect on testosterone level: “The modest decline in blood testosterone among older men, usually coupled with nonspecific symptoms, such as easy fatigue and low sexual desire, may be due to symptomatic disorders that accumulate during aging, including obesity and heart disease. It does not appear to be a hormone deficiency state.”³

Examining the scientific and anecdotal evidence, in con-junction with years of experience, leads each to his or her own rationale for prescribing finasteride. There is no doubt that it has proven to be an effective medication.

References1. Merck prescribing information: http://www.merck.com/

product/usa/pi_circulars/p/propecia/propecia_pi.pdf2. See http://www.mayoclinic.org/healthy-living/sexual-

health/in-depth/testosterone-therapy/art-200457283. See http://www.sciencedaily.com/releases/2011/06/110607121129.

htmu

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How I Do ItTimothy Carman, MD, FISHRS La Jolla, California, USA [email protected]

Hairline design and execution can be one of the most challenging aspects of hair transplant surgery. It is the very first feature that is directly viewable in the hair transplant patient, and is often that which leads to the general overall impression of a “natural” vs. “man-made” appearance. Dr. Muhammad Ahmad describes his system for creating hairline designs in his practice setting.

If you have a suggestion or a tip you employ in your practice that you would like to share with your peers in the ISHRS, please feel free to email me at [email protected]

Designing the Hairline: The Role of the ThumbMuhammad Ahmad, MD Islamabad, Pakistan [email protected]

Hairline design is the most important point in hair transplant surgery. Basic hairline design follows guidelines discussed in the literature.1-4 Creation of the hairline is one of the biggest concerns for the patient and one of the most difficult and artistically demand-ing aspects for the surgeon.4 The newly designed hairline should have two important features. First, it should look like a natural one (in terms of hair angles and distribution). Second, it should be individualized. With advances in hair transplant surgery, comes new innovations that have resulted in the use of more equipment in our field (e.g., the laser-guided device for hairline design).5,6

Many points should be kept in mind before deciding a defini-tive hairline: shape of the forehead, angle of inclination, age of the patient, severity of hair loss, and the patient’s expectations. At-tempts to over-standardize the hairline will result in aesthetic fail-ure. Below is a simple and low-tech method of marking hairline.

MethodFirst, the anterior mid-point is marked in the midline on

forehead. It is marked at a distance above the mid-glabellar line that is equal to or greater than the distance from the mid-glabellar line to the tip of the nose. This is in keeping with the “Rule of Thirds” in facial proportion (Figure 1A).

Next, the surgeon marks the hairline on the lateral sides starting from the outer edges of the eyebrows (Figure 1B). The surgeon then uses his or her left thumb to position and mark the left half of the hairline (Figure 1C). Last, the thumb is moved to the right side to position and mark the other half of the hairline (Figure 1D). (A left-handed surgeon would use the thumb on his or her right hand.)

DiscussionProper marking of the hairline is the most important factor

determining the ultimate naturalness of the results. A proper hairline design suitable to the shape of the forehead and adjusted to the overall facial profile will result in a natural hairline. No

Figure 1. Method of marking the hairline.

Figure 2. Different thumb positions showing changes in the hairline.

other part of the procedure will have as much as impact on the patient’s appearance. The position and shape of the hairline is the template on which present and future surgery is patterned.7

The literature mentions various hairline designs (triangular, oval, flat, crescent, etc.), but it takes years of practice to know which hairline would suit each individual patient the best.

The above thumb method easily mimics the hairline and can be used to design many hairline types—from triangular to oval to crescent—whatever best suits each patient (Figure 2). Because the hairline is illustrated by the full width of the thumb, this method also gives the patient and surgeon a three-dimensional view of the anticipated hairline, which helps in making adjust-ments according to the patient’s preferences.

ConclusionUsing a thumb is a very easy method to mark a hairline and

can help illustrate to the patient the proposed result of the hairline in transplant surgery.

References1. Unger, W.P. Hair Transplantation, 3rd Ed. Marcell Dekker:

New York, 1995; pp. 105-110.2. Rose, P. Considerations in establishing a natural hairline.

Int’l J Cosmetic Surg. 1998; 6(1):24-26.3. Seery, G. Guidelines for designing and locating hairline.

Am Cosm Surg. 1998; 15:21-25.4. Rovira, R.V., et al. Importance of hairline study previous

to hair transplant. ESHRS Journal. 2010; 53-54.5. Shiao, T.K., and I.S. Shiao. Laser-guided hairline design and do-

nor strip marking. Hair Transplant Forum Int’l. 2007; 17(2):53.6. Ng, B., et al. Laser-assisted hairline placement. Hair Trans-

plant Forum Int’l. 2008; 18(5):169-172.7. Parsley, W.M. Frontal hairline design. In: M.R. Avram

and N.F. Rogers, eds. Hair Transplantation. Cambridge University Press: New York, 2010; pp. 35-48.u

65


Complications and Difficult CasesMarco N. Barusco, MD Port Orange, Florida, USA [email protected]

I have previously presented a case report in this column describing the management I use in transplant-ing patients with irradiated scalps and the potential dangers we may encounter. The previous case focused more on managing the recipient site and trying to avoid poor growth and tissue necrosis while achieving a cosmetically pleasing result for the patient. This is a different case, which required a slightly different ap-proach and, as it turned out, could have been complicated during the donor removal phase of the procedure.

A Close Call with Donor Area Harvesting on a Patient with Irradiated Scalp

The objective of this case description is to highlight important decisions that we need to make pre- and intra-operatively when assessing donor areas for procedures in these patients in order to minimize the risk of complications.

Fortunately, the outcome for this patient was excellent and she is extremely happy with her results, not only in her physical appearance but, even more importantly, in her self-confidence and psyche. So this case incidentally also highlights the dif-ference we are able to make in a patient’s life with a “simple” surgical intervention and how important our job is to our patients.

BackgroundM.P. came for a consultation with me in 2013. She was 55

years old at the time. She was accompanied by her husband of many years. As I introduced myself, I started to visually assess her hair and could not see any obvious hair loss, so my initial thoughts were that she would be another one of the countless patients who need only medical therapy, if anything, for their perceived—and not yet visible—hair loss. It was not to be so.

The problems with her hair started at age 17 when she had to undergo surgery for a brain tumor located in her cerebellum. For about 4 years before she was diagnosed and operated, she suffered from debilitating headaches and a progressive ataxia that made it difficult for her to walk normally. For a female teenager, it was very difficult to cope with this situation. Then the diagnosis of the tumor was finally made and emergency surgery was indicated due to the imminent danger of herniation of her brain stem from the mass effect and increased intra-cranial pressure caused by the tumor.

The tumor was partially resected and was diagnosed as a Cerebellar Pilocytic Astrocytoma. After the procedure, she de-veloped aseptic meningitis and was finally released home after a lengthy hospital stay. Because the tumor was not completely removed with the surgery, she had to undergo radiation therapy to prevent recurrence, which caused hair loss over a large area of her parieto-occipial scalp (Figures 1, 2, and 3). The silver lining was that with intensive physical and occupational therapy she recovered most of her motor abilities. Fortunately, she has not had recurrence of the tumor.

But the long-lasting physical and psychological scars from this experience would be a constant source of anxiety for her. Due to the hair loss that she experienced in her occipital scalp, she was not able to ever pull her hair up or go swimming. On a windy or rainy day she would worry that the areas of hair loss would become visible. For a young woman in her teens, this was really bad. Though eventually she married, and her husband is

very supportive of her, en-couraging her every step of the way, she carries deep emotional scars from what she had to endure.

After an emotional conversation, I examined her scalp and determined that she had an exten-sive area of post-radiation alopecia covering most of her occipital scalp and extending laterally into the parieto-temporal areas. I also noticed a vertical scar along the midline of the in-ferior posterior area of her occiput, extending into the upper neck. On palpation, I could feel that there was a soft spot on the inferior area of her occipital bone. She had no pain in these areas. Capillary refill was adequate and the skin, although thin, was supple and with a good amount of subcutaneous tissue. Luck-ily for her, the remainder of her scalp hair was thick and showed no signs of miniaturization. She has medium to coarse hair cali-ber, with an overall density of 75-80 follicular units per square centimeter.

Based on the above, an FUT procedure was proposed to add hair to the irradiated scalp area, staying away from the soft spot that was noticed in her inferior occipital area. As part of the pre-operative work-up, her medical records were reviewed and a skull series X-ray was ordered (Figures 4 and 5), which

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Figure 1. Pre-operative view of the area of hair loss.

Figure 2. Pre-operative view—right oblique.

Figure 3. Pre-operative view—left oblique.

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Complications from page 65

confirmed the lack of occipital bone near the foramen mag-num. No hardware or cranio-plasty material was present, other than a few surgical clips in her cerebellum.

Case PresentationHistory

The patient is otherwise healthy. No medications other than over-the-counter health supplements. She is allergic to Codeine (it caused her to feel anxious and “shaky”). No other surgical history.

Regarding her hair loss, there is no hair miniaturiza-tion and no history of female pattern alopecia in either side of her family.

Physical ExaminationM.P. is a healthy 55-year-

old female. Very pleasant, with good eye contact but emotional when talking about the hair loss problem. General physical exam is normal other than a slight tremor and ataxia of the extremities.

Scalp exam shows areas of hair loss as previously described, along with the scar from the neurosurgery. Anterior scalp, mid-scalp, and crown areas are fully covered with medium to coarse caliber hair, with no signs of miniaturization and overall density of 75-80 follicular units/cm2.

After considering all options and discussing all potential prob-lems and complications of the hair transplant surgery, the patient and her husband decided to follow through with the procedure.

Intervention1. Pre-operative management

a. Mupirocin ointment to both nostrils three times daily was started 3 days prior to the procedure and continued for a total of 5 days (MRSA prevention).

b. Hair and body (except face) were cleansed with Hibiclens (4% chlorhexidine) once daily starting 3 days before surgery.

2. Intra-operative managementa. Pre-operative photographs and marking were done and

her hair was washed with chlorhexidine. b. I opted to take a donor strip high in the occipital area,

leaving about 1cm of hair between the edge of her hair loss and the lower edge of the donor strip. This was done in an effort to avoid excising into the irradiated scalp (Figure 6).

c. Donor density measurements were taken yielding an average density of 75 FU/cm2.

d. Donor elasticity measurement using the Meyer-Pauls sys-tem yielded an elasticity of 18%, so I knew that the area was somewhat tight. Based on this observation, the maximum width of the proposed donor strip was kept at 12mm.

e. Planned occipital strip of donor tis-sue was marked, taped, and shaved according to my normal protocol.

f. Before anesthesia, the skin was pre-pared again with Hibiclens.

g. S ince the do-nor area in this case was located above the re-cipient area, the anesthetic ring block was done to include both the recipient and donor sites inside the ring, to avoid causing the pa-tient to feel both the donor site and the recipient site anesthesia separately (Figure 7).

h. Sterile drapes were applied to expose only the shaved strip of donor hair to be removed.

i. Just before harvesting, a small amount (6cc total) of normal saline was injected for tumescence along the donor strip.

j. Donor harvesting was done per my usual protocol using a single-blade scalpel.

k. The scalp had a normal amount of subcutaneous tissue, and I stayed above the galea aponeurotica. The first incisions were made with a width of 10mm, instead of 12mm, to test for skin elasticity. After the removal of the strip, the scalp was noticed to be very inelastic, particularly in the central area of the strip, with very limited movement infe-riorly and superiorly. At maximum approximation, there was still a 3-4mm gap between the edges of the wound. At this point, I felt that familiar “spine chill” that we feel when this happens, and I am sure I thought of a couple of expletive words, but managed to keep them to myself.

l. I decided to do a small amount of undermining superiorly (3-4mm), but not inferiorly, in order to prevent going into the irradiated area and to preserve the blood supply coming into the wound. Even with the undermining, the gap still persisted at 2-3mm.

m. 4 small galeotomy incisions (1cm in length) were made along the donor incision, to improve mobility and stretch-ing. They failed to do much.

n. Towel clamps were gently applied and after 5-10 min-utes, the gap was reduced to 1-2mm.

o. At this point I decided not to pursue any more strategies to close the gap completely, to avoid too much trauma to the already frail tissue.

p. Deep sutures were attempted, but the tissue started to tear so this was abandoned.

q. Skin sutures were applied with 4.0 Mononylon, approxi-

Figure 4. Pre-operative skull X-ray—lateral view.

Figure 5. Pre-operative skull X-ray—AP view.

Figure 6. Proposed donor strip before harvesting.

Figure 7. Proposed recipient area avoiding the soft spot.

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mating the skin edges as much as possible but gently, without putting too much pressure on the edges. The resulting gap of 2mm was left open to heal by secondary intention (Figure 8).

r. After sutures were applied, the suture line was covered with Bacitracin ointment and was occluded with sterile Telfa and sterile gauze.

s. Hibiclens solution was used to prepare the recipient area of the scalp.

t. No tumescence or epinephrine were used in the recipient area, in order to preserve the vascular supply as much as possible.

u. Before the recipient sites were made, the skin was cleansed with Hibiclens. 18-gauge needles were used to create the recipient sites, bent to create a depth of 3-4mm. Dense-packing was avoided. Instead, we opted for even distribu-tion of hair, knowing that the patient would come back if necessary for a second surgery for density (Figure 9).

level laser treatments were done in the office every other day for the first 10 days.

