Volume 12, Number 3
Hair Transplant Forum International
❏
May/June 2002
Hair Transplant Forum International
forum
Volume 12, Number 3
May/June 2002
○
○
○
○
○
○
○
○
○
ABHRS Offers Certificate of
Added Qualification in Hair
Restoration Surgery
Shelly Friedman, DO, FAOCD
Scottsdale, Arizona
Immediate Past President, ABHRS
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
The ABHRS will begin to offer a
Certificate of Added Qualification in
Hair Restoration Surgery (CAQ) in
2002. This new certificate is designed
for those hair transplant surgeons who
do not qualify for ABHRS board
certification but would like tangible
acknowledgement that they have
achieved additional training in hair
restoration surgery. The CAQ also
could be seen as achieving the first
step toward board certification.
○
○
○
○
○
○
○
The requirements for the CAQ are
as follows:
1) Attendance at two ISHRS Annual
Meetings.
2) Attendance at one ISHRS endorsed
Live Surgery Workshop.
3) Successful passing of the ABHRS
written examination. This is the
same 200 multiple choice examination taken by those seeking board
certification. The ISHRS Review
Course for the ABHRS examination will be very helpful for those
surgeons taking the written examination.
○
○
○
*Committee members included: Chairman: James
Vogel, MD; Members: Michael Beehner, MD;
Robert Bernstein, MD; Paul Cotterill, MD;
Shelly Friedman, DO; Robert Haber, MD;
Sheldon Kabaker, MD; Russell Knudsen, MBBS;
Robert Leonard, DO; Antonio Mangubat, MD;
Daniel Rousso, MD; Dow Stough, MD;
Bradley Wolf, MD
○
○
continued on page 120
○
president, Dr. Bobby Limmer, asked me
to chair a special ad hoc committee to
evaluate the issues of certification and
credentialing in our specialty. A credentials committee was formed and consisted of experienced hair restoration
surgeons from diverse backgrounds.
Half of the committee consisted of
members of the American Board of Hair
Restoration Surgery (ABHRS), and the
others were current or past members of
the ISHRS board of governors or
executive officers. Frank discussions were
held during the meetings and the
committee was quite focused and direct
in securing options and alternatives.
These included the names for certificates, criteria for different types of
○
Last October in Puerto Vallarta, our
○
○
○
○
○
○
James Vogel, MD
Baltimore, Maryland
Chairman, Ad Hoc
Committee on
Certification
○
Report of Vogel Ad Hoc
Committee on Certification*
○
Resolution of ISHRS-ABHRS Differences
Accomplished
continued on page 120
Regular Features
President’s Message ............................... 94
Co-Editors’ Messages ............................ 95
Notes from the Editor Emeritus ........... 96
Cyberspace Chat ................................. 115
The Dissector ...................................... 122
Life Outside of Medicine .................... 123
Salute to Surgeon of the Month .......... 124
Surgical Assistants Corner ................... 125
Journal Review .................................... 129
Letters to the Editors .......................... 130
Feature Articles
Up Close and Personal in
Orlando .............................................. 97
You Go Where the Knowledge Is ........ 102
Follicular Regeneration Study of
Bisected and Transected Follicular
Units Observed Individually Over
at Least One Hair Cycle .................... 105
The Role of Tissue Expansion in
Hair Transplant Surgery: Presentation
of Two Unique Cases ........................ 108
10th Annual Meeting Preliminary
Schedule ........................................... 112
10th Annual Meeting Hotel
Reservation Form .............................. 114
Commentary on An Argument Against
Tissue Removal During Transplantations: Incisions vs Punches ................. 117
Response to Commentary ................... 119
Pull
out c
nte
for 1 te
0 h A r spread
Mee
nn
Rese ting H ual
otel
r
v
a
Preli
m i n a tion Form
ry S
ched &
ule
Official publication of the International Society of Hair Restoration Surgery
93
Hair Transplant Forum International
❏
May/June 2002
Hair Transplant Forum International
Volume 12, Number 3
Hair Transplant Forum International is published
bi-monthly by the International Society of Hair
Restoration Surgery, 930 East Woodfield Road,
Schaumburg, IL 60173. First class postage paid
at Schaumburg, IL and additional mailing offices.
POSTMASTER: Send address changes to Hair
Transplant Forum International, International
Society of Hair Restoration Surgery, Box 4014,
Schaumburg, IL 60168-4014. Telephone: 847/3309830; Fax: 847/330-1135.
President: Bobby L. Limmer, MD
Executive Director: Laura Musgraves
Editors: Michael L. Beehner, MD, and
William M. Parsley, MD
Surgical Assistants Corner Editor:
Shanee Courtney, RN
Managing Editor & Graphic Design:
Cheryl Duckler, [email protected]
Advertising Sales (Interim): Lisa Rafael,
847/330-9830; [email protected]
Copyright © 2002 by the International Society of Hair
Restoration Surgery, 930 East Woodfield Road,
Schaumburg, IL 60173-6016. Printed in the USA.
The International Society of Hair Restoration Surgery
does not guarantee, warrant, or endorse any product
or service advertised in this publication, nor does it
guarantee any claim made by the manufacturer of
such product or service. All opinions expressed are
those of the authors, and are made available for
educational purposes only. The material is not
intended to represent the only, or necessarily the
best, method of procedure appropriate for the
medical situations discussed, but rather is intended
to present an approach, view, statement, or opinion
of the author that may be helpful to others who face
similar situations. The ISHRS disclaims any and all
liability for all claims that may arise out of the use of
the techniques discussed.
Hair Transplant Forum International is a privately published newsletter of the International Society of Hair
Restoration Surgeons. 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 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).
The ISHRS Golden Follicle Award sculpture, as seen
on the cover of this issue, was designed by Francisco
Abril, MD. Dr. Abril offers for sale, copies of a small
bronze hair follicle sculpture (10" high). For more
information, please contact: Clinica Dr. Francisco
Abril, PO dela Habana, 137, 28036 Madrid, Spain.
Phone: 34-1-359-1961; Fax: 34-1-359-4731.
94
Volume 12, Number 3
President’s Message
As our year
progresses, pointing toward the
Annual Meeting
in Chicago in
October, all seems
well with the
ISHRS ship. The
Annual Scientific
Meeting Committee, under the
Bobby L. Limmer, MD
San Antonio, Texas
direction of Dr.
John Cole, has a wonderful program
outlined, and we hope that each and
every one of you will be in attendance
in Chicago. Plan now to bring your
staff with you to share both the
educational and social benefits of the
meeting.
The Website Committee, under the
direction of Dr. Tony Mangubat,
continues actively searching for ways
to keep hair restoration surgery and
the ISHRS readily available to the
public through the World Wide Web.
The Ad Hoc Certification Committee, under the direction of Dr. Jim
Vogel, has met on the issue of international credentialing in an effort to
take an issue that has been divisive
and generate a mechanism that is
inclusive of all who have acceptable
qualifications. While there exist
differing views on the mechanisms of
credentialing, I would hope that a
magnanimous spirit of what is good
for the vast majority of patients and
practitioners alike will lead to continuing discussion and a final conclusion that is uniformly beneficial to all
members of the ISHRS.
Long-term management of the
ISHRS is in the process of review, as
the Society was recently informed that
its current management provider,
Association Management Services, a
subsidiary of the American Academy
of Dermatology, will be closing
operations at the end of this calendar
year. We have received several informal
and one formal proposal for continuing management beginning in 2003.
Every effort is being made to create a
smooth transition from our management services to a new management
to carry on the goals of our Society.
As I penned this month’s message, I
was notified that Ms. Laura Musgraves,
the current ISHRS executive director,
will be moving on to new opportunities in association management at the
end of May. Many of us in the ISHRS
leadership had the opportunity to
meet Laura at the 9th Annual Meeting, and to work closely with her. The
ISHRS membership at large may
know Laura through her article “What
Matters Most” in the January/February 2002 issue of Forum. In her own
words, she said, “It has been a pleasure to work for ISHRS and to get to
know you personally and professionally.” We wish Laura all the best.
Your leadership continues to wish
to hear from all of you in the course of
the year. Please do not hesitate to
contact us—no issue or concern is
inconsequential. Communication is
the backbone of a good Society.✧
Bobby L. Limmer, MD
Volume 12, Number 3
Hair Transplant Forum International
May/June 2002
❏
Co-Editors’ Messages
I was
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
Over the past
12 years there
have been many
changes in a
positive direction
with the hair
transplantation
procedure. There
seemed to be a
sequence of big
William M. Parsley, MD
Louisville, Kentucky
round grafts,
small round grafts, quadrisected round
grafts to holes, quadrisected round
grafts to incisions, multi-bladed strip
excisions (MBSE) cut to produce
minigrafts and micrografts, MBSE cut
to produce linear grafts for slot or slit
grafting, single-bladed strip excisions
(SBSE) cut to produce minigrafts, and
○
can’t imagine the task being done
repeatedly without some serious
follicular damage. Anyone who has
spent time looking under a microscope
cutting grafts knows that the hairs in
many FUs, when followed from their
common exit area in the skin, down
into the dermis and subcutaneous
layers, often diverge from each other to
form “teepees” and various configurations of seaweed. I have often tried to
core out an errant single hair on the
forehead with a 2mm diameter punch,
never mind a 1mm one, and at least half
the time miss the bulb.
I have always been a little bewildered
by all of the resistance to introducing
microscopes in a hair transplant office.
excellent job in getting everyone’s
diverse opinions onto the table so that
the differences could be resolved in a
constructive way. All in all, it is a
major step forward for our specialty.
The recent articles on FUE (follicular
unit extraction) and all of the hullabaloo
on the Internet remind me of my
younger days when magic was one of
my hobbies. Each time I saw a new
magic trick performed, I was always
intensely anxious to learn how it was
done. Well, FUE certainly looks like a
magic trick to me. The only problem is
that, unlike every other technique in
hair restoration history, those of us
wanting to become magicians can’t even
get hold of the instructions. But I’ve got
to tell you: Short of an act of God, I
heartened
to see the Ad
Hoc Committee
on Certification
and the ABHRS
resolve their
differences. I am
confident that,
if a spirit of
good will takes
Michael L. Beehner, MD
root from this
Saratoga Springs, New York
time on, that we
can all progress forward to the benefit
of all hair transplant surgeons
throughout the world. I think a lot of
credit is owed to Bobby Limmer, our
president, for having the foresight to
create the ad hoc committee, and to
James Vogel for having done an
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
more recently SBSE to produce microscopically prepared follicular unit
grafting. With these changes in hair
graft transplantation, some of the
standard accepted surgical procedures
became less popular. Among these
procedures were scalp reductions, flaps,
and scalp lifts. A number of hair restoration surgeons developed considerable
expertise at these procedures and have
scores of satisfied patients to show for it.
Should these procedures be discarded
for the newer techniques? We need to
take a look at this realistically.
Some say that these techniques have a
high complication rate. With scalp lifts,
problems with necrosis and bad press
have severely reduced the numbers of
cases. Flap surgery is a broad field but
continued on page 104
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
flaps can suffer from tip necrosis, poor
hair angle, and poor density blending
with the existing scalp. Scalp reductions
are a little more complex. There are
many techniques used here—Mercedes
cut, midline excision, lazy S, etc. The
most common problems are a visible,
sometimes depressed scar; stretch back;
and slot formation. If too much hair is
removed, a “parting of the Red Sea” look
can occur where the hair falls away from
the scar with activity (or wind) causing
the scar to be exposed. Should these
procedures be dropped because of the
above problems?
Mini-/micrografting and follicular
unit grafting have their own problems.
Graft survival, stretched donor scars,
continued on page 104
To Submit an Article or Letter to the Forum Editors
Please send submissions via a 3½" disk or e-mail, double space and use a 12 point type size. Remember to include all photos and figures referred
to in your article as separate attachments (JPEG, Tiff, or Bitmap). For e-mail submissions, be sure to ATTACH your file(s)—DO NOT embed
it in the e-mail itself. We prefer e-mail submissions with the appropriate attachments. Send to:
William M. Parsley, MD
310 East Broadway, Suite 100
Louisville, Kentucky 40202-1745
E-mail: [email protected]
Submission deadline for July/August, June 10; September/October, August 10.
95
Hair Transplant Forum International
❏
May/June 2002
Volume 12, Number 3
Notes from the Editor Emeritus
Hair Loss in Females
A number of
papers have
been published
in recent years
drawing
attention to
the fact that
female pattern
Richard C. Shiell, MBBS
Melbourne, Australia
baldness is not
just a variation on male pattern
baldness but an entirely different
entity with different hormonal
mechanisms and possibly different
genes involved.1,2,3 An additional
problem is that diffuse, unpatterned
alopecia is also commonly seen in
females both young and old, and in
the early stages this may appear very
similar to the patterned variety.
Female alopecia is further complicated by the fact that there are
obviously differing incidences of
female baldness in different countries.
In Australia, I seldom see the Ludwig
patterns described in 19774 but see a
lot of diffuse and pattern alopecia in
Asian women, those of Mediterranean
origins, and second-generation
descendants of Polish Jews.
These girls start hair loss with late
puberty just like the males, and most
have a similar pattern though not as
strongly developed. These ethnic groups
would make up perhaps 25% of our
population in Melbourne but would
not be seen as frequently in the smaller
cities of Australia or the USA. The postmenopausal ladies with alopecia of male
and Ludwig patterns are more evenly
distributed over both the Anglo-Saxon
stock and ethnic groups.
Diffuse alopecia occurs in BOTH
sexes; diagnosis in males can be
complicated by the fact that some
unfortunate men have both types of
alopecia. There is no doubt in my
mind that diffuse alopecia is inherited and that androgens act as a
trigger but that it has a totally
different genetic make-up to patterned androgenetic alopecia. The
females tend to inherit this from
mothers or grandmothers, and the
degree of hair loss in their fathers
seems to be irrelevant. I have never
been able to form an opinion about
the source of the inheritance of pure
diffuse hair loss in males.
Much more work needs to be done
with female alopecia. We have some
wonderful hair growth researchers
including female physicians Marty
Sawaya and Angela Christiano. Some
of the major drug companies are at
last taking an interest so I hope that
elucidation of the problem will follow
in the near future.✧
Richard Shiell, MBBS
REFERENCES
1. Norwood OT, Lehr B: Incidence of
female androgenetic alopecia.
Dermatol Surg 2001; 27:53-54.
2. Norwood OT: Female androgenetic
alopecia a separate entity. Dermatol
Surg 2000; 26:679-82.
3. Cullen OS, Messenger AG: Diffuse
female hair loss: Are androgens
necessary? Br J Dermatol 1999;
141:521-23.
4. Ludwig E. Classification of the
type of androgenetic alopecia
(common baldness) occurring in
the female sex. Br J Dermatol
1977; 97:247-53.
! ABHRS Announces New Website
Robert Cattani, MD, president of the American Board of Hair Restoration Surgery, announced that the
Board has a new Website that can be accessed at either www.abhrs.com or www.abhrs.org Physicians
wanting to know more about the application process can obtain this information there. A history of the
Board’s origin and purpose are detailed, along with a list of the current Board of Directors and the
Diplomates of the Board to date. The application form for taking the Board Exams can be directly downloaded from the site also. Dr. Cattani and the Board of Directors of the ABHRS hope that the
creation of this Website will make it easier for hair transplant physicians to become familiar
with the Board and will hopefully eventually go through the process of becoming a Diplomate. The overall goal is for the Board to become more inclusive and to welcome all eligible
candidates to want to participate.
"
96
Volume 12, Number 3
Hair Transplant Forum International
❏
May/June 2002
Up Close and Personal in Orlando
8th Annual ISHRS-Sponsored Live Surgery Workshop
Day One
Reported by Jennifer Martinick, MBBS Perth, Western Australia
The 8th Annual Live Surgery Workshop
was the most exciting and stimulating so
far. To the strains of “Welkome” from
Cabaret, Dr. Matt Leavitt greeted us and
implored us to “never stop learning.” It
was heartening to see so many new faces.
The other co-founders of the Workshop
along with Dr. Leavitt—Drs. Marcelo
Gandelman and Patrick Frechet were
both present, as was the current president of the ISHRS, Dr. Bobby Limmer.
The Beginner’s Workshop that first
morning covered all of the “basics,”
including many practical aspects of
hair transplantation. The speakers
were to be credited with their open
and frank approach to their topics.
The morning began with Dr. Sharon
Keene pointing out that patients are
more knowledgeable than in the past
and want to know the doctor’s credentials, experience, and results.
Dr. Bill Parsley, speaking on the
integration of medical and surgical
therapies for hair loss, emphasized that
patients must understand that medical
treatment is slow in its effect. Dr. Craig
Ziering spoke on the difficulty of
choosing assistants. Dr. Limmer followed by describing his efficient method
for harvesting donor hair to make
follicular units, emphasizing that, by
excising the donor hair in a solid elipse
and “slivering,” there is very little
follicular damage.
Dr. Cole showed a video of graft
preparation, and Dr. Puig spoke on how
to organize a comfortable, safe, and
efficient hair transplant office. Dr.
