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HAIR
TRANSPLANT
Volume 24
Number 1
January/February
2014
I N T E R N A T I O N A L
Inside this issue
President’s Message..........................2
Co-editors’ Messages.........................3
Notes from the Editor Emeritus:
Francisco Jimenez, MD.......................5
Complications & Difficult Cases:
Hair Transplantation on a Patient
with a Large Cranioplasty.................8
FUE Donor Site Ischemia and
Necrosis..........................................12
How I Do It: The “Sweet Spot”
for Strip Harvesting.........................14
Meetings & Studies: Day-by-day
Review of the 21st ASM.................15
21st ASM Meeting Highlights............22
Message from the 2014 ASM
Program Chair................................29
Message from the 2014 ASM
Surgical Assistants
Program Chair................................29
Regional Societies Profiles: ISHR....30
Hair’s the Question: Recipient
Sites: BASIC Questions..................31
Obituary: Dr. Neil F. McLeod.............33
Cyberspace Chat: To Dye or
or Not to Dye..................................34
Review of the Literature....................36
Classified Ads...................................38
SAVE THE DATE!
Concepts and Challenges in Hair Follicle Cloning
Claire A. Higgins, PhD, Department of Dermatology, Columbia University New York, New York, USA
[email protected]; and Colin A.B. Jahoda, MD, PhD, School of Biological and Biomedical Sciences,
Durham University Durham, UK [email protected] *The authors declare no conflict of interest.
Introduction
It was shortly after World War II that Lille and Wang first demonstrated that feather follicle development is dependent
on mesenchymal-epithelial interactions.1 Mechanisms underlying follicle development are reprised in the development
of other appendages, and so these observations by Lille and Wang paved the way for advances in the field, in particular
regarding the recognition that all hair follicle development and adult activities are regulated by interactions between the
mesenchyme and the epithelium. Later on, Oliver was the first person to demonstrate that rodent mesenchyme–derived
papilla, when isolated from the follicle, can initiate these interactions and induce new hair follicle growth in adult skin.2
Since this, a multitude of experiments have demonstrated that both intact papilla and also cultured papilla cells are
capable of inducing de novo hair growth not only in skin, but several other types of epithelia.3 Interestingly, one other
striking behaviour of cultured rodent whisker papilla is their propensity to aggregate, both in vitro and after subdermal
injection.4 Cultured rat dermal papilla cells are capable of self-aggregating to form condensate-like clumps, while we
have never observed this aggregation phenomenon after injection of human cells into the skin.
Dichotomy of Activity Between Hair Follicle Dermis and Interfollicular Skin
We have previously proposed that dermal papilla, sheath, and fibroblasts are not in a steady state within the skin.5
Moreover, there is experimental evidence supporting the lack of a steady state between the papilla and sheath cells
during the follicle cycle.6 We believe that hair follicle dermal cells may have an additional role in skin, acting as
wound healing fibroblasts in the context of skin injury or trauma.7 This idea is supported largely by the observation
that hair follicle dermal cells assume different roles after cell culture. Once in culture, hair follicle dermal cells can
act as mesenchymal stem cells and differentiate down a variety of mesenchymal lineages.8 This raises the question
of whether cultured hair follicle dermal cells will act as hair follicle cells, or in another capacity, when transplanted
back into the skin for the purpose of hair follicle regeneration.
Strategies for Targeting Follicle Regeneration
For several years, researchers have been trying to
exploit the inductive potential of the dermal papilla and
demonstrate that human dermal papilla cells hold the
same inductive properties as rodent cells.9 To this effect,
there are currently two experimental strategies that utilise
hair-associated dermal cells for follicle regeneration. The
first of these involves injecting cultured dermal cells into
the dermis, where it is hypothesized that they will augment existing follicles, and transform a vellus follicle to a
terminal fate by contributing to, and enlarging the size of
the dermal papilla. This is supported by observations that
the size of the dermal papilla is directly related to the size Figure 1. Cartoon illustrating differences between rat and human dermal papilla
of the hair fibre produced.10 The second strategy involves cells. After injection into skin dermis, cultured rat whisker dermal papilla cells have
a propensity to aggregate, while human cells often act in an opposite manner and
injecting or grafting hair follicle dermal cells so they are disperse. The aggregation of rat dermal papilla cells enables them to initiate epithelialin contact with skin epithelium, where it is proposed they mesenchymal interactions, resulting in the growth of de novo follicles in specific sites.
will initiate mesenchymal-epithelial interactions to instruct new follicle growth. By and large, these experiments have
been unsuccessful, and to understand this, we have to go back and look at the behaviour of human hair follicle dermal
cells when compared to their rodent counterparts (Figure 1). In the absence of spontaneous aggregation by human papilla
cells, they may be behaving as fibroblasts in what is essentially a wound environment after their injection or grafting.
Coupled with their loss of specificity by culture, hair follicle dermal cells will not necessarily incorporate into a hair
follicle, but rather will contribute to the surrounding interfollicular tissue.
[ page 7
Official publication of the International Society of Hair Restoration Surgery
Hair Transplant Forum International
Hair Transplant Forum International
Volume 24, Number 1
Hair Transplant Forum International is published bi-monthly by
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Street, Geneva, IL 60134 USA. Telephone: 1-630-262-5399,
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President: Vincenzo Gambino, MD
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Executive Director: Victoria Ceh, MPA
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Editors:
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Robert H. True, MD, MPH
[email protected]
Managing Editor, Graphic Design, & Advertising Sales:
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Basic Science: Jerry Cooley, MD
Controversies: Russell Knudsen, MBBS
Cyberspace Chat: John Cole, MD; Bradley R. Wolf, MD
Difficult Cases/Complications: Marco Barusco, MD
Hair’s the Question: Sara M. Wasserbauer, MD
How I Do It: Timothy Carman, MD
Meeting Reviews and Studies: David Perez-Meza, MD
Regional Society Profiles:
Mario Marzola, MBBS; Robert H. True, MD, MPH
Review of Literature:
Nicole E. Rogers, MD; Jeffrey Donovan, MD, PhD
Surgical Assistants Corner: Aileen Russell, NCMA
Copyright © 2014 by the International Society of Hair Restoration
Surgery, 303 West State Street, Geneva, IL 60134 USA. Printed
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The views expressed herein are those of the individual author
and are not necessarily those of the International Society of Hair
Restoration Surgery (ISHRS), its officers, directors, or staff.
Information included herein is not medical advice and is not
intended to replace the considered judgment of a practitioner
with respect to particular patients, procedures, or practices. All
authors have been asked to disclose any and all interests they
have in an instrument, pharmaceutical, cosmeceutical, or similar
device referenced in, or otherwise potentially impacted by, an
article. ISHRS makes no attempt to validate the sufficiency of
such disclosures and makes no warranty, guarantee, or other
representation, express or implied, with respect to the accuracy or
sufficiency of any information provided. To the extent permissible
under applicable laws, ISHRS specifically disclaims responsibility
for any injury and/or damage to persons or property as a result of
an author’s statements or materials or the use or operation of any
ideas, instructions, procedures, products, methods, or dosages
contained herein. Moreover, the publication of an advertisement
does not constitute on the part of ISHRS a guaranty or endorsement
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Hair Transplant Forum International is a privately published
newsletter of the International Society of Hair Restoration Surgery.
Its contents are solely the opinions of the authors and are not
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newsletter was designed to be and continues to be a printed forum
where specialists and beginners in hair restoration techniques can
exchange thoughts, experiences, opinions, and pilot studies on all
matters relating to hair restoration. The contents of this publication
are not to be quoted without the above disclaimer.
The material published in the Forum is copyrighted and may
not be utilized in any form without the express written consent
of the Editor(s).
2
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January/February 2014
President’s Message
Vincenzo Gambino, MD Milan, Italy
[email protected]
I am planning as much as possible to devote each of my
messages in the Forum to an issue that is important to a different nation or region. While we are universally involved with
the subject of hair restoration and science, we face different
situations because of what is and is not allowed where we
practice medicine.
In this issue I want to talk about a very big problem in the United States that may
“infect” other parts of the world.
Currently, the Board of Governors of the ISHRS is receiving more and more letters
from concerned doctors regarding the proliferation of tech-organized hair restoration
practices that hire doctors untrained in hair restoration to supervise and legitimize
the office.
Why is this happening now?
Many doctors in other fields of medicine are seeing their income shrinking as
government and insurance companies are reducing fees for services and they are
drowning in paperwork to receive payment.
Esthetic medicine is their solution. Some manufacturers of FUE medical devices
are seeing a big financial opportunity. They are marketing a “turnkey” model to these
doctors. They supply the equipment and the trained techs who perform the surgery.
The doctor in effect becomes the “front man.” Now we see this going one step further—techs themselves are marketing that they can run a hair restoration practice for
you under your medical license.
With the increased interest and demand for FUE, there is no strip removal, and in
some jurisdictions, licensed non-physician ancillary staff is legally allowed to harvest
and place under the supervision of a doctor. The patient’s assumption being that the
supervising doctor specializes in hair restoration.
Why is this dangerous?
Hair restoration surgery is not a one-size-fits-all proposition. There is the medical
diagnosis, current classification, prediction of future hair loss based on age, quality
of existing hair, family history, donor availability, anesthetic concerns, medication
and medical treatments, and many other possible factors. We have all seen bad hair
restoration, but I am afraid that patients can face much worse consequences in this
shady scenario.
What worries me most is there seems to be no easy solution to this problem that
already was predicted by past presidents. The Board of the ISHRS is monitoring the
situation and looking at possible avenues to address the issue, but the Society is much
larger than just the Board. I would like to tap into this larger pool of minds and ask
any of you with an idea to contact me. I will respect your confidentiality.u
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January/February 2014
Co-editors’ Messages
Mario Marzola, MBBS Adelaide, South Australia [email protected]
Hello! Welcome to every hair transplant surgeon in the world.
Whichever country you live in, whatever your background training, if you are interested in hair restoration, you are welcome
here at the ISHRS. Please join us in sharing all aspects of hair
restoration—surgical and medical—so we can learn from each
other for the benefit of our patients.
We are always interested in North and South America and
Europe where a lot of experience lies, but, increasingly now, we
are interested in the East. Middle East, Far East, and South-East
Asia, where three-quarters of the world’s population lives.
Within the ISHRS are doctors with great experience and great
knowledge of the hair follicle who are very keen to teach and
share that knowledge. My co-editor and friend, Dr. Bob True,
will confirm that articles for this Forum from new doctors are
greatly sought after. So please put something together and send it
to us. When you share your thoughts, concerns, or good outcomes
other doctors are able to learn from your contributions as well
as provide feedback or additional insight. Also, at our meetings,
the “same old faces” would like nothing more than the program
chair to announce that new presenters will take their place. If
you need it, there is plenty of assistance available to help you
take the step to publishing and presenting.
What’s New? Bob and I have the
pleasure of guiding this Forum for the
next three years. Just to show our commitment to the “International” word in our
name, we will aim to publish international
contributions as often as possible. If the
English language is a concern, seek the
help of a translator and try to edit it as well as you can. We will
do the rest once you send it in.
You may be aware that the ISHRS has a Global Council meeting
at every annual conference where each country’s hair society meet
to discuss what is happening around the world. Presently, there are
17 such societies. Bob and I hope to feature a society in every issue
of the Forum during our tenure. In this issue, we have an interview
with Prof. Franco Buttafarro, President of the Italian Society of
Hair Restoration (ISHR). If you do not have a hair society in your
country, let’s start one up immediately, we know how.
All the leaders in the ISHRS believe that once we have knowledge it is our responsibility to teach and share that knowledge
with all who seek it. This is our take-home message in our first
edition as editors. We believe it will be the same message in
three years’ time. Let’s enjoy our time together.u
Robert H. True, MD, MPH New York, New York, USA [email protected]
I am excited about joining Mario Marzola as the new Forum
editors. I am excited because I believe we belong to a dynamic
international specialty society full of the spirit of innovation and
collaboration. I expect to have a lot of worthwhile material to
publish over the next three years.
Drs. Nilofer Farjo and William Reed did an outstanding job
as co-editors. They brought informed, precise, inquisitive intellects to the journal. It is a bit daunting to follow them, but at the
same time I am very grateful for their contributions and giving
us great role models to emulate.
I am very pleased to welcome a great lineup of columnists.
Dr. Jerry Cooley will report on Hair Sciences; Drs. John Cole
and Bradley Wolf will share the Cyberchat column; Drs. Nicole
Rogers and Jeffrey Donovan will cover Review of the Literature
and Studies; Dr. Tim Carman will take over the How I Do It section; Dr. Sara Wasserbauer will continue her entertaining and
informative Hairs the Question; Dr. Marco Barusco is launching
a new column, Difficult Cases and Complications; Dr. Russell
Knudsen will continue Controversies; and one of my personal
favorite features, Editor Emeritus will continue, starting with the
always informative Dr. Francisco Jimenez in this issue.
The San Francisco meeting was very successful based on
reviews and comments. That success was made possible by the
great location along with a really solid scientific program. The
report on the meeting in this issue recaps much of the meeting
general sessions. But the reporting does not cover the workshops,
symposia, and expert tables. As Program Chair, I had the opportunity to wander around and see almost all of them, and I thought
the faculties did a wonderful job making these perhaps some of
the best meeting content. In particular, I was very impressed with
the quality of the Assistant’s Workshop. One of the surprise hits
of the meeting was the ISHRS & ABHRS
Morbidity and Mortality Review. Many
of those who participated said it was
the highlight of the meeting for them.
Participants found the intimate and frank
discussion of significant complications
was of superb educational value. I agree
and I am pleased that this program will
continue at next year’s meeting.
Problem cases and complications present learning opportunities. In this issue, Dr. Sezgin’s article presents a previously
unidentified complication of FUE, and Dr. Barusco describes a
masterful management of a very unusual case. I hope for more
such cases to be part of every issue.
Dr. Colin Jahoda’s Norwood lecture in San Francisco received rave reviews, so I am pleased we are able to present
Concepts and Challenges in Hair Follicle Cloning by Dr. Clair
Higgins and Dr. Jahoda as this issue’s lead article.u
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January/February 2014
INTERNATIONAL SOCIETY OF HAIR RESTORATION SURGERY
Vision: To establish the ISHRS as the leading unbiased authority in hair restoration surgery.
Mission: To achieve excellence in patient outcomes by promoting member education, international collegiality, research, ethics, and public awareness.
2013–14 Chairs of Committees
American Medical Association (AMA) House of Delegates (HOD) and
Specialty & Service Society (SSS) Representative: Carlos J. Puig, DO
(Delegate) and Robert H. True, MD, MPH (Alternate Delegate)
Annual Giving Fund Chair: John D.N. Gillespie, MD
Annual Scientific Meeting Committee: Damkerng Pathomvanich, MD
Audit Committee: Robert H. True, MD, MPH
Bylaws and Ethics Committee: Robert T. Leonard, Jr., DO
Communications & Public Education Committee: Robert T. Leonard, Jr., DO
Ad Hoc Committee on Branding: Bernard P. Nusbaum, MD
CME Committee: Paul C. Cotterill, MD
Regional Workshops Subcommittee: Matt L. Leavitt, DO (Chair) &
David Perez-Meza, MD (Co-Chair)
Subcommittee on EBM and Research Resources: Marco N. Barusco, MD
Subcommittee Expert Panel: Paul C. Cotterill, MD
Subcommittee on Webinars: James A. Harris, MD
Core Curriculum Committee: Anthony J. Mollura, MD
Fellowship Training Committee: Robert P. Niedbalski, DO
Finance Committee: Ken Washenik, MD, PhD
FUE Research Committee: Parsa Mohebi, MD
Hair Foundation Liaison: E. Antonio Mangubat, MD
International Relations Committee: Bessam K. Farjo, MBChB
Membership Committee: Michael W. Vories, MD
Nominating Committee: Kuniyoshi Yagyu, MD
Past-Presidents Committee: Jennifer H. Martinick, MBBS
Pro Bono Committee: David Perez-Meza, MD
Scientific Research, Grants, & Awards Committee: Michael L. Beehner, MD
Surgical Assistants Committee: Aileen Ullrich
Surgical Assistants Awards Committee: Tina Lardner
Ad Hoc Committee on Database of Transplantation Results on Patients
with Cicatricial Alopecia: Jeff Donovan, MD, PhD
Ad Hoc Committee on FUE Issues: Carlos J. Puig, DO
Ad Hoc Committee on Regulatory Issues: Paul T. Rose, MD, JD
Subcommittee on European Standards: Jean Devroye, MD,
ISHRS Representative to CEN/TC 403
Subcommittee on Alberta, Canada Standards: Vance Elliott, MD
Task Force on Physician Resources to Train New Surgical Assistants:
Jennifer H. Martinick, MBBS
Task Force on Finasteride Adverse Event Controversies: Edwin S. Epstein, MD
2013–14 Board of Governors
President: Vincenzo Gambino, MD*
Vice President: Sharon A. Keene, MD*
Secretary: Kuniyoshi Yagyu, MD*
Treasurer: Ken Washenik, MD, PhD*
Immediate Past-President: Carlos J. Puig, DO*
Alex Ginzburg, MD
James A. Harris, MD
Sungjoo Tommy Hwang, MD, PhD
Francisco Jimenez, MD
Melvin L. Mayer, MD
Paul J. McAndrews, MD
David Perez-Meza, MD
Arthur Tykocinski, MD
Bessam K. Farjo, MBChB
Robert S. Haber, MD
*Executive Committee
Editorial Guidelines for Submission and
Acceptance of Articles for the Forum Publication
Bernard Nusbaum, MD
1.
Articles should be written with the intent of sharing scientific
information with the purpose of progressing the art and science
of hair restoration and benefiting patient outcomes.
2. If results are presented, the medical regimen or surgical techniques that were used to obtain the results should be disclosed
in detail.
3. Articles submitted with the sole purpose of promotion or
marketing will not be accepted.
