orum The Pairing Technique of the Moser Medical Group Karl Moser, Joerg Hugeneck, MD, Wolfgang Rohrbacher, MD, Claudia Moser Vienna, Austria

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1 f HAIR orum HAIR TRANSPLANT INTERNATIONAL Volume 15, Number 2 March/April 2005 The Pairing Technique of the Moser Medical Group COLUMNS 42 President s Message 43 Co-Editors Messages 45 Notes from the Editor Emeritus 51 From the Literature 52 Cyberspace Chat 54 Once Upon a Time 55 Surgeon of the Month 62 Hair Repair 75 Classified Ads FEATURE ARTICLES 47 H-Factor: 10 Years Later 49 Female Pattern Hair Loss 50 Recent Research Brings Generation of New Hair Follicle One Step Closer 57 Scalp Dermatology: Seborrheic Dermatitis & Psoriasis 59 Review of the Orlando Live Surgery Workshop 65 Aussi Culcha Corner 67 A Quick-Reference Guide to Australian Lingo Karl Moser, Joerg Hugeneck, MD, Wolfgang Rohrbacher, MD, Claudia Moser Vienna, Austria I n 1992, we introduced the Moser Method of hair transplantation in Rio de Janeiro. 1 To our knowledge, as pioneers in the development of large sessions of small grafts, our clinic was the first to produce more than 1,000 slits in a single surgery. The Moser Method not only encompasses the removal of epidermis around the hair follicle but also a very careful preparation of the graft by our assistants. Any excess tissue is removed from the graft so only the slim follicular unit (FU) itself is implanted. 2 We also gently mash the grafts with the side of the #10 blade like a spatula, which helps in dissecting these skinny grafts. Because of this way of dissecting, we have more single- and 2-hair FUs compared to other preparation techniques. By using these techniques, we usually obtain 40% singlehair grafts, 50% 2-hair grafts, and only 10% 3-hair grafts, depending on the patient. In most cases, we will then combine these skinny grafts to create pairs, thus creating multi-hair grafts composed of only hair follicles (Figure 1). That s how Moser s pairing technique the technique to implant two FUs in one slit was born. We did this as early as 1993 and therefore have been using the pairing technique for over ten years. We believe the pairing technique is very helpful to produce density and naturalness. While the exact Figure 1. figures vary from patient to patient, depending on the density and the natural arrangement of the patient s follicular units in the donor area, we might create about 1,200 slits in a typical case and actually implant approximately 2,000 grafts into these slits, with most of them being pairs (Table 1). We only charge for the number of prepared slits and not the number of follicular unit grafts implanted. For the pairing we combine: a) 1-hair grafts and 1-hair grafts b) 1-hair grafts and 2-hair grafts c) 2-hair grafts and 2-hair grafts d) 1-hair grafts and 3-hair grafts Table 1. The Moser Pairing Technique: A Typical Case with 2,000 Grafts in 1,205 Slits Grafts made by assistants hair 1,050 2-hair hair 2,000 total See pages for Annual Meeting, Award Nomination, & Grant Application information. Number of sites hair slits hair slits & 4-hair slits 1,205 slits , 90 3s 160 2s , Official publication of the International Society of Hair Restoration Surgery continued on page 46

2 42 Hair Transplant Forum International Volume 15, Number 2 Hair Transplant Forum International is published bimonthly by the International Society of Hair Restoration Surgery, 13 South 2nd Street, Geneva, IL First class postage paid at Chicago, IL and additional mailing offices. POSTMASTER: Send address changes to Hair Transplant Forum International, International Society of Hair Restoration Surgery, 13 South 2nd Street, Geneva, IL Telephone: , U.S. Domestic Toll Free: ; Fax: President: E. Antonio Mangubat, MD Executive Director: Victoria Ceh, MPA Editors: Jerry E. Cooley, MD, and Robert S. Haber, MD Managing Editor & Graphic Design: Cheryl Duckler, cduckler@comcast.net Advertising Sales: Cheryl Duckler, ; cduckler@comcast.net Copyright 2005 by the International Society of Hair Restoration Surgery, 13 South 2nd Street, Geneva, IL Printed in the USA. The International Society of Hair Restoration Surgery (ISHRS) does not guarantee, warrant, or endorse any product or service advertised in this publication, nor does it guarantee any claim made by the manufacturer of such product or service. All views and opinions expressed in articles, editorials, comments, and letters to the Editors are those of the individual authors and not necessarily those of the ISHRS. Views and opinions are made available for educational purposes only. The material is not intended to represent the only, or necessarily the best, method or procedure appropriate for the medical situations discussed, but rather is intended to present an approach, view, statement, or opinion of the author that may be helpful to others who face similar situations. The ISHRS disclaims any and all liability for all claims that may arise out of the use of the techniques discussed. Hair Transplant Forum International is a privately published newsletter of the International Society of Hair Restoration Surgery. Its contents are solely the opinions of the authors and are not formally peer reviewed before publication. To facilitate the free exchange of information, a less stringent standard is employed to evaluate the scientific accuracy of the letters and articles published in the Forum. The standard of proof required for letters and articles is not to be compared with that of formal medical journals. The newsletter was designed to be and continues to be a printed forum where specialists and beginners in hair restoration techniques can exchange thoughts, experiences, opinions, and pilot studies on all matters relating to hair restoration. The contents of this publication are not to be quoted without the above disclaimer. The material published in the Forum is copyrighted and may not be utilized in any form without the express written consent of the Editor(s). Hair Transplant Forum International March/April 2005 President s Message E. Antonio Mangubat, MD Seattle, Washington What we think, we become. Buddha (B.C ) Buddha is still considered the source of life wisdom for many people, both as a religion and as a well of inspiration. We have all heard the saying, If you think you will fail, you re probably right. We have come a long way in terms of artistry, knowledge and surgical skill in hair restoration surgery (HRS); yet our specialty is still an infant in the general E. Antonio Mangubat, MD world of medicine. One of my major goals this year is to make positive strides towards increasing the visibility and credibility of our specialty, and these have been outlined in the final draft of our new strategic plan: 1. The ISHRS will demonstrate a measurable increase in the public and our physician-peer s awareness and perception in the value of medical and surgical hair restoration. A. Obtain ACCME accreditation. B. Publish the ISHRS Core Curriculum for HRS in a peer-reviewed journal. C. Join traditional medical associations such as the AMA and other international medical organizations in order to improve peer physician relations. This year, we have taken major strides to achieve these milestones and I think it is important to understand the significance of each of these items and where we are today. Accreditation Council for Continuing Medical Education (ACCME) is a universally recognized organization that sets and administers educational standards and criteria for providers of quality CME for physicians. We strive for this accreditation because it is a significant credential to the medical community that we measure up to their standards; that our educational meetings and activities are of the highest quality and that ISHRS is serious about physician education. Dr. Paul Cotterill s CME Committee has taken full charge of this task working in tandem with our Annual Scientific Meeting Committee to put on the high quality educational offerings that fulfill ACCME requirements. ACCME accreditation is a long and stringent process but I predict we will have our certification within the next two years. Publishing the ISHRS Core Curriculum for HRS (CCHRS) in a peer-reviewed journal has been a dream of mine for several years. Congratulations to Dr. Carlos Puig and his hard working Core Curriculum Committee for accomplishing this milestone this year. You may ask why is the CCHRS so important to us? Well, it is the first document in HRS history that actual defines our specialty and establishes the knowledge base that a competent HRS physician must possess to practice safely and effectively. Furthermore, it ties in closely with ACCME accreditation by defining the critical learning elements and guides our educational planning. The ISHRS should become a member of other traditional medical associations like the AMA and other international organizations. This logic is simple; it gives us an opportunity to interact with our fellow physicians and to educate them on the incredible state-of-the-art of HRS. Dr. Martin Unger recently submitted a thorough and exciting report of his Ad Hoc Committee on AMA Membership for ISHRS concluding that the ISHRS is extremely close to being able to apply for AMA membership and possibly hold a voting seat in the AMA House of Delegates! There are several criteria and the ISHRS satisfies all criteria save two: a) at least 35% of our American ISHRS members must also belong to AMA to be eligible for the AMA Specialty Societies Section (SSS) and b) we must remain a member in good standing of the AMA SSS for 3 consecutive years. Currently 28% continued on page 44

3 Co-Editors Messages Jerry E. Cooley, MD Charlotte, North Carolina It is with enthusiasm and trepidation that I join Dr. Bob Haber in trying to fill the scary big shoes of Drs. Mike Beehner and Bill Parsley as co-editors of the Forum. What an outstanding job they have done over the past three years! Most of you know that these two are not only the finest of surgeons but also the finest of men. Jerry E. Cooley, MD At my first ISHRS meeting, held in Nashville in 1996, I had the good fortune to be randomly put in a foursome with Bill and Mike at the sponsored golf outing. Little did I know how the friendships that began then would strengthen and shape me over the ensuing years. They served as mentors for me, showing me what it means to be completely committed to improving our craft and how to conduct oneself with honesty and fairness. Over the years, we reunited frequently to play golf, sharing not only golfing tips but surgical and practice pearls as well. They never gave up on trying to make me a better surgeon. Sadly, I gave up a long time ago on trying to help them become better golfers. The Forum, as it did in ancient Greece, provides a place for all of us to get together, to discuss and debate the ideas that are important to us. As the saying goes, half of our current medical knowledge is wrong, but the problem is we don t know which half. For hair restoration, our mission is to evolve and find these new truths and dispel the untruths. The result will be improved diagnostic and evaluation skills and better tools and techniques. Ultimately, our patients will get better care, which is what it s all about. Unfortunately, this process of searching for truth can be a little messy. I was reminded of this recently after performing my civic duty by doing four days of jury duty for a robbery trial. Innocent or guilty? All twelve of us heard the same testimony and presentation of evidence. Yet, we all saw it differently and were evenly split prior to deliberations. During the ensuing debate, many of us changed our minds, suddenly seeing things in a new light after listening to each other. A few jurors never budged, refusing to even consider another s viewpoint, despite the judge s admonishment to be firm, but not stubborn, in our convictions. Some acted as if they had attached their opinion to their inner being, so to question or criticize their ideas was interpreted as a personal attack. We see the same process at work in our own field. There are many questions and controversies facing us. The Forum will continue to serve as the record of our progress. No doubt we will find ourselves frequently disagreeing with one another. A fair, open-minded, and critical mind-set is necessary for our deliberations, for without it the truth will not emerge. Be firm, not stubborn, in your opinions. And let s agree to not make it personal and to have some fun along the way. Jerry Cooley, MD Robert S. Haber, MD South Euclid, Ohio Greetings to the readers of the Forum! It is with a mixture of excitement and anxiety that I look forward to the next three years as co-editor. I have had the good fortune to serve the ISHRS in many capacities. Each of those tasks required a commitment of time and effort, and each was rewarded with friendships and an extraordinary respect for the Society and its members. Editorship Robert S. Haber, MD of the Forum will undoubtedly be the most challenging task yet, in time and effort, yet I have no doubt that with the assistance of Cheryl Duckler, Victoria Ceh, and of course my good friend Jerry Cooley, this too will be rewarding beyond my imagination. With this issue, Dr. Jerry Cooley and I become only the seventh and eighth editors in the Forum s history, and we follow in giant footsteps that have laid the groundwork for a remarkable vehicle for the sharing of ideas. Dr. O Tar Norwood s creation, in 1990, permitted surgeons to rapidly share ideas and thoughts with each other without the long delays inherent in peer-reviewed journals. He served as sole editor of the Forum for 5 years, until Dr. Richard Shiell ably assumed the burden. Richard presided over the expansion of the Forum, and carried out his responsibilities not only with a keen eye and critical mind, but without benefit of the Internet. Eighteen issues later, it was time for him to rest, and he handed over the editorship to the dynamic duo of Drs. Dow Stough and Russell Knudsen. These two thought leaders put their intellect to good use, and over the next three years and 18 issues further expanded the Forum to include lengthier submissions and navigated through sometimes controversial waters with grace and style. The past three years brought yet another new look and editorial style to the Forum under the stewardship of Drs. Bill Parsley and Mike Beehner. I ve never known two finer men, both skilled as surgeons but also blessed with keen intellect and a sense of fairness that guided them well. The ISHRS membership has now grown accustomed to issues filled with a wide array of featured columns, historical insights, and cutting-edge articles that have both tracked and led the field of hair restoration. Where do Jerry and I take the Forum now? We will continue to reflect the needs and desires of the membership. The Forum, like the ISHRS, is maturing, and like parents, the editors do not so much control what it becomes, but strive to help it become its best. The layout and color scheme has of course changed, but many of the features that have been enjoyed by the readers will be maintained. The Forum must always remain a vehicle for the honest exchange of ideas, however controversial, and it must be able to do this quickly. So don t be bashful! Do you have something to say? Something to complain about? A new idea or technique you d like to share? Write it up and send it in, as there will be many who would like to hear about it, and the Forum is your voice. Bob Haber, MD 43