Shapiro, speaking on follicular unit
transplanting, mentioned that the
Celia Gandelman, Dr. Matt Leavitt, and Dr. Marcelo Gandelman
occasional lack of density is an issue that
must be discussed with patients. He
suggested “follicular pairing” as a means
for improving this problem. Dr. Frechet
spoke on the use of scalp extension
combined with alopecia reduction
procedures, and emphasized that he
only has to transplant 60–70 cm2 after
the reductions are completed. Dr.
David Perez-Meza discussed his Guide
for Beginners, emphasizing the importance of the surgical assistants, and
explaining how an all-FU case versus a
mini/micro case affects the organization
and the relative roles of the physician
and the assistants. Dr. Bob Leonard
spoke on avoiding complications, and
stated that proper candidate selection is
the most important first step in doing
so. He also emphasized informing our
patients of all the risks involved.
The afternoon included an innovative Mentor Program, in which oneon-one training in different aspects of
hair transplantation took place. Also,
four surgeries were undertaken, one
specifically organized as a “Workshop
for Nurses,” coordinated by Drs.
Craig Ziering and Carlos Puig, in
which assistants had the opportunity
to place grafts.
In my opinion, there is more to be
gained in one day of attending the Live
Workshop in Orlando than in buying
an around-the-world ticket, while
stopping along the way to visit several
individual doctors. The difference being
that in Orlando there is tremendous
camaraderie present, and every day
multiple pearls of wisdom are picked up
in corridor conversations. The day
wound up with an exhausted but
exhilarated group of doctors and
assistants enjoying an invitation to
Procyte’s cocktail party by the pool.✧
Day Two Reported by Ivan Cohen, MD Fairfield, Connecticut
The official opening of the regular
meeting featured Dr. Matt Leavitt
welcoming everyone to Orlando and the
8th Annual Live Surgery Workshop. He
pointed out that this year’s faculty
represented all of the continents except
Antartica, which was represented by the
polar bears at Sea World, and he stated
that the principal three goals for this
meeting were: education, science, and
friendship.
After Dr. Price’s keynote speech on
women’s hair loss, the morning’s special
symposium on the subject of alopecia in
women continued, with Dr. Zeiring
speaking. He emphasized that women
are used to styling their hair, so that
transplanting just a small area may have
a large impact on the final result.
Because they often wear their hair up in
the back, he noted that it is important
to place the donor scar where it will not
be noticeable. He emphasized the
importance of using minoxidil in
conjunction with hair transplantation.
He was followed by Dr. Paul Rose, who
spoke on the subject of communicating
with our female patients and the
importance of emphasizing compliance
with the treatment program.
In the panel that followed on Female
Alopecia, Dr. Price noted that ginseng
might elevate testosterone in women
and that Estratest, a common hormone
replacement therapy, may also increase
testosterone levels. As a result, both of
these may cause hair loss. Also of
importance is that women with hair
loss, who take birth control pills, should
be switched to non-androgenetic oral
contraceptives, such as those containing
continued on page 98
97
Hair Transplant Forum International
❏
May/June 2002
Volume 12, Number 3
Up Close in Orlando
continued from page 97
Keynote Lecture
norgestimate or ethynodiol diacetate.
All of the panel members agreed that
minoxidil should be applied twice daily
to be effective. Additional panels on the
consultation, hair design, and graft
preparation were also presented.
Dr. Robert Leonard was the moderator for the panel on “The Consultation.”
Dr. Carlos Puig stated that any alopecic
female without the classic signs of
androgenetic alopecia should have a
scalp biopsy to rule out scarring alopecia. The importance of spending
adequate time with each patient was
discussed, and Dr. Leonard’s mantra is
“Be honest. You’ll sleep better at night.”
The Hairline Design panel, moderated by Dr. William Parsley, led to a
lively discussion when four live patients
98
Dr. Vera
Drs. Robert Haber, Paul Straub, Paul Rose, and Sharon Keene
were presented for evaluation. Dr.
Limmer stated that the four most
common errors in transplanting the
hairline are placing the hairline too low,
using too large grafts, failure to keep
some frontal-temporal recession, and the
failure to anticipate future hair loss in
younger men.
Dr. Limmer was the moderator for
the Graft Preparation panel. He showed
a video that demonstrated how he
produces his slivers from the donor
ellipse and then separates the follicular
units with a less than 1% transection
rate. Dr. Antonio Mangubat discussed
his “Mango Whacker,” and stated that
he now gets his follicular unit hairline
grafts by dissecting the triangular
corners at the ends of his donor incision.
Dr. Mangubat also stated that he felt
his results approached those of total
follicular unit transplantation because
he saves everything he cuts and expects
at least a 60% growth of the transected
hairs.
Dr. Leavitt moderated the panel on
Recipient Sites. Dr. Ivan Cohen empha-
Price, from the University of California-San Francisco, delivered the Keynote
Lecture for the Women & Hair Loss Symposium, entitled “The Diagnosis and Treatment of Hair Loss in Women.” She reviewed the hair growth cycle, emphasizing that the
length of hair is dependent on the length of anagen, and that the diameter of the hair
shaft is directly related to the size of the bulb. She then discussed telogen effluvium
where the patient presents with a history of shedding hair and on examination these
hairs are coming out “by the roots” (telogen hair). The common causes of telogen effluvium include high fever, childbirth, severe illnesses, major surgery, thyroid disease, crash
diets or inadequate protein intake, severe psychological stress, and various drugs. The
shedding occurs 1-3 months after the offending event. On examination, there is marked
shedding with a positive pull test (more than 6 hairs). Dr. Price states that treatment is rarely necessary
because telogen effluvium is self-limited and reversible. The exceptions are correcting thyroid disease, improving dietary deficiencies, stopping offending drugs, and treating associated illness or infection.
Dr. Price also discussed alopecia areata, which is characterized by circular patches of baldness where the scalp
is as smooth as a “baby’s bottom.” Alopecia areata is an autoimmune disease, the target of which may be a
melanocyte-associated protein. There are also HLA associations with this disease. DQ3 is a general susceptibility marker. KQB1*0301 and DRB1*0401 are increased in frequency in alopecia totalis. In patients under 30,
37% have a family history of alopecia areata. In patients with an onset of disease over age 30, only 7% have a
positive family history.
Dr. Price then discussed androgenetic alopecia in females, which is characterized by miniaturization of hair
follicles. An invaluable tool for visualizing miniaturized hairs is a card, which Dr. Price refers to as her “black
and white card,” that she uses during her exams. Black hairs can be easily visualized on the white background
and light colored hairs are easier to see with the black side. Women with androgenetic alopecia have increased
levels of 5 alpha reductase and increased androgen receptors in the frontal scalp as compared to the occipital
scalp (these levels, however, were much less increased than those seen in men). Women also have increased
aromatase, which stimulates the production of more estradiol, which may be protective. These changes may
explain why androgenetic alopecia in women is usually less severe than in men.
Dr. Price commented on an interesting theory of why the common patterns of baldness exist and why hair
in the frontal and parietal areas of the scalp is different than the occipital hair. Hair in these two regions has
different embryologic derivations. Hair in the frontal and parietal areas of the scalp is derived from the neural
crest, whereas occipital hair comes from the mesoderm. The different genetic derivations may be the best
explanation for why the hair in these two regions behaves so differently.✧
—Ivan Cohen, DO
Volume 12, Number 3
sized the importance of not producing
linear or geometric patterns in the
hairlines. Irregularity combined with
variations in density is the key to a
natural looking result.
The meeting continued at Dr.
Leavitt’s MetroWest Surgery Center,
where participants were treated to
simultaneous multiple live surgeries.
Dr. Mangubat demonstrated his
method of automated graft prepara-
Dr. David Perez explaining details of surgery to assistants.
tion. A multi-bladed knife is used to
create the donor strips, which are
then placed on vertical blades spaced
1mm apart. After meticulously lining
up the follicles parallel to the blades
to avoid transection, a tongue blade is
placed over the strip and then
“whacked” with a hammer. Many of
the doctors had a chance to step up
and take a few “whacks.”
Dr. Limmer coordinated the follicular
unit surgery procedure and used the
stick-and-place method of graft placement, whereby the grafts are placed as
each hole is made.
Dr. Yung Chul Kim demonstrated
the use of the KNU implanter. Working
with only one assistant, who must load
each implanter prior to placement,
grafts were placed at the rate of 6–7 per
minute. Placement would have been
much more rapid if Dr. Kim had his
usual number of technicians available.
Dr. Shapiro demonstrated his meticulous technique of follicular unit transplanting, with his trademark attention
to detail in the hairline. Of additional
interest was his “buddy technique” of
graft placement, in which one person
dilates the hole with a forceps while the
other inserts the graft.
Dr. John Cole and Dr. Melike
Kuelahci conducted a scientific study,
“Hair Yield and Appearance by Varying
Density,” theorizing that dense packing
Hair Transplant Forum International
of the frontal hairline may interfere with
the blood supply, thus resulting in less
growth. The study was designed by
dividing the scalp in half from the
midline. Each side was subdivided into
three zones. On one side, grafts were
sparsely transplanted in the frontal
zone and increased in density posteriorly. On the other side, grafts were
densely packed in the frontal zone
and decreased in density posteriorly.
The growth will be evaluated based
on hair weight and the results will be
presented at a future meeting.
Dr. Yves Crassas demonstrated his
Automated Hair Restoration System
(OmniGraft). This automated system
utilizes strips of hair harvested with a
multi-bladed knife, which are then
placed onto parallel vertical blades
similar to Dr. Mangubat’s device. The
strips are covered with silicone sheets
and are placed into a pneumatic press
where they are separated into
minigrafts. Using the method, Dr.
Crassas was able to rapidly produce
1,000 grafts from 7 strips, which,
Dr. John Cole performing surgery as Dr. Gandelman
and participants observe.
taken together, measured 1.2cm in
width and 20cm in length. This
system has an automated implanter
that is different from the HIP Implanter, because the entire graft is
sucked up into the tubing and then
released once the implanter is inserted
into the recipient hole. The system
works on a vacuum suction principle.
Dr. Crassas advises all of us to “have
no fear of automation.”
Dr. Frechet once again impressed the
attendees with his flawless techniques of
midline alopecia reduction with the use
of the Frechet Extender. He states that
any patient who is a Type V or a Type
VI is a good candidate for extenders.
Type VII is probably too wide for
❏
May/June 2002
Drs. Sharon Keene, Patrick Frechet, and Carlos Puig.
extenders to be successful. The success
of the extenders is based on mechanical
creep (immediate stretching of the
tissue) and biological creep (stretching
over time as a result of the production of
collagen fibers).
The final procedure featured Drs.
Gandelman, Limmer, and Leavitt
performing corrective surgery on a
previously transplanted patient who had
a very unnatural appearing hairline. Dr.
Leavitt demonstrated his suturing
techniques for closing the donor wound.
By placing the sutures in between
existing hairs and staying superficial, the
resulting scar should be imperceptible.
With so much information to absorb
during the 11-hour day, there was little
time to process it all before the evening’s
festivities. Looking back, two thoughts
come to mind: It is important to realize
that expert surgeons using different
techniques can each have excellent
outcomes. There is no one right way.
The key to maintaining state-of-the-art
results is to be receptive to new ideas
and be able to incorporate them into
one’s own practice. This meeting
certainly provides the forum for helping
these interactions occur.✧
Drs. Michael Beehner, Robert Leonard, and Paul Straub
continued on page 100
99
Hair Transplant Forum International
❏
May/June 2002
Volume 12, Number 3
Day Three Reported by Marcelo Gandelman, MD São Paulo, Brazil
When we met Friday morning, Dr.
Limmer described it as being a typical
San Antonio winter morning: It was
sunny, cloudless and a little chilly.
Dr. Mel Mayer started off the lectures
by teaching us about the particular
follicular characteristics of the hair on
African-Americans and how to address
these special needs during surgery.
Micrografting hair into the pubic region
was then expertly outlined by Dr. Pierre
Bouhanna. Dr. Marcelo Gandelman
conducted a piece about Eyebrow and
Eyelash Reconstruction made simple.
Our spirited Co-Chairman, Dr. David
Perez-Meza, addressed the topic Hair
Transplantation on Hispanics.
Dr. Mayer’s “Temple Peak Approach”
was most appreciated for its applicability, having never been discussed before,
and gave all present a much-wanted
parameter.
Our experienced Dr. Shelly Friedman gave us a splendid lecture about
Hairpieces and their integration with
transplants placed anterior to them.
Dr. Kim showed that finer results
can be attained on Asians by using his
special technique for Eyebrow Transplantation.
“Lowering the Hairline Without
Grafts” was Dr. Sheldon Kabaker’s
Dr. Michael Beehner lectures on surgery shown to the participants.
Day F
our
Four
Drs. Robert Haber, Matt Leavitt, David Whiting,
and Elise Olsen
The Follicular Regeneration study by
Dr. Mayer was a very impressive threeyear follow up showing the split hair
grafts transplanted to his own legs.
Dr. Perez-Meza presented Microscopy
of the Graft Healing Process, and Dr.
Kim demonstrated the KNU Implanter.
Dr. Kenneth Washenik skillfully
moderated the Hair Loss Symposium
during the afternoon segment that day.
The guest speakers included Dr.
David Whiting, who presented
Traumatic Alopecia and Histopathology of Propecia®.
Hair loss evaluation and Management
was Dr. Elise Olsen’s theme, and Dr.
Janet Roberts raised the polemic issue of
Psychosocial Aspects of Hair Loss and
Long-Term Propecia®.
Finally, Dr. Kenneth Washenik gave
Dr. Keith Kaufman’s lecture and
reviewed Propecia® Data and gave us
an update on what’s new in this field.
Dining at the Sea World’s Discovery
Cove was our delightful evening social
gathering. Over dinner, we were
pleasantly surprised by Dr. Leavitt’s
flash-back slide presentation of the
best moments of our workshops over
the past eight years.
All in all, it was a typical Orlando
night.✧
Reported by Antonio Mangubat, MD Seattle, Washington
The fourth and final day of the Live
Surgery Workshop highlighted an
interesting potpourri of gems. Even
though the pace of the workshop was
grueling, the lecture hall was full,
indicating the great interest in the
information presented.
100
concern, consisting essentially in a
forehead lift combined with an
advancement flap of the hairline,
beveling the wound in such a way
that the hair grows through the scar.
Dr. Mike Beehner expanded on his
Frontal Forelock, a very important
first approach to patients with a scarce
donor area or those who are very
young and show warning signs for
advanced balding later on.
Scalp Reduction was the topic chosen
by Dr. Jerzy Kolasinski, and his technique consists of sliding a jacket with
subcutaneous flaps.
The next step took place at the
MetroWest Surgery Center, a state-ofthe-art facility of Medical Hair Restoration, and we all had the pleasure of
meeting Matt Leavitt’s fantastic staff.
Dr. Craig Ziering deftly performed a
very densely packed follicular unit on a
female patient. Drs. Perez-Meza and
Mayer made a practical demonstration
on a Hispanic patient. Dr. Kim’s team,
assisted by Dr. Marko, efficiently
operated on an Asian patient. Drs.
Gandelman, Bradley Kurgis, and
Marcelo Pitchon carried out the Eyebrow and Eyelash surgery, while Dr.
Limmer undertook the task of cutting
the follicles under the microscope, thus
contributing to the excellent result.
Back at the hotel, Dr. Leavitt
resumed his role as moderator and
presented the Orlando 2001 Research
Study results, as follows:
Site Angulation study by Dr. Leavitt,
Storage of Grafts by Dr. Perez-Meza,
Skinny vs. Chubby Grafts, a remarkable
study by Dr. Parsley, Graft Density
Survival by Dr. Mayer, and Comparison
of Graft Stress Factors by Dr. Beehner.
Dr. Ricardo Mejia kicked off the day
with an interesting two-year follow up
on the treatment of a very large 15 ×
6cm keloid scar in the donor scalp of a
black male using serial excisions, I&D of
a hidden abscess, and intralesional
steroids.
Seeing white hair follicles is difficult
even under the best lighting conditions
using a microscope. Dr. John Cole
demonstrated his new innovation
harnessing the physical properties of
monochromatic light (reflection,
refraction, color addition, and subtrac-
Volume 12, Number 3
Dr. Jennifer Martinick observes Dr. Bobby Limmer
using the microscope.
tion) to create a backlit glow chamber
that significantly improves the visualization of nonpigmented follicles. This will
further reduce follicular transection.
In the never-ending quest for the
undetectable hairline, Dr. Matt Leavitt
shared his “cross hatching” technique for
recipient site creation. This simple
process seemed to better randomize graft
orientation to yield more natural results.
The venerable Dr. Patrick Frechet
updated us on his microstrip grafting
technique using a graft measuring
0.6×3.0mm containing 4–6 hairs that
allows him to place up to 600 grafts
per hour. Despite the fact that he
admits to producing grafts with a 40%
transection rate, he showed us several
excellent results. He also announced the
development of a new graft-cutting
device that will automate the production of these microstrip grafts. We
anxiously await its release.
Our president, Dr. Bobby Limmer,
commented on several controversies in
hair restoration surgery. Perhaps the
timeliest issue is that of credentialing
in hair restoration surgery. In light of
the continued increase in governmental regulation, the Society needs to
address this issue and develop a
comprehensive plan to govern ourselves, lest we find ourselves being
controlled by others. This will take a
concerted effort of our leadership.
