orum A New Advance in Baldness Surgery Using Platelet-Derived Growth Factor Carlos O. Uebel, MD Porto Alegre, Brazil

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1 f HAIR orum HAIR TRANSPLANT INTERNATIONAL Volume 15, Number 3 May/June 2005 A New Advance in Baldness Surgery Using Platelet-Derived Growth Factor COLUMNS 78 President s Message 79 Co-Editors Messages 81 Notes from the Editor Emeritus 89 Scalp Dermatology 91 Letters to the Editors 92 Once Upon a Time 94 Pioneer of the Month 95 Surgeon of the Month 96 Cyberspace Chat 99 Pearls of Wisdom 111 Classified Ads FEATURE ARTICLES 85 A Perspective on Transplanting Females 88 Prevention of Forehead Edema and Periorbital Ecchymosis after Hair Transplantation 101 Focus on Protecting the Tools of the Trade 104 Reports on Orlando Live Surgery Workshop XI 109 Australia: A Little Political History and Anthropology Don t for orget to regist egister er for the Annual Meeting! Revised Program with detailed General Session now available! 13thAnnualMeeting.html Carlos O. Uebel, MD Porto Alegre, Brazil W e have performed an experimental study in 23 male patients with pattern hair loss using follicular units (FUs) and growth factors derived from autologous platelet-rich plasma to assess the effectiveness of those factors in the growth and density of transplanted FUs. Introduction Figure 1. Schematic view of micrografts being implanted with platelet derived growth factors. The first works on growth factors, derived from plasma, originate from the 1970s and 1980s, and they demonstrated usefulness in the healing process of ulcers and wounds. The growth factors contained in platelets of blood plasma are primarily of three types: the platelet-derived growth factor (PDGF), the transforming growth factor beta 1 (TGF beta 1), and the vascular endothelial growth factor (VEGF). These protein molecules interact with their respective receptors and enhance tissue angiogenesis. Their anti-inflammatory effects stimulate healing and the growth of new organic structures. Clinical use of growth factors consists of obtaining autologous platelet-rich plasma and applying it as a concentrate over the wound areas to be treated or implanted. Results have been most promising and are utilized in many plastic surgery procedures. The action of growth factors on the germinative hair cycle has already been studied both in its embryological phase and in its adult phase, however, not in hair micrograft surgery. Growth factors are present in the bulge area, where stem cells are found, and they interact with cells of the matrix, thus activating the proliferative phase of the hair. Stem cells are more primitive and of ectodermal origin; they give origin to epidermal cells and sebaceous glands. Cells of the dermal papilla, which are found at the capillary base, are of mesenchymal origin. Both cells need each other, and when they interact through the action of various growth factors they will give rise to the future follicular unit. In the first seven days after hair transplantation, there occurs an inflammatory process involving neutrophils, eosinophils, macrophages, platelets, fibroblasts, and growth factors. Both edema and erythema occur in the scalp. After this period, apoptosis occurs and the micrograft enters into an involution phase resulting in hair shedding. The next growth cycle begins after the third month and continues up to the seventh month. Up to 15% of these micrografts do not survive; they become atrophic and are absorbed or expelled. In our research, we added platelet-rich plasma including growth factors to the FUs with the intent of activating the proliferative phase and increasing the survival of the FUs (Figure 1). Official publication of the International Society of Hair Restoration Surgery continued on page 83

2 Hair Transplant Forum International Volume 15, Number 3 Hair Transplant Forum International is published bimonthly by the International Society of Hair Restoration Surgery, 13 South 2nd Street, Geneva, IL First class postage paid at Chicago, IL and additional mailing offices. POSTMASTER: Send address changes to Hair Transplant Forum International, International Society of Hair Restoration Surgery, 13 South 2nd Street, Geneva, IL Telephone: , U.S. Domestic Toll Free: ; Fax: President: E. Antonio Mangubat, MD Executive Director: Victoria Ceh, MPA Editors: Jerry E. Cooley, MD, and Robert S. Haber, MD Managing Editor & Graphic Design: Cheryl Duckler, cduckler@comcast.net Advertising Sales: Cheryl Duckler, ; cduckler@comcast.net Copyright 2005 by the International Society of Hair Restoration Surgery, 13 South 2nd Street, Geneva, IL Printed in the USA. The International Society of Hair Restoration Surgery (ISHRS) does not guarantee, warrant, or endorse any product or service advertised in this publication, nor does it guarantee any claim made by the manufacturer of such product or service. All views and opinions expressed in articles, editorials, comments, and letters to the Editors are those of the individual authors and not necessarily those of the ISHRS. Views and opinions are made available for educational purposes only. The material is not intended to represent the only, or necessarily the best, method or procedure appropriate for the medical