4. Authors should acknowledge all funding sources that supported
their work as well as any relevant corporate affiliation.
5. Trademarked names should not be used to refer to devices or
techniques, when possible.
6. Although we encourage submission of articles that may only
contain the author’s opinion for the purpose of stimulating
thought, the editors may present such articles to colleagues
who are experts in the particular area in question, for the purpose of obtaining rebuttal opinions to be published alongside
the original article. Occasionally, a manuscript might be sent
to an external reviewer, who will judge the manuscript in a
blinded fashion to make recommendations about its acceptance, further revision, or rejection.
7. Once the manuscript is accepted, it will be published as soon
as possible, depending on space availability.
8. All manuscripts should be submitted to [email protected].
9. A completed Author Authorization and Release form—sent as
a Word document (not a fax)—must accompany your submission. The form can be obtained in the Members Only section
of the Society website at www.ishrs.org.
10. All photos and figures referred to in your article should be sent
as separate attachments in JPEG or TIFF format. Be sure to
attach your files to the email. Do NOT embed your files in the
email or in the document itself (other than to show placement
within the article).
11. We CANNOT accept photos taken on cell phones.
12. Please include a contact email address to be published with
your article.
Submission deadlines:
February 5 for March/April 2014 issue
April 5 for May/June 2014 issue
A Note from Dr. Mario Marzola:
The Learning Never Stops—
201 Years of Experience in One Room
On November 22, 2013, with several of my colleagues, I
found myself learning in the operating room of Dr. Russell
Knudsen in Sydney, Australia. He was demonstrating a female
hairline lowering operation using follicular unit transplants.
Besides being too high, the patient’s hairline was also a little
see-through, not having a strong front edge. For this reason,
the alternative way of lowering the hairline with an anterior
scalp reduction was not suitable. We watched the harvesting,
the making of the sites, the preparation of the grafts, and graft
placement, all elegantly done with ease and comfort.
During the session, someone remarked that there was a lot
of experience here. Adding it all up, it came to 201 years in
4
Back (L to R): Drs. Russell
Knudsen, Mario Marzola, Bessam
Farjo, Vincenzo Gambino and
Robert Haber. Front (L to R): Drs.
Nilofer Farjo and Richard Shiell.
total—helped by a few “seniors” present including yours truly.
Dr. Gambino, our current President was there, also a smattering
of past presidents, past Forum editors, textbook authors, and
award winners. Most enjoyable, thank you Russell.
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Notes from the Editor Emeritus
Francisco Jimenez, MD Canary Islands, Spain [email protected]
Platelet Rich Plasma (PRP) in Patients with
Androgenetic Alopecia (AGA): Does It Work?
Introduction
There are numerous doctors and hair clinics worldwide that
regard PRP simply as a hip, easy to perform, and, above all,
lucrative form of therapy that may or may not work, but at least
does no harm. In addition, its application in hair loss disorders is
becoming very popular among the general population and many
patients are asking for it in our clinics. To illustrate this, a standard
internet search for “PRP and hair loss” will give over 3 million
hits. However, a similar search in the PubMed scientific literature
will reveal a total of just 9 published papers on the subject.
At the 2013 ISHRS Annual Scientific Meeting in San Francisco, I was invited to organize a round table session on the use
of PRP in hair loss. Since this is a controversial topic, I invited
along a number of highly respected colleagues (including Drs.
John Cole, Joe Greco, Bob Niedbalski, Bob Reese, David PerezMeza, Fabio Rinaldi, and Ryan Welter), who are well known for
their experience in the use of PRP. Prior to the meeting, I sent
them all a questionnaire addressing a number of key questions
such as PRP preparation, injection technique, patient satisfaction,
etc. In the absence of evidence-based data, we need to rely on the
experience of “PRP experts,” and so I would like to summarize
the results of the questionnaires that were returned to me about
this complex and controversial subject.
Points of agreement
There are several points in which there is general agreement:
1. The ideal candidates for PRP: All experts responded that
patients with thinning but not fully bald areas are the best
candidates, which includes patients in early stages of AGA
and female androgentic alopecia (FAGA). Patients with AGA
Norwood types I-IV and FAGA Ludwig types I-II are better
candidates than Norwood types V-VI and Ludwig III.
2. Assessment of patient satisfaction after PRP injections: Most
experts agree that approximately 70-90% of patients will see
some degree of improvement (this is a subjective assessment
since no randomized clinical trials have been performed using objective measurements of hair mass/density). Around
20% will be disappointed with the results. However, when
questioned about the realistic outcomes that the patients are
told can be achieved with PRP, most of the experts keep
patient expectations relatively low, stating that they expect
a modest improvement in the diameter of miniaturized hair
and the maintenance of existing hair.
3. Time when improvement in hair growth is expected to be seen:
Most of the experts were of the opinion that improvement
would be seen between 2 to 6 months after the PRP injection.
Dr. Greco thinks it is important to explain to the patient that
the peak effect is at 4-6 months and that the treatment must
be continued to achieve long lasting results.
4. Anesthesia prior to PRP injections: All use an anesthetic
prior to injection, normally ring block with 1% lidocaine.
Differences in approaches
There were several differences in approaches:
1. PRP preparation:
• Joe Greco uses the Emcyte Pure PRP kit.
• Bob Reese uses the Cytomedix kit.
• John Cole uses the Angel system.
• Ryan Welter and David Perez use the Harvest system.
• Bob Niedbalsky uses PRP plus ACell. For the PRP, he
uses the Harvest system.
• Fabio Rinaldi does not use any kit, instead he buys the
components separately.
2. Activation of platelets: We know that platelets need to be
activated in order to release growth factors, but we do not
know whether an exogenous activator is needed or, if this is
the case, which one works best. Platelets can be activated by
exogenous activators (thrombin, calcium, mechanical trauma)
or by a natural activator (collagen). In theory, exogenous activation is not needed for soft tissue injections. Some experts
use thrombin (Greco, Cole, Perez, and Reese) or calcium
gluconate (Rinaldi) or mechanical trauma by multiple injections (Niedbalsky and Welter) to activate the platelets. Greco
also “stimulates” the scalp with a roller prior to injection.
3. The number of and interval between PRP sessions required
for improvement: Although in this respect the approach of
each expert is different, the majority favor two or more sessions 3 to 9 months apart.
4. Duration of the increase in hair growth after PRP injection:
Nobody seems to know for certain, but it would appear that
the treatment must be continued to achieve long lasting results.
5. Cases in which PRP is offered to patients: This seems to be a
personal choice with a different approach used by each doctor. Dr. Greco, for example, offers it to patients with early
stages of AGA who refuse to take approved FDA therapy or
complain of its side effects, or simply to those who would
like to add a secondary therapy for AGA, even after being
informed that PRP injections do not always achieve a positive effect. Drs. Cole and Rinaldi offer it to anyone provided
they are good candidates (see ideal candidates above). Dr.
Perez-Meza offers it only to patients who do not respond to
medical therapy or who do not wish to try any medical treatment including low level laser therapy. Dr. Niedbalski offers
it as an alternative to medical therapy to patients who are too
young for surgery and who are non-compliant/intolerant of
medication. Dr. Bob Reese performs PRP injections only
during hair transplantation, but not as a medical therapy for
patients with AGA.
[ page 6
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Hair Transplant Forum International
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Editor Emeritus from page 5
Discussion
The few studies that have been conducted on PRP and hair
loss have shown that it does appear to have positive effects on
hair growth. PRP induces dermal papilla cell proliferation in
vitro, induces angiogenesis via VEGF, and up-regulates Wntsignaling proteins and beta catenin, all of which appear to have
important roles in hair follicle activation.
The overall positive experience of serious “PRP experts,”
including those whose opinion has been sought for this article,
tempts us to consider trying PRP in our practices. However, caution is a must. The intervention has to be performed correctly, following the indications of those more experienced than us, and it
is important to realize that until randomized, placebo-controlled,
clinical studies have proven its efficacy (using objective tools for
measuring hair growth), in the eyes of the scientific community
PRP will continue to be regarded as a controversial form of
therapy for hair loss.
January/February 2014
The following are unsolved areas that, in my opinion, need
to be addressed:
1. We need to standardize a protocol for PRP preparation. The
number of different PRP devices on the market makes it difficult to compare the results.
2. Clinical research studies are needed to assess the concentration of platelets that are being injected into the tissue as well
as the concentration of growth factors, correlating both with
the clinical response.
3. Although experience and anecdotal clinical data are important, we still need randomized, placebo-controlled, clinical
trials to be certain that PRP does in fact induce hair growth.
Let’s keep PRP inside the scientific boundaries. Throughout
its history, our field has been plagued by the invasion of “miracle”
cures through hair potions and lotions. It would be sad to see
PRP having a similar fate to these, becoming yet another trivial
and short-lived form of untested “popular” therapy.u
Dear Members: The session at the 2013 Annual Scientific Meeting to which Dr. Jimenez refers was recorded and is available to members in the Members Only section of the ISHRS website at www.ishrs.org. See page 28 of this issue for details.
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Hair Follicle Cloning from front page
New Approaches for Follicle Regeneration
By expansion of dermal papilla cells by growth in culture, you
are essentially taking them from a three-dimensional environment
where they are surrounded by other cells, to a two-dimensional environment where they have plastic on one side and culture medium
on the other. This results in a decrease in communication between
the dermal cells, which likely contributes to their loss in specificity or identity in culture. Recently, we demonstrated that growth
of cultured human dermal papilla cells in hanging drop cultures
results in formation of three-dimensional dermal spheroids. We
were able to show that dermal spheroids maintain their specificity
after transplantation into human skin, where they are capable of
inducing growth of de novo hair follicles, rather than contributing
to the interfollicular dermis.11 Moreover, 22% of genes expressed
in intact papillae, whose expression was deregulated by normal
culture growth, were restored by growth of dermal papilla cells in
spheroids. This indicates that the microenvironment within dermal
spheroids results in increased communication between cells, and
a partial restoration of dermal papilla identity—enough to initiate
the cascade of events leading to new follicle development. This
being said, the molecular contribution of the epidermal cells to
the interactive process has still to be elucidated.
Conclusions
Thirty years ago, we first demonstrated that cultured rodent
dermal papilla cells could be used to induce new hair follicle
growth.12 We now know that hair follicle cloning is possible using
human hair follicle cells. However, the hairs we have produced are
quite small, directionally non-uniform, and it remains to be seen
how long they will grow for and whether the follicles will cycle.
Therefore, many reproducibility and engineering challenges still
remain before conventional hair transplantation procedures will
be replaced; however, we will continue to take lessons from biology, and by developing a better understanding of the properties
of hair follicle cells we will, in time, be able to improve on this
important proof of principle study.
January/February 2014
References
1. Lillie, F.R., and H. Wang. Physiology of development of
the feather V. Experimental morphogenesis. Physiol Zool.
1941; 14(2):103-135.
2. Oliver, R.F. The experimental induction of whisker growth
in the hooded rat by implantation of dermal papillae. J Embryol Exp Morphol. 1967; 18(1):43-51.
3. Fliniaux, I., et al. Transformation of amnion epithelium into
skin and hair follicles. Differentiation. 2004; 72(9-10):558-565.
4. Jahoda, C.A., and R.F. Oliver. Vibrissa dermal papilla cell
aggregative behaviour in vivo and in vitro. J Embryol Exp
Morphol. 1984; 79:211-224.
5. Jahoda, C.A. Cellular and developmental aspects of
androgenetic alopecia. Exp Dermatol. 1998; 7(5):235-248.
6. Tobin, D.J., et al. Plasticity and cytokinetic dynamics of
the hair follicle mesenchyme during the hair growth cycle:
implications for growth control and hair follicle transformations. J Investig Dermatol Symp Proc. 2003; 8(1):80-86.
7. Jahoda, C.A., and A.J. Reynolds. Hair follicle dermal sheath
cells: unsung participants in wound healing. Lancet. 2001;
358(9291):1445-1448.
8. Jahoda, C.A. et al., Hair follicle dermal cells differentiate
into adipogenic and osteogenic lineages. Exp Dermatol.
2003; 12(6):849-859.
9. Cooley, J. Follicular cell implantation: an update on “hair
follicle cloning.” Facial Plast Surg Clin North Am. 2004;
12(2):219-224.
10. Ibrahim, L., and E.A. Wright. A quantitative study of hair
growth using mouse and rat vibrissal follicles. I. Dermal
papilla volume determines hair volume. J Embryol Exp
Morphol. 1982; 72:209-224.
11. Higgins, C.A., et al. Microenvironmental reprogramming
by three-dimensional culture enables dermal papilla cells to
induce de novo human hair-follicle growth. Proc Natl Acad
Sci USA. 2013; 110(49):19679-19688.
12. Jahoda, C.A., K.A. Horne, and R.F. Oliver. Induction of
hair growth by implantation of cultured dermal papilla cells.
Nature. 1984; 311(5986):560-562.u
Cause of Graft Injury:
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HYPOTHERMIC STRESS
Try HypoThermosol®
7
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January/February 2014
Complications and Difficult Cases
Marco N. Barusco, MD Port Orange, Florida, USA [email protected]
This is a new column for the Forum, and one that I believe will provide a great learning experience for
us all. I want to take a moment to thank the editors, Drs. Robert True and Mario Marzola, for inviting me
to contribute by writing this column. I invite everyone to submit difficult and complicated cases to me for
future columns. If anonymity is preferred, please indicate this to me and I will make sure your information
and the information on the patient are kept confidential and only the clinical data is shared.
Since this is the first article of this new column, I decided to start with one of my own difficult and
challenging cases.
Hair Transplantation on a Patient with a Large Cranioplasty
Background
This case report describes a successful hair transplant
procedure performed on a patient who had been a victim of
a motorcycle accident that resulted in severe head injury that
required multiple neurosurgical interventions, culminating with
a cranioplasty for both cosmetic and reconstructive purposes.
As a matter of disclosure, I must state that the following is
an account of our decisions and their outcomes. These decisions were based on the review of currently available literature;
however, due to the lack of specific recommendations for this
patient’s particular situation, empiric adjustments were made in
an attempt to provide the safest experience and the best outcome
for the patient. The following describes a suggested protocol. It
is not the objective of this article to provide official guidelines
for anyone attempting to treat patients in similar situations.
Case Presentation
History
This procedure was performed in 2011 on a 42-year-old male
who came for consultation regarding hair restoration surgery.
In 2007, he was victim of a motorcycle accident. He was not
wearing a helmet and hit the left side of his head on the pavement,
which caused compound and depressed skull fractures involving
portions of his frontal, parietal,
and temporal bones, resulting in
a large skull defect (13cm×8cm).
The patient eventually made a
full recovery with no permanent
neurological sequelae. A few
months after the accident, a
delayed cranioplasty procedure
was performed using an acrylic
resin allograft material (polymethyl methacrylate) to correct Figure 1. Skull series X-ray, AP view.
the skull deformity in order to
offer protection to the central
nervous system and restore his
comesis. The acrylic cranioplasty material was secured in
place with titanium miniplates
(Figures 1 and 2).
For the past 4-5 years, the patient has experienced progressive Figure 2. Skull series X-ray, left lateral
view.
8
male pattern baldness with worsening bitemporal recession and
thinning of his hair diffusely, which has caused some of the scalp
scars from these procedures to become more visible. The patient
denies a family history of hair loss. He has tried saw palmetto as
a medical treatment to retard the progression of his hair loss, but
there has been no effect. He also denies having tried finasteride,
minoxidil, and/or low level laser therapy.
The patient’s main goals encompass the following:
1. To fill in bitemporal anterior hairline recessions and frontal
scalp thinning
2. To cover the scars located in the left side of his anterior
hairline and along his left temporal and parietal areas, a
consequence of the craniotomy and cranioplasty
Physical Examination
Scalp inspection and examination revealed the presence of
androgenic alopecia (AGA), Norwood IV, with bilateral anterior
hairline recession and a strong
frontal tuft present. Throughout the midscalp and crown,
there was a slight degree of
hair miniaturization (Figure
3). The donor area had an
overall density of 110 FUs/
cm2. Hairs were medium to
coarse in caliber, dark brown, Figure 3. Extent of AGA (hair miniaturization)–
top frontal view.
and wavy.
Fortunately, skin and tissue loss due to the trauma and the
surgical procedures were minimal, and the patient retained an
adequate amount of subcutaneous tissue over the cranioplasty
areas. Skin and hair were mostly preserved, but the scars from
the surgeries were visible along his left anterior hairline, left
temporo-parietal, and left temporo-occipital areas. These
temporo-occipital scars were
present in the normal donor
harvesting zone. On the left
frontal area, just below the
natural anterior hairline, close
examination revealed signs of
the edge of the skull defect
and some of the miniplates
and screws were palpable in
Figure 4. Skull and scalp irregularities (scars,
that area (Figure 4).
screws and plates), visible and palpable.
Due to the nature of this
case and the potential for complications, I called the patient’s
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neurosurgeon and discussed the case in length, mainly about
the risk of introducing skin bacteria on the cranioplasty material
and causing an infection. The neurosurgeon thought that the risk
was low if certain precautions were taken but advised that if the
cranioplasty material was to become infected, then it would have
to be removed and the patient would more than likely need intravenous antibiotic therapy. Once the infection was treated, then
another cranioplasty would have to be performed. A conference
between the patient, his wife, the neurosurgeon and me was then
scheduled, and after much deliberation and consideration of the
risk/benefit of the procedure, the patient decided to proceed with
the hair restoration procedure. An addendum was made to our
standard informed consent for hair transplant surgery to reflect
understanding of the additional potential risks of this procedure.
Intervention
Due to the potential risk of complications involving the synthetic cranioplasty material, some precautions were taken during
the pre-, intra- and post-operative phases of the hair transplant
procedure, mainly in regards to prevention of infection.