Dr. David Perez-Meza discussed how
digital photography has become a
practical and valuable addition to
cosmetic surgery. Documentation has
improved along with the excellent
quality of the digital photographs. After
reviewing the essential requirements and
equip, the most important task once
you adopt the digital format is data
backup regularly and often. Keep
several copies of your data in case of a
Hair Transplant Forum International
disk crash. Replacing computer
hardware is easy. Replacing your
photos is impossible.
Classification schemes in hair restoration surgery have been very useful in
standardizing communication as well as
guiding treatment. Dr. Pierre Bouhana
points out that the Hamilton and
Norwood Classifications lack information critical to the hair restoration
surgeon such as hair caliber, curl,
density, scalp laxity, and several other
parameters. He reviews a new classification of androgenic alopecia that incorporates all of these important factors.
Interestingly, his innovation applies to
both men and women.
Dr. Jennifer Martinick gave us a
summary of the factors that should be
considered when contemplating transplantation to the vertex. We are keenly
aware that the vertex has been the
bottomless pit of hair grafts because it
always enlarges with age. Before undertaking a large vertex reconstruction,
consider factors such as age and hair loss
severity to estimate if sufficient donor
will be available in the future. Furthermore, if reconstruction is performed,
placing grafts concentrically to effectively reverse the pattern of hair loss will
leave a naturally occurring pattern and
provide a significant safety advantage.
Dr. William Reed delivered the last
lecture discussing the issue of quality
control in follicular unit transplantation
(FUT) and the see-through look so
common to FUT. If the transection rate
in FUT at its best is 3%, and 9% with
the use of the multi-bladed knife, the
difference is only 6%. The inherent
quality control issues (e.g., graft
dessication, prolonged time out of
body) with FUT is well-known and
could easily make up the difference
between the techniques, especially if
Drs. Norma Jeane Flack, Patrick Frechet, Melike Kuelahci,
and Arman Firouzi; Liz Rose; Drs. Paul Rose, Ricardo Meija,
Sharon Keene, and Gregory Shannon
❏
May/June 2002
undertaken by less experienced operators. He warned against using FUT as
the only method offered to the patient
because no single technique can offer
everything to the patient.
We then departed for our last afternoon of live surgery after Dr. Leavitt
closed the final plenary session to
observe in our fourth day of live surgery.
Dr. Frechet demonstrated his now
famous triple flap slot correction
procedure, Drs. Melvin Mayer and
Bradley Kurgis showed their approach
to the African-American patient, and
Dr. Mike Beehner performed an isolated
frontal forelock procedure. In addition,
four scientific studies were initiated:
1. Dr. William Parsley began a study
to determine if the diameter of a hair
changes after it is transplanted. He
placed 30 grafts and will measure
their hair shaft diameters at 6, 9, and
12 months post-transplant.
2. Dr. Martinick examines the effect of
graft orientation (sagitally or tangentially) on growth and naturalness.
3. Drs. Paul Rose, David Perez-Meza,
Jerzy Kolasinski, John Cole, William
Parsley and Bob Limmer will
duplicate the experiment reported
by Dr. Kolasinski where non-folliclebearing debris derived from donor
tissue yielded viable hair. In addition, histological examination will be
conducted.
4. Drs. Perez-Meza, Cole, Beehner, and
Leavitt will evaluate the scar width
appearance and wound in the donor
site; comparison of a single layer
versus two layer closure.
This brought us to the conclusion of
another extraordinary experience. The
camaraderie was considered as important as the clinical and scientific knowledge gained. Even though we were
exhausted, most of us are already
anxiously planning for 2003 to continue the this unique event where
novices learn from seasoned veterans and
the seasoned vets have an exceptional
chance to bounce cutting-edge ideas
between one another in a comfortable
yet exciting environment. Many
congratulations and thanks go to Drs.
David Perez-Meza and Matt Leavitt for
a successful and gratifying 8th Annual
ISHRS Live Surgery Workshop.✧
101
Hair Transplant Forum International
❏
May/June 2002
Volume 12, Number 3
You Go Where the Knowledge Is
Alan Feller, DO Great Neck, New York
Bravo to Matt Leavitt, DO, and the
other co-coordinators of the 2002 Live
Surgery Workshop! This was the first
one I had attended and found it to be
quite literally the highlight of my nineyear, full-time hair transplantation
career. As advertised, I picked up new
techniques and perspectives from people
I’ve always considered icons in the field.
Just as important, I made new friends
on both the professional and personal
level, which made flying away on
Sunday that much more saddening.
The experience began at 8:30 Tuesday
morning as I walked through the huge
sun-drenched atrium toward the
Wedgwood room in the Renaissance
hotel to register. (Sorry about the purple
prose!) I encountered strange faces,
accents, and languages coming from the
people huddled in small cliques
throughout the lobby area waiting for
Valarie to give us our name badges.
As I held up my USA Today, pretending to read it (I’m shy by nature), I saw
Bill Parsley striding in my direction. He
was the first person I recognized, which
must have shown acutely on my face
because he approached me as one would
an old acquaintance. As our relationship
heretofore was purely unilateral (I
recognized him only from his picture
and have read all his articles), he could
have had no clue who I was. Despite
this, Dr. Parsley was able to diffuse the
awkward situation in a microsecond
with a congeniality he easily exudes
from his tall, lanky frame and soft voice;
which is how I’ve warmly characterized
him since.
As I entered the nearly empty lecture
room, I was shocked by the number of
chairs available. I estimated a hundred,
and wondered could there really be this
many people attending the workshop?
Yup. Hordes of people started walking
through the oversized doors. Loners
looking as uncomfortable as I did, and
small groups of old friends and acquaintances mumbling in low tones amongst
themselves. Feeling more and more
102
isolated within the crowd, I began to
realize that my initial perception of this
event was way off the mark. As the
background noise grew ever louder, I
began to wonder what I was doing
there. That is until I overheard someone
say over the deign (I think it was Alan
Bauman) “…Hey, you go where the
knowledge is.” That described it
perfectly! It became my catch phrase
throughout the Workshop.
As my excitement and expectations
grew, loud invigorating music began to
play and Dr. Leavitt marched from the
sidelines to the podium with the proud
stride of a parent who has had seven
healthy children and was now watching
the successful birth of his eighth. He
was in his element. He was in Elysium.
Drs. Shelly Friedman and William Parsley talking with live
patients during the hairline design panel.
The first panel convened and all the
fancy (but hardly reliable) audio/
visual equipment was snapped on.
The first breath of the event was taken
and the didactic part of the workshop
came to life.
While I feasted on the information
coming from the podium, I wasn’t
unaware of the individuals who were
serving it to us. Their specific characters, as well as that of those I would
later meet in the halls and around the
coffee tables, would impress themselves on me: Dr. Cole’s natural
swagger and booming southern
accented voice made him a commanding figure whenever he was encountered throughout the workshop. I
found myself consistently jealous of
his full head of hair, which seemed to
have its own agenda throughout the
first day. Dr. Puig with his sonorous
voice and quick witted intelligent
humor. Dr. Perez-Meza with that
wonderful aristocratic Spanish accent
and gift for short, concise statements
that deliver more information in a
phrase than most of us can in a
paragraph. Dr. Tony Mangubat the
“icon inventor” who floored me with
his open honesty concerning the
differences between his “cosmetic
surgery practice” and those utilized
by “Hair Transplant Only practices”
like mine. Then floored me again with
the effectiveness of his “wacker” as
used by his tech Gigi to produce very
acceptable grafts in seconds. Then
floored me a third time with his
interest and genuine objectivity when
presiding over an impromptu debate
between me and several others about
the ABHRS (that discussion is worth
an article in its own right). Dr.
Kabaker, the gentile giant who
patiently and generously spoke with
me for two hours about various
subjects in hair transplantation and
various “life lessons” in minute detail.
Dr. Leonard, the attorney-doctor, even
though he doesn’t have his JD, tells us
to watch our legal flank and reminds us
that the lawyers are always at the gates.
Dr. Beehner, the “stoic icon,” who is
indeed dedicated and brilliant. His
research and results were quoted many
times in the hall. His affability and
kindly nature, coupled with his excellent surgical techniques compelled me
to videotape his surgery (which I
watched several times on the way home
in reminiscence) and to make it my
business to get to know him a bit better.
I’m proud to say he’s from my state of
New York. Dr. Frechet, the champion of
the flap, ever intent on cleansing its
reputation while speaking in his well
measured French accent. Dr. Washenik,
the PhD, MD doctor, new Bosley
medical director, and another member
of the extremely tall club who posses an
encyclopedic knowledge of Propecia®
Volume 12, Number 3
and a gift for engaging an audience
already exhausted from information
overload and lack of sleep (the $500
didn’t hurt, either). After listening to
him I’ve decided to start myself and my
patients on Propecia®, and am also
considering using it as a fuel additive for
my car. (I did discuss this last concept
with him and he thought it might
increase not only the longevity of my
car, but its fuel economy as well.) Dr.
Kim, who is soft spoken and reserved in
every way. Clearly proud of his accomplishments, but deeply modest when
praised. His new implanter is brilliant,
not to mention the unique way he cuts
grafts. That’s something everyone
should see. And the list goes on and on.
At the end of the day’s didactic
session, we got our scrubs and headed
out to the bus enroute to the actual
surgeries. I read great excitement in
the faces of those around me. Most
had never performed a hair transplant
surgery and it was marvelous to hear,
or overhear, their expectations as
question after question was fired from
person to person.
Another thing that struck me was
the range of talent on this bus. As
people introduced each other, I would
hear in machine gun fashion “I’m a
dermatologist, …a plastic surgeon,
…a general surgeon, …an ENT, …an
ophthalmologist,…etc.…” When
asked what I “was,” I simply replied a
“hair transplant doctor,” which is all
I’ve done since leaving my radiology
residency nine years ago. Curiously,
this question was always followed by
the same second question “Do you do
hair full-time?” My answer was
always, “Of course, doesn’t everybody?” I learned that most people on
the bus, at least the “newbees” as I
affectionately called them, were really
only interested in augmenting there
own practices with hair transplantation and not dedicating their careers
primarily to the field. While I’ve no
doubt this is possible, I think this
route is a lot harder for logistical
reasons. Call me a purist.
When we reached the center, I was
impressed with its size. I guess it had to
be big considering the number of
attendees. I walked through a spacious,
Hair Transplant Forum International
well-appointed waiting room that held
a large TV hooked up to a video camera
in one of the operating rooms. I continued further inward and reached my
destination, the surgical suites. I was
given the appropriate disposable attire
and simply walked in while Dr. Shapiro
was discussing how to make a hairline.
The second part of the Workshop was
now given life. Several surgeries were
started at once, and I felt like a kid in a
toy store bouncing from room to room
sampling the different techniques and
view points.
As mobs of masked doctors vied for
position in the rooms, I couldn’t help
but realize that a lot of the differences
between the doctors began to melt
away. It was as if the hidden features
and the common garb made us as one
entity, a super-doctor. The private
cliques that had existed simply vaporized. If someone had a question, it
would now be asked aloud, and then,
just as quickly, would be answered three
different ways, by three different
people—all, heretofore, strangers to
each other.
I felt my own shyness replaced by a
compulsion to not only share my
perspective and experience, but to inject
it where I thought necessary. The hair
transplant veteran in me was brought
out and I enjoyed every second. I was
given a chance to validate some of my
own observations and techniques while
learning and questioning others. It
didn’t take long to realize this event was
worth far more than I paid, and I
wondered if the other attendees felt the
same way. All those I asked did.
As one may feel time contract while
watching an excellent movie, so did the
hours pass quickly while in the surgical
suites. Interestingly, even after many
hours, I did not see a single person
posture their selves in such a way as to
show exhaustion. If anything, I noticed
the opposite.
As the crowd streamed toward the
bus to head back to the hotel, I
couldn’t help thinking that this scene
was no different than what I’ve
encountered walking to the parking
lot after a particularly engrossing film.
The only difference was that this
audience was able to participate and
❏
May/June 2002
could now see themselves in the
staring role. Who wouldn’t want to be
Rocky or John Wayne? Or Matt
Leavitt or Mike Beehner for that
matter?
It seemed everybody was charged up
now that their aspirations to perform
this surgery had taken on a very organized and concrete form. The once
ethereal possibility of performing this
procedure (on a practical basis) had now
become tangible, an ascension to
reality… the Live Workshop had, for
many, become “touching the rock.”
The days were rounded out by
cocktail gatherings in scenic places. The
first evening was by the very inviting
warm waters of the Renaissance Hotel
pool. Here, while dressed in formal
wear, I noticed people reverting back
to “cliquing.” Perhaps this was to
commune with one’s familiars to help
synthesize and digest all that had
happened. Maybe some people were
still stiff. But subsequent gatherings in
front of Penguins and later Dolphins at
Sea World cracked the ice for good, and
I could see little or no remnant of the
old groups.
The integration was near complete,
and so was, unfortunately, the “grand
event.” Perhaps this was timely as the
discussions at the gala dinner had little
or nothing to do with hair transplantation. The verbal excitement had been
replaced with more intimate conversations. My table covered topics from
romance and college experiences to
current events and the existence of God.
No one had known each other prior to
the workshop.
Even after the cocktail parties I would
manage to find myself in a small crowd
and off we would go until midnight or
later to the hotel bar. I’d say I averaged
four hours of sleep per night (I’m not
quite sure how many drinks though…).
Leaving was difficult for me, but I
took with it a renewed love for the field
and couldn’t wait to get back to my
office and a return to surgery.
In New York, while in the cab from
the airport, I began to think of the next
meeting and in doing so had realized
that, yes, you do go to “where the
knowledge is,” but you also go back to
where your friends are.✧
103
Hair Transplant Forum International
May/June 2002
❏
Volume 12, Number 3
Beehner Message
continued from page 95
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
med school, met and married my wife,
and saw my first daughter born. Being a
lifetime Bear, Cubs, and Bulls fan
doesn’t hurt either. I remember, as an
eighth grader, many times taking the
“El” for thirteen cents to Wrigley
Field and getting into the center field
bleachers for $1.50. By the way, for
those not familiar with Chicago, I
strongly recommend the following:
the Art Museum, Natural History
Museum, Museum of Science and
Industry, an elevator ride to the
observation deck of the Sears Building, a boat tour ride from Navy Pier,
walking (and perhaps shopping) down
Michigan Avenue, and just walking
around beautiful Grant Park at the Lake
shore. Maybe if John Cole makes his
pre-convention visit to the city, we can
buy him a special pair of sunglasses, and
he’ll declare the meeting site a “resort”
for the third consecutive year—and I
can bring my blue and white Hawaiian
shirt.✧
the main operating one). In addition
to helping with the training of our
two new assistants, I plan to use it to
monitor all of the “cutters” on a
monthly basis. Anyone wanting more
details on the model we have is
welcome to contact me.
I think it’s a welcome trend that at
meetings and in our literature there are
more discussions about the physiology
of hair and the nuances of its growth
cycles. I think we are all humbled by
how much we really don’t know. We can
all be proud that several of our members
are involved in these debates and
research, and making significant input.
The last time I checked, Chicago,
despite all of its museums and attractions, was not listed as a “resort”—so I
guess I better fold up that bright blue
and white Hawaiian shirt and put it in
the bottom drawer, and get my suit coat
to the cleaners. Having the meeting in
Chicago probably has more special
meaning for me than for most members,
since it is where I attended college and
The cost is always brought up as an
obstacle, but, when considering the
years of use a good microscope provides
and the average income in a hair
transplant practice, that excuse seems a
little silly. The more common complaint is staff resistance to change and
the fact that they will be greatly slowed
down. Around six years ago, we
switched over to exclusive cutting of
grafts with microscopes. For us, there
was no slowdown in graft production. I
have done a fair amount of cutting
myself and have to side with those who
do insist on microscopic dissection if
one wants to call their grafts “follicular
units.” It’s like going under the water in
your scuba gear or snorkel, as opposed
to simply gazing into the water from
shore. There is so much more detail to
see than meets the plain eye (even with
loupes). A recent turnover of two staff
members prompted me to spend a little
extra to obtain a “teaching microscope” (an extra observing lens in
parallel, about 2½ feet to the left of
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
Michael L. Beehner, MD
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
Parsley Message
continued from page 95
pitting, bumps, and poor density can
occur. With experience and good
technique, these problems can be
minimized. But the same can be said for
these other techniques, particularly
scalp reduction. The skills of the
experienced scalp reduction surgeons are
quite amazing and complications are
low in their hands. On repair cases,
good results often cannot be obtained
without reductions and flaps. It is my
opinion that these valuable techniques
should be allowed to develop just as hair
graft restoration has been allowed to
develop. Time will sort out the ultimate
worth of all of our techniques. Open
minds will speed our field along at
maximum rate. Critically looking at any
technique is not only acceptable but is
beneficial, but censorship is neither.
If you haven’t already marked off
October 10-13 on your calendar, please
do it now. Save this date for the 10th
Annual Meeting of the ISHRS in
Chicago as it will almost certainly be
the best meeting in our history. Dr.
John Cole is the Program Chairman.
He is as tireless as he is innovative—
standard protocol may bite the dust.