situations discussed, but rather is intended to present an approach, view, statement, or opinion of the author that may be helpful to others who face similar situations. The ISHRS disclaims any and all liability for all claims that may arise out of the use of the techniques discussed. Hair Transplant Forum International is a privately published newsletter of the International Society of Hair Restoration Surgery. Its contents are solely the opinions of the authors and are not formally peer reviewed before publication. To facilitate the free exchange of information, a less stringent standard is employed to evaluate the scientific accuracy of the letters and articles published in the Forum. The standard of proof required for letters and articles is not to be compared with that of formal medical journals. The newsletter was designed to be and continues to be a printed forum where specialists and beginners in hair restoration techniques can exchange thoughts, experiences, opinions, and pilot studies on all matters relating to hair restoration. The contents of this publication are not to be quoted without the above disclaimer. The material published in the Forum is copyrighted and may not be utilized in any form without the express written consent of the Editor(s). Hair Transplant Forum International May/June 2005 President s Message E. Antonio Mangubat, MD Seattle, Washington Give, Connect, Elevate: Lessons Learned from the Starbucks Coffee Company During my return from our annual Live Surgery Workshop in Orlando, Florida, I was seated next to a young woman from Florida in her early 20s, professionally dressed, going to Seattle, Washington, to attend her first Starbucks Leadership Conference. Laura Ruiz had only been managing her E. Antonio Mangubat, MD Starbucks store for 3 years but had grown the store s profitability so significantly that she was chosen for this honor at such a young age. After asking the obvious question, How did you do this?, she was eager to share her secret for success: the Starbucks Values, Purpose, and Mission, all written on a tri-fold card about the size of a credit card. I was so intrigued that she gave me her little card of wisdom. I d like to share the highlights of how a small coffee store in an open-air market in Seattle transformed itself into a world power of 9,000 retails stores in 35 countries serving 30 million customers and generating $5 billion in revenues annually, and, more importantly, how the Starbucks philosophy (paraphrased below) applies to the ISHRS and to each and every one of our members. The Starbucks Lesson Values Passion for everything we do Integrity, pride and success Respect for each other Entrepreneurial spirit and drive Purpose To provide an uplifting experience that enriches people s lives daily Mission To be the best in the world without compromising principles as we grow How We Do It Together In legendary ways, big and small By living our values that guide us: passion, integrity, entrepreneurial spirit, pride and respect Be Welcoming Offer everyone a sense of belonging Be Genuine Connect, discover, and respond Always make it right, do whatever it takes for every person every time. Be Knowledgeable Love what you do. Share it with others. Each of us is responsible for being knowledgeable. Be Considerate Take care of yourself, each other, and our environment. Help each other. Always deliver high quality products Be Involved In the store, in the company, and in your community Connect with one another, with the company and with your community 78 continued on page 80

3 Co-Editors Messages Robert S. Haber, MD South Euclid, Ohio Everything that can be invented has been invented. So spoke Charles H. Duell, Commissioner, U.S. Office of Patents, in We know this statement was shortsighted, to be kind. But only a few years ago, members of the ISHRS were saying that there couldn t possibly still be major advances to be made in our field. How wrong they were! In this issue of the Forum, Carlos Uebel presents an exciting new Robert S. Haber, MD concept in using growth factors to enhance graft survival and growth, Mike Beehner shares his techniques for transplanting women, we hear more about the recent Live Surgery Workshop in Orlando, and we learn about how to protect new intellectual property (sorry Mr. Duell), among other interesting items. My only concern with Tony Mangubat s enthusiastic embrace of the Starbucks philosophy in his President s Message is that Starbucks is a nationwide chain that has moved into every city and virtually eliminated locally owned and operated coffee shops. Hmmmm. It s time to discuss an exciting new direction for the Forum. As we as a Society and as a field of expertise have continued to mature, so has the quality of the submissions to this journal. As those of us who peruse the medical literature are aware, there is a dearth of quality articles about hair restoration surgery. We are ready to take the next step, and begin to solicit articles for the Forum that will be evaluated by the peer-reviewed process. If we are successful in this endeavor, at some point in the future we may qualify for inclusion in Index Medicus, and researchers will be able to find the Forum when conducting searches. Many of our members