4 President s Message continued from page 42 of our American ISHRS members also belong to the AMA. We only need 25 more of our members to join to satisfy this requirement and clear the way for the ISHRS to become an active voting member of the largest medical association in the world. I will be sending a personal invitation to all of our American members to join the AMA now. It would be a huge milestone to submit our application to the AMA SSS this year. The door is open to us; all we have to do is walk through it. Dr. Nilofer Farjo chairs our international counterpart, Ad Hoc Committee on International Medical Association Membership for ISHRS. She has a more difficult job having to look in many different countries with potential language barriers; thus far all non-us organizations only allow individual physicians to join. We are an international organization and if any international member can contribute personal knowledge to this effort, please contact Dr. Farjo. We are making huge strides in three major objectives in the first initiative of our strategic plan. By the time you read this message, the Board of Governors will have met for a third time this year and will have approved the complete strategic plan formulated in October I must extend my deepest appreciation to my colleagues who volunteer their time on our behalf to make the ISHRS stronger. Together we have developed a unified vision and we are moving steadily forward. Consider Buddha s wisdom and apply it to ourselves. We must believe HRS is a specialty if we are to become a specialty recognized as credible in the eyes of our peers and the public. Again, I encourage all of you to become a part of our future and do your part: volunteer for committee work, invite a fellow physician to join the ISHRS, and American members join the AMA. There is so much that we have accomplished and yet so much left to be done. E. Antonio Mangubat, MD The ISHRS Forum Archives Article Database Housed in the Members Only section of the ISHRS website, we are proud to announce the launch of a valuable new resource exclusive to ISHRS members...the Online Forum Archives Article Database. You may search the database by various criteria (e.g., keyword, author, issue, or advanced search) to locate past Forum articles. The database currently starts at Volume 9 and includes years 1999 to the present. New and Exclusively for Members Only Board of Governors Chairs of Committees President: E. Antonio Mangubat, MD* 2005 Annual Scientific Meeting Committee: Vice President: Paul T. Rose, MD * Jennifer H. Martinick, MBBS Secretary: Bessam K. Farjo, MD* Audit Committee: Robert S. Haber, MD Treasurer: Paul C. Cotterill, MD* Bylaws and Ethics Committee: Robert T. Leonard, Jr., DO Immediate Past-President: Mario Marzola, MBBS* CME Committee: Paul C. Cotterill, MD Michael L. Beehner, MD Core Curriculum Committee: Carlos J. Puig, DO Edwin S. Epstein, MD Fellowship Training Committee: Carlos J. Puig, DO Jung Chul Kim, MD Finance Committee: Paul C. Cotterill, MD Melike Kuelahci, MD International Advisory Committee: Russell Knudsen, MBBS Matt L. Leavitt, DO Live Surgery Workshop Committee: Matt L. Leavitt, DO William M. Parsley, MD Membership Committee: Marc A. Pomerantz, MD Arturo Sandoval-Camarena, MD Past-Presidents Committee: Robert S. Haber, MD David J. Seager, MD Pro Bono Foundation Committee: Paul T. Rose, MD Surgical Assistants Representative: Scientific Research, Grants, & Awards Committee: Cheryl J. Pomerantz, RN Richard C. Shiell, MBBS Surgical Assistants Executive Committee: *Executive Committee Helen Marzola, RGN Website Committee: Vance W. Elliott, MD Ad Hoc Committee on AMA Membership for ISHRS: Martin G. Unger, MD Ad Hoc Committee on Board Certification: John Gillespie, MD Ad Hoc Committee on Hair Foundation: Matt L. Leavitt, DO & Dow B. Stough, MD Ad Hoc Committee on International Medical Association Membership for ISHRS: Nilofer P. Farjo, MD Ad Hoc Committee on Patient Education: Michael L. Beehner, MD To Submit an Article or Letter to the Forum Editors Please send all submissions electronically via e- mail. Remember to include all photos and figures referred to in your article as separate attachments (JPEG, Tiff, or Bitmap). Be sure to ATTACH your file(s) DO NOT embed them in the itself. Any person submitting content to be published in the Forum agrees to the following: 1. The materials, including photographs, used in this submission do not identify, by name or otherwise, suggest the identity of, or present a recognizable likeness of any patient or others; or, if they do, I have obtained all necessary consents from patients and others for the further use, distribution, and publication of such materials. 2. The author indemnifies and holds harmless the ISHRS from any breach of the above. Send to: Robert Haber, MD HaberForum@aol.com Submission deadlines: May/June, April 10 July/August, June 10 44

5 Notes from the Editor Emeritus Russell Knudsen, MBBS Sydney, Australia Where To from Here? With the almost universal acceptance of follicular unit grafting (FUG)/ micro-grafting as the technique of choice, it is tempting perhaps to consider that the evolution of grafting from standard plugs to 1- to 4-hair grafts is Russell Knudsen, MBBS now complete. After all, the grafts can t get any smaller or more natural can they? If so, what further new developments can make it worthwhile for experienced surgeons to attend scientific meetings? How can we make our undetectable and completely natural results any better? There are two major aspects to hair restoration surgery: technical and artistic. The technical focuses on the mechanics of achieving quality grafts and their successful implantation so that reproducible, natural results are achieved. This area has provided major advances in technique in the past 15 years that have popularized this type of surgery to patients and surgeons alike. Scientific meetings are dominated by technique lectures that largely focus on the mechanics of accurately creating ever-larger numbers of grafts per session, and the implantation of these tiny grafts into tiny incisions or holes at ever-higher densities. The artistic focuses on the planning aspects and arrangement of the grafts to achieve the patient s goals. This seems to have been largely relegated to discussion of hairline design and placement with the unspoken assumption that with modern FUT/micro-grafting, once you get the hairline design right, everything else falls into place. In my view, this is a dangerously simplistic view that threatens to continue to create unhappy patients despite superior technique. The artistic area that continues to vex our profession relates to patient selection. In my view, the improvements in techniques have not made much difference to patient selection. The exception here is that a single session of FUT/ micro-grafting looks natural from the first session (if at appropriate density). A decision to have no further surgery may, in certain patients, still produce an acceptable cosmetic outcome. What has not changed is our approach to the young patient requesting surgery (i.e., under 23 years of age), or to the extensively bald patient with poor donor hair quality and/or quantity the marginal patient. Unrealistic expectations on the part of the patient, or complacency on the surgeon s behalf, threaten to continue to harm our field. No amount of technical improvement, applied to an inappropriate patient, achieves an acceptable outcome. A recent article in Dermatologic Surgery suggested that the incidence of body dysmorphic disorder in patients seeking cosmetic dermatology is 12%. How many of us make that diagnosis in every 8 th patient? Or 10 th patient for that matter? The irony is that although the technical improvements in our field have enlarged the pool of potential patients, they have also threatened our reputation as we increasingly see patients with both greater expectations and demands. Who among us has not recently experienced the following statement during consultation: I would never have considered doing the surgery with the old plugs, but if it is completely natural and undetectable, and I can shave my head in the future if the baldness progresses, and there is no visible scarring, then I am happy to go ahead.? The temptation for us is to make soothing noises and go along with these increased patient demands. The aggressive marketing of FUE/FIT in recent years has convinced many prospective patients that scar-less surgery is now available. We need to be careful to emphasize what is likely to occur, not just what might be possible. Rather like promising everyone a great outcome after a single session of dense grafting. I continue to believe that it is to whom we say NO that determines our worth as surgeons. Realistic expectations create happy outcomes. So, if we choose appropriate patients, how can we improve our results if technically we can t produce better grafts? The areas where we can still improve our results fall into two categories: planning and execution. Planning improvements encompass techniques that help create the illusion of density for any given number of grafts performed (e.g., angle, orientation, direction, specific areas of increased density, shingling, specific planning of placement of 3-haired grafts, use of multi-unit grafts). In addition, prevention of further balding (offer of medications such as finasteride and minoxidil) may assist in the maintenance of the surgical benefit. In my view, most surgical patients may potentially benefit from the offer of medication in addition to the surgery. However, if patients commence medication, surgical planning must allow for the possibility that the patient will eventually stop medication and balding will resume. Our design must allow a fallback position that minimizes the cosmetic risk of the surgery despite further hair loss. In addition, the vexing question of how (or whether) to treat a significantly sized thinning crown, particularly in the younger patient, continues to divide surgeons and provides no definitive answer. Execution improvements might relate to the minimization of donor area scarring, techniques that help achieve a safe increase in graft density for any given session, and possibly the avoidance of post-operative anagen effluvium in both the grafted hair and the remaining recipient-area hair. We are still waiting for a definitive answer as to the comparative results of sagittal angle grafting (SAG) versus coronal angle grafting (CAG). Techniques to repair previous donor scarring might also make significant improvements, as well as techniques to repair poorly performed surgery. In addition, we await the coming improvements in graftstorage solutions that conceivably will improve graft yields. In summary, it seems to me there remain plenty of reasons for both experienced and inexperienced surgeons to continue to attend scientific meetings. There is much left to improve upon. See you in Sydney! Russell Knudsen, MBBS 45

6 The Moser Pairing Technique continued from front page In a typical megasession, we use about hair grafts, 2,100 2-hair FUs, and hair FUs placed into about 2,000 sites. The blades we use are: 0.65mm for the single-hair grafts, mm for the 2-hair FUs, and mm for the 3- and 4-hair FUs. We usually place our grafts in the parallel orientation (not lateral slits). Using the pairing technique, we have observed that the transplanted hair does not grow in a tufted way but as if it had been implanted as single hairs (Figure 2). The arrangement of the new hair was much better and the result looked much more natural (Figure 3). At the frontal hairline, we implant only single-hair grafts with finer and lighter hair (removed from the side) (Figure 4), and behind this line we use normal single-hair grafts. Then, moving back to the top of the scalp, we place FUs with two hairs featuring the single-hair effect when growing (Figure 5), or we plant two 1-hair graft pairs into one slit. Behind this is almost all paired grafts. Although the Moser pairing technique is a major improvement in hair restoration, it requires a technician with more experience than usual. Grasping two skinny follicular grafts with the forceps requires an especially gentle touch (Figure 6). The implanter must be experienced not only at being gentle in grasping the two grafts together but also in selecting which two grafts will look good together. However, we believe the results are well worth the extra effort. References 1. Hair Transplant Forum International Vol. 3, No. 1, September November Hugeneck J. et al. Non Tufted Incisional Slit Grafting. Journal of Dermatologic Surgery 1994; 20: I had seen graft pairing demonstrated before by Ron Shapiro, MD, but it wasn t until I visited the Mosers in 2003 that I saw the widespread use of this technique for most of the recipient sites and in almost all cases. Since then, I have used pairing on many cases and have been pleased with the results. I have found it particularly helpful in 1) patients with fine, straight hair, 2) females, and 3) building up density in the egg shaped frontal tuft area, and placed in lateral slits. JEC Editor s Note Figure 2. Figure 4. Figure 5. Figure 3. Before and after one session with pairing technique: About 2,700 slits, in 50% of the slits we used the pairing method. Figure 6. 46

7 H-Factor: 10 Years Later Joseph F. Greco, PhD, PA/C Sarasota, Florida Results from hair restoration procedures continue to improve because of scientific studies and the evolution of aesthetic and scientific concepts. X-factor, first described by Drs. Richard Shiell and O Tar Norwood 20 years ago, was one of the first concepts regarding poor yield after hair transplantation. They defined X-factor as something consistently producing unexplained and unexpected poor results in 4mm grafts and estimated that it occurred in 1% of hair transplant procedures. 1 While transitioning to total micro-grafting megasessions more than 10 years ago, the author began to wonder if X- factor was the name for the unexplained cases of poor growth, then what about the explainable reasons for poor growth? The issue of reported cases of poor growth secondary to megasessions had many etiologies, and numerous studies were done to answer these important questions, including Masumio Inaba s follicular bulge studies, Kim s follicular transection studies, 2 Bobby Limmer s graft survival studies, 3 recipient site oxygenation studies by Klemp and Kansted, 4 and Toshitani, et al. 5 and tissue hypoxia studies by Goldman. 6 I propose changing the classification of H- factor as direct and indirect, rather than primary and secondary. Furthermore, I believe the indirect effects such as improper technique in graft hydration or staff fatigue may have just as disastrous an effect on graft yield as direct trauma. In the early 1990s when most hair restoration surgeons began utilizing follicular units in megasessions, many surgeons experienced less follicular yield than they had with minigrafts. In a 1994 Forum article, the author postulated the concept of H-factor, stating that outwardly grafts may appear normal, but iatrogenic trauma may cause invisible damage resulting in H-Factor, human factor, which may be misrepresented as true X-Factor. This subtle iatrogenic trauma will lead to inconsistent results, even when the surgeon takes great care in harvesting and artistic design. 7 Numerous factors were listed at that time that were thought to contribute to H-Factor such as improper handling of tissue, over handling of tissue, aggressive forceps pressure while planting (crush injury), graft dehydration, fatigue, improper technique in placement, and a cavalier attitude in handling tissue. In an editorial comment on the article Is It X-Factor or H-Factor (Forum 1994) regarding follicular yield, Dr. Norwood stated: In my hands I see more H-factor in micrografts than I do in minigrafts and H-factor would be that part of X-factor that had to do with technique. In a subsequent Forum article in 1996, the author further described H-factor as being primary and secondary. Primary H-factor may occur at any stage during the strip removal or its subsequent dissection. It may also occur during the later handling of grafts while they are being transferred from cutting board to saline storage or from storage to the scalp. It can also occur still later during reinsertion as grafts pop from their recipient sites. Secondary H-factor is damage that occurs indirectly due to other predisposing factors. Examples of this may include the effects of heat and drying on the growth center. Blunt blades, poor lighting, and excessive drying due to air conditioning all contribute to this problem. Another factor contributing to secondary H-factor would be the sizing of grafts with respect to recipient incisions because improper sizing will lead to over handling of the grafts. There have been many independent studies indirectly illustrating the effects of primary H-factor after 1994, such as Dr. David Seager s chubby and skinny micrograft study, which showed higher yield in chubby grafts than overly dissected skinny grafts, 8 this author s crush study, 9 and Dr. Jerry Cooley s observation that grafts often lose their dermal papilla during dissection and placement without this being apparent to the surgeon or assistant. 10 Dr. Gandleman later demonstrated the damaging effects of drying and increased temperature on micrografts. 11 These studies have provided the stepping-stones to more ideas and concepts, increasing our understanding of the factors important for optimal growth. There is still quite a lot of misunderstanding regarding H-factor and its relationship to X-factor. Most confuse H- factor with only crush injury during graft placement, but this is only one type of primary H-factor, the insult that is directly caused by the surgeon or the assistant. I propose changing the classification of H-factor as direct and indirect, rather than primary and secondary. Furthermore, I believe the indirect effects such as improper technique in graft hydration or staff fatigue may have just as disastrous an effect on graft yield as direct trauma. Simply stated, X-factor would be the unexplainable reasons for no growth and H-factor would be the explainable reasons for no growth that had to do with poor technique. Ten years later, as Dr. Cooley states, Most of us accept that the most important factor in obtaining optimal growth is avoiding physical trauma by transplanting intact hair follicles that have not been transected, dehydrated, or crushed. 12 continued on page 48 47