Patient EvolutionOn a routine phone call on the night of the procedure, the

patient stated that she was having significant pain in her donor site (7-8 out of 10), particularly the central portion of it, but the pain was adequately controlled with a combination of Ibuprofen and Hydrocodone/APAP. She denied any major bleeding and the bandage stayed dry overnight.

On the first post-op day, the donor bandage was removed and the donor area looked good, with a small amount of coagulated blood now filling the gap between the edges. The patient’s pain was better (5-6 out of 10) and she continued to show good prog-ress and good healing.

Fortunately, the patient recovered without any problems, and the sutures were removed on the 14th day post-op. No tissue necrosis was noted on the donor area, and the incision showed nice granulation and healing.

The patient came for follow-up visits at 4, 8, and 12 months, and steady hair growth was noted in the recipient areas. At the 12-month visit, she had a big smile on her face and her husband was also very happy with the changes he noticed on her. She was feeling much more confident with her hair and could not wait to have another, smaller procedure to improve density in the area that was treated. The final donor scar measures 2mm in width at its widest point. The patient is able to conceal it with no problems and is not worried about it (Figure 10).

Figure 8. Donor area immediately after closure; notice the gaps highlighted by the yellow areas.

Figure 9. Recipient area immediately after graft placement.Figure 10. 12-month’s post-op. Good growth and results. Donor scar is shown in the yellow rectangle.

v. The patient tolerated the procedure well. A total of 1,693 follicular unit grafts were transplanted (we had originally planned for 1,800-2,000 FUs).

w. Patient was instructed to return to the office the next day for a post-operative evaluation and hair wash. I advised her of the possibility of increased pain in the donor site, due to the tight closure. I also discussed with her and her husband the possibility of hair loss along the incision and the possibility of an area of necrosis that would have to be addressed later, if necessary.

3. Post-operative managementa. Patient was prescribed pain control according to our

standard protocol.b. Patient was instructed to take Cephalexin 500mg tablets

3 times a day for 10 days, due to the open gap left along the donor site.

c. Hair washes were performed daily at the office and low

Thoughts and PearlsThis case illustrates very well how we are sometimes sur-

prised by intra-operative observations as far as the elasticity of the donor area. Countless cases have been reported on necrosis and hypertrophic scarring that occurred from donor areas that were too tight and/or the strip removed was too wide.

In this patient, even though all steps were taken to assess the donor elasticity before the strip was taken, the added precaution of taking less than what I marked is what I believe helped avoid a much worse complication, together with not undermining in-feriorly in this particular patient and with the choice of leaving a small gap in lieu of trying to pull the skin together with the sutures.

We must always be thinking about potential unexpected prob-lems, and should always be prepared to manage intra-operative complications. But the best approach is always to try to prevent problems.u

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We are pleased to continue our Ask the Fellows series in which unanswered clinical questions identified by participants at the Kuala Lumpur meeting are answered by our Fellows. As we saw last issue, their replies are clear and comprehensive. It is evident that we have a great deal of knowledge and wisdom contained within our Society.

Ask the Fellows

Why are more doctors now preferring FUE? David Josephitis, DO, FISHRS

There are many different ways in which to address this ob-servation. Over the past decade, there has been a great rise in the number of FUE procedures performed worldwide. In fact, there was a six-fold increase in the total number of patients undergoing FUE from 2007 to 2013, whereas during the same time period, there was very little growth in the yearly average of FUT.* There appears to be more of an evolution in the use of FUE going on than there is simply more physicians choosing FUE over FUT. One factor among many may be that the indications for the use of FUE have been growing as physicians have improved their techniques leading to a concomitant increase in yield, a lower transection rate, and a more reliable result. FUE has opened up hair transplantation to more candidates than ever before. There are those patients who psychologically did not want the strip procedure and those patients who desired a shorter haircut who are now becoming new patients. FUE has been found useful as a way of getting more donor out of patients previously unable to do any more strip procedures. The procedure has also found value in giving surgeons an ability to harvest additional hair from other areas of the body, which was not practical before. And these are just a few examples. FUT may continue to be the procedure of choice for the majority of surgeons and their patients, but the broadening use and benefits of FUE will surely drive the field of hair transplantation to an ever-widening audience.

*International Society of Hair Restoration Surgery: 2007 & 2013 Practice Census Results. Retrieved from www.ishrs.org Media Center.

I met several unsatisfied patients after FUE from another clinic: Why and what should I do?Sara Wasserbauer, MD, FISHRS

This is always a tricky question: how do you deal with a dis-satisfied patient who has had work done somewhere else? The first order of business is to be professional. Try to refrain from passing judgment on the previous surgeon since you were not in the operating room during that last surgery to see for yourself what might (or might not!) have been done. It does harm to our profession as a whole when one surgeon belittles another in front of a patient.

Next, get as many facts as you can—including exactly what was done—and get the medical records from the other clinic. This might tell you why they are dissatisfied. Were their expectations higher than what could reasonably be accomplished? Did they start on medical treatment or have they had further hair loss since the surgery? Your question specifically notes that these were FUE patients and there is currently a lot of hype and false promises being promulgated on the Internet regarding that method of hair transplantation in particular, so be aware that the other clinic may not be completely to blame for an unsatisfied patient.

Finally, assess how well equipped you are to rectify the situ-ation. As physicians, we have a tendency to want to help every-one, and we can have a higher opinion of our own work than is warranted! (And I am not exempting myself from this category!)

If you understand what the problem was with the each pa-tient’s first surgery and it was a fairly simple issue (such as not transplanting enough grafts or progressive hair loss), consider re-transplanting the patient yourself, but be cautious. Addi-tional FUE is possible after a first (unsatisfactory) attempt, as is traditional strip surgery depending on the patient, so you are likely to have additional resources for obtaining grafts for your patient, but you still may not be able to reach the patient’s goals for his or her hair.

There are many options for getting a reasonable result for these patients (including SMP and starting medical treatment among others!), and making the effort on their behalf can be enormously rewarding. When in doubt, consult your fellow hair surgeons and always choose what is in the best interest of the patient, even if it means not treating them yourself.

How do you treat female androgenetic alopecia as well as is possible with androgenetic alopecia? Shelly A. Friedman, DO, FISHRS

Female androgenetic alopecia is also known as female pattern hair loss (FPHL) and can be treated in several ways: 1. Hair transplantation. Hair Transplantation in women is

very successful as long as the donor region is insensitive to dihydrotestosterone (DHT). Unlike males, who typically do not bald or thin over the posterior occiput and parietals, women frequently experience scalp thinning over the parietals and occasionally over the posterior occiput. In the younger woman, it is difficult to “read the future” regarding future areas of hair thinning. Statistically, more women are not good candidates for hair transplantation as compared to their male counterparts.

2. Low level laser therapy (LLLT). LLLT has proven to be very successful in controlling future hair loss and miniaturization. By increasing adenosine triphosphate (ATP), there is a release of energy and stimulation of the metabolic process required for hair growth. There is also a release of nitric oxide resulting in an increase in scalp blood flow. LLLT has the following effects: a. Increases cell survivalb. Reduces follicular apoptosis c. Reduces inflammationd. Increases the anagen phase and decreases the telogen

phase e. Increases hair tensile strength f. Reverses miniaturization

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3. Minoxidil (Rogaine®). Minoxidil acts as an arteriolar vaso-dilator that opens potassium channels. Minoxidil sulfate is the active metabolite that stimulates hair follicles.

4. Spironolactone (Aldactone): Spironolactone is a potassium-sparing diuretic with antiandrogen properties that has been successful in stopping hair loss in some women.

5. Finasteride (Propecia®). Finasteride inhibits type II 5-alpha-reductase, interfering with the conversion of testosterone to 5-alpha-dihydrotestosterone. Propecia is not FDA cleared for women due to potential birth defects.

What technical factors increase the risk of necrosis in the recipient area?Scott A. Boden, MD, FISHRS

Scalp necrosis caused by localized microcirculatory collapse is a serious complication and can occur in both the donor and recipient areas.1,2 Any factor that decreases the blood supply may induce an ischemic or potentially necrotic response in both the donor and/or recipient area.3 Although the scalp is well vascular-ized, risk of recipient area necrosis is increased when local blood supply is compromised and cannot meet vascular demand within the recipient zone. Pre-existing medical conditions including prior scalp surgery (e.g., recipient site scarring, scalp reduction, brow lift), diabetes mellitus, and atrophic skin changes may predispose a patient to recipient area necrosis.

Avoiding recipient area necrosis is critical; early recogni-tion of potential vascular compromise may prevent progres-sion. At the first sign of delayed capillary refill or cyanosis, the surgeon should stop and assess possible contributing factors. These factors may include “dense packing” of incision sites that overwhelm local blood supply or incision sites that are too large or deep, causing damage to the local vascular bed. Risk of ischemic injury and scalp necrosis can be mitigated by limiting concentration of epinephrine-containing solution and thereby avoiding excessive vasoconstriction.

Patients who smoke should be encouraged to quit or at least stop smoking in the weeks prior to and following surgery. Nicotine may cause vascular lesions from inflammation3 and have deleterious effects on microcirculation. For smokers who undergo hair transplantation, it is recommended to reduce epi-nephrine concentration, avoid dense packing techniques, and follow the patient closely in the post-operative period.

References1. Konior, R.J. Complications in hair restoration surgery. Fa-

cial Plast Surg Clin North Am. 2013(Aug); 21(3):505-520.2. Unger, M.G. Postoperative necrosis following bilateral

scalp reduction. J Dermatol Surg and Onc. 1988(May); 14(5):541-543.

3. Perez-Meza, D., and R. Niedbalski. Complications in hair restoration surgery. Oral and Maxillofacial Surg Clin North Am. 2009(Feb); 21(1):119-148.

How can I minimize my FUE transection rate?Robert M. Bernstein, MD, FISHRS

For the past 2½ years, I have performed FUE exclusively us-ing the ARTAS® Robotic System, as I found that my yield was higher using the robot than with handheld devices. The basic principles to reduce transection apply to both manual and robotic techniques, although I find them easier to apply with the robot.

1. Patient selection. Patients with tight or tough scalps are generally the best candidates for FUE. Patients with loose, distensible scalps generally have the greatest transection rates and are often poor candidates.

2. Motorized devices. A motorized or robotic device will have less side-to-side movement than when using fingers to rotate the punch.

3. Tension. A mechanical tensioner is applied to the scalp to create very consistent traction on the area to be robotically harvested. In regular FUE procedures, manual traction can create tension to decrease tissue movement and decrease transection.

4. Tumescence. The superficial injection of fluid just before extraction can help in some, but not all, FUE cases to decrease transection by increasing rigidity (stability) and slightly changing the angle of the hair.

5. Angle of entrance. The angle that the punch enters the scalp should be less acute than that of the emergent hair. The robotic device adjusts for this automatically.

6. Speed of rotation. Rapidly rotating punches seem to cause less transection than slower ones.

7. Punch sharpness. Blunt dissection seems to yield less tran-section than a very sharp punch.

8. Punch depth. A more superficial punch depth causes less transection on cutting, but may cause more damage (shear-ing) on the extraction step.

9. Punch size. A larger punch will always cause less transec-tion than a smaller one, although it will also produce more scarring. The punch size needs to be determined on a case-by-case basis.

10. Magnification. The greater the magnification used, the more control you will have over the extraction and the less transection.

11. Graft selection. The larger the FU selected (with respect to # of hairs), the greater the transection, but the smaller the FUE the more scarring/hairs harvested. These two factors have to be balanced with the aesthetic needs of the patient.

12. Extraction. There is less trauma to follicles when extracted manually (i.e., with forceps) than with suction.

Bibliography 1. Bernstein, R.M. Integrating robotic FUE into a hair trans-

plant practice. Hair Transplant Forum Int’l. 2012; 22(6): 228-229.

2. Rose, P.T., and B. Nusbaum. Robotic hair restoration. Der-matol Clin. 2014; 32:97-107.

How do you harvest follicles in an FUE megasession?Craig Zeiring, MD, FISHRS

Careful planning of the donor site in an FUE megasession is crucial. Typically, the donor area is completely shaved, but this is not always the case, especially if the patient has previous strip scarring. We harvest follicles with the SAFE system and the ARTAS® Robotic System. Whether we use manual or robot, the donor area is marked with a surgical marker or China pencil. The donor area is mapped out to predict yield and to keep spacing even and cosmetically ideal

For a manual FUE megasession, (I use the SAFE system) the donor area is mapped. An appropriate sized punch is selected

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for the patient. The angle and direction are carefully evaluated. The RPM is selected, with appropriate tension applied by the assistant, and the first punch is performed. It is immediately harvested to evaluate for surrounding tissue as well as possible transection. The puncture depth is determined by the surgeon, in order not to bury the follicle. The angle is adjusted by the surgeon to avoid transection. A few additional follicles are harvested and quickly evaluated for transection. Once the angle, depth, and RPM are appropriate for the patient, the section of donor is harvested and extracted. Each attempt at extraction is well thought out, well executed, and repeated many times. Care is taken to avoid overharvesting, with the goal of approximately 15% of donor follicles being removed. The remaining mapped donor area is harvested and extracted, with careful observation to see if any transection is occurring. For patients who have previous scars, care is taken to harvest between the scars, without overharvesting.