already periodically submit articles to peer-reviewed journals for publication, and this is an opportunity to submit directly to your most receptive readers. Have no fear! The Forum will not change. All of the current features will remain, and the rapid dissemination of ideas and commentary will always be possible. Only the peer-reviewed articles will need to adhere to the rigid academic process. From the standpoint of you, the reader, the only change will be the inclusion of articles that have the standard format of peer-reviewed articles, including abstract, introduction, method, results, and discussion. The difference is that these articles may take many months to appear in print, as they wind their way through the process. Many of our current members currently serve as reviewers for major journals, and the Forum editors would like to invite those members to volunteer for this new task. We welcome your comments about this exciting concept. The Forum looks forward to publishing reports from the upcoming meetings of the Italian Society of Hair Restoration in Modena, Italy, and the European Society of Hair Restoration Surgery in Brussels, Belgium. Hopefully, every reader is planning to attend the ISHRS annual meeting in Sydney, Australia, and include extra time before or after the meeting to leisurely explore one of the most extraordinary destinations in the world! Keep your articles, ideas, letters to the editors, and other contributions coming! Bob Haber, MD Jerry E. Cooley, MD Charlotte, North Carolina What is the best holding solution for hair follicles during a hair transplant? First, let s put this topic in perspective. If the goal is to produce the best graft growth, we have to avoid physical trauma (transection, crushing, dehydration) and respect the vascular integrity of the recipient bed. After consistently doing this, we can look at using the best holding Jerry E. Cooley, MD solution as the icing on the cake. In my opinion, our current state of knowledge does not allow us to definitively state which solution is best. Dermatologists sometimes speak about the characteristics of the ideal filling agent for wrinkles and soft tissue defects. Likewise, I think we can talk about the ideal holding solution. Hydration and osmotic balance is the first requirement. We don t want our grafts to shrink or explode because the osmolarity of our solution is wrong. Protection from ph changes while out of the body requires that an effective buffer is present. Nutrients and metabolic support (e.g., glucose, insulin, amino acids) may be important to keep cellular machinery going while outside the body. Antioxidants (e.g., vitamin E, glutathione) help protect the grafts from ischemia-reperfusion injury. Temperature appropriateness is another consideration because chilling tissue causes pathophysiologic changes compared to storage at body temperature or room temperature. Hypothermic tissue storage solutions are specifically designed to hold cells, tissues, and organs at cold temperatures. Finally, the ideal holding solution should be cost-effective to justify a switch from cheap old saline. Possible alternatives to chilled normal saline include lactated ringer s solution, cell culture media (e.g., DMEM with or without additives), hypothermic tissue transplant media (e.g., HypoThermosol, BioLife Solutions, Inc.), and platelet-rich plasma described by Carlos Uebel in this issue. We need a convincing comparative study to sort this out. The problem with doing these studies on our day-today patients is that there are so many other variables involved in the typical procedure that to arrive at statistically significant, clinically meaningful results requires a large-scale, long-term study that is beyond the scope of most of us. An in vitro or animal model can overcome these problems. One such approach was used by Chinese researchers who implanted human hair follicles under the skin of nude mice, studying the survival of follicles soaked in lactated ringer s solution vs. cell culture media (DMEM). 1 In my opinion, this animal model appears to have numerous advantages over other study designs in that it removes most of the variables besides the one in question and yet closely continued on page 80 79

4 President s Message continued from page 78 I found these principles to be simple, yet they are not second nature to many of us. We have to consciously elevate them into our daily lives if they are to become a part of our lives. Continuous, unrelenting growth requires the commitment to our values and our goals. Not all of Starbucks lessons apply to us, but I am surprised how much of their corporate philosophy would benefit our Society and each of our practices. If we are to grow as a Society and as a specialty, we will need to live these principles every day. Have passion for our specialty, make everybody welcome, always make it right, be knowledgeable, be considerate, and be involved. If every ISHRS member lived this philosophy, I believe we would have success beyond the imaginable both individually and as a Society because it can only lead to sustained growth, expansion, and success. Be involved by learning the latest in HRS by attending every Annual Meeting, sharing your knowledge with others, welcoming