8 H-Factor: 10 Years Later continued from page 47 In a 2004 Cyberspace Chat article, several doctors voiced their opinions. Dr. Bobby Limmer states, It is my impression, based upon experience, that the result of a transplant is more related to how grafts are handled than to the density of the transplant. Dr. Bill Parsley also reviews important factors in achieving good survival and lists numerous examples of primary H-factor transaction such as too much manipulation of the grafts, too little trimming of the grafts, and cutting instrument size. In addition, Dr. Bill Reed discusses many examples of secondary H-factor predisposing grafts to damage because burn out or fatigue can lead to improper handling, inadequate hydration, and ischemia reperfusion injury. 13 Today advances in graft survival and yield continue with the study of tissue culture media and other graft holding solutions. It is critical to keep in mind the importance of H- factor as new techniques are developed. For example, with follicular unit extraction (FUE), most surgeons trying this technique acknowledge the heightened risk of H-factor. As instrumentation and technique improve so will the follicular yield. By keeping attention on H-factor and how to reduce it, we can all come closer to achieving optimal growth in every case. References 1. Norwood O. T., and R. C. Schiell. Hair Transplant Surgery, 2 nd ed. Springfield, IL: Charles Thomas, Kim, J. C., and Y. C. Choi. Regrowth of grafted human scalp hair after removal of the bulb. Dermatol Surg 1995; 21: Limmer B. L. Micrograft survival. In: Stough D. B., Haber R. S., eds. Hair replacement, Medical and Surgical. St. Louis, Mosby: 1996(95) Klemp, P., and B. Kansted. Subcutaneous blood flow in early male pattern baldness. J Invest Dermatol 1989; 92: Toshitani, S., et al. A new apparatus for hair regrowth in male pattern baldness. J Dermatol Surg Oncol 1991; Goldman B. The effect of hair micrograft surgery on scalp oxygen levels. Presented at the 1995 Annual Meeting of the ISHRS in Las Vegas, Nevada. 7. Greco, J. F. Is It X-factor or H-factor? Hair Transplant Forum International 1994; 4(3): Seager D. J. Micrograft size and subsequent survival. Dermatol Surg 1997; 23(9): Greco, J. F., R. D. Kramer, and G. D. Reynolds. A crush study review of micrograft survival. Dermatol Surg 1997; 23(9): Cooley, J., and J. Vogel. Loss of the dermal papilla during graft placement: Another cause of X-factor? Hair Transplant Forum International 1997; 7(1): Gandleman, M. Light and electron microscopic analysis of injured grafted micrografts: Stage II. Presented at the Annual Meeting of the International Society of Hair Restoration Surgery, September 1998, Washington, D.C. 12. Cooley, J. Ischemia-Reperfusion Injury and Graft Storage Solutions. Hair Transplant Forum International 2004; 14(4), Quotes from Cyberspace Chat. Hair Transplant Forum International 2004; 14(5): 167 Regardless of whether we call it H-factor or simply factors related to poor growth, it is helpful to frequently remind ourselves of the many factors under our control that affect graft yield. Only after all of these possibilities have been eliminated should we entertain the possibility of X-factor, or unexplained poor growth. JEC Editor s Note Toppik Makes Thinning Hair Look Full and Natural in 30 Seconds Toppik fibers are pure keratin, colored to match the 8 most common hair colors (black, dark brown, medium brown, light brown, auburn, blonde, gray & white). You simply hold the Toppik container over the thinning area and shake it in. In seconds, the fibers combine with the patient s remaining hairs to give the undetectable appearance of a fuller head of hair. Toppik resists wind, rain and perspiration. It is totally compatible with all topical treatments for hair loss. And Toppik is ideal in conjunction with hair transplant surgery, as it effectively conceals any post-operative thinning. For a free tester kit containing all 8 colors, call, fax or Spencer Forrest, Inc. 64 Post Road West Westport, CT Before Toppik After Toppik Phone: , ext. 10 Fax: info@toppik.com 48

9 Female Pattern Hair Loss Susan Kingsley, MBA, PhD (Susan Kingsley, a professional medical writer and President of BioPharma Solutions in Vancouver, BC, Canada, is an independent consultant to the ISHRS and assisted the Forum in covering several keynote talks at the ISHRS Annual Meeting in Vancouver.) Based on Dr. Elise A. Olsen s Female Pattern Hair Loss: Androgenetic vs. Age-Related, presented Friday, August 13, 2004, at the 12th Annual Meeting of the ISHRS in Vancouver, British Columbia. Female pattern hair loss is not a specific diagnosis but a clinical phenotype, declared Dr. Elise A. Olsen, MD, of Duke University Medical Center in Durham, North Carolina, USA, at the 12 th Annual Meeting of the ISHRS (August 2004, Vancouver, BC). The patterns of hair loss in women are not as easily defined as those in men. In fact, female hair loss may present as one of three major patterns: male pattern baldness; a diffuse loss across the entire top of the scalp; or with frontal accentuation. Frontal accentuation is found in approximately 70% of women with obvious hair loss, advised Dr. Olsen. Furthermore, unlike men, the definitive cause of hair loss in women is often difficult to determine. Thus, naming all female hair loss androgenetic alopecia, the term given to androgen-dependent genetically determined male pattern baldness, may be misleading. Dr. Olsen recommended instead that the term female pattern hair loss be used to describe the type of hair loss in women that is primarily central and characterized by miniaturization of hairs. Dr. Olsen identified three important potential etiologic factors for female pattern hair loss: androgen irregularities, age, and inflammation. In part, these different causes can be distinguished by determining hormone levels, particularly free testosterone. She then described how various types of hair loss can be distinguished and diagnosed. Such differential diagnosis is important as it will influence treatment choices. Dr. Olsen advised that scalp biopsy data can offer supportive information to the clinical clues, such as the presence of fine hair, frontal accentuation, central scalp thinning, or the microscopic results of hairs extracted by the hair pull technique. For example, miniaturization of the follicles is seen both clinically and histologically. Scalp biopsy is also critical for diagnosing cicatricial alopecia, and female and male pattern hair loss may, in some cases, have a component of this. Dr. Olsen continued her presentation by identifying and describing the two different subgroups of women with hair loss, a classification based on age. The early onset group first exhibits hair loss, with or without hyperandrogenemia, between puberty and 30 years of age; the hair loss of the late onset or postmenopausal group starts from the age of 40 years or later and, again, includes women with or without excess androgen. Fewer women in the older group have obvious hyperandrogenemia. Although hyperandrogenemia may present as irregular menstruation and/or hirsutism, and is frequently related to polycystic ovary syndrome in younger patients, Dr. Olsen stressed that most women with female pattern hair loss do not have any signs or symptoms of androgen abnormalities. So what other factors may be behind female pattern hair loss? Dr. Olsen identified three important potential etiologic factors for female pattern hair loss: androgen irregularities, age, and inflammation. In part, these different causes can be distinguished by determining hormone levels, particularly free testosterone. For example, hyperandrogenemia is found in more than 85% of women with both hirsutism and female pattern hair loss. However, hormonal changes may also be age related, rather than pathologic, particularly in menopausal women. Dr. Olsen concluded that androgen abnormalities in younger women almost certainly indicates a subtype of androgen dependant alopecia, i.e., androgenetic alopecia, but in older women the diagnosis is not as clear. Additional testing may be needed in the latter group to determine etiology. Inflammation may have a role in alopecia, acting as a primary or secondary etiological factor, emphasized Dr. Olsen. Although histological evidence of inflammation is found in patients without hair loss, its presence is far greater in women with female pattern hair loss and can lead to scarring. Clinically, inflammation can be seen surrounding the hair follicle (peripilar) or in focal atrichia (so named by Dr. Olsen to describe small areas of absent hairs in female pattern hair loss). Microscopically, in female pattern hair loss inflammation typically involves the upper follicle, including the bulge area. Dr. Olsen concluded that the reason for female pattern hair loss may be different in the two age groups identified above. In women with female pattern hair loss who have the onset of hair loss between puberty and the age of 30 years, the cause is frequently androgen dependent. In those whose hair loss starts in their 40s or 50s, the cause is likely multifactorial and may involve changes in estrogens, androgens, and/or other hormones. Finally, she acknowledged, the role of inflammation in female pattern hair loss is still unexplored and needs further evaluation. 49

10 Recent Research Brings Generation of New Hair Follicle One Step Closer Susan Kingsley, MBA, PhD (Susan Kingsley, a professional medical writer and President of BioPharma Solutions in Vancouver, BC, Canada, is an independent consultant to the ISHRS and assisted the Forum in covering several keynote talks at the ISHRS Annual Meeting in Vancouver.) Based on Dr. George Cotsarelis s Hair Follicle Stem Cells, presented Thursday, August 12, 2004, at the 12th Annual Meeting of the ISHRS in Vancouver, British Columbia. George Cotsarelis, MD, of the University of Pennsylvania School of Medicine, shared his research on hair follicle stem cells with delegates attending the 12 th Annual Meeting of the ISHRS, held in Vancouver, BC, in August Dr. Cotsarelis set the scene by describing hematopoietic stem cells, the well-characterized common ancestors of all mature blood cells. These self-renewing, multipotent, permanent, and highly proliferative cells are clinically applied in the treatment of diseases such as cancer and congenital immunodeficiencies. However, Dr. Cotsarelis stressed that hematopoietic stem cells are not the only self-renewing, multipotent, persistent cells with high proliferative potential. Epithelial stem cells, including those in the epidermis and hair follicle, also have these characteristics and their manipulation has wide ranging applications, including tissue transplantation and new approaches to hair loss. Summarizing the history of hair follicle research, Dr. Cotsarelis described experiments during the 1980s and 1990s that found stem cells present in the hair follicle in the form of keratinocytes. These keratinocytes had a high in vitro proliferative potential or were long-lived, slowly cycling label-retaining cells (LRCs) in animal models. Although the hair follicle contains rapidly proliferating and differentiating cells, its growth (anagen) is interrupted by periods of regression (catagen) and rest (telogen), with subsequent regeneration. After conducting LRC studies on human scalp grafted to immunodeficient (SCID) mice, Dr. Cotsarelis and his colleagues determined that the stem cells responsible for this cyclical regeneration reside in an area of the follicle called the hair follicle bulge. Further analysis of these bulge stem cells found them to be generally slowly-cycling, long-lived cells that preferentially proliferate at the onset of anagen. They also selectively expressed cytokeratin 15 (K15) throughout all stages of the hair cycle. Dr. Cotsarelis then described the results of recent studies that isolated and characterized bulge stem cells from adult mouse skin. These experiments followed the fate of the isolated cells and demonstrated that they do actually repopulate the hair follicle epithelium. In the first set of studies, the scientists used a K15 promoter in combination with a fusion protein (CrePR1: consisting of Cre recombinase and a truncated progesterone receptor) to design transgenic mice (K15-CrePR1). These mice actively expressed CrePR1 in the bulge cells, but the recombinase was activated only following topical treatment with RU486 (a ligand for PR1). The K15-CrePR1 mice were crossed with another strain of mouse, called R26R. R26R mice express LacZ after activation by Cre, which allows for genetic tagging of the bulge cells and their progeny. The hybrids were given RU486 for 5 days, after which the follicles spontaneously entered anagen. LacZpositive cells were found throughout all epithelial cell types of the new hair follicle, indicating the multipotency and high proliferative potential of the hair follicle stem cells. The scientists then used a different type of transgenic mouse, the K15-EGFP mouse, which expressed EGFP specifically in the bulge. Once extracted from the mouse skin, the EGFP-containing cells fluoresced and could be sorted. Fluorescent cells were again found to have a high in vitro proliferative potential. But, asked Dr. Cotsarelis, do these stem cells maintain the ability to make new hair follicles? He and his colleagues addressed this question by conducting experiments known as recombination assays. They isolated fresh genetically-tagged bulge cells from adult mice and combined these with mouse neonatal dermal cells. This combination of cells was either directly injected into immunodeficient (SCID) mouse skin or inserted into a chicken trachea, then implanted into the SCID mouse. After 4 weeks of growth, new hair follicles derived from stem cells were detected. Clearly, isolated bulge stem cells have the potential to make new follicles, as well as regenerate existing ones, Dr. Cotsarelis concluded. Dr. Cotsarelis continued his presentation by describing the molecular signals behind bulge stem cell survival. Using microarrays (gene-based computer chips), he and his colleagues compared global gene expression patterns between isolated hair follicle bulge stem cells and non-bulge basal keratinocytes. They found that over 150 genes were differentially expressed in the cells from the two sources, with 100 genes from the bulge stem cells comparatively upregulated (enriched expression) and 58 down-regulated (lower expression). Both the up-regulated and down-regulated genes included various growth factors, receptors, and transcription factors. The gene expression patterns were also consistent with the concept that the hair follicle is immune-privileged since numerous histocompatibility genes were down-regulated in the hair follicle stem cells. The scientists were able to identify a set of at least 12 up-regulated genes that may be responsible for maintaining bulge cells in a quiescent and undifferentiated state, and additional genes potentially involved in hair growth. These data demonstrate that bulge stem cells proliferate and repopulate the lower hair follicle at anagen onset during normal hair growth, Dr. Cotsarelis concluded. This new understanding of hair follicle stem cells leads us one continued on bottom of page 51 50

