The past 1 2 years have been pretty exciting for us. After seeing multiple cases of

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1 f HAIR Lateral, Dense, Mega Is This the Future? Jerry Wong, MD Vancouver, BC, Canada orum HAIR TRANSPLANT INTERNATIONAL Volume 15, Number 1 January/February 2005 COLUMNS 2 President s Message 3 Co-Editors Messages 5 Notes from the Editor Emeritus 20 From the Literature 21 Pioneer of the Month 22 Cyberspace Chat 25 Pearls from Providence 27 Letter to the Editor 28 Once Upon a Time 33 Surgical Assistants Corner 35 Classified Ads The past 1 2 years have been pretty exciting for us. After seeing multiple cases of 4,000 FUs dense-packed using lateral slits, we re convinced that for patients with advanced hair loss (Norwood 5 or 6) these sessions are ideal. There has been a lot of very positive feedback from both patients and colleagues. Following is how we approach and do one of these megasessions. As Figure 2 shows, perpendicular slits are cut perpendicular to the direction of hair flow with the blade handle slanted to match the existing hair angle. With this technique, the slits sandwich the grafted hair shaft to consistently maintain a much more acute angle during the healing process. The closer grafted hair matches existing hair the better it blends and thus the less detectable it becomes. The angulations and the resulting shingling effect will also provide improved coverage. FEATURE ARTICLES 7 Whorl on Scalp of Thai Monk and Nun 9 Solutions to Solving the Public s Perception of Hair Restoration 11 Facial Framing: It s not all about the hair, it s about the eyes! Utilizing Art and Mathematic Principles in Facial Framing and Hair Restoration Design 15 Irregular and Sinuous Anterior Hairline: Prior Technique Refinement and Male and Female Trace Parameters 17 The Psychological Impact of Hair Loss Can Be Alleviated 29 In Memory of Robert Thomas, MD, and Pierre Pouteaux, MD 35 Offering Financing Options Allows More Patients to Afford Surgery See page 34 for information on booking your flights and hotel for Sydney. Figure 1. Pre-op and 8 months post-op side view of patient in mid-40s with 5,825 follicular. Figure 2. Figure showing hair direction and plane of incisions. This procedure has been made possible by the following two technological advances: 1. Dr. Limmer s microscopic slivering and graft dissections. Since adopting this technique, our graft quality and graft count have both dramatically improved. In our clinic we have 20 cutting stations using the Mantis microscope. 2. A blade cutter making custom-sized razor recipient blades (Figure 3). To minimize vascular and tissue damage we use only the chisel tip, and because these blades are so sharp there is no need to use the pointed tip. The chisel tip creates a more exact and shallow pocket for the grafts. Official publication of the International Society of Hair Restoration Surgery continued on page 18

2 2 Hair Transplant Forum International Volume 15, Number 1 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 Schaumburg, 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: Michael L. Beehner, MD, and William M. Parsley, 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 Surgeons. Its contents are solely the opinions of the authors and are not formally peer reviewed before publication. To facilitate the free exchange of information, a less stringent standard is employed to evaluate the scientific accuracy of the letters and articles published in the Forum. The standard of proof required for letters and articles is not to be compared with that of formal medical journals. The newsletter was designed 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 Volume 15, Number 1 President s Message E. Antonio Mangubat, MD Seattle, Washington It is more e impor ortant not to o oper erat ate e badly than it is to o oper erat ate e exceptionally eptionally well. Jack Anderson, MD The practical nature of medicine is that all physicians are not created equal; certainly in terms of knowledge, skills, and artistry. Dr. Anderson s wise words summarize the dilemma the HRS specialty faces today. There is a relatively small enclave of surgeons worldwide who epitomize E. Antonio Mangubat, MD artistry in HRS and continue to share their skills with all who are interested in learning. In fact, this is the old way of passing medical knowledge forward before the days of internships and residencies. Unfortunately, it is the most inefficient and unreliable way of educating physicians new to HRS. Although the ISHRS takes physician education very seriously, we are not currently capable of turning out physicians competent in HRS. More striking is that there is no formal and reliable way of turning out competent HRS physicians in today s medical environment. As shocking as this may seem, consider the facts. What medical specialty has a residency capable of training a surgeon to perform HRS to the level we expect today? The sad answer is that no formal residency program exists today that can accomplish the task. This is precisely why we must consider HRS a true specialty and develop programs to fill the educational void if we are to expand our specialty and establish credibility. Unfortunately, the surgeons most prone to suboptimal results are newcomers to the field. Even surgeons with vast experience in other surgical specialties, such as plastic and general surgery, are likely to achieve poor results due to lack of education in basic HRS skills and artistry, and the absence of a skilled HRS team. The surgical portion of HRS is deceptively simple and most experienced surgeons do not appreciate the details necessary to achieve acceptable results. Perhaps the most striking example, we cannot achieve our current level of results without an experienced surgical team. The traditional surgical procedure requires the surgeon to primarily perform the procedure. On the other hand, hair transplantation requires the team to perform the majority of the surgery. Cutting and placing grafts is the most time-consuming segment of the operation. Assembling and training that team is the Achilles heel of our specialty, because without the HRS team, we could not attain the height of achievement we observe today. This is precisely why we must turn our attention to the HRS surgical assistant. We need to nurture their education, create a formal curriculum for them, and ensure they have adequate surgical skills so that they can operate in any physician s office. This is analogous to the school of surgical technology offered in many regions of the United States and the world. Any certified surgical technologist (CST) is capable of operating competently with virtually any surgeon in the world. While it is true that CSTs must learn the specific nuances of each surgeon, their basic skills will bring them up to a level where they can quickly adapt to any new surgical environment. The surgeons in our Society will understand this concept. HRS assistants are currently in short supply and each individual physician must take on the responsibility of training each new assistant hired. Regrettably, each physician s investment of time, money, and energy in training their assistants is always at risk of losing them to illness, marriage, transfers, and to their competition. To address this severe shortcoming, the ISHRS is seriously evaluating the feasibility of creating a training academy for HRS assistants. Each assistant will be given the same core education of basic anatomy and physiology and be surgically trained in graft preparation, handling, and placement. continued on page 6

3 Co-Editors Messages Michael L. Beehner, MD Saratoga Springs, New York Some Final Thank-You s This month it is a somewhat nostalgic task to pen my final column, as it is my last issue to edit. It has been a great run for Bill and me. I m sure Bill would agree that the past three years have been a work of joy, lots of hours on the computer, and, at the same time, a true privilege to be a part of. I would like to take this occasion to Michael L. Beehner, MD thank a number of people: The ISHRS, for having the confidence in Bill and me and giving us the opportunity to head up the Forum. Cheryl Duckler, our invaluable copy editor in Chicago, who took all of our rough copy and notes and made it into an elegant, professional looking journal her advice and suggestions were always right on and enhanced our articles tremendously. To Victoria Ceh, who tirelessly contributed suggestions and performed our final edit on every issue, always in a helpful way. What a treasure she and Cheryl are for the ISHRS! To my partner, Bill, who was a joy to work with, always handling every small crisis and challenge with his usual wry sense of humor and never getting ruffled. He s one of those rare guys you could work with for 25 years and never exchange a cross word. To all our regular column contributors and all of you that sent in articles over the past 3 years. To Richard Shiell, whose sage advice and presence was always there for us to tap (and we did!). Richard warned us that, after we finished up our William M. Parsley, MD Louisville, Kentucky As our time with the Hair Transplant Forum International comes to an end, one can t help but reflect on the past 3 years and assess our current health. We have a President, Dr. Tony Mangubat, who has boundless energy and a zest for advancing and uniting our field. We have two new techniques lateral grafting and follicular unit extraction that are developing William M. Parsley, MD rapidly and are changing our field. Diversity being our greatest strength, we have active, valuable members from nearly everywhere on earth. We have two new Editors Drs. Bob Haber and Jerry Cooley who already are developing innovative and educational ideas. We have the seeds of future landmark developments hair multiplication and holding solutions. In short, the health of the field of hair restoration is very good! Having observed hair restoration grow and develop for over 30 years, it has occurred to me that there are several categories of doctors who have contributed greatly to our field: 1) thinkers, 2) appliers, 3) scientists, and 4) promoters. Frequently an individual can be several of these. Thinkers are always coming up with innovative thoughts, but often don t act on them and they die in place. How many great ideas never leave the head? Appliers take promising ideas, then develop editorship, along with a sense of relief, we would suffer some withdrawal symptoms and actually miss being in the midst of the battle. And, finally, my wife, Harrilyn, who sacrificed some of my availability to her, so I could serve as editor. More Positive TV Exposure for HT The show Dateline (NBC) recently began following five men for one year who are each using one of five different treatment regimens for hair loss hair transplant, lasercomb, herbal remedy, single medical therapy, and combined medical therapy. A recent show, which looked at their 6- month progress, appears to be a tremendous shot-in-thearm for the HT field, as the hair transplant patient appeared to be leading the pack by several lengths. Alan Baumann, MD, of Florida, is the patient s surgeon. A follow-up show is planned at the one-year point, and, as we all know, will most likely show a huge increase in hair growth. The fact that so many people will have the opportunity to see results that counter the commonly held image of transplants being pluggy and detectable is a huge PR plus for our field. At the Orlando workshop, I heard Alan s talk on marketing one s practice, and he is certainly one of the Society s foremost experts in this area. Hopefully, one day soon the Forum can get him to summarize the points he made in that talk here on these pages. I recall a few years back seeing him featured on page one of USA Today with packaged Florida vacations combined with hair transplant surgery. continued on page 4 and apply them, often with great energy, in the clinical workplace. Scientists want to analyze the data of the appliers to determine their value and significance. Promoters explain and spread the idea or technique to the doctors and to the public. So who is the most important? They all are, and they need to work together. Absence of any of these steps could bring the contribution down. We have all seen what happens if a promoter acts without the other three in place. Promoters with integrity are of immense value to our profession, while shady promoters continue to give us a bad public image. Appliers are always listening to the thinkers, often taking their ideas and applying them and we are the better for it. Now for the scientists ; they are another matter. They are the thorn in everyone s side. For some reason, they want to act before the promoters. The audacity! I think that in spite of his awards and books, Dr. Walter Unger is still one of the most under appreciated members of our Society. Appliers and promoters see results in a general way and are quite confident in their validity; but to be accepted by the medical community at large, valid scientific data must be presented. Most of us really don t know how to interpret data and run valid scientific tests, and we are intimidated by them plus, they are a lot of work. So the scientists are often a royal pain. We need to give them a little more respect, as they are the ones who give validity to the general medical field. It is a tough, often thankless job. continued on page 4 3

4 Beehner Message continued from page 3 To my knowledge, at least three of the Extreme Makeover shows have featured hair transplants as part of the cosmetic improvement project but, alas, the show s producers don t have the patience to wait for transplanted hair to grow. In the show I viewed, after Dr. Bill Rassman performed the transplant, they marched the patient right down to the hairpiece salon for a hair addition that was placed over the top of the transplant for the patient s official coming out. (Bill privately told me that that particular patient had hair growth from his grafts right out of the gate, without the usual telogen dropout, threw away the piece after a few weeks, and is thrilled to death with his new hair!) Focal Dense Packing One of the frustrating aspects of hair transplant surgery is that when we try a new technique or approach, it is often several months or even a full year before we get to see the results from our new way of doing things. This was the case for me over the past year and a half, during which I have been performing what I call focal dense packing transplanting small key areas of the scalp with dense packing, using mostly 3-hair grafts at a density of per cm 2 with either 18 or 19g needles. Most commonly, this was done either in the frontal core area or just behind the front-lateral hairline in the recession area. I have used this technique in about 50 patients and have seen around 20 back so far. While there have been some with gratifying results, overall I am somewhat disappointed with the hair growth, especially in the female patients, who made up the majority of these patients. In these women, I dense-packed a small 3 4 cm 2 area in the frontal core just behind the central portion of the front hairline, using a stick-and-place method. I am starting to strongly suspect that the key for obtaining good growth with closely packed FUs is to use as small an incision as possible. The study I presented in Vancouver of FUs placed at 20, 30, 40, and 50 FUs per cm 2 showed that hair growth remained high at 90% survival in both patients even at 50/cm 2, and, looking back, I think this is due to the fact that I used 20g needles (all FUs were 2 hairs apiece). Where I think I went wrong in my method of dense packing was trying to perform this technique with all 3-hair FUs, which in many patients with coarse hair required an 18g needle. I am continuing to use this technique, but in a smaller number of patients (until I see what results it brings), and am now limiting myself to using only 2-hair FUs and making recipient sites with only 20 and 19g needles. Many observers have commented on Drs. Victor Hasson and Jerry Wong s impressive results to the effect that maybe the key to their success is the small incision sites (and well-trained staff!), rather than the lateral orientation of the micro-slit recipient site. It will be interesting in the next few years to see how all of this pans out as we search for the magic formula for ideal FU growth. Welcome A final word of welcome and congratulations to our new editors, Drs. Jerry Cooley and Bob Haber, who will take over the reins of the Forum with the next issue, and who I am confident will continue the great tradition we have as ISHRS members of using the Forum s pages to rapidly exchange information and learn. Michael Beehner, MD Parsley Message continued from page 3 I would also like to remind the readership that our Forum and organization are run by some very valuable and extremely competent women. Victoria Ceh (what can you say?) is nothing short of incredible, along with her wonderful staff. Everyone thinks Dr. Limmer s biggest contribution to the field was in FUG, but in reality it was bringing back Victoria as Executive Director. The small, but growing, number of female doctors are some of the best in our field. And don t forget some of the most valuable women to us all our assistants, as most are women. If all women dropped out of our field tomorrow, it would be far more devastating than if all the men left. Finally, all of us need to give a heartfelt thanks to Cheryl Duckler, our Managing Editor and Graphic Design expert, with whom working has been a true pleasure. For the past year she has been dealing with health problems of her young son Zach, yet has continued putting together the Forum with the special expertise she possesses. All of her family at the ISHRS wish the best for Zach. Most of all, I would like to thank my wife Mary Ann for both supporting me and putting up with me for these past 3 years. I could not have done it without her. This is my last piece as Editor, even though it appears that most if not all of the past Editors will be taking part in the Editor Emeritus column. We have been blessed to be able to work with a great staff. Particular thanks go to Drs. Ed 4 Epstein, Jennifer Martinick, Bernie Nusbaum, Vance Elliott, Jerry Cooley, John Gillespie, and Bob Leonard, who have freely donated their time and worked so hard over the past 3 years. Finally, I want to thank the ISHRS for allowing me to work with my good friend Mike Beehner for the past 3 years. Mike is a special individual, and I did not fully appreciate all of his skills and passion for the field until we had the chance to work together on the Forum. He is one of the most intellectually honest doctors in our field and has a unique ability to teach. I remember one meeting during which we had the Breakfast of Champions, where a faculty member would sit at each table and, during breakfast, answer any questions from regular attendees. Mike s table filled up first, and for a while I sat with 2 other faculty members at my empty table one was one of the most brilliant members in our field and the other was the developer of the hottest new technique, both of whom also had empty tables. But that is Mike, the pied piper of the teachers. I will miss working with him. Now is the time for an influx of new ideas and educational tools that the hands of Drs. Haber and Cooley will bring. I can t help but be excited by the abilities and energy they bring to the table. One note to the readership: Please don t hesitate to communicate with them. This Forum is for you, and your feedback is necessary and very much appreciated. I have been told by some authors that they were honored that we published their articles. The truth is that we were honored that they took the time to send them to us. Thanks to all of you. William Parsley, MD