For ARTAS robotic FUE, the donor section is mapped out using the tensioner. The puncture depth, coring depth, angle, and RPM are determined by the system, but continuously ad-justed by the surgeon at the hair pendant. We use a paper grid to determine the placement of the tensioner, and with each placement of the tensioner, ensure that the skin blanches and the tensioner is tight to the scalp. Occasionally, tumescence is performed. Approximately 5-10 punches are made at the start and harvested to evaluate if the appropriate amount of tissue sur-rounding the bulb is present and if any transections are present. Once the appropriate settings are determined, the robot harvests the follicles within the tensioner. The first grid is fully harvested and harvest continues with random extraction of follicles while the robot is harvesting within the tensioner to ensure a minimal amount of transection. Typically, 1-2 grids are done at a time without stopping to reduce the amount of time spent in the robot. If transections are present, then the robot is paused, and the set-tings adjusted, and the robot is allowed to harvest an additional 5-10 follicles before proceeding. The spacing between follicles is typically 1.8 mm to allow sufficient donor follicles to remain.

Patient position is important for maximal harvest as well as patient comfort. We have the patient typically in a donut pillow for comfort and to keep the patient still. Occasionally, we have patients on their side in order to harvest the follicles at more difficult angles.

With both harvesting techniques, particular care is taken to feather the donor area for optimal post-op aesthetics.

Please note that all harvesting is completed in one day. If a patient is receiving more than 1,500 grafts, then the recipient sites are made the afternoon before.

How do you avoid poor growth?Wen Yi Wu, MD, FISHRS

Poor growth can arise because of graft dehydration, physical trauma to the grafts, excessive placing time, popping of grafts, grafts placed too deep, piggybacking, empty recipient sites, bent grafts, and/or poor graft angle and direction.

Good visualization is critical to successful graft placement:• Use magnification when placing.• Keep all eyes on the target; the placers need to limit the

number of times they look away from the recipient sites

to avoid losing the positions, increasing the chance of missed sites, piggybacking, and wasted time.

• Follow a pattern; this is more efficient than randomly placing the grafts and continually searching for empty sites.

• Leave donor hair a little longer; this helps the placer locate the filled sites and make adjustments easier.

• Control bleeding; excess bleeding is one of the common causes of poor visibility, traumatic placing, and prolonga-tion of procedure time.

Avoid graft dehydration:• Make sure that all grafts are submerged at all times in

the holding solution.• Spray grafts frequently when not in solution.• Limit the number of grafts taken out of solution and

placed on a finger for implantation.

Maintain proper graft sizing:• A snug fit of the grafts and incisions is crucial.• When grafts are too big, forceful insertion is necessary,

which can lead to multiple failed attempts and popping.• When grafts are too small for the sites, buried grafts and

piggybacking may result.

Maintain proper incision spacing and depth:• When sites are too close, popping may occur.• Incisions that are made too deep may cause increased

bleeding, buried grafts, and pitting. • Incisions made too shallow may lead to difficult graft

insertion and popping.

How do you prevent and manage bleeding during megasessions?Melvin L. Mayer, MD FISHRS

Remember the THREE P’S:PREVENTION: There are many supplements, medications,

and activities that increase coagulation time. Since blood is the “glue” that initially holds the graft in place, supplying nutrients and hydration, it is preferred to have the blood as viscous as pos-sible on surgery day. Therefore, you should advise patients to avoid ASA, fish oil, and blood thinners such as Eliquis, Xarelto, Plavix, Coumadin, and several others for about one week prior to surgery. You should also take a detailed history including ALL medications and understand the action of each. Before any anticoagulation is discontinued, you should work in consultation with the patient’s treating physician.

To help prevent excessive bleeding, it is imperative to limit the depth of the incision to the varied length of the follicular units, usually 3.5-6.0mm. Also, the width of the blade is important to match a snug fit. You might consider decreasing the density of receptacle sites.

PRESSURE: Allow tumescence including 1:100K dilution of epinephrine in normal saline to set for 5-10 minutes before making receptacle incisions. Typically 10cc’s in the front half and the same in the crown usually suffice. Repeating the dose using a #30 gauge needle after a couple of hours may be helpful. Spraying frequently with cold, normal saline is helpful. It is a must to keep the recipient field CLEAN and DRY, refreshing the gauze frequently used to apply GENTLE PRESSURE on the

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most recently placed graft. If a graft “pops,” replace it quickly to stop bleeding and again hold GENTLE PRESSURE while picking up another graft with the forceps.

PATIENCE: Rotate staff, if available, to help reduce anxiety when placing an oozing patient. Keep your level of frustration down; realize that occasionally you will have a patient who takes 1-2 hours longer than usual to place. Always use the “art of gentle insertion.”

How do you prevent and treat donor infection?Eileen Tan, MBBS, FISHRS

In general, hair transplantation surgery is considered a clean procedure. Antibiotics prophylaxis is not mandatory for every patient except in immunocompromised state. I would like to share some useful tips to prevent scalp infection after surgery.

Pre-operative. One useful preventive tip is to prescribe an antiseptic wash, such as Cetrimide or Hibiclens, to be used 3-5 days prior to the procedure. Make sure that the patient does not have an active scalp condition or folliculitis, which requires medical intervention, before scheduling an elective surgery.

Intra-operative. To prevent surgical site infection, doctors and other healthcare providers will take several aseptic measures to ensure that the surgical site is as clean as possible. This includes cleaning the skin at the surgery site with chlorhexidine solution.

Post-operative. Daily washing of the hair is important after the surgery. Shampooing helps remove blood and debris and will gently dislodge the “crusts” or scabs on both the donor and recipient sites. Topical antibiotic creams, such as mupirocin, are applied to the donor site for the first 2 weeks.

Treating Donor Site InfectionDonor site infection is fortunately rare. The signs of scalp

infection include localised tenderness, painful and itchy bumps, purulent discharge, and crusty appearance. Bacteria culture is advised to be taken from the inflamed site prior to starting antibiotics. A topical antibiotic ointment and oral anti-staphylo-coccal antibiotics are prescribed for several days. Good hygiene practices, such as using clean towels, avoiding scratching, and avoiding excessive sweating, aid in the wound healing process.

Patient InstructionsTo prevent infections in skin wounds, follow these tips:• First control bleeding, and then clean the wound with

soap and water.• Keep all foreign matter (i.e., hair, clothing, dirt, and

fluids) out of the wound.• Do not try to remove matter embedded in the wound.• Use sterile materials for the first dressing of the wound.• See your doctor for final, definitive cleaning of the

wound.

What is the correct way to report our cases? Graft count or hair count?Vance Elliot, MD, FISHRS

My preference has always been to record both graft count and hair (follicle) count. We record the number of grafts of each type and the average follicle content in each graft category and then calculate the estimated total follicle count transplanted based on those numbers. In my opinion, both numbers are important.

In the call for abstracts for the ISHRS annual meeting, the

following guidelines are given: “For ISHRS meeting presenta-tions and articles for the Forum, it is important to report on the number of hairs, and not only the number of grafts. If you have HairMass Index data, then you should also include it. You should also disclose the methodology used to calculate all rates (e.g., sur-vival rate, transection rates). Finally, you should include proper pre- and post-operative photographs (before and after photos) when reporting your cases. Photographs must be high quality, clear, have good lighting. For examples of proper photographs, go to: http://www.ishrs.org/content/faculty-information-2.”

How long should be the duration of time out of body from the time of extraction to placement?Steven Gable, MD, FISHRS

There are many factors that contribute to the survival of fol-licular unit grafts, and the length of time when a graft is extracted from the body and placed back is absolutely crucial. There have been several studies demonstrating decreased graft survival the longer time that a graft is out of the body. In 1996, Dr. Bobby Limmer’s landmark study1 showed out of body graft survival rates of 95% at 2 hours, 86% at 6 hours, 88% at 8 hours, 79% at 24 hours, and 54% at 48 hours after extraction when the grafts were stored in chilled normal saline. Since this report, many studies have been performed showing the effects of temperature variation of the holding solution (room temperature vs. cooler temperatures), alternative storage solutions (Lactated Ringer’s solution, Plasmalyte A, HypoThermasol®), additives (ATP), and many other solutions on graft survival. However, the basic tenet that these studies are compared against is the time out of the body, and the overall goal is to achieve a high survivability of the grafts not only in the short term, but also prolonged times out of the body.

In practice, hair restoration physicians should plan the pro-cedures to minimize the amount of time that the grafts are out of the body knowing the above statistics for normal saline, and also for alternative solutions as well. For practical purposes, focus-ing solely on time out of body, I plan my cases so that all of the grafts are placed within a goal of 6-8 hours after the strip has been removed, or 2 hours after the grafts have been extracted via the FUE (follicular unit extraction) method, alternating between graft extraction and placement so the grafts are placed as soon as possible. Also, if I am planning for a long case when the grafts may be out of the body for longer than 4 hours, I incorporate alternative storage solutions with strict temperature controls to maximize graft survivability.

Reference1. Limmer, R. Micrograft survival. In: D. Stough and R. Haber,

editors. Hair replacement. St. Louis (MO): Mosby, 1996; pp. 147-149.

How do you prevent and treat post-operative facial edema? Humayun Mohmand, MD, FISHRS

Edema, or swelling, caused by the retention of tissue fluid begins almost immediately at the time of surgery and its de-velopment continues for a short but variable period of time. Post-inflammatory edema usually appears 3-5 days after surgery when it moves down over the forehead and reaches the peri-orbital region.

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Prevention is the best treatment and includes both physical as well as pharmacological measures. Physical Measures include the following:

1. The fluid is massaged away.2. A cool pack is placed over the forehead for 15 minutes,

3-4 times a day.3. The patient is encouraged to sleep with upper body

elevated at 45 degrees.

Pharmacological measures include corticosteroids, which are commonly used for preventing edema. However, there is no conclusive evidence that oral or injected systemic cortico-steroids prevent or control edema after hair transplant surgery. Some have claimed to have reduced incidence of post-operative swelling from 20% to less than 5% by using systemic cortico-steroids and adding 50mg of triamcinolone acetonide to 50ml of lidocaine (1 mh/ml) for operative anesthesia.

The Abbasi solution has important implications in preven-tion of post-operative facial swelling. It consists of 100-200ml of N/S, epinephrine 1ml (1:1000), and triamcinolone 40mg. It reduces post-operative edema by 95-97%. Since 2005, I have used it on 8,000 patients with less than a 2% incidence of post-operative edema. However, elderly patients with loose skin have an increased incidence even with this solution. Use of ice packs helps bring down the swelling in such patients.

How do you treat a patient with general miniaturization of hair in both the recipient and donor regions?T.K. Shiao, MD, FISHRS

General miniaturization of hair, including recipient and donor areas, is found in diffused unpatterned alopecia (DUPA). DUPA was first described by Dr. O’Tar Norwood in 1975, but only fully incorporated into hair transplant workup by Drs. Bernstein and Rassman 1997 publication, Follicular Transplantation, Patient Evaluation and Surgical Planning.1

In addition to the regular Norwood Classes, there are two additional types: diffuse patterned alopecia (DPA) and DUPA. Despite their similarities during early stages (diffuse thinning in the front, top, and vertex with persistence of frontal hairline), their prognosis and treatment modality are vastly different.

DUPA, while uncommon in males, is the predominant type of hair loss in females. These patients have diffuse thinning in both the donor and recipient areas; that is, the miniaturization process occurs over the entire scalp, so that the person lacks a stable permanent zone. Under magnification, their donor density is in the range of 1.0-1.5 hair/mm2 with donor minia-turization in excess of 35% (often 50% or greater). Because the donor hair is undergoing the same balding process as the recipient area, the hair that is transplanted will eventually thin. The transplanted DUPA patient may experience extensive shedding of existing miniaturized hair in the area that receives the new grafts, continued loss after the transplantation, and a donor scar that may become visible over time. This condi-tion is therefore a relative contraindication for hair restoration surgery.

In treating suspected DUPA, non-androgenic differential diagnoses must be first considered, especially in women. Workup includes anemia, thyroid disease, connective tissue disease,

gynecological conditions, and severe emotional problems. Medi-cal therapy includes minoxidil, finasteride (when appropriate), LLLT, and conservative hair transplant, preferably FUE harvest-ing small number of grafts over a large donor area.

Case Presentation

H.M. was a 52-year-old female in good health. She first noticed her hair loss when she was 45. Her hair loss progressive-ly worsened and showed no sign of stopping. She had no significant past medical history and had a clean soc ia l h i s to ry . Significant fam-ily history is that her mother started wearing wigs in her 40s. H.M. was using 2% Rogaine and several nutri-tional supplements from her hair styl-ist at the time of presentation.

Physical exam-ination showed Ludwig type II pattern with significant thinning in the donor area, microscopic examination showed normal density of 100 FU/cm2 but only 1-2 fine hairs in most FUs.

Initial treatment plan included topical minoxidil, intensive LLLT therapy using LaserCap, and a small 309 FU FUE session for the posterior two-thirds of her left part and the ipsilateral side of the vertex. ACell was placed with the grafts into the recipient sites and also used to fill the donor sites.