1. Preoperative Management
a. Trimethoprim/sulfamethoxasole (Bactrim DS) was prescribed, 1 tablet twice daily starting 3 days before the
procedure, continuing until the time of suture removal
(MRSA prevention).
b. Mupirocin ointment to both nostrils three times daily
was started 3 days prior to the procedure and continued
until the time of suture removal (MRSA prevention).
c. His hair and body (except his face) were cleansed with
Hibiclens (4% chlorhexidine) once daily starting 3 days
before surgery.
2. Intraoperative Management
a. The operating room was prepared to afford surgery under
sterile conditions with sterile drapes, sterile surgical table
covers, etc.
b. One hour before the procedure, he was instructed to
take 2g of amoxicillin orally (recommended protocol
for prevention of bacterial endocarditis and bacterial
infection of prosthesis during dental and dermatological
procedures).
c. After pre-operative photographs and marking had been
completed, his hair was washed with chlorhexidine. Once
applied, the chlorhexidine was not rinsed but only towel
dried
d. Planned strip of donor tissue was marked, taped, and
shaved according to our normal protocol. We chose to
harvest the donor strip from the right occipital and right
temporal areas in order to avoid operating over previous scars and, more importantly, over the cranioplasty
material.
e. Before anesthesia, the skin was prepared again with
Hibiclens.
f. Sterile drapes were applied to establish a sterile field,
which exposed only the shaved strip of donor hair to be
removed.
g. Anesthesia, low-volume tumescence, donor harvesting,
and suturing were done under normal fashion but under
sterile conditions.
h. The harvested donor strip was handed to our surgical assistants for graft preparation, which was done also under sterile
January/February 2014
conditions (microscopes were covered with sterile drapes,
and backlights were covered with sterile plastic bags.
i. After sutures were applied, the suture line was covered
with Bacitracin ointment and was occluded with sterile
non-stick pads (Telfa) and sterile gauze, followed by a
compression headband with an ACE bandage.
j. Hibiclens solution was used to prepare the recipient area
of the scalp.
k. A hole was cut in a sterile drape, large enough to be
placed snugly over and around the patient’s scalp, exposing the recipient area.
l. Recipient-area anesthesia was undertaken using a ring
block with superficial injection of the anesthetic solution.
m. Low-volume injection of a solution of 0.9% sodium
chloride and epinephrine 1:1,000 was used in the recipient area for hemostasis and light tumescence. A
solution of 0.9% sodium chloride was used to tumesce
gently the skin overlying the cranioplasty material, in
order to increase the depth between the epidermis and
the cranioplasty, which would permit that the recipient
sites be made without touching the acrylic plate.
n. Under sterile conditions, the recipient sites were made.
Custom-cut blades were used, mainly to limit the depth of
the incisions. Also, the recipient incisions were angled more
acutely against the surface of the skin, in order to minimize
depth and allow the necessary length for the insertion of
the follicular units (the patient’s follicular units measured
4mm in length on average). These precautions were taken
to avoid as much as possible the contact between the blade
and the cranioplasty material, in order to avoid possible
seeding of skin flora into the synthetic cranioplasty material.
This precaution was especially important in the areas of the
scalp where the skin and subcutaneous tissue were thin.
o. During the course of the hair transplant procedure, extra
precautions were taken to maintain a sterile field.
p. The patient tolerated the procedure well. A total of 1,480
grafts were transplanted. Most of the scars received
grafts, with a small
portion of the left
parieto-occipital scar
remaining untreated
(not a major priority
for the patient) (Figures 5, 6, and 7).
q. Before returning
home, the patient
Figure 5. Immediate post-operative view
received another 2g showing graft placement—1,480 FUs; frontal
oral dose of amoxi- view.
cillin.
r. Patient was instructed
to return to the office
the next day for a
post-operative evaluation and hair wash.
3. Postoperative Management
a. Patient was pre- Figure 6. Immediate post-operative view
graft placement—1,480 FUs. Note
scribed pain control showing
relationship between the transplanted FUs and
according to our the cranioplasty area.
standard protocol.
[ page 10
9
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Complications & Difficult Cases from page 9
b. Patient was instructed
to continue taking
Bactrim DS twice
daily and applying
the mupirocin ointment to his nostrils
three times daily
until time of suture
Figure 7. Immediate postoperative view
removal. In addition, showing graft placement—1,480 FUs. Note
he was prescribed FUs placed along the anterior two-thirds of
cephalexin 500mg to the left parietal scar.
be taken 3 times daily starting the night of the procedure
and continuing until the day of suture removal.
c. Hair washes were performed daily in the office for the
first 5 days. His healing was assessed at every visit, and
no complications were noted. He also reported experiencing very little post-operative pain.
d. He was treated with low level laser therapy in the office starting on the day of surgery and every other day
thereafter until time of suture removal.
4. Patient Evolution
One last precaution we took on this patient was the
prescription of doxycycline 100mg daily for a total
period of 6 months starting shortly after the time of
suture removal. This was done in order to provide some
antibiotic coverage for the initial growth period of the
transplanted hairs, when the incidence of folliculitis and
ingrown hairs with pustules would be highest.
Surgical sites continued to heal beautifully and the
patient experienced steady hair growth. No pustules or
folliculitis were noted.
At the time this report was written, the patient was
approaching the 12-month post-operative mark. He
noted he was extremely happy with his results. Most of
the scars were covered with hair with the exception of a
small portion of the
scar, which makes
it much easier for
the patient to style
his hair so as to conceal the scar (Figure
8). He continues to
take finasteride on a
daily basis with no
Figure 8. 12 months post-op—parietal scar.
adverse effects and Note anterior two-thirds of the scar are well
his hair loss is now covered; posterior two-thirds will be addressed
at a subsequent procedure.
stable.
Thoughts and Pearls
This case illustrates a few principles that I think are very
important. There are many patients out there searching for solutions that will allow them to conceal or cover scalp or facial
scars caused by accidents, trauma, burns, or cancer treatments.
Some of these patients may be candidates for hair transplantation,
but it is important to thoroughly evaluate each situation before
recommending surgery.
In the majority of these cases the pressing issues will be scars,
bald scalp areas from radiotherapy treatments, and/or burned
10
January/February 2014
areas that may have required skin grafts. In areas such as the
ones mentioned above, the patient may have thin skin, which
may become an issue when trying to implant hairs. In addition,
there is the issue with blood supply in the scarred areas, which
normally requires placement of hair grafts with lower density
to allow for optimal growth.
One subset of patients, however, may present challenges.
These are patients who were submitted to neurosurgery, as the
patient in this case.
Infections in prosthetic materials originating from skin and
dental procedures are a rare but important risk. Transient bacteremia caused by rupture of the continuity of the skin and/or
oral mucosa may cause bacteria to seed the synthetic materials
and be challenging to treat, due to the lack of vascularization in
these prostheses, which can severely limit antibiotic delivery to
the affected area. Frequently, in order to fully treat an infected
prosthesis, its removal is necessary, followed by intravenous
antibiotic therapy and then subsequent surgical repair with a new
prosthesis. This strategy becomes even more important with the
recent increase in the number of community-acquired cases of
methicillin-resistant staphylococcus aureus (MRSA).
Guidelines are in place for patients with prosthetic heart
valves and others, but not specifically for cranioplasty materials.
In my opinion, the take-home points here are as follows:
1. In patients who are subjected to neurosurgery and trauma with
skull fractures, it is vital to understand exactly what happened
and to order imaging studies to help determine if synthetic
materials were used and to help establish where they were
placed in relation to the proposed region of surgical interest.
If cranioplasty was undertaken, it is vital to know the type
of material used, since cranioplasties made from organic
materials (e.g., bone, etc.) usually carry less risk of infection
than the ones made from synthetic materials.
2. As should be done with every patient, a detailed consultation must be done, during which all of the potential risks and
benefits must be extensively detailed to the patient, including
disclosure of the rare but potential need for removal of the
prosthetic material, hospital admission, prolonged need for
intravenous antibiotics, and reconstructive surgery. These
procedures, should they become necessary, may compromise
the viability of the follicular units that were transplanted,
in addition to their inherent risks. We must not forget that,
should a complication occur, there are financial implications,
loss of work productivity, and other factors that must be taken
into consideration.
3. These are NOT cases for neophytes and hair restoration
surgeons with little experience.
4. Once the patient and you have carefully considered the risks
and benefits and have decided to proceed with the hair transplantation procedure, it is important to err on the side of caution. Based on existing guidelines for treatment and prevention
of community-acquired MRSA infections and the guidelines
available for preoperative prophylaxis in patients with prosthetic heart valves, we decided to combine different types of
antibiotics during the pre-, intra-, and post-operative periods,
as described above, in order to minimize the potential risk of
infection. Antibiotics were chosen due to their efficacy against
normal skin flora as well as their indications against MRSA.
5. Even though in the United States hair transplant procedures
are not routinely performed under sterile conditions, this case
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(and similar cases in my opinion) warrants this precautionary
measure.
6. It is important to follow up closely with the patient in order to
intervene at the first sign or symptom of a potential problem.
There is no substitute to a good clinical exam, and simple
blood tests may help guide you in the right direction. Working in conjunction with the patient’s neurosurgeon as we did
(the neurosurgeon was aware of our plan and ready to take
care of the patient if needed) is also very important, as it will
save precious time in the event of a problem.
These types of situations are not that uncommon. There are
many patients out there with similar problems and scars all over
their scalp, which are constant reminders of the tough times they
endured. As patients find out more about hair transplantation
and what it may do for them, it is only logical to assume that we
will see an increasing prevalence of similar scenarios. In fact,
this patient’s neurosurgeon has since referred a few additional
patients to me for consultation, and I have been able to help some
of them in a similar fashion.
Bibliography
1. Al-Mukhtar, A., et al. A simple prophylaxis regimen for
MRSA: its impact on the incidence of infection in patients
undergoing liver resection. Ann R Coll Surg Engl. 2009;
91(1):35-38.
January/February 2014
2. Erman, T., et al. Risk factors for surgical site infections
in neurosurgery patients with antibiotic prophylaxis. Surg
Neurol. 2005; 63:107-112.
3. Gladstone, H.B., et al. Implants for cranioplasty. Otolaryngology Clinics of North America. 1995(Apr); 28(2):381-400.
4. Kelly, M., et al. Propionibacterium acnes infections after
cranial neurosurgery. Can J Neurol Sci. 2006; 33:292-295.
5. Matsuno, A., et al. Analyses of the key factors influencing
bone graft infection after delayed cranioplasty. Acta Neurochir. 2006; 148:535-540.
6. Park, J., et al. Large defect may cause infectious complications in cranioplasty. J Korean Neurosurg Soc. 2007;
42:89-91.
7. Seckin, A., et al. Cranioplasty: review of materials and techniques. J Neurosci Rural Pract. 2011(Jul-Dec); 2(2):162167.
8. Tokoro, K., et al. Late infection after cranioplasty—review of 14 cases. Neurol Med Chil (Tokio). 1989 (Mar);
29(3):196-201.
9. Yu, C., et al. Antobiotic Prophylaxis in non-shunt, clean
cranial surgical procedures: a meta-analysis. Phil J Microbiol Infec Dis. 2000; 29(2):33-36.u
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FUE Donor Site Ischemia and Necrosis
Cagatay Sezgin, MD Adana, Turkey [email protected]
The follicular unit extraction (FUE) method for hair transplantation is becoming more popular because of the patient
preferences and it has the advantages of rapid recovery, comfortable post-operative period, and, for some patients, increasing
donor supply. However, FUE donor site complications are rare
in the literature.1
I want to present and discuss one of these rare donor site
complications that I have encountered: a patient with donor site
ischemia and necrosis, which progressed, increased during the
extraction period, and than healed with a scarring alopecia area.
Case Study
The 39-year-old male patient was a Norwood type V. The
patient reported no known disease and no medications and/or
supplements. He had been smoking heavily (20-40 cigarettes/
day) since his twenties. His preoperative hemogram test had
shown HB: 17g/dL, HCT: 51.5% (upper limit of normal 52).
We planned two FUE sessions. In the first session, 2,720
grafts were harvested and transplanted. We used lidocaine 2%
with 1:100000 epinephrine for donor site anaesthesia. A total
of 6-8cc was administered to the entire donor area. We began
harvesting from the right temporal region moving around the
head and finishing in the left temporal region.
It took approximately 3 hours and 15 minutes to harvest the
grafts with a micromotor using 0.9mm sharp punch inserted to
an average depth of 2-3mm. After finishing the extraction, I
noticed an ischemic area on the right temporal region. We did
the routine dressing of the donor area, and after 30 minutes began to create recipient sites followed by graft placement. After
completing placement, I examined the ischemic region again
and saw some resolution, but also noted that some points had
worsened (Figure 1).
Figure 1.
I prescribed pentoxifylline 600mg twice per day for 7 days
post-operatively, and warned the patient not to lean this side
of his head on the pillow while sleeping. After two months,
part of the ischemic area
reduced and healed, but
the necrotic area healed
with a 1.5-2cm wide scar
(Figure 2).
Discussion
The possible factors
that might have lead to
and/or triggered the isch12
Figure 2.
emia and necrosis in this case are heavy smoking, very thin subcutaneous tissue, and prolonged compression (lying on this side
of the head for a long period during graft extraction). Although
his HCT was only high normal, it must be noted that high HCTs
in heavy smokers are associated with increased blood viscosity,2
another potential risk factor for ischemia.
Conclusion
Heavy smoking, thin subcutaneous tissue, prolonged pressure, and perhaps increased blood viscosity together and/or
solely may reduce tissue blood circulation that may lead to
tissue ischemia and necrosis in FUE harvesting.
References
1. Karaçal, N., et al. Necrosis of the donor site after hair restoration with follicular unit extraction (FUE): a case report.
J Plast Reconstr Aesthet Surg. 2012(Apr); 65(4):e87-89.
2. Alkan, F.A., et al. The evaluation of plasma viscosity
and endothelial dysfunction in smoking individuals. Clin
Hemorheol Microcirc. 2013 Oct 29. [Epub ahead of print]
Editor’s Note: I asked Dr. Sezgin if there had been any arterial
bleeding at the time of anesthesia injection or punch insertion in
the area of necrosis. He reported there was none. —RT
Commentary:
James A. Harris, MD, FACS Greenwood Village, Colorado
USA [email protected]
This is likely the first reported case of donor area necrosis
after an FUE procedure in the literature. Dr. Sezgin has reviewed
the pertinent risk factors and it is apparent that it should be routine to ask patients about these factors. The question of a high
hematocrit may be a little difficult to answer as pre-operative
laboratory testing is not routine in all offices. Smoking has been
identified as a risk factor in recipient area necrosis.
It seems that some factors that might place the patient
at obvious risk for donor necrosis did not play a role in this
case. I’m referring to excessive amounts of high concentration
epinephrine as a tumescent solution to aid in graft dissection,
deep insertion of sharp punches, high density extractions, and
the use of large punches. The author does not describe the
use of tumescence in this case so this would not have been a
contributing factor.
The total linear trauma from the dissections would be related
to the size of the punch and number of attempts. The author
states that the procedure involved 2,720 extraction attempts,
which does not seem excessive for the apparent size of the donor
area. In addition, a .09mm punch was used, which is not “large”
for FUE cases. Just as the recipient area is subject to excessive
trauma and at risk for necrosis, one might expect the donor area
to have the same risk factors.
Every month we see examples on the internet of surgeons,
or their staff, attempting FUE cases of 5,000 to 6,000 grafts.
The photos of these cases certainly appear extreme and one can
only imagine the complications we don’t hear about. I would
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urge physicians performing FUE to be cautious, ask about the
risk factors that Dr. Sezgin discusses, and be observant for any
indications of blood supply disruption.
In spite of this report, and having performed FUE for 11
years, this is the first time I have heard of a case of donor
area necrosis related to FUE. Notwithstanding extraction
site hypopigmentation and over harvesting, we are fortu-
January/February 2014
nate that donor area complications from FUE are relatively
rare. As in most areas of hair restoration, we have no data
for FUE procedures to indicate what the limits are in terms
of total linear trauma, the volume of tissue removed, extraction densities, and punch size limits. It would seem that
this area would be a fruitful area of study for the ISHRS
FUE Research Committee to consider.u
13
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January/February 2014
How I Do It
Timothy Carman, MD La Jolla, California, USA [email protected]
I would like to take this opportunity to thank Drs Mario Marzola and Robert True for their support
and encouragement entrusting me with such a gratifying honor as serving as editor of the “How I Do It”
section of the ISHRS Forum. I would like to invite any and all ISHRS members interested in contributing
their insights to do so by contacting me via my email address. Ours is a continually evolving field and
progress in developing “standards” arises from daily practice by working clinicians.
As dedicated surgeons, in our alliance in the ISHRS, when we share our experiences with each other,
we solidify our commitment to our patients to provide consistent, reproducible results. I look forward to hearing from many of
you in the future as you contribute to making our society the “Gold-Standard” for all those seeking information on surgical and
non-surgical treatment options for both male and female pattern hair loss issues.
The “Sweet Spot” for Strip Harvesting
Timothy Carman, MD La Jolla, California, USA [email protected]
Following is how I
select the harvest area
in the donor zone. It is
generally agreed that the
lower limit to this zone
is at or slightly below
the superior nuchal line
extending bilaterally
from the central external occipital protuberance (line LL, Figure
1). I have observed that
removing strips below
this level can result in Figure 1. Donor area margins and harvesting levels.
wider donor scars. As this area may ultimately be affected by
retrograde alopecia, harvesting below the line carries the risk
that transplanted follicles may not last.
Judging the upper limit of the ideal harvesting zone may be
a bit more challenging, as you need to take into account future
losses as male pattern hair loss evolves, especially in the younger
patient. 30× magnification may help to visualize subtle miniaturization occurring in an otherwise “normal looking to the naked
eye” area, below any obvious crown thinning. Such areas should
be excluded from the harvesting zone (line UL in Figure 1). Once
identified, these upper and lower borders usually will demarcate
an area roughly 3-5cm wide where routine donor harvest is best
performed. I call this the “sweet spot.”