5 Notes from the Editor Emeritus Richard C. Shiell, MBBS Melbourne, Australia Although I signed off my 9- year shift in the December issue, I find that I have been drafted to write the first EE Notes of In the future, readers will be getting the Notes from Drs. Bill Parsley or Mike Beehner or any of our six Editors Emeriti who feel moved to comment. Our two new Editors, Drs. Bob Richard C. Shiell, MBBS Haber and Jerry Cooley, are already hard at work choosing the colors, fonts, and headers for their new baby. High on their agenda is getting more recognition for this baby notably a listing in the important scientific Indexes. As we are all aware, the Forum is the premier print authority on what is happening in the field of hair restoration. The occasional article that appears in the dermatology or surgery journals is often poor in content and well out of date to the eyes of experienced practitioners by the time it is published. This can sometimes be a year or more after submission of the manuscript. The delay is caused largely by the cumbersome peer review process that, while supposedly protecting the readership from mediocrity and scientific fraud, frequently serves to inhibit the transmission of truly original concepts while encouraging the continuation of the status quo (see box). The Forum has sidestepped the traditional peer review process these past 13 years by having a series of very experienced and farsighted Editors who act as built-in reviewers. The Editors frequently call on the services of fellow experts if any doubts arise about the merit of a particular paper. The fact that the authors and reviewers are well known to each other has the benefit of preventing some of the petty objections and occasional rejections that arise when egos and professional rivalries clash. The peer review process is rarely truly blinded. The expert reviewer nearly always knows the author of a paper by his style and subject, and the hapless author generally has a fair idea of the identity of the reviewer who has harshly criticised his paper. Having said all this and pointing out some of the flaws in the peer review process, there is no way we can change it. If we wish our articles to be listed in the Index, we need to play by the established rules. It is up to our new Editors to negotiate some arrangement with the proprietors. It would be counterproductive to insist that all material in the Forum (Norman Orentreich s original article, Autografts in Alopecias and Other Selected Dermatological Conditions, was rejected by the reviewers of Archives of Dermatology and later accepted by the lesser known Annals of the N.Y. Academy of Sciences. This immensely influential paper that founded the hair transplant industry was published in November Closer to home, Dr. David Seager s truly outstanding article, The One Pass Hair Transplant A Six-Year Perspective, was rejected by Dermatologic Surgery in 2002 on the grounds of style and published by the Forum a few months later to great acclaim. be peer reviewed as this would mean a great reduction in the speed and spontaneity for which the Forum has become renowned. Perhaps we could aim for one or two articles in each edition for a start and build from there. It would be great to gain greater prestige for our newsletter but we must be careful that in doing so we do not discard the baby with the bathwater. The December Forum Dr. Marcelo Gandelman s reverse extraction method certainly gives food for thought, but although there will be an absence of tiny circular scars, I wonder if the resultant linear scar will always be ideal. Some scalps seem to heal with an undesirable scar even when the closure is seemingly free from tension. This was the main rationale for the development of follicular extraction in the first place. Dr. Cam Simmons is Dr. David Seager s partner in Toronto and his paper on hairline design (page 201) shows him to be a worthy successor. Most of the principles he expounds are not new but deserve a fresh airing in this well-written paper. I am not sure if his three new bony landmarks will be useful to the tyro in hairline design, but perhaps I have been eyeballing my hairlines for too long and have forgotten how difficult this was in the early days. Also interesting was Dr. Craig Ziering s article (page 205) discussing his technique for the advancement of donor wound edges without traditional undermining techniques by making multiple perpendicular tunnels. Time will show whether this technique proves to be as useful as claimed by the author. I certainly hope it is. Dr. William Reed gives a timely warning about the potential dangers of oral spironolactone in older patients and particularly those with congestive heart disease and those already taking ACE inhibitors (page 207). While this will not be a problem to most of the thousands of young to middle-aged women taking spironolactone for hair loss, it is a warning to doctors that we do not know where the safety line actually lies. Sydney Meeting Only 7 months to go until the big meeting Down Under that you all say you have been waiting for these many years past. You need to book well in advance to use those accumulated travel points, so contact your airline immediately. If you are frightened by the prospect of the long flight to Australia, then break your journey up into two parts. Hawaii is ideal if flying from the American continent, or Bangkok or Singapore if you are coming from Europe. Now let me give you a crash course in Australian culture to try and expel a few misconceptions: 1. Most Australians do not live in the Outback like Crocodile Dundee, but in large modern cities within one hour s drive from the ocean. Most Aussies have never seen a koala, kangaroo, or emu in the wild. 2. Although Australia is home to an extraordinary range continued on page 6 5

6 Editor Emeritus continued from page 5 of man-eating sharks, deadly snakes, and poisonous spiders, jellyfish, and octopi, you are very unlikely to even see one, let alone be the victim of such critters. You are 1,000 times more likely to be hit by an automobile, which, for reasons known only to our Founding Fathers 200 years ago, travel on the opposite side of the road to those in America and most of Europe. 3. Most of the black skinned individuals that you will see on your visit to Australia will not be Australian Aborigines but Indian and Sri Lankan doctors and engineers, African taxi drivers, and American basketball players. Yes, Australia has a black indigenous population, the ancestors of whom arrived here some 30 50,000 years ago from what is now the Indonesian region (yes, well before man arrived in the Americas). They were treated badly by the Europeans after colonization began around 1788 and are now mostly very poor, of mixed-blood, and number about 500, The cost of most goods and services is a little cheaper in Australia than in the USA, but it is a pity you did not come a couple of years ago when our dollar was worth US 50 cents (it is now around 70 c). 5. Australia uses the European metric system for currency, temperature, distance, weights, and measures so brush up on your kilos, hectares, kilometers, and degrees Celsius. 6. Giddaymate owaryagoin-orrite? is a common Aussi greeting/question. (Translation for the benefit of non Australians is Good afternoon sir. Are you well? ) The reply required is Fine, thanks or just Orrite-mate if you want your new friend to think you are a local. More cultural pearls next month. Seeya, Richard Shiell, MBBS President s Message continued from page 2 They will have complete instruction in the use of all the instruments available to the HRS physician, including microscopes, backlit dissection blocks, graft cutters, multibladed harvesting scalpels, etc. At the end of their training, they will have earned a performance certificate that will quantify their skills (graft preparation and graft placement per hour) and that will be invaluable when presented to an HRS physician. Similarly, we should consider a physician HRS training academy. As stated previously, there is no surgical training program in existence that prepares a physician to practice HRS to the high level we expect today. As such, there are limited opportunities for HRS training and almost nonexistent opportunities for hands-on training. I held my first live surgery workshop (LSW) in Seattle in June 2004 with a unique opportunity due to the laws of Washington State; any physician with a valid license can operate in Washington State. That meant we could give each and every participant the opportunity to perform part of the surgical procedure. I was fortunate to have outstanding faculty in Drs. Bill Parsley and Steve Hopping, both extraordinary teachers who could control the surgical theater and provide meaningful experiences to their students. As powerful as this instruction was, however, it only scratched the surface of what the attendees needed to be competent. Thus, a structured and formal physician education in HRS is obviously needed. This could take many forms but we should address the entire spectrum of physician experience: Basic, Intermediate, Advanced, and Special Topics. To disseminate the core knowledge, we are investigating developing online tutorials or lectures for each category. Dr. Carlos Puig introduced us to the video conference room, which provided a unique opportunity to view the AV material while also allowing for interactive discussion. I feel we can use this technological infrastructure to provide monthly seminars on HRS in every category. 6 To address the hands-on surgical skills, we must look to hold LSWs in the many regions that will allow this type of surgical training. In fact, the ISHRS now co-sponsors LSWs with member physicians to help fellow members learn and sharpen their skills (see the Members Only section on the ISHRS Website for more information). The basic LSW primarily consists of an introduction to HRS and serves to familiarize the newcomer to the artistry and skills needed to be competent. Once they have the basic didactic knowledge, they will then need skills training. The major obstacle in skills training would be acquiring patients who would agree to serve to train physicians in a new procedure. We should borrow a chapter from our dental colleagues who run hands-on programs where each physician would bring their staff and patients to a training site. There they would perform the procedure on their patients under the supervision of an experienced team of physicians and assistants. This would be ideal and those physicians needing more training can return as often as is needed with as many patients as necessary to attain the essential skills. If we are successful in implementing these programs, we can ensure that new HRS physicians will understand that it is critically important not to operate badly and they will take the time to learn how to operate exceptionally well. The horizon for HRS is broad and deep. I feel we are just now seeing the surface of what we can achieve together. In order to be successful, however, we must believe in ourselves that HRS is a specialty with special educational needs and we must commit the resources necessary to expand our knowledge, training, and credibility around the world. As a reminder, your Board of Governors will be meeting for an unprecedented third time in person this fiscal year in Orlando, Florida, March 1, Again, I welcome comments and suggestions. E. Antonio Mangubat, MD

7 Hair Transplant Forum International Volume 15, Number 1 Whorl on Scalp of Thai Monk and Nun Viroj Vong, MD Bangkok, Thailand Whorls on scalps are called Quan in Thailand. Thai treat Quan almost like a spirit whenever Thai do things. They have to wake up their Quan, which has been called Tum Quan. Rub Quan is a traditional Thai ceremony for welcoming anybody who comes to visit or returns home. Thai children shave their heads, and leave only the hair on the whorl to protect their Quan until they grow up. This style of hair in Thailand is called Wai pom juk. The man in Figure 1 has multiple segments of hair, with the tip of the segment joining at the center. This type of whorl also is featured by the absence of rotation or the presence of only a slight rotation of the segment of hair around the center (see Figure 1A). This is my first type of whorl, which I will call a non-rotation whorl. It is very uncommon, with only 1 found in my series. Figure 1. Static or non-rotating whorl Figure 3 shows a nun with a single counterclockwise rotation whorl, which is an uncommon finding about 5% in my series. From the laws of probability, I would assume that there should be a range of whorl, from non-rotation to full rotation, that would be found; for example, 15, 30, 90, 270 degree clockwise, counterclockwise, but the extremes in this range should be very rare. Figure 1A. When we look at the back of the head, we see the direction of hair, not the axis, as the axis is an imaginary line so the whorl is named according to the direction of hair. Figure 2 shows a nun with a single clockwise rotation whorl. This is the most common found, occurring in around 90%. Most commonly it is located at the mid-point of the inter-parietal line, but can be right or left of the center also. Figure 3. Single counterclockwise whorl Figure 4 shows an example of a double whorl, which I found in about 5% of the nuns and monks in my observation study. The most common feature among these double whorls is the double upper opposing whorl direction of hair, which oppose each other at the upper midline but follow each other smoothly in the lower midline. Right is counterclockwise; left is clockwise. Hair Figure 2. Single clockwise rotation whorl Axis CounterClockwise Rotation Direction = Clockwise Figure 4. Double opposing whorl In Figure 5, the counterclockwise whorl is seen on the left; clockwise whorl can be seen on the right. The reverse of a double upper opposing whorl is a double lower opposing whorl. Figure 5. Double lower opposing whorl Figure 2A. continued on page 8 7