Over the next 21 months, H.M.’s hair showed significant improvement. However, on the untransplanted side of the ver-tex, the scalp still showed through and H.M. wanted her entire part strengthened. In a second FUE, we harvested 488 FUs and transplanted each FU with two plucked hairs into her part and vertex. She continued the same medical regimen (topical minoxidil + LLLT) post-operatively, and at 6 months notable improvement can be seen. Between her 6-month and 12-month follow-up, H.M.’s antiaging physician put her on testosterone supplement along with ¼ of 5mg finasteride. Photos of her at 12-month follow-up are shown below. In this case of DUPA, medical therapy with topical minoxidil, aggressive LLLT, and conservative surgical treatment using FUE and ACell resulted in a very satisfied patient.

Reference1. Bernstein, R.M., and W. R. Rassman. Follicular transplan-

tation: patient evaluation and surgical planning. Dermatol Surg. 1997; 23:771- 784.

H.M. Before (top) and after (bottom)

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What creates the perfect hairline?Bertram Ng, MBBS, FISHRS

The basic in hairline design is well described in Unger’s and Lam’s textbooks.1,2 Here are just some of my personal tips.

Naturalness: The hairline has always been described as the upper frame of the face. It should be created in such a subtle way that the eyes remain the focus of attention.

Density: If you cover a small area with a good density, the patient is happy to pay for a second procedure to cover more. If you cover a large area with low density, the patient will either demand a refund or a free session, or badmouth you on the internet. So don’t be too generous in offering a low hairline. The lowering of just 1cm will demand an extra 300-400 grafts.

Aspect: Here, aspect refers to the ratio between the height and width of the forehead. When lowering the frontal hairline, you may have to bring forward the temporal hairlines as well. The fronto-temporal points should be located in a line above the lateral canthus.

Symmetry: Take some pictures of the hairline you’ve drawn. Ask the patient to check the camera pictures as well as the mir-ror reflected images. Explain that there may be a discrepancy in symmetry between the two. Retrace the hairline until the patient is happy with both.

Widow’s peak: Setting a midpoint with the widow peak may reveal any facial asymmetry. Try not to create one unless the temporal hairlines are equal distant from the midline.

Orientation: Ask the patient how he or she would like to comb his or her hair. The angle and direction of the transplanted hair should flow with the existing ones to help in styling.

References1. Unger, W., et al. Surgical Planning and Organization. In:

Hair Transplant, 5th Edition. Informa, 2011; pp. 106-1902. Lam, S. Creative Thinking Through Case Studies 360. In:

Hair Transplant 360 for Physicians. Jaypee, 2011; pp. 143-169.

What are the best ways to treat female alopecia?Kongkiat Laorwong, MD, FISHRS

Women who present with hair loss should have a detailed medical history, scalp examination, and workup to rule out the other causes that can be treated, such as polycystic ovarian cyst, hypo- and hyper-thyroidism, or chronic iron deficiency, and scalp biopsy should be done if necessary before the diagnosis of female pattern hair loss (FPHL).

The treatment should start with non-surgical options and then consider the addition of hair transplantation. The non-surgical treatments include topical 2% and 5% minoxidil lotion or foam type (only FDA approved), oral spironolactone, finasteride, contraceptive pills, ketoconazole shampoo,1 low level light therapy (LLLT), and platelet rich plasma (PRP) injection. These treatments can be combined to make the results better and in-crease patient satisfaction; patients should be encouraged to try treatment for at least 6-12 months.

During treatment, follow-up and monitor the result or pro-gression with dermoscopy, HairCheck, and global photography, and also monitor for side effects.

Hair transplantation should be considered in Ludwig type 2-3 hair loss after non-surgical treatment has been tried for 6-12 months. Assessment of donor hair is the most important factor determining the result because not everyone is a good candidate. The consequences and complications of the procedure, such as the shock loss, must be discussed with the patient to avoid unrealistic expectations.

After surgery, non-surgical treatment should be continued to prevent further hair loss and stabilize the existing hair, because the hair loss will otherwise worsen.

Reference1. Rogers, N. Medical therapy for female hair loss (FPHL).

Hair Transplant Forum Int’l. 2014; 24(3):86-88.u

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74


Introduction to UK Hair Restoration Surgery Clinical Standards Greg Williams, MBBS, FRCS (Plast) London, UK [email protected]

The British Association of Hair Restoration Surgery (BAHRS) convened a meeting on January 26, 2014, to discuss and establish BAHRS Members “Common Practice” on the subject of Optimising the Patient Experience and Graft Care with a view to establishing an initial set of UK Hair Restoration Surgery Clinical Standards on the same subject. The Association is unaware of a similar set of standards having been agreed upon and published by any other ISHRS Global Council Regional Association Member.

It is acknowledged that “common practice” does not neces-sarily entail “best practice” and that there might be an individual, or minority of individuals, whose practice is outside the norm but from whom the majority could learn and adapt their practice. Common practice therefore is only a measure of activity at one point in time and might vary when the same parameters are discussed in the future.

Also, for this purpose, “common practice” was taken as the practice undertaken by the majority of respondents. This is there-fore dependent on the number of respondents at the time of the survey. For example, if 11 out of 20 respondents performed an activity in a certain way, that would be deemed common practice. If the same 11 individuals performed an activity, but the survey was taken at a later date when there were 23 respondents and 12 did not perform the activity that way, then it would no longer qualify as common practice.

From the 2014 BAHRS Members “Common Practice” a subset of items was selected where it was agreed upon that the common practice represented best practice and there was no debate or controversy about this. This was then collated as a first version of the UK Hair Restoration Surgery Clinical Standards, which was ratified at the BAHRS Annual General Meeting on July 26, 2014. This first version is limited to a small number of standards relating to optimising the patient experience and graft care, but will be built upon in the future adding standards to do with follicular unit extraction, infection control, systems and safety, etc.

It is hoped that other regional associations (and the ISHRS) will develop and adopt similar sets of Clinical Standards that will be accessible to patients from the relevant regions to educate them on what they should expect before, during, and after their hair transplant surgery.

Professional Standards DevelopedThe following UK Hair Restoration Surgery Clinical Stan-

dards (Version 1, 2014: “Optimising the Patient Experience and Graft Care—Sharing Protocols and Establishing UK Common Practice”) have been developed by the British Association of Hair Restoration Surgery (BAHRS) in conjunction with the BAHRS Professional Standards for Hair Transplant Surgeons following the January 26, 2014, meeting.

These UK Hair Restoration Surgery Clinical Standards (Ver-sion 1, 2014) represent recommendations only, but patients can expect that all BAHRS Hair Transplant Surgeon members will follow these standards in principle unless there are individual circumstances when an alternative practice may be used. It is

anticipated that further versions will be developed as other areas of BAHRS Common Practice are established.

General Principles and PracticePatients undergoing hair restoration surgery should expect

a BAHRS Hair Transplant Surgeon member to abide by the principles found in: • The General Medical Council’s (GMC’s) 2013 publication

Good Medical Practice: http://www.gmc-uk.org/guidance/good_medical_practice.asp

• The Royal College of Surgeons of England’s 2008 publication Good Surgical Practice: http://www.rcseng.ac.uk/publica-tions/docs/good-surgical-practice-1 (and the future version that began development in 2014)

• GMC Guidance, 2008: Consent: Patients and Doctors Mak-ing Decisions Together: http://www.gmc-uk.org/guidance/ethical_guidance/consent_guidance_index.asp

• The Academy of Medical Royal Colleges, 2008: A Clinician’s Guide to Record Standards—Part 2: Standards for the Struc-ture and Content of Medical Records and Communications When Patients Are Admitted to Hospital: https://www.rcoa.ac.uk/sites/default/files/FPM-clinicians-guide2.pdf

Principles and Practice Specific to Hair Restoration Surgery

With Regards to Pre-Operative Patient Preparation, BAHRS Hair Transplant Surgeon Members Should:• Routinely send written clinical information to their patients

before the day of surgery including general information about hair transplant surgery and the consent form for the planned surgery.

• Routinely send written instructions to their patients to stop doing or taking certain things the day of surgery (such as smoking, non-steroidal anti-inflammatory drugs [NSAIDS] including aspirin if more than 75mg, some vitamin supple-ments, and some herbal remedies).

• Routinely orally instruct their patients to do certain things (such as donor site scalp massage) or take certain things (such as minoxidil or finasteride) before the day of surgery, but the specifics of the instructions may vary from patient to patient.

• Routinely photograph their patients before surgery using standardized lighting, positioning, views, and background.

With regards to Intra-Operative Patient Care, BAHRS Hair Transplant Surgeon Members should:• Routinely use an antiseptic to wash their patients’ scalp/hair

immediately pre-op.• Not routinely give their patients an intravenous sedative as

part of the procedure. • Routinely use a combination of lignocaine and bupivacaine

as local anesthetic to perform their hair transplant procedures. • Routinely give their patients intra-operative analgesia. • Routinely give their patients refreshments at a set stage during

the procedure.

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Executive Director’s note: For the past several years, the ISHRS has had an ongoing project to define current and best practices in hair restoration surgery (HRS). The project ex-amines all aspects of the HRS practice, including diagnostic skills, patient education and consultation routines, surgical procedure routines, personnel utilization, and management of quality assurance and risk management. These aspects have been categorized into 14 modules. Overall, the goal of the project is to identify important learning objectives for the ISHRS’s continuing education programs by examining the gap between “best practices,” compared with the “current practices.” The first three modules have been completed. Data analysis has been conducted and a manuscript is be-ing prepared for publication of the first three modules. The ISHRS membership will be notified when the publication is released. –VCu

• Routinely provide their patients with audio-visual entertain-ment during the procedure.

• Routinely clean their patients’ hair at the end of a “strip” procedure.

• Routinely monitor their patients’ pulse, blood pressure, and oxygen saturation during the procedure.

• Routinely try to reduce the potential for swelling after the use of tumescent fluid—either pharmacological with, for example, oral prednisolone, or physiological, such as sleeping position advice or the use of topical ice packs.

With regards to Post-Operative Patient Care, BAHRS Hair Transplant Surgeon Members should:• Supply their patients with analgesic and/or anti-inflammatory

medication post-operatively.• Advise their patients to wash their hair around the “strip”

donor site within 48 hours. • Provide their patients with advice on post-operative follicular

unit extraction (FUE) donor care.• Provide their patients with advice on post-operative recipient

site graft care. • Supply their patients with written post-operative care instructions. • Supply their patients with an out-of-hours emergency contact

telephone number.

With regards to Graft Care, BAHRS Hair Transplant Sur-geon Members should:• Chill the follicular unit grafts during the procedure. • Consider the maximum safe “out of body” time for follicular

unit grafts to be 8 hours, but would routinely try to have follicular unit grafts implanted within 6 hours of extraction/removal.

• Not allow Hair Transplant Surgical Assistants to make fol-licular unit extraction (FUE) incisions.

• Supervise Hair Transplant Surgical Assistants who extract FUE grafts.

With regards to Patient Follow-Up, BAHRS Hair Transplant Surgeon Members should:• Routinely have their patients telephoned in the first week

after surgery by a member of their team. • Routinely see their patients at least once for follow-up of the

hair transplant result. • Routinely take post-operative photographs to document the

outcome of the hair transplant.• Periodically ask their patients for written feedback (Patient

Experience Questionnaire).

With regards to Recording the Patient Experience—Medical Notes, BAHRS Hair Transplant Surgeon Members should:• Have varied consent forms for different types of hair trans-

plant procedures (e.g., scalp, eyebrows, beard/moustache, scars, revision/reconstruction, etc.) that cover risks and complications.

• Routinely record the hair transplant surgery start time and finish time.

• Routinely record volume/dosage of local anesthetic used during the hair transplant procedure.

• Routinely record total number of follicular unit grafts trans-

planted and the breakdown of follicular units with respect to number of hairs.

• Routinely tell their patients the number of grafts/hairs trans-planted.

• Routinely record procedure complications or adverse events. • Routinely offer to send a letter to their patients’ General

Practitioner regarding the hair transplant surgery.

Editor’s note: I want to thank Dr. Williams for sharing the Practice Standards adopted by the BAHRS. I think this is a very significant accomplishment and hope that other re-gional societies of the ISHRS will consider adopting similar standards.

Agreeing on practice standards is not an easy thing to do. Earlier in my career I was in charge of the quality assur-ance programs and Joint Commission Accreditation for two hospitals in the United States. Part of what we had to do was develop practice standards that could be used to measure qual-ity of physician and institutional performance. This was hard work that entailed extensive review of the medical literature to establish an evidence base for practice standards and then coming to agreement in committee on the exact wording of standards. In order to pass the committee, there had to be unanimous agreement.

In establishing its standards, the BAHRS has used practice surveys and simple majority as the basis for setting standards. I wonder if this is really rigorous enough to establish true standards. I wonder if standards would be more reliable if practiced by 75% or more of intermediate to advanced prac-titioners and supported by literature citations. I also think that standards should allow for inconsequential variation. For example, the BAHRS standards include the recommen-dation to: “Routinely use a combination of lignocaine and bupivacaine as local anesthetic to perform their hair transplant procedures.” I think this would read better and better reflect legitimate variations in practice if it included the phrase “or related local anesthetic agents.”