newcomers to HRS, connecting with your colleagues to solve difficult problems, connecting with your community by providing pro bono reconstructive services to those who cannot afford it, and sharing yourself every day. In any competitive environment, it is often easier to ignore these principles, but the results are short-lived. We have certainly seen this in our specialty and we all have to be vigilant each day to guard against compromising our principles and ethics for the sake of profit. Starbucks president, Orin Smith, alluded to this in a magazine interview and I paraphrase his comment to fit our Society: Ethics cannot be an add-on to our business; it must be an essential part of who we are. Unethical behavior has been an issue in HRS for years and we have made significant progress in educating our members; however, if a small coffee company can live by these principles and grow to be a worldwide powerhouse, it should be second nature for physicians who have taken the Hippocratic Oath. I learned a lot from this young executive during the five-hour plane ride back to Seattle, and I started implementing most of the Starbucks philosophy in my own office. Thank you, Laura Ruiz, for sharing your company s vision. If any of you happen to be in Seattle, stop by my office and have a cup of coffee! E. Antonio Mangubat, MD Cooley Message continued from page 79 resembles an actual transplantation procedure. One theoretical advantage of this approach over in vitro assays is that it also includes the ischemia-reperfusion injury, which grafts are subject to after transplantation. I would like to see a study using this animal model repeated looking at the various candidate solutions mentioned above. Then we would have much more convincing reasons to make a change. Jerry Cooley, MD 1. Qian JG, Li WZ, Zhang GC, Yan LB. Is delayed micrograft hair transplantation possible? Evaluation of viabilities of hair follicles preserved in two storage media. Br J Plast Surg January; 58(1): Board of Governors Chairs of Committees President: E. Antonio Mangubat, MD* 2005 Annual Scientific Meeting Committee: Vice President: Paul T. Rose, MD * Jennifer H. Martinick, MBBS Secretary: Bessam K. Farjo, MD* Audit Committee: Robert S. Haber, MD Treasurer: Paul C. Cotterill, MD* Bylaws and Ethics Committee: Robert T. Leonard, Jr., DO Immediate Past-President: Mario Marzola, MBBS* CME Committee: Paul C. Cotterill, MD Michael L. Beehner, MD Core Curriculum Committee: Carlos J. Puig, DO Edwin S. Epstein, MD Fellowship Training Committee: Carlos J. Puig, DO Jung Chul Kim, MD Finance Committee: Paul C. Cotterill, MD Melike Kuelahci, MD International Advisory Committee: Russell Knudsen, MBBS Matt L. Leavitt, DO Live Surgery Workshop Committee: Matt L. Leavitt, DO William M. Parsley, MD Membership Committee: Marc A. Pomerantz, MD Arturo Sandoval-Camarena, MD Past-Presidents Committee: Robert S. Haber, MD David J. Seager, MD Pro Bono Foundation Committee: Paul T. Rose, MD Surgical Assistants Representative: Scientific Research, Grants, & Awards Committee: Cheryl J. Pomerantz, RN Richard C. Shiell, MBBS Surgical Assistants Executive Committee: *Executive Committee Helen Marzola, RGN Website Committee: Vance W. Elliott, MD Ad Hoc Committee on AMA Membership for ISHRS: Martin G. Unger, MD Ad Hoc Committee on Board Certification: John Gillespie, MD Ad Hoc Committee on Hair Foundation: Matt L. Leavitt, DO & Dow B. Stough, MD Ad Hoc Committee on International Medical Association Membership for ISHRS: Nilofer P. Farjo, MD Ad Hoc Committee on Patient Education: Michael L. Beehner, MD To Submit an Article or Letter to the Forum Editors Please send all submissions electronically via e- mail. Remember to include all photos and figures referred to in your article as separate attachments (JPEG, Tiff, or Bitmap). Be sure to ATTACH your file(s) DO NOT embed them in the itself. Any person submitting content to be published in the Forum agrees to the following: 1. The materials, including photographs, used in this submission do not identify, by name or otherwise, suggest the identity of, or present a recognizable likeness of any patient or others; or, if they do, I have obtained all necessary consents from patients and others for the further use, distribution, and publication of such materials. 2. The author indemnifies and holds harmless the ISHRS from any breach of the above. Send to: Robert Haber, MD HaberForum@aol.com Submission deadlines: July/August, June 10 September/October, August 10 80