I recall that at one of our recent annual scientific meetings,
an audience survey revealed most surgeons prefer to harvest
at or adjacent to that inferior occipital border as defined by the
superior nuchal ridge. It has been my informal observation that
many surgeons choose to take the strip from the lower portion
of this area (line b, Figure 1).
I use a slightly different approach and choose to harvest
higher (line a, Figure 1) in the donor area because there is typically much more laxity of the scalp at this level than lower in the
zone. Removing the donor strip from this “middle” area allows
me to remove a slightly wider strip, increasing the total follicular
unit harvest. Because of the greater laxity, the tension of wound
closure is generally less, and we have found patients report less
“tightness” following surgery (Figure 2).
When taking subsequent strips from the ideal harvest zone,
14
I excise the old donor
scar as the middle portion of my strip. I have
found that when the scar
from a previous harvest
is placed at the upper or
lower edge of the excised
strip, some residual scar
tissue remains adjacent
to the new incision. With
excision, placing the scar
in the mid portion of the
strip, I get more consisFigure 2. Sutured donor incision one day post-op.
tent minimal scarring on
second procedures in the area. (I haven’t been doing this long
enough to evaluate a third strip as of yet.) In addition to these
benefits, I have also found that this more superior harvest location helps patients (especially our military patients) who want to
utilize a “fade” hair cut with the hair longer above decreasing to
almost shaved lower along the sides and back of the head. The
higher location comfortably lies in an area of longer styled hair,
assisting in its concealment. An informal survey of my patients
seems to point to a decreased perception of tightness in the donor
area one week post-op than previously reported by our patients
when we utilized a lower (more conventionally located) donor
strip. I welcome comments and observations.u
Meetings and Studies
David Perez-Meza, MD Mexico City, Mexico [email protected]
COuRSES
www.ISHRS.org
Hair Transplant Forum International
FEE:
$895
January/February
2014
LEVEL: Beginner
BASICS CO
David Pe
Marco N
San Francisco, California, was the perfect location for the 2013 ISHRS annual meeting. I say “perfect” because
we already have the final attendance numbers, which indicate that San Francisco was the largest ISHRS attended
meeting in history! A staggering 520 physicians and residents, an impressive 146 assistants and administrative
staff, culminating in a grand total of 681 total attendees. We had a great meeting and kudos to Dr. Robert True
(Chairman), the entire faculty, the assistants, Victoria Ceh, and the entire ISHRS Team for a job well done.
As a medical society, it was great to see the increase of doctoral attendance at this year’s session. Prior to
Davidand
Perez-Meza,
this event, the two previous highest meetings consisted of 414 doctors in attendance at the 1994 annual meeting
415 atMD
the
2012 annual meeting. With an increase of over 20%, bringing us to 520 doctors in the audience, this demonstrates the ISHRS’s
influence and leadership in hair loss and hair restoration around the world. I fully expect to see high attendance numbers for
the 2014 Annual meeting in Bangkok, too!
“I left my heart in San Francisco…” After a great meeting, seeing my old friends and making new ones, I can see where this old adage came from. I truly enjoyed the companionship, the sharing of ideas, and the camaraderie that was established during that busy time.
Thank you to my friends and colleagues: Drs. Roy Stoller, Jerzy Kolasinski, David Josephitis, Ed Epstein, and Jeffrey Donovan for taking the time to write summaries from this fantastic educational experience. Their detail and perspective will only aid
in the preservation and continuing growth of hair loss and restoration knowledge for future generations of doctors and staff.
As a personal note: I was elected President of the SILATC (IberoLatinAmerican Society of Hair Transplant Surgery); the
society involves Spanish and Portuguese speaking hair restorations in Ibero-America and around the world. It is an honor and
Marco N. Barusco, MD
privilege to be the leader.
Day-by-Day Review of the 2013 ISHRS
21st Annual Scientific Meeting
The 2011
on and in
overall em
contempo
this cours
and core
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surgery.
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the different skills. The course co
and Ask the Experts.
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Lecture Series enduring material
15 pre-recorded comprehensive
surgical hair restoration. The UR
sized the need to recognize the potential for retrograde
alopecia
in It is hig
to you prior
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positioning the donor strip. His usual strip limits
1cm behind
the 15are
lectures
PRIOR TO THE M
student
receive
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the anterior fringe, from 28-38cm in length, with
thewill
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may bring th
he injects tumescent solution superficially and
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Thursday/October 24, 2013
Roy Stoller, DO New York, New York, USA
[email protected]
Dr. Robert True
opened the meeting and welcomed
all participants. Dr.
Carlos Puig gave the
president’s address.
He spoke about adding credibility to
ISHRS membership
by expanding current
designations.
T h e m e e t i n g Robert H. True, MD, Chair of the Annual Scientific
opened with a two- Meeting
part session on State-of-the-Art Hair Restoration Surgery. The first
section focused on Hair Restoration via Donor Strip Harvesting.
Strip Harvesting (FUT)
Dr. Victor Hasson, who, along with his partner, Dr. Jerry
Wong, has set the benchmark for performing large FUT sessions,
gave a comprehensive and detailed presentation of his approach.
He focused primarily on donor harvest. In preparing patients for
surgery, he emphasized use of finasteride as he is convinced that it
stabilizes hair loss all over the scalp including in the donor region.
Dr. Hasson has many of his patients stretch the donor area with
daily exercises for 4-12 weeks before surgery to increase yield
by allowing a wider donor strip to be removed. He stressed for
patients with class IV or greater baldness, it is essential to harvest
as many grafts as possible to produce the best results. He empha-
galea to create an optimal stretch and tautness. He takes the donor
PRECAUTION NOTE: This course will ut
in sections, adjusting the width in each area with
theallwidest
Although
tissue isstrips
pre-screened for co
Precautions
must be observed
coming from the temporal and mid-occipitalUniversal
areas
and
narrower
see the Attendee Agreement on the regist
but you mayundermines
wear scrubs for this course i
in the parietal and supramaxillary areas. He routinely
coverings will be provided, including stan
and uses a single layer closure with staples. Heandescribed
a unique
allergy to latex
or glove powder, pleas
approach to slivering along the length of the strip rather than the
typical cross strip slivering; an approach that he believes improves
the efficiency and accuracy of graft dissection.
Dr. Arthur Tykocinski agreed with the value of pre-operative
18 ANCHORAGE  2011
stretching exercises to increase yield and with the need to measure and adjust strip width during harvesting. He uses less tumescence as he finds that the fluid increases closure tension; and
he employs a two-layer closure supplemented by an intermittent
holding suture. He harvests as high in the permanent donor zone
as possible because of lower tension, best density, and better
healing than lower. Finally, he uses a superior trichophytic in
almost all cases except when there is high closure tension.
Dr. Bobby Limmer concurred that his excision stays above the
superior nuchal ridge to avoid tension of the closure; he usually
performs a trichophytic closure.
Extraction Harvesting (FUE)
Dr. James Harris presented a comprehensive review of the development of extraction harvesting (FUE) noting that the variety
[ page 16
15
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Hair Transplant Forum International
2013 ASM Review from page 15
of methods developed continue to be refined through ongoing individual and collaborative innovation. He emphasized that the “state
of the art” is not ONE thing… it’s not the fastest production, the
lowest transection rate, powered, manual, sharp, dull. It’s not one
device, one technique, or one surgeon… it is the sum of all these—
it’s the result of the collective effort viewed at a point in time.
He suggested that further advancements would be enhanced
by FUE surgeons worldwide collaborating in evidence-based
research. The FUE Research Committee formed by the Society
in 2012 will be an important vehicle for such research. The
committee has already created standardized terminology and a
literature database, and it will launch its first multicenter study
in early 2014.
Dr. Jose Lorenzo identified 10 components of state–of-theart extraction harvesting: proficiency with the method, proper
selection of punch size and cutting surface, extraction speed, time
out of body, maintaining intra-operative graft statistics, patient
selection, quality of donor hair, surgical strategy, and teamwork.
Dr. John Cole added that with transection rates now being
minimized with many different FUE approaches, the real focus
of state-of-the-art surgery is donor management and preservation.
Research Studies
Dr. Sara Wasserbauer analyzed the difference between FUE
and FUT grafts in her practice. She found that her FUE cases
contained a higher percentage of 3-hair FUs than her FUT cases.
Acknowledging that results might be different in other hands, she
has found this study to help her decide which type of procedure
would be best suited for each case. Dr. Michael Beehner reported
results of an ongoing study comparing the yield in FUE vs. FUT.
With two cases comparing test boxes, he is seeing lesser and more
variable growth rates in FUE graft growth rates than with FUT,
but he has not been able to come to any conclusions at this time
and is adding more cases. Dr. Cole found in 253 cases that in
measuring donor area cross-sectional trichometry (CST) before
and after FUT and FUE, donor hair mass is preserved more by
FUE. He also has found that the average donor area CST for his
patients was 68.9, which is lower than previously reported by
Drs. Bernie Cohen and Alan Bauman. Dr. James Harris used
CST to compare yields for FUT, conventional FUE, and robotic
FUE. Unfortunately, the hair mass in the test areas was not sufficiently large for reliable CST measurements and therefore no
conclusions could be reached.
Beyond FUT/ FUE
In an intriguing presentation, Dr. Carlos Wesley presented
his ongoing research and development of piloscopy, a form of
endoscopic harvesting of donor follicles. He demonstrated how
he has been harvesting hair grafts under the skin without any
of the punctate scarring associated with FUE or linear scarring
with strip harvesting. The technique promises the potential of a
truly scarless hair transplant
procedure and also carries the
potential for enhanced graft
yield because the stem cells
of the dermal papilla are optimally harvested (Figure 1).
Figure 1. Piloscope
16
January/February 2014
Jeff Donovan, MD, PhD Toronto, Ontario, Canada
[email protected]
Cicatricial Alopecia
Dr. Vera Price gave a
lecture entitled “Cicatricial Alopecia: What You
Should Know About the
Many Different Types.”
She began by reminding
us that in primary cicatricial alopecia, the hair
follicle is the primary Featured Guest Speaker Vera H. Price, MD, FRCP
target of destruction. The (C), speaking on Cicatricial Alopecia, alongside
panelist Gholami Abbasi, MD
clinical hallmark of all
scarring alopecias is loss of follicular markings or pores. One of
the key histological and cellular features of scarring alopecias is
inflammation and destruction of the sebaceous glands and stem
cells located in the bulge.
The cause of scarring alopecia is largely unknown. New
research suggests that perifollicular inflammation may be due to
lipid-metabolic changes in the sebaceous gland. In some scarring
alopecias, such as lichen planopilaris (LPP), frontal fibrosing
alopecia (FFA), and central centrifugal alopecia (CCCA), loss
of function of transcription factor PPARg may be contributory.
Dr. Price reminded us that at the present time, primary scarring alopecias are classified into three main groups: the lymphocytic group, the neutrophilic group, and the mixed group. The
lymphocytic grouping is by far the most common and includes
conditions such as LPP, FFA, and CCCA. The neutrophilic group
includes folliculitis decalvans and dissecting cellulitis.
Dr. Price advocates one or two 4mm punch biopsies for all
suspected cicatricial alopecias. A close relationship with the
dermatopathologist will help determine whether the patient has a
lymphocytic, neutrophilic, or mixed scarring alopecia. Dr. Price
cautions that dermatopathologists cannot reliably distinguish
various conditions within a grouping (i.e., lichen planopilaris vs.
central centrifugal cicatricial alopecia), and that clinical information is needed to help differentiate these conditions.
Treatment is administered with the goal to alleviate symptoms and signs, and to retard or slow progression. Regrowth of
scarring alopecias is not possible. Hair transplantation may be
considered if the condition is quiet, but Dr. Price cautions that
reactivation is possible months or years later.
Prior to hair transplantation, treatment with topical and/or
oral medications may be needed to bring the condition under
control. For some conditions, this may take many years. For
treatment of the predominantly lymphocytic group, immunomodulating agents are used including topical and injection of
steroids, and oral medications such as hydroxychloroquine,
doxycycline, mycophenolae mofetil, and cyclosporine. For the
predominantly neutrophilic/plamacytic group, treatment with
antimicrobials is required. For the mixed group, antimicrobials,
anti-inflammatories, and isotretinoin may be used.
Edwin S. Epstein, MD Virginia Beach, Virginia, USA
[email protected]
Post Finasteride Syndrome
The session opened with an audience response system
(ARS) survey about clinical experience with Post-Finasteride
Syndrome (PFS). 79% (87) reported in the past 12 months not
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Hair Transplant Forum International
seeing any cases in their practices of persistent sexual dysfunction after discontinuing alpha reductase inhibitors (ARIs);
18% (20) 1 to 2 cases; 1.8% (2) 3-5; and .91% (1) more than
5 cases. Among 111 responses, 78 had not seen any patients
with persistent sexual dysfunction after discontinuation of
AR in their practices prior to the last 12 months; 23–1 to 2
cases; 8–3 to 5 cases; and 2 more than 5 cases. The duration of
symptoms was not included in the survey. Experience varied
in the percentage of patients with persistent effects who also
had one or more concomitant conditions contributing to sexual
dysfunction with 38% reporting coexisting factor(s) present in
a majority of patients and 62% identifying such factors in less
than half of affected individuals. 65% expressed concerns about
reported persistent side effects after discontinuation of ARIs.
All participating in the survey reported having discussions of
risks and benefits when prescribing ARIs, and 16% include a
written information sheet and 22% use a signed consent form.
95% of responders continue to prescribe ARIs for androgenic
alopecia. Though informative, the value of this survey is limited
by the reality that it is not common medical practice to obtain
a detailed sexual history on all patients presenting for hair restoration surgery whether they are prescribed ARIs or not and
so the data collected by ARS response is biased.
Invited guest speaker Dr. Wayne Hellstrom gave an overview
of 5-alpha reductase
inhibitors (5-ARIs),
including indications,
benefits, prevalence
of side effects, risks
and benefits, critique
of adverse events data,
labeling changes, and
the post-finasteride Finasteride Symposium Panel with Featured Guest
syndrome. Finaste- Speaker, Wayne J.G. Hellstrom, MD, FACS, moderated
ride reduced the risk by Edwin S. Epstein, MD
January/February 2014
of prostate cancer by one
third, and while high-grade
prostate cancer was more
common in the finasteride
vs. control group, 18-year
follow-up had no difference in cancer survival
rates. The low incidence of
Gambino, MD leading a Coffee with
sexual side effects is well Vincenzo
the Experts table on Treating the Young Patient.
documented in controlled
studies, and although the prevalence may be higher than reported
in pre-clinical trials, it is also low. Post-marketing reports of
sexual side effects are likely real and may be under reported;
however, recent published studies identifying persistent side
effects have significant shortcomings and require validation
by well-designed studies. Nocebo effect and increased public
awareness/lawsuits may account for an increasing number of
reported sexual adverse events. Dr. Hellstrom projected that
further investigation of PFS will focus on neurosteroids.
Recipient Sites and Cosmesis
Dr. Bradley Wolf discussed the critical details of recipient
sites and graft placement. He emphasized precision in site depth
and size, and that the best healing occurs when graft epithelium
is left 0.5mm above the scalp surface. Dr. Tony Ruston used
several examples to demonstrate that it is not only the number
of grafts that are harvested, but also how they are distributed and
placed that results in the appearance of maximum density. Dr.
Jennifer Martinick demonstrated that although hair restoration
surgery appears “easy” to do, it is important to recognize the
subtleties, which take time to master, including technique and
planning of the surgery in order to ensure good cosmesis. And
Dr. Bertram Ng outlined his approach to extending or lowering
the female hairline, emphasizing the need to follow the flow of
existing hair in planning and graft placement.
Friday/October 25, 2013
Jerzy R. Kolasinski, MD, PhD Poznan, Poland
[email protected]
If you’re going to San Francisco
Be sure to wear some flowers in your hair
If you’re going to San Francisco
You’re sure to meet some gentle people there
—Scott McKenzie
We came to San Francisco, but there were no flowers in our
hair. We met a few old friends, many of whom could certainly
be called “gentle people,” and made new ones. And we all
were united by one passion—hair restoration surgery. Each day
brought insights into this area of study.
Morning Workshops
The morning workshops were organized by Dr. James Harris
and included the following:
Workshop 201: “Non-Androgenic Alopecias by Medical
and Surgical Super Specialists: When You Should and When
you Should Not Indicate Surgery for the Patients Who Do Want
Hair Transplantation.” Drs. Vera Price and Marcelo Pitchon
addressed the issue of when to perform surgery when a patient
requests hair transplantation, but the diagnosis is not androgenetic
alopecia. Hence, various methods of cicatricial alopecia and its
management were discussed. Indications and contraindications
of surgical management of alopecia were also presented.
Workshop 202: “Corrective Surgery and Strategies.” Dr.
Jerzy Kolasinski, focused on prevention and corrections of
complications of hair restoration surgery and cosmetic surgery.
Workshop 203: “Hair Design and Recipient Area Planning.”
Dr. Antonio Ruston, focused on the crucial issue of adequate
hairline planning, which is the most conspicuous hallmark of a
surgeon’s work. The lectures and video presentations demonstrated not only the principles of hairline planning, but also ways
to rectify past mistakes.
Workshop 204: “Body Hair FUE.” Dr. Alex Ginzburg pointed
out that chin and chest regions, as well as extremities, are all good
donor areas for hair transplants. Body Hair Transplant is now a
very good supplementation of classic hair transplant procedures
in which hair is collected from typical donor areas on the head.
The presentation discussed not only indications but also analyzed
technical aspects of the BHT technique.