Drs. Jennifer Martinick and Jerry
Cooley will run the Beginner’s Program
and the Beginner’s Hands-On Workshop, respectively. Special attention is
being given to making the Surgical
Assistant’s Program the best ever. Don’t
miss this one. Like hair? Be there!✧
William M. Parsley, MD
He’s a great man and a great leader
leader.. He sees all the signs along the
way
way,, and never speeds in a thinking zone.
—Reggie Jackson, describing New York Yankee Manager Joe Torre
104
○
Volume 12, Number 3
Hair Transplant Forum International
❏
May/June 2002
Follicular Regeneration Study of Bisected
and Transected Follicular Units Observed
Individually Over at Least One Hair Cycle
Melvin L. Mayer, MD San Diego, California
Figure 1
At the very first ISHRS meeting in
Dallas, when I was just an infant in the
great big world of hair transplantation
absorbing as much knowledge as
possible, Dr. Jung Chul Kim presented
his fascinating data regarding follicular
regeneration. Surprisingly, he demonstrated that hairs could grow without
the papilla! When transected mid shaft
horizontally, the upper half produced
40%, and the lower half 20%. This
demonstrated that regenerative cells
were not exclusively located in the
papilla, and it was not necessary for
reproduction of the follicle.1
Dr. Bobby Limmer in 1994 published his data indicating that the
upper half produced new follicles
7.1% of the time, compared to
21.9% production with the lower half
of the follicle. He observed that the
caliber of most of these new follicles
were of smaller.2
Two ideas were planted in my head
from these two studies:
1. If the follicle could always be
transected at the “perfect” level so
that regenerative cells could always
be present in the upper and the
lower segment, theoretically one
could double hair production.
2. Because the resultant hair produced from a transected follicle is
smaller caliber, one could possibly
find a use to further soften the
frontal hairline for men and
particularly women, also eyebrows
and even eyelashes.
Figure 2
Figure 3
The first question was partially
answered with 133% production from
transected follicles, which I presented
at the ISHRS meeting in September
of 19983 and the second in a study
performed at the Live Workshop in
Orlando in the Spring of 1999,
placing bisected follicles in the frontal
hairline.4,5
With the above abbreviated history in
mind and assistance of a grant from the
ISHRS and the help of Drs. Jim Arnold,
Marco Barusco, Michael Beehner, Jung
Chul Kim, Jennifer Martinick, David
Perez-Meza, and Craig Ziering, we set
out to evaluate the following characteristics of single-hair follicular units
bisected in the region of the bulge, and
follicles transected through the papilla
compared to controls:
1. Rate of growth
2. Pigmentation of resultant hair
3. Curl
4. Maintenance of implantation angle
5. Percent production
6. Time in tellogen effluvium
7. Extend the study for years to evaluate
the above qualities in subsequent
hair cycles
naturally occurring as “single” follicular units were selected. The hairs were
1–2cm long for accurate diameter
measurements. These grafts were
organized in three rows of 20 on
chilled saline telfa pads by Dr.
Martinick, and each was identified by
row number and position in the row.
She then measured the diameter of
each hair with the Electronic Digital
Starrett Micrometer (Figure 1).
Following the diameter measurement, Dr. Kim, with the 10× Meiji
dissecting microscope, bisected 20
single follicular units at the level of
the insertion of the arrector pili
muscle in the area of the bulge. Dr.
Kim also transected 20 single follicular units midway through the papilla
returning them to their proper row
and graft number.
Next, Dr. Beehner tattooed three
vertical rows of 20 gray dots in each
row on Mayer’s right upper anterior
thigh. Row I was 20 control, intact
single follicular units; Row II, the
bisected follicles (upper segment
medial to the dot, lower segment
lateral to the dot); and Row III
consisted of placing the 20 upper
segments medial to the dots and the
lower half of the papilla placed lateral
to the dot.
A device created by Dr. Arnold to
maintain and 18 gauge needle at 45
degrees downward was used to prepare
all receptacle sites.
Study Design
This study was initiated at the
Orlando Live Surgery Workshop on
March 2, 2000. Donor hair was
removed from Dr. Mayer’s occipital
area by Dr. Ziering. Subsequent
microscopic dissection was performed
with the 10× Meiji scope. Only those
continued on page 106
105
Hair Transplant Forum International
❏
May/June 2002
Volume 12, Number 3
Follicular Regeneration
continued from page 105
Figure 4
Periodically the following measurements were obtained:
1. Growth or no growth
2. Length in mm
3. Diameter in microns
4. Color
5. Curl characteristics
6. Skin evaluation for epidermal cysts,
persistent erythema, etc.
7. Angle of exit at the dermal cutaneous
junction
Results
Production
Row I Control: 12 of 20 = 60%
Row II Upper Segment: 10 of 20 =
50%
Row II Lower Segment: 6 of 20 = 30%
Row III Upper Segment: 7 of 20 =
35%
Row III Lower Segment of Papilla: 0 of
20 = 0%
Growth Rate
These measurements are markedly
limited because of mechanical trauma
to the hair follicle in the area of the
upper thigh. Despite the use of
multiple protective bandages and silk
undergarments, most hairs were
adversely affected by mechanical
trauma (Figure 2).
Row I Control: Only hairs #6, 14,
and 17appeared not to be traumatized.
Hair #6 grew 53mm, #14 grew 35mm,
and #17 grew 51mm. 53 + 35 + 51 =
46.3mm. Over 23 months = 46.3/23 =
2.02mm/month growth rate.
Row II Upper Segment: All were
affected by trauma (Figure 2).
Row II Lower Segment: Only seemed
to be unaffected by trauma (Figure 3).
Hair #12 = 32mm; 32mm/23 months
= 1.4mm/month
106
Figure 5
Example of two hairs from one
follicle (Figure 9).
Row III: All less than 1mm due to
trauma.
Diameter
Row I Control: Only 3 of the 12 hairs
that grew were not broken off at the
dermal cutaneous junction. Hair #6 =
46um, #14 = 64um, #17 = 57um.
Diameter difference pre- and posttransplant:
Hair #6: 57 – 46um = 11um
Hair #14: 64 – 64um = 0um
Hair #17: 60 – 57um = 3um
Average decrease in diameter 23 months
transplant: 11 + 0 + 3/3 = 4.7um
Row II Upper Segment: Because all
hairs appeared traumatized and had
lengths less than 1cm, the Starrett
Micrometer could not measure these.
However, they appeared to be in the
25–35um diameter range.
Row II Lower Segment: Only one of
the six hairs survived the mechanical
trauma to grow to a measurable
length.
Hair #12: 38um
Diameter difference pre- and posttransplant: 61um – 38um = 23um
Row III: Of the 35% production, none
escaped the trauma to be sufficiently
measured by the micrometer.
Color
Row I: Little or no change from the
medium brown color.
Row II and III: Most appeared lighter
brown (Figure 4).
Curl Characteristics
Row I Control: Increase in curl (Figure
5, hair #6 & #14)
Row II: Upper Segment: Length
Figure 6
insufficient to determine
Row II: Lower Segment: Hair #12
marked curl (Figure 6)
Row III: Length insufficient to determine
Skin Characteristics
Row I Control: Little or no perifollicular reaction
Row II: Upper Segment: Increased
perifollicular inflammation
Row II: Lower Segment: Increased
perifollicular inflammation (Figure 7)
Row III: Upper Segment: Many
inflammatory epithelial cysts
(Figure 8)
Row III: Lower Segment: No significant dermal changes
Angle
No consistency of angle
Discussion and Conclusions
This study confirms previous work
that production is usually decreased
significantly by transection of the
follicle.1,2 There is some variability of
production depending on the level of
bisection1,2,3,4,6 and whether the
bisected follicle is part of a two-haired
follicular unit.7
Hwang has presented the theory
that the recipient area influences
greatly the growth characteristics of
the hair. Interestingly, the control
production rate in this study on the
upper thigh was 60%, Hwang’s
production on the leg was 60.2%.
This compares to a usual 95%+
production on the scalp. Certainly,
this study adds credence to Hwang’s
theory that Orentreich’s Theory of
Donor Dominance is certainly influenced by local growth and reproduc-
Volume 12, Number 3
Hair Transplant Forum International
❏
May/June 2002
This study would suggest that we
3. Mayer M. Paper presented at
tion characteristics of the recipient
should not adopt intentional bisection
International Society of Hair
area.10
on a full-scale basis because of the
Restoration Surgery Annual MeetThe rate of growth was significantly
following four reasons:
ing. Washington, D.C., 1998.
diminished. Olsen’s text indicates the
1. Decreased survival of the follicle
4. Mayer M: Follicular regeneration:
average growth rate of scalp hair is
Use of bisected hairs in a frontal
0.37–0.44mm/day.11 This compares to 2. Increased curl, even to the point of
“kinky” hair
hairline. Orlando Live Workshop,
the control growth rate of 2.02mm/
3. Unable to predict consistency of
Orlando, 1999.
month (0.067mm/day), and 1.4 mm/
angle because of the shorter segment 5. Mayer M, Kim JC, Martinick J,
month (0.047mm/day) for bisected
length
Beehner M, Barusco M. Internahair. Both are significantly diminished
4. Increased likelihood of erythemational Journal of Cosmetic Surgery and
compared to those on the scalp. This
tous epithelial reaction
Aesthetic Dermatology Vol. 3, No. 2,
could have been adversely affected by
2001, pp 135–138.
frictional trauma due to location of this
The greatest disappointment with this 6. Reed W. Paper presented at the
study. The diameter of the controls
study has been my inability to protect
International Society of Hair
decreased an average of 4.7um comRestoration Surgery Annual Meetpared to the bisected decrease of 23um. these hairs from local trauma. Because I
work out almost every day, there is a lot
ing, Washington, D.C., 1998.
These results certainly confirm but
7. Martinick J. Paper presented at
quantify previous observations.1,2,3,4,5,6,8,9 of frictional trauma in this area of the
International Society of
The resultant
Hair Restoration
hairs are lighter
Surgery Annual Meetin color. It is
ecause of increased curl, sometimes even to the ing, San Francisco,
unknown
1999.
whether this is
point of being “kink
y,” I have been reluctant to 8.
“kinky
Swinehart,
because of the
JM. Paper presented at
decreased
recommend this as a procedure we all should adopt International Society of
caliber of hair
Hair Restoration
shaft giving the
to further refine our hairlines.”
Surgery Annual Meetillusion of a
ing, Waikola, HI, 2000
lighter colored
9.
Swinehart,
hair or if there is
upper thigh. I would recommend this
JM: “Cloned” hairline: The use of
truly a decreased concentration of
area not be selected in the future to study
bisected hair follicles to create finer
melanin in the hair follicle.
hair growth characteristics.✧
hairlines. Dermatol Surg 2001;
Swinehart has proposed the use of
27:868–872.
bisected hairs in the frontal feathering
REFERENCES
10. Hwang S. Donor dominance vs.
zone.8,9 Because of increased curl,
1. Kim JC. Paper presented at the
recipient’s role in hair transplantasometimes even to the point of being
International Society of Hair
tion. Paper presented at the Interna“kinky,” I have been reluctant to
Restoration annual meeting, Dallas,
tional Society of Hair Restoration
recommend this as a procedure we all
1993
Surgery Annual Meeting, Puerto
should adopt to further refine our
2. Limmer BL: Relating hair growth
Vallarta, Mexico, 2001.
hairlines.
theory and experimental evidence to 11. Olsen E. Disorders of Hair Growth.
There was more perifollicular
practical hair transplantation. J
McGraw-Hill 1994, p. 7.
erythematous epithelial reaction around
Cosmetic Surg 1994:2
the transected hair (Figures 7 and 8).
“B
Figure 7
Figure 8
Figure 9
107
Hair Transplant Forum International
❏
May/June 2002
Volume 12, Number 3
The Role of Tissue Expansion in
Hair Transplant Surgery: Presentation
of Two Unique Cases
Jeffrey S. Epstein, MD, FACS Miami, Florida
The literature is replete with references
to the use of tissue expansion in scalp
reconstruction. No other technique is as
capable of reconstructing large defects,
especially those of burn and other scars.
This is because tissue expansion, when
induced over a period of weeks to
months, generates an actual dividend of
additional tissue by inducing biological
creep (the actual growth of new tissue,
similar as to in pregnancy), in addition
to mechanical creep (stretching of the
existing tissue and extrusion of the
ground substance), the latter of which is
generated by short-term stress for a
period of minutes to days.
Indications for tissue expansion in
surgical hair restoration include
expanded scalp flaps (e.g.,
temporoparietoccipital flap), expansion-assisted scalp reduction, and
reconstruction of alopecic scars from
burns and other trauma with expanded scalp skin. However, for most
hair restoration and scalp reconstruction indications, less invasive and
deforming techniques are available,
such as extender-assisted scalp reduction, and hair grafting into alopecic
scars. These alternative techniques
usually are as or almost as effective as
tissue expansion techniques, but there
are definite indications for tissue
expansion.
In the following two cases, tissue
expansion was, appropriately, the
technique of choice. These cases of
traumatic alopecic scarring, with
deformation of the normal hairline,
were treated with a combination of
tissue expansion and hair grafting.
Case 1 was a 20-year-old female, who
at the age of 2 avulsed a large portion of
her forehead and frontal hairline skin,
with associated frontal skull fracture as a
result of a motor-vehicle accident.
Repair at that time included the
108
anterior advancement and rotation of a
right frontal pericranial hair-bearing
flap, and primary closure of other
forehead lacerations. As Photo 1A
illustrate, the defect upon presentation
included an irregular hairline that, at
4cm cephalad to the right eyebrow, was
too low on the right side, and receded
centrally, with islands of hair-bearing
tissue in the center of the forehead with
associated scars.
Photo 1A
Photo 1B
Photo 1C
The plan of treatment included
expanding the skin on the right side of
the forehead to elevate the hairline on
that side, while lowering the central
region of the hairline with hair grafting.
At the first surgery, a 4 × 5 cm tissue
expander was inserted in the right side
of the forehead, and 150 1–3-hair grafts
were transplanted into the left and
central aspect of the hairline. Photo 1B
shows the near fully inflated expander in
place 6 weeks after placement just
before the second procedure. At the
second procedure, the expander was
removed, and the expanded right
forehead skin was advanced superiorly
and the excess hair bearing skin was
excised and used to create another 125
2–4-hair grafts that were placed into the
left hairline region. Six months later,
another 550 grafts containing 1-4 hairs
were transplanted into the left and
central aspect of the hairline and into
the small scar along the once leading
edge of the expanded forehead flap.
Results are shown at 5 months after the
last transplant procedure (Photo 1C).
The isolated islands of hair were treated
with laser hair removal.
Case 2 was a 13-year-old female,
who at 3 years suffered a burn to the
right side of her face and scalp. Upon
presentation (see Photo 2A), the
defect included a large alopecic scar
along the right temporal region with
loss of the sideburn and eyebrow on
that side, as well as atrophic scarred
hyperpigmented skin along the right
cheek and forehead.
The plan of treatment included
expanding the skin surrounding the
facial scars, and the hair-bearing skin
along the edge of the temporal
alopecic scar, and advancing the
expanded flaps. In addition, hair
grafting would be used to restore the
eyebrows. At the first surgery, three
tissue expanders were placed: subcutaneously in the right cheek,
subfrontalis in the left side of the
forehead, and subgaleally in the right
temporal region. Simultaneously, 125
1–2-hair grafts were placed in the
right eyebrow region. Photo 2B was
taken close to the end of the expansion cycle. Eight weeks later, the
expanders were removed and the
expanded tissue was advanced: the left
forehead flap advanced to the right
side of the forehead, the right cheek
flap advanced anteriorly-superiorly,
and the right temporal flap advanced
Volume 12, Number 3
Hair Transplant Forum International
Discussion
Photo 2A
Photo 2B
Photo 2C
anteriorly and inferiorly to advance
the entire temporal scalp and to create
a sideburn. Results are shown 8
months later.
It is the author’s opinion that most
cases of scalp scarring are best treated
with hair grafting, and in fact, transplantation is far and away the most
common procedure performed to treat
all types of scalp scarring. However, in
the two cases presented here, as well
as several other cases I have treated,
hair transplantation by itself would
have been unable to provide the
results that were achieved. In the first
case, elevating the abnormally low
hairline would have been impossible
without first expanding the forehead
skin below it. Perhaps laser hair
removal would have been reasonably
effective to raise the frontal hairline,
but it likely would have incompletely
removed all the hair, and also would
have left obviously scarred tissue. In
this case, the patient was very accepting of the relatively short period of
❏
May/June 2002
deformity to achieve the results she
attained.
In the second case, tissue expansion
permitted the removal of large areas of
atrophic scarred facial skin, as well as
the dramatic advancement of the
temporal hairline. Refinement of the
hairline, as well as partial restoration
of the eyebrow, was achieved with
subsequent hair grafting.
It is the unusual patient who is
accepting of tissue expansion. However,
it is those patients with the most
scarring who are best treated with, and
are most willing to undergo, tissue
expansion. While cosmetically deforming (temporarily) and at times very
uncomfortable, the risks of tissue
expansion are very low. This procedure
should be considered in patients for
whom hair transplantation cannot meet
the needs of the alopecic defect.✧
109
Hair Transplant Forum International
110
❏
May/June 2002
Volume 12, Number 3
Volume 12, Number 3
Hair Transplant Forum International
❏
May/June 2002
111
Hair Transplant Forum International
May/June 2002
❏
Volume 12, Number 3
International Society of Hair Restoration Surgery
10th Annual Scientific Meeting
October 10–13, 2001
Chicago Marriott Downtown
Chicago, Illinois USA
Make
Make your
your reservations
reservations today!
today!