5 Notes from the Editor Emeritus William M. Parsley, MD Louisville, Kentucky One of the primary concerns of the ISHRS is the education of new doctors and their assistants. For many years the process was far simpler than today. Plug grafts required very little preparation before reinserting them into the scalp. Usually only 100 to 200 grafts were placed, and a team of 2 or 3 could perform the procedure quite adequately. Now we are William M. Parsley, MD transplanting 2,000 to 3,000 grafts at a single session, and in some offices over 5,000 grafts. Often a team of 6 8 assistants are necessary to help the hair restoration surgeon. Smaller grafts, such as follicular unit grafts, are usually prepared using a stereomicroscope, and skill demands are much greater. Are new doctors being scared away? Are they confused about how to prepare to enter this field? I am sure in some cases, the answer to both questions is yes. The ISHRS has fellowship training programs that have steadily been growing in number. Dow Stough, MD, Walter Unger, MD, Damkerng Pathomvanich, MD, Dan Rousso, MD, and Marc Avram, MD, all have approved programs in addition to at least 3 fellowships being run by Medical Hair Restoration (Matt Leavitt, DO, Melvin Mayer, MD, Bob Niedbalski, DO, and Carlos Puig, DO). Fellowships can run from 1 2 years and require exposure to at least 100 hair restoration cases. In addition, an educational and reading program is involved. Dr. Carlos Puig has spent countless hours nurturing these programs and deserves much credit. Contact the ISHRS office or Dr. Puig if you have an interest. For many, however, their life and career situations will not allow this type of sacrifice. For those doctors, there are still ways to develop your knowledge and skills to a level where a hair restoration practice can begin. I would like to make a few suggestions to those interested in pursuing hair restoration. Step 1. Join the International Society of Hair Restoration Surgery and also your national hair restoration society, if you have one. If you are reading this, more than likely you have already accomplished the first step. Step 2. Begin reading. The Hair Transplant Forum International and the Dermatologic Surgery journal are musts. The most recent textbook is Hair Transplantation by Drs. Walter Unger and Ron Shapiro. While there are over 900 pages, it is loaded with pictures and diagrams so it reads pretty easily. In addition, Disorders of Hair Growth by Dr. Elise Olsen and The Structure of the Human Hair Follicle by Dr. David Whiting are excellent informational sources. Step 3. Attend the ISHRS Annual Meeting at least twice and the Live Surgery Workshop in Orlando at least once. No, you are still not ready to start. Step 4. Visit some offices. Most doctors will allow you to visit for a day or two and try to give you helpful exposure. Remember, they are helping you, not training you. If possible, and if they permit, take some of your assistants with you. Their education is as important as yours. Some of the more renowned doctors are very busy and too many observers can impede their practices, so be understanding if they turn you down. Some might request payment or a donation to an ISHRS fund. Doctors in your immediate region might be wary about letting a potential competitor into their office, so a little travel might be necessary. Ideally, one should visit at least 3 offices. Make sure you know how to design a proper hairline. You are getting closer. Step 5. Get your office setup and staff in place. Keep in mind that if you buy cheap equipment, you might be replacing it soon. Make sure you are committed before making these purchases, because paying them off might be down the road a bit. If you are going to do follicular unit transplantation, get a two-headed teaching stereomicroscope (Motic is good and has the best price). You are almost ready. Step 6. Let people know that you are ready to start. Send some letters to doctors in your region. Talk to hair salons or hair stylist organizations. Consider advertising phone book, radio, newspapers, and TV. Step 7. Perform your first few cases. This can be the tough part. Whatever you do, don t do the first cases with both novice assistants and a novice doctor. If it is possible, try to find an established doctor working part-time or a doctor on vacation who will let you pay his assistants to help you for a few days. Additionally, there are some independent assistant teams who can fly in to help. Line up some cases and have these visiting assistants help teach your staff. Another possibility is to take a patient to an established office with the idea that you can give hands-on assistance during the surgery. Ideally, they would also allow your assistants to do some cutting. Pick small easy cases at first, avoiding females and very young men. These steps will help you get started with your plunge into hair restoration, but please remember some important rules. First, don t try to hire any of the office s staff bad behavior. Second, don t ever visit someone for a few days and make claims that you were trained by them. Third, no gifts are necessary. The most sincere thank you is to do the same when you develop experience. Anything else is inadequate. Orlando Workshop I was able to watch Alan Bauman, MD, and Jim Harris, MD, perform follicular unit extraction in Orlando during the March Live Surgery Workshop. How refreshing to see them trying their best to teach their skills to others. Jim Harris has developed an excellent technique using a sharp punch to score the skin very superficially and then finish removing the graft with a dull punch. It is by far the most effective technique for follicular unit extraction that I have seen to date. He had less than 5% transection in the grafts that I continued on page 82 81