11 Hair Transplant Forum International March/April 2005 From the Literature Eric Eisenberg, MD Toronto, Ontario, Canada Cultured human and rat tooth papilla cells induce hair follicle regeneration and fiber growth. Reynolds, A. J., and C. A. Jahoda. Differentiation December; 72(9-10): Adult human (and juvenile rat) tooth papilla cells were implanted into surgically inactivated (lower half of the follicle was amputated) rodent whisker follicles, and the human cells interacted with follicle epithelium to regenerate new bulbs and create multiple differentiated hair fibres. This illustrates the inductive and stem cell like properties of the mesenchymal (dental papilla) cells. However, the authors caution that even though they have demonstrated that adult human papilla cells can induce hair growth, they do not foresee that tooth extraction and papilla cell culture will lead to a baldness cure. How long can hair follicle units be preserved at 0 and 4 degrees C for delayed transplant? Jiange Q., L. Wenzhong, Z. Guocheng, Y. Liangbin, and S. Wei. Dermatol Surg 2005 January; 31(1):23 6. Department of Dermatologic Surgery, Institute of Dermatology, Peking Union Medical College and Chinese Academy of Medical Sciences, Nanjing, PR China. qianjiange@sohu.com The authors set out to determine the viability of hair follicle units preserved at 0 C and 4 C in Ringer s solution for various periods of time. Their experiments were carried out in vivo in mice, and they determined that the percent of hair regrowth was better at 0 C than at 4 C, and that growth was best if the hairs were transplanted within 24 hours (and no later than 48 hours) of being placed in the holding solution. They contend that their finding greatly helps to further alleviate the concern for the survival of hair follicles that have been chilled for hours before being inserted back into the skin. Of course, caution should be exercised in applying these experimental mice data to human hair transplantation. Is delayed micro-graft hair transplantation possible? Evaluation of viabilities of hair follicles preserved in two storage media. Qian J. G., W. Z. Li, G. C. Zhang, and L. B. Yan. Br J Plast Surg 2005 January; 58(1): Their previous report (Dermatol Surg 2005 January; 31(1):23 6.) on delayed hair transplantation concluded that 0 C solution is better than the commonly used 4 C for long-term preservation of hair grafts. In this extension of the previous experiment with athymic mice, the authors compared preserving the hair follicles in Ringer s or DMEM at the temperature of 0 C. DMEM is a nutrition-rich medium that is commonly used for cell cultures; however, it was not clear to the authors why hair follicles kept in DMEM at 0 C have lower viabilities than in Ringer s solution. This was an unexpected result of their experiment. They concluded that Ringer s solution is superior to DMEM for preservation of hair follicles. Recent Research continued from page 50 step closer to developing new approaches to treating hair loss by means of altering hair follicle cycling (e.g., preventing catagen, triggering anagen onset, preventing exogen) or by generating new hair follicles (neogenesis). Although the procedure is many years away from regulatory approval by the U.S. Food and Drug Administration (FDA), autologous transplants for new hair follicle generation are most likely to be pursued initially. However, allogeneic transplants may be possible, with one anecdotal case reported in which a male hair follicle transplanted into the arm of a woman grew as normal hair, with a mixture of male and female cells. Note: Additional details on some of these studies can be found in Morris R. J., et al. Capturing and profiling adult hair follicle stem cells. Nature Biotech. 2004; 22:

12 Cyberspace Chat Edwin S. Epstein, MD Richmond, Virginia Please send your comments/questions to: EMLA FOR FUE CHEST HAIRS Paul C. Cotterill, MD Toronto, Ontario, Canada I have recently finished my second case of taking 350 grafts from the chest to fill in a scalp scar in the occipital area. While not a mega FUE session, it worked great. Using a topical anesthetic cream, with an occlusive dressing, applied 1-hour prior to anesthetizing the chest donor area really helped to minimize discomfort, because I found this area is not as amenable to a typical field block and was more difficult to anesthetize. OLD PLUG CORRECTION: FUE vs PUNCH EXCISION Bill Rassman, MD Beverly Hills, California With the new methods of FUE using the added step that Jim Harris put in to the process, one can now excise almost every FU in a plug. The older punch excisions depended upon the size of the punch and angle to get it all out. Clearly with the old way to excise grafts, the larger the punch the better the certainty that it would come out. With the new FUE approach, there is virtually 100% certainty to individual FU removal, thereby thinning the grafts to acceptable densities. I have found this technique wonderful and it again changes the paradigm for graft excision. Now, in my practice, I take out FUE style the FUs inside the plugs for some of the cases where this approach has clearly advantages. Eric Eisenberg, MD Toronto, Ontario, Canada I recommend punch excision and suture, and I tell the patient that it is likely that there will be regrowth of some residual hair at many of the punch excision sites that may later require further excision(s). It really is remarkable how hardy the previously transplanted hair is, in spite of our efforts to remove or destroy it (e.g., laser). For reasons previously noted (fibrosis and splaying of hairs at the root level and size of punch used), it is not uncommon to see residual hairs post-excision of previously transplanted plugs. Of course, a larger punch will minimize persistent hairs, but will increase scarring in the frontal area. Mike Beehner, MD Saratoga Springs, New York When I use the 3mm punch with the Bell engine, I fully expect that several of these are still going to have a residual hair or two that aren t encircled by the punch, but I find the scars are more undetectable and there is less dog earring with repairing this size hole. I can then later go back with a far narrower punch and remove any residual hairs. In the crown I have done cases of a large number of large grafts, in which I virtually cored out almost all of the large grafts posterior to the vertex transition point curve and then individually sutured them closed. After I do a few of them, the remaining hole defects take on a slightly oval shape, which tells me the direction of least tension (the elongated axis), and I close it in this direction. Eventually I reach a point where there is not enough laxity to close any more holes. I then go into the balding spaces on top, and I use the Bell engine to cut out the required number of blank, bald circles of tissue (usually 0.5mm larger than the holes I am filling in back). I then close them on top, where there is now plenty of laxity, and then put the blanks into the remaining holes in back and usually put a drop or two of super glue at the edge of this implanted bald tissue graft to help hold it in place. I would not recommend doing this on the front hairline, as the healing of these circular bald patch grafts may not be as aesthetic in this critical area, but I find you can get away with it in the crown area. John Cole, MD Atlanta, Georgia This is one instance in which FUE within the plugs works very well. It typically requires 2 sessions, but he will be much better with one pass. It is not an easy procedure to do unless you see it done. Then it is quite easy to perform, but you must be prepared to take some time to learn it right. Some cases are very easy and some are not. I gather the incisions together with a suture. The FUE will de-bulk the plug elevations and hypopigmentation nicely. Skin resurfacing at the end may be necessary or you may need to perform entire plug excision on some of the grafts, selectively, for the elevated grafts. Some of these grafts do not have much growth in them. These may need to be removed as entire entities. I think it is very important to ask this patient what he wants. Does he want a more natural look, does he want more hair, or does he want more hair and a more natural look? If he simply wants to look normal, you can remove the grafts and simply add back some single hairs in and around the scars you will leave him with to help conceal the scarring. I find that many individuals simply wish they had never done anything and long for a normal bald look. While this may seem surprising to many in the hair restoration field, I run into them often. In the balding process follicular units are lost last. What is lost first is diameter and color. Next you lose hairs within the follicular unit. The last thing you lose is the entire follicular unit. 52

13 GATE THEORY ANALGESIA REVISITED E. Antonio Mangubat, MD Seattle, Washington If I recall the physiology from medical school 25 years ago, pain sensation runs along the slow unmyelinated delta fibers; touch and vibration sensation run along the faster myelinated alpha fibers. All terminate at the same nerve root ganglion. By stimulating the injection area with vibration or touch (rapid conduction), the pain signal (slow conduction) caused by the needle will reach the nerve root after the vibration sensation and find a busy signal and be blocked (closed gate), thus pain is never sensed at the brain. We have used the technique for years with vibrators and simply touch and it really works better than valium. Bill Rassman, MD Beverly Hills, California I purchased a dozen vibrators at the dollar store (actually 99 cents each) with a concern that my staff would eventually take them home and I would need to replace them. With that knowledge, I watched to see what happened. To my pleasure, none disappeared so I maintained my cost of doing business. The patients love their use and they found the pain much less with the vibration than without it. I add a bit of humor when I use them telling the patient that the team leader brought their personal vibrator in from home especially for them. That always gets a smile, making the experience even more positive. Bill Parsley, MD Louisville, Kentucky I have used a very small hand-held massager for several years now. Bernie Nusbaum gave me the idea with one of his talks. It has been one of the most valuable tools I use. I just hold it down just proximal to the injection site along the nerve pathway, as close to the needle as possible. Right before I inject, I press down slightly and pull away from the needle as an extra distraction. We wrap ours in Saran Wrap and paint it with betadine for sterility, but you can put it into the finger of a surgical glove also. Brookstone sells them for about $20. Eric Eisenberg, MD Toronto, Ontario, Canada I have been using it for several years and have found it to be very useful in both the donor and recipient areas. I also find cryoanesthesia a useful distraction in the recipient area prior to anesthesia and during the surgery. I use a refrigerated gel pack that is soft and malleable on the lower forehead, and then over the eyes post-anesthesia. The patients find this very comforting, and it keeps light out of their eyes when working near the frontal hairline. the donor, I apply Betacaine LA ointment (Custom Scripts pharmacy, Tampa, FL) to the hairline, which eliminates feeling the needle when you later go back to anesthetize the recipient. I have found Betacaine LA superior to EMLA or ElaMax and use it for Botox, Restylane, silicone, etc. Mike Beehner, MD Saratoga Springs, New York We have our super wimp protocol, in which I first draw a red line along the route to be anesthetized, and then we have a little parade of the Brookstone vibrator, a small miniature ice cube with one-ply of gauze over it, and lastly the 30g needle making a series of tiny wheals. A third distractant, besides the vibration and the cold of the ice cube, is that, just as I make the needle injection, I also press down with the ice cube, creating a firm pressure sensation also. Lots of sedation before starting the procedure is the best help, along with the all-important factor of including some narcotic (either a Percocet tablet a half-hour before or IV Demerol more commonly). SUPER-JUICE EPINEPHRINE COCKTAILS Carlos Puig, DO Houston, Texas I use super juice all the time. I use 0.6cc epi in 30cc NaCl. I don t think the epi looses its potency, but I do use a 30cc vial in about a month. I do believe that many patients become refractory to the epi after about 6 to 8 hours. About 30% of our larger cases tend to become refractory late in the procedure. CORONAL vs SAGITTAL INCISIONS Jeffrey Epstein, MD Miami, Florida I perform primarily sagittally-oriented incisions, which I will supplement towards the end of a procedure, when I am working with my assistants with some stick-and-place graft placement, using some coronally-oriented incisions when they fit better between the already placed grafts. It is my experience that the most important factor determining naturalness and aesthetics in graft placement is the angle at which the hairs grow. I can control this best when using the smallest possible micro blades, which have two advantages: the smaller incisions allow the graft less ability to rotate back up as the fit is tighter and, second, the smaller blades permit a more acute angulation of incision. My recipient sites are 0.6 or 0.7mm for one-hair grafts, 0.8mm for two-hair grafts, and usually 1.0 or 1.1mm for threeand four-hair grafts. TRANSPLANTS IN YOUNG MEN Jerry Cooley, MD Charlotte, North Carolina I prefer the pocket massagers (Brookstone). Just ask a patient to tell you when you anesthetize with and without it to prove it to yourself. We also put in a ring of tumescence before full strength lidocaine. Prior to numbing Jeffrey Epstein, MD Miami, Florida The age criteria for determining suitability for transplanting young men is one that challenges me every day as I am confronted by these patients seeking cures for their hair loss. The issue is more than viewing the individual as continued on page 54 53

14 nce Upon a Time Norman Orentreich reviewed the past 50 or more years of hair transplant surgery and looked to the future, which, he believes, may lie in transplantation of dermal papillae. This procedure consists of taking a plug, pushing out the dermal papillae of the follicles, growing them in culture, then either placing them back into the same person or planting them into a different person. The technique is already meeting with minimal success in animals. It is also being done with human skin for the benefit of burn patients. O Tar Norwood, MD Oklahoma City, Oklahoma (Vol. 2, No. 3, January/February 1992, p. 2) Reporting on the annual meeting of the American Academy of Dermatology, Dallas, Texas. We are all competitors. Competition is good. We should all be competing to see who can get the best results, but we are artists and we certainly don t think alike. When a patient comes into my office and says, I got a different recommendation from another hair restoration surgeon. I tell him, This is like going to two interior decorators. One may tell you to paint your walls blue and another may tell you to paint your walls yellow. This doesn t mean one is right and one is wrong. It only means that it will look different. Paul Straub, MD Torrance, California (Vol. 4, No. 4, September/October 1994, p. 2) Say good-bye to postoperative swelling! I have reduced the postoperative swelling from twenty percent to less than five percent with the following technique. Add triamcinolone acetonide to the lidocaine to achieve a concentration of 1mg/cc. This is accomplished by adding 50 mg of triamcinolone acetonide to 50 cc of lidocaine. Triamcinolone acetonide comes in 40 mg/cc concentrations so you add 1.25 cc of the triamcinolone acetonide to each bottle of 50 cc lidocaine. This gives you 1 mg/cc of triamcinolone acetonide. Usually you will use a 50 cc bottle of one percent lidocaine on each patient so they are receiving a total of 50 mg intradermally. Whether the reduction in swelling is due to the systemic effect of the 50 mg of Kenalog or the local effect of the Kenalong being injected directly into the dermis I do not know, but the result is minimal or no swelling. This is in addition to the usual preoperative intramuscular steroid injection and postoperative oral prednisone. O Tar Norwood, MD Oklahoma City, Oklahoma (Vol. 3, No. 1, September November 1992, p. 13) Dr. Norwood shared this simple technique over ten years ago. Many of us are rediscovering the value of using steroids in the recipient area. I put the triamcinolone in the tumescent anesthesia so it is evenly distributed throughout the area. By doing this, I find less swelling and less post-op redness. I also give intramuscular triamcinolone acetonide 40mg as well. JEC Editor s Note Cyberspace Chat continued from page 53 someone with a Class 6 or 7-hair loss pattern, which has a chance of being halted at a Class 5 if there is an excellent response to finasteride. After transplanting over 40 young men 24 years or younger over the past two years, I am sure about a few things, but am no more sure about several other issues. Limiting the work to the frontal forelock, advising of the higher incidence of wide scar formation, and stressing the importance of taking finasteride but not relying on compliance are all givens. What I remain unsure about is how to best assess psychological suitability for these procedures, which incorporates elements of maturity, emotional stability, intelligence, and appropriate motivation. I know it makes me sound a bit old fashioned, but today s young men are less respectful of the adult figures they come in contact with, thus potentially compromising the confidence of the doctor-patient relationship, which can have adverse consequences. Please me with your ideas on these topics for the next Cyberspace Chat: CORONAL vs SAGITTAL INCISIONS TRANSPLANTS IN YOUNG MEN or comments on any other topics: esehairmd@verizon.net 54