The Windy City is expecting you! We hope you are planning to attend the 10th Annual Meeting of the ISHRS.
Beautiful (and accessible!) Chicago, Illinois, is a perfect venue to plan a family vacation along with this
meeting. We are including the hotel and airfare discount information in this flier, so you can make your
reservations now.
The meeting program and registration forms will be available in July. However, we have outlined below the
general times and sessions of the meeting, so you can make your travel arrangements appropriately.
Preliminary*
Preliminary* Meeting
Meeting Schedule
Schedule
Wednesday, October 9, 2002
8:00AM–5:00PM ........................................ An Introduction to Hair Transplantation (formerly called “The Beginner’s
Program”; for both Physicians and Assistants)
8:00AM–5:00PM ........................................ Board of Governors Meeting
8:00AM–11:00AM ....................................... Committee Meetings
NOON–4:00PM ............................................ Exhibitors Set-Up
5:00PM–7:00PM ........................................ Welcome Reception
7:00PM–10:00 PM ...................................... ISHRS Review Course for Preparation of the ABHRS Exam (Part I)
Thursday, October 10, 2002
7:00AM–8:30AM ........................................ Early Morning Workshops
7:00AM–10:00AM ...................................... ISHRS Review Course for Preparation of the ABHRS Exam (Part II)
8:00AM–5:00PM ........................................ Surgical Assistants Program
8:00AM–5:00PM ........................................ Exhibits
8:00AM–5:00PM ........................................ General Session (Combined for Physicians and Assistants)
6:00PM–8:00PM ........................................ Reception at the 95th Floor, John Hancock Building
Friday, October 11, 2002
7:00AM–8:30AM ........................................ Early Morning Workshops
7:00AM–10:00AM ....................................... ISHRS Review Course for Preparation of the ABHRS Exam (Part III)
7:00AM–11:00AM ....................................... Surgical Assistants Program
8:00AM–5:00PM ........................................ Exhibits
8:00AM–5:00PM ........................................ General Session (Combined for Physicians and Assistants)
Saturday, October 12, 2002
7:00AM–8:30AM ........................................ Early Morning Workshops
8:00AM–2:00PM ........................................ Exhibits
8:00AM–12:00NOON ................................... General Session (Combined for Physicians and Assistants)
1:00PM–4:00PM ........................................ Workshops and Off-Site Live Surgery Observational (Limited attendance)
6:00PM–10:00PM ....................................... Gala Dinner/Dance and Awards Ceremony
Sunday, October 13, 2002
7:00AM–8:30AM ........................................ Early Morning Workshops
8:00AM–12:00NOON ................................... General Session (Combined for Physicians and Assistants)
*Please note: This is a preliminary program and subject to change. The final program will be listed in the registration materials
to be distributed in Summer 2002.
112
Volume 12, Number 3
Hair Transplant Forum International
Air Travel Information
The ISHRS has arranged for discounted convention airfares with Delta
and United Airlines. Those attending the ISHRS meeting in Chicago
can take advantage of the following savings:
# 5% off any published fares OR
# 10% off of unrestricted coach fare when tickets are purchased seven (7)
days prior to travel
# Additional 5% discount when tickets are purchased 60 days prior to travel
❏
May/June 2002
Rese
fligh r v e y o u
t
r
early and room
adva a n d t a k e
n
I S H R tage of
S ra
tes!
To take advantage of these savings, you may call Travel Technology Group, the ISHRS official travel agency,
at: 800-677-5537 (USA) or 312-527-7270 (collect) in Canada and Non-U.S. between 8:30AM–5:30PM (CDT/CST)
Monday through Friday. If you wish, you or your local travel agent may call direct to:
Delta Airlines, 800-241-6760 (File #182516A)
United Airlines, 800-521-4041 (File #550KH)
Hotel Reservation Procedure
The ISHRS has secured discounted group rates at the Chicago Marriott Downtown (540 N. Michigan Ave.).
Hotel rates are subject to applicable state and local taxes per room, per night. To make reservations, you
may call 312-836-0100 or toll-free at 800-228-9290. Be sure to identify yourself with the ISHRS group in
order to receive the discounted rates. Or, you may fax Hotel Reservation Form found on page 114 directly
to the hotel at 312-245-6928. Reservation requests made after September 16, 2002, will be confirmed on a
space available basis at prevailing hotel rates. Hotel check-in time is 4:00PM and check-out is 12:00 NOON.
Rates*:
Standard
Standard
Additional Person
For suite information
$200 single
$200 double
$ 20 each
and availability, call Marriott’s Event Housing Department at 312-245-6902.
*Pending the hotel’s availability, these rates are good for the meeting dates as well as 3 days prior and 3 days postmeeting, should you wish to add on a vacation. Therefore, the valid dates for the listed rates are October 6–15, 2002.
Hotel Deposit/Guarantee
A deposit equal to one night’s stay is required to hold each room reservation. Such deposit shall serve to
confirm the room reservation and shall be applied to the first night of the reserved stay. Guaranteed
reservations are held for arrival until midnight on the day of arrival. To avoid a cancellation charge of one
night’s room deposit, reservation cancellations must be made 72 hours prior to the scheduled day of arrival. Call the hotel directly to cancel your room reservation.
To obtain a room at the discounted rate within the ISHRS block of rooms, you must make your
reservation prior to September 16, 2002. Reservations and room types will be confirmed on a
space-available basis. Make your reservations early!
113
Hair Transplant Forum International
❏
May/June 2002
Volume 12, Number 3
ISHRS 10th Annual Scientific Meeting
October 10–13, 2002
Hotel Reservation Form
Chicago Marriott Downtown
540 North Michigan Avenue
Chicago, Illinois 60611 USA
Phone: 312-836-0100 Fax: 312-245-6928
Complete this form and fax directly to the Chicago Marriott Downtown to make hotel reservations for the ISHRS 10th
Annual Scientific Meeting. (Do not fax this form to the Society.) Please note: It is your responsibility to make your own hotel
reservations for the meeting. You may fax this form or call the hotel directly to make reservations.
Name: ___________________________________________________________________________________
Address: __________________________________________________________________________________
City: _________________________________________
State/Region: ______________________________
Postal Code: ___________________________________
Country: __________________________________
Phone: _______________________________________
Fax: ______________________________________
Payment Information:
Type of Credit Card: __________________________________
Expiration Date: ____________________________
Credit Card Number: _________________________________
A deposit equal to one night’s stay is required to hold each room reservation. Such deposit shall serve to confirm the room
reservation and shall be applied to the first night of the reserved stay. Guaranteed reservations are held for arrival until
midnight on the day of arrival. To avoid a cancellation charge of one night’s room deposit, reservation cancellations must be
made 72 hours prior to the scheduled day of arrival. Call the hotel directly to cancel your room reservation.
Date
ARRIVAL
Time (if known)
Date
DEPARTURE
Time (if known)
Accommodations: (please check preference)
❏ Standard US $200 (single/double)
______Additional Person US $20
(Suites—Call 312-245-6902 for information and availability.)
Occupancy:
Single
Double
Additional Person(s)
Guest name(s): ___________________________________________________________________
To obtain a room at the discounted rate within the ISHRS block of rooms, you must make your
reservation PRIOR TO September 16, 2002. Reservations and room types will be confirmed
on a space-available basis. Make your reservations early!
The hotel will mail your confirmation letter to the address indicated above. It is your responsibility to ensure that the hotel
received your fax. The ISHRS is providing this fax-in reservation form as a courtesy to our meeting attendees.
FAX TO CHICAGO MARRIOTT DOWNTOWN
Fax: 312-245-6928
Attn: Reservations Department
114
Volume 12, Number 3
Hair Transplant Forum International
❏
May/June 2002
CYBERSPACE CHAT…
Editor:
Edwin S. Epstein, MD
Richmond, Virginia
Please send your
comments/questions to:
[email protected]
HAIRLOSS AND HIV
SERO-CONVERSION
Marc A. Pomerantz, MD
Chicago, Illinois
I recently saw a 40-year-old man who
is HIV positive. His disease is stable on
treatment with an anti-viral cocktail. He
also takes small amounts of a steroid
intermittently. He is a life-long vegetarian, but he pays close attention to his
protein intake, and he appears to be
well developed with better-than-average
muscle development.
He has typical male pattern baldness
in an early, classical Norwood Class IV
pattern. He has medium-fine, blond
hair with some early graying, and the
color contrast between his hair color and
skin color is very low. His donor hair
density in a 4mm circle appears to be
22, and he also appears to have some
uncountable “invisible” hairs. He,
presently, applies 5% Minoxidil
solution once daily, and he is sure that
the Minoxidil is effective because he
began losing crown hair when he
stopped using it. He immediately
resumed using the Minoxidil, and
regrew the lost crown hair. He also takes
Finasteride, although he is unsure
whether Finasteride is effective for him
because he has seen no additional
improvement over the gains he made
with Minoxidil.
Shortly after his HIV sero-conversion, he lost all of his body hair,
almost all his axillary hair, and most
of his pubic hair. His eyebrow hair
and eyelashes appear to be normally
full. He feels that he didn’t begin to
lose much scalp hair until the steroid
was added to his drug regimen. The
steroid dosage was decreased. The
scalp hair loss stopped, and it has
been stable for 2 years.
Question 1: Is this man a candidate
for hair transplantation? I have seen
and successfully treated several
patients who are HIV positive and
stable on treatment. (I always warn
HIV patients that if their HIV disease
progresses, their transplanted hair and
possibly some of their background
hair will be lost.)
Question 2: Have you or any other
readers seen patients who lost their
body hair after sero-converting for HIV?
I am not aware of any, although I must
admit I haven’t asked that question
before. I will ask in the future.
Question 3: Do you know of other
conditions that cause a selective loss of
body hair while sparing the eyelashes,
eyebrows, and scalp hair?
David Parenti, MD
Dept. Infectious Disease
George Washington University
Washington, DC
I doubt HIV positivity would affect
the effectiveness of hair transplantation unless the CD4 count was quite
low. I have not heard of “total body”
hair loss during sero-conversion or the
“sparing” that was described.
Bob Haber, MD
Cleveland, Ohio
I agree with your assessment of
probable Alopecia Totalis Universalis
(almost). I see AA every day in my
Dermatology practice, and almost
never in HIV patients, and I do not
know of a notable association between
the two.
ICE PACKS FOR POST-OP
EDEMA
Brad Wolf, MD
Cincinnati, Ohio
I instruct patients to use ice packs
on the donor area and on the forehead
for at least 48 hours post-op, never
directly on the grafts. Patients find the
donor area feels better and is soothed
immediately when ice is applied to the
painful area. Presumably, ice prevents
and reduces swelling on a cellular
level, which contributes to pain in the
donor area. Patients who apply ice to
the forehead report less swelling. If
edema develops in the forehead, even
within 72–96 hours post-op, application of ice hastens its resolution. I
instruct patients to apply ice for 5
minutes up to every hour. When I
had transplants performed on me, I
would apply ice to the forehead for
about 5 min, which is all I could
tolerate, and then switch to the donor
area. I know of no one who has reported
or had any problems with frozen skin or
delayed healing post-op.
We have flexible cold gel packs to
give patients. Alternatively they can
use ice cubes in a plastic bag or frozen
vegetables, peas or corn work well. I
have not tried lima beans or okra but
they would probably work equally
well.
Patients more likely to get forehead
edema are those with thin skin,
females, more than normal bleeding,
those having large sessions done in the
frontal area, and those who require
more anesthesia injection (fluid) in
the recipient area. I do not use
continued on page 116
115
Hair Transplant Forum International
❏
May/June 2002
tumescence in the recipient area nor
do I use buffered anesthetic.
Russell Knudsen, MBBS
Sydney, Australia
I allow patients to apply ice to the
grafted area for 10 minutes every 2
hours for the first 24 hours provided
they cover the grafted area first. I have
not had a problem with grafts sticking
or being lost. I agree that patients
report less swelling. No compromise
of grafts has been noted.
POST-TRANSPLANT ANAGEN
EFFLUVIUM
John Cole, MD
Washington, DC
I find that anagen effluvium is very
difficult to avoid if the miniaturization is advanced. Provided I do not
super dense pack, I feel I can most
often avoid anagen effluvium of the
existing hair by carefully making my
incisions parallel to the direction of
hair growth. While this care is almost
always successful, it is not absolute.
When the hairs are short, minimally
pigmented, and extremely fine, even
marked care seems to provide minimal
defense in the prevention of anagen
effluvium. I am careful to discuss this
probability with my patients prior to
surgery. Interestingly, in such cases, the
hairs rarely return with any significant
degree of cosmetic impact. I wonder
whether these hairs are susceptible to
the inflammatory response elicited by
local skin trauma and destroyed by the
autoimmune response. Perhaps efforts to
minimize the inflammation might
prove beneficial.
MANAGEMENT OF WIDENED
DONOR SCARS
Tony Mangubat, MD
Seattle, Washington
If his laxity is good, I suggest a
simple excision and staple closure
without much undermining and leave
the staples in at least 2 weeks. If there
is a collagen crosslink defect, like
Ehlers-Danlos or one of the variants,
the scar will widen again, no matter
what you do.
116
Volume 12, Number 3
Carlos Puig, MD
Houston, Texas
Richard Shiell, MBBS
Melbourne, Australia
Frequently the entire width is not
surgical scar, but rather scar surrounded
by hair loss. This can result from too
much tension on the wound, i.e., skin
sutures that strangulate the surrounding
hair bulbs, or harvesting close to prior
scars without removing the scar. I
suspect another source of these scars is
an acute toxic reaction to the absorbable
sub-q suture. I have seen a few of these
that I know I closed without any of the
above risk factors, and I think some
patients just react to the absorbable
material. That is another argument for
not using them. In any event, the
solution resides in scar revision only…
no associated transplants, closure in one
layer if possible, and no tension.
I have used the Frechet extender to
expand the upper hair-bearing flap to
secure enough tissue to repair donor
scars on two occasions. One patient did
very well, the other not so well. I believe
the difference was in the location of the
scar. The one who did well’s problem
was more toward the midline, the other
behind his left ear. In both
cases, I generously undermined the
upper hair-bearing flap, to encourage
most of the extension to come from
there rather than the bald neck.
We all tend to think that we can do
better surgery than the last guy. In
most cases, this is not true, and
whatever caused the first scar to widen
will cause the next one to widen also.
If we measure these scar repairs before
surgery and then 6 months later
(rather than at the time of suture
removal), there is often very little
difference. There is often a “placebo
effect” in that the patient feels that
the scar is much better because you
have done something for them.
I have spent over 20 years doing
scar corrections using every technique
imaginable and except in cases where
I know that the surgeon was consistently hopeless, I never expect to see
more than perhaps 30% improvement.
The Frechet Extender will give you
extra tissue and allow you to close
without tension but, remember, that
you have to do another procedure to
remove the Extender. Also, they are
quite expensive.
Marc Avram, MD
New York, New York
I have seen scar revisions look great
for a few months and then revert back
to their broad state 6–12 months
later. For widened scars with persistent erythema, I have had success
with a series of pulsed dye laser
treatments that would reduce or
eliminate the erythema, and would
help improve its cosmetic appearance.
Sheldon Kabaker, MD
Oakland, California
Most of these cases are almost guaranteed successes with tissue expansion of
the superior side of the scar. In 6 weeks
and 2 procedures, complete scar excision
and closure without tension is a slamdunk. The possibility of later widening
of the scar due to a rare connective
tissue disorder is the only seeming
downside.
Eric Eisenberg, MD
Toronto, Canada
I’ve had success in reducing donor
scar width by removing a portion of it
at a time (serially), always suturing
scar tissue to a healthy hair-bearing
margin under very little tension. I
have been able to bring a 2cm wide
scar to 1cm in width, about 8 months
post-op.
Edwin Epstein, MD
Richmond, Virginia
I have had success dusting off the
old Bell drill, and removing scar with
dermal punches of varied sizes depending on scar width. I use the
“dove-tail” closure, and this allows me
to remove a controlled amount of scar,
without exceeding maximum skin
tension that may promote future
scarring. However, I do find that
widening will recur despite our best
efforts.✧
Volume 12, Number 3
Hair Transplant Forum International
May/June 2002
❏
COMMENTARY ON
$
An Argument Against Tissue Removal During
Transplantations: Incisions vs. Punches
Commentary #1: Marc Pomerantz, MD, FACS Hinsdale, Illinois
I
read Dr. Bradley Wolf’s article
(Forum, Vol. 12, No. 1; January/
February 2002, p. 5) with interest. The
mathematical presentations were
elegant. It is a shame that they were
fallacious. Much of the reasoning was
original and bold. Unfortunately, much
of it was erroneous. Reviewing the
statements one point at a time:
1. “Net removal of scalp tissue.” Dr.
Wolf makes the statement that the scalp
cannot be reduced without reducing the
size of the skull. While this may be true
from some sort of semantic standpoint,
it is also specious. Doctors who do
surgical hair replacement understand
what is meant by this verbal shorthand,
and it would take too many words and
too much time to describe the process
more exactly. More importantly, Dr.