As Dr. Williams points out this is only a first step in an ongoing and evolving process. I think the BAHRS has made a great beginning for us all. –RHT

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Hair’s the Question* Sara Wasserbauer, MD, FISHRS Walnut Creek, California, USA [email protected]*The questions presented by the author are not taken from the ABHRS item pool and accordingly will not be found on the ABHRS Certifying Examination.

I got a new toy a few Christmases ago—a magnifier for my iPhone camera. I have to tell you: I LOVE this thing! For diagnositic usefulness during a consult, you cannot beat magnification (Dr. Nicole Rogers even won the poster competition in Alaska with a little device like this)! If you are not already using it for your patients, having a camera like this (or a video microscope) enables instant analysis and feedback for your patient. They will love it and you will, too. Now let’s test your skills for diagnosing some of these commonly seen photomicrographs of the scalp.

1. This patient has been:A. Shaving his hair recentlyB. Plucking out his own hairC. Using keratin hair fibers (aka Toppik®, etc.)D. Getting regular “Brazilian blowouts”

4. The following microscopic photo is an example of:A. An ingrown hairB. Diffuse folliculitisC. Donor area 6 months post FUE hair surgeryD. Follicular plugging

2. This patient shows evidence of:A. Exclamation point hairs indicating trichotillomaniaB. Alopecia areataC. Loss of follicular openingsD. Miniaturization

3. The above microscopic photo was most likely taken on which part of the patient’s body?A. HairlineB. ChestC. BeardD. Donor area

5. What recently happened to the hairs in this photo? A. They were recently backcombed as evidenced by their

ruffled cuticle.B. They were recently cut as shown by their blunt (i.e., not

tapered) ends.C. They show evidence of recent electrolysis.D. They recently experienced a laser hair removal treatment.

6. The brow hairs in this photo are evidence of: A. Trichotillomania due to their short lengths in various

stages of growthB. Recent trimming due to their blunt (not tapered) endsC. Recent growth from transplantation due to their various

stages of growthD. Recent thermal or chemical damage due to their blunt

(not tapered) ends

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u

[ Answers on page 78

7. The hairs in this photo are:A. Almost 100% miniaturizedB. Fine women’s facial hairsC. Located at the back of the patient’s neckD. Brow hairs

Bonus Question9. The following photo pairs A:B and C:D were taken to il-

lustrate the growth of grafts in the transplanted areas. Both patients had androgenetic alopecia. Which of these photos represents the DONOR area?A. A and D are the donor areas.B. A and C are the donor areas.C. B and D are the donor areas.D. B and C are the donor areas.

8. Compare these two photos of African American hair (same scalp, 1cm apart); one shows affected area of scalp and the other an unaffected area. What might be causing the alopecia in the affected area photo?Affected:Unaffected:A. Trichotillomania, as evidenced by the hairs of multiple

lengths presentB. Scarring (cicatricial) alopecia, as evidenced by the loss

of follicular ostia presentC. Androgenetic alopecia, as evidenced by the miniaturiza-

tion presentD. Folliculitis decalvans, as evidenced by the peri-follicular

inflammation present

A B

C D

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Hair’s the Question from page 77

1. C. When I first saw this through magnification, I thought it was a recent haircut, but since the fibers are so much finer than the rest of the hair answer A is incorrect. Had the hairs been plucked, you might see an empty follicular ostia, but that is not the case. “Brazilian blowouts” can cause breakage, but again, that would be seen further along the shaft and would not leave such fine fragmentary fibers on the scalp surface.

2. D. Miniaturized hair among a few robust follicular units is consistently seen in androgenetic alopecia. Exclamation point hairs are narrower at the base and are a characteristic finding in several alopecias including alopecia universalis, totalis, and areata. In this photo, follicular openings can be seen. Trichotillomania would show broken hairs in various stages of growth.

3. D. “Dis is Dee Donor Area!” (I think Arnold Schwarzenegger said that). Chest hair contains more single and double-haired follicular units. Beard hair likewise would lack a 5-hair fol-licular unit and tends to have less uniformity to the hair shaft and a thicker caliber (hair shaft diameter).

4. D. A hair is growing OUT, so it is not an INgrown hair. Donor area 6 months post FUE would show small scars and a diffuse folliculitis would involve more of the FUs in this photo than just one!

5. B. Recent electrolysis would show a profound lack of hair and recent laser hair removal would either show the same OR some singeing with resultant peri-follicular erythema if in the immediate past. Backcombing does ruffle the cuticle, but that cannot be seen at this level of magnification.

6. A. I actually used this photo to prove to a young man that he was actually pulling out his own hair. The ends are blunt, so this is not new growth, and trimming would have left the hairs more or less the same length. For those of you who an-swered D, you can give yourself a half point, but the answer is incorrect since it would be difficult (though admittedly NOT impossible) to have chemical or thermal damage in brow hair.

7. D. Note the predominance of single-haired follicular units and directionality. These are not vellus hairs, as would be found on a female face, they are terminal and do not demonstrate interspersed miniaturization so much as a caliber (i.e., hair shaft diameter) gradient. Even hairs at the back of the neck would have some multi-haired follicular units. (Don’t believe me? Get some magnification and look for yourself!) However, I will give a half-point for answering C.

8. B. These two photos were taken within a centimeter of each other and demonstrate how cleary the loss of follicular ostia can give you the diagnosis of a scarring alopecia. Those with sharp eyes will also note a few tiny fibers from a keratin hair concealing powder (Toppik, etc.). There is no peri-follicular erythema in this photo, and although an argument could be made for miniturization in the “affected” photo, it is clearly not present in the “unaffected” photo, and thus androgenetic alopecia is not the whole answer.

9. B. I know this questions seems a little like “alphabet soup,” but B is correct since the photos labeled A and C have little to no miniaturization present. Miniaturization is the hallmark of androgenetic alopecia and can readily be seen in a micro-scopic analysis of a scalp.u

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Review of the Literature

e

Long-term Side Effects in Men Taking FinasterideSingh, M.K., and M.R. Avram. Persistent sexual dysfunction and depression in finasteride users for male pattern hair loss: a serious concern or red herring? J Clin Aesth Dermatol. 2014; 7:51-55.

In this commentary, the authors review data about long-term side effects in men who took finasteride. They specifically review the largest randomized, controlled trials to date investigating incidence of sexual side effects with finasteride. The 1992 Fin-asteride Study Group (895 men) showed no reports of irrevers-ible or prolonged sexual side effects. Kaufman’s 1998 study on finasteride for male pattern hair loss (MPHL) (1,558 men for 1 year, 1,215 men in the blinded extension over 5 years) showed that sexual side effects resolved in all patients after discontinu-ation of the drug and also resolved with time in most men who stayed on therapy. The only double-blind, randomized, controlled trial to report persistent sexual side effects was the PLESS trial (2003), in which only 50% of finasteride users with sexual side effects had symptoms resolve after discontinuation; whereas just

e

41% of the placebo group had resolution. In the Prostate Cancer Prevention Trial (2007), none of the 17,313 participants reported persistent sexual dysfunction.

In terms of depression, the authors found one retrospective case series of 19 patients who developed mood changes after starting finasteride for MPHL. All resolved after discontinua-tion of the drug. One prospective study followed 128 finasteride users for depressive symptoms over 1 and 2 months. Although the incidence increased with finasteride usage, all symptoms resolved after discontinuation of the drug. Overall, these large studies stand in contrast to the biased and poorly designed publi-cations by Irwig et al. reporting persistent sexual side effects and depressive symptoms even after discontinuation of finasteride.u

Nicole E. Rogers, MD Metairie, Louisiana, USA [email protected]

Challenges Associated with Eyebrow TransplantationUmar, S. Eyebrow transplant: the use of nape and periauricular hair in six patients. Derm Surg. 2014; 40:1416-1418.

Here the author describes challenges associated with eyebrow transplantation, namely obtaining hairs that are soft enough in caliber to mimic a natural eyebrow. He describes the use of FUE to harvest hair from the nape of the neck and hairline margin. In his report he uses a rotary tool with a modified 19g needle

to transplant 4 women and 2 men. For each patient, 200-600 grafts were harvested from the back of the scalp. He reports good healing in this area but admits that long-term outcomes are unknown and that women who wear their hair in a ponytail should be well-informed prior to surgery.u

Outcomes of FUEAvram, M.R., N. Rogers, and S. Watkins. Side-effects from follicular unit extraction in hair transplantation. J Cut Aesth Surg. 2014; 7:177-179.

In this letter to the editor, the authors discuss important out-comes of follicular unit extraction (FUE). Although this technique is favored for its lack of a linear scar, the authors point out that in some cases there can be atrophic white scars measuring less than or equal to 1mm, and patients should be aware that this is not a completely “scar-less” procedure. In addition, the authors point out that in some very large FUE cases, grafts are harvested from outside of the permanent donor zone. If follicles taken together from high risk locations are then transplanted together, the patient

may develop localized loss of grafts in that area. To avoid this, the authors recommend mixing all of the grafts together before placing them back into the areas of thinning. Finally, the authors point out that there are no established guidelines for how many follicular groupings can be safely harvested before the harvested donor area appears too thin. As with all things in medicine, both physician and patient should be aware of the short- and long-term consequences of FUE.u

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In this installment of our ongoing series profiling Regional Societies that are members of the ISHRS, we are pleased to have a report from Dr. Frank Neidel, current President of the Society of German Hair Surgeons.

Regional Societies Profiles

Society of German Hair SurgeonsFrank Neidel, MD Düsseldorf, Germany [email protected]

Manfred Lucas, MD, Ursula Halsner, MD, and Sibylle Eberle, MD founded the Society of German Hair Surgeons in 1994. We hold annual meetings. Our next meeting will be November 28, 2015.

The current officers are: Frank Neidel, MD, President; Ursula Halsner, MD, Vice president; Danuta Sobczak, MD, Treasurer. There are about 20 hair restoration practitioners in Germany and 10 of them are members in the Society. Drs. Frank Neidel, Ursula Halsner, and Andreas Finner are also members of the ISHRS.

Hair transplantation has become a common procedure in Germany. There is a trend for physicians of many different backgrounds to try offering it; however, too many of them are without basic education in hair transplantation. Advertising is allowed in in Germany within a well-defined framework; “before and after photos” are not allowed. Hair restoration is increasingly recognized in the media, and HRS is growing in acceptance by both patients and the medical community. Most of us are quite busy, but may not do procedures every day. Some of the doctors

do not do hair transplant procedures exclusively. In Germany, 80% of the procedures are FUT and 20% FUE. I think this makes sense given that most of out patients have lighter, finer hair. In 2015, 3-4 ARTAS® Robotic Sys-tems are expected to be introduced in Germany.

Currently, I am not aware of any research on cell-based therapy that is going on here. Drs. Frank Neidel, An-dreas Finner, and Ursula Halsner are all active in educational programs in and outside of Germany.

We are fortunate in our Society to have an open, collegial atmosphere and easy communication.

How can the ISHRS help us in the Society of German Hair Surgeons? We would like to see ISHRS publications for the media and patients and some of the web site translated into the German language.

Frank Neidel, MD

Dr. Frank Neidel is a specialist hair restoration surgeon with over 25 years experience. He has performed over 6,000 surgeries.

His strong involvement in hair transplantation is evident through being a member in leading medical societies and in his scientific collaboration with teams of experts at the skin clinic of Bochum University, the clinic of Lake Constance in Lindau, the “Rosenpark” clinic in Darmstadt and the “Rosen-gasse” clinic in Ulm.

His primary practice is located in Düsseldorf, Germany. Dr. Neidel also supervises hair transplantation clinics as an advisory doctor abroad in Holland (Transhair NL) and in Moscow (RTH). He is president and a board member of societies for hair transplantation including the Association of German Hair Surgeons in Berlin and the European Society of Hair Restoration Surgery in Paris, and is a member of the ISHRS. His extensive subject knowledge can also be found in several medical specialty textbooks in which Dr. Neidel has contributed as an author.u

(L to R) Drs. Frank Neidel, Dusseldorf; Helena Olbrich, Stuttgart; Danuta Sobczak, Freiburg; Andreas Finner, Berlin; Gerd Westphal, Berlin; Joachim Beck, Heidelberg

81


Letters to the Editors

[ page 82

Re: Transition from forceps to implantersFrancisco Jimenez, MD Las Palmas Gran Canaria, Canary Islands, Spain [email protected]

After visiting many colleagues and attending numerous meet-ings and workshops, I have seen and tried a variety of methods for the insertion of grafts into a recipient scalp.

After more than 10 years using fine-tip forceps for inserting grafts, either with the stick-and-place method or with pre-made sites, I decided 5-6 years ago to switch to implanters and I continue to use them to this day. The reason for this letter is to reflect on the issues that could be encountered when making the transition from the use of forceps to implanters.

Readers may recall that the use of implanters started in Ko-rea in the early 1990s, and that for a long time only our Korean colleagues used them. I remember trying Choi implanters in the mid-90s, but for some reason I found them inefficient at that time. I was probably not persistent enough with their use to assess their advantages. At that time (in the mid-90s) in Europe, as far as I know, only the Greek DHI group managed by Kostas Giotis used implanters. In the past 5-10 years, a remarkable increase in the use of implanters has occurred. Those new to the field adapt readily to their use, but even veterans like myself can be persuaded of the advantages they offer.