15 Vance W. Elliott, MD Edmonton, Alberta, Canada Hair Transplant Forum International March/April 2005 Surgeon of the Month Patricia Cahuzac, MD Patricia Cahuzac, MD Paris, France Patricia Cahuzac was born and raised in Paris. In her traditional French family, the girls as well as the boys were encouraged to pursue university studies. She decided to follow the example of her grandfather and uncle who were both physicians. Once she graduated from the University of Paris in medicine, Patricia specialized in dermatology and hair disorders. In 1986, she received a program for the upcoming World Congress on Hair Restoration Surgery, to be held in Los Angeles. Without a doubt in her mind, Patricia immediately thought: I have to go and see what it looks like. She was warmly welcomed at this congress, even though she knew no one and was the only female physician present. She was very impressed by the techniques and results, as they were not well known in Europe at that time. While there, she met her countryman and future mentor, the world-famous Dr. Pierre Pouteaux. He was an artist, says Patricia. Once back in Paris, she joined Dr. Pouteaux s busy hair practice and worked with him until his retirement in the mid-1990s. They benefited from visiting American colleagues over the years, especially Dr. L. Lee Bosley and Drs. Walter and Martin Unger. Patricia s practice is located in the center of Paris and is completely devoted to hair transplantation. The clinic most often uses the multi-unit graft (MUG) technique, utilizing two or more follicular units in many of the grafts. A typical operation consists of 150 single follicular unit grafts and 500 to 800 MUGs. Patricia believes that this combination method gives the best results to her patients. Patricia has contributed to our specialty, presenting regularly at the annual scientific meeting. These presentations have included how to standardize before and after patient photographs and a study comparing needles vs. blades for making recipient sites. In Vancouver, she presented her research comparing measurements of hair shaft diameter using the micrometer with those obtained through image analysis. Currently, Patricia is Secretary of the French Society of Hair Restoration. She also serves on the Ad Hoc Committee on Board Certification for the ISHRS and is active in the European Society of Hair Restoration as well. She has been married for 25 years to Jerome, a plastic surgeon, who is also a former member of French Parliament and is currently the mayor of a large town in southwest France. They have three grown children. In her free time, Patricia enjoys swimming, skiing, and playing golf. Another of her passions is singing opera, which she does with a teacher twice a week. Patricia says, I think it is quite a challenge for a woman to be a specialist in hair transplantation, and at the same time have a real family life and time for hobbies and sports. But it makes for a life that is rich and full of satisfaction. 55

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17 Scalp Dermatology for the Hair Restoration Surgeon Seborrheic Dermatitis & Psoriasis Bernard P. Nusbaum, MD Miami, Florida One of the goals of the hair transplant consultation is to identify any concurrent scalp pathology that might influence the surgical outcome. In this regard, the most commonly encountered scalp conditions are seborrheic dermatitis (SD) and psoriasis. Seborrheic Dermatitis Seborrheic dermatitis presents as a chronic, recurrent condition that ranges from mild involvement, called dandruff, to moderate and severe forms. The prevalence of SD (excluding dandruff) is 2% to 5% of the population. If dandruff cases were included, the prevalence would probably be much higher. Dandruff, characterized by itching and flaking of the scalp, involves the upper layers of the epidermis. Moderate and severe SD involves the dermis as well and is associated with a much greater degree of inflammation, presenting as erythema, yellowish scaling, and oozing and crusting of serum. Aside from the scalp, SD commonly involves the ears, nasolabial folds, glabella, and hair bearing areas of the face, such as the eyebrows, eyelashes, beard, and moustache. A normal yeast colonizer of the scalp, Pityrosporum, is thought to play a role in the pathogenesis of SD by causing the formation of free fatty acids that act as an irritant, causing hyperproliferation of the epidermis. 3 SD is not, however, contagious from borrowing a comb or brush from someone else. Patients often relate flare-ups with emotional stress. Treatment is aimed at keeping the condition under control rather than curing it. Over the counter (OTC) shampoos containing tar, salicylic acid, zinc pyrithione, and selenium sulfide may be sufficient for dandruff. Prescription ketoconazole and ciclopirox shampoo have been shown to be effective due to their antifungal effect. For moderate to severe SD, topical corticosteroid lotions, foams, and shampoos are usually required. In refractory cases, oral antibiotics, oral antifungals, and systemic corticosteroids are options. A typical sequential treatment approach is to use a topical corticosteroid at bed time and a non-steroid (i.e., tar or antifungal) shampoo in the morning during the initial treatment phase. Once the condition is improved, the frequency of topical steroid application is tapered while the daily shampoo is continued. For maintenance, the corticosteroid is eliminated and the OTC or antifungal shampoo is continued for maintenance. If a flare-up occurs, the patient returns to the first phase of treatment and repeats the sequence. Although there are no studies evaluating resistance to treatment, it is generally accepted that, to maintain efficacy, patients need to rotate between different medicated shampoo ingredients. This is probably due to the fact that different active ingredients treat different components of the disease and OTC shampoos contain only one active ingredient. 3 Psoriasis Psoriasis and SD have overlapping clinical features. In contrast to SD, however, psoriasis is characterized by sharply defined, raised, erythematous scaly plaques, rather than the diffuse erythema and scaling seen in SD. Some authorities feel that the diagnosis is likely to be psoriasis if the disease extends beyond the frontal hairline onto the forehead. Involvement of the nails and plaques on the elbows and knees are commonly present although psoriasis may be confined to the scalp. Sebo-psoriasis is a term used to describe the patient s condition when it has features of SD and psoriasis and is difficult to differentiate between the two entities. Psoriasis of the scalp is a common condition and affects 2% of the population. 4 It occurs in those genetically predisposed and as a result of environmental triggers. These triggers include tobacco use, medications such as betablockers, and infections (e.g., strep pharyngitis). Injury to the skin can result in the appearance of psoriatic lesions, the so-called isomorphic response, or Koebnerization. Psoriasis of the scalp can be treated with topical agents including corticosteroids, anthralin, vitamin D3 analogues, and salicylic acid (for removal of thick scales). Persistent scalp plaques can be injected with intralesional triamcinolone acetonide (e.g., 2.5mg/ml). Shampoos containing tar or salicylic acid are important components of topical therapy. A sequential approach like that described for SD can be utilized because prolonged topical steroid application can result in tachyphylaxis or decreased efficacy with continued use. Relevance to Hair Transplantation The presence of SD and psoriasis is relevant for several reasons. Generally, one would like to avoid incising affected skin in the donor or recipient areas. Also, both disorders are associated with compromised skin barrier function and a possible increased incidence of staph colonization. Of particular concern in psoriasis patients is the isomorphic or Koebner phenomenon, which describes the appearance of psoriasis lesions in normal skin that has been subjected to even minor injury. The incidence of the isomorphic response as a result of hair transplantation must be uncommon as the author has transplanted several psoriasis patients throughout the years and has never witnessed its occurrence. Eisenberg 1, however, describes one patient who developed psoriasis in the transplanted area. From a historical perspective, it is inter- continued on page 58 57

18 Scalp Dermatology continued from page 57 esting that in Orentreich s original paper on transposition of skin punch grafts, the only psoriasis patient studied developed psoriasis in all four grafts performed; including when normal skin was transplanted into a normal recipient area. Psoriasis also occurred when normal skin was transplanted to a psoriatic site and when a psoriatic graft was transferred into normal skin. 2 It is not clear, however, if the grafting in that psoriatic patient was performed on the scalp. Patients may ask whether their condition causes hair loss. Although some authorities believe that the underlying inflammation of SD and psoriasis may be a factor in hair loss, patients should be reassured that in general it does not. However, frequent scratching can disrupt the hair shaft cuticle and result in hair breakage. In scalp psoriasis, hair loss is rare and usually associated with vigorous attempts at removing scales. Both SD and psoriasis should be treated aggressively and cleared as much as possible prior to surgery. The author recommends patients with SD or psoriasis to be on topical therapy during the 2 weeks prior to the transplant procedure. Although its occurrence is probably uncommon, the possibility of an isomorphic response in the donor or recipient area should be discussed with psoriasis patients at the time of the consultation. The reason we do not see more cases of the isomorphic response in hair transplantation of psoriatics may have to do with the routine administration of oral corticosteroids to prevent post-operative edema. Likewise, the practice of adding triamcinolone to the recipient area anesthesia should perhaps be incorporated in psoriatics to mitigate against the development of an isomorphic response. If, on the operative day, psoriasis or severe SD is identified in the proposed donor zone, it may be prudent to avoid the affected area if possible. The author is not aware of any studies or anecdotal reports describing complications resulting from incorporating affected donor tissue in hair transplantation procedures. REFERENCES 1. Eisenberg, E. Hair Transplantation, Fourth Edition. Unger, W. P., and R. S. Shapiro eds. Marcel Dekker: Orentreich, N. Autografts in Alopecias and Other Selected Dermatological Conditions. Annals New York Academy of Sciences, 1959: (83) Wolf, J., et al. Inflammatory Scalp Disorders: Seborrheic Dermatitis. Supplement to Skin and Aging. December Van de Kerhof, P. C. M., and M. E. J. Framssem. Psoriasis of the Scalp: Diagnosis and Management. Am J Clin Dermatol 2001: (2)

19 The ISHRS annual Live Surgery Workshop was held in Orlando this March 2 5, The venue for the didactic morning sessions was the Contemporary Resort in Disney World, which provided comfortable facilities with state-ofthe-art audiovisuals. Wednesday was devoted to beginners programming and started with opening remarks from Program Chairman Dr. Matt Leavitt. He explained the unique opportunity for participants to interact with world-renowned faculty at this meeting. Dr. Leavitt expressed his hospitality in a very frank and warm manner and stated that if anyone in the audience needed any help to call him personally. He then actually announced his cell phone number at the podium! It was with this spirit of camaraderie that newcomers as well as seasoned veterans were made to feel at home. The meeting was co-chaired by Dr. David Perez-Mesa, who spent countless hours coordinating the well-run lecture sessions as well as the live surgery workshops. The first day s beginner s program started with Dr. Bernie Nusbaum describing stepwise methods for hair loss diagnosis. Dr. Robert Leonard spoke about the consultation with emphasis on how to avoid pitfalls that lead to unrealistic patient expectations. He emphasized our responsibility to do the right thing for our patients and for our profession as a whole. Dr. Arturo Sandoval spoke on proper hairline placement, specifically what he terms the shingling point, which is the point at which transplanted hairs can overlap with each other giving the appearance of greater density. He described a maneuver whereby the ulnar part of the hand is placed on the frontal or temporal area and gradually moved upward. The point at which the hand begins to slide on the horizontal plane is the point where Dr. Sandoval likes to start his hairline. Dr. Vance Elliot described how maximal tumescence optimizes multiblade harvesting so that it can be extended to the temporal area without neurovascular transection, thus expanding the available donor zone. Dr. Robert Niedbalski lectured on graft preparation and explained how to tailor the graft to the patient s scalp characteristics and described the benefits of backlighting as well as optimal techniques for slivering. He also touched on the importance of ergonomics for the cutting work station. Reports on Orlando 2005 Bernard P. Nusbaum, MD Coral Gables, Florida Wednesday, March 2 Participant Tutorial Cutting Station This year s annual meeting program chair in Sydney, Dr. Jennifer Martinick, did her usual outstanding job of describing the essentials of recipient site creation. Specifically, keeping sites small to avoid vascular interruption and facilitate dense packing. She is a proponent of recipient area tumescence and expounded on ways to achieve optimal, but safe, recipient site density. She wisely reminded the audience that it s not how many follicular units you transplant, but how many grow. Dr. Ives Crassas described his vast experience with automation and Dr. Carlos Puig discussed ethics, stressing the need to provide patients with complete, truthful information so that they can make informed decisions. Dr. Puig also stated that lay consultants should be used only to educate patients, and not assume the role of physician in providing evaluations and treatment plans. Dr. Alan Bauman gave some extremely valuable insight into how publicity and public relations can benefit a hair restoration practice, and Dr. Marco Barusco described the keys to developing an efficient staff. Dr. Edwin Suddleson described state regulations of office anesthesia and suggested the minimum requirements for emergency care in the hair transplant office setting. As an important reminder to beginners and experienced surgeons, Dr. Perez-Mesa described hair transplant complications and provided excellent advice to all in the audience. He stated that the worst mistake a doctor makes in the face of a complication is to deny or minimize it and not be supportive and accessible to the patients. Dr. Leavitt closed the morning session with a lecture on how to provide a world class experience to our patients. He emphasized how important patient referrals are to building one s practice. After lunch, we were off to the afternoon live surgery workshop, where four follicular unit cases were being demonstrated simultaneously. OR coordinators were Drs. Edwin Suddleson, Ed Epstein, Matt Leavitt, and Glenn Charles, each assisted by other faculty members and technicians. Participants were able to observe surgeries in the ORs, and the procedures were also simultaneously broadcast live, with sound, to viewing lounges. Each lounge had a faculty member with a microphone able to relay questions to the doctors performing the surgery. These audience coordinators continued on page 60 59