Wolf misses the main thrust of the
question of scalp reduction with
punches. A punch removes a small area
of bald scalp; inserting a graft into the
empty space replaces that bald area with
hair-bearing tissue. Punch grafting may
not be scalp reduction by strict definition, but it does reduce the total area of
bald scalp, and by filling the hairless
spaces between hairs or grafts with hairbearing tissue decreases the reflectance
of light from the bare skin.
2. “Incision damage and healing
surfaces, linear incision damage, and
linear healing surface are greater with
scalp tissue removed by punches.” (sic)
The reasoning sounds intuitive and
attractive. It has been restated many
times; however, while repeating a false
datum may make it sound true, repetition does not alter the veracity of the
datum. The question is whether minor
differences in healing surface area cause
any difference in the rate of healing or
in the quality of hair growth afterwards.
No one has ever shown a difference in
healing time or in hair growth between
similar sized grafts placed into incised
and punched recipient sites. Actually,
the opposite is true. It is regularly stated
in hair transplant texts and articles that
grafted hairs are all shed and regrow
about 6–12 weeks after a procedure.
With small punched grafts, we routinely see visible hair growth beginning
4–5 days after the procedure. Although
a few hairs are always shed as the crusts
come off the healing grafts, in the great
majority of patients, most of the hairs
continue to grow and are not shed. In
other words, the phenomenon of a postoperative telogen phase is not a necessary component of hair transplantation.
Another problem with this portion of
the article is the question of its mathematical significance. Dr. Wolf ignores
the fact that grafts are three-dimensional
objects while slits have only two dimensions. Accordingly, each slit must be
slightly longer than the graft it contains
in order to accommodate the width of
the graft. Failure to make this allowance
results in graft compression, which
produces cobblestoning. With cylindrical punched out recipient sites, the sites
quickly shrink down around the round
or roundish grafts so the sides of the
grafts and the sides of the recipient sites
are closely applied to each other and the
amount of scar between the grafts and
the recipient sites is minimal. With a
slit that is longer than the graft it
contains, there is an unfilled corner at
one or both ends of the slit that will
have more scar because the two sides
cannot closely abut each other. However, all this mathematical nonsense
seems moot to me. Its importance could
have been argued in the days of 4–5mm
grafts. But, when dealing with grafts
ranging in size from 0.75–1.5mm and
containing 1-6 hairs, the difference in
the amounts of scar between the two
methods are probably so minute as to
be inconsequential. No one has ever
shown a negative effect on healing time
or on hair growth with punched grafts
of these sizes.
3. “Scarring.” The photos below
show highly magnified results of two
patients of varying ages, varying color
contrasts, and varying hair textures with
grafts placed into punched sites.
Although they are presented here in
black and white, color reproductions are
available. Color photos have been sent
to the editor, and I trust he will assure
the readers that no color changes of
any type are visible despite the high
magnification.
Patient G.L. 26-year-old male, post-op 6 months after second
procedure; 2 sessions @ 500 micro-/minigrafts
Patient G.N. 58-year-old male, post-op 6 months after second
procedure; 2 sessions @ 800 micro-/minigrafts
4. “Langer’s Lines.” Although a circle
may be tangent to a line in only 2o of its
arc when measured mathematically, we
deal with human tissue that is plastic
not with paper and pencil. Anyone who
repeats Langer’s original experiment of
punching holes in skin, dropping India
ink into the holes, and observing the
results should note, as Langer did, that
continued on page 118
117
Hair Transplant Forum International
❏
May/June 2002
Volume 12, Number 3
Commentary
continued from page 117
within a short time, the small round
holes deform into ellipsoids oriented
along Langer’s lines. Therefore, the
portion of the perimeter of a graft that is
tangent to Langer’s lines becomes much
greater. And again, we have the question
as to whether these minute interruptions of Langer’s lines have any practical
significance. Certainly, there was no
visibly appreciable deformity of the
anatomy of the type suggested when
surgeons were making 4mm punched
recipient sites.
5. “Alteration of anatomy.” This is
another position taken because of bias
with total absence of evidentiary
support. If small punches really altered
the anatomy, destroyed the neural and
vascular infrastructure, or wreaked
anatomical havoc as claimed, the
abundant early hair growth that is seen
in actual practice could not occur. If the
excessive scarring that is claimed either
existed or were a significant factor in the
equation, then the excellent hair growth
that occurs would not be seen. Hair
transplantation is an art, but it is an art
that should be based upon science not
prejudicial bias.
6. “Removal of non–hair bearing
tissue.” (sic) I must admit this one
stumped me. This section reminds me
of one of those magic tricks where the
performer pours liquid into a container
and then poof, it’s gone. I don’t understand the reasoning. A punch removes a
cylinder of bald skin that is replaced
with a cylinder containing hair follicles
that then grow into terminal hairs. The
issue in question is not the volume of
two-dimensional space occupied by the
hair shaft at the skin level. The crucial
factor in hair density is not the hair
density at the level of the skin. It is the
volume of space occupied by the hair
fiber after it exits the skin. This became
apparent when Dr. Rassman and I were
collecting the database for the Hair
Densitometer. We noted that the follicle
count of many persons of African
descent was lower than that of most
Caucasians. Many African descended
men have follicle counts in the range of
13–16 follicles per 4mm circle. De118
pending upon their particular ethnic
and genetic heritage, Caucasian men
typically have follicle counts that vary
from 20–48 follicles per 4mm circle.
Despite their low follicle counts, African
descended men often have thick, dense
mats of hair because of the large volume
of space occupied by each tightly curled
hair fiber after it leaves the skin. In
contrast, Caucasian men with the
highest follicle counts, typically men of
Scandinavian descent, often have very
fine blond hairs that lie limply on the
scalp and have an appearance of limited
density.
6. “Removal of non–hair bearing
tissue.” (sic) This is another elegant
demonstration of voodoo mathematics.
Close examination of any area of a
normal scalp shows that there is a large
area of hairless skin between follicular
units. The amount of hairless skin varies
from one person to another depending
upon the hair density of the individual.
But even an individual with high
follicular density has a large aggregate
area of skin between hairs if the measurement is confined to the plane of the
scalp. By Dr. Wolf’s criteria, hair
transplantation cannot succeed. The
success of hair transplantation does not
depend upon the area occupied by hair
fibers at the plane of the scalp; success is
possible because of the volume of space
occupied by hair fibers above the level of
the skin. This includes the fact that
adjacent hair fibers tend to overlap each
other. Underlying hairs lift the overlying
ones above the surface of the scalp. To
describe this phenomenon, I have
borrowed a term from the downinsulated garment industry—“loft.” The
degree of loft of any hair mass is a
function of both the number of hairs
and the body or texture of the individual hair fibers. The greater the degree
of loft that a hair mass possesses, the
greater its density will appear to be.
7. “Fit.” (#1) This is another argument that may look good on paper but
does not translate into practice. When
large grafts were in vogue, some doctors
proposed the thesis that square grafts
placed into adjacent square recipient
sites would fit more closely together
than round grafts in round sites leaving
fewer spaces between the grafts. On
paper it made perfect sense. However,
experience showed that square grafts
rounded up when placed into human
tissue. Fragments of human tissue
disconnected from their supporting
background take on the surface characteristics of water. Approximately round
grafts placed into round recipient sites
become round to fit the sites leaving no
visible gaps between the sides of the
grafts and the sides of the recipient sites.
8. “Fit.” (#2) Rotation is a critical
factor in graft placement. The orientation of the graft determines the direction in which the hair will grow. If
round grafts were cut as vertical cylinders with flat tops, it might be difficult
to determine the proper orientation for
the grafts. But round grafts are not
vertical cylinders; the cylinders are
angled. Cylindrical recipient sites must
be cut on an angle paralleling the
angulation of adjacent hairs. When this
is done, the graft can only be inserted at
the proper angle so that the direction of
hair growth will parallel the direction of
the surrounding hairs. If the graft is
rotated even a few degrees, the skin
surface of the graft will not be flat in
relation to the surrounding recipient
area skin. When the skin surface of the
graft is flat in relation to the surrounding skin, the graft MUST be properly
oriented. (See Figure.)
This illustration shows the effects of improper graft insertion.
1a shows a typical round recipient site. 1b shows a typical
round graft. 2 shows what happens when the graft is inserted
but rotated 90° out of true. 3 shows what happens when the
graft is rotated into its proper position. It is clear that a graft
cannot lie flat if it is rotated only a few degrees out of true.
N.B.: Spaces between grafts and recipient sites have been
exaggerated for purposes of illustration.
9. “Space.” This is an interesting
argument. Compression occurs when
the recipient site is too small to adapt to
the size of the graft it contains regardless
of the number of follicular units in the
graft. In the days of large grafts, grafts
Volume 12, Number 3
Hair Transplant Forum International
cut with a 4mm punch fit perfectly into
3.5mm recipient sites, and there was no
compression. Large follicular unit grafts
placed into recipient slits that are too
small will be compressed. When a graft
is compressed, the center of the graft
becomes elevated. We call this effect
cobblestoning. The effect is permanent;
the compression does not go away
despite the passage of time.
The simplest and most effective
treatment of cobblestoning is to
punch out recipient sites immediately
adjacent to the elevated grafts. Even
when the cobblestoning is the result
of a procedure performed many years
earlier, the creation of an empty space
in the immediate vicinity of a compressed graft releases the pressure, and
the elevation smoothes out. A graft of
appropriate size can then be inserted
into the residual space.
10. “Economy.” I must admit, this
one had me stumped. In part, it is
based on a misunderstanding, misinterpretation, and misrepresentation of the
facts as they really are. No one except a
fool or an idiot would place round grafts
$
into recipient sites that were too small
for the grafts. It is a natural property of
all incisions whether round or linear to
contract slightly. Any reasonably
prudent surgeon places only grafts of
appropriate sizes into recipient sites
regardless of the type of recipient
sites. I agree with Dr. Wolf that a
graft that is larger than the site will be
compressed and its center will become
elevated, but this applies for both
punched and slit recipient sites. That
is why we don’t do it that way unless
we are mentally deranged. Given this
simple fact, the reasoning in subheads
1, 2, and 3 disappears.
Like Dr. Wolf, my comments and
observations are based on experience. I
personally do far more than the number
of grafts cited per year. Although I do
not place grafts, I personally inspect
each graft with magnification to ensure
that they fit properly and that they are
neither elevated nor depressed. Some
patients are “poppers,” whose grafts
refuse to lie flat when they are first
done. All such patients are carefully and
❏
May/June 2002
thoroughly re-examined within 24–48
hours after a procedure. Without
exception, the grafts of such patients
suck down and lie flat within 24 hours
after the procedure. Our patients do not
exhibit cobblestoning.
In summary, it is a positive feature of
ISHRS that our members constantly
re-examine our processes and techniques. Unless we constantly question
and re-evaluate what we do, we are in
danger of becoming complacent and
stultified. Comparing one technique
with another is the way science advances, but when making comparisons,
we should play fair. Pettifoggery—
making unsupported allegations of
excessive scar tissue because some fancy
math seems to predict that it will exist
in the absence of proof that excessive
scar exists is not playing fair. A silly
statement suggesting that round grafts
inserted into punched sites are too large
for those sites is dishonest. The bottom
line in surgical hair replacement is
results. I invite comparison of my results
at any time.✧
Response to Dr. Pomerantz
Response #1: Bradley R. Wolf, MD, ABHRS Cincinnati, Ohio/Aspen, Colorado
1. Net removal of scalp tissue. The
small amount of actual scalp removed
with punches compared to the damage,
misdistribution of follicles, and scarring
incurred is not appropriate in terms of
cost/benefit ratio. Please refer to #7 in
the article for a complete discussion.
2. Incision damage and linear healing
surface. These measurements correlate
with quantity of scar tissue. Neither
rates of healing nor differences in hair
growth are questioned or analyzed. Due
to the elastic property of unscarred skin,
full thickness incisions widen to accommodate properly sized grafts without
creating an “unfilled corner.” Proper fit
between graft and incision will prevent
compression. Proper placement will
prevent cobblestones.
4. Langer’s Lines. Dr. Langer used a
fine-tipped instrument to pierce the
skin. He did not remove circular
portions of skin with a punch. I have
not observed holes created by punches
to change shape.
5. Alteration of anatomy. No correlation is made between scarring and
growth of transplanted hair. While it is
easy to grow hair, especially in larger
grafts, it is difficult to create natural
results with any sized graft. Scarring
replaces elastic tissue with fibrous tissue,
making subsequent sessions of grafts
more difficult. When placing in scar,
grafts are not held (gripped by the side
walls) due to the replacement of elastic
with fibrous tissue. Bleeding is often
greater, and with increased cleaning of
the bloody surface, unsecured grafts are
more likely to become depressed
causing pitting. Grafts are also more
likely to escape from the sites. Excess
scarring also causes hypo- and hyperpigmentation leading to unnatural and
noticeable results.
6. Removal of non–hair-bearing
tissue. This again addresses the issue of
unnecessary scalp removal. The argument against addresses the issue of
density. The method that creates the
most “natural density” should be used.
10. Economy. The paragraph in
question is actually an addendum that
doesn’t concern economy. This
paragraph was added when surgeons
experienced in punch grafting with
continued on page 120
119
Hair Transplant Forum International
May/June 2002
❏
Volume 12, Number 3
Wolf Response
continued from page 119
grafts of 4mm diameter and smaller
adamantly disagreed with my calculations using a 1mm diameter graft
placed into a 1mm diameter hole. They
informed me that they routinely place
grafts into holes smaller than the
diameter of the graft, an example being
a 4mm graft into a 3.5mm hole.
11. Placing. Placing is an invisible
art, the importance of which should
not be underestimated. Once the
graft is in the recipient site, inspection cannot detect bent, folded,
piggybacked, or mutilated follicles
below the scalp surface, which can
lead to poor yield, disorganized
growth, post-transplant kinkiness,
inclusion cysts, as well as other
complications that contribute to
unnatural results. To say one inspects
grafts to determine placing quality is
like inspecting a golf ball putted into
the hole by someone else and thinking the person (inspecting the ball)
can read greens and putt. As in life,
it’s not just where we are but the
process that got us there that is
equally if not more important.
tee agreed that the disagreements
between ABHRS and their brothers in
ISHRS concerning the appropriate
use of the term ”board certified” and
other contentious issues must end.
Absolutely no one wanted to see
division or disharmony among our
group of colleagues and friends.
Because 50% of the Committee on
Certification members were also on
the board of the ABHRS, communication between the two groups was
rapid. The ABHRS stood up to the
plate and answered the concerns and
requests by their own board members
and the committee in a resounding
manner. The ABHRS also elaborated
in detail on programs and concepts
they had formulated at an earlier date
and that were still in the planning
stages. The result was a very excellent
and fair resolution to the issues and
concerns from “both sides of the
fence.” The results I am referring to
are detailed in Dr. Friedman’s summary on policy changes. Thank you
to the ABHRS for a job well done and
to my committee members for helping
to make this a successful mission.✧
In summary, one only has to look at
the scalp to determine that punches
create greater amounts of scar tissue.
This is supported by the dramatic
decline in their use and the efforts of
patients to avoid them. What is seen
is explained by logic and the magic of
numbers.✧
Vogel Report
continued from front page
certificates, who should administer these
documents, the relationship between
the ISHRS and the ABHRS, whether
there should be a “two-tier system”
allowing entering surgeons in the field
to obtain some type of certificate of
qualification, whether an international
board should exist, etc. Concerns were
expressed for the ethical use of certification being used for marketing advantage, the inclusion of international
members being able to obtain such
recognition, and the opportunity of
ABHRS founders to have perpetual
”grandfather” status. All on the commit○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
ABHRS Offers CAQ
continued from front page
With more grafts being transplanted
per surgery, less surgeries are being
performed due to the increased time
involved in transplanting large numbers
of grafts. With this in mind, the
ABHRS has recognized the need to
lower the required number of surgeries
for certification to a minimum of 50
cases per year over the past three years.
The lowering of the minimum case
should open the door to many surgeons
who perform one surgery per week.
The ABHRS has also recognized the
need to open another avenue to certification for those surgeons who have
many years of experience performing
hair restoration surgery, but do not
120
currently perform 50 or more cases per
year. Effective immediately, the Lifetime
Achievement Route will allow surgeons
to qualify for Board Certification if they
have a minimum of 400 hair restoration
surgeries over the course of their career.
Hopefully, this will encourage our more
experienced surgeons to qualify for their
many years of dedication to the hair
restoration field.
The ABHRS has established The
International Board of Hair Restoration
Surgery as a subsidiary of the ABHRS.
This new board certification will be
available to all hair transplant surgeons
outside of North America. The requirements for certification will be the same
as the ABHRS and will utilize the
ABHRS oral and written examinations.
The examination will be given annually
alternating between Europe and Asia.
The ABHRS felt that an International
Certificate was more desirable than an
American Certificate for our nonAmerican brethren. We look forward to
certifying new Diplomates from all parts
of the world.