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2013 ASM Review from page 17
General Session
The first session, “Anatomy and Basic Science,” was moderated by Dr. Damkerng Pathomvanich, host of next year’s Annual
Meeting in Bangkok. Dr. Rangsit Sittiwangkul demonstrated that
temporal and fronto-temporal points are angulated in shape in a
majority of individuals. The most commonly observed angles at
temporal and fronto-temporal points are 90° and 80°, respectively.
Dr. Bisanga, described how miniaturization negatively affects a
person’s donor area, effectively reducing the available donor hair
supply and decreasing the chances that a patient will be a candidate for hair transplantation. Ms. Sheida Abbasi demonstrated
that detailed knowledge of eyelash anatomy is crucial in HRS.
Eyelashes are structurally similar to scalp hair, but the follicle cycle
and pigmentation are markedly different, as well eyelid epidermis
thickness, the absence of a hypodermis, and the shortness of eyelash follicles. Dr. Antonio Ruston demonstrated how merely 200
to 300 follicular units on each side of the temporal points make an
enormous difference in appearance, with incision angle imitating
the existing hair angle, usually sharp and angled backward.
General Membership Business Meeting
Dr. Sharon Keene was elected vice-president of the ISHRS.
Next year she will take over the duties of ISHRS president Dr.
Vincenzo Gambino. Sincere thanks were expressed to retiring
president Dr. Carlos Puig, noting the increase in regional workshops and the subsequent improved prestige of ISHRS worldwide.
Norwood Lecture
Dr. Colin Jahoda, Professor at Durham University, U.K., gave the
Norwood Lecture, “Hair
Follicle Cloning, Regeneration, and Other Prospective Developments
for the Transplant Clinic:
Where Are We Now?”
Colin Jahoda, MD, PhD, Norwood Lecturer
He detailed the biological
constraints that limit “hair follicle cloning” using cultured follicle
dermal papilla cells, and outlined new frontiers for hair cloning.
In her “Highlights from the 7th World Congress for Hair
Research,” Dr. Nilofer Farjo, described the breadth of multidisciplinary research presented at the congress in Edinburgh, including
hair follicle attributes, genetic testing, and stem cell experimentation that may lead to new diagnostic and therapeutic modalities.
General Session I
Dr. Ken Williams moderated this session, “Advancing the
FUE Technique.” Dr. Georgios Zontos discussed the injection
of saline to minimize the injury of the donor area and accelerate
healing by making the follicular units more vertical, or by expanding the skin and reducing the amount of skin mass removed
by the punch. Dr. Juyong Kim, discussed methods to increase the
efficiency of FUE procedures for donors with problematic scalp
characteristics. Dr. Suneet Soni discussed “the safe donor zone,”
emphasized that mega sessions of FUE should be restricted to
lower grades of baldness with high donor density and should not
18
January/February 2014
be considered in patients
with higher grades of
baldness or with a strong
family history of baldness. Dr. Paul T. Rose,
outlined advantages of
using vacuum-assisted wound closure to
minimize FUE wound- Advancing the FUE Technique session, moderated by
site scars. Dr. Tejinder Ken Williams, DO
Bhatti detailed numerous instances of botched FUE procedures
to emphasize the importance of adequate HRS training. Dr. Anil
K. Garg described a prototype vacuum-assisted follicle extraction
device VAFED that notably reduces follicle transection.
General Session II
This session, “Enhancing
Donor Management in Strip
Harvesting,” was moderated
by Dr. Henrique Radwanski.
Dr. Bertram Ng noted that
immediate post-operative
steroid injection has no bearing on scar esthetics in the
donor area. Dr. Prapote Asawaworarit similarly noted that applying a low-dose ACE inhibitor (Enalapril) in the donor area did not
improve scar appearance. Dr. Parsa Mohebi showed that partial
trichophytic closure can improve overall appearance of the donor
scar in many patients. Dr. Wen-Yi Wu described the injection of
hyaluronidase to the donor area to increase scalp laxity, enhancing wound closure. Dr. Paul Rose described the use of liposomal
bipuvicaine in reducing post-operative discomfort, noting dangers
associated with lidocaine interaction.
Commentary
The training courses this year were very good, featuring
thoroughly prepared lectures. From the standpoint of someone
who has participated in ISHRS Annual Meetings since 1997,
though, this year’s contributions also included a few sub-standard
presentations. Yes, there were numerous presentations supplemented with valid material that might be classified as Grade 2
or 3, according to Evidence-Based Medicine (EBM) ratings,
however, there were also papers that compiled only to cursorily
present observations, not always supported by adequate data,
which at most might be classified as EBM Grade 5.
The choice of guest lecturers included a fascinating variety:
Dr. Cheng-Ming Chuong, Dr. Colin Jahoda, Dr. Vera Price and
Dr. Wayne Hellstrom. It has become a tradition to invite researchers to the ISHRS from areas indirectly related to hair restoration
surgery. These experts cast new light on issues of hair restoration
medicine in a broad sense. I would like to take the liberty of suggesting that in the future the subject matter of lectures include
more of these and fewer of the marginal HRS papers.
The international character of our meetings is most encouraging. The ISHRS includes growing numbers of participants from
countries in Asia, including China, India, and Korea. Looking
to the future, we can continue to grow globally while increasing the quality of conference presentations, thus enhancing the
reputation of our organization.
Hair Transplant Forum International
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January/February 2014
Saturday/October 26, 2013
David Josephitis, DO Bloomington, Minnesota, USA
[email protected]
Difficult Cases I
This panel, moderated by Dr. James Vogel, discussed unique
ways to handle some challenging cases. Dr. Jerry Cooley reviewed the case of a 50-year-old male undergoing a routine
hair transplant with platelet rich plasma (PRP). Thrombin was
inadvertently injected into the recipient area instead of tumescence, and the patient subsequently incurred necrosis in a small
part of the frontal zone. A possible treatment option would have
been to wait until the area scarred over and then to have added
new grafts. Instead, the necrosis was excised early on, the surrounding grafts grew normally, and the patient ultimately had a
good result. This case brings up the importance of good quality
control in the office in order to help prevent mistakes. Also, in
these situations, patients deserve honesty and a high level of
consideration and care while they undergo additional procedures.
Dr. Daniel Rousso presented the case of a 55-year-old female
with an oil burn to the scalp. A tissue expander was attempted
but failed secondary to a tight scalp and pain. Instead, a small
alopecia reduction was done as well as three sessions of 500
grafts each with the results providing a notable improvement for
the patient. Having strong relationships with your patients and
always having backup plans are keys to successful outcomes.
Finally, Dr. Alan Bauman presented a case that upholds the
notion that it is sometimes better not to perform a surgery at all
on certain patients. A 70-year-old female with poor donor and
diffuse loss, who had been treated in the past for alopecia areata,
requested HT. Instead of surgery, this patient received a combination of medical therapy with low level laser therapy (LLLT) and
a minoxidil formulation called 83M. She had excellent results.
Advances in Hair Biology
The guest speaker for
the 10th annual Advances
in Hair Biology lecture
was Dr. Cheng-Ming
Chuong from USC. He
discussed the ever-evolving topic of hair regeneration. Hair growth and
follicular regeneration is
extensively affected by its
external environment as
Cheng-Ming Chuong, MD, PhD, Advances in Hair
well as being determined Biology Lecturer
by the intrinsic character
and composition of the follicle. The surrounding dermal and
adipose tissues as well as other external factors such as puberty,
pregnancy, and aging can have a notable cascade effect upon hair
cycling and character. In the future, by modifying the external
environment, we may be able to improve hair growth and possibly induce follicular regeneration.
Dr. John Cole spoke specifically about hair follicle regeneration in the arena of FUE. He showed the possibility of follicle
regeneration in the donor region after FUE. He used a technique
of minimal depth FUE (2-2.5mm punch insertion) followed by
an application of porcine derived acellular matrix (ACell), and
sealing the sites with a heat activated polymer. He reported that
compared to his standard FUE technique, on average, there was a
48% increase in donor area follicle regrowth. He acknowledged
that some of the regrowth might have come from transected
follicles in the sites.
Dr. Jerry Cooley succinctly summarized all of the current
adjunct therapies including platelet rich plasma (PRP), acellular
matrix (ACell), HypoThermosol, and liposomal ATP, in what
has been called “bioenhancements,” a term coined by Dr. Robert True. Even though current hair transplant surgery is of such
high quality that we may think we don’t have to consider other
therapies, we all have had occasional surgery results that are less
than superior. In cases like those and others, bioenhancements
may help to improve our overall results.
Diagnostic Aids and Treatment Outcome Assessments
with a Focus on FPHL
Dr. Francisco Jimenez moderated this session focused on the
importance and utility of devices for diagnosing and treating female pattern hair loss (FPHL). It began with Dr. Russell Knudsen
discussing the use of a commercial device called the HairCheck
to measure the cross-sectional trichometry (CST). The device
was found to be very easy to use and gave reproducible CST
measurements. Benefits of using the device include assessing the
stability of hair loss in patients, quantifying their improvement in
density over time, and also using a measuring device in clinical
trials. Finally, the device clarifies for the patient their amount of
hair loss and assists in assessing the results of treatment.
Dr. Bernard Nusbaum talked about the challenges we all face
when trying to evaluate the efficacy of various medical treatments
for hair loss. A computer program called the FotoFinder helps
to standardize patients’ photos, and in doing so, helps to create
uniformity to better show patient improvement.
Another inexpensive tool that is often underutilized is the
dermatoscope. Dr. Alessandra Juliano discussed easy ways one
can evaluate hair loss in female patients and distinguish between
various diagnoses. Important benefits of using the dermatoscope
include its low cost, non-invasiveness, and the confidence it
can give both the patient and physician in making the correct
diagnosis.
Low level laser light therapy (LLLT) has been used for the
treatment of hair loss for many years despite a shortage of studies showing its effectiveness. Dr. Sara Wasserbauer spoke about
a study to determine the usefulness of LLLT by using CST to
measure its benefit. The preliminary results at 8 months showed
no clear trends comparing the study group with the control group.
Despite the lack of larger studies on LLLT, many hair surgeons
still recommend laser treatment for their patients as an option,
and they continue to have good results. Dr. Shelly Friedman
showed a number of impressive before-and-after photos over a
5-year period of patients who experienced both subjective and
objective improvements with LLLT. The primary benefit of LLT
is reversal of miniaturization.
[ page 20
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2013 ASM Review from page 19
Dr. Sharon Keene discussed the complex issues involved
in the diagnosis and treatment of women with hair loss. She
recommended a full lab panel for the majority of her female
patients in order to rule out any hormonal, thyroid, or vitamin
deficiency causes of hair loss. Androgens may also play a role
in some women's hair loss and testing for androgen sensitivity
may be helpful in creating treatment options.
Advanced Surgical Videos I
With Dr. Carlos Puig moderating, the first section of videos
demonstrated “FUT Donor Management.” Dr. Dae-young Kim
noted a change in up to 10 degrees in the angle of exiting hairs
from the top to the bottom of an excised area of donor strip. It
was noted that the use of a two-layer closure can possibly minimize the difference in this exit angle by straightening the hair
around the incision. An interesting concept for tight closure of
the donor was discussed by Dr. Ji-sup Ahn. The donor should
first be closed without any tension. In the remaining open area
of the defect, a sliver of donor tissue termed a “composite graft”
can be re-inserted and sutured into place, reducing the overall
amount of area needing to heal by secondary intention.
The final videos in this section dealt with “Improving Cosmesis.” Some physicians shave the recipient area to assist in
recipient site creation and graft placement but find that some of
their patients resist having this done. Dr. Sara Kotai revealed
that there are cultural and religious significances of cutting hair
for some patients, and she discussed her own technique to avoid
having to shave the head completely. One of the potential drawbacks of the FUE procedure is the need to completely shave the
donor area. Dr. Marco Barusco demonstrated an effective, albeit
time-consuming, method of strategically trimming the hairs of
selected FUs and then extracting grafts for FUE. No more than
1,000 grafts are extracted when using this method. Dr. Emre
Karadeniz discussed the importance of taking intra-operative
transection rates both early in the procedure and throughout
in order to make adjustments to the instrumentation or FUE
technique. This can help improve the extraction of grafts and
their overall quality.
Difficult Cases II
This session was also moderated by Dr. Jim Vogel. The first
case presented by Dr. Robert
Bernstein was a patient with a
scalp and facial burn and considerable scar tissue. A common
misconception in the community
has been that grafts don’t grow
Shelly Kabaker presenting during the
well in scar. The key to im- Dr.
Difficult Cases Panel.
provement in cases like these is
to take it slowly. Grafts will grow quite well as long as they are
staged appropriately and grafted over time.
Dr. Sheldon Kabaker discussed the case of a female hairline
placed too low. While it might have been an option to remove
some of these grafts by FUE and/or laser, this particular patient
wanted all of the grafts removed. An expander and galeotomy
was used in order to hasten the expansion process, and subsequently, all of the grafts were removed. These first two cases
20
January/February 2014
also showed that emotional
support is essential when caring
for these challenging patients.
In addition, as physicians, we
need to help guide our patients
in making educated decisions
about their care.
Another patient by Dr.
Russell Knudsen and Robert Bernstein
Bernstein was an elderly wom- Drs.
dialogue during the Difficult Cases II Panel,
an who presented shortly after chaired by Dr. James Vogel.
a small FUE case from another physician. Areas of irregular
alopecia around the transplants were biopsied and found to be
frontal fibrosing alopecia (FFA). Another patient who presented
after losing her transplanted hair was also found to have FFA
with biopsy. Both of these cases emphasize the importance of
understanding that patients may have more than one diagnosis
at a time.
Advanced Surgical Videos II
The second round of videos
moderated by Dr. John Cole included “Innovation in the Use of
Implanters and Improving Efficiency in FUE Procedures.” Implanter
use has risen over the years. Dr.
Jae Park discussed a method of us- Dr. Conradin von Albertini presenting
ing implanters to speed up the hair during the Advanced Surgical Videos
restoration process. With practice II session, chaired by Dr. John Cole.
and proper planning, 1,600 grafts or more can be placed in an
hour. He emphasized the key to this efficiency is maintaining
his focus on the patient’s scalp rather than having to look away
while he is handed the implanters.
Both Drs. Michael Vories and Conradin von Albertini demonstrated ways of doing large FUE sessions in a single day using a
motorized FUE and implanter pens. Finally, Dr. Kavish Chouhan
demonstrated the possibility of doing FUE gigasessions of 3,500
grafts or more in one day. The keys to these very large-sized
procedures include powered FUE, using a sharp punch, high
magnification, simultaneous extracting and placing, and rotation
of staff to prevent fatigue.
Live Patient Viewing
The close of the meeting as organized by Dr. Jerry Wong
was one of the meeting highlights with outstanding cases being
presented by Drs. Sara Wasserbauer, Jerry Wong, James Harris, Craig Ziering, Sheldon Kabaker, Parsa Mohebi, Michael
Beehner, Tejinder Bhatti, and Jerry Cooley.u
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Hair Transplant Forum International
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January/February 2014
2013 Annual Scientific Meeting Committee
Thank you to the 2013 Annual Scientific Meeting Committee
for a great conference!
2013 Annual Scientific
Meeting Committee
Robert H. True, MD, MPH, Chair
Paul J. McAndrews, MD,
Advanced/Board Review Course Chair
Bertram M. Ng, MBBS,
Advanced/Board Review Course Co-Chair
Jonathan L. Ballon, MD, Basics Course Chair
Samuel M. Lam, MD, Basics Course Co-Chair
James A. Harris, MD,
Workshops & Lunch Symposia Chair
2013 Annual Scientific Meeting Committee
(L to R) Bessam Farjo, Sara Wasserbauer (Local Liaison),
Robert True, Diana Carmona Baez, James Harris,
Sam Lam, Jon Ballon
Jerry Wong, MD, Live Patient Viewing Chair
Antonio Ruston, MD
Jerzy R. Kolasinski, MD, PhD
Francisco Jimenez, MD, Immediate Past-Chair
Diana Carmona Baez, Surgical Assistants Chair
Bessam K. Farjo, MBChB, Newcomers Program Chair
The many technicians who participated on the
Tissue Prep Team
THANK YOU to the 2013 Tissue Prep Team
and their Physicians!
Diana Carmona Baez of Dr. Timothy Carman’s office; Laura
Burdine of Dr. Robert Elliott’s office;
Carol Wade and Shannon Surgeson of Dr. Vance Elliott’s
office; Aileen Ullrich of Dr. Steven Gabel’s office;
Deanne Barron, Jessica Garner, Marcy Heasman,
Wilson Mendoza, and Kathryn Morgan of Dr. John Gillespie’s
office; Tina Lardner of Dr. Jim Harris’s office;
Emina Karamanovski of Dr. Sam Lam’s office; Dan Leach and
Kirsten Baetz of Dr. Bob Reese’s office;
Brooke Graham of Dr. Alison Tam’s office;
Laureen Gorham of Dr. Ken Washenik’s office.
Dr. Carlos Puig (R) congratulates Dr. Robert True (L) for his
efforts in chairing the 2013 Annual Scientific Meeting.
22
THANK YOU
to volunteer photographers
Dr. Bob Haber and
Dr. and Mrs. Kuniyoshi Yagyu!