If you want to start using implanters, I advise you to visit a colleague, watch videos, or read about the techniques required. When I became interested in trying them, I got in touch with my fellow countryman, Dr. Jose Lorenzo, who kindly showed me some of his videos and shared some tips with me for im-planter use. These tips are described in detail in a couple of Forum articles that I highly recommend.1,2 I use basically the same setup Dr. Lorenzo describes in these articles: 2 techni-cians loading the grafts in four implanters (two of 0.8mm and two of 1mm). The only thing I have changed recently is that I like to use another technician whose role it is simply to pick up the implanter and place it in my fingers. In this way, I do not need to move my shoulder, elbow, hands, or arm, which means less movement, less fatigue, and a consequently faster insertion speed. I saw this technique in a video presented by one of our Korean colleagues at a couple of our ISHRS an-nual meetings.

When switching to implanters, you will encounter the fol-lowing issues:1. How many implanters to buy? At the beginning, just get two

0.8 and two 1.0 implanters and a few needles. Do not spend too much money until you are sure you want to switch to implanters. Then, ask your best technician to take over re-sponsibility for the implanters: he or she has to learn how to assemble the different parts of the implanter, how to sterilize the implanters, how to change new needles for each case, and how to change needles during a case if they become blunt. If the technician takes good care of the implanters, they can last for years.

2. You will also need two technicians able to load the grafts in the implanter needles. With practice, sufficient speed can be quickly attained. The good thing is that they can practice over and over again with just a few grafts that can be saved and placed in formalin.

3. Finally, the third important part is for the surgeon to practice the insertion of the implanter needle into the skin and the hair follicle graft release. Though the use of any new instrument and technique involves a period of adaptation, the learning curve in this particular instance is quite short compared with that for the stick-and-place method with forceps. Use a silicon scalp model to practice and feel comfortable with the implanters in your hands. The most difficult part is insertion of the graft at the adequate depth, because at the beginning there is a tendency to insert the graft too deep by pushing the implanter while triggering the shooter. This might cause folliculitis and cysts.

As somebody who has tried various insertion methods, I am in a position to assess and compare the advantages of the implanters. The most important advantage for me has been that I can now insert more grafts in less time and with less fatigue. Additional advantages of the implanters are less trauma to the hair follicle graft (because the follicle is never grasped at the delicate dermal papilla, but only at the superior dermis during the implanter loading), minimal trauma to the recipient site (the slit made with the needle is immediately filled with a snug-fit graft), and the previously mentioned short learning curve, especially important for those new to the field.

As a final comment, if a colleague were to ask me to recom-mend one particular graft insertion technique, I would simply recommend the technique that works best in their hands and that most suits their practice. All types of insertion techniques achieve excellent results in expert hands. For me and for my practice, I choose implanters, but if, for example, you do not want to be involved in the insertion part, and prefer to make the recipient sites and delegate to your technicians the task of insert-ing the grafts, then implanters are not for you. Again, no graft implantation technique is better than any other provided you do not forget that the ultimate goal of graft implantation is to place the grafts with the minimal possible damage and distribute them in the most aesthetic manner and in sufficient quantity to satisfy the patient’s expectations when the hair grows.

References1. Lorenzo, J., and X. Vila. Introduction to the use of implant-

ers. Hair Transplant Forum Int’l. 2011; 21(4):121-122.2. Lorenzo, J. Introduction to the use of the implanter: part II.

Hair Transplant Forum Int’l. 2011; 21(5):170-171.u

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Re: “State-of-the-Art FUE: Non-Shaven Technique” (Hair Transplant Forum Int’l. 2014; 24(5):161, 166-169).Jae Hyun Park, MD Seoul, Korea [email protected]

I have personal experience with more than 10,000 cases of hair transplantation surgery and have used non-Shaven FUE (NSFUE) since 2006. I have no knowledge about the operating technique that Dr. John Cole introduced to Korea in 2008, and have not had the chance to observe the procedure to date.

Most hair surgeons are aware that NSFUE is a delicate and difficult surgery that physically and mentally tires both the patient and surgeon, since it is highly time consuming.

I would especially like to relay a message of gratitude to Dr. Cole, who is greatly advancing FUE surgery around the world, and I would also like to state my personal opinion as follows.

1. Does a sharp punch become dull very soon?This is not a usual occurrence. If a sharp punch actually

becomes dull very soon, it would be an important problem to address. However, there are many factors that affect the degree of punch dullness. Firstly, the company and the product to which the punch tip belongs, is very important. Additionally, hair coarse-ness, skin texture, punching depth, and method of implantation have an effect as well. Analogously, a knife produced for the purpose of cutting meat does not easily dull on cutting 200-300 pieces of tofu. I have rarely experienced a punch that rapidly becomes dull in my vast clinical experience. Furthermore, if a punch tip actually becomes dull, it is generally changed to a new tip. Changing tips takes approximately just 1-2 minutes.

2. What is the duration of the operation? There are 3 major steps that take up a long period of the

operation time in a typical NSFUE procedure.The first is pre-trimming the hair prior to surgery. This step

does not increase the actual operation time, since it is done by an assistant prior to surgery. However, it is still a time-consuming and laborious step for both the assistant and the patient.

The second is the time required to seek the next target hair to punch after completing the previous one. This step takes a longer time in pre-trimmed cases and requires a very high level of concentration. With fewer amounts to harvest or a wider pre-trimmed area, the time needed to locate the next trimmed hair will be longer. In direct NSFUE, the surgeon visually seeks the next target in the adjacent area while the previous punching is in progress, thus reducing the required time. This leads to a shorter operation time. Critically, it takes much time to find pre-trimmed hair among crowded long hair.

The third time-consuming step is the extraction. Flipping and extracting over long strands of hair to find the punched graft requires expert skill. A well-trained assistant must be assigned for this procedure in order to lower the discard rate caused by capping, as well as to decrease the out-of-body time and injury to hair follicles. There are a few tips to decrease the extraction time. First is the use of an ATOE forceps, which was developed by Dr. Cole for the purpose of FUE.

An ATOE forceps is very useful in NSFUE. It is very difficult to conduct graft extraction by flipping over long strands of hair us-ing the two-handed forceps extraction technique. Using the ATOE forceps makes it much easier to extract the punched graft while

turning over long strands of hair. Second is the fine control of the punching depth. For instance, if 2.8mm is the minimal depth that enables extraction, 3.0mm is the depth that makes easier extraction possible without a significant increase in the transection rate (TR). TR increases if the depth is over 3.2mm, so I mainly choose 3.0mm as the punching depth in such cases, since this can prevent the graft from being dried up or damaged during the extraction process.

My personal target goal is approximately a 10% transection rate in NSFUE. (For reference purposes, I have a target of ap-proximately 5% in total shaven FUE.)

Thirdly, I perform surgery with 2 assistants on my right and left sides. I demarcate 8-10 areas from one ear to the other side according to the amount of grafts to harvest prior to starting the procedure. When I finish punching the left side, an assis-tant on the left conducts extraction, while I move to the right for punching the next zone. When I move to the next zone to proceed with punching, I skip 2 or more zones in a box zone from the punched zone, in advance. If there is a zone from 1 to 8, I usually start punching from zone 6, and move to zone 3, while skipping zones 4 and 5. This enables easy extraction of grafts without encroaching individual operator hand space when punching the next zone.

There is no similar pre-trimming time in direct NSFUE and the required time to seek the next target to be punched is also decreased. There is no difference in extraction time. Ac-cordingly, shortening of the operation time is possible. This is an important issue in NSFUE where extremely long operation time is crucial.

3. Position for operation.My personal opinion is that direct NSFUE should be done in

the sitting position. This sitting position is essentially required for the direct NSFUE technique, because it is not hindered by long hair, and it is easy to find the hair exit angle.

4. Is tumescence required?Surgeons usually decides this on a case-by-case basis accord-

ing to his or her preference. I personally prefer to use tumescence. With tumescence, I can conduct easier and consistent punching. Methods that help with consistent punching can be of great help, especially in situations similar to that of NSFUE where there are many surrounding barriers.

5. Is it difficult to see the angle of the hair emergence with long hair?

This is correct. It is the biggest challenge of the direct NSFUE technique, which requires a long and steep learning curve. I can provide a few surgical guidelines to reduce the learning curve and to get better results, as follows:

a. Direct NSFUE must be performed in the sitting position.b. Use the ATOE forceps and a motorized punch with both

oscillating and rotating modes.c. Punch from the inferior to superior-ward and upward,

because blood flows downward. It is very important to secure a clear operation field.

d. Use multiple clips to hold the hair within a 1cm-wide area, and undo clips sequentially from the bottom.

e. Conduct clipping less than 1cm wide, if possible. To adjust the natural hair exit angle, it is more advisable to punch immediately after undoing the clip if possible,

Letters to the Editors from page 81

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Reply to Dr. Jae Park from Dr. John ColeNon-shaven FUE is the future for hair transplant surgery. As

Dr. Park states, there are many who want FUE to avoid a strip scar, however, they also are unable to shave their head. For this reason, I introduced non-shaven FUE in 2003. I introduced the totally non-shaven technique in Korea in 2008.

Initially, we offered shaven patches, which is the same thing as Dr. Park’s shaven strips. We discovered within the first year that shaven patches limited the number of grafts we could obtain, as much of the donor area was non-shaven. The chief complication of shaven patches was linear areas of thinner density, which resulted in linear patches having a moth-eaten appearance. The result was as bad as a strip scar in the author’s opinion. Therefore, I believe that shaven patches or shaven strips should NEVER be performed.

If a physician is going to shave a portion of the donor area, while leaving the remainder of the hair long, the preferred method is to shave the entire safe donor area while leaving the surround-ing hair long. Of course, this requires long hair, which is more common in women. Grafts should then be harvested in an irregu-lar, diffuse manner so that there is no resulting extraction pattern.

We prefer the totally non-shaven approach. We require ap-proximately 1 hour to prepare a donor area for a 3,000-graft non-shaven procedure. We do our best to trim only the grafts that we intend to remove, however, we always seem to overtrim. Overtrimming is preferable to undertrimming only because un-dertrimming decreases the desired graft count. We harvest grafts nearly as fast as if the donor area is not shaven. Of course, my speed is higher because I have performed over 1,000 cases of non-shaven FUE already. We also find that with practice, the follicle transection rate is nearly the same as with a shaven procedure. It simply takes time and practice.

It is always nice to find ways to cut corners. Using the punch to cut hair as you proceed is one way. However, there are problems resulting from this method. Hair follicles are hard. When you use the punch to cut the hair shaft, the hair follicles will accelerate the dulling of your punch. Asian hair is often coarse and the dulling affect is greater with coarser hair. It is far easier to use this technique with fine hair. The second problem is that it is more difficult to approximate the hair shaft exit angle when you leave the hair long. Hair grows along a curve angled down toward the skin. With longer hair, this curve will make the hair appear to exit more acutely from the skin than it actually does. The physician must guess the true angle with longer hair. The coarse nature of the hair requires greater axial force from the physician to cut the hair follicles. This greater axial force displaces the hair follicle and thus further complicates the extraction process while increasing the risk of follicle transection needlessly. The preferred method of non-shaven FUE is to pre-cut the hair shafts so that these risks and complications are avoided. The author feels that saving time is not acceptable when it carries greater risk to hair follicles.

There are many different types of skin. Some are hard, some are soft, and some are rubbery. It is impossible to make generaliza-tions from a limited number of Caucasian cases. One can assume that Asian skin will be firmer and the follicles will be deeper and coarser. There are Caucasians with deep follicles and firm skin, however. In general, I like the firm skin of the Asian patient. I feel it helps limit follicle displacement while excising the graft.u

rather than finding hair to be punched by throwing the long hair backwards. Therefore, it is better to have a narrower width of clipping.

f. It can be difficult to determine the hair exit angle when hair gets tangled and sticks to one another due to blood clot. For such cases, it is advisable to prepare a sterilized saline spray and comb. Lightly spray the saline and comb, thus making the direction of hair more noticeable.

g. When undoing the clip from the bottom, sometimes the clip indents the hair, resembling a curl. Since it resembles a curl in the hair, it makes it difficult to find the hair’s exact exit angle. The saline spray and combing can make it easier to find the direction and angle of the hair strand in such situations.

h. Despite the prevailing controversy, if tumescence is used, and an assistant conducts a little traction on skin in an upward direction, easy punching and reduced TR are facilitated.

Applying the various surgical tips will permit easier finding of the hair exit angle and direction. However, finding the exact hair exit angle and accurately processing punching is still an extremely difficult process. However, there are always obstacles and hurdles in new operations. The future of hair transplant surgery is leaning towards NSFUE. Many outstanding surgeons worldwide will continue to discuss and discover improved opera-tion techniques and know-how.

6. What is the transection rate?Every surgeon views TR differently, but I aim for a TR of

10% or below using the NSFUE technique. If the punch is very superficial, the TR can be lowered. However, the extraction takes a long period of time, and the survival rate can be lowered because the proportion of skeletonized grafts increases, and the grafts are out of body for longer. Recently, increasing experi-ence and know-how of the method has led to a generally slightly less than 10% TR.