8 Whorl on Scalp continued from page 7 Figure 6 is a combination of two whorls in the same direction that are situated closely together. Hair direction is parallel to each other. I call this pattern a double parallel whorl. Figure 7 shows a double counterclockwise whorl. If one has a double whorl and one other whorl on the frontal hairline or the nape hairline, then this would be a triple whorl. Usually a whorl on the frontal hairline is not a complete whorl, but rather mostly a half whorl or a partial whorl, which is part of or a remnant of a vellus hairline. 1 Type of Whorl Figure 6. Double counterclockwise, parallel whorl 1 Static whorl 1% 2 Single clockwise whorl 90% 3 Single counterclockwise whorl 5% 4 Double upper opposing whorl 3% 5 Double lower opposing whorl 1% 6 Double counterclockwise whorl 1% 7 Double clockwise whorl probable 8 Triple whorl No photo Figure 7. Double clockwise whorl I am still looking for an example of the mirror image of the double counterclockwise whorl described above, which would be a double clockwise whorl. It would seem to be possible by probability, but I have not been able to document its existence yet. Significance of a Whorl 1. A whorl makes the hair in that area of the scalp look fuller and more voluminous because of the radial rotation arrangement of hair within it. To transplant hair at the crown, if one tries to copy this radial pattern of hair, it is very difficult to do perfectly and requires a large number of follicular unit grafts. 2. There are also what I call dermal lines around a whorl, which appear almost like a circumference of the center. It is very similar to Langer s lines on the face. The direction of hair on the scalp is almost always perpendicular to this line 3. Hair in the crown region is arranged transverse to or obliquely to the mid-line. Thus, when I do a hair transplant procedure in this area, I try to make it transverse or oblique to this axis, so as better to mimic nature. Figure 8. Triple whorl REFERENCE 1. Viroj Vong, MD. Normal Hair Line. Hair Transplant Forum International Vol. 9, No. 6; November/December GET HAIR Making good marketers great, and great marketers greater. Easy to remember number keeps prospective patients out of the phone book and away from the competition. Available to only one physician in each regional area You ll be kicking yourself when you see or hear it in your competitor s ads. Will make your phone ring more gets prospective patients on the line; you convert them to clients. A simple way to significantly increase the benefit of your precious advertising dollars and grow your patient base. Call to find out how to make your phone ring more and your competitor s less. 8

9 Solutions to Solving the Public s Perception of Hair Restoration 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 E. Antonio Mangubat s Advances in Hair Restoration: Changing the Public s Image, presented August 12, 2004, and John Ohanesian s ISHRS in a Changing Market, presented August 14, at the 12th Annual Meeting of the ISHRS in Vancouver, British Columbia. The 12 th Annual Meeting of the ISHRS, held in Vancouver, BC, in August 2004, offered Dr. Antonio Mangubat, MD, an ideal opportunity to suggest solutions to improving the poor public image of hair restoration surgeons. Despite significant improvements in hair restoration techniques over the past 30 years, the public still seems focused on the poorquality transplants of the 1960s 1980s. Furthermore, neither the public nor many physicians working in other medical specialties respect the skills required for hair restoration and related surgeries. In fact, even hair restoration surgeons themselves tend to have negative views of their fellow practitioners! Why should such attitudes persist in this day and age of skilled medical professionals? Within the hair restoration community, a major issue is the erroneous belief that fellow surgeons are the competition. Dr. Mangubat, an officer of the ISHRS practicing in Seattle, Washington, suggested that one of the problems is that transplants now look so natural that the public can t see them. Laypersons and other physicians also tend to view hair transplantation as merely cosmetic, with no understanding of the enormous contribution the procedure can make to a patient s self-esteem and quality of life. Within the hair restoration community, a major issue is the erroneous belief that fellow surgeons are the competition. Dr. Mangubat emphasized that the key to changing these negative perceptions is education: education of the public, education of medical peers outside the hair restoration community, and education of hair restoration practitioners. By changing the attitudes of the latter, we should be well placed to change the beliefs of the other two groups. Within the hair restoration community, cooperation and high ethical standards are essential. Secret techniques and an unwillingness to share knowledge and experiences should be things of the past, as should overt hype and denigration of colleagues. Running a practice purely as a commercial endeavor, without consciously thinking of ethics, should also be consigned to history, along with biased advertising and selective information. Such unprofessional, unethical behavior just scares the public and reinforces the negative impressions of our medical colleagues. There is no reason for hair restoration surgeons to be secretive there are more than enough potential patients worldwide for each quali- fied surgeon to have 200,000 patients! Dr. Mangubat stressed that, by working together, we could easily double the percentage of people with hair loss who currently seek any type of treatment from 3% to 6%. Furthermore, we can ensure that all surgery uses the most up-to-date techniques to best serve the needs of individual patients. An important way to change the attitudes of non hair restoration physicians is to promote our surgical field as a skilled specialty, perhaps by registering it as a specialty with the American Medical Association. Furthermore, non hair restoration physicians need to be educated about our accomplishments and expertise. Dr. Mangubat exhorted the audience to remember that hair restoration is a true specialty and if we don t think it is, then no one else will. He questioned why the discipline s major professional society, the ISHRS, had only 600 of the many thousands of hair restoration surgeons as members. Perhaps the Society needed to run more training programs and general meetings to make membership more worthwhile. He also wondered why so few hair restoration surgeons take the Board certification exam. Are they still affected by the controversies of the past? Do they think it is too difficult, or do they feel it to be unnecessary? How can we persuade our non hair restoration peers of our professionalism if we have such beliefs? Dr. Mangubat emphasized that we need to prove to our colleagues that we are just as serious about our specialty as they are about theirs. The ISHRS is doing its best to improve public perception that hair restoration lacks any benefit other than a purely cosmetic one. Its jewel is the Operation Restore pro bono program that provides hair restoration services to people who have suffered hair loss as a result of trauma or illness and are unable to pay for hair restoration. In fact, the most heartfelt part of Dr. Mangubat s presentation was a speech from the mother of an 11-year-old boy who had survived major burns and painful skin grafting procedures. She put a human face to the significant benefits of hair restoration surgery, describing how Operation Restore is changing her son s life by restoring hair to the bald, burned side of his head. As Dr. Mangubat stated, if all hair restoration surgeons treated just one pro bono case a year, the public perception of the discipline could be positively changed forever. Additional Strategies Following Dr. Mangubat s recommendations for public and physician education, John R. Ohanesian, President and CEO of continued on page 10 9

10 Solving Public s Perception continued from page 9 Bosley in Beverly Hills, California, suggested additional strategies for improving the public perception of hair restoration surgery. He lamented the fact that the public viewed hair restoration as a joke and that the media still focused on the poor quality plugs of 30 years ago. He believed that this was due to a lack of focused public communication. The ISHRS s only public communications outlet at the present time is its Website. People may perceive this site as biased as it only discusses the merits of surgical and medical options for the management of hair loss. On the other hand, it is unlikely that many members of the public even access the site, as a Google search of the Internet brings up over 4 million hits for hair loss, with the ISHRS Website absent from the first 100 references listed. Mr. Ohanesian identified this initial public resource as a major area for improvement for the ISHRS. Mr. Ohanesian also described how the Wall Street Journal and the New York Times had recently published stories on hair restoration and had contacted the American Society for Aesthetic Plastic Surgery and the American Society of Plastic Surgeons, respectively, for informed comment, not the ISHRS. As a result, the conclusions in both articles were erroneous. And why were these other societies contacted? he asked. Because major media outlets are unaware that the ISHRS exists. The only relevant links on the American Medical Association s list of National Medical Specialty Society Websites is the American Academy of Cosmetic Surgery, the American Society for Aesthetic Plastic Surgery, and both the American Association and American Society of Plastic Surgeons. The ISHRS is nowhere to be seen. The solution to the ISHRS s lack of visibility, according to Mr. Ohanesian, is for the Society to recognize the importance of communications in today s changing market. To this end, he recommended that the ISHRS establish a major communications capability. The Society s communications strategy could include the commissioning of market research with consumers to identify issues relevant to hair loss and hair restoration, the appointment of a public relations (PR) company to get the message out, and partnering with a well-regarded industry organization for legitimacy. He contended that technology alone is no longer enough in today s marketplace and that appropriate communications are key to shaping public opinion. In terms of market research, Mr. Ohanesian described how Proctor and Gamble keeps its hair products on the public s radar screen. The company spends millions of dollars on market research each year to determine public understanding of its hair products and to identify areas for targeted communication. Mr. Ohanesian suggested that the ISHRS could do something similar: conduct its own market research and then develop targeted information campaigns to remedy the identified misconceptions. He believed that the most successful way to disseminate these messages is through the use of a PR agency. PR is a positive and powerful tool and should be harnessed by the ISHRS, he stated. The solution to the ISHRS s lack of visibility is for the Society to recognize the importance of communications in today s changing market. Mr. Ohanesian also recommended that the ISHRS partner with a respected industry organization to get its message out into the wider community. He identified the National Hair Hour radio program, sponsored by the National Hair Journal, as an appropriate unbiased partner with a wide public following. With such third-party partnering, the ISHRS should become a trusted source of information for the public. By utilizing a multiplicity of communication strategies, including Website improvement, conducting market research, and working with PR agencies and respected third parties, Mr. Ohanesian concluded that the ISHRS should be able to widely publicize its expertise and services, and change public perceptions of hair restoration. 10

11 Facial Framing: It s not all about the hair, it s about the eyes! Utilizing Art and Mathematic Principles in Facial Framing and Hair Restoration Design Joseph F. Greco, PhD, PA/C Sarasota, Florida Like any play or film, a picture must be put together so that its component parts make a balanced, harmonious whole to hold the attention of the viewer. It is the blueprint for a painting or the composition. Good composition is achieved when all elements of the picture relate to each other in a balanced way. The artist will design a focal point, which the viewer s eye tends to be drawn to most strongly, and these focal points may be mathematically predetermined. In more complex images, no one element is more important than another. So the artist has to guide the viewer s eye around and sometimes into the picture, by the way the elements are arranged. This author feels that the focal point in any facial surgery, especially facial framing with hair transplantation, would be the eyes, and not the particular portion of the face or hair that was enhanced. The basis for the above opinion has both a mathematical and an artistic basis, as ancient as the pyramids. The ancients called it the Divine or Golden, Mean, Section, or Ratio. Is it also, by correlation or coincidence, how the first three Fibonacci numbers (1,2,3) relate to the natural hair growth pattern of 1, 2-, and 3-hair follicular bundles in humans? Figure 1. Figure 2. can be seen in everything from beehives to sunflowers. A study of the spiral reveals why the great thinkers and artists utilized it to achieve perfect balance and proportion. 3 Because of the perfect balance, mathematical proportion, and beauty in the Fibonacci spiral design, one can see the reasoning for utilizing this spiral pattern in posterior crown restorations. The spiral can be clockwise, counterclockwise, or a double spiral in either direction. Therefore, by orienting FUs in an acute angle following the direction of the spiral, the hair will grow out into the areas of future recession in a uniform manner, creating a natural aesthetic density (Figures 3 and 4). The Egyptians used both Pi and Phi to design and construct the pyramids. In 500 BC the Greeks used both Pi and Phi to build the Parthenon and Phidias used Phi to design the statues in the Parthenon. Plato considered Pi and Phi to be the two most important mathematical relationships concepts and the key to the physics and the universe. 1 Leonardo Fibonacci, an Italian born in 1175 AD, discovered the Fibonacci series in which the sum of the two previous numbers will equal the next Fibonacci number (1,1,2,3,5,8,13,21) and the property results in the Fibonacci spiral have a unique relationship to Phi The series is ubiquitous throughout nature. A study of how the numbers of peddles and leaves in plants and flowers correlates to the Fibonacci series is truly amazing! Is it also, by correlation or coincidence, how the first three Fibonacci numbers (1,2,3) relate to the natural hair growth pattern of 1-, 2-, and 3-hair follicular bundles in humans? The innate brilliance of the Fibonacci spiral (Figure 1) can be seen when compared to the Nautilus (Figure 2). The spiral can be appreciated throughout nature and Figure 3. Figure 4. As artists choose focal points in their portraits, so must the skilled aesthetic surgeon choose when resculpting the face. When there is no hair loss, attention is focused on a person s eyes. However, when someone experiences frontal or temporal recession, the focal point moves toward the area of recession and it is critical to return the focal point toward the eyes. The photos below illustrate a subtle, but extremely important, difference in facial perspective. Figure 6 demonstrates the traditional Rule of One Thirds, which works, but gives the effect of a long face, whereas Figure 5, which is based on Phi, demonstrates both reality and beauty. 4 As Meisner would point out, It is the difference between Da Vinci and Picasso. continued on page 12 11

12 Facial Framing continued from page 11 Figure 5. Figure 6. The beauty of Phi in your face is that the head forms a Golden Rectangle with the eyes at mid point. The mouth and nose are placed at Golden Sections forming the bottom of the chin. 5 Da Vinci s Mona Lisa, one of the most famous faces of all time, is an illustration of how Leonardo utilized math in his art to bring attention to her face and eyes (Figure 7). Note the edges of the squares of the Golden Rectangle are the focal points the chin, the nose, and even the corners of her mouth and notice how the triangle brings attention to her head. 6 Figure 9. Figure 10. Additionally, the author feels that all three hairlines must be restored to achieve true balance, beauty, and proportion. These are the frontal hairline, the lateral temporal corners, and the temporal peaks. The frontal hairline should be referred to as a hairline and not the hairline because it is only one portion of facial framing. Merely restoring a frontal hairline will only achieve balance in one dimension. Whenever a patient has recession in the lateral hairlines, the temporal peaks along with the lateral hairlines must be sculpted to bring attention back to the eyes (Figure 11). Figure 11. Figure 12, taken five months after the lateral peaks have been restored, shows how the restoration moves the focal point back to the eyes. Figure 7. The Golden Rectangle has been used for centuries in creating paintings and other works of art. This author utilizes a vertical rectangle or portrait format to plan composition (Figure 8). Figure 12. Figure 13 illustrates a Golden Section of the lateral head notice where the temporal peak is located relative to the section. Figure 8. The Picture Plane is placed in front of the patient s face and the eyes are aligned with the marks on the viewfinder. Measurements are then taken from the exact center of the patient s face to create the frontal hairline. By turning the Picture Plane laterally, measurements can be taken from the eyes and the lateral temporal peaks are then marked if restoration is required there (Figures 9 and 10). Figure