6 Editor Emeritus continued from page 81 checked under the microscope and was moving with good speed. He still has some problems with buried grafts, but the overall technique was surprisingly good. We will certainly be hearing more about this technique in the future. Join Us in Sydney Finally, one last appeal to attend the Annual ISHRS Meeting in Sydney, August 24 28, The Australian surgeons for years have traveled all over the world to meetings, and their contributions are too numerous to count. They have been indispensable members of the Society. Now, this is their day. We owe it to them to show our commitment. Plus, I suspect it will be the best meeting ever. William M. Parsley, MD Hair Transplant Forum International May/June 2005 Free DermMatch Samples If you have patients who use sprays, sprinkles or lotions to conceal hair loss or recent surgery, they ll just love DermMatch Topical Shading. And now s your chance to try it free. DermMatch coats every hair for the thickest, fullest appearance possible. It s the only product that you can fade gradually for a perfect, natural hairline. Your patients can swim with DermMatch. It s waterresistant. They can also brush or comb their hair with it. Don t try that with sprays or sprinkles. Only DermMatch comes with the EZ Grip, EZ Reach applicators. They make application quick, clean and precise. No more clouds of spray or aimless sprinkles. The primary ingredients in DermMatch are emollients that moisturize and protect. DermMatch contains no dyes and is loaded with botanical and natural ingredients. FREE SAMPLES Why not carry DermMatch in your office? Your patients deserve it. Try it first. If you ve never received samples from us before, call before June 30 th and we ll send a free sample kit with everything you need... Monday Friday 8AM to 5PM Eastern Time State-of-the-art instrumentation for hair restoration surgery! or For more information, contact: 21 Cook Avenue Madison, New Jersey USA Phone: Fax: cellis@nac.net 82

7 New Advance in Baldness Surgery continued from front page Figure 2. 80cc of autologous blood are collected and centrifuged at 1000 rpm. Method We selected 23 male patients, ranging in age from 25 to 55 years old, with pattern baldness in the frontal, parietal, or occipital areas. We delineated two bald and symmetric cm areas and on the right side used FUs imbibed with platelet-derived growth factors; on the left, untreated FUs served as controls. Both areas were planted with an equal number of FUs. All patients were duly informed about this experimental clinical research and had signed informed consent. Follicular Unit Harvesting From the posterior area of the scalp we obtained a hairbearing ellipse, usually measuring 15cm in length by 2cm in width, in order to obtain around 800 FUs. The donor area is closed without tension using intradermal or continuous sutures. In the standard technique, these micrografts are kept moist in a saline solution, ready to be implanted. In the experimental group, portions of the micrografts were also treated with platelet-rich plasma containing growth factors. Figure 3. The total plasma achieved is centrifuged again to concentrate the plateletrich plasma (PRP) and growth factors. Some residual red cells can be there. Obtaining Platelet-Derived Growth Factors Prior to surgery, we collected 80cc of blood from the patient in 8 vacuum flasks containing sodium citrate as an anticoagulant (Figure 2). The flasks are centrifuged at 1000 rpm for 10 minutes. The slow speed is important so that the platelets remain separate from the red cell mass. The plasma layer is removed and redistributed into 4 other flasks for a second centrifugation of 5000 rpm for 10 minutes. The plasma supernatant is then removed, leaving only 2cc of the concentrate, which is the platelet-rich plasma (PRP). The PRP contains 4 to 6 times more platelets than normal plasma and includes a high concentration of growth factors. This concentrate is then added to the FUs prior to their implantation. The PRP is kept in contact with the hair follicles for 15 minutes to allow the growth factors to attach to the stem cells located in the bulge area (Figure 3). Next, we add 10 drops of 10% calcium chloride with the intent of transforming fibrinogen into fibrin in order to produce a plasmatic gel that will seal the micrografts with the growth factors around them (Figure 4). Implanting the Follicular Units The entire scalp area is massively infiltrated with saline solution and epinephrine at 1:200,000. This tumescence, which we call scalp ballooning, and the vasoconstriction obtained lessens bleeding and enables implanting the micrografts more easily. Into the delineated area on the right scalp we implant the units imbibed with the plasmatic growth factors and, into the left scalp, the units considered to be of the standard type. Both test zones receive the same number of grafts (Figure 5). For this procedure we use microblades and microforceps and the technique used is the stick-and-place, published by the author. After these two areas are implanted, we conclude implantation onto the whole remaining baldness by using FUs of the standard type. We apply moist gauzes, and an elastic bandage is maintained over them for 24 hours. The patient then removes the bandage and Figure 4. After 15 minutes of imbibition we add 10 drops of calcium chloride to transform fibrinogen into fibrin. The plasma gel with the growth factors seals the follicular units and they are ready to be implanted. continued on page 84 83