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January/February 2014
ISHRS Leadership
October 23-26, 2013 • San Francisco, California, USA
ISHRS 2012-2013 Board of Governors
Front (L to R): Victoria Ceh-Executive Director, Kuniyoshi
Yagyu, Sharon Keene, Carlos Puig, Vincenzo Gambino,
Jennifer Martinick
Back (L to R): Arthur Tykocinski, Alex Ginzburg, Bernard
Nusbaum, Russell Knudsen, John Gillespie, Bessam Farjo,
Paul McAndrews, David Perez-Meza, Ken Washenik
Global Council of Hair Restoration Surgery Societies
Back (L to R): Kuniyoshi Yagyu (Japan, ISHRS), Kapil Dua
(AHRS-India), Sotaro Kurata (Japan), Akira Takeda (Japan),
James Harris (ABHRS), Robert Reese (ABHRS), Peter Canalia
(ABHRS), John Gillespie (Canada), Rajesh Rajput (AHRSIndia), Luis Ortega Peña (Iberic Latin American),
Jorge Gaviria (Iberic Latin American), Paul McAndrews
(ABHRS), Russell Knudsen (Australasian), Jerzy Kolasinski
(Polish), Akio Sato (Japan), Arthur Tykocinski (Brazilian),
Fernando Basto (Brazilian), Francisco Le Voci (Brazilian)
Front (L to R): Victoria Ceh (ISHRS), Greg Williams
(BAHRS), Andrea Marliani-guest (Italy-SiTri),
Pietro Lorenzetti (Italy), Franco Buttafarro (Italy),
Vincenzo Gambino (Italy, ISHRS), Carlos Puig (ISHRS),
Bessam Farjo (British, ISHRS Ambassador),
Jennifer Martinick (Australasian), Nilofer Farjo (British,
Forum Editor), William Parsley (ISHRS Ambassador),
Ricardo Lemos (Brazilian)
ISHRS Past Presidents
(L to R) Jennifer Martinick, Robert Haber, Robert Leonard,
Paul Rose, Russell Knudsen, Bessam Farjo, Edwin Epstein
ISHRS 2012-2013 Executive Committee
(L to R) Jennifer Martinick (Immediate Past-President),
Vincenzo Gambino (Vice President), Carlos Puig (President),
Sharon Keene (Treasurer), Kuniyoshi Yagyu (Treasurer)
ISHRS Meeting Staff
(L to R) Matt Batt (Integrated Communications Manager),
Melanie Stancampiano (Program Manager), Victoria Ceh
(Executive Director), Jule Uddfolk (Meeting & Exhibits
Manager), Amy Hein (Meeting Planner), Katie Masini
(Registrar), Sue Reed (Registrar),
Kimberly Miller (HQ & Administrative Manager)
23
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Hair Transplant Forum International
January/February 2014
2013 ISHRS Research Grant Recipients
Development and Validation
of Patient-Reported Outcome
Measurement Questionnaire
after Hair Restoration
Surgery
Sang W. Kim, MD
(Not pictured)
FUE and Strip Graft Harvest Survival
Study
James A. Harris, MD
A Pilot Study, Evaluator Blind- Results
of Scalp Micropigmentation Tattoo for
Treatment of Female Pattern Hair Loss
Adipose Derived Stem
Cell Applied on Hair
Transplantation Surgery
Federica Zanzottera, MSc
(Not pictured)
Rattapon Thuangtong, MD
2013 ISHRS Poster Awards
1st Place
Restoration of Hair-Inducing Capacity of Cultured
Human Dermal Papilla Cells by Three Dimensional
Spheroid Culture
Moonkyu Kim, MD, PhD
2nd Place
Hair Removal Laser for Creating Fine Hairs
Jae Yoon Jung, MD
Hair Removal Laser for Creating Fine Hairs
Jae Yoon Jung , 2Hyun Sun Park, 2Jin Yong Kim, 1Wonseok Han, Jee Soo Ahn, Kyle K. Seo
Modelo Clinic,
1Hanhui
Clinic ,2Department of Dermatology, Seoul National University Boramae Hospital, Seoul, Korea
(A)
Introduction
(B)
 Conventional hair transplantation
 Use the thickest diameter hairs from the occipital scalp
 Asian females: thicker hairs compared to Caucasian or African
 Unnatural hairline and necessitates a special technique to create fine hairs in Asian females
 A few surgical methods to make natural hairline
 Grafting of bisected hair follicles
 Follicular unit transplantation of body or leg hairs
Fig. 1 (a) A factitious hairline after HCHT in an Asian woman with thick donor hairs (b A more
 Refined hairline correction technique: sorting one-hair follicular unit with small diameter
natural hairline after revision by creating fine hairs with HRL (long-pulse Nd:YAG)
from the occipital strip-excision and transplanting them in the front-most hairline.
(A)
(B)
 Limitation: poor yield, longer operation time, need for higher skill, variations in hair
angulation or quality, and lack of sufficient body hair
 Few studies upon a non-surgical revisionary method to improve an unnatural foremost
hairline with thick donor hairs after hair transplantation for hairline correction (HTHC)
Objective
Fig. 2 Another patient. (a) A factitious hairline after HCHT in an Asian woman with thick donor
Investigation of the efficacy and safety of creating fine hairs with hair
hairs (b) A more natural hairline after revision by creating fine hairs with HRL
removal laser (HRL) in Asian females with thick donor hairs
 Change of hair diameter
 Mean hair diameter: 80.0 11.5m(before procedures)  58.4 13.2m (after procedures:
Materials & methods
measured mean 6.3 months (range 3-14 months) after the last session) (P=0.00)
 Mean reduction rate of hair diameter: -25.7%. (from -44.6 to 5.7)
101 patients received HRL screened
77 patients failed to meet inclusion criteria
 A number of laser sessions and hair diameter after procedure: negative correlation. (r=-0.410,
Female pattern hair loss (n=6)
P=0.046)
Treated with HRL other than long-pulse
 Patients treated with single session: median post-laser diameter of 69.6m (n=6)
Nd:YAG (n=3)
24 patients met the criteria
 Two sessions 55.8 m (n=14), more than three 50.8m (n=4).
Data was not sufficient (n=68)
 Median of reduction rate of a hair diameter according to the number of laser procedures
showed the same tendency, 18.0%, 27.6%, and 30.5%.
Retrospective chart review
Age
Parameter of HRL
Hair diameter measured by a micrometer
(Mitutoyo®, Kawasaki, Japan) before and after
procedures
Number of procedures
Subjective assessment of treatment
Adverse effects
(B)
(A)
Fig. 3 (A) An example of fine hairs created with HRL. The fine hairs were used for eyebrow hair
transplantation. (B) Statistically significant reduction of hair diameter after laser treatment. (*P <
0.05 by paired t-test )
 Adverse effects
 Acute adverse reactions: erythema or swelling - most of the patients. tolerable and transient.
 Chronic adverse reactions: folliculitis (n=1), focal alopecia (n=1). no HRL-associated
chronic adverse effects. (n=22)
Results
Discussion and conclusion
 Basic information
 mean age of 28.8
5.4 years (range 22-45)
 donor hairs for HTHC were acquired from strips of occipital scalp and one-hair
follicular units were transplanted in the foremost hairline.
 They were generally satisfied with previous HTHC but wanted to improve the thick
hairs of the foremost hairline
 Laser treatment procedure to create fine hairs
 A long-pulse Nd:YAG laser (Coolglide®, San Francisco, California, USA)
 Initial procedure: at least 5 months after HTHC (mean 15.7 months, range 5-36 months).
 Treated area: foremost anterior two to three rows of hairline
 Treatment parameters: fluence 35 ~36J/cm2; pulse duration 6 ms; spot size 10mm
 Mean number of laser sessions were 2.6 (range, 1 to 5 times)
 Laser treatment interval: 3-month to check regrowth of hairs
24
 HRL using long-pulse Nd:YAG can create fine hairs in Asian female patients with
thick donor hairs.
It can be a useful alternative method when the patients do not want additional
surgery to revise their hairline formed by previous conventional HTHC.
It can reduce the diameter of foremost hairs and increase patient satisfaction of
HTHC. The limitation of this study includes the retrospective and uncontrolled nature
of the study without long-term follow up data.
References
1. Swinehart JM. "Cloned" hairlines: the use of bisected hair follicles to create finer hairlines.
Dermatol Surg 2001;27:868-72.
2. Jones R. Body hair transplant into wide donor scar. Dermatol Surg 2008;34:357.
Best Practical Tip
A New Ergonomic Microscope for Hair Transplantation
Robert S. Haber, MD
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Hair Transplant Forum International
January/February 2014
2013 Awards
2013 Golden Follicle Award
For outstanding and significant clinical
contributions related to hair restoration
surgery.
John P. Cole, MD
2013 Distinguished
Assistant Award
Presented to a surgical assistant for
exemplary service and outstanding
accomplishments in the field of hair
restoration surgery
Ailene Russell, NCMA
2013 Platinum Follicle Award
For outstanding achievement in basic
scientific or clinically-related research in hair
pathophysiology or anatomy as it relates to
hair restoration
Sharon Keene, MD
Forum Editors
Dr. Nilofer Farjo, and Dr. Carlos Puig on
behalf of Dr. William Reed, accept awards as
outgoing Forum Editors, term 2011-2013.
Nilofer P. Farjo, MBChB &
William H. Reed, II, MD
THANK YOU TO OUR SPONSORS
We gratefully acknowledge the Corporate Supporters of the meeting!
Bosley • Restoration Robotics • A to Z Surgical
Cole Instruments • Ellis Instruments • HSC Development
Micro-Vid • Q-Optics • Robbins Instruments
25
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Hair Transplant Forum International
January/February 2014
2013 Recognition
Officer and Outgoing Board Members
Dr. Carlos Puig accepts the president’s
award and pin from Immediate PastPresident, Dr. Jennifer Martinick.
Dr. Vincenzo Gambino accepts a plaque
for service as Vice President.
Dr. John Gillespie and Dr. Bernard
Nusbaum accept awards for service on
the ISHRS Board of Governors,
terms 2007-2013.
Dr. Sharon Keene accepts
a plaque for service as
Treasurer for the past two
years.
An appreciation pen is presented to
past-president Dr. Russell Knudsen for
service on the ISHRS
Board of Governors.
Congratulations to the Daily
Evaluation Winners!
The following were randomly selected as the winners
of the daily evaluation incentive prize drawings! Each
winner received $100 off of an upcoming ISHRS annual
meeting.
Last Man Standing Club:
Attended All 21 Meetings!
The following members were acknowledged as having
attended all 21 ISHRS Annual Scientific Meetings:
(L to R) Mario Marzola, Paul Straub, Russell Knudsen,
Bob Haber, Paul Cotterill, Ivan Cohen, John Gillespie,
Bessam Farjo, Ed Epstein, and
not in photo: Ed Griffin, Bob Leonard
26
Thursday: Katsumi Ebisawa MD, PhD
Friday: Jorge Salazar, MD
Saturday: Truett Bridges, MD
The online Overall Evaluation winner received $250 off
of the 2014 Bangkok, Thailand Annual Meeting!
Overall Eval: Carlos Buenrostro, MD
Thank you to everyone who completed the evaluations.
We appreciate your feedback and suggestions so we
can continue to improve the Annual Scientific Meeting.
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January/February 2014
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Hair Transplant Forum International
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January/February 2014
Recorded Session from 2013 San Francisco
Annual Scientific Meeting Now Available
We recorded one session that we thought the membership would find interesting.
The recordings are available for viewing exclusively to ISHRS Members until April 1, 2014.
Access the video links via the Members Only section at www.ishrs.org.
Lunch Symposium 213: New Interventions That Can Improve Outcomes of
Hair Transplant Surgery
Presented on Friday/October 25, 2013, 12:00noon–2:00pm
Moderator: Francisco Jimenez, MD
Learning objectives:
• Describe the influence of holding solutions in hair graft survival. Evaluate the characteristics of the different holding solutions currently used in HRS. Discuss new substances under
investigation that may increase graft survival or accelerate hair graft growth.
• Discuss the published scientific evidence for the use of PRP in hair loss disorders. Describe how to prepare PRP, how
to inject it, and its usefulness in HRS.
• Describe the indications and method of application of porcine-derived extracellular matrix product in HRS.
• Formulate ideas for a future possible role of adipose-derived stem cells in hair loss therapy and HRS.
Factors Affecting Growth: Personal Perspective
12:33 running time
Jerry E. Cooley, MD
Different Graft Storage Solutions Currently Available
for Hair Transplant Use: A Comparison
14:14 running time
Aby Mathew, PhD
What’s the Future in Tissue Preservation?
9:21 running time
William D. Ehringer, PhD
28
Getting Started with PRP in a Hair Transplant Clinic
7:13 running time
Robert P. Niedbalski, DO
Platelet Rich Plasma: Does It Really Increase
Hair Growth? Where Is the data?
29:07 running time
Francisco Jimenez, MD
Follicle Regeneration with ACell
6:59 running time
John P. Cole, MD
Adipose Derived Mesenchymal Stem
Cell
8:31 running time
Mario Marzola, MBBS
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January/February 2014
Message from the 2014 Annual Scientific Meeting
Program Chair
Damkerng Pathomvanich, MD Bangkok, Thailand [email protected]
We had a successful meeting at the
ISHRS 21st Annual Scientific Meeting in
San Francisco. The attendance was at an
all-time high, and I wish the next meeting
in Bangkok will be even more, so please
mark the date on your calendar to attend
November 12-15, 2014. Recently, I returned
from India where I attended the AAHRS
2013 & HAIRCON 2013 Annual Scientific
Meeting. Over 200 physicians attended and
I was reassured that those who have been in
practice many years will attend the Bangkok meeting. The attendees from Asia have increased yearly, and I believe we will
see an even greater increase at the Bangkok meeting since it is
very close to the neighboring Asian countries and there is easy
access to visas to enter Thailand, which is an affordable worldfamous tourist destination for shopping, sightseeing, and dining.
Hair restoration techniques have changed gradually. Next
year’s meeting will “reflect for ultimation and evaluate the current and new trends in Hair Restoration Surgery for optimum
outcomes.” Newcomers will learn more from the Basics Course.
For the experienced surgeons, there are the Advance Course and
General Scientific Sessions. You will be happy to see unexpected
old friends, and of
course, get to know
new friends. We are
in the process of
planning a day-by-day schedule that will
offer topics that are of interest to everyone
plus research and advance in new technology in the field of hair restoration surgery.
I invite everyone to submit an abstract.
All the abstracts will be rated blindly by
the Scientific Meeting Committee. If your
abstract is selected for oral or video presentation, then you must
send in PowerPoint (PPT)/video at least 6 weeks prior to the
meeting to ensure that both the quality of the presentation and
the learning objectives are being met. If your abstract is selected
as a poster, then you need to send in a PPT presentation (or
described format to be listed later) instead of the paper poster
because we will have e-posters this year.
This is our annual meeting, and I hope you will enhance
your knowledge by attending the meeting. Please bring along
your assistants so that they may attend the Surgical Assistants
Program meeting, and also bring your family to enjoy Bangkok,
one of the best destinations in the world to visit!u
Message from the 2014 Surgical Assistants Program
Aileen Ullrich Hillsboro, Oregon, USA [email protected]
This year’s annual scientific meeting will
educational opportube held in Bangkok, Thailand, one of the
nity for all levels of
world’s top tourist destinations. This will be
experience. Hence,
an opportunity to enjoy the city’s rich culture
if there are any speand history with our colleagues and friends,
cific topics that you
expand our knowledge, share insights and
would like to have
techniques, and to learn of new developments
covered, please let me know. I want to hear
within the field of hair restoration.
your suggestions, ideas, and comments so we
I am honored to be your 2014 Surgical As- Photo from the Surgical Assistants Workshop at the can do our best to incorporate them into the
sistants Chair. It was only a few short weeks 2013 Annual Scientific Meeting in San Francisco. program. Additionally, if you are interested
ago that we all gathered in San Francisco for the 2013 Program, in presenting at the meeting, I want to hear from you as well.
which from the feedback I have received, was a great success.
You can contact me at [email protected].
We are currently in the planning phase of our surgical
I look forward to hearing from you!u
assistant’s 2014 program. Our goal is to provide a valuable,
29
Hair Transplant Forum International
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January/February 2014
Regional Societies Profiles
Your new editors strongly believe in the International aspect
of ISHRS. To this end, we have introduced this new column to
highlight the various Hair Societies around the world, one society
per issue. We take a lead from the ethos of our Global Council
of Hair Restoration Surgery, listed below:
Benefits of a National Society
1.
2.
3.
4.
5.
6.
7.
8.
Bring awareness of one another.
Less denigration.
Share knowledge, exchange ideas.
Speak with an organized voice.
Handle challenges (e.g., dentists, artificial fibres, etc.).
Provide education/certification of new members.
Maintain a culture of CME in that country.
Deal with practitioners of clinics who continuously produce
bad work.
9. Host national or international conferences and live surgery
workshops to continuously raise standards.
10. Support live surgery workshops in less developed HRS
countries.
11. Help to set up national societies in new countries.
Benefits of the Global Council to National Societies
1. Share experiences; for example, One national society may
have solved a problem facing another national society.
2. Help to regulate the calendar of yearly meetings to coordinate and avoid clashes.
3. Publish in the Forum on national society meetings
4. Provide a uniform educational and certification system
5. Offer strength in numbers for negotiations with other medical
societies and government bodies (e.g., restrictions of practice)
We believe that all these points are valuable for experienced and
new societies alike. Sharing our hair restoration surgery experiences
will help to bring together individual members of each society, as
well as the societies of each country. When we start our hair restoration career and know no one, or very few people, it is easy to think
of our established colleagues as simply opposition and view them
negatively. However, as we get to know them, we usually find the
opposite to be true. Often, they become our friends and mentors.
Below we highlight the Italian Society of Hair Restoration
(ISHR) in this short interview with its president, Dr. Franco
Buttafarro (FB).
Italian Society of Hair Restoration (ISHR)
Q: Dr. Buttafarro you are the 13th President
of ISHR, can you tell us about your society?
FB: It began in Rome in 1994 at the time of
great changes in hair restoration. Scalp reductions were still popular and grafts were getting
smaller all the time. Microscopes and follicular
units were new. There was a lot of interest in hair restoration in
Italy amongst the public, but medical advertising was not allowed
so we had a lot of issues. Forming a society was the best thing
we ever did, for all the good reasons mentioned above, especially
bringing the doctors together. To join the ISHR, 2 years’ experience in hair restoration is needed. Currently, we have 44 members.
Q: Who are the other office holders?