13 Restoring the temporal points is not a new issue. The past few years, it has been standard to restore the temporal points in all our patients who look like they will eventually lose them. Additionally, it is not uncommon to bring in older patients to sculpt the points, because 1) it does not take many FUs, and 2) an aesthetic density can be achieved in only 5 months because of the acute angling and layering. It really makes a subtle, but effective change, which slows the appearance of lateral recession by bringing more attention to the eyes by simply moving the focal points. If we design and restore the lateral humps and temporal points in the initial session, for patients that need them or are going to recede in these areas, we have done them a huge service. Knowing what we know about progressive hair loss, especially with transplanted hair, it should be the standard to restore the temporal points. The purpose of this paper is not to discuss how measurements should be taken, but rather why it is essential from a beauty and artistic perspective to achieve perspective and balance when framing the face or designing a posterior crown. While the method may vary from surgeon to surgeon, the basic mathematic and artistic principles must be utilized to move the focal points back toward the eyes to achieve true three-dimensional balance and proportion in facial framing. In summary, art and aesthetic surgery is simply our humble attempt to re-create what the creator has already given us. It is unnecessary to reinvent the wheel, but rather utilize what has been the cornerstone of nature and beauty since the beginning. REFERENCES 1. Meisner, G The Phi Guy. goldennumber.net/.htm. 2. Knott, R., Quigley, D.A., and Pass Math. September The Life and Numbers of Fibonacci. Cambridge University Knott, R. May 24, Fibonacci in Nature. University of Surry, Guildford, Surry, UK Meisner, G Phi and the Golden Section in Art Meisner, G The Human Face. goldennumber.net/face.htm. 6. Anderson, M., Fraizer, J., Popendorf, K The Fibonacci Series. applications6.htm?tqskip=1. 13

14 14 Hair Transplant Forum International Volume 15, Number 1

15 Irregular and Sinuous Anterior Hairline: Prior Technique Refinement and Male and Female Trace Parameters Fernando Basto, MD Graças, Recife, Brazil We carefully analyzed 43 people with no baldness, of which 19 were male and 24 female. This research demonstrated the main differences in the natural and anatomic contour of the anterior hairline in both the non-bald male and female. We feel that it resulted in the recognition of distinct design parameters for both genders. The objective of the study was to show the distinct parameters for the trace of the anterior hairline in transplanting both bald males and females, due to the fact that our transplanted hairlines could then more accurately mimic those of their natural non-bald counterparts. Methods For male patients, the trace starts from a point located approximately 1.5 2cm over the highest frontal wrinkle (called point A ) also determined by the distance of this point to the nasal root, around 8 9cm. From this point, it begins in an anterior convex contour, going laterally and backwards in a very irregular way, creating asymmetric entrances and extending until it reaches the temporal areas, making an angle of approximately between 80º to 90º with the hairline area of this region. It creates a discreet temporal entrance, presenting a considerable distance between the tail-end of the eyebrow and this entrance (Figures 1A, B). The same line is drawn on the opposite side, totally irregular, following the same principles of the technique from point A, but the opposite second trace must be completely different from the first. In drawing these hairlines, we are seeking to get a bigger space in a V shape in the frontal area (Figures 1A, B, C). In all cases, this line is completely irregular, simulating a non-bald male anterior hairline. For female patients, the hairline contour is completely different. The point A, for instance, is projected approximately 6 7cm from the nasal root, getting a much shorter frontal area. From this point, the anterior hairline is directed toward the lateral aspect, though it is not very backward, based in the irregularity principles, with its entrances reaching the temporal area without making an angle with the hairline of this area. This creates a discreet curve in the projected line, so that it joins the temporal hairline and creates a short distance between the tail-end of the eyebrow and the junction of the anterior and the temporal hairlines. The same process is done on the opposite side, but the second trace must again be completely different from the first, allowing the irregular entrances of the anterior hairline to create varied sizes, with the tendency of getting a bigger space in a V shape in the central area, which is more acute in the female patient. This kind of V shape appears in 96% of the nonbald females we studied (Figures 2A, B, C, D, E). In the 43 non-bald patients studied, we found the following main characteristics: 1. The anterior hairline was irregular in 95.4% of the cases. 2. The distance of the A point to the nasal root was approximately 8 9cm in males and 6 7cm in females. continued on page 16 Figure 1A. No baldness male patient: Notice the natural irregular drawing of the anterior hairline. Figure 1B. No baldness male patient: Notice the temporal entrances that make an angle of approximately 80º 90º in this area. Figure 1C. No baldness male patient: Pay attention for the natural irregular anterior hairline. Figure 2A. No baldness female patient: Natural irregular anterior hairline, attention for shorter forehead and no entrances in the temporal area. Figure 2B. No baldness female patient: Natural irregular anterior hairline making a discreet curve in the drawing of the temporal area. Figure 2C. No baldness female patient: Pay attention to a bigger group of hair in a V shape in the central forehead. 15

16 Irregular and Sinuous Hairline continued from page 15 Figure 2D. No baldness female patient: Pay attention to a bigger group of hair in a V shape in the central forehead. Figure 3. Male patient: 7 degree baldness before the surgery: Notice the drawing designed irregularly according to the technique. Figure 5. Female patient: Notice the drawing designed irregularly according to the technique. Figure 2E. The distance between the tail-end of the eyebrow and temporal hairline is shorter in females. Figure 4. Post-operative result (2 sessions): Front view. Figure 6. Female patient post-operative: Right view (1 day after the surgery). 3. In 83.4% of the cases there was a larger amount of hair in a V shape in the central forehead. 4. The temporal entrances, for the most part, are presented in 84.2% of males, making an angle of 90º in this area, while in females, this number dropped drastically to 4.16%, tending to be a curved hairline on the temporal area. 5. The distance between the tail-end of the eyebrow and temporal hairline is larger in males (Figures 1B, 2B, 2E). 6. In our studies, the female forehead, for the most part, is shorter than males. 7. To make an irregular anterior hairline, it is necessary to make varied entrances in a V shape along the forehead (small and big entrances), with the central V shape usually being the largest (Figures 1A, 1C, 2A, 2C, 2D). Discussion The technical concepts described, called Irregular and Sinuous Hairline, published in 1996 by the author in the Brazilian Society Plastic Surgery magazine, were an important advancement in hair restoration surgery, improving the aesthetic results of hair transplantation and leaving behind the doll hair stigma of the past. However, the observation of the anterior hairline in non-bald persons made us realize the difference between the male and female hairline contours. This research enabled us to obtain clearer definitions of the range of natural hairlines, as they applied to male and females, thus allowing us to offer even better hair transplant results to our patients, and more satisfaction to us as surgeons in our search for perfection. Results Due to the new concepts of irregular anterior hairlines and the use of new equipment, such as the 3D microscope in helping to make follicular unit sites, delicate blades, and other new philosophical modern concepts, we achieved a more natural aesthetic result in our work. Editors Note: A large list of references is available from the author ( address is fbasto@fernandobasto.com.br). Each patient carries his own doctor or inside him. The hey come to us not knowing that truth. We e are e at our best est when we e give e the doctor or who resides within each patient a chance e to o go to o work. Albert Schweitzer 16

17 The Psychological Impact of Hair Loss Can Be Alleviated 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.) Article based on David H. Kingsley s The Quality of Life Implications of Androgenetic Alopecia and the Importance of Helping Patients Deal with Its Psychological Effects, presented August 14, 2004, at the 12th Annual Meeting of the ISHRS in Vancouver, British Columbia. Hair loss affects body image, self-esteem, general psychological state, and perceived physical attractiveness, stated Dr. David H. Kingsley, PhD, at the 12 th Annual Meeting of the ISHRS in Vancouver, BC, in August He insisted that the disorder should not be trivialized as it can also cause various psychosocial problems as well as serious anxiety and major depression. Dr. Kingsley, of British Science Corporation in New York City, was able to identify the key concerns of hair loss sufferers as part of a major research initiative to measure the impact of androgenetic alopecia on quality of life. He interviewed many hundreds of American and British men and women with and without hair loss and identified 38 key questions that should be asked of people with hair loss. By using this validated and reliable questionnaire (the Kingsley Alopecia Profile), Dr. Kingsley determined that the quality of life issues of hair loss victims fell into six major categories: anxiety/depression, control, self-esteem, social, support, and miscellaneous. In detailing these categories, Dr. Kingsley described how men and women with hair loss were angry, afraid, and worried by their condition. They also felt that lack of control of their hair led to a lack of Quality of life issues of hair loss victims fell into six major categories: anxiety/depression, control, self-esteem, social, support, and miscellaneous. control in their lives. However, as Dr. Kingsley pointed out, people regained some control by using disguises in the form of hats or caps, and by visiting medical practitioners to discuss potential cures. Hair loss also had a negative effect on the body image and perceived attractiveness of alopecia sufferers, and impacted on their daily routine and work situation. Besides a lack of support from many people in the medical profession, Dr. Kingsley also found that hair loss sufferers felt a lack of adequate support from friends and relatives who, in their words, just didn t understand. In his research, Dr. Kingsley identified various categories of people with hair loss, with each category affected differently by the condition. The so-called motivated group, who had seen a hair loss specialist for their androgenetic alopecia, reported high levels of psychological symptoms, particularly if they were female. Dr. Kingsley stated that, in women, the greater their quantity of hair loss, the more their quality of life was affected. Men were also psychologically affected during all stages of hair loss. However, Dr. Kingsley believed that, in general, a man s quality of life was more affected in the early stages of hair loss as he was able to come to terms with the condition more readily than women during the later stages. The socalled non-motivated group, those with androgenetic alopecia who had never seen a hair loss specialist, did not seem to be affected by their hair loss. In fact, they had a Kingsley Alopecia Profile score similar to that of people without hair loss. Dr. Kingsley concluded that people who say that they are not concerned with hair loss may actually be telling the truth. He then described some of the severe psychological implications for persons whose quality of life had been negatively impacted by hair loss. Many were fixated on their hair: they keep touching it, running their fingers through it, and think everyone s looking at it. Some people exhibited coping behaviors, such as always sitting against a wall so that the back of their head could not be seen; others were obsessive, such as a woman who brought in three carrier bags full of hair, or those who counted the number of fallen hairs in the morning and allowed the resulting quantity to color the rest of their day. Dr. Kingsley has demonstrated that the psychological impact of hair loss can be reduced if medical practitioners just spend time listening to patients and empathizing with them. He gave examples of how various physicians had wrongly treated their hair loss patients, comments that would be amusing if they were not so upsetting. To a young girl the comment was, Don t worry, at least you ll look like your father ; to another woman: It s a shame you re so short, if you were taller people wouldn t notice your hair so much. The key to improving a patient s quality of life is to take their concerns seriously and to be gentle and patient with them, Dr. Kingsley advised. Physicians should also evaluate blood test and biopsy results to determine a potential physical cause of the hair loss, and they need to discuss treatment options in some detail. He recommended training other office staff to deal with patients if the physician doesn t personally have the time to spend with them. He concluded: Hair loss can be psychologically devastating but, with adequate time and empathy, the psychological impact can be alleviated. 17

18 Is This the Future? continued from front page Because the calibration nut on the cutter is not accurate, we always measure the first 2 3 blades to determine the exact blade size (Figure 4). A change of 0.05mm in blade size is significant when it comes to dense packing. We have found the Ellis handle works well (Figure 5). Prior to making recipient sites and in order to minimize vascular damage, it is crucial to do the following: 1. Tumesce the recipient site. I personally use saline with 1/50,000 adrenalin (some people use only saline). Tissue turgor usually doesn t last for long. I frequently top up every few minutes when making recipient sites. Figure 3. Block cutter for making cut-tosize recipient site blades. Donor strip removal is done in the prone position. 4,000 FUs require 50 55cm 2 of donor tissue, sometimes requiring a strip 2cm wide, which is possible only in people with very loose scalp. Pre-op we encourage all patients with tight scalps to push the donor scalp up and down with their palm to increase laxity. The strip is removed under 1% xylocaine. The galea is approximated with 4-0 vicryl, and the skin edge stapled, using a 3M precise stapler. I stay above the occipital neurovascular (NV) bundle when removing the strip. During closure, the needle passes through the fatty SQ layer and takes a small bite into the galea, which is then pulled together with slight tension. These sutures are spaced to either side of the NV bundles. Because the surgery can last 8 to 11 hours, the donor area is topped up with 0.25% marcaine 2½ hours after initial xylocaine injection. We have not found increased widened scars with those wider strips. Figure 4. Caliper instrument used to standardize blade width. 2. To keep the incisional depth to a minimum, always adjust the blade depth to the length of the graft (Figure 6). Go just deep enough to prevent popping. It is a good idea to make a few test sites to see how the graft sits before making several hundred slits. Figure 5. Blade handle (Ellis Instruments). Figure 7. Crown reconstruction. Once the strip is removed and the crown area anaesthetized, the crown swirl is cut for hair FUs using a 1.0 or 1.05mm blade (Figure 7). The down slope (anywhere the hair is angled and pointed posterior) is then planted with the patient prone. Next, the hairline is ring blocked with 1% xylocaine and tumesced. By now approximately one-third of the grafts are cut and we have a fairly good estimate of the number of single-hair available, usually ranging from The hairline is cut next (600 slits using 0.7mm blade, see Figure 8). Figure 6. Grafts laid upon blades, to adjust blade depth. Figure hairline lateral slit incisions (0.7mm wide blade). 18

19 Figure 9. 1,600 additional 1mm slits made behind hairline zone. Behind the hairline, 1, mm slits are cut for 2- hair FUs (Figure 9). To keep grafts moist, we recently began using a graft holder made from aluminum sheeting (Figure 10). Once the front and remaining crown slits are filled, the mid-scalp will be filled using mainly 3- to 4-hair grafts. A 4,000 FU surgery will usually run 9 hours; adding another 1½ hours for crown work makes for a full day. Dense packing is a dynamic, ever-changing process involving technical precision and surgical and staffing skill. Lateral slits as described here will provide the tools to eventually reach that FU/cm² if you so desire. Special thanks to Dr. Victor Hasson for his insight and drive to keep pushing the envelope on dense packing. Figure 10. Homemade graft holder. A few years ago there was never any goal set to eventually do the 5,000 FU/surgery. Each time we did a few more hundred grafts the results improved, and over the past year we began hitting 5,000 grafts. Each surgical team needs to find their own comfort level regarding size of surgery. If the goal is to go bigger, it is probably best to increase the numbers slowly; my team currently consists of 10 surgical assistants. I would like to thank the staff of Hasson and Wong for their dedication and hard work; all too often it s the surgeons who get the recognition while the staff does most of the hard work. I desire e so to conduc onduct the affairs fairs of this administration ation that, if at the end, when I come to lay down the reins of power er,, I have lost ever ery other friend on earth, I shall at least have one friend left, and that friend shall be e down inside me. Abraham Lincoln State-of-the-art instrumentation for hair restoration surgery! For more information, contact: 21 Cook Avenue Madison, New Jersey USA Phone: Fax: cellis@nac.net 19