20 were experienced faculty and were able to discuss topics of interest as they arose during the course of the surgery. The broadcast quality was at a professional level and the viewing lounges were equipped with large Fujitsu plasma monitors, the Rolls Royce of video screens. At times, the view of the surgical field was better from the viewing lounge than in the packed operating rooms! This setup worked beautifully, as the viewing audience was able to communicate freely with the surgeons at any moment. Techniques demonstrated ranged from surgical planning to anesthesia to graft placement, and everything in between. Drs. Charles and Epstein performed cases utilizing perpendicular sites, as Dr. Leavitt demonstrated various choices of instruments for recipient site creation. In another OR Dr. Bauman was performing follicular unit extractions and doctors as well as technicians were being instructed in microscopic dissection in the cutting stations. It was quite a show! The day ended with a delicious buffet at the welcoming reception held back at the hotel with a view of the enchanting Magic City in the background. We were all exhausted and yet, it was only day one. Michael L. Beehner, MD Saratoga Springs, New York Thursday, March 3 The 11 th Annual ISHRS Live Surgery Workshop program officially opened Thursday morning with a warm welcome of the nearly 150 attendees from co-directors, Matt Leavitt, DO, and David Perez-Mesa, MD. ISHRS President Tony Mangubat, MD, also spoke and urged all of those new to hair transplantation to join the ISHRS, and gave an update on progress for our subspecialty to eventually have a seat in the AMA House of Delegates. Panel 1 The Younger Patient: The morning was structured around panels on different topics of current interest in HT. The first group addressed how to handle the younger patient who presents in consultation. Before the group was two young men in their early 20s with Norwood IV V hair loss who were considering HT. Dr. Robert Cattani adroitly directed questions to the patients and the members of the panel, composed of Drs. Leavitt, Dow Stough, and Bill Parsley. Both Drs. Stough and Parsley expressed reluctance to transplant young men in their 20s and favored medical treatment during this time period, while Dr. Leavitt was willing to begin transplanting a frontal frame if the young man s expectations were realistic. Dr. Leavitt did point out, however, that many patients in this age group approach this decision with too much emotion, a lot of peer pressure, and often don t have the financial means to handle such surgery. Dr. Parsley encourages such men to also consult with 2 3 other hair surgeons and get different opinions. Both patients said that they would start out with medical therapy, as long as they were assured their hair loss situation would definitely improve. Panel 2 Follicular Unit Extraction (FUE): Dr. Jim Harris next moderated an exciting panel presentation on FUE. Joining him on the panel were Drs. Marc Avram, Marcelo Gandelman, Yves Crassas, Alan Bauman, and Paul Rose. Dr. Bauman emphasized that there are no standards yet for its use. He also noted that good magnification is 60 necessary. He uses a 3.3 Zeiss lens that attaches to his glasses. Dr. Avram feels the punch size should never exceed 1mm in diameter. In a series of 200 patient consultations, upon questioning he found that less than 5% cared about having donor scarring so minimal that they could later shave their heads. He therefore concluded that FUE is indicated in less than 5% of patients presenting for HT. Dr. Crassas demonstrated on video his drill suction technique, in which either a 1.0 or 1.5mm diameter powered rotary drill is used to remove the individual FUs. In Panel Discussion, Follicular Unit Extraction : Drs. Paul Rose, Alan Bauman, Marcelo Gandelman, Marc Avram, Yves Crassas, and James Harris (Moderator) closing, he called the whole process a lot of work! Dr. Gandelman shared his reverse follicular extraction technique for obtaining long hairs for fine eyelash and eyebrow work. Dr. Rose called his and Dr. John Cole s procedure FIT (follicular isolation technique). He feels FUE is indicated for a minority of HT patients chiefly the young patient, a person with limited donor supply, one concerned about a later donor scar, and in scar revision projects. He pointed out that some patients, especially those with slightly darker skin, develop hypo- or hyperpigmentation in the speckled donor sites and can t later shave their head without these showing. Dr. Harris presented his technique, which utilizes two maneuvers: an initial circular sharp punch incision to a depth of around 1.3mm, followed by a duller second punch, which completes the remainder of the freeing up of the follicle. In a study of 40 patients, involving over 10,000 grafts, he found a 5.6% transection rate, and could remove 25 grafts every 2.76 minutes (a rate of 543 grafts per hour), although he concedes that 300 grafts per hour is probably a more realistic and practical limit with his technique. He found graft burial to be the biggest problem, followed by capping (a sloughing of the epidermis off the graft). In one case that he studied, there was a 7.2% graft burial rate and he recommended the

21 best way to handle these may be to leave them buried. He feels 100% of HT patients are potentially FUE candidates and that a FOX test is not necessary. He demonstrated his technique later in the live surgery portion that afternoon, and those in attendance were impressed with the high percentage of intact grafts and the rapid smoothness with which the procedure was carried out. Panel 3 Recipient Sites: Dr. Carlos Puig moderated this panel, with Drs. Bill Parsley, Vance Elliott, Ron Shapiro, and Matt Leavitt contributing. Dr. Parsley first presented an overview of all the instruments available for making sites and stated his preference for either needles or small custom-cut blades. Dr. Shapiro emphasized that the number of grafts needed for a session depends on one s goals for density, and stressed the need for creating a gradient of density. He has recently changed to using custom-cut blades of mm range of width, but creates them with an angled, sharp end rather than a flat one. He uses follicular families and small MFUs of 3 4 hairs in the frontal tuft region. In the mid-scalp region, he uses the slightly larger MFUs and places them coronally to give more visual fullness. All the panelists agreed that angle and direction were the two most important factors in creating superior aesthetic results. There were mixed opinions on when using perpendicular (coronal or lateral slits ) or parallel (sagittal) sites were preferable. The perpendicular sites were most favored in the frontal hairline region, and most felt they were less important further posterior. Panel 4 Dense Packing: Dr. Mike Beehner moderated this discussion, with the help of panelists Drs. Sharon Keene, Ed Epstein, and Ron Shapiro. Dr. Keene questioned whether extremely highdensity planting yields good survival percentages or not, as no one has studied this. Dr. Epstein emphasized the importance of using small sites that precisely fit the graft placed therein. Dr. Shapiro again pointed out that we actually only can dense pack above 40/cm 2 in a limited area in the frontal region because the remaining grafts, even in a large case of 3,000 FUs, have to be placed at gradually reduced densities to cover even the front 50 60% of MPB. Dr. Beehner referred to his research, in which he obtained 89% FU survival at both 40/cm 2 and 50/cm 2 with 2-hair FUs in 20g needle sites. He pointed out that previous studies had shown a big drop-off in survival when exceeding 25/cm 2, but were done mostly with 18g needle recipient sites. He feels the size of the recipient site seems to be the key factor in successful hair growth at these densities. Panel 5 Increasing Density, Hair Growth, and Survival: Dr. David Perez-Mesa led this panel presentation, assisted by Drs. Marc Avram, Mike Beehner, and Carlos Puig. Dr. Avram stressed the importance of using minoxidil and finasteride to hold on to preexisting hair. Dr. Puig demonstrated the use of 5% methylene blue solution for coloring white and gray hairs, so that they are better visualized by the dissecting team. The donor ellipse is immersed first in the solution, and later the individual slivers are immersed for a second phase, both of which have to be very limited (5 7 minutes) to avoid over-darkening the tissues. Dr. Beehner referred to mixed results in dense-packing females in the frontal tuft region with 3-hair FUs in 18g sites. Only a third of the patients showed excellent growth and twothirds showed only fair growth. He is now using 2-hair FUs in 20g needle sites in the same region in a limited number of female patients and will evaluate growth later this year. Panel 6 Complications: Dr. Tony Mangubat presented a series of patient photos of difficult repair situations (old HT work and burn patients) to a panel composed of Drs. Bessam Farjo, Dow Stough, and Paul McAndrews. Most of the cases involved hairlines that were too low and flat, and consisted of old large grafts. Dr. Mangubat pointed out that those patients with loose forehead skin could be best handled by performing a brow lift combined with excision of the offending grafts. The panelists suggested elliptical excision of grafts for most of the patients and small individual excisions or punchouts for others. Dr. Stough pointed out that sometimes an alopecia reduction, performed behind these grafts, often elevates and brings in the flat, outer hairline contour. Most of the group felt that electrolysis and laser worked poorly in removing these grafts, as they don t work that well in hair this dense and laser can sometimes leave pitting. The use of scalp expanders was necessary in two burn patients to cover the alopecia defect, and one of Dr. Mangubat s female patients was present and spoke to the group, Drs. Bernard Nusbaum, James Harris, Randall Sword, Susan and Dr. E. telling how this surgery had such Antonio Mangubat, and Dr. Andrew D. Kanalec (back row) a profound impact on her self-image and sense of well-being. Eyebrow and Eyelash Transplantation: In the day s final lecture, Dr. Marcelo Gandelman gave an exquisite review of these two procedures. He stated that having a drawing in front of you, with the natural directions of the hairs in the human eyebrow, as you plan the patient s session is invaluable. He also demonstrated his technique for transplanting the upper eyelashes, using a curved needle with a needle eye, through which is threaded a long donor hair with its attached follicle. This is brought down through the skin overlying the eyelid and brought out through the tarsal plate area, so that the follicle-hair junction of the graft is brought precisely to the eyelid surface. Live Surgery Workshop and Research: The group then headed to the surgery center where Drs. Alan Bauman and Jim Harris demonstrated their FUE techniques, as referred to earlier. Dr. Ron Shapiro performed a 1,500 FU dense pack- continued on page 62 61

22 Hair Repair: Donor Scar Repair Steven C. Chang, MD Newport Beach, California History A 53-year-old Caucasian was referred with a history of numerous surgeries starting 20 years ago that left him with wide, cosmetically unacceptable donor scars. A scar revision had been done seven months prior in an attempt to improve the appearance. No improvement was seen after scar revision. His main complaint is that he has to use upper parietal hair to cover up the scars on the posterior occipital donor area. On windy days, the scar is very noticeable. His physician retired and referred him to my clinic. This case was first presented in a previous issue of the Forum (Vol. 14, No. 4, July/August 2004, page 143). Exam The donor scar measures 24cm long by 4cm wide (Figure 1). There is only sparse hair growing within the scar. There is almost no donor hair available from the traditional donor area. After close examination, I found there is still a little bit of donor hair available at both upper parietal areas. The maximum donor from one side that I can remove is 8cm long by 0.4cm wide. Another side is 7.5cm long by 0.4cm wide. Total donor area available is 6.2cm 2. And the total scar area is 96cm 2 (24cm long by 4cm wide). Treatment A previous scar revision had failed, and it was decided that more attempts to excise the scar would not be successful. If the whole scar area is grafted, the improvement will be minimal. This increase in density is not going to help much at all. Therefore, the scar area in each temple, measuring 5 cm long by 4 cm wide, was not treated. A decision was made to transplant only the occipital area and the transplanted area was reduced to 14cm long by 4cm wide (56cm 2 ). From 6.2cm 2 of excised donor area, 320 double follicular unit grafts were produced. The occipital scar was grafted at higher density at the top of the scar to give more hair to shingle downwards. Follow Up Seven months later, the patient returned for the follow up visit. He was completely satisfied with the posterior hair coverage (Figure 2). This case demonstrates that focusing a relatively small number of grafts into a cosmetically critical area can have a significant impact. Figure 1. Figure 2. Live Surgery Workshop continued from page 61 ing session, and Drs. Marco Barusco and Marcelo Gandelman combined their talents in performing an eyebrow transplant. In a research study comparing transection with a multi-blade knife versus free-hand incision, Dr. Vance Elliott used a 3-blade multi-blade knife holder and Dr. Glenn Charles excised with a #10 Personna blade. Identical 3cm lengths were examined and surprisingly there were 41 transected hairs in the multi-blade cut section and 70 transected hairs in the free-hand section. Dr. Bill Parsley added, I watched Jim Harris perform his FUE and checked his grafts. They were incredibly good. Checking them under the microscope, the grafts were intact with less than 3-4% transection. There was a little kinking of the base of some of the follicles but it looked insignificant. I walked away feeling privileged to have been there to witness what I consider a breakthrough. Jim s too modest to brag on himself, so we will do it for him. His technique seems to be to rotate the sharp end 90 in only one direction, going no more than 1.3mm deep. Then switching to the dull end, he rotated it back and forth (counterclockwise, then clockwise) until it popped through to the subcutaneous layer. Removing the grafts consisted of simply plucking them out. Not only were the grafts good, but he was doing them fast. With another full and intense day under their belts, faculty and attendees alike all headed for Pleasure Island for cocktails, snacks, and socializing. 62