8 New Advance in Baldness Surgery continued from page 83 washes the entire implanted scalp with an antiseptic neutral shampoo. Results A statistically significant difference in the FU yield was seen between the experimental and control sites (P< 0.001). The experimental sites with the PRP yielded an average of 18.7 FUs per cm 2 while the control sites yielded an average of 16.7 FUs per cm 2. This difference of 2.4 (95% CI : 1.6 to 3.2) FUs per cm 2 represents a 15.1% increase in the FU density between the two sites. Differences in the study patients ranged from 3% to 52%. Conclusion Treating FUs with platelet-derived growth factors obtained from platelet-rich plasma produced a significant increase in growth. With this technique, for every 100cm 2 area to be treated, an average increase of 240 FUs, or 480 hairs, can be expected. Further studies should be done to improve the efficiency of this technique. This technique can be easily introduced into our clinics with low costs and minimal personnel involvement. Figure 5. Standard FUs planted on the left, PGF treated FUs planted on the right. Figure implanted micrografts. After 7 months,126 counted on the right and 97 on the left. An improvement of 30% with platelet-growth factors. 84

9 A Perspective on Transplanting Females Michael L. Beehner, MD Saratoga Springs, New York Over the past ten years I have become very intrigued with the art, science, and frustrating nuances of transplanting the fairer sex. Transplanting women has consistently made up approximately 15 20% of my practice over the past several years. Many years ago, one of our colleagues was quoted as saying that he disliked transplanting females because of the hand-holding and emotional aspects of dealing with them. And in private conversations with many of my colleagues, I still very often sense a deep reluctance to become involved in transplanting this group of patients. I recall hearing a couple such physicians, who have very good reputations, state that they only agree to transplant 5 10% of the women who present to them. My own feelings are much different. My experience has, for the most part, been a very positive one, and I have found that helping women with their hair loss is one of the most emotionally rewarding aspects of my practice. In general, I feel comfortable offering hair transplantation to around 80% of the women I see with hair loss. I certainly would have to agree that, in general, there are more ups and downs, especially in the early going, than with male patients. In this article I will share some of the insights that I have gained, which now help me feel confident that I can guide the proper candidate to a future result that she will be happy with, and which realistically matches the expectations she had when she started out on the hair transplant journey with me. The Consultation This is the most critical step toward later having a satisfied patient. The physician s task is to be sure the woman has realistic expectations, is psychologically stable, and does in fact possess the proper donor and recipient area characteristics that lend themselves to a marked improvement in her appearance. I try to almost under-sell the procedure. I clearly point out the possibility of post-operative shocking to some of the existing hair. I find that, if my graft spacing is not too aggressive and the epinephrine concentration in the tumescent solution is no greater than 1:150,000, shocking occurs visibly to a degree that the patient would notice in only about 35% of first sessions (I find it very rare in second sessions). I usually tell them that most of this hair will grow back, and theoretically, most of it should; but I have to honestly say that, in some of the these patients who have had 2 3 procedures, when I look into their central scalp a few years later, very often all I see is the hair that I transplanted and I am left to assume that most of the original native hair has disappeared or become severely miniaturized. Pre-existing native female hair on top just seems to be more vulnerable than in the male. In evaluating all of my female consult patients, I use a 30 power handheld scope (Micro-VID), which I place over various areas of the patient s scalp, looking for the degree of miniaturization present. I find that this is a good predictor for what is likely to occur in future years and also gives some hint as to how vulnerable the hair on top might be to 1 2 Figure 1. Patient A: Five initially drawn Figure 2. Patient A: Seen from frontal view. points are designated with arrows: 60 years old. The front center point of the hairline, the two shallow fronto-temporal points in line with the lateral canthal line, and the two outermost curved points of the anterior temporal hair. Figure 3. Patient A: 10 months after one transplant session of 280 slit MFU grafts and 800 FUs. shocking during the transplant process. It is particularly valuable for evaluating the donor hair, to be certain that it is significantly stronger (larger caliber and smaller percentage of miniaturization) than in the recipient area. This device is attached to a computer screen directly in front of the patient, so she can follow along as I make these