I anticipate a further decrease in TR.

7. OthersThe surgeon can make a direct selection of the hair strand

for punching in the direct NSFUE method. Additionally, the hair can be cut according to the quantity sought for extraction, without over trimming. Therefore, even in cases of punching more than 2,000 grafts, the possibility of surgery being obvious due to over trimming is low.

8. ConclusionIt is my personal opinion that non-shaven FUE will be one of

the most important future techniques of hair restoration surgery. I anticipate that more discussion and interchange of ideas will promote further innovation of NSFUE.

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Meetings and StudiesReview of the 6th Annual Hair Transplant 360 Workshop

October 23-26, 2014 • St. Louis, Missouri, USAMarco N. Barusco, MD Port Orange, Florida, USA [email protected]

2014 was the 6th consecutive year of the Hair Transplant 360 Workshop in St. Louis and my first year as faculty. I must say that it was an honor to have been invited and I was very impressed by what I saw. I had heard that the workshop was a huge success every year, and now I know why.

The OrganizersDrs. Sam Lam and Emina

Karamanovski are well known for their organizational skills and their hard work. This “dynamic duo” works so well together that they don’t even need to talk to each other. They know exactly what the other one wants and share the same intense passion for education and for our spe-cialty. They made sure all of us felt welcome, valued our input and suggestions, and were very gracious to all of us.

The VenueSt. Louis University is a

beautiful university located near downtown St. Louis. The campus is very large, occupying a large geographical area of the city. Old buildings share space with new, modern ones. The PASE (Practical Anatomy and Surgical Education) building is a beautiful 3-story building with a French-inspired interior full of beautiful details and woodwork. The top floor housed the hall where all meals were and coffee breaks were served and where the various exhibitors were set up, allowing for intense interac-tion with the participants/faculty.

The middle floor contains offices of the university and a large lecture hall with comfortable seating and a large stage area. The audiovisual equipment and resources are great and a unique 3-D system is available for live demonstrations on patients and cadavers right from the stage, with the audience being issued 3-D glasses.

The lower floor of the building houses the anatomy labs, which are extensive and large. One room is equipped with high-quality microscopes for surgical training, and the other with dissecting tables. Cadavers were numerous and the staff incredibly helpful, making sure we always had what we needed.

Transportation to and from the various hotels used to house faculty and participants was offered by the organizers and were always on time and plentiful.

The ProgramThe program was packed

and very intense. Drs. Lam and Karamanovski put a lot of thought into creating a program that progressed very well over each day. A physicians’ pro-gram ran concurrently with an assistants’ program, with some overlap. Lectures were given in the morning and practical, hands-on activities occupied the afternoon. Opportunity for interaction between faculty and participants were plenty and at the end of each day all of the participants and us were ex-hausted but happy. The program covered every aspect of the procedure, from consultation to post-op, both for strip sur-gery and FUE. Hairline design, donor hair removal, recipient site creation, graft preparation, storage, and placement were all well discussed and demon-strated.

Participant and Vendor FeedbackOne common comment I heard from participants was how

much time they had to interact with the faculty and each other during the cadaver sessions. This is invaluable for a great learn-ing experience. The fact that the lectures were given in a more informal setting, which stimulated active discussion with the participants, was also well received. Vendors also enjoyed plenty of exposure and time with the faculty and participants, and all of them were very happy with the event.

ConclusionThis was an intense but very rewarding event. I would like

to personally thank Drs. Lam and Karamanovski for inviting me and for treating me so well. I look forward to next year.u

Vance Elliott, Ken Williams, Larry Samuels, Marco Barusco, Jim Harris, Sam Lam, Emina Karamanovski, Nicole Rogers, Tina Lardner, Aileen Ullrich,, Heather Steward, Robin Collins (Not pictured: Robert True)

SAVE THE DATENovember 19-22, 2015

2015 SLU HRS Cadaver Workshop

Participants in the Anatomy Lab

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Review of the Japan Society of Clinical Hair Restoration 19th Annual Scientific Meeting and Live Surgery Workshop

November 23, 2014 • Okamaya, JapanVincenzo Gambino, MD Milan, Italy [email protected]

The 19th Annual Scientific Meeting and Live Surgery Work-shop of the Japan Society of Clin-ical Hair Restoration (JSCHR) was held on November 23, 2014 at Okamaya Convention Center in Okamaya, Japan. The meeting began with the welcome address by Society President Shinsaku Kawada, MD.

The Korea Japanese Friend-ship Session began with a pre-sentation by Dr. Chang-Hun Huh entitled “Current and Future Sur-gical Treatment for Androgenic Alopecia.” He spoke about vari-ous surgical approaches to HRS and his opinion that the ARTAS® Robotic System is the current best option for FUE.

Dr. Gwang Soeong Choi’s paper, “Current Perspectives on Medical Therapeutic Options for Androgenic Alopecia,” discussed the various current and promising future treatments. Aside from finasteride, dutasteride, and mi-noxidil, there are cell medicated treatments, such as cell secreted factors, cultured cells of hair follicles, and platelet rich plasma, that are showing positive results. Low level laser and light treatments are being used, but there is little peer review on their efficacy.

Dr. Ralph M. Trueb presented “Patterned Hair Loss, Hair Aging, and Anti-aging Strategies.” He theorized that aside from the currently recognized factors in hair loss and hair aging, fol-licular micro-inflammation and fibrosis could also be co-factors and new strategies could be developed.

Dr. Vincenzo Gambino provided insight in his presentation, “Hair Transplantation on Patients Younger than 25.”

In “Clinical Utility and Validity of Minoxidil Response Testing in Androgenetic Alopecia,” Dr. Andy Goren noted that sulfotransferase enzyme activity can predict a patient’s positive response to minoxidil therapy.

Presenting “Future Restoration Medicine Beginning from Hair,” Dr. Yasuyuki Amoh detailed how he developed a system of mass production of follicular stem cells by cell culture, and he studied repair of injured tissue including regeneration of neuron synapse using follicular stem cell in mice.

Dr. Manabu Ohyama presented “Strategy for Optimization of Cellular Components for the Human Hair Follicle.” He noted how he used multi-potential stem cell, including human IPS

cells, and he analyzed the signal conduction pathway in human dermal papilla cells. He also stud-ied the induction of hair follicles using IPS cells in vivo.

In his presentation, “Research Strategy and Future Regeneration of the Hair Organ,” Dr. Koei Toy-oshima detailed his study on the use of fetal epidermal stem cells and mesenchymal stem cells, and how he succeeded in neogenesis of functional hair follicles with hair cycle in mice.

In “New Nano Medical Treat-ment of Skin and Hair Using Fullerene” Dr. Shigek Inui pre-sented his study on the anti-oxidative effect of fullerene. He studied cell protection of hair follicle cells and epidermal cells using 1% fullerene lotion.

Dr. Yasusuke Ito presented “Treatment for Alopecia Areata.” He talked about IFN-gamma signal conduction pathway and suppression of JAK-STAT path-way. He also discussed targeted therapy with JAK1/2 antagonist

and JAK3 antagonist. In addition, he won the Hirayama Award of the JSCHR this year.

At the closing ceremony and gala, Dr. Kwada and incoming President Dr. Ryuichiro Kuwana spoke. Drs. Takahiko Morigudi and Kuniyoshi Yagyu presented awards. A traditional dinner and classic Japanese entertainment was graciously provided by the JSCHR.u

(left to right) Sotaro Kurata, MD, Mrs. Irene Gambino, Prof. Vincenzo Gambino, MD, Prof. Andy Goren, MD , Prof. Ralph M. Trueb, MD, Kuniyoshi Yagyu, MD

Classic Japanese entertainment made for an enjoyable end to the evening.

SAVE THE DATEDecember 5-6, 2015

20th Annual Meeting of the JSCHRDr. Ryuichiro Kuwana, Program Chair

Kochi, Japan

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ISHRS Annual Giving Fund 2014 Year-End Report

Dear Colleagues:

As we start another exciting new year with ISHRS, it seems appropriate to look back on 2014 and celebrate what has been accomplished through the generous donations made to the Annual Giving Fund (AGF). It is inspiring that so many members care enough about the ISHRS and the AGF mission to make such transforming gifts.

2014To recap, while the ISHRS Annual Giving Fund fell slightly short of its 2014 fundraising goal of $47,500, it still supported

many valuable ISHRS initiatives. I want to personally thank all who contributed so generously this year making it possible for us to raise $42,350. Each of you has helped the ISHRS achieve many of its philanthropic and educational goals. Your kindness and ongoing support of the Society through your AGF donation is very much appreciated by the ISHRS leadership.

The proceeds from the year’s Annual Giving Fund were used to support several projects. Here is an example of what your gifts helped to fund in 2014:

• Operation Restore Pro Bono Program• Cicatricial alopecia research• Communications & public education, including website improvements and SEO• Support of the 9th World Congress for Hair Research

2015 GOALSIn 2015, we hope to reach our $40,000 fundraising goal. We will be reaching out to new and old members asking them

to carry the torch. It is my hope that many of you will be inspired by the important work that past donations have funded. Your 2015 donation will help continue to fund the OPERATION RESTORE Pro Bono Program, hair research, and additional public education via our www.ISHRS.org website in multiple languages.

PLEASE CONSIDER DONATING: For those who have not yet contributed, it is easy to support the Society. If you choose to donate for 2015 or make another multi-year pledge, please complete the online donation form that can be found at http://www.ishrs.org/content/ishrs-annual-giving-fund.

Or, if you prefer, you can contact Kimberly Miller at the ISHRS headquarters office at [email protected] with your credit card information, amount of donation, and number of pledge years. New donors will receive a lapel pin, and we ask you to wear it proudly at the ISHRS meetings. Those who make a 2015 charitable contribution to the AGF at the Trustee or Leader-ship Circle levels will receive two complimentary tickets to the Gala in their registration packets and will be acknowledged during the Gala Dinner Dance and Awards Ceremony.

Your generosity in giving makes a concrete statement that you support the ISHRS and its initiatives. Thank you for your consideration of a gift to the Annual Giving Fund. All gifts are tax-deductible within provisions of your national income tax laws. Should you need additional information, please contact the ISHRS Headquarters at 1-630-262-5399.

Most sincerely,

John D.N. Gillespie, MDChair, ISHRS Annual Giving Fund

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Thank You to Our 2014 DonorsThe ISHRS gratefully acknowledges the generosity of the following individuals who

have made donations to the Annual Giving Fund.

Trustee Circle: $2,000Bernardio Arocha, MD, FISHRSMark A. Bishara, MDJohn P. Cole, MD Mark S. DiStefano, Sr., MD, FISHRSVincenzo Gambino, MD, FISHRS John D.N. Gillespie, MD, FISHRSSara Wasserbauer, MD, FISHRSKuniyoshi Yagyu, MD, FISHRS

Leadership Circle: $1,000Timothy P. Carman, MD, FISHRSGlenn Charles, MDVance W. Elliott, MD, FISHRSEdwin S. Epstein, MD, FISHRSKoray Erdogan, MDBijan Feriduni, MD, FISHRSSungJoo Hwang, MD, PhD, FISHRSGrant F. Koher, DO, FISHRSSamuel M. Lam, MD, FISHRSJose Lorenzo, MDEmorane Lupanzula, MDMario Marzola, MBBSWilliam Parsley, MDDamkerng Pathomvanich, MD, FISHRSAsim I. Shahmalak, MBBS, FRCSPiero Tesauro, MDRobert H. True, MD, MPH, FISHRSAnastasios Vekris, MDKenneth Williams, DO, FISHRS

Supporter's Circle: $500Jonathan Ballon, MD, FISHRSMichael L. Beehner, MDJames A. Harris, MD, FISHRSWolfgang Haindl Barry H. Hendler, MD, DDSCarlos Puig, DO, FISHRSNicole Rogers, MDCagatay Sezgin, MDT.K. Shiao, MD, FISHRSArthur Tykocinski, MD, FISHRSConradin von Albertini, MD

Contributor’s Circle: $250Kulakarn Amonpattana, MDJulieta P. Arambulo, MDGerlinde BarnikelHyo Kang, MDWilliam J. Woessner, MDWen-Yi Wu, MD, FISHRS

A Comprehensive, International

Hair Research Meeting for the

Advancement of Knowledge

In Hair Growth, Hair and Scalp Disease,

and Clinical CareFor all inquiries, please contact

NAHRS Administrator, Victoria Ceh, [email protected]

November 18-21, 2015

9th World Congress for Hair Research

Miami • Florida • USA

Wilma F. Bergfeld, MDCONGRESS CO�CHAIR

Cleveland Clinic Foundation

Angela Christiano, PhDCONGRESS CO�CHAIR

Columbia University

Maria K. Hordinsky, MDCONGRESS ASSOCIATE CHAIR

University of Minnesota

Victoria H. Barbosa, MD, MPH, MBARush University

Valerie D. Callender, MDHoward University

Luis Garza, MD, PhDJohns Hopkins University

Antonella Tosti, MDUniversity of Miami

Ken Washenik, MD, PhDNew York University/ Bosley

INVITATION

Plan to AttendFOR INFORMATION AND REGISTRATION GO TO:

www.hair2015.org

Hosted by

Reflect, Rejuvenate, and REGENERATE

The North American Hair Research Society (NAHRS), with participation from the Australasian Hair & Wool Research Society, the European Society for Hair Research, the Hair Research Society of India, the Japanese Society for Hair Research, and the Korean Hair Research Society, will host the 9th World Congress for Hair Research, which will bring together hair biologists, dermatologists, cosmetic scientists and hair transplantation surgeons for this three and a half day comprehensive hair research meeting.