20 From the Literature John D.N. Gillespie, MD Calgary, Alberta, Canada BOOK IN REVIEW: Hair Restoration and Removal. Facial Plastic Surgery Clinics of North America. May 2004, Volume 12 Number 2. Jeffrey S. Epstein, MD, FACS Editor This little book is a gem and a practical addition to any bookshelf. Dr. Jeffrey Epstein has recruited a dozen experienced hair transplant surgeons from around the world as authors. This volume sums up in 100 pages much of the theory, science, and surgical techniques required to perform quality hair transplants. Even though the articles are concise, one does not feel they are skimpy. Dr. William Parsley presents a well-illustrated personal study of natural hairlines and hair patterns. He discusses both the congenital patterns and the balding patterns. Better surgical results require better observations of nature. He has made astute observations. Dr. Ron Shapiro follows with principles and techniques to create a natural hairline. He discusses the theory of the hair transplant zones and gives practical tips for hairline placement. He then follows with a step-by-step systematic approach for creating a natural hairline. Almost a Hairline for Dummies. Dr. James Harris writes a chapter on follicular unit transplants, including dissecting and planting. He gives a thorough discussion of planting techniques, comparing stickand-place to pre-made holes, and sagittal vs. coronal slits. He talks about types of magnification and the specifics of graft insertion. He reviews all the techniques in an unbiased manner. Dr. Russell Knudsen is assigned the chapter on the donor area. He illustrates safe donor boundaries and the various techniques of donor removal and closure. He emphasizes ways to reduce transection of the follicle and to reduce the incidence of other complications. He gives a good summary of the new technique of follicular unit extraction and of the potential pitfalls. Dr. Epstein, also the editor, authors the chapter on female pattern hair loss and other causes of hair loss in women. He discusses the diagnosis, investigations, and various treatment options, both surgical and non-surgical. He also illustrates surgical treatment of hair loss following various cosmetic procedures. Oops... Par ardon Us We would like to apologize to Dr. Mauro Speranzini, who should have been listed as a co-winner in the category of Best Practical Tip on page 218 of the 2004 November/December Forum (Volume 14, Number 6). Dr. Jennifer Martinick contributes a short article on new developments in hair transplants. She also discusses follicular unit extraction and coronal slits, and the advantages and disadvantages of these techniques. There is an excellent chapter by Dr. Marcelo Gandelman and Dr. Epstein on transplants to other parts of the body including eyebrows, eyelashes, chest, and pubic hair. This is an important section to use as a reference when transplanting unusual areas. Eyebrow transplantation is relatively common, but most of us can use a little refresher on eyelashes and other unusual areas. The surgical aspect of this book ends with Dr. James Vogel writing on the topic of correcting problems in hair restoration surgery. As a plastic surgeon who is also adept at hair transplantation, he is an excellent source of knowledge. With many excellent photographs illustrating his fine text, Dr. Vogel s chapter provides a great resource when faced with a difficult problem. This little text does not just discuss surgical treatment. Dr. Robert Haber has an outstanding chapter on the medical treatment of hair loss. He discusses both male and female pattern hair loss and the effects of androgens on them. He discusses all the medical treatment options and their mechanism of action. A good refresher for the experienced surgeon and a good primer for the novice. A book on hair restoration would not be complete without an update on hair follicle cloning. Dr. Jerry Cooley gives a rundown of the latest research in follicular cell implantation and the outlook for the future. For those who are wanting to get rid of hair there is even a chapter on laser hair removal by Dr. Neil Sadick. This publication is a practical resource for the experienced hair transplant surgeon and a quick reference and guide for the less experienced. It is very well written and edited. POSTER AWARD Best Practical Tip Mauro Speranzini, MD of Sao Paulo, Brazil Storage, Count & Deliver Grafts Congratulations on your achievement. 20

21 Pioneer of the Month Pioneer of the Month David J. Seager, MD By William M. Parsley, MD Louisville, Kentucky David J. Seager, MD David J. Seager, MD Scarborough, Ontario, Canada Scarborough, Ontario, Canada In spite of his many accomplishments and contributions to the field of hair restoration surgery, Dr. David Seager is primarily known to the majority of the ISHRS for one thing his incredible results. For the past 8 years, except for a couple of missed meetings, he has brought patients to the meetings for the Live Patient presentations. The talk in the hallways was always something like, Did you see those patients Dr. Seager brought? He set the bar up in the air and certainly inspired many of us to take the quality of our work to a higher level. And it worked, because the impressive results we are seeing today are greatly influenced by the challenge of David Seager. To appreciate the quality of his work is quite easy; to know him as a person is not. He is a complex man with strong opinions. At one moment he is shy and retiring, and at another he is vigorously challenging a position or technique from the floor of the meeting. David was born in London in 1945, and was the middle of three children, having two sisters, born of Coleman and Gwendolyn Seager. His father, who immigrated from Russia in 1912, worked in London as a general practitioner. David has three children by his first wife. The oldest is Jeremy, age 33, who works as a computer consultant in Kansas City, Missouri. Next is 32-year-old Sara, who works in Washington, D.C., as an astrophysicist. The youngest is Julia, age 30, who works as a professional musician (harp) in Toronto, where she teaches and plays with various orchestras. His second spouse, Wanda, is well known to the ISHRS members and had helped with many of the meetings. For medical school, David attended King s College Hospital, London University from He was a Surgical Intern from and then a Medical Intern from , both at King s College Hospital. During this period, David spent six months of Residency in Obstetrics and Gynecology before deciding that he preferred general practice. From he was a general practitioner, however, something happened in 1989 that would change the course of his career. That year he visited Dr. Pierre Bedard, a hair transplant specialist in Montreal. His interest peaked, and he visited Dr. Bedard 6 more times over a 3-month period. Dr. Bedard then came to Toronto to assist David on his first 4 procedures. The next year, 1990, he visited Dr. O Tar Norwood for 2 days. After combining general practice and hair restoration for 2 3 years, he finally gave up general practice to concentrate on hair. In 1993, he attended the Marzola School of Hair Surgery in Australia, where he learned scalp lifts and scalp reductions along with further refinement of his punch grafting technique. On this trip, he also spent 20 hours with Dr. Richard Shiell. His real turning point as a hair restoration surgeon came in December of 1995 when he visited the office of Dr. Bobby Limmer in Texas. After being exposed to follicular unit grafting and microscopes, he decided that this was the future and changed his entire practice to follicular unit grafting, utilizing the stick-and-place planting technique developed by Dr. Limmer. To help, Dr. Limmer sent one or two of his staff to Toronto on three different occasions to assist in training Dr. Seager s staff. Even though his technique has mirrored Dr. Limmer s, he has made some changes. For example, instead of one assistant planting, David uses two, enabling him to transplant a greater number of grafts per session. David has been one of the strongest proponents of follicular unit grafting, and his impressive results have convinced many doctors to abandon older methods and take up microscopes and all the other changes considered necessary to carry out this new technique. David has lectured all over the world and has written numerous journal articles in addition to several textbook chapters. In 1998, he sat for (and passed) the first exam of the American Board of Hair Restoration Surgery. At the 9 th Annual Meeting of the ISHRS in Puerto Vallarta, Mexico, he was given the prestigious Golden Follicle Award for contributions in clinical hair restoration. In his spare time David has many interests: tennis, which he plays several times weekly; recreational astronomy, for which he has several telescopes; and dancing, both Latin and ballroom. David considers his greatest contributions to be 1) that he was the first person to effectively perform 1-pass surgery, giving excellent results in only one session without requiring a second procedure, and 2) that he was the first person to dense pack 3,000 or more grafts with at least 35 follicular unit grafts\cm 2. While intensely private, he is surprisingly very approachable for those truly interested in doing quality work. When he speaks or writes, even the most experienced doctors stop and take notice. His opinions were developed with a great deal of thought and experience, and he will defend them with passion. This unique individual has made great contributions in one of the most important aspects of hair restoration results. We are pleased to honor him as a Pioneer. 21

22 Cyberspace Chat Edwin S. Epstein, MD Richmond, Virginia Please send your comments/questions to: FRONTAL FIBROSING ALOPECIA Jennifer Martinick presented a 70-year-old female who developed frontal scarring alopecia after a perm. Biopsy showed no active inflammation, but anti-nuclear antibodies were positive in low titers. Francisco Jimenez-Acosta, MD Las Palmas, Spain Although the pattern is not typical, I would consider frontal fibrosing alopecia in the differential diagnosis. All cases I have seen are in postmenopausal women and the skin looks shiny and devoid of follicular orifices. However, the recession also involves the temporal hairlines. Depending on where you take a biopsy, you may see more or less inflammation, which affects the upper and mid portions of the follicle with a lymphocytic infiltrate and apoptotic cells (quite similar to lichen planopilaris). My other differential is a scarring alopecia caused by traction. Eric Eisenberg, MD Toronto, Ontario, Canada I agree with frontal fibrosing alopecia (FFA, perhaps a variant of lichen planopilaris). Consider a direct immunofluorescence biopsy of lesional skin to look for discoid lupus. Look for eyebrow (alopecia) involvement, and/or any other clinical (skin or mucosal) findings consistent with LP. I do not believe that trauma would necessarily be a trigger, but could be a coincidental event. Tony Mangubat, MD Seattle, Washington I had a woman who suffered significant hair loss and, when questioned, found she had been placed under a hair dryer while having a perm. The chemicals used in hair perms and bleaches can be quite toxic when heated. CHRONIC TELOGEN EFFLUVIUM Jim Vogel was referred a woman with a diagnosis of chronic telogen effluvium. She had a normal part width and temporal thinning along with a history of hair shedding. The referring university dermatologist recommended Prednisone 2.5mg daily for the elevated DHEA-S, and Biotin Forte 3mg and Aldactone 50mg daily. Bernie Nusbaum, MD Miami, Florida All these factors are consistent with a diagnosis of chronic telogen effluvium (CTE). What does not go along with the diagnosis is a normal hair-pull test. The hair-pull test findings can be confirmed by having the patient do a 7 consecutive day hair collection and quantifying the shed hairs. I agree that she could in fact have AGA (I am seeing more and more female patients with this temporal thinning pattern). I recently reviewed a paper by Sinclair, who showed that performing three 4mm contiguous biopsies from the top-scalp area and submitting all three specimens for horizontal sections increases the diagnostic capability of scalp biopsy for differentiating AGA from CTE. Patients with minimal loss of part width need medical therapy, not surgery, and I would add Minoxidil to the recommended regimen of Biotin Forte and Aldactone. Although I am not sure, I think some endocrinologists also use lowdose steroids to suppress adrenal androgen production. The data on Aldactone is questionable, although it may be more effective in the setting of elevated androgens. Finasteride may be effective in women with hair loss due to elevated androgens. Robert Haber, MD Cleveland, Ohio The diagnosis of chronic telogen effluvium is difficult to prove and has significant clinical overlap with pattern hair loss. I favor benign medical treatments, and definitely would not operate on her. Eric Eisenberg, MD Toronto, Ontario, Canada Since there is no widening of the central part, this would not support female pattern hair loss, although there is slight thinning of the fronto-temporal triangles, which is more consistent with a male pattern of hair loss. Chronic TE is more typically of shorter duration than that described here, but the very good density described certainly supports good hair replacement of hairs lost as a result of telogen shedding. In other words, she either has chronic TE or recurring physiologic shedding that is either pronounced or perceived as exaggerated by those involved (patient and/or physicians). Chronic iron deficiency may be contributing to ongoing TE, and this should be corrected and monitored regularly. POOR HAIR GROWTH BETWEEN 2 HT SESSIONS Jennifer Martinick, MBBS Perth, Western Australia I have seen such situations in the vertex (with chronic sun damage) and in a full thickness scar that was tethered to the scalp. There was no growth (or a few hairs with acquired kinking) the first time, followed by excellent growth on the second occasion. I feel that it is possible, that by 22