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25 AUSSI CULCHA CORNER Richard C. Shiell, MBBS Melbourne, Australia A continuation of Dr. Shiell s guide to Australia and correct behaviour when Down Under. There are lots of wild and crazy guys in Australia. This is not surprising when you realize how and why we all got here, in this far-off corner of the globe. Disregard for Authority From the earliest years of settlement in Australia, the Colonial Governors and other respectable citizens were writing back to England about the disrespect shown to them by the citizenry, both free and fettered. In the Olde Country it was customary to doff one s cap or, if you were illdressed enough to be hatless, tug one s forelock when passing someone of higher social status. In the new land, the convict workers, already social outcasts, could not be convinced of the necessity for this action and the free settlers and others who had served their time had the audacity to consider themselves as social equals!! This disregard for authority is so marked here that one of our great national heroes, Ned Kelly, is in fact an anti-hero. There were grievous faults on both sides, but in the final analysis he was a 23-year-old Irish-born horse thief and bushranger who was hanged in 1880 for the cold-blooded murder of three policemen. He was regarded as something of a Robin Hood in the area where he lived in northeast Victoria, but although he certainly robbed some of the rich, there was never a lot left over for distribution to the poor after handouts to his other gang members. It was the manner of his final capture that settled his legend for all time and established the phrase game as Ned Kelly, which is still used to this day. Cornered with his gang in the Glenrowan pub, which had been set alight by the besieging constabulary, he donned a suit of heavy armour that he had made from leather and beaten plough shares and emerged in the morning mists with two guns blazing. As bullets ricocheted off him he seemed indestructible. It took the police some few minutes to realize that there was only a leather flap below the knees and they quickly cut him down. He was captured, patched up, tried, and hanged in the space of a few months. Legend has it that his last words were such is life, and his death mask can be found in the Old Melbourne Jail. This disregard for rank was noted in the soldiers who volunteered to go to the Boor War in 1898 and in all subsequent wars. Much to the annoyance of British senior officers, first names and nick-names were used between the officers and members of all ranks except for official purposes and when on parade. This familiarity was supposed to sap morale and discipline but the soldiers had an outstanding battle record and besides, they were all volunteers, rather than conscripts as in Britain, and would not have it any other way. This familiarity persists to the present day and in fact it has become more widespread in recent years with almost all lawyers and clients, doctors and patients, school teachers and pupils now using personal names rather than titles and surnames in conversation. I seldom see this in the United States and NEVER in the old cultures of Europe. Religion Australia has had several interesting migration waves. Unlike the United States, very little migration to our shores was a result of religious persecution in Europe. A few shiploads of Lutherans from some sect in Germany came to Adelaide in the 1840s. There have also been a small number of Jewish refugees from Europe. They had been arriving since the 1890s but their numbers increased considerably in the years immediately before and after WW2. So How Did the Rest of Us Get Here? The majority of us are descended from the following: 1. Convicted persons from Britain mostly petty thieves, prostitutes, and political malcontents (The murderers and serious thieves were hanged promptly in Britain and not deported.) 2. Custodians of the above and soldiers to guard the custodians (The members of both groups were often more bent and immoral than the convicts they were sent to guard.) 3. A small number of younger sons of rich British and Scottish landowners who, because of the British laws of primogeniture, did not get to inherit land from Dad in Britain 4. Adventurers from all over the world seeking their fortune during the very rich gold-rush period ( ) 5. British migrants seeking a new life after the austerity of the War years 6. Refugees from Italy, Greece, Holland, and the Baltic region after WW2 (mostly Catholic and Greek Orthodox) 7. Buddhist refugees from Cambodia and Vietnam from the 1970s onwards 8. Islamic refugees (Iraqis, Iranians, Turks, and Afghanis) from the 1980s onwards. These now make up a substantial Muslim population in some areas of Australia. The result of all this is that Australia, although still a nominally Christian country, with Christian prayers read in Parliament before each session, is really quite a melting pot. In practice it is a predominantly irreligious nation with very few people attending religious services regularly. (I don t know about the Muslims but I think the Catholics and Baptists can barely manage 20% regular attendance and the rest less than 5%.) Church attendance was a lot higher in the early years of the 20th Century but declined rapidly after the 1970s. In spite of this, the anti-drink policy of the Methodists almost got us landed with Prohibition in the 1930s. Fortunately the Heathen majority somehow prevailed! To illustrate the difference between the U.S. and Australia, our present Prime Minister, John Howard, is the first Prime Minister for decades who is a professing Christian (Methodist), but he doesn t make a big deal of it. There are seldom any photos of him going to Church with his family, continued on page 66 65

26 Aussi Culcha Corner continued from page 65 although I think there was one in the lead up to the elections last October. This was to remind the public of the difference between Howard and his main opponent (who was a declared atheist). Howard won. Can you imagine any serious politician in the United States daring to declare that he was a nonbeliever! Guns The other big difference here is that the Gun Lobby is very weak and we have very strict laws making it enormously difficult for a law-abiding citizen to own a gun. (I handed my two rifles in 7 years ago because it became all too hard after the Port Arthur Massacre in which 34 innocent tourists were murdered in a 30-minute rampage by a crazed gunman). Of course, the cops and criminals still have handguns and kill each other quite regularly, but domestic murder by gunshot, outside of the drug scene, is quite rare in Australia. Alcohol Liquor can be served to anyone over 18 years of age. It is available in pubs, liquor stores, and many supermarkets, and drunkenness is a common problem in teenagers and young adults. Beer is much stronger than U.S. beer (4.9% alcohol), although light beer of 2.9% is easily available. Wine is excellent and very cheap in Australia by American standards. Drinking to excess has always been a problem in Australia since the earliest years when, due to a lack of hard currency, rum was used as a vehicle of exchange for a few years. The Officers of the New South Wales Corps had the monopoly on the production of rum and when Governor William Bligh (yes of Mutiny on the Bounty fame) tried to curtail this, he provoked another mutiny known as the Rum Rebellion, and he was arrested and imprisoned by his own soldiery in Driving on the Roads Roads are pretty good, and there are well-marked motorways. We have pretty strict road laws, particularly in regard to alcohol consumption and driving at blood levels over 0.05 %. The wearing of seatbelts by the driver and all passengers has been compulsory for the past 35 years and has saved a vast number of lives. Tipping and Gratuities There is no obligatory tipping for services in Australia, although bellhops, waiters, and taxi drivers will certainly not refuse it if offered. In fact, if you tell your taxi driver to keep the change he will probably thank you profusely and even take your suitcase out of the trunk for you! Restaurant tipping is a little more common, particularly in the better class places but never in cafes and bars. If you got a really great meal and great service, 10% would be plenty. There is seldom a service charge added to hotel bills, but it pays to check as everything is subject to change these days and I seldom visit four-star establishments in Australia. Some More Language Tips for Use in Taxis As in most Western countries, at least half the taxi drivers will be from a recently arrived immigrant or student group Nigerian, Afghan, Chinese and will speak very little of the Australian dialect. If you are from the United States, you might be lucky, as they have probably been brought up on a cultural diet of American movies and TV programs and very likely will be able to understand you better than they can the Aussies. The rest of the taxi drivers will be well-established Australians of Anglo, Italian, Greek, Turkish, or Lebanese persuasion and will speak English with broad Aussie accents mixed with a little of their native tongue. She s a nice die t die. = A fine day isn t it. Yousa froma Chicago? You musta knowa my cousin Luigi! (No translation necessary) Apart from the above small points and driving on the left hand side of the road, things are not so different here in Australia. To be continued 66

27 A QUICK-REFERENCE GUIDE TO AUSTRALIAN LINGO Russell Knudsen, MBBS Sydney, Australia G day mates. How y er going? Hear you re coming Down Under to have a bit of a natter with your mates. Strewth! Reckon you d better practice your Aussie otherwise you ll be completely up the spout. Our lingo is a bit unusual to youse lot and especially to the septic tanks. Have a gander at the list below: Pissed = drunk Piss-pot = heavy drinker Bloke = male Sheila = female True blue = genuine Fair dinkum = honest Dunny = loo = toilet Buggered = tired Drongo = stupid person Dropkick = obnoxious person Aggro = aggressive Amber fluid = beer Kick arse = totally amazing Ankle biter = young child Arvo = afternoon Boozer = public hotel Dough = money Example A bloke and his sheila took the ankle biter to the boozer one arvo. After a couple of amber fluids he needed to go to the dunny, but as he tried to enter he was stopped by some drongo who wanted a lend of some dough. He said to the guy, who was pissed, Fair dinkum, you look buggered, a man doesn t need to keep on the piss does he? The dropkick started giving a bit of aggro, but our bloke, being a true blue family man, managed to calm the piss-pot down and went to the loo. When he came back to his sheila, who had noticed what had happened, she said admiringly: You re a kick arse bloke, you could get lucky tonite! Translation to Above Introduction Hello friends. How are you? I believe you are coming to Australia to have a conversation with your friends. Goodness! I think you should practice your Australian language otherwise you will be completely confused. Our language is a bit unusual to others and especially to yanks (U.S. citizens). Have a look at the list below: 67

28 Make plans to attend The Big One, Down Under! Working Towards a Sustainable Industry for the Future MESSAGE FROM THE PROGRAM CHAIR Dear Colleagues, Here is a prediction: You will feel the warmth of the Australian sunshine as it glistens on Sydney and its beaches. You will take in the spectacular view of Sydney harbour and feast on seafood just so fresh. If you take the trip to the Great Barrier Reef, you will be in tropical paradise amid rugged natural beauty, and experience exotic gardens where frangipani perfumes the evening air. Yes, all this will be yours if you are coming to the ISHRS Conference in Sydney August of this year. Arrangements for the Sydney meeting are well advanced and a large number of high-quality abstracts have been received for the General Session. The program has been determined using feedback from last year s attendees, along with assistance from the CME Committee, and advice from previous Program Chairs and the Forum literature review. It is what you have requested, and it truly reflects the industry s needs and direction for the future. Highlights will include panel discussions on Complications and Emergencies, Corrective Work, Young Unrealistic Patients, Asian and Ethnic Hair, a Comparison of Different Graft Types, their harvesting and use, how to avoid litigation through Conflict Resolution, and a Media Panel exploring the public s view of hair restoration surgery. The very popular Live Surgery Workshop and Live Patient Viewing along with Video Theater have been included. An exciting new program of Workshops will be taught at different levels. Excellent Basics, Advanced, and Surgical Assistants courses round out the program. Another Prediction: You will thoroughly enjoy this meeting. See you at the Big One, Down Under. Warmest regards, Jennifer Martinick Program Features Live Surgery Observational Workshop Basics in Hair Restoration Surgery Course Advanced Review Course Surgical Assistants Program 14 Workshops & 2 Courses Peer Networking and Discussion Forums Two Courses (each consists of two parts) Course A: Hairline Design & Maximizing Transplant Density (Intermediate) Course B: Preparing Grafts & Making Incisions and Placing Grafts (Beginner) 2005 Annual Scientific Meeting Committee Jennifer H. Martinick, MBBS, Chair Edwin A. Suddleson, MD, Basics Program Co-Chair Vance W. Elliott, MD, Basics Program Co-Chair James A. Harris, MD, Advanced Program Chair Arthur Tykocinski, MD, Workshop Chair Russell Knudsen, MBBS, LSW Local Liaison Edwin S. Epstein, MD, Immediate Past-Chair Helen Marzola, RGN, Surgical Assistants Chair Pamela Hulley, RN, Asst. to the Surgical Assistants Chair 12 Workshops Taught at Varying Levels FUE (Advanced) Female Hair Loss and HT (Advanced) Managing Group Discussions Fellowship Director Training (Advanced) Testmanship Prep for ABHRS Board Exam (Advanced) Lateral Slits Coronal/Transverse (Advanced) Pearls from HT on Asians (Intermediate-Advanced) Multi-Follicular Unit Grafts (Intermediate) Do s & Don ts in HRS (Beginner) Backbone of HT for Beginners (Beginner) Donor Area (Beginner) Marketing & Ethics (All Levels) Scalp Dermatology (All Levels) CME Credit The International Society of Hair Restoration Surgery s 13th Annual Scientific Meeting (program # ) is recognized by the American Academy of Dermatology for 40 hours of AAD Category I CME credit and may be used toward the American Academy of Dermatology s Continuing Medical Education Award. As always, visit the ISHRS Website for continually updated information on the meeting! 68

29 ATTENTION: Fellowship Training Directors and Moderators! The following workshop is being offered in Sydney to provide ISHRS Fellowship Training Directors with instructor training, which is part of the requirement to maintain Director status. Because the topic this year is on managing group discussions, we are encouraging all moderators at the Sydney meeting, especially those moderating panels, to register for this workshop. Instructor Training Workshop: Managing Group Discussions as an Effective Training Tool Director: Carlos J. Puig, DO This workshop is designed to assist Directors and Co-Directors of ISHRS Fellowship Training Programs and moderators of panel discussions in fine-tuning their teaching skills in leading discussion groups. Through the use of lecture and onsite practice, workshop participants will learn how to direct a discussion group in such a way as to include important topics, facilitate the development of the learners cognitive and problem-solving skills, and mediate discussion conflicts. Suggestions for handling specific problem situations, such as the domineering or talkative student/ panelist or the non-participating student/panelist, will be presented. Learner Objectives Upon completion of this workshop, you will be able to: List the essential requirements for properly directing a discussion group and moderating a panel. Mediate discussion conflicts. Apply techniques for managing problem situations in discussion groups including panels. Helen Marzola, RGN Surgical Assistants Program Chair MESSAGE FROM THE SURGICAL ASSISTANTS PROGRAM CHAIR Pamela Hulley, RN Assistant to Surgical Assistants Program Chair Plans are coming along and we are thrilled to present an amazing program for Assistants in Sydney! This year s Surgical Assistants Program is divided into four sessions. Session I, scheduled for Thursday morning, will be of particular interest to beginner assistants and will provide a refresher for experienced assistants. The focus will be on hair anatomy and physiology, and graft preparation, handling, and placement with a special emphasis on placement. Session II, on Thursday during the lunch hour, will include our annual business meeting luncheon along with a motivational speaker. There will be time to socialize and share. On Friday morning Session III will take place. This session will include free papers of varying topics and a panel discussion that will be of interest to the experienced assistants looking to further refine their skills and knowledge base. We recommend that beginner Surgical Assistants consider registering for Course B: Preparing Grafts, Making Incisions, and Placing Grafts (Workshops 201 and 211), which also takes place during this time (on Friday morning and the Friday afternoon lunch hour). Session IV will be interesting to all as we delve into the psychological effects of hair loss and how to best meet the needs of our patients. The program was designed to encourage camaraderie and participation amongst all Surgical Assistants at varying levels. We hope you are planning to join us in Sydney for the BIG One, Down Under! Helen Marzola & Pamela Hulley 69