The ABHRS is optimistic that with
the changes described above, more hair
transplant surgeons will strive to achieve
Board Certification in the future. All
Diplomates of the ABHRS, including
those grandfathered, must re-certify ten
years from the date of their certification.✧
Volume 12, Number 3
Hair Transplant Forum International
❏
May/June 2002
MARCELO’S MEETING: MEXICO 2001
Our
Gerard Seery, MD Carmichael, California
great Society will have many future successful meetings but none likely to surpass Mexico 2001 in terms of
camaraderie and esprits de corps. Here are some of the highlights as seen by this attendee:
Best Paper ................................................................................................................................................... Jim Arnold
Runner up ..................................................................................................................................................... Bill Reed
Hit of the meeting ....................................................................................................... Mario Marzola’s Roving Mike
Runner up ....................................................................................................... Dow, Russell, and Bob’s Open Mike
Best Controversy .................................................................................................................................. Artificial fibers
Most heard complaint .......................................................................................... Departures from printed program
Most talked of paper ................................................................................................................................ Saigid Khan
Best maiden papers .......................................................................................................... Antonio Alvi, Vance Elliott
Sterling performances ..................................................................................... John Cole, Bill Parsley, Mike Beehner
Most deserved awards .............................................................................................. David Seager and Bob Bernstein
Most jarring note ................................................................................................... Appallingly loud Mariachi Music
Best statesman-like address ................................................................................................................. Bobby Limmer
Most joie de vie ......................................................................................................................... Australian contingent
Most charming ....................................................................................................... Massimo Marselli’s Italian group
Best family contribution ............................................................................................................ Bessam/Nilofer Farjo
Greatest improvement ................................................................................................................... Time for questions
Three cheers ...................................................................................................................... For Laura and ISHRS staff
Appreciated improvement ................................................................................................ Speakers finishing on time
Best dressed .................................................................................................................................. Nobody came close
Largest contingent ................................................................................................................................. The Limmers
Greatest sartorial sin .......................................................................................................................... Bermuda shorts
Knobbliest knees .................................................................................................................................... Dan Didocha
Finest gentleman ................................................................................................................................Shelly Friedman
Tour de force .................................................................................................................................. President’s address
Most pleasant event ......................................................................................................... Excellent dinner/gala/show
Man of the meeting .............................................................................................................. Each and every attendee
121
Hair Transplant Forum International
❏
May/June 2002
Volume 12, Number 3
The Diss e
ector
e
ctor
TheRoyalParade
t happened that long ago in
a faraway kingdom named
Graftelot, there was a large
royal family that ruled the land. And
it happened that there was to be a
grand parade one year hence to
celebrate the 200th anniversary of the
realm. For this grand event each
member of the royal family was to be
adorned in a stunning ornamental
gown, all of which were to be made
by the finest seamstresses and tailors
in the land.
For centuries, these experts of the
cloth had developed many different
styles and methods for creating their
gowns and coats. The cotton and
wool that came to them were spun
into various size strands, which were
then woven together in patterns of
different textures, to best accomplish
the end result desired by this or that
customer. Each tailor took pride in
how he artistically combined all of
these different fabrics and sewing
techniques.
However, during this period there
existed a small but very influential
group of wealthy tailors in the
kingdom’s largest city, who had come
up with a new method for creating
the cloth fabric and sewing it together, which was called the “fug”
technique. These men were very
outspoken and used every means of
communication they could think of
to spread the word into the smaller
hamlets of the kingdom that theirs
was the only method that should be
used for making fine clothes.
In essence, the “fug” technique was
an overreaction to some of the much
older techniques used many years
earlier, in which coarse cloth was
stitched together with thick thread,
creating thick overlapping folds,
which were characteristic of the
clothes of that time. The “fug”
advocates argued that, if you spun
122
An article by anonymous
the wool down to its individual strands
and wove these fragile threads together,
one at a time—never gathering two or
three together—that there was then no
chance of anyone ever noticing any folds
or coarseness of texture in the cloth.
As you can imagine, many of the
individual artisans of fine clothing
throughout the kingdom were put on
the defensive, despite the fact that many
of them had been creating beautiful,
full-textured clothes for many years.
They were put in the position of having
to defend their older sewing and
weaving techniques. But, with each
passing week, the carrier pigeons and
travelling minstrels of the day continued
to carry the news from one town to
another that the “fug” method was the
only way cloth should be handled, and
that tailors using other methods were
“behind the times” and using obsolete
methods.
And so, when the assignments were
handed out to the top 50 tailors in the
land for making the garments that the
royal family would wear in the big
parade, each of the assembled clothiers
from all over the kingdom looked at
each other, and each feared the possible
disapproval of his peers and the public if
he didn’t conform and use the new
“fug” method.
And so, reluctantly, each tailor
returned to his village and began
planning how to make his assigned
royal garment using the “fug” method.
They saw right away that, in order to
accomplish all of the slow, tedious steps
required by this method, they would
have to hire many additional apprentices and buy several more looms. After
spending a great deal of time training
these many new helpers, each tailor
began the laborious task of making cloth
with the “fug” technique exclusively.
After several weeks, it was obvious that a
wide range of skills were evident among
the many helpers. While some were
quite adept at handling the delicate
fibers, many others did so carelessly and
weren’t up to the demanding dexterity
necessary. Many of their fibers could be
seen to often break, and sometimes their
strands of cloth became dry and brittle
and had to be thrown out, or worse yet,
were placed in the cloth out of laziness.
Each of these masters, whose previous
artistic methods were very individualized and varied for each piece of clothing, were saddened by what he saw.
Well, the day finally came for the
grand parade. During the week before,
each of the garments—most of which
were made with the new “fug” technique—was delivered to its royal wearer.
When it was time for the parade to
begin, trumpets could be heard from
miles around, announcing the onset of
the much-awaited event. It was rumored that the king himself would lead
this wondrous pageant and would be
atop the first carriage in the parade. In
the large square of the capital city,
people crowded along the route tendeep to get a view of his majesty. As the
first carriage with His Highness atop
approached, there could be heard many
cries from the crowd: “Long live the
king!” “How splendid he looks!” “Never
has he looked finer!”
Oddly enough, hardly any children
could be seen in the front rows behind
the ropes. But one determined 6-yearold lad did force his way between the
bigger adults and was able to reach the
front just as the king was approaching.
As the king’s carriage came into view,
the little boy squinted hard with his
eyes to get a good look. He had heard
all the stories of the wonderful new
clothes that the royal family would be
wearing. But, upon seeing the king, the
little boy turned to everyone around
him and yelled out: “The emperor is
hardly wearing any clothes!”✧
Volume 12, Number 3
Hair Transplant Forum International
❏
May/June 2002
LIFE Outside of Medicine
Jim A. Harris, MD, and Paul C. Cotterill, MD, are the sectional Co-Editors for this column of the Forum.
Carlos P
uig, DO
Puig,
Water has long been a symbol of life.
The flowing river representing the
passage of time; the ebb and flow of
the ocean, a reminder of the natural
cycles of human existence. Beyond the
symbolism, however, is the reality of
what water means to life. This is one
aspect of why Carlos Puig, DO, of
Houston, Texas, has been an active
volunteer for Living Water International (LWI).
Formed about 11 years ago, LWI’s
primary goal is to provide clean water
and basic medical services to countries
that require these basic needs. (The
World Health Organization estimates
that 30% of the world’s population
lives with a contaminated water
supply, and 35% of the daily deaths
in the Third World are caused by
diseases either transmitted by or
require water for vector breeding.) Dr.
Puig has been involved in LWI for
approximately seven years.
His efforts in this organization
began after an exceptionally challenging time in his life and were inspired
by a return to his Christian roots. He
felt a call to join, and his journey in
this endeavor began with a trip to
Guatemala, working in a remote, unstaffed, general medical practice office.
The rewards he felt from this trip
have inspired him to return time and
time again.
Carlos was asked to become a
member of the LWI Board of Directors three years ago. As a member of
the board, he developed a workshop
that trains team leaders in crosscultural evangelism, medical and nonmedical emergency management, and
In his years of performing this work,
Carlos has seen amazing things. He
recalls an 18-year-old woman, with a
large, painful abscess, who walked ten
hours carrying her 1½-year-old infant
in order to see him. The treatment
required surgery and antibiotics and a
recovery time of weeks. He watched
the community come together to give
her and her family food and shelter
during her recovery.
Besides his involvement in LWI and
his hair practice, Carlos has great fun
being involved in a Jazz quartet
general leadership skills. His other
playing the bass guitar. He works four
interests in this area include the
to five gigs a month at private parties
implementation of a centralized
or the occasional club date.
medication ordering system, the
Carlos feels that in the field of
development of mobile “boxes” of
cosmetic
surgery it is easy to forget or
medications that allow clinic workers
ignore
the
healing gifts and insights
to see 750–1,000 patients, and the
that
have
been
given to physicians.
deployment of a 35 foot mobile
He
says
that
his
work in LWI has
medical van in Panama.
He has had the opportunity to watch allowed him to stay grounded and
better able to see what is important to
LWI grow into a program that will
him. His countless encounters with
provide more than 35,000 patient
patients, many of whom had walked
visits and 6,000 dental visits to the
villages of Central and South America hours for the visit, touched his heart
next year. As of December 2001, LWI with their cheerfulness, thankfulness,
has completed over 300 water projects and strong sense of family.
LWI currently needs an Ob-Gyn, an
in 13 countries around the world.
ophthalmologist, and general practice
The goal in these areas is to establish
physicians. The team members will
a long-term relationship with the
native people and train them in water have to be ready to “rough it” and
travel two days by plane and boat to
drilling and filtration techniques as
the Peruvian headwaters of the Amawell as general health and hygiene.
zon. The experience may turn out for
At this time, Carlos finds training
people to go into the field particularly others as it did for Dr. Puig: one of
the best decisions of his life. For more
rewarding. In his experience, it is
information about LWI, visit their
gratifying to see physicians get back
in touch with what attracted them to Website at www.Living-Water.org.✧
medicine in the first place: the
emotional rewards.
Article submitted by Dr. Jim Harris.
123
Hair Transplant Forum International
❏
May/June 2002
Volume 12, Number 3
Surgeon of the Month
alute to
Sharon Keene, MD
Jerry E. Cooley, MD Charlotte, North Carolina USA
Sharon
Keene, MD, grew up in
suburban Minneapolis, Minnesota.
She received a degree in psychology
from the University of Minnesota and
attended medical school there as well.
She decided to pursue a career in
surgery, completing her surgery residency at the University of Arizona in
Tucson, followed by further specialty
training in trauma and critical care at
Tucson Medical Center. Sharon also
completed a postgraduate fellowship in
endocrine surgery in Perth, Australia.
After returning to the United States in
early 1990, Sharon began searching for
a practice location. Unexpectedly, she
had the opportunity to observe some
hair transplantation procedures. This
was followed by an invitation to join the
group, the “Professional Hair Institute.”
Although she intended for this to be a
temporary job prior to a more permanent surgery position elsewhere, she
was bitten by the transplant bug and
never left. Although the group she
was in later disbanded, she remains
associated with one of her original
colleagues, Dr. Ron Shapiro.
Sharon comments, “Dr. Shapiro was
kind enough to share many of his
early operative experiences with the
124
Sharon Keene, MD
Tucson, Arizona
punch graft techniques, prior to
switching to all incisional grafting.
When he made the switch, I was
impressed enough with the results to
consider performing the surgery full
time. I observed a single “megasession”
surgery and changed my operative
approach forever.” Sharon currently
works in association with the Shapiro
Medical Group in Minneapolis several
weeks a year, while maintaining her own
private practice in Tucson, Arizona.
“My philosophy for hair transplantation,” she says, “is that nature is an
excellent teacher, and nature tells us
there is no one-size-fits-all way to
assess every patient. In my opinion,
follicular units are how hair is naturally distributed and therefore the
best way to achieve naturalness in
surgical hair restoration. But how you
arrange the follicular units, how close
together you place them, and how
you distribute 1s, 2s, 3s, and 4s do
contribute to the cosmetic outcome of
a single surgery—and differentiates
the artist from the technician.”
Sharon’s current research interests
focus on ways to make transplantation
easier. She is currently investigating
the use of liposomes to transfer dye to
hair follicles to make gray and white
hair visible for dissection.
She has also developed a multiple
recipient site scalpel that greatly reduces
operative time and hand fatigue by
cutting down on the movements
required to make thousands of incisions.
She plans to develop additional instruments to make megasessions more
efficient, less time consuming, and less
labor intensive.
Sharon’s hobbies, when she has
time, include hiking, biking, scuba
diving, and traveling.✧
Volume 12, Number 3
Hair Transplant Forum International
❏
Surgical Assistants Corner
May/June 2002
A fter much debate and after searching for the right person to serve as your Editor one has been
found.
I am pleased to introduce you to Shanee Courtney, RN. Shanee was born in Galveston,
Texas, raised in Houston through grade school, then her family moved to Denver, Colorado.
Shanee fell in love with the Rocky Mountains, went to college, got married, and is currently
raising her two teenage children there.
Shanee graduated from Loretto Height College with a B.S. in Nursing. She worked for three
years as charge nurse of an ICU\CCU. At the end of that time, she knew she needed a change, and she started
looking for a new position. She found the door of Dr. Emanuel Marritt. The sign on the door said “Hair Transplant
Surgery.” She thought this sounded interesting but was a little wary about this field of practice. It sounded kooky,
but she went in and asked about a job. After her first three months on the job, she told Dr. Marritt that she had
first thought that he was a quack but that now she knew that he a great doctor who made magic happen for
patients who did not want to lose their hair. She felt she was fortunate to be a nurse with Dr. Marritt and helping
to change people’s lives for the better. She was part of the team of magicians now.
Shanee loved her job and stayed with Dr. Marritt. She cut grafts and planted grafts. She was a scrub nurse, a
patient care nurse, a front office nurse, a front office manager and nurse, a business
and personnel manager, a nurse consultant, a patient advocate, and co-editor of many
medical articles.
Shanee stayed with Dr. Marritt until he retired. She now works with Dr. James
Harris, and still enjoys making magic happen for patients.
Shanee comes to us with a great wealth of experience and a great love and passion
for surgical hair restoration. I feel that we will all benefit from her knowledge and
experience.
Shanee will be looking forward to meeting everyone at the ISHRS Annual Meeting
in Chicago. Be sure to greet her.
Welcome Shanee
Cheryl Pomerantz, RN
Shanee Courtney, RN
Englewood, Colorado
Editor Emeritus, Surgical Assistants Corner
We are planning a fabulous
time in the Windy City for you.
Help us celebrate the ISHRS‘s
10th anniversary. A black tie
event has been planned. We
will party hearty in Chicago.
You may even see a doc dance
with his wife in Chicago, It’s
My Kind of Town—CHICAGO.
All
correspondence for Surgical Assistants
Corner should be directed to Shanee
Courtney, RN, at:
Shanee Courtney, RN
James A. Harris, MD
5445 DTC Parkway, #1015
Englewood, CO 80111 USA
Office phone: 303-694-9381
Get your outfits ready…
It’s going to be an
unforgettable experience!
Cell phone: 303-694-9381 x O
Fax: 303-694-9373
E-mail: [email protected]
125
Hair Transplant Forum International
❏
May/June 2002
Volume 12, Number 3
Challenges and Opportunities:
A Letter to the Surgical Assistants
Dear Surgical Assistants,
Wow! In my debut as editor of the Surgical Assistants Corner, I would like to thank Dr. Bobby Limmer for having so
much confidence in me that he would ask me to take this on.
When he first approached me, my first reaction was no! I don’t have time! What would I have to say? But I realized that
this has been my reaction for many years, and I know it’s the same for many of you. Somehow, I thought that after 18 years
in hair replacement, and working with Manny Marritt, that I had done my stint. After Dr. Marritt’s retirement, it seemed
that is was time for me to just coast for a while. But, although Dr. Limmer didn’t know it, it took his phone call to get me
back on track, and realize that it’s not time to be passive. It must be time for challenges and opportunities!
I spent time reviewing all of the past Assistants Corner articles to find out what you have wanted. What were the
challenges? And what topics have been covered? …Wow! What did I take on? All of us face challenges and opportunities. We face them personally and we face them in our work place. I see that the challenge with the Surgical
Assistants Corner has been that we have spent time reading and watching, and have not had the courage to participate. We, the Assistants, are the “secret weapon” that our doctors have. We watch, we listen, we report. And many
of us have guarded our knowledge.
In the wake of so many social issues happening in the world, I think it’s time to change a few of the old philosophies. First, we are still a “secret weapon” to our doctors. In a field that is highly competitive, we are one of the
strengths behind them. It is our job to be our best. And yet, we are above all else patient advocates. We have seen the
patients who come in overwhelmed with “buzz words,” misinformation, and even poor work. As Medical Assistants,
Nurses, and caregivers, we have a responsibility to our patients, to learn, to be up-to-date in the latest thinking, the
lastest techniques, and give the best patient care possible. The patients deserve our best. I see this challenge as an
opportunity to bring about cohesiveness among our group.