23 seeding these pilo-sebaceous units into the scar tissue, these small full-thickness skin grafts have the ability to replace scar tissue over time. I have also had an HT patient who had an L shaped scar on his upper lip that puckered when he spoke. So, during the hair transplant, I used a 0.7mm punch to remove islands of scar tissue and replaced it with FUs. Two years later the scar is not only invisible, but his lip no longer puckers around the scar on movement. So, what I am suggesting is that the seeding of follicles on the first procedure is improving the quality of the skin or the scar (I have also noticed increased perfusion with an increase in pinkness) and so the second procedure s follicles have a better chance to grow. Carlos J. Puig, DO Houston, Texas In the old days I would punch graft large mature burn scars, thermal and chemical, with 3.5mm or 4.0mm grafts, working from the perimeter to the center of the scar in sequential sessions. These patients always did well, and the earlier grafts not only replaced the scar, but also supported the next session of grafts. One could see a dramatic improvement in the blood supply of the scar tissue during the second grafting session. I believe this was due not only to the grafted tissue replacing the scar, but also because the presence of the normal grafted tissue stimulated an enhanced blood supply to the surrounding scar tissue well. We are just beginning to understand the extent to which the component cells of the hair follicle communicate with each other and affect each other s behavior. William Parsley, MD Louisville, Kentucky While you often get variable growth in scars, to get no growth (or get no growth in one session followed by great growth in the next) I would have to conclude that something more catastrophic occurred. The only catastrophic event I can come up with is the holding solution, and the only mistake that I can see being made easily is accidentally substituting sterile water, which is found in the refrigerator of many offices. Perhaps the manufacturer could have mislabeled it. A long-shot would be the substitution of isopropyl alcohol in the strip dish, but I would think that the odor would give it away quickly. DYEING THE DONOR STRIP William Parsley, MD Louisville, Kentucky We have been dyeing the donor strip in patients with white hair for some time and have found it quite helpful. We like Just for Men. It comes in a hair dye and a mustache dye. You are supposed to use the entire box for hair dye but can get multiple applications from the mustache dye. It s supposed to be left on for 5 minutes. I recommend using the dark brown color. We always dye before harvesting. With good care it can be pretty well confined to the strip if it is clearly marked where you are cutting. It has helped me, as a planter, tremendously, and has been a big help for the sliverers. The FU cutters have mixed feelings. PEARLS ON TRANSPLANTING AFRICAN-AMERICAN PATIENTS Bessam Farjo, MD Manchester, England 1. In general, I would not go for more than 20 grafts per cm 2 in the recipient area, and I allow extra operating time due to the slower graft cutting process. 2. Depending on the curl of the hair inside the skin and the quality of the skin, I find myself using MUGs in punch holes 2 2.5mm behind the hairline zone. 3. As a general rule, I tend to use larger incisions for the same size graft compared to non African-Americans due to the shape of the grafts as well as the extra bulk. 4. I avoid angulating the graft incisions, and make the incisions close to 90 degrees. 5. I avoid dissolving sutures for external donor closure. 6. The patient is counselled at length on the subject of donor scars and keloids. African-Americans tend to have their hair short and have higher risk of scars showing through, even with good healing. 7. In African-American women with traction alopecia, I ask them to come back for consultation without their braids, extensions, etc. They are also told, should they go ahead with surgery, that they should never apply these styles again. Ron Shapiro, MD Minneapolis, Minnesota The extreme curl increases the potential for transection when taking a strip. Here are some harvesting suggestions: Bend the blades to follow the curl of the hair. Use a single strip rather than multiple strips from a multibladed knife. Use Dr. Arturo Sandoval s technique of scoring a single strip to just past the epidermis and then using mosquito forceps to spread the tissue works well for limiting transection in this type of patient. The potential problem of keloid formation needs to be discussed: FU grafts are larger in African-Americans because of the curve and increased caliber of hair. For this reason a larger incision is usually needed, e.g., a 1.2mm blade rather than a 1mm blade for two-hair grafts. This slightly larger graft also usually means that the spacing between grafts needs to be greater or conversely the density is less than with Caucasian hair. A density of about 20 FU/cm is easy to achieve. Donor density in African-Americans is usually lower than Caucasians and is another reason that we transplant at a lower density. However, as we all know, the increased curl, caliber, and minimal contrast make the coverage that occurs from a lower density appear much greater in African-Americans. Placing is more difficult in African-Americans for a number of reasons including: The skin seems to be tougher and have more turgor, so the transmission of the force of placing is greater and popping occurs much more often. The incisions are very hard to see due to the lack of contrast between the incision and the dark skin. To continued on page 24 23

24 Cyberspace Chat continued from page 23 overcome this increased difficulty in placing, I will often try one or more of the following measures: As stated above, use larger incisions spaced farther apart. Occasionally use a small 1.25mm punch rather than an incision if the FU seems particularly larger than usual and the incisions are particularly hard to see. Do more stick-and-placing, if needed. Use a two-person buddy technique for placing, if needed. This is one of the situations where small MUGs would work in the central area if one does not have the team to create the FU without transection. Paul Rose, MD Tampa, Florida I use a single blade, cut down to the level of the fat/ dermis junction, and then use the large hemostat to separate out the strip from the surrounding skin. I find that the curl is not usually a problem until it gets to the fat. It is crucial to test to make sure that the incision sites fit with the grafts before making a lot of incisions. I also consider going in sections rather than committing to make all of the recipient sites at one time. This aids in seeing the sites. Jerry Wong, MD Vancouver, BC, Canada In addition to the harvesting and dissecting difficulties, African-Americans tend to have more bleeding and popping. Initially we will make no more than 500 sites, fill these, and then move on to the next area. The longer these sites remain open, the worse it gets. 24 HOW TO MANAGE RIDGING Robert Bernstein, MD New York, New York It has been my experience that punch excision using 2.5 and 3-0 punches, if punched deeply and sutured carefully (with 5-0 Nylon left in for 9 days), can significantly decrease ridging as it removes some tissue and redistributes the tissue surrounding the punch. It will also reduce pitting and the white circles from the original punches. It is important to keep the sutures in for at least 9 days, or the depressions will return. Stitch marks are rare and, if they occur, will fade quickly. Once the skin is in better shape, an Alexandrite or Diode can be used to remove the remaining hair. Vance Elliott, MD Edmonton, Alberta, Canada I have done U-shaped hairline excisions in about 10 patients in the last 4 years. I have always been amazed at how thin the scar is that forms. However, I have always proceeded to build a new hairline in the area, often covering part of the scar. I have treated ridging using kenalog 10mg/ml spaced 6 weeks apart, and this has made a noticeable difference. John Cole, MD Atlanta, Georgia There are many patients who do not want this form of elliptical incision and the resulting scar can make some of them quite unhappy. In my opinion, ridging is due to volume displacement. I feel that steroids simply cause fat atrophy. Removing volume reduces the ridging. It is not a hyperfibrotic ridge; it is an elevation of the skin due to volume displacement. I feel firmly that ridging is not fibrosis for the most part; rather it is volume. Volume equals mass divided by density. Larger grafts containing extra subcutaneous fat, dermis, etc., represent a much greater mass, and subcutaneous fat is very low in density. The combination of low density and high mass create more volume. When you plant this volume into slits you get volumetric displacement. This is one reason why ridging is much less common with welltrimmed follicular units. I noted that, when I began removing slit grafts with a small scalpel and with FUE, the ridging would often begin to sit down. I also inspected the extracted grafts quite carefully and found a huge mass of tissue below the skin. The grafts look like onions: very compact stalks at the surface and blossoms of tissue below the surface. I also noted that the surrounding fibrosis was not that significant. It is not scar tissue that envelopes the grafts, but is fat for the most part. It is liposuction in reverse. I suspect that you do not shrink the fibrotic scars as much as you think. Rather, you get fat atrophy and this is why the scars sink into the skin. Of course, it could be a combination. Certainly, with elevated scars, there is an increase in fibrotic mass. I simply do not see that much fibrosis around the grafts I have removed. William Parsley, MD Louisville, Kentucky I have always thought that ridging was most commonly due to fibrosis, created possibly by a continued stimulus from buried hair spicules. Richard Shiell, MBBS Melbourne, Australia Some patients get much more local fibrosis than others, resulting in lumpy grafts. This can occur with transplants of almost any diameter, although I have seen it after small minigrafts, but not in FUs. If you do several sessions on the same patient, the fibrosis builds up to the extent that they can exhibit the rare phenomenon that we term ridging. In my experience the vast majority of patients can have up to 25 sessions without any sign of ridging. I do not think it has anything to do with spicules. If spicules were the culprit, it would be more random or related to new assistants on the team. Marc Avram, MD New York, New York I have treated several patients with ridging from grafts over the years with good results using the Pulse dye laser and kenalog injections. I get improvement, but never complete resolution. Different wavelengths respond slightly difcontinued on bottom of page 25

25 Pearls from Providence Robert T. Leonard, Jr., DO, FAACS Cranston, Rhode Island Wow! What a magnificent meeting we had in Vancouver. From a room with a view of the beautiful harbor to top-notch educational lectures and panels; from the freshest sushi this side of Tokyo to cutting-edge scientific reports. Because it was so great at our northernmost meeting to date, I can t wait for our next one way, way Down Under. Begin to make your plans NOW to attend it will be one not to miss! As always, please submit your pearls to me at: docrtl@aol.com so we all can learn from your ingenuity. This issue of Pearls brings ideas that seem so simple, but actually required years and years of experience to discover. Dow B. Stough Hot Springs, Arkansas All hair transplant surgeons individualize their method for producing recipient sites posterior to the frontal hairline. Some choose to start in the most anterior point, while others begin making sites in the posterior, working forward. A random pattern placement can also be used. Some surgeons utilize a second pass method to increase density. Dr. Stough s method is somewhat unique. Using a plastic comb, the small ends are pressed into the mid-scalp, leaving minor indentations. This produces a straight template from which recipient sites are then created. This indented pattern allows for appropriate spacing and the indentations disappear within one minute. He has found this method allows for greater uniformity of density compared to various other methods. Thus, pattern placement utilizing indentation appears to offer the advantages of even graft distribution, minimizing operator errors, and maximizing density. This approach is NOT used to create the frontal hairline! Paul T. Rose, MD Tampa, Florida To match the contour of the recession area bilaterally, create a template for one side. The template can be made from paper. Reversing the template will create a mirror image for the other side. Align the template with the hairline and draw in the recession following along the template s pre-drawn contour. And Use hair spray to keep the hair in the donor area out of the way of the surgical field. (This pearl actually comes from Dr. Rose s surgical tech, Jane Stevens Thank you, Jane!) Edwin S. Epstein, MD Richmond, Virginia In performing a double-layer closure using 3-0 Vicryl, penetrate the needle initially through the skin at one end of the incision. Now within the incision, initiate the needle throws deep to the bulbs first on the inferior edge of the incision, then across to the superior edge, then to the inferior edge, and so on until the opposite end of the incision is reached. As you are sewing, continually tighten down the incision by pulling on each end of the suture. Once you reach your final subcutaneous bite, bring the needle out of the skin at the incision s other end. Tighten once again and then snip the Vicryl at the skin s surface on both ends. Then use a 5-0 Nylon suture to close the already closely approximated skin edges. I learned this from Ed a few months ago and have been using it with great ease and success. It is faster, more uniform, and less difficult to achieve deep closure than with individual sutures. Cyberspace Chat continued from page 24 ferently from patient to patient. I have had failures with an Alex and good results with the Yag in the same patient and vice versa. In thickened scar tissue, varying the pulse duration and wavelength may produce better results. Bob Haber, MD Cleveland, Ohio To reduce ridging I favor the Alexandrite laser over the LightSheer. It is much faster and much less expensive long term than many sessions of punch excision. I have not had great success with the PDL for ridging, however, and doubt that ILK will provide sufficient change for his satisfaction. 25

26 26 Hair Transplant Forum International Volume 15, Number 1

27 Letter to the Editors We would like to thank Tracey for her heart-felt letter. Her experience as a live surgery patient is wonderfully described in her own words, and the entire leadership of the ISHRS is so pleased to hear her comments. When you read Tracey s letter, you ll get a sense of what goes through a patient s mind and an appreciation for how much work both patient and doctor go through to prepare for the decisive moment. We are grateful for Tracey s generosity in sharing a part of herself in such intimate detail as she is a voice that is to be truly cherished by our Society members. LIVE SURGERY EXPERIENCE Dear ISHRS: My name is Tracey Swinarsky and I just finished participating in the ISHRS symposium as a Live Surgery Patient. Dr. Kabaker performed a hairline advancement with a brow lift on me. I would like to provide a little feedback about my experience. First let me say that Dr. Kabaker is an absolute artist. I totally love the results and many people comment on my new hairline. I still cannot believe all what happened the past few months. Dr. Epstein introduced me to Dr. Kabaker in February. Dr. Epstein prescribed Propecia for me a few years ago as I tried to prevent any further hair loss. I consulted with Dr. Epstein earlier this year about hair transplants to feminize my hairline. He assessed my needs and realized a hairline advancement would provide the quickest and best results. He inquired if I could travel and if I was interested in participating in the symposium. I was so happy and amazed Dr. Epstein even considered me. He took a bunch of pictures and sent them off to Dr. Kabaker. It was almost a month until I heard from Dr. Kabaker (Dr. K). Cecelia from Dr. K s office scheduled a phone call. Dr. K. asked a bunch of questions and decided he needed to see me in his office. He explained the difference between a one-step hairline advancement and a two-step using an expander. My scalp was so tight I needed an expander. Placing the expander in my head was performed at Dr. K s office the second week of June. I was a little apprehensive being so far from home and all by myself. Everyone at Dr. K s office was so sweet and understanding most of my fears dissipated. They made the surgery as easy as possible and made me feel extremely protected. The care and concern shown to me was outstanding. I felt so safe! Rose was a godsend! She looked after me the night after surgery. The first night was rough!! The pain was extreme! Rose kept a watchful eye and attended to all of my needs. The next day she transported me to the airport and took care of my rental car. A few days later I was in Dr. Epstein s office for my first fill of the expander. Two times a week Dr. E filled my expander. At first it was a little uncomfortable as my scalp started to grow. As time went on the pain started increasing. The last two weeks before the final surgery was pretty unbearable. Drs. Epstein and Rose were so patient with me. Both were so gentle, understanding and caring during the whole process. Because of my job, there were many early mornings and a few Saturdays where Dr. Epstein came in to fill the expander. Finally I was on plane to Vancouver to finish the process. I could not wait to have the expander taken out. I saw Dr. K at the Westin Hotel Friday afternoon where as he said everything is a go. Christina at Dr. Wong s office contacted me that day and now all that was left was to show up Saturday. I arrived at Dr. Wong s office and was met by again another sweet person, Christina. She said I could wait in Dr. Wong s office and use the massage chair to relax. She checked on me periodically to make sure I was okay. She was busy preparing for everyone to show up. After Dr. K arrived I was prepped and escorted to the surgery room. I had one of the most beautiful views of Vancouver sitting in the chair during the surgery. After Dr. K administered a sedative, the surgery started. I remember waking up and squeezing one of the nurse s, Vanessa, hands so much I was scared I broke them. The room did appear to be filled with a lot of people. I remember everyone telling me I will love the results. I cannot count how many times I heard the words amazing and wonderful during the surgery. Dr. K was so patient and answered my questions during surgery. After a short recovery, Christina brought in a plate of food. She went out of her way to save some food for me even though she had her hands completely filled with managing the office. The night after surgery was okay. I felt some pain, but the medicine quickly stopped the pain. Dr. K came in the morning to check me and to remove the drain and change the dressings. He proclaimed his work good! The next day was my first time seeing the results when I took a shower. I slowly removed the bandages and gently washed my hair. I was a little concerned when I saw the tub filled with reddish brown water and then remembered that was a combination of dried blood and betadine solution. After drying my hair and seeing the results I was in tears. I cannot explain the joy I felt. Prior to the surgery I did not know if I would have gone through the surgery because of the sometimes debilitating pain caused by the expander. Upon seeing the results I know I would have done this no matter what. I can say the live surgery has been one of the best experiences of my life. I came across so many kind, caring, sweet and professional people. I thank the ISHRS for providing me with the opportunity and to Dr. Wong and his staff for the use of their facilities. Thank you Christina for being so thoughtful. I thank Dr. Kabaker for his expertise and artistry. I thank Dr. K s whole staff for their care and concern. Thanks to Jane at Dr. Epstein s for her patience as the expander fills became more challenging and hurtful. Last but not least, a hug of thanks to Dr. Epstein for opening this door for me. I am so grateful to him and to everyone who made this all happen. Sincerely, Tracey Swinarsky 27