FB: Pietro Lorenzetti is the incoming President, Marco Toscani is Past-President, Ciro De Sio is Treasurer, and the rest of
the Board Members are Vincenzo Gambino, Piero Tesauro, Luigi
Belliazzi and Michele Roberto Arbiter. Of course, we are very
proud of Dr. Gambino, who is the current president of ISHRS.
Q: How often do you have meetings and workshops?
FB: Almost every year. In 20 years, we have had 15 meetings, congresses, or workshops. We have benefited from many
international experts attending our meetings. Martin Unger, Bob
Leonard, Ron Shapiro, Anthony Mollura, Joe Greco, Patrick Rabineau, and Pierre Bouhanna to name a few, but there were many
others. It’s been absolutely crucial having this input as it helped
to raise our standards quickly to the point where our members
now frequently present at national and international meetings.
Q: Are there any restrictions in advertising?
FB: No this changed in 2005, but we have untrue or exaggerated advertising as the new problem. We have many new
30
practitioners from dental, gynecological, orthopedic, and aesthetic and other backgrounds
entering the field with lots of advertising and
little training. We are worried that all the hard
work in raising standards and outcomes in the
last 20 years in Italy is at risk. However, the
market is increasing so all will be well if we rise to the challenge
of maintaining our standards.
Q: FUT, FUE, robots, independent techs in Italy?
FB: Still about 70% of operations are FUT and 30% are FUE.
Some doctors are offering large numbers of grafts per sitting, but
these are still short of the super giga sessions offered elsewhere. I
believe there is one ARTAS robot in Italy now, but no NeoGraft
machines. However, there’s no doubt this will grow in the future
as in other parts of the world. There are a few independent techs,
but not many at this time.
Q: Is PRP popular?
FB: Yes. It has been used in Italy for five years, but there
seems to be little benefit.
Q: What could ISHRS do to help ISHR?
FB: The ISHRS could continue the excellent leadership,
have more ISHRS members attend our meetings and have more
ISHRS regional workshops (in Italy, of course).
Q: When is your next meeting?
FB: Our next meeting is in Syracuse (Sicily), 26-29 June
2014, hosted by Franco Buttafarro and Pietro Lorenzetti. See
you there!u
Hair Transplant Forum International
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January/February 2014
Hair’s the Question*
Sara Wasserbauer, MD Walnut Creek, California, USA [email protected]
*The questions presented by the author are not taken from the ABHRS item pool and accordingly will not be found on the ABHRS Certifying Examination.
After helping about 50 talented beginning surgeons learn at the “Recipient Sites” station in the Basics
Course at the San Francisco ISHRS meeting, I have realized that after the first few hundred surgeries, the
art of making recipient sites gets taken for granted. As most teachers will tell you, the young talent in the
room taught me more than I taught them. With their revelations in mind, here is a review of the important
BASIC concepts of what is a very complex topic: recipient site creation in the frontal scalp area. If you are
a beginner (or just want a refresher), this question set is for you!
Recipient Sites: BASIC Questions
1. The three MAIN variables for a recipient site are:
A. Angle (to the scalp), direction, size
B. Direction, shape (curved or flat slits—especially important with curly hair), and depth of site incision
C. Pitch ( rotation), coronal versus sagittal orientation, size
D. Size, angle, and proximity to its neighbor site
7. In general, the number of FUs per cm2 that provides enough
density for most patients is:
A. 20-30 FU/cm2
B. 30-45 FU/cm2
C. 90-100 FU/cm2
D. 10-20 FU/cm2
2. Outer diameter of a 19G needle is:
A. 0.75mm
C. 1.07mm
B. 1.0mm
D. 1.5mm
8. In studies of recipient-site density, which of the following
consistently has the highest survival rates?
A. 10 and 20 FU/cm2
B. 20 FU/cm2
C. 30 FU/cm2
D. 35-45 FU/cm2
3. Outer diameter of a 20G needle is:
A. 0.8mm
C. 0.91mm
B. 1.0mm
D. 0.75mm
4. In order to compensate for the growth of the grafts, recipient
sites should be created:
A. At a 50° down angle from the desired angle of growth
B. At a 15° down angle from the desired angle of growth
C. Precisely parallel to the desired angle of growth (i.e.,
matched angle to the existing hair)
D. At a slightly higher angle than the existing hair
5. This bent needle is used to make recipient sites and will be
helpful in which of the following ways?
A. Correct direction and angulation of the implanted graft
B. Reducing hand fatigue for the surgeon due to the superior ergonomics of the bent needle
C. Limiting the depth of the incision site in order to minimize damage to the vascular bed
D. This needle would not be helpful and was probably
dropped, thus creating the angle.
6. Coronal incisions refers to sites that are:
A. Made parallel to the direction of the hair growth
B. Made only in the crown (hence the name “coronal”) in
a whorl pattern
C. At lower risk for cutting the native hair growth
beneath the surface of the skin and should thus be
avoided in restoring temporal points
D. Made perpendicular to the direction of hair growth and
can result in precise hair direction and angle control.
9. Which of the following is the best tool for making recipient
sites?
A. 0.75-1.2mm Minde (minimum depth) site making
tools (either angled 45° or chisel)
B. Chisel blades cut to size (0.5-1.0mm) from Personna
prep blades
C. SP 89, 90, and 91 spear point blades
D. 18-, 19-, and 20-gauge needles
10.When in doubt for a recipient site’s direction:
A. Create a hairline that splays at the sides (i.e., a radial
pattern)
B. Match the direction of the existing hair, but if no hair
exists or if the hair is small in diameter and likely to be
lost with continued androgenetic alopecia, opt for an
anterior facing direction (i.e., facing forward)
C. Anterior facing direction only
D. Rightward flow starting at the frontal forelock
Bonus Question:
11.In order to obtain maximum density, recipient sites should be:
A. Staggered
B. Linear
C. Scattered randomly and then
filled in with a smaller diameter
site-making tool
D. Placed using implanter pens or similar devices
[ Answers on page 32
31
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Hair’s the Question from page 31
Answers
1. A. This is most fundamental to a beginner’s understanding
of this process. If you get these three right, you have a good
chance at giving your patient a reasonable result. However,
ALL of the variables listed are important considerations.
2. C. If you are using needles for making your recipient sites,
you need to know this kind of information in order to match
your sites to the graft size. There is a great resource for this
kind of information on the web at http://www.sigmaaldrich.
com/chemistry/stockroom-reagents/learning-center/technicallibrary/needle-gauge-chart.html.
3. C. I just did this to check if you went to the site I referenced
in the last answer…. Actually knowing the size of the sites that
you are making and taking the time to tailor them to the grafts
is an integral part of a good hair transplant. For beginners, this
is a habit that should be cultivated.
4. B. Hairs tend to lift as they grow in!
5. C. The needle was NOT dropped (and if it were, would you
be using it?). Attention to direction and angulation is still
needed when using this little trick, however, because if you
do not monitor your direction, you might end up making the
sites parallel to the shaft of the needle instead of the tip that
is making the site! In particular, if the bends are not made at
precisely 90 degree angles, this will introduce small variations
into your recipient sites and the grafts will grow in an unintended direction.
The best way to reduce hand fatigue is to use larger diameter holding mechanisms for whatever recipient-site-making
tool you are using. Dentists deal with this same problem all
the time, and there is a great online resource at http://www.
ada.org/sections/educationAndCareers/pdfs/ergonomics.pdf.
Check out the suggestions at the top of page 3, they are the
most relevant to a hair surgeon.
6. D. Though D is correct, keep in mind that there is a higher
risk of transecting native hair beneath the skin surface when
compared to sagittal incisions (which are made parallel to the
direction of the hair growth.) For this reason, coronal incisions
should be created with care, especially if you are just starting
your hair transplantation career. Situations that respond very
well to coronal incisions are 1) transplanting into scars and 2)
for restoring areas with very sharp angulations (like temporal
points or sideburns).
7. B. Argue as much as you want (and as hair surgeons, our
arguments are more entertaining than most), but when you
review the last decade or so of all that has been written by the
most experienced surgeons in our field, this is the range that
consistently appears.
8. A. And this is the real crux of the matter, isn’t it? You try to
make the recipient sites as dense as possible for good results
for the patient (see the answer in the last question), but studies
have shown that 10-20 FU/cm2 has 97% and 94% survival
(and here I am referring to many reports but specifically the
2002 Live Surgery Workshop as reported at the Puerto Vallarta
ISHRS meeting). There are those who have obtained excellent growth with more FUs per cm2, but the preponderance
of the data seems NOT to favor dense packing as a method of
assuring high graft survival rates, and the question was about
survival rates.
32
January/February 2014
9. Trick question! You cannot answer this question for anyone
but yourself. I have used all of them to good effect and in the
final analysis; my advice to the newbies out there is to pick
your own favorite and make the sites as small as you can while
still fitting chubby grafts into them.
10. B. This is the generally accepted best practice. The sunburst or
radial pattern has the tendency to create “parts” and separate
artificially. Many frontal areas will have a rightward flow, and
anterior facing hair will have superior coverage because it will
hang below the hairline if it has any length to it. However,
when in doubt, the strategy detailed in answer B contains the
best guidelines to follow.
11. A (with credit for D as well). This question is in the quiz mainly
to make readers think about how they make their sites. What
is the best way? Implanter pens (answer D) MAY be the best,
and in some surgeon’s hands they are certainly superior to
my own technique! If you make sites by scattering randomly
and then reviewing, there may be gaps where you could have
fit more sites that cannot be filled. Linearly placed recipient
sites run the risk of connecting and forming a bigger site than
intended (like a “slot graft site”), which is not optimal.u
State-of-the-art
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January/February 2014
In fond memory
Dr. Neil F. McLeod
In our specialty, some surgeons make a big “splash” in a
short time and rapidly fade from view. Others make subtle
changes that remain with us for decades without their contribution being fully appreciated.
So it was with Neil Francis McLeod who was born in New
Zealand on 9th November 1926 and died of cancer on 28th
December 2013. He worked as a successful GP in Christchurch
for 20 years until, after having a hair transplant for his type VI
baldness around 1971, he started performing the procedure
himself. In March 1975, after the tragic death in a plane crash of
his teacher and mentor, Dr. Tom Pirotta, Neil bought his practice
and became a full-time HT practitioner in New Zealand and
Australia, where I was his main competitor in those early days.
During this period, Neil, a fine classical pianist and a
perfectionist by nature, was constantly trying to improve the
techniques of the old 4mm plug operation. As a patient himself,
he had quickly realized that pre-medication was far superior
to “cold-turkey,” and he convinced me to administer 5mgm
of intravenous diazepam to my patients prior to surgery. I
was impressed, and it became standard practice in Australia
as more surgeons entered the field. When midazolam, with its
much shorter half-life, became available in 1985, we changed
to that drug. This required routine pulse-oximetry to avoid the
potential hazard of respiratory depression.
Neil was quick to realize the advantages of the Australian
carbon steel punches, and understanding that they had to be
kept razor sharp, he devised a do-it-yourself (DIY) apparatus
for doing this at his office. Neil described his sharpening techniques on pages 267-274 in Hair Transplant Surgery, 2nd Ed.
by Norwood & Shiell (published by Charles C Thomas, 1984).
These techniques were used by many offices throughout the
world until punches were supplanted by grafts dissected from
scalpel-cut strips in the early 1990s. For those surgeons having trouble keeping FUE punches sharp, his chapter could be
revisited or reprinted.
Neil’s greatest contribution to our profession was probably
as mentor to our esteemed former ISHRS President, Dr. Mario
Marzola (Golden Follicle Awardee and now Co-editor of the
Forum). He was deservedly proud of the achievements of his
former pupil who, like Neil, claims to have been “in love with
his work” since his very first case over 30 years ago.
The loss of his wife Mary to cancer in 2001 was a great
blow to Neil, but he carried on working part-time with one assistant for a few more years, finally retiring in 2005 at age 79.
He maintained a multitude of intellectual interests and played
Chopin and Bach on his Steinway grand piano, until near the
end in 2013. He leaves five children and many grandchildren.
The few of us who knew him well and loved his gentle
nature and giant intellect will miss him greatly.
Richard C. Shiell, MBBS
Melbourne, Australia
33
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January/February 2014
Cyberspace Chat
John P. Cole, MD Alpharetta, Georgia, USA [email protected], and
Bradley R. Wolf, MD, Cincinnati, Ohio, USA [email protected]
John P. Cole
Bradley R. Wolf
To Dye or Not to Dye
Dyes, including gentian violet and methylene blue, have been
used during hair transplant surgery for staining to facilitate microscopic dissection, recipient site creation, and graft placement. In
patients with darkly pigmented skin, recipient incisions may be
seen easier for graft placement after staining the recipient skin.
Staining white or non-pigmented hair during strip dissection may
help visualize the follicles and reduce transection. Staining the
external shafts of white or non-pigmented hair can make them
easier to visualize during the procedure.
In an internet communication, Melvin Mayer asked:
Are any of you aware of studies that have been done to evaluate graft production staining sites with gentian violet? Living in
San Diego, I have many darker skinned patients. We are also
using smaller recipient sites. These factors have led me along
with my staff to use more staining. I don't think it is affecting
my production, but occasionally a patient comes back not getting
the production I would expect and I wonder if the staining has
had a negative effect.
Bradley Wolf replied:
If you are experienced at placing and use high magnification
(4.0 or greater), there is no need for staining. A slight alteration
in the scalp surface, lack of resistance to the tip of the forceps,
and knowledge of the incision pattern show you where the incisions are and aren't. I've never used any staining.
John Cole reported:
I agree with Brad Wolf. I believe that with high power magnification, staining the recipient sites is unnecessary for graft
placing. I've never used any staining.
Bob Haber added:
I’ve been using 1% methylene blue in almost all my cases for
several years. Occasionally, I use 5%. We generally enjoy excellent growth, so the occasional case of less than optimal growth I
do not feel is related to the use of the stain. I used gentian violet
for a year or so before switching to the methylene blue. While
my staff appreciates the improved visibility of the sites with the
stain, I find that applying stain when I have 500 or so sites left
to make reveals many small gaps in my pattern, and allows me
to refine my sites. I will then reapply the stain after all sites are
made. I'm not aware of any studies looking at toxicity.
Bessam Farjo, Michael Beehner, Paul Rose, and Bob True
added:
Bessam Farjo: I agree with Bob and share the same experience. Without a doubt, it speeds up the placing. I believe its
gentian violet rather than methylene blue that has toxicity question marks against it.
Michael Beehner: I've done around 30 cases with gentian
violet, usually the full strength, and have had no problems
with poor growth. I've used methylene blue around the same
34
number of times and again no problems. I dilute it usually 1:1
with saline.
Paul Rose: I would think that the gentian violet is toxic. It
is used as an antiseptic. We use the methylene blue, as does Dr.
Haber.
Bob True: I also use methylene blue, but only in very dark
skinned patients. I have not observed this to reduce yield. Typically, the stain is washed away completely with spraying during the procedure. I use gentian violet rarely to control donor
incision oozing.
Melvin Mayer followed up:
What I have been using is 1% gentian violet. I also use 2
drops in 30cc normal saline and place the “white hair” slivers in
it. My techs think this is very helpful identifying the white hair.
I also, as many of you do, dye the hair dark brown or black to
better identify the external portion of the hair. Most seem to use
methylene blue and I am going to switch because of occasional
questionable production with gentian violet. It seems that none
of us are aware of any comparative studies regarding production
and the use of stain.
Comment
Gentian violet or crystal violet is a triarylmethane dye. The
dye is used as a histological stain and in Gram's Method of
classifying bacteria. Gentian violet has antibacterial, antifungal,
and anthelmintic properties, and was formerly important as a
topical antiseptic. The medical use of the dye has been largely
superseded by more modern drugs, although it is still listed by
the World Health Organization. The name “gentian violet” refers
to its color, being like that of the petals of a gentian flower; it is
not made from gentians or from violets.
One study in mice demonstrated dose-related carcinogenic
potential at several different organ sites.1,2 The U.S. Food and
Drug Administration has determined that gentian violet has
not been shown by adequate scientific data to be safe for use
in animal feed (to prevent mold). Use of gentian violet in animal feed causes the feed to be adulterated and is a violation of
the U.S. Federal Food, Drug, and Cosmetic Act. On June 28,
2007, the U.S. food and Drug Administration issued an “import
alert” on farm raised seafood from China because unapproved
antimicrobials, including gentian violet, had been consistently
found in the products. The FDA report states: “Gentian violet
is readily absorbed into fish tissue from water exposure and is
reduced metabolically by fish to the leuco moiety, leucocrystal
violet (LCV). Several studies by the National Toxicology Program reported that the carcinogenic and mutagenic effects of
gentian violet in rodents. The leuco form induces renal, hepatic
and lung tumor in mice.”3 It has even been applied to the mouth
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and lips of premature infants, and has a long history of safe use.
La Leche League recommends gentian violet for thrush on the
nipple.4 However, in large quantities, gentian violet may lead
to ulceration of a baby's mouth and throat and is linked with
mouth cancer.5 Gentian violet has also been linked to cancer in
the digestive tract of other animals.6
Methylene blue (MB) is a heterocyclic aromatic chemical
compound. It has many uses in a range of different fields, such
as biology and chemistry. At room temperature, it appears as a
solid, odorless, dark green powder that yields a blue solution
when dissolved in water. Methylene blue is a remarkable compound in the history of pharmacology and chemotherapeutics.