So, how does that change our philosophy? As Surgical Assistants we are given the opportunity to share. We, as surgical
assistants, would not be able to refine our techniques, to learn, to up-date, if we did not have a few offices that were not
afraid to share their technique and their thinking with us. We don’t learn, if people decide not to share. That is the same
for our Surgical Assistants Corner. I am certainly not the authority here. It humbles me to even think that I was searched
out for this endeavor. There are so many of you that have been in this field for a long time, through regular plugs, slit grafts,
quarter grafts, micrografts, and finally follicular unit grafts. Don’t sit on your knowledge. Your opinion counts. There’s no
intimidating factors here. There’s no judge and jury. If you feel you can’t write, call me. If you can’t find the time to talk
to me, write me. If you can’t write, well, I’ll help you. If you only want to send a brief note, do so. For the benefit of our
patients, it is time for all of us to take a deep breath, move forward, and participate.
On that note, I would like to pose a few new areas of interest. For many of us who attend the meetings, it is difficult to
get to know each other. I would like to introduce a new section called “Under the Lights.” It will feature a team or an
individual assistant. It can be submitted by fellow team members or a doctor. And you should concentrate on something
of a personal note. Perhaps one of your teammates does something interesting in their private lives, has some interesting
hobby. Or perhaps you, doctor, have a team that you are proud of (I know that you do!) that needs to be introduced. Send
a picture. Send a note. It doesn’t have to be pages… but it helps us to get to know each other. Breaking the ice helps us to
trust that we can share our ideas. I have started it off with my team at Dr. Harris’ office to give you an idea. And don’t
worry, if I don’t hear from you, I will call upon you for input, and I will provide you with a questionaire to guide you.
We are six months away from the meeting in Chicago. As you know, it is critical to keep up-to-date and understand
what is going on in our field. There is no better way than to hear from the doctors who are leaders in our field. Assistants
must talk to their doctors about going. Especially in times of recession! Any team will tell you that the meeting provides
cohesiveness in teams, and opens the door for improvement among all of us. Also, if you’re not getting your own copy of
the Forum, it is critical that you ask for that as well. I am an advocate of education. It starts with your office. The Forum is
an invaluable tool for education in your office. Remember: Our patients deserve the best from us!
Thanks to all of you, this newsletter will continue to serve you. For the assistants…by the assistants! If you have
comments or concerns about the challenges and opportunities you see, please feel free to contact me. I look forward
to meeting and hearing from all of you.
Shanee Courtney, RN
Englewood, Colorado
126
Volume 12, Number 3
Hair Transplant Forum International
❏
May/June 2002
This
month I would like to introduce you to the team of Dr. James A. Harris. They reside in the beautiful city of
Denver, Colorado. They are mothers of small children, teenagers, and young adults. Janiece is the front office manager.
She loves to crochet and plans weddings in her spare time. Tina is the OR Coordinator. She is busy building a new
house. Lauren, Crystal, and Annie are part of the planting team. Although from diverse backgrounds, they work
together very well. Annie is an avid skiier; Lauren loves to plan projects at home; and Crystal loves to sing and dance.
Our cutters are Carolyn, Sonja, Helen, Steve, Tuya, and Byamba. Carolyn loves to shop; Sonja is a runner; and Helen
loves to cook Korean. Steve, Tuya, and Byamba, the newest members of the team, are from Mongolia. Tuya is a
champion ping-pong player. Needless to say, they all love to have pot-luck meals where they can sample everyone’s
latest authentic recipes.✧
127
Hair Transplant Forum International
❏
May/June 2002
Volume 12, Number 3
10th Annual ISHRS Meeting Update
Appointed Surgical Assistants Auxiliary Committee:
Cheryl Pomerantz, RN, Chair
Marilynne Gillespie, RN, Vice Chair
MaryAnn Parsley, RN
T he
committee has been working to provide you with a meaningful and informative program. The format of the
meeting is a little different from the format of past meetings. The Assistants will have breakfast together followed by
morning meetings, then proceed into the General Meeting. At lunch time, we will have our own luncheon with
workshops.
Topics for discussion on Thursday, October 10, 2002:
Topics for discussion on Friday, October 11, 2002:
Operating Room Organization:
✰ Operating Room Set-up
✰ Time Line of Procedures
✰ What the Doctor Expects, Needs, and Wants
✰ What the Assistant Expects, Needs, and Wants
Hair Restoration Complications:
✰ Intra-Operative
✰ Immediate Post-Op
At the end of the presentations, the speakers will stay to answer questions and hear comments from the audience.
This meeting has been designed so that everyone will be able to participate in the exchange of knowledge and
experience.
Surgical Assistants Luncheon Workshops
Thursday, October 10, 2002
Stress in the Work Place
Friday, October 11, 2002
Communication Skills
Presented by: Justin Koehler, MA Psych., PhD Psych. Candidate; Former Surgical Assistant with
Dr. Marc Pomerantz; Kari Taylor, MA Psych., PhD Psych. Candidate
The program has been designed to teach you how to increase your job efficiency, ease and lighten your
work load, and make your work place happier. You will learn effective communication skills and ways to
reduce the stress in your work place. The program is built around our needs as Surgical Assistants. When
our needs are met, we can more easily meet the needs of our patients.
Hair and Scalp Pathology and Surgery Diploma
Academic year: 2002–2003
Information and Registration:
UNIVERSITE PARIS VI
UFR de Stomatologie et de Chirurgie Maxillo-Faciale
Pitié Salpêtrière Hospital
47, Bd de l’Hôpital, 75651 PARIS CEDEX 13 - FRANCE
Coordinators: P. BOUHANNA, M.D., and
M. DIVARIS, M.D.
Phone: 33.1.42.16.12.83
Chairman: Pr J. Ch. BERTRAND
Fax: 33.1.45.86.20.44
4 sessions of 3 days each, starting
November 14, 2002, ending June 2003
E-mail: [email protected]
Pre-registration deadline: September 28, 2002
128
Volume 12, Number 3
Hair Transplant Forum International
❏
May/June 2002
Journal Review
Long-term (5-year) multinational experience with finasteride 1mg in the treatment of
men with androgenetic alopecia
European Journal of Dermatology, Vol. 12, Issue 1; January-February 2002, 38–39
John D.N. Gillespie MD ABHRS Calgary, Alberta, Canada
This article reviews the results of the
2-year studies on the efficacy and
safety of finasteride and reports on the
same over 5 years.
Androgenetic alopecia (male pattern
hair loss, MPHL) occurs in men with
inherited sensitivity to the effects of
androgens on scalp hair. It is characterized by loss of visible hair over the scalp
due to progressive miniaturization of
hair follicles. MPHL does not occur in
men with the genetic deficiency of the
Type 2 5alpha-reductase. It converts
testosterone to dihydrotestosterone
(DHT), implicating DHT in the cause
of MPHL. Type 2 5alpha-reductase is
present in hair follicles as well as the
prostate. Finasteride is a type 2-selective
5alpha reductase inhibitor.
Although developed for the treatment of BPH, finasteride has been
shown in previous studies to be
efficacious in the treatment of MPHL.
The initial studies evaluated efficacy
using (1) hair counts of color macrophotography; (2) patient self-assessment; (3) investigator assessment; and
(4) independent assessment of scalp
hair growth using global photographs.
Hair Counts
In the group that received
finasteride for up to five years, there
was a significant increase in hair
counts (versus baseline for all time
periods). The maximal increase was at
month 12 = 91 hairs per inch circle.
It declined somewhat after 12
months, but remained above baseline
throughout the study with a mean
increase of 38 at 5 years. The placebo
group showed a progressive decline in
hair counts over the 5 years. The
difference between the treatment and
placebo groups progressively increased
from 107 hairs at 12 months to 277
hairs at month 60.
Patient Self-Assessment and
Investigator Assessment
The patient self-assessment and the
investigator assessment confirmed that
treatment with finasteride was superior to placebo at each time point.
Independent Assessment Using
Global Photographs
The global photographic assessment
confirmed the efficacy of the treatment. Maximal improvement by
photographic assessment was not
observed until 24 months versus
month 12 by hair counts. This can be
easily explained by the exceedingly
important concept of hair-mass.
We know that DHT causes progressive miniaturization of hair and that
finasteride stops or reverses it. An
increase in hair count of 20% results in
a 20% increase in density. An increase
in hair diameter of 20% results in a
44% increase in density or hair-mass.
Dr. James Arnold reviewed the
concept of hair-mass well at the last
meeting of the ISHRS in Puerto
Vallarta.
Irrespective of hair re-growth, 5year treatment with finasteride led to
sustained protection against further
hair loss in nearly all (90%) subjects,
while further visible hair was evident
in most (75%) subjects treated with
placebo over the same period.
Adverse Effects
The adverse effects of finasteride are
well reported and include impotence
and reduced libido. The incidence of
these, however, is exceedingly small.
Withdrawal from the study due to the
side effects occurred in 2–3% of those
on active drug and about 1% on
placebo. Finasteride has been shown
to be safe while attempting to conceive and during pregnancy as long as
the pregnant woman has no direct
contact with the medication.
Summary
Finasteride is a very helpful medication to the hair transplant surgeon. It is
effective in slowing or reversing hair loss
in young men who should wait until
older to consider surgery. It is also very
effective in preventing further hair loss
in most transplant patients. As we all
know, further hair loss can be a disaster
for the hair transplant patient.
I offer finasteride to almost all my
patients.✧
New Products Now Available
New Product Guide Now Available
For more information contact:
21 Cook Avenue, 2nd Floor • Madison, New Jersey 07940 • Tel 1-800-218-9082 • Fax: 973-593-9277
129
Hair Transplant Forum International
❏
May/June 2002
!Letters to the Editors
Response to The Dissector Article
Like many others, I enjoy the
anonymous barbs and humor of The
Dissector and have no objection to
being the target in the December
Forum (Vol. 11, No. 6, page 184).
It behoves the anonymous author to
get the facts right, however, and I would
be pleased if you would kindly print the
following minor critique of the article.
1. It is not true that the new artificial
hairs have been inadequately evaluated. The NIDO Z-type fibres date
only from 1999 but have passed all
the Japanese tests and are increasingly used in that country. The
Medicap Biofibres have been around
since 1996 and have passed all the
tests asked of them in Italy. Thousands of patients have received the
fibres and a medically supervised
trial of 200 patients with 2-year
follow-up was conducted by Drs.
Palmieri B, Griselli G, D’Ugo A. et
al. It was reported in Minerva Medica
in March 2000 (42(1):49–53).
2. The purported “Manifesto” for all
synthetic hairs is a worthwhile
attempt to clean up a previously
dubious field and I agree with
most points made by the author of
The Dissector. Some points need
clarification by those more familiar
with the technique.
(a) More than one fibre needs to be
inserted in the test period. One
hundred fibres is a better test as
complications are now rare that
the patient can gauge the
cosmetic effect of the new hair at
the same time any minor adverse
effects are being assessed.
(b) A three- to four-month test
period is quite adequate. The
suggested one year is probably
being unduly cautious. While
the loss of fibres increases
numerically with time, the
patients are all warned to expect
between 10–20% loss per year.
Breakage is rare with the newer
type fibres.
(c) Minor degrees of inflammation
or mild infection are quite
acceptable to most patients and
usually respond promptly to
applications of topical or oral
steroid or oral antibiotic. We do
not ask for a ban on hair transplants because of occasional
minor inflammation or infection
so why treat these improved
artificial hairs so harshly?
(d) One would expect that patients
with artificial hair implants
would all return regularly for
removal of sebum plugs but
some seem oblivious to it and
allow the sebum to accumulate
until unsightly. I have seen the
same with accumulated scalp
seborrhea after transplant
procedures.
(e) While it is fine to speak of the
“hard-won legitimacy of surgical
hair restoration,” the various
restoration techniques still
result in many minor and
major complications. Many of
these problems are not readily
correctable—unlike most of the
problems we encounter with
modern artificial hair implants.
Finally, The Dissector suggests that
we delay use of artificial fibres “until
that time when man evolves into a less
greedy and selfish creature…” This is an
admirable suggestion but not much
comfort to a patient desperate for more
hair yet possessing inadequate remaining donor hair. We frequently see the
effects of corporate greed resulting in
poor results from traditional hair
transplant techniques. Why should
suitable patients be denied the undoubted benefits of modern artificial
hair fibres because of the moral laxity of
a few unethical practitioners? Better
controls are needed certainly, but the
present ban on the artificial hair technique in the USA is most unfortunate.
Once upon a time it was necessary
to walk in front of a moving automobile waving a red flag. Time has
moved on and, in careful hands, the
car has evolved into a safe mode of
transportation. I believe it is time for
hair transplant practitioners to reappraise the role of artificial hair fibres
for selected patients.
Richard C. Shiell, MBBS
Melbourne, Australia
Cheryl Duckler, Managing Editor of the Forum, has teamed with Medical Center
Graphics to offer competitively priced photo-quality, inkjet printing:
➤
➤
➤
➤
Volume 12, Number 3
Full-color posters & displays designed to your specifications
(10 inches to 10 feet)
Use your text files, charts & graphs, scanned images, x-rays,
logos, etc.
Laminated and rolled to fit a 3 foot mailing tube
Can be mounted for extra durability
Mentio
n this
and re
a
ceive F d
REE
delive
ry to
the Ch
icago
Meetin
g
Call Jackie
or Cheryl at
414-258-5454
We can design your poster presentation or display, or use your supplied files. We also
or e-mail
offer PowerPoint and digital slide imaging, and video capture. Check out our Web site
at www.medicalcentergraphics.com. We look forward to servicing your needs! [email protected]
130
Volume 12, Number 3
Hair Transplant Forum International
❏
May/June 2002
Guidelines for
Submitting Articles to
the Forum
All submissions to the Forum must be in electronic format: e-mail, 3.5" PC-
formatted disk, or PC-formatted Iomega Zip 100 disk. We prefer Microsoft
Word documents, however, WordPerfect and ASCII text files are also acceptable. Please adhere to the following additional guidelines when submitting
your article(s):
✔ E-mail submissions will only be accepted with an ATTACHED
document file—do not embed the file in your e-mail as we will be
unable to use it. Your e-mail program should have an option to
attach a file. When e-mailing an article, also be sure to attach any
graphic files as well. Artwork (images) must be separate attachments (see bullet #3).
✔ If you are mailing your article, please submit both a hard copy of
the article(s) AND a disk with the article and any graphic files
(TIFF, JPEG) copied onto it. Before mailing, please be sure that
your article did in fact copy onto the disk.
✔ Any artwork, photos, or figures that are referenced in your article
must be enclosed with your mailed submission or saved on the
disk in either TIFF or JPEG format. Any graphics that are
submitted for scanning must be clean, original copies. When scanning
photos, please scan at a minimum of 150 dpi; for best output, scan at
300 dpi. Keep in mind that most figures appear no larger than 3
inches (width) in the publication, so size accordingly. (This will also
reduce the size of your TIFF/JPEG file and keep it manageable.)
✔ Please submit clean originals and clear photos. If you need
artwork, graphics, or photos returned, please supply a selfaddressed, stamped envelope with your submission and they will
be returned promptly.
Send your submissions to:
William M. Parsley, MD
310 East Broadway, Suite 100
Louisville, Kentucky 40202-1745
E-mail: [email protected]
✄
*Please Note: All entries will be returned if incomplete or
not adhering to guidelines.
131
Upcoming Events
Hair Transplant Forum International
❏
May/June 2002
Volume 12, Number 3
Following is a guide to upcoming meetings and workshops related to hair restoration. For more information, contact the appropriate sponsoring
organization at the number listed. Meeting organizers are reminded that it is their responsibility to provide the Forum Editors with advance notice of
meeting dates.
Date(s)
Venue
Sponsoring Organization(s)
Contact Information
June 10–14, 2002
DHI Live Surgery Workshop
& Aegean Cruise Meeting
Athens, Greece & Aegean Islands
DHI Plastic Surgery Clinic
Fax: 00 30 10 9249378
Tel: 00 30 10 9245297
E-mail: [email protected]
July 6, 2002
Hair Pathology and
Live Surgery Workshops
Paris, France
Société Francaise Médico-Chirurgicale
du Cuir Chevelu
Fax: +33 (0)1 43 34 50 39
Tel: +33 (0)1 43 34 50 99
October 9–11, 2002
ABHRS Board Review Course
Chicago, Illinois
American Board of Hair Restoration Surgery
ABHRS Office
Tel: 708-474-2600
October 10–13, 2002
10th Annual Meeting of the ISHRS
Chicago, Illinois
International Society of Hair Restoration Surgery
Fax: 847-330-1135
Tel: 847-330-9830;
800-444-2737
November 14–17, 2002
Hair and Scalp Pathology and
UFR de Stomatologie et de Chirurgie Maxillo-Faciale
Surgery Diploma—Universite Paris VI
Paris, France
Fax: +33 1 45 86 20 44
Tel: +33 1 42 16 12 83
January 18, 2003
ABHRS Oral and Written Exams
Dallas, Texas
American Board of Hair Restoration Surgery
ABHRS Office
Tel: 708-474-2600
October 16–19, 2003
11th Annual Meeting of the ISHRS
New York, New York
International Society of Hair Restoration Surgery
Fax: 847-330-1135
Tel: 847-330-9830;
800-444-2737
HAIR TRANSPLANT FORUM INTERNATIONAL
International Society of Hair Restoration Surgery
930 East Woodfield Road
Schaumburg, IL 60173 USA
Forwarding and Return Postage Guaranteed
132
FIRST CLASS
US POSTAGE
PAID
CHICAGO, IL
PERMIT NO. 6784