28 nce Upon a Time Why are people with average hands even doing these procedures? The techniques for extender use and the three-flap closure are advanced surgical techniques, and they need to be viewed as such. James E. Vogel, MD Baltimore, Maryland (In Issues and Answers on Scalp Extenders: Responding to Dr. Rassman. Vol. 5, No. 2, March/April 1995; pp ) I spoke with one such marketing professional who, for a fee, would provide before and after photos of patients not performed by me, provide advice on marketing a hair restoration practice, train the office staff to properly answer the phones, train me how to do hair transplant surgery, and teach the staff to track leads. Did you catch that? he was going to train the physician to perform surgery! I asked him how he could do something like this; he responded that he observed the Masters, and, therefore, could walk me through my first few surgeries. Robert T. Leonard, DO Providence, Rhode Island (In his presidential address. Vol. 5, No. 5, September/October 1995; pp. 1 2) Lacking sufficiently powerful science, the issue of superior surgical technique is at risk of being settled by popular sentiment and the most vocal among us, an intellectual fascism if you will. Shame be on us if we allow the object of our passion, that is, the growth of the transplanted hair follicle, to be stunted by a premature rush to obvious superiorities William H. Reed, MD LaJolla, California (In his cover story, Rethinking Some Cornerstones of Hair Transplantation. Vol. 9, No. 5, September/October 1999; pp. 133, ) 28

29 In Memory of... Pierr ierre e Pout outeaux, MD The field of hair transplantation lost one of its outstanding pioneers with the passing of Pierre Pouteaux on March 6, Pierre was born on August 4, 1925, in Algeria. He studied medicine at the French University there and trained in otorhinolaryngology and maxillofacial surgery. He moved to Paris during the War of Independence in Algeria to specialize in cosmetic surgery of the face. In 1967, he heard of hair transplantation and phoned Dr. Norman Orentreich s office to see if he could come and observe the procedure. He was welcomed with open arms and was impressed by all he saw. He began slowly carrying out an ever-increasing number of procedures, until finally his practice was limited entirely to hair transplantation. At the time he began his work, only Drs. Jean Arouet and Patrick Rabineau were engaged in hair transplanting in Europe. Dr. Pouteaux spoke English and Italian quite well and had the novel idea of opening clinics in London and Milan, which he visited once every three months to interview potential patients. He soon became widely known for his hair transplant work. He was active in lecturing and taught many physicians in his office, passing on to them what he had learned over the years. Unfortunately, Dr. Pouteaux was forced to retire from practice in 1997 after three operations on his spinal column. Dr. Pouteaux was a very cultivated individual. He loved opera music and was known to travel to Milan or to London, especially to listen to one of his favourite operas. He also enjoyed travelling to Tunisia and going back to his North African roots. His friendly manner and real sense of humor were much appreciated, as well as his calm and posed manner. We will remember his warm smile and quiet strength. We are lucky to have known and learned from this man. He will be greatly missed. Patricia Cahuzac, MD Paris, France Pierre Pouteaux, the oldest of a triumvirate of French pioneers in hair transplant surgery, has died in Paris at the age of 79. (The other two were Drs. Jean Arouette and Patrick Rabineau. See The Three Musketeers of French Hair Transplant Surgery by William P. Coleman [Forum No. 3, May/ June 1997, pages 29 30].) He always regarded Dr. Robert Fosnaugh of Chicago as his principal mentor, however, because he favored his method of using larger numbers of smaller grafts in hair restoration procedures. Dr. Pouteaux was using 2mm grafts by the mid-1970s and switched to minigrafts from multiblade strips when these were introduced in the early 1990s. Pierre was always very musical and was trained as a violinist and opera singer before settling down to his medical studies. He maintained an avid interest in opera throughout his life. He was a charming man and, along with his long-term surgical assistant, Madam Lulu, was a welcome visitor to many ISHRS meetings over the years. He will be missed. Richard C. Shiell, MBBS Melbourne, Australia Rob ober ert t Thomas, MD With the death of a mentor, a friend, and colleague, it is very difficult to find the words or express the feelings of his loss. Robert A. Thomas, MD, Medical Director of Robert Thomas Medical Associates and Cleveland Hair Centers, was killed in an automobile accident on Thanksgiving Day, 11/25/04. He will be deeply missed by his wife, Sue, his daughter, Kristen, and his son, Blake. He too will be missed by his friends, colleagues, and patients. Dr. Thomas received his B.A. from Northwestern University in Evanston, Illinois. He then graduated with an M.D. from the University of Health Sciences, the Chicago Medical School, in This was followed by residency training in General Surgery at Loyola University in Maywood, Illinois. After honorably serving as a General Medical Officer with the U.S. Navy, Dr. Thomas returned to the Chicago area where he practiced Emergency Medicine. In 1987, he discovered the exciting professional opportunities that hair restoration surgery presented and quickly realized that he could improve the results that he desired, and give his patients greater satisfaction by devoting more and more time to his new practice. For over 10 years, Dr. Thomas has devoted his practice of medicine exclusively to hair restoration surgery. He was a member in good standing of the American Medical Association, the Illinois State Medical Society, The Chicago Medical Society, and the International Society of Hair Restoration Surgery. Dr. Thomas firmly believed that the most important step in helping any patient was to listen to that patient s concerns and problems. The next step was educating the person about their medical condition and possible solutions for it. Only then should a treatment plan be formulated, with the patient playing an active role in the planning. At the memorial service, his best friend and personal attorney, Mr. Michael Falls, gave one of three eulogies. His eulogy best described Dr. Thomas, the man and the surgeon. What follows is excerpts from Mr. Fall s eulogy: continued on page 30 29

30 In Memory of Robert Thomas, MD continued from page 29 I am Michael Falls and I am proud to say that Bob Thomas was my best friend. We met in 1988 at a time when Bob was contemplating a dramatic change in his career, planning to leave the hospital emergency room to join a hair restoration surgery practice. He spoke of more time with his wife and young children, being freed of the night shifts, the weekends, and the holidays spent on duty. They seemed excellent reasons to me. Bob made the change and we came to know each other well. Bob always placed the welfare of those entrusting their body to his care as the absolute priority. His quiet authority comforted all in the emergency room but Bob felt the strain and wisely moved on. Did Bob Thomas restore just hair? Not hardly. I won t ask the men among us for a show of hands as to who, besides me, that is, was a patient. Each of you will, as I do, remember Bob each morning as we look in the mirror, seeing the results of his careful work and superb skills. But I want everyone here today to know what Bob really gave to thousands of men and even a few ladies respect, compassion, and assurance that his skills would make their lives better. Know, as Bob did, that his patients sought to regain a measure of control over a piece of their lives that made them unhappy with how they looked. Was that a serious matter? The patients surely thought so and Bob never failed to make clear to them his belief that appearance was integral to self-confidence, self-respect, and inner peace. Bob knew that a good doctor treats both the body and the soul. Restoring a patient s pride in their appearance met that goal. I will miss Bob more than I can say, as I know you all will. I too will miss Dr. Thomas. Our Society has lost a valuable member, a member who has contributed his life to the well-being of his patients. We have all lost a very special colleague. Cary Scott Feldman, MD Rochester, Michigan Dr. Thomas worked with his church, St. James Lutheran Church, in a program called PADS (Public Action to Deliver Shelter). This program provides one meal per month to a local shelter. Dr. Thomas was part of a team that served the meals to the shelter guests and remained late into the night. Mrs. Thomas has designated a particular site called CENTER - Waukegan to receive memorials for Dr. Thomas. Memorials for Dr. Thomas may be sent to: PADS Crisis Services, Inc., 3001 Green Bay Road, Building #5, North Chicago, Illinois , USA. In the memo field denote: Dr. Thomas Memorial, CENTER - Waukegan. A frog in a well cannot be talked to about the sea. Ancient Chinese philosopher (anon.) 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 30

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32 REPORT FROM THE CME COMMITTEE CHAIR The Continuing Medical Education (CME) Committee continues to meet on a regular basis with one of the primary objectives being to oversee the ongoing educational needs of the membership. The ISHRS Needs Assessment Survey has been completed. It is your invaluable input that drives the direction of the evolving ISHRS educational activities. I am pleased to report our highest response rate ever with 27% responding, or 213 received of 788 mailed out to the membership. Previous years showed response rates that ranged from 12% 20%. Two reasons that contributed to this year s success is the first time offering of the survey online, making for quicker and easier responses. This form of response was favored over mail and fax. Additionally, an incentive prize for completing your survey was also provided. The lucky winners are: Robert Shapiro, MD, Kathryn Lawson, and Sam Gershenbaum, DO. This year an independent research firm performed descriptive statistics and frequencies on the data. The responses were further broken down by country (USA, international), as well as surgery experience level (novice, intermediate, and advanced). Highly rated topics to be included in the 2005 Annual Meeting for all response categories are: Avoiding Poor Graft Growth, Complications, and Maximizing Density. Low-rated topics include Lasers and Flaps and Reductions. It was interesting to note that some topics, for example, Hair Loss in Women, rated higher for advanced members compared to novice members. This breakdown of frequencies has implications as to how the CME Committee will recommend to the program chairs different topics to be kept or dropped in a given year. An example of how the data can be used to plan a meeting is with the topic of Consultations and Evaluation. This was ranked mid to low in interest overall compared to other topics, but novice members ranked this topic higher than advanced members. This information can then be passed on to the upcoming program chair that perhaps this topic should not be given great emphasis in the General Session at the Annual Meeting, as there is not enough interest overall; instead, a workshop that would be aimed at the novice level should be offered. The most conducive learning methods are reported to be live surgery, hands-on workshops, and didactic workshops. With this in mind, upcoming meetings will strive to provide more of these learning venues. The feedback provided on the annual Orlando Live Surgery Workshop is very valuable. The comments and ratings are directly being used to shape the Orlando Workshop this coming year. In addition, the ratings and comments on the items regarding the Forum are very useful. In response to your feedback, the incoming co-editors have changed the de- sign and layout of the Forum, will enhance various columns, and will add new columns and features. The demographic and general information questions reveal the following: Seventy percent of the respondents are in solo practice compared with 27% in group practice and 3% in an academic setting. Compared to previous years, we are doing fewer hair transplants per year but more grafts per session. There is a mean of 16.9 hair transplant surgeries per month (median 15, mode 20) reported on this survey, compared to a mean of 21.7 (median 20, mode 30) on the Needs Assessment Survey. The maximum number of grafts in one procedure is 2,175 grafts per session (median 2,215, mode 2,500), compared to last year when there was a maximum average of 2,038 grafts per session (median 1,800, mode 1,300). For the typical transplant surgery on a new patient, the average number of grafts is 1,456 (median 1,500, mode 1,500), compared to a mean of 1,210 (median 1,200, mode 1,500) in The number of assistants in surgery is 3.8 (median 4, mode 4) and the average time to complete a surgery is 5.1 hours (median 5, mode 4). Follicular units are the most common graft used with a 96% occurrence, up from 94% the year before. Advanced members used FU grafting more than novice and intermediates, and 98.8% of international members used FUs compared to 94% in the USA. The average number of scalp reductions done in the past year was 0.7 (median 0, mode 0). Forty-five percent report an increase in practice volume in the past year, while 17% report a decrease. Thirtyeight percent indicated practice volume stayed the same in the past year. When asked about primary training background, 22% reported dermatology, 20% plastic surgery, 17% general surgery, 14% general practice/family medicine, 5% emergency medicine, 5% cosmetic surgery, and the remaining from other various specialty backgrounds each with less than 5%. The three main responses to the inquiry about what the top 3 goals of the Society should be in the upcoming year were to increase membership, to develop standards, and to increase public awareness. The Board of Governors is reviewing this valuable information and aligning the Society s Strategic Plan with this in mind. It is with the membership s valuable input by filling out post-course surveys and Needs Assessment Surveys that the Board of Governors, CME Committee, and program planning committees can respond to our members changing needs. Please feel free to contact me if you would like further information from the recent Needs Assessment Survey. Sincerely, Paul C. Cotterill, MD, Chair CME Committee 32