30 Patients Love DermMatch If you have patients who use sprays, sprinkles or lotions to conceal hair loss or recent surgery, they ll just love DermMatch Topical Shading. And now s your chance to try it free. Now accepting applications for 2005 ISHRS Research Grants DermMatch coats every hair for the thickest, fullest appearance possible. It s the only product that you can fade gradually for a perfect, natural hairline. Your patients can swim with DermMatch. It s waterresistant. They can also brush or comb their hair with it. Don t try that with sprays or sprinkles. Only DermMatch comes with the EZ Grip, EZ Reach applicators. They make application quick, clean and precise. No more clouds of spray or aimless sprinkles. The primary ingredients in DermMatch are emollients that moisturize and protect. DermMatch contains no dyes and is loaded with botanical and natural ingredients. FREE SAMPLES Why not carry DermMatch in your office? Your patients deserve it. Try it first. If you ve never received samples from us before, call before April 30th and we ll send a free sample kit with everything you need... Monday Friday 8AM to 5PM Eastern Time or The ISHRS offers research grants for the purpose of relevant clinical research directed toward the subject of hair restoration. Research grants are typically in an amount of up to $1,200 (USD) each. All ISHRS members in good standing are eligible to submit an application on a proposed project. The Scientific Research, Grants & Awards Committee oversees the research grant process including rating the proposals and determining the awardees. The submission deadline to be considered for a 2005 ISHRS Research Grant is May 1, Applications with instructions and guidelines can be obtained via the ISHRS Website at or by contacting the Society headquarters office. Deadline to submit a resear esearch ch grant ant proposal: May 1,

31 Dear ISHRS Colleagues, The Golden and Platinum Follicle awards are given each year to those deemed to have contributed most to the science of hair restoration (Platinum Follicle Award) or to the hair restoration profession in general (Golden Follicle Award). Nominations may be submitted by members of the Awards Committee and by the general membership of the ISHRS. Please take special care in outlining why you think that your nominee is deserving of a particular award. It is not sufficient that he or she has been active in the profession for 10 years or is a great guy. These awards are extremely prestigious and are judged by a committee consisting entirely of past award recipients. We are looking for candidates who have made a genuine contribution to our profession. Best regards, Richard C. Shiell, MBBS Chair, Scientific, Research, Grants, and Awards Committee 2005 Golden & Platinum Follicle Awards Call for Nominations The Golden Follicle and Platinum Follicle Awards will be presented at the ISHRS 13 th Annual Scientific Meeting, August 24 28, 2005, at the Hilton Sydney in Sydney, NSW, Australia. This is your chance to nominate a deserving peer for one of these prestigious awards. Members in good standing may mail, fax, or nominations with an explanation of why the person is deserving of the award by May 15, 2005, to: ISHRS Scientific Research, Grants and Awards Committee Fax: info@ishrs.org Specific information and accomplishments should be included on the nomination. All nominees will be reviewed and voted upon by the Scientific Research, Grants, and Awards Committee. Award recipients will be announced during the Gala Dinner at the 13 th Annual Scientific Meeting in Sydney. DEADLINE: The deadline for nominations is May 15, Golden Follicle Award Criteria For or outstanding and signific icant ant clinical al contributions relat elated ed to hair rest estor oration surger gery.. Platinum Follicle Award Criteria For or outstanding achievement ement in basic scientific ic or clinically-r ally-relat elated ed resear esearch ch in hair pathophysiolo siology gy or anatomy omy as it relat elates es to hair rest estor oration. 1. The recipient must have been the principal person involved in clinical research or in developing innovations or made a significant contribution furthering the advancement of hair restoration. 2. The work of the recipient must have resulted in demonstrated improved patient outcomes. 3. The recipient may not have been awarded the Golden or Platinum Follicle Awards within the previous 5 years. (Exceptions may be made in the event of extraordinary circumstances regarding new work conducted by the nominee.) 4. The recipient will preferably be a member of the ISHRS, however, non-members whose work has been significant may be considered. 1. The recipient must have been the principal investigator involved in basic scientific or clinically-related research related to hair restoration. 2. The results of the research must represent significant advancement the science of hair restoration. 3. The recipient may not have been awarded the Golden or Platinum Follicle Awards within the previous 5 years. (Exceptions may be made in the event of extraordinary circumstances regarding new work conducted by the nominee.) 4. The recipient will preferably be a member of the ISHRS, however, non-members whose work has been significant may be considered. Please make sure to include your name, the person you are nominating and the reason they are deserving of the award. 71

32 2005 Distinguished Assistant Award Call for Nominations Presented to a surgical assistant for exemplary service and outstanding accomplishments in the field of hair restoration surgery. Examples of exemplary service may include, but are not limited to, extending superior patient care, developing new protocols (related to clinical care or office management), active participation in ISHRS events and projects, assisting in research or contributing to the advancement of the science of hair restoration surgery, implementing new tools or techniques, maintaining the highest standards, and dedication to the field of hair restoration surgery. Members in good standing (assistants or doctors) may mail, fax, or nominations with an explanation of why the person is deserving of the award by May 15, Eligible candidates must be members of the ISHRS Surgical Assistants Auxiliary, however, non-members whose service has been significant may be considered. Nominees will be reviewed and voted upon by the Surgical Assistants Executive Committee. The winner will be announced during the Gala Dinner/Dance & Awards Ceremony on Saturday, August 27, 2005, at the 13 th Annual Scientific Meeting in Sydney, Australia. *Submit nominations to: ISHRS Surgical Assistants Awards Committee Fax: info@ishrs.org Deadline for nominations: May 15, 2005 *Remember to include your name, the person you are nominating, and the reason he or she is deserving of the award. Direct Yourself to the ISHRS Website: The Membership Directory Exclusively for Members. Now Online. For the first time, the ISHRS Membership Directory is now available exclusively online. You can access the information from anywhere, at anytime simply by logging in to the Members Only section on the ISHRS Website. 72

33 MISSION: To provide hair restoration services to individuals with hair loss as a result of trauma or illness and who lack the resources to obtain this corrective surgery. Thank you! The ISHRS gratefully acknowledges the generosity of the following individuals who have made donations to OPERATION RESTORE: OPERATION RESTORE, and Mitchell, OR s first patient (11- year-old fire victim), is featured as the March cover story in the magazine Forum, which is the publication of the Association Forum of Chicagoland ( forum.org). Association Forum is the professional society to which our Executive Director belongs. It is a society comprised of more than 3,000 association executives representing business, charitable, civic, and professional organizations headquartered in Chicago. After Washington, D.C., Chicago is the next largest city in the world for professional society headquarters. There are also supplier partners as members (e.g., hotels, airlines, and convention & visitors bureaus). The magazine is distributed to its members and state and federal politicians. We are hopeful that the story will bring publicity to OPERATION RESTORE and greater awareness of HRS, and potentially lead to partnership opportunities with other associations and/or hotels and airlines. The Association Forum recently redesigned their publication both visually and contextually beginning with their December 2004 issue. Their cover story is now always based on the tag line One idea can change the world. OPERATION RESTORE fits right in with this concept. A copy of the article can be found on the ISHRS website: Michael Akkashian, MD James Arnold, MD Michael L. Beehner, MD Victoria Ceh, MPA Edwin S. Epstein, MD Jeffrey S. Epstein, MD Cary Feldman, MD Robert S. Haber, MD James A. Harris, MD Jae Heon Jung, MD Jung Chul Kim, MD Yung-Joon Kim, MD Russell Knudsen, MBBS Jerzy Kolasinski, MD Robert T. Leonard, Jr., DO E. Antonio Mangubat, MD Maritess P. Mauricio, MD William M. Parsley, MD Gregory A. Pistone, MD Paul T. Rose, MD Marla Ross, MD Daniel E. Rousso, MD Walter P. Unger, MD Panagiotis Venetsanos, MD Alberto Vizcaino, MD William J. Woessner, MD 73

34 Do you know what the ISHRS website has to offer? Check it out. Go to The ISHRS Website Committee has been hard at work enhancing our Society s site. The number of visitors is increasing each month as a direct result of our marketing campaign and greater awareness of The ISHRS website is the leading unbiased, peerreviewed site on hair loss and restoration. It is a tremendous resource for patients and physicians. There is a large bank of educational articles for patients on the many aspects of HRS. The Find a Doctor database search has been enhanced to allow patients to search by a variety of variables, including geographic region, doctor s last name, and technique/procedure. Physician members can now easily edit their Physician Profile via an administrative interface in the Members Only section of site. The Members Only section includes information about our Regional Workshops program, Research Grants program, and Member Recognition program; lists of past award winners; information about fellowship opportunities; ISHRS position papers; and the Bylaws and Code of Ethics. It includes expertly written content in an easy to access Word format that as a member you are eligible to use for your patient pamphlets and website. The Members Only section also includes a searchable database of members of the Surgical Assistants Auxiliary; the ISHRS Members Only logo, which is reserved exclusively for members of the ISHRS; the most recent Membership Directory as a PDF; access to discounts for textbooks; access to the interface to edit or add your Physician Profile; and more. The Calendar of Events is a valuable resource that lists hair meetings around the world. Visit the Annual Meeting section to find continually updated information as it becomes available. MORE Features Coming Soon The Forum Online Archives. A searchable database of articles from past and current issues of the Forum. Search by author, keyword, volume, category, or a combination of the above. Enhanced Patient Stories section. The Patient Stories page is one of the most popular sections visited. We encourage you to talk with your patients about submitting their hair loss and restoration stories along with before and after photos. You will be listed as their surgeon with a link to your Physician Profile page. Media Center. A section of our website devoted specifically to the media. This section will include the latest statistics and trends in HRS, information about the ISHRS, and press releases. Ask the Experts. A feature whereby members can ask their expert colleagues questions via about various hair restoration surgery topics and cases. EXCLUSIVELY FOR MEMBERS EXCLUSIVELY FOR MEMBERS What can you do to help promote In order to better promote our profession, it is important to increase our visibility on the Web and with the search engines, including that of the ISHRS website. One easy way of increasing our visibility on the Web is by placing a search-relevant text link on your website. You are encouraged to add a link on your website to the ISHRS website. For those of you who already have such a link, you are encouraged to update the lshrs link to be more search-relevant, which means using words in the clickable part of the link that are relevant to our industry. How to Link to the ISHRS Website Effectively To make it easy for you, go to select the link you want to place on your site, and then ask your webmaster to copy-and-paste the applicable link code to your web page. This will take visitors to the home page of the ISHRS website. 74

35 Classified Ads Hair Restoration Clinics for Sale Offices on Florida s East and West Coasts and Orlando. Well-known and respected company with 35 years experience in Hair Restoration. $600,000 gross per year. Inquiries kept confidential. mikepatterson52@aol.com ; Fax: Hair Restoration Clinics for Sale Group offices in Virginia. Huge client base with 11 years experience in Hair Restoration. 1.3 million gross per year. Inquiries kept confidential. Roxydani@aol.com ; Fax: International Laser Hair Transplant Surgery Center Is looking for a trained Hair Transplant Surgeon/Hair Technicians to help devoted doctor with over 25 years experience in the field at busy offices located in San Diego and Chicago. All inquires confidential. ilhts@aol.com or call Aubrey at : Fax Traveling Technician Wanted For surgical hair restoration practice in Indianapolis. Must have experience and be qualified to work in hospital O.R. Excellent pay. Inquiries confidential. mmckhamilton@aol.com Volunteer Translators Needed The Forum is looking for volunteers to translate the Forum into any non-english language. It is our intention to create text documents in several languages that could be opened and printed from our Website at ISHRS.org, or have the documents routinely ed to requesting doctors. Ideally, it would be our goal to have several volunteers in any given language to share the work load. If you speak both English and another language, we certainly would appreciate any help in this regard. If interested, please contact Dr. William Parsley at bparsley@bellsouth.net. 75

36 Advancing the art and science of hair restoration Upcoming Events Following is a guide to upcoming meetings and workshops related to hair restoration. For more information, contact the appropriate sponsoring organization at the number listed. Meeting organizers are reminded that it is their responsibility to provide the Forum Editors with advance notice of meeting dates. Date(s) Venue Sponsoring Organization(s) Contact Information Academic Year May 12 14, 2005 June 2 4, 2005 Diploma of Scalp Pathology & Surgery University of Paris VI School of Medicine Paris, France 10 th ISHR International Conference Modena, Italy Coordinators: P Bouhanna, MD and M. Divaris, MD Director: Pr. J. Ch. Bertrand Italian Society of Hair Restoration Tel: 33 +(0) Fax: 33 +(0) marie-elise. neker@admsto.jussieu.fr Euromeeting Tel: Fax: emeet@tin.it June 2 5, th Annual Congress and Live Workshop of ESHRS Brussels, Belgium European Society of Hair Restoration Surgery Congress Host: Dr. Jean Devroye ESHRS Headquarters: Tel: (33) Fax: (33) eshrs@eshrs.com August 24 28, th Annual Meeting of the ISHRS International Society of Hair Restoration Surgery Tel: ; Sydney, Australia Fax: Tell us what you think of the Forum s new look... info@ishrs.org with your comments. HAIR TRANSPLANT FORUM INTERNATIONAL International Society of Hair Restoration Surgery 13 South 2nd Street Geneva, IL USA FIRST CLASS US POSTAGE PAID CHICAGO, IL PERMIT NO Forwarding and Return Postage Guaranteed 76