International colleagues will present new research, share experiences, and discuss new directions for the advancement of knowledge in hair growth, hair and scalp disease, and clinical care.

The Congress will include general sessions, scientifi c posters, pre-Congress workshops, networking opportunities, a full exhibits program, company sponsored satellite symposia, and more. We invite you to attend!

Sincerely yours, Congress Scientifi c Planning Committee

15WCHR EADV half pg FINAL.indd 1 1/29/15 1:38 PM

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Message from the 2015 Annual Scientific Meeting Program ChairNilofer P. Farjo, MBChB, FISHRS Manchester, UK [email protected]

Preliminary ProgramNow that all the abstracts have been received for the Chicago

meeting, it’s time to work towards completing the program over the next couple of months. The Annual Scientific Committee has been working hard to assess the abstracts and once the scores are collated, I will be putting the preliminary program together. You will be notified in the next 4-6 weeks if your presentation has been accepted, so thank you to all of those who have sent in abstracts. Without your contributions, the meeting would not be a success.

Please remember that if your abstract is chosen you will be asked to submit your PowerPoint or video 6 weeks ahead of the meeting. The moderator for your assigned session will check that both the content of your presentation meets the required guidelines for quality and time limit and also fulfils the learner objectives.

Invited Guest SpeakersWe have confirmation of this year’s guest speakers. They will

cover a number of topics that I hope will be interesting to the members: basic sciences, etiology of female pattern hair loss, the latest research on Post-Finasteride Syndrome, and nutrigenics.

The invited speaker for the Advances in Hair Biology Lecture is Valerie Horsley. She is the Maxine F. Singer Associate Pro-fessor of Molecular, Cellular & Developmental Biology at Yale University. She has already received many honours for her work on the cellular and molecular mechanisms that control stem cell activity and function within epithelia. These honours include the Presidential Early Career Award for Scientists in 2012. I have asked her to speak on her work with adipocytes and their role in regulation of fibroblast function.

Another of our honoured speakers is Andrew Messenger, Professor of Dermatology at the Royal Hallamshire Hospital in Sheffield in the United Kingdom. He will give the Norwood Lecture in honour of O’Tar Norwood, a dermatologist, who is a co-founder of the ISHRS and founder of this journal, Hair

Transplant Forum International. Dr. Messenger is world renowned as an expert on female pattern hair loss, so I look forward to his update on the latest theories behind the causes of hair loss in women.

Side effects of finasteride are still a controversial topic for our patients. Mohit Khera, Associate Professor of Urology at Baylor College of Medicine, has been invited to present the results of his study on genetic and epigenetic factors in Post-Finasteride Syndrome patients. This syndrome, characterized by persistent sexual, neurological, and physical side effects after stopping finasteride, can be a very devastating condition for patients, but so far there has not been a convincing explanation for its existence. Hopefully, Dr. Khera’s study will shed some light on this condition.

Finally, we have a lecture entitled Natural Ingredients for Activating Biological Targets in Hair and Skin that will be given by Ranjit Bhogal, PhD, a research scientist with Unilever Ltd in their Research and Development Division in Colworth in the United Kingdom. Unilever has a long history of working on hair biology research both in their own lab and in association with leading universities. Dr. Bhogal will give us some insight into another under researched topic, namely the interaction of external nutrient factors on hair and skin.

Chicago the DestinationSeptember is a great time of year to visit Chicago. The

weather is pleasant during the day with temperatures in the mid-70s Fahrenheit (24°C ), but it can get a bit chilly at night 54°F (12°C), so it would be advisable to carry with you a warmer jacket or sweater for the evenings. The milder temperatures also mean that there are no crowds of tourists, which makes it a perfect time to enjoy sight-seeing without the excessive queues. So come a few days ahead of the meeting and enjoy all the sights that Chicago has to offer. See you there!u

www.ishrs.org/AnnualMeeting.html

SAVE THE DATESeptember 9-13, 2015

2015 ISHRS Annual Meeting

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Message from the 2015 Surgical Assistants Program ChairJanna Shafer Bloomington, Minnesota, USA [email protected]

Excitement is building as the annual ISHRS conference in Chicago this September will be here before we know it. Sara Roberts, who works with Drs. Bessam and Nilofer Farjo, and I promise to host a wonderful SA Program and Workshop this year. Attending the SA Program and Workshop is the best way to make new friends from somewhere in your own city or from half way across the world. The SA Program and Workshop is geared towards assistants with experienced skills and those brand-new to the field. In 2013, Sara helped organize the surgi-cal assistants training in a very successful ISHRS-sponsored Regional Workshop in Manchester, UK. I have every confidence she’ll do the same in Chicago.

We implore upon all the lead techs of each clinic to be more

active in the SA community. How do you go about being more active? Here are few suggestions: 1) empower yourself and your co-workers by read-ing up on the ISHRS Forum newsletters, 2) share your pearls and wisdom by contributing articles to the Forum, 3) become a faculty member in the SA Workshop or participate in the SA Program by giving suggestions for presentation topics or by giving a presentation.

Please don’t hesitate to contact Sara or myself if you would like to participate in the SA Program and/or Workshop at [email protected] or [email protected]. See you in Chicago!u

SAVE-THE-DATE May 1–3, 2015

over 20 hours of hands-on training live surgery observation learning in “real-life” surgical setting intimate group / instant feedback

NEW: after the course, sponsoring physician will receive the student’s skill level evaluation

Hosted by: James A. Harris, MD, FACS, FISHRSWorkshop chairs: Emina Karamanovski & Tina LardnerSponsored by: Hair Science Center of Colorado

LOCATION The Hair Sciences Center of Colorado, 5445 DTC Parkway, Suite 1015 Greenwood Village, CO 80111 USA

FEE $ 1,700 per student* To register [email protected] or 1-303-694-9381

Hands-on Surgical Assistant Training Program Graft Preparation and Placement (FU-strip & FUE)

*Includes access to online ISHRS Assistant Resource Center from the date of registration through May 15. 2015 (value of $2000 )

I SHRS REGIONAL WORKSHOP

Go to: http://www.ishrs.org/content/educational-offerings, and scroll to “ISHRS Regional Workshops” for Registration Form

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Classified AdsHair Transplant Surgeon for NYC

Ziering Medical is searching for an experienced Hair Transplant Surgeon to join our Chicago, New York, and Dubai clinics.Generous compensation package in an established market, with tremendous upside.

Interested candidates, please send your CV and cover letter to [email protected]

Seeking Full-Time Physician AssistantImmediate opening for a Full-Time Physician Assistant for a Hair Restoration Clinic in West Hollywood.

Must have experience with anesthetic injections and suturing. Knowledge of cosmetic laser treatments, injectables, and fillers is preferred but willing to train ideal candidate. Some Travel involved and must have excellent communication skills.

Candidate will be trained in all aspects of hair restoration including hand-held Follicular Unit Extraction, ARTAS Robotic System, hairline design, etc.

Please send résume to: [email protected]

Hair Tech for busy practice just west of Boston, Worcester, MA. Experience not necessary, but very desired. Work 4-5 days per week, your choice, paid at competitive rates.

Excellent benefits, 401 K, Vacation 2-3 weeks based on experience, 10 paid holidays, sick time and personal days.Great place to work, people come and never seem to want to leave. Growing office.

Please email Bonnie Minardi, Head Technician, DiStefano Hair Restoration Centers, at [email protected].

Seeking Hair Tech

91


2015 AnnuAl Scientific Meeting coMMittee

Nilofer P. Farjo, MBChB, FISHRS Chair I UK

Sara M. Wasserbauer, MD, FISHRS Advanced/Board Review Course Chair I USA

Ratchathorn Panchaprateep, MD Advanced/Board Review Course Co-Chair I THAIlAnD

nicole E. Rogers , MD Basics Course Chair I USA

Aman Dua, MBBS, MD Basics Course Co-Chair I InDIA

Samuel M. lam, MD, FISHRS Workshops Chair I USA

Marco n. Barusco, MD M&M Chair I USA

Márcio Crisóstomo, MD L ive Pat ient Viewing Chair I BRAzIl

Jennifer H. Mar tinick , MBBS Newcomers Chair I AUSTRAlIA

Janna Shafer Surgical Assistants Chair I USA

John D.n. Gillespie, MD, FISHRS Surgical Assistants Co-Chair I CAnADA

Damkerng Pathomvanich, MD, FISHRS Immediate Past Chair I THAIlAnD

Jef frey Donovan, MD, PhD I CAnADA

Piero Tesauro, MD I ITAly

www.ISHRS.org/AnnualMeeting.html

generAl SeSSionS Combining FUE and Strip Surgery Advances in Hair Biology Update on Finasteride and Side Effects Hair loss Diagnostic Dilemmas Unique Issues in Ethnic Transplantation live Patient Viewing Small Group Discussion Tables Interactive Panels Female Pattern Hair loss Management of Complex Cases

other offeringS FUE Hands-On Mini-Courses lunch Symposia and Workshops Basics in Hair Restoration Surgery Course Advanced/Review Course Surgical Assistants Program &

Hands-On Workshop M&M Conference Exhibits Program E-Poster Exhibits Social program including optional tours

and activities, Welcome Reception, Gala Dinner/Dance

neWcoMerS Are WelcoMe! We offer a “Meeting newcomers Program” to orient those who are new to the ISHRS annual meeting. newcomers will be paired with hosts. We want to welcome you, introduce you to other colleagues, and be sure you get the most out of this meeting.

The IShRS annual ScIenTIfIc meeTIng is The premiere meeting of hair transplant surgeons and their surgical assistants.

You don’t want to miss it.

international Society of hair restoration Surgery303 West State Street I Geneva, Il 60134 USAT El 1 630 262 5399 or 1 800 444 2737 FAx 1 630 262 1520info@ishrs .org I www.ISHRS.org

Plan to Attend

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Hair Transplant Forum International March/April 2015www.ISHRS.orgHAIR TRANSPLANT FORUM INTERNATIONALInternational Society of Hair Restoration Surgery303 West State Street Geneva, IL 60134 USA

Forwarding and Return Postage Guaranteed

2015: 23rd ASM September 9-13, 2015 Chicago, Illinois, USA

2016: 24th ASM October 19-22, 2016 Panama City, Panama

Dates and locations for future ISHRS Annual Scientific Meetings (ASMs)

Date(s) Event/Venue Sponsoring Organization(s) Contact InformationUpcoming Events

Presorted First Class Mail

US PostagePAID

Mt. Prospect, IL Permit #87

Advancing the art and science of hair restoration

HAIR TRANSPLANT

I N T E R N A T I O N A L

forumAdvancing the art and science of hair restoration

December 5-6, 2015 Dr. Ryuichiro Kuwana, Program [email protected]

www.jschr.org

20th Annual Meeting of the JSCHRKochi, Japan

Japan Society of Clinical Hair Restoration (JSCHR)Hosted by Ryuichiro Kuwana, MD

September 9-13, 2015 Tel: 1-630-262-5399 Fax: 1-630-262-1520

23rd Annual Scientific Meetingof the International Society of Hair Restoration Surgery

Chicago, Illinois, USA

International Society of Hair Restoration Surgery www.ishrs.org

March 3-6, 2105 &May 26-29, 2015

Dr. Pierre Bouhanna, Course Director [email protected]

University Diploma of Scalp Pathology and SurgeryParis, France

University of Paris VI Coordinators: P. Bouhanna, MD and M. Divaris, MD

www.hair-surgery-diploma-paris.com

November 18-21, 2015 For details: [email protected]

9th World Congress for Hair ResearchMiami, Florida, USA

North American Hair Research Societywww.hair2015.org

March 28-29, 2015 For details: [email protected]

AAHRS Scientific Meeting & Live Surgery Workshop Bangkok, Thailand

Asian Association of Hair Restoration SurgeryHosted by Damkerng Pathomvanich, MD, FACS

www.aahrs.asia

November 19-22, 2015 Dr. Samuel L. Lam, Course DirectorEmina Karamanovski, Assistant

Course Directorhttp://pa.slu.edu

7th Annual Hair Restoration Surgery Cadaver Workshop St. Louis, Missouri, USA

Practical Anatomy & Surgical Education (PASE), Center for Anatomical Science and Education, Saint Louis University

School of MedicineIn collaboration with the International Society of Hair

Restoration Surgeryhttp://pa.slu.edu

May 1-3, 2015 ISHRS Regional Workshop Surgical Assistant Training Program:

Graft Preparation and Placement (FU-strip & FUE)Denver, Colorado, USA

International Society of Hair Restoration SurgeryHosted by James A. Harris, MD, FISHRS

Workshop Chairs: Emina Karamanovski & Tina Lardner

For details:http://www.ishrs.org/content/

educational-offerings

hair transplant - · pdf filehair transplant forum international is a privately published...

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