33 Surgical Assistants Corner Office Techniques of Transmed Hair Surgery Clinic Ergin Er, MD, Resmiye Kokden Istanbul, Turkey Transmed Staff Back row (L to R): Dr. Ergin Er, Bilge Arýkan, Perize Senturk, Aysegul Bahar, Resmiye Kokden (head nurse) Emine Aracý, Dr. Melike Kuelahci Paeffgen Front row (L to R): Selma Basoren, Eylem Kýlýç, Arzu Temiz, Oznur Altuntas, Sevgi Karatay, Dr. Emirali Hamiloglu The Transmed clinic was founded by Dr. Melike Kuelahci and Reiner Paeffgen in Istanbul in February of 1994 as an international medical center offering state-of-the-art hair transplantation surgery. The goal and desire of Drs. Melike Kuelahci and Reiner Paeffgen is to serve all clients with the newest medical technologies, the utmost care, and, of course, the highest grade of service. Under the leadership of Drs. Kuelahci and Paeffgen, the team of Transmed, which also comprises Dr. Ergin Er, Op. Dr. Emirali Hamiloglu, and 12 medical assistants, we have successfully performed more than 6,500 hair restoration operations. Our team is renowned for their continuously improving medical knowledge and proven aesthetic skills. The clinic is open Monday through Friday from 8AM to 7PM and with 3 operation theaters, we re able to perform 4 hair transplantation operations (3 FUT and 1 FUE) a day. Technique Following the strip harvesting, we work under microscopes (Mantis) and each assistant cuts grafts per operation and performs 2,000 2,600 grafts in a typical regular session. Recently we began to increase the graft number to 3,000 3,200, and we plan to increase this number more for certain indicated patients. We are basically dividing the strip into parts and then preparing the follicular units with Aesculap 510 scalpels. We are only working with follicular units. We are routinely storing our grafts in our special Transmed Storage Solution. Our doctor s award-winning study has proven that this is better for graft survival; the results of this study were presented at the 12 th Annual ISHRS Meeting in Vancouver During the time while the assistants are dissecting the grafts, our doctors are preparing the slits. They typically use the perpendicular slit technique popularized by Drs. Hasson and Wong. Sometimes, however, our doctors prefer blue slits, to work in between existing hair follicles and to prevent harm to the existing follicles. Next, we begin to place the grafts. The most important point for us is to keep the grafts as moist as possible and prevent desiccation during placing. To achieve this goal, we are taking 50 grafts in wet gauze and an assistant is always spraying this solution upon the grafts. Also, we are very careful about placing the grafts in 1 or 2 movements and try not to squeeze them during this step. This is sometimes very time consuming, but we always consider the well-being of the patient and know very well this extra caution will improve our results. Three to 4 assistants can work on the patient placing grafts at the same time. We use fine jewelers forceps (Robbins #815). After the procedure, we wash the donor site with betadine soap and use only a bandage for the donor site. At the end of the day, we clean and sterilize our tools for the next day. On the next day, our patients return for the first washing. We show them how to wash their transplanted area and explain in detail how to perform this washing by themselves. We look forward to seeing you in Istanbul, which is a historic and beautiful city. Tips * During the transplantation, we moisten the follicular units with Transmed solution to prevent them from drying. * We allow the patient to walk around or see their spouses for a short time if he or she gets tired from sitting too many hours in the operating chair. * In the operating room, we keep magazines for our patients and they are also able to watch cable TV if they wish. * On the day after the operation, we invite the patient for a hair wash, in order to control the transplanted areas and teach/explain to them how to wash their hair by themselves. 33

34 Working Towards a Sustainable Industry for the Future Last Call for Abstracts! Go to: 13thAnnualMeeting.html to submit your abstract for the meeting. The deadline to submit an abstract is February 10, 2005, by 12:00am Midnight (CST). United Airlines: Reference ID number: 529CF Hours: 7 days a week; 8:00AM 10:00PM Eastern time Travel dates between: August 17 September 2, 2005 Make Your Airline Reservations for the Meeting We encourage you to make your airline reservations early flights to Sydney are limited! The ISHRS has contracted with Qantas Airways to hold a limited number of specially priced coach seats in a group block. BOOK EARLY these seats and fares are only available while supplies last. These seats are at a special fare of $1,025 (USD) plus tax for round trip between Los Angeles and Sydney, on certain flights. Note that these block tickets are restricted and non-refundable. In order to book into the ISHRS Qantas block, you must contact the ISHRS travel agent, On the Go Travel, by with your ticket request (you may not contact Qantas directly for this group block). Please send your to: Denise Weingart at On the Go Travel: onthegotravel@att.net or seeus@onthegotravel.com The phone number for questions is Note that On the Go Travel charges a $60 (USD) booking service charge, and there is also a $30 (USD) change service fee on any ticket changes. The ISHRS has also secured group discounts with the following U.S. domestic carriers so that you may save on the domestic portions of your flight. You may book these domestic flights through On the Go Travel (in conjunction with your overseas flight, at no additional booking service charge), or directly with the airlines if you just need the domestic flight to connect to a Sydney flight that you booked on your own. Both United and American Airlines are offering: 5% off published fares, or, 10% off unrestricted coach fares when purchased at least 7 days prior to travel, plus an additional 5% discount when booking at least 30 days in advance. American Airlines: Reference star file: 0685AD Hours: 7 days a week; 5:00AM 12:00AM Central time Travel dates between: August 17 September 3, 2005 Hotel Reservations The Hilton Sydney will accept reservations directly via the official ISHRS Reservation Fax Form beginning in March Our group block is not yet open for reservations. This fax form will be included in the March program mailer and will also be available on the ISHRS Website beginning in March. Please note that you cannot make reservations online through the Hilton Website for this meeting. Post-Meeting Trip The ISHRS, through Tour Hosts Destination Management in Sydney, is planning a 5-day/4-night Reef and Rainforest trip, August 28 September 1, 2005, for those interested in extending their stay in Australia. North of Cairns you ll discover one of the most beautiful regions of Australia. Here, at the meeting point of an ancient rainforest and the earth s largest living coral structure, is the Great Barrier Reef, slow to a unique rhythm found only in Tropical North Queensland. There is limited availability on this ISHRS group trip, so book early to secure your place! The trip includes everything as listed in the itinerary, but does NOT include air travel between Sydney and Cairns (or return) you will need to book the air component on your own or you may book air through Tour Hosts Destination Management. For details on the itinerary and information on how to book your trip, go to: 13thAnnualMeeting.html As always, visit the ISHRS Website for continually updated information on the meeting! 34

35 Offering Financing Options Allows More Patients to Afford Surgery Rob Morris, Vice President, Marketing/Care Credit Anaheim, California By the time prospective patients make contact with a hair transplantation practice, there is no doubt they have seriously considered and even dreamed of the positive effects hair transplantation could have on their lives and self-esteem. Because hair loss is a gradual process, most potential patients have watched over time as their appearances have changed and are now ready to take action and do something about it. So imagine the frustration many feel when they have to delay or decline a procedure because of the cost associated with treatment. Financing programs from a third-party patient financing company may be an option for patients to be able to afford the cost of treatment. In most practices, patients are given the choice to pay with cash, check, or major credit cards. Recent studies show, however, that most Americans have only $300 in available credit on their consumer cards, and many find it difficult to comfortably write a check for more than $500 out of their monthly budget. Many practices are now offering patients financing plans through third-party companies. There are many finance companies to choose from, and they may offer a full range of payment plan options to patients, including 3-, 6-, and 12-month interest free and 24-, 36-, & 48- month low interest extended payment plans. With these types of programs, patients pay no up-front cost, annual fees, or prepayment penalties, so they can schedule their treatment and pay it off over time with a convenient low monthly payment that fits comfortably into their budgets. Plus, by choosing to pay for treatment this way, patients can reserve their credit cards for household or unplanned expenses. A Plan for Every Need Typically there are two types of financing available to patients: interest free payment plans and low interest extended payment plans. The interest free payment plans are extremely popular and give patients up to 12 months to pay for treatment, without incurring any interest charges as long as the balance is paid off within the specified time period. The low interest extended payment plan options are designed for patients who desire lower monthly payments. The plan stretches payments over a specified period for example, 48 months or 4 years. These loans feature a low, fixed interest rate of 12 to 15 percent. And, because some compa- nies offer a revolving line of credit, once patients are approved, they can use their credit line again and again, usually without having to reapply. Benefits Your Patients and Your Practice In addition to giving more patients a way to say yes and schedule their treatment, offering third-party financing can benefit a practice in other ways as well. A low merchant rate, which is the fee the practice pays the third-party financing company, offers a much lower cost to your practice then your practice would incur extending credit. Once the patient has accepted credit, your practice then receives payment within two business days, which can greatly improve its cash flow. Plus, there is no responsibility or recourse to your practice if the patient is slow to pay or defaults because you have received payment and are no longer involved in the financial relationship. An often overlooked advantage to offering patient financing is the fact that it can be used as a marketing tool to help grow a business. Many finance companies often provide support materials, such as counter signs and patient brochures, that a business owner can use in their patient materials to promote the benefit of interest free financing. Prospective patients may be more likely to seek treatment at a practice that offers them the payment flexibility they need or desire. The success of using patient financing revolves around the way practices present the option to their patients. To optimize the program, practices should offer patient financing to all patients as one of their payment solutions during the discussion of treatment recommendations and fees. It is usually very effective to present the treatment cost as a monthly payment, in addition to the total fee (for example, This treatment will run you about $134 a month, or $5,000 total. ). A lot of people don t like to ask for financing and most won t; instead they may simply choose to say, I ll think about it, and hang up or walk out of the door. By providing patients with more financing options, you may be removing the obstacle that has been keeping them from obtaining the treatment they so desire. Prospective patients will appreciate this added service, which will provide them with the means to afford their desired results. Offering patient financing is something to consider. DUES REMINDER: 2005 membership renewal payments were due December 31, If you are past due, contact the ISHRS office to avoid interruption with your member benefits. 35

36 ISHRS Regional Workshops Program Physician Members! Consider hosting a live surgery workshop through the ISHRS s Regional Workshops Program. This is an excellent opportunity for members to partner with the ISHRS to offer a live surgery workshop in their region. All ISHRS Physician Members in good standing are eligible to submit an application. The complete guidelines and application are available by contacting the ISHRS headquarters office at or , or online at in the Members Only section. New Polish Society of HRS Management Board The Polish Society of Hair Restoration Surgery (PSHRS) was brought into being in the year The Society consists of 15 members; however, currently there are 8 active members dealing with the issues of hair transplantation, the majority of whom are surgeons. Jerzy Kolasiñski, MD, has been the President of the Society for the first four years ( ). The meetings of the Society take place once a year and have a purely scientific character. The last meeting took place on September 26, 2004, in the Society s office in Poznañ. At that meeting, attendees had an opportunity to hear three reports, including an interesting one presented by Kazimierz Cieœlik, MD, who paid a lot of attention to the issues of culturing hair blastema and its cloning to restore scalp hair. During the second part of the meeting, a new management board of the Society was chosen. This Board consists of Ma³gorzata Kolenda, MD, PSHRS President; Kazimierz Cieœlik, MD, Vice-president; and Jerzy Kolasiñski, MD, Past President. The new President may expect an interesting but also a difficult job. The ISHRS would like to extend our heartfelt condolences to all those affected by the recent tsunamis. Our prayers are with those who have suffered as a result of this tragic disaster, and we pray that all of our members and their families are safe and well at this time. 36

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38 HAIR TRANSPLANTATION Fourth Edition, Revised and Expanded Edited by: Walter P. Unger Mt Sinai School of Medicine, New York, New York, U.S.A. and Johns Hopkins Medicine, Baltimore, Maryland, U.S.A. Ronald Shapiro The Shapiro Medical Group, Minneapolis, Minnesota, U.S.A. March 2004/ ISBN: / 1318pp. List Price: $235.00/ ISHRS Member Price: $ Completely reorganized and expanded to reflect the state-of-the-art in hair transplantation technology, this Fourth Edition describes modern practices and emerging methods in hair transplant surgery meticulously illustrating procedures utilized by 80 of the most recognized leaders in the field to showcase current trends, controversies, and innovations that are impacting the future of hair replacement. HOW TO ORDER ISHRS must use the following promotion code to receive the 20% discount: Order directly from Marcel Dekker, and ISHRS Members receive a 20% discount! 008SS To contact Dekker customer service by phone, please call (USA, Canada & South America) or (Europe, Far East, Middle East & Africa). Marcel Dekker, A Division of Taylor and Francis Books 270 Madison Ave. New York, NY 10016, USA Website: Tel: Fax: promoorders@dekker.com 38

39 Please Hair Transplant Forum International Volume 15, Number 1 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: Board Certified or Eligible Plastic or Facial Plastic Surgeon Wanted to join Board Certified Facial Plastic Surgeon in a first class hair transplant practice. Some hair experience preferable, most important is a desire and commitment to specialize in surgical hair restoration. Main office in south Florida, with growing practice in Tampa and New York. All inquiries completely confidential. Please Roxy@foundhair.com or call Roxy at 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. make note... Please note the new Forum submission information below. To be considered for publication, all articles should be sent electronically, via , to Robert Haber, MD, at HaberForum@aol.com Board of Governors Chairs of Committees President: E. Antonio Mangubat, MD* 2004 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: March/April, February 10 May/June, April 10 39

40 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 March 24 26, 2005, and May 12 14, 2005 Diploma of Scalp Pathology & Surgery University of Paris VI School of Medicine Paris, France Coordinators: P Bouhanna, MD and M. Divaris, MD Director: Pr. J. Ch. Bertrand Tel: 33 +(0) Fax: 33 +(0) marie-elise. neker@admsto.jussieu.fr March 2 5, th Annual Live Surgery Workshop, Orlando, Florida, USA Co-sponsored by International Society of Hair Restoration Surgery & Matt L. Leavitt, DO Tel: Fax: HValarieM@leavittmgt.com June 2 4, 2005 June 2 5, th ISHR International Conference Modena, Italy 8 th Annual Congress and Live Workshop of ESHRS Brussels, Belgium Italian Society of Hair Restoration European Society of Hair Restoration Surgery Congress Host: Dr. Jean Devroye Euromeeting Tel: Fax: emeet@tin.it 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 40