MB was the first phenothiazine compound developed and it has
active biological properties that have been under investigation
for over 120 years. Methylene blue was first prepared by Caro in
1876 as an aniline dye that became the first synthetic chemical
tested in human patients, which Ehrlich demonstrated in 1891 as
effective in malaria treatment. The early works of Ehrlich lead
to a great interest in the use of methylene blue for numerous
therapeutic applications, from microbiology to psychiatry. For
example, methylene blue is a therapeutic dye with antimicrobial
activity, supravital staining and diagnostic histopathological uses,
blood staining activity, medicinal photosensitizer action, cancer
chemotherapeutic uses, and psychoactive uses in dementia and
psychosis. Currently, some of the most important clinical uses
of methylene blue include the therapy of methemoglobinemia,
septic shock, encephalopathy, and ischemia.7
In an interesting article in Biochemical Pharmacology, the
authors propose the use of methylene blue as a means of suppressing the production of superoxide radicals O2– by acting as
an alternative electron acceptor for xanthine oxidase. Accordingly, they propose that methylene blue may represent a new
class of antioxidant drugs that competitively inhibit reduction of
molecular oxygen to superoxide by acting as alternative electron
acceptors for tissue oxidases.8
Summary
Dyes are used by some hair transplant physicians to stain
the skin, helping to visualize incisions for recipient sites and to
visualize white or non-pigmented hair during graft dissection and
placement. This may speed up placing and decrease transection.
Staining to identify where incisions have and have not been made
allows additional incisions to be made to create greater density.
Staining white or non-pigmented external shafts can make them
easier to see during the procedure. Some physicians use high
magnification to facilitate these tasks precluding the use of dyes.
Some use commercial hair dyes to color external shafts. While no
studies with respect to toxicity have been performed in the hair
restoration field, studies described above have been performed
on gentian violet and methylene blue stains. While methylene
blue has been used extensively internally without toxicity at indicated doses, gentian violet has been shown to be carcinogenic
in animal studies. While Melvin Mayer’s original question as
to whether staining recipient sites with gentian violet affects
the growth of the transplanted hair has not been fully answered,
it is our experience and opinion that staining of recipient sites
is not necessary. However, if a surgeon chooses to use a dye,
methylene blue should be used to stain skin or tissue rather than
gentian violet. If it is necessary to dye the external hair shafts, a
commercially available hair dye should be used. It is interesting
January/February 2014
that methylene blue may reduce ischemia/reperfusion injury.
Further studies using methylene blue in graft storage solution
may be warranted and would be interesting.
Editors’ Note: In the course of this discussion and investigation, there was an incidental revelation of possible further potential application of methylene blue in hair restoration surgery. So,
we want to include this comment from Dr. John Cole:
“I think that it is important to encourage a study using methylene blue as an antioxidant to evaluate its potential role in hair
restoration surgery beyond its function as a visual aide. The
primary reason we use liposomal ATP (LATP) is to prohibit the
production of ATP through anaerobic means. Of course, LATP
is very expensive. Minimizing the production of ATP anaerobically limits the production of hypoxanthine. Hypoxanthine is
subsequently converted to hydrogen peroxide, super oxide, and
the most damaging of all free radicals, the hydroxyl free radical.
Minimizing this conversion by xanthine oxidase has the potential
to either augment the benefits of LATP or even replace LATP
at a more economical price point. LATP may not be allowed or
available in many countries as well. We should look more closely
at methylene blue with a focus on its potential to improve yields
due to its anti-oxidative properties. I think this is clearly far more
interesting than its capacity to stain the skin.”
References
1. Littlefield, N.A., et al. Chronic toxicity and carcinogenicity studies of gentian violet in mice. Fundam Appl Toxicol.
1985; 5(5):902-912. doi:10.1016/0272-0590(85)90172-1,
PMID 4065463.
2. Carcinogenic Potency Database (CPDB)
3. Questions and Answers on FDA's Import Alert on FarmRaised Seafood from China: What Evidence Is There That
Malachite Green, Gentian Violet and Nitrofuran Cause Cancer? U.S. Food and Drug Administration, 2009. Retrieved
18 August 2010.
4. www.lalecheleague.org
5. Drinkwater, P. Gentian violet—Is it safe? The Australian
and New Zealand Journal of Obstetrics and Gynaecology.
1990; 30:65. doi:10.1111/j.1479-828X.1990.tb03199.x.
6. FDA Veterinarian. Vol. VI, No. VI, November/December
1991.
7. Wainwright, M., and K.B.J. Crossley. Review methylene
blue—A therapeutic dye for all seasons? Chemother.
2002(Oct); 14(5):431-443.
8. Salaris, C., et al. Biochemical Pharmacology. 1991(Jul);
42(3):499. Hillenbrand Biomedical Engineering Center and
Department of Veterinary Physiology and Pharmacology,
Purdue University, West Lafayette, IN 47907, USA.u
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Hair Transplant Forum International
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January/February 2014
Review of the Literature
Jeff Donovan, MD, PhD Toronto, Ontario, Canada [email protected]
Chao-Chun, Y., et al. Higher body mass index is associated with greater severity of alopecia in men with
male-pattern androgenetic alopecia in Taiwan: a cross-sectional study. J Am Acad Dermatol. 10.1016/j/
jaad.2013.09.036
There is accumulating evidence that androgenetic alopecia
(AGA) is associated with an increased risk for cardiovascular
disease and “metabolic syndrome” in general. Metabolic syndrome includes a number of risk factors that increase one’s
risk for cardiovascular disease including obesity, dyslipidemia,
hypertension, and abnormal glucose tolerance. Whether obesity
is independently associated with AGA is unclear.
Researchers from Taiwan set out to determine if there was a
relationship between body mass index (BMI) and the severity of
AGA. They studied 142 men (average age 31 years) with male
pattern baldness who were not using minoxidil or finasteride.
Approximately 60% had normal BMI and 40% were overweight
or obese (defined as BMI ≥ 24 kg/m2).
Men with more severe hair loss (Hamilton Norwood grade
V-VII) had a higher BMI than those with less severe hair loss
(grade I-IV) (25.1kg/m2 vs. 22.8kg/m2). After adjusting for
various other factors such as age, smoking, and hypertension,
the authors showed that men who were overweight or obese
had an approximately 3.5-fold greater risk for severe hair loss
than men with normal BMIs. In addition, young overweight or
obese men under 30 years of age had a nearly 5-fold increased
risk of severe hair loss.
Comment: This data supports the notion that obesity is one
of the metabolic syndrome parameters that is independently associated with severity of balding. Further studies are needed to
determine if being overweight or obese is directly causal in the
pathogenesis of male balding, and whether encouraging weight
loss in our overweight or obese patients could impact the progression of AGA or the effectiveness of treatments.u
e
Kim, H., et al. Low-level light therapy for androgenetic alopecia: a 24-week, randomized, double-blind, sham device-controlled
multicenter trial. Dermatol Surg. 2013; 1177-1183.
Low level light therapy (LLLT) has been used in the treatment of androgenetic alopecia (AGA) for a number of years.
Some previous studies with LLLT devices showed a statistically
significant increase in hair density or hair caliber in a small target
area following treatment, whereas other studies did not. In some
studies, this translated into patients or blinded investigators
detecting an improvement in hair density with use of LLLT,
whereas in other studies these improvements were not seen.
A study from South Korea evaluated the efficacy and safety of a
helmet-type LLLT device (Oaze, Won Technology, Daejon, Korea) in
men and women with AGA. They conducted a 24-week randomized,
double-blind study with use of a sham device. The primary endpoint
of the study was the change in hair density in a 70mm2 target area
from baseline to 24 weeks. Secondary endpoints included changes in
the hair shaft diameter and the degree of satisfaction of the subjects.
A total of 29 subjects completed the study, including 15 in the
LLLT group and 14 using the sham device. The device was safe
with no reports of severe adverse reactions. Subjects using the
LLLT device had a statistically greater increase in hair density
(approximately 19 hairs/cm2) and thickness (approximately 9μm)
compared to those using the sham device. Investigators detected a
statistically significant increase in hair density in those using the
LLLT device compared to those using the sham device. However,
there was no difference in subjects’ perception of improvement
or satisfaction ratings between LLLT and sham users.
Comment: This study adds to a number of studies supporting a
stimulatory effect of LLLT on hair growth and production of thicker
caliber hairs. However, whether this translates into an LLLT user
feeling that his or her hair looks better with use of the device and
whether this translates into an LLLT user projecting to the world
better scalp coverage requires further meticulously designed studies.
Given the differences that exist in male and female AGA, separate
studies of LLLT in men and women will be important.u
e
36
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January/February 2014
Nicole E. Rogers, MD Metairie, Louisianna, USA [email protected]
Facial Plastic Surgery Clinics of North America: Hair Restoration. Raymond J. Konior and Steven P. Gabel,
Eds. J. Regan Thomas, Consulting Ed. Elsevier, 2013. ISBN-13:9780323186032
This new textbook was written by and for members of the hair
transplant community. The last version of this text was published
in 1994. Because of that, the editors describe their goal as to
capture the last 20 years of hair transplant achievements. And
indeed, they ambitiously packed all of the most cutting-edge
techniques into 21 colorful and easy to read chapters. Despite
the fact that “pluggy” results have long been surpassed by more
natural and aesthetic results, this book updates readers on the
amazing breakthroughs that continue to be made in the field of
hair transplantation.
From the outset, this book guides readers about natural
hairline phenotypes, how to avoid transplanting AGA-imposters, and how to best incorporate medical management
of hair loss. It goes on to review the essentials of patient
selection, hairline design, and graft harvesting with an emphasis on natural, safe results. There are also chapters on
how to treat advanced hair loss, as well as separate chapters
on dense packing and megasessions. Whereas few doctors
were even performing follicular unit extraction (FUE) in
1994, this book features two important
chapters by experts in this technique.
Particularly innovative are the chapters on scalp micropigmentation (SMP), body hair transplantation, and techniques for optimal graft growth. The frontier
includes and advancements in regenerative hair techniques and
robotic harvesting of grafts (ARTAS).
The book is slim and lightweight (ships at 1.6 pounds) despite
its 550 pages. The photos and diagrams are excellent. Overall, I
believe this text is a must-have for every hair surgeon’s library,
regardless of their area of specialization. The reviewer’s favorite
pearl from Dr. Konior was to ask patients “What is your goal?”
during the consultation. By asking this, we as surgeons can
identify patient expectations as quickly and easily as possible,
without passing judgment or eliciting confusion.
Editors’ Note: Dr. Rogers was a contributing author for a
chapter in this textbook.u
37
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January/February 2014
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Fellow of the ISHRS (FISHRS)
After several years of consideration by the Board of Governors followed by ratification by the
membership of the International Society of Hair Restoration Surgery (ISHRS), the designation of
Fellow has been established in order to recognize members who meet its exceptional educational criteria. In order to be considered, the hair restoration surgeon must achieve a specific level of points in
a system of various educational parameters such as serving in leadership positions, American Board
of Hair Restoration (ABHRS) certification, writing of scientific papers, and/or teaching at scientific programs, among others.
It is a great honor for a member to achieve the Fellow designation of the International Society of Hair Restoration Surgery
(FISHRS). This recognizes the surgeon who strives for excellence in this specialized field. To maintain this status, the surgeon
must continue to meet established educational criteria over time. Fellows may vote and hold office in the Society, and they
may use the ISHRS Fellows logo on their websites and in other promotional materials.
We encourage all Physician Members to consider applying for Fellow status.
Qualifications and process can be found in the Members Only section of ISHRS website at:
http://www.ishrs.org/members-only/ishrs-fellow-category
Congratulations to the first class of FISHRS! As of October 23, 2013
Mohammed A. Abushawareb, MBChB, FISHRS
Ji-sup Ahn, MD, PhD, FISHRS
Bernardino A. Arocha, MD, FISHRS
Fernando Basto Jr., MD, FISHRS
Robert M. Bernstein, MD, FISHRS
Scott Boden, MD, FISHRS
Patricia Cahuzac, MD, FISHRS
Timothy Carman, MD, FISHRS
Ivan Cohen, MD, FISHRS
Paul Cotterill, MD, FISHRS
Jean Devroye, MD, FISHRS
Mark DiStefano, MD, FISHRS
Vance Elliott, MD, FISHRS
Edwin S. Epstein, MD, FISHRS
Bessam Farjo, MBChB, FISHRS
Nilofer Farjo, MBChB, FISHRS
Cary Scott Feldman, MD, FISHRS
Shelly A. Friedman, DO, FISHRS
Vincenzo Gambino, MD, FISHRS
John D. Gillespie, MD, FISHRS
Robert Haber, MD, FISHRS
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James A. Harris, MD, FISHRS
Kenichiro Imagawa, MD, FISHRS
Francisco Jimenez, MD, FISHRS
Sheldon Kabaker, MD, FISHRS
A. Arthur Katona, MD, FISHRS
Richard S. Keller, MD, FISHRS
Dae-Young Kim, MD, PhD, FISHRS
Russell Knudsen, MBBS, FISHRS
Grant F. Koher, DO, FISHRS
Jerzy Kolasinski, MD, PhD, FISHRS
Malgorzata Kolenda, MD, FISHRS
Samuel M. Lam, MD, FISHRS
Young Ran Lee, MD, PhD, FISHRS
Robert T. Leonard, Jr., DO, FISHRS
Bobby Limmer, MD, FISHRS
Melvin Mayer, MD, FISHRS
Paul J. McAndrews, MD, FISHRS
Parsa Mohebi, MD, FISHRS
Mohammmed Humayun Mohmand, MD, FISHRS
Bertram Ng, MBBS, FISHRS
Ahmmed Adel Noreldin, MD, FISHRS
Peter J. Nyberg, MD, FISHRS
David Perez-Meza, MD, FISHRS
Carlos J. Puig, DO, FISHRS
Rajendrasingh Rajput, MCh, FISHRS
Robert J. Reese, DO, FISHRS
Marino A. Rios, MD, FISHRS
Daniel E. Rousso, MD, FISHRS
John Schwinning, MD, FISHRS
Paul Straub, MD, FISHRS
Edwin A. Suddleson, MD, FISHRS
Eileen Tan, MBBS, FISHRS
Robert True, MD, MPH, FISHRS
Arthur Tykocinski, MD, FISHRS
Martin Unger, MD, FISHRS
James E. Vogel, MD, FISHRS
Bradley R. Wolf, MD, FISHRS
Wen Yi Wu, MD, FISHRS
Kuniyoshi Yagyu, MD, FISHRS
Craig L. Ziering, DO, FISHRS
Hair Transplant Forum International
www.ISHRS.org
January/February 2014
SAVE THE DATE
TEL
A N C I L L A R Y M E E T I N G S As you
plan your itinerary, please make note of
these Ancillary Meetings to occur in Bangkok
preceding the ISHRS Annual Scientific Meeting.
We have coordinated the events for the
convenience of our attendees. Each will have
separate registration with details to come.
International Society of Hair Restoration Surger y
303 West State Street, Geneva, IL 60134 USA
1.630.262.5399 or 1.800.444.2737 FA X 1.630.262.1520
[email protected] I www.ISHRS.org
November 10, 2014
November 11, 2014
AbHrS/IbHrS e x Am
A AHrS LIve Surgery WorkSHop
bangkok, Thailand
bangkok, Thailand
Sponsored by: American Board
of Hair Restoration Surger y
w w w. ABHRS.org
For details contac t: abhr s @sbcglobal.net
Sponsored by: Asian Association
of Hair Restoration Surgeons
w w w. A AHRS.asia
For details contac t: aahr s2010 @gmail.com
39
www.ISHRS.org
Hair Transplant Forum International
January/February 2014
HAIR TRANSPLANT FORUM INTERNATIONAL
Presorted
First Class Mail
US Postage
PAID
Mt. Prospect, IL
Permit #87
International Society of Hair Restoration Surgery
303 West State Street
Geneva, IL  60134 USA
Forwarding and Return Postage Guaranteed
Dates and locations for future ISHRS
Annual Scientific Meetings (ASMs)
2014: 22nd ASM
November 12-15, 2014
Bangkok, Thailand
2015: 23rd ASM
September 9-13, 2015
Chicago, Illinois, USA
2016: 24th ASM
November/December 2016
Central America, TBC
f orum
HAIR
TRANSPLANT
I N T E R N A T I O N A L
Advancing the art and science of hair restoration
Upcoming Events
Date(s)
Event/Venue
2 Sessions:
March 11-14, 2014
May 20-23, 2014
University Diploma of Scalp Pathology and Surgery
Paris, France
Sponsoring Organization(s)
Contact Information
University of Paris VI
www.hair-surgery-diploma-paris.com
Tel: 33 (0)1 + 42 16 13 09
[email protected]
Valarie Montalbano,
Workshop Coordinator
[email protected]
April 9-12, 2014
20th Annual Orlando Live Surgery Workshop
Orlando, Florida, USA
International Society of Hair Restoration Surgery
Hosted by Matt L. Leavitt, DO
May 21-24, 2014
5th Brazilian Meeting of Hair Restoration Surgery
Maresias Beach, Sao Paulo, Brazil
Brazilian Society of Hair Restoration Surgery (ABCRC)
www.abcrc.com.br/congresso
Arthur Tykocinski, MD, Program Chair
[email protected]
June 13-15, 2014
ISHRS European Hair Transplant Workshop
Brussels, Belgium
International Society of Hair Restoration Surgery
Hosted by Jean Devroye, MD
www.European-Hair-TransplantWorkshop.com
June 26-29, 2014
XV ISHR International Meeting:
Advancing in Hair Restoration
Siracusa (Sicily), Italy
[email protected]
Italian Society of Hair Restoration
Hosted by Franco Buttafarro, MD & Pietro Lorenzetti, MD
[email protected]
[email protected]
www.ishr2014.com
October 23-26, 2014
6th Annual Hair Restoration Surgery Cadaver Workshop
St. Louis, Missouri, USA
Practical Anatomy & Surgical Education (PASE), Center for Anatomical
Science and Education, Saint Louis University School of Medicine
In collaboration with the International Society of Hair
Restoration Surgery
http://pa.slu.edu
http://pa.slu.edu
November 12-15, 2014
22nd Annual Scientific Meeting
of the International Society of Hair Restoration Surgery
Bangkok, Thailand
International Society of Hair Restoration Surgery
www.ishrs.org
Tel: 1-630-262-5399
Fax: 1-630-262-1520
40