observations using a laser pointer. I would add here that there will be women in their socially critical 20s and 30s age groups in whom you do see some degree of miniaturization in the occipital donor area, but still the quality of hair here is so much better than what exists on top, that you can offer them years of improved appearance in their frontal appearance by transplanting them in the frontal region with this hair. They must be made to understand that this miniaturization may herald later moderately severe hair loss in the occipital area and of the transplanted hair taken from there, but that this hair will still likely serve a valuable service for a number of years ahead. As long as this concept is understood and accepted, I am willing to transplant in those circumstances. Minimum of Two Sessions I also ask my female patients not to go through hair transplantation unless they are mentally committed to having at least two sessions performed. This is for two reasons: First, many women, with their first surgery, experience somewhat of a philosophical trade-off. That is, the newly moved, genetically favored donor follicles to some extent are swapped for those that are spooked out of existence or into a wispier life cycle. The patient is better off a year later, with hairs that will last a lot longer, but a certain percentage of them may not be convinced of it when they look into the mirror. Following the second surgery, I find shocking to be unusual. Second, the cumulative effect of two sessions, which usually comprises 6,000 7,000 hairs, is twice what can be done with only one surgery, and this critical mass of hair is important in helping to erase the thin, see through look (from the frontal view) that most of 3 continued on page 86 85

10 Transplanting Females continued from page 85 Figure 4. FU grafts Figure 5. MFU grafts these women have. I usually advise separating the first two sessions by at least one year. I find it very important to stress that they will not fully appreciate the effect of a given transplant session until around 15 months after the surgery. I clearly recall one woman from a nearby town who called at around 8 9 months and was bitterly disappointed with her results and said she wished she had never had the surgery. The very same woman came in to see me at 18 months and profusely apologized for her earlier comments and thanked me profusely for how much thicker her hair was now. At the consultation, you have to be sure that these longer-range time spans are established for when improvement will be noted. One final word of warning about sorting out in the consultation who will be a good candidate or not: Be wary of transplanting the woman who is very early in her thinning pattern. On close examination with the hand-held video scope, they often will have 10 15% miniaturized hairs despite their apparent relatively full look, but some of these will have such a negative response to shocking that you will never see them again after that first surgery. I try very hard to convince such patients to put off surgery until the thinning is a little worse, to a point where they will appreciate the results I can deliver. Obviously, the emotional maturity of the patient and their ability to look down the long road and not be overly discouraged by early, temporary setbacks helps you in predicting who will be happy and who will be difficult to deal with. Design of Transplant Area In planning the transplant zones, because most women with female pattern hair loss retain their natural front hairline, it is almost always preferable to stay just behind the very edge of their own frontal hairs, as it is almost impossible to duplicate the fine naturalness of these hairs. Exceptions would be those instances in which there is an extremely weak hairline zone or the hairline is too high and needs to be lowered. Before drawing the contour of the front hairline and anterior temples, I first mark five reference points (Figures 1 3). First, I mark a small curved arc at the front center point of the hairline. Second, in line with the lateral canthal point on each side, I make a mark in the fronto-temporal recession that is only slightly posterior (usually 1 2cm) to the frontcentral point already drawn. Lastly, I draw a small curved line along the anterior curve of the temple hair as it descends along the side of the face on each side. I then simply try to connect these five points with gently curved lines. Surgical Procedure The great majority of patients with female pattern hair loss have very sparse donor density on the side of their heads, as compared with the flat occipital rear aspect, where the density is usually very good in the proper candidates. For this reason, the donor harvest has to be disproportionately weighted toward obtaining as much tissue from back as possible without causing a wide donor scar. I draw and then excise free hand a narrow, horizontal rectangle approximately 8.5cm long and cm wide in the occipital area, and then continue the excision into the parietal corner, but narrow the width down to around 8 10mm in this area, usually harvesting a 22 23cm long ellipse in all. I find that using a combination of slit MFUs on the top centrally along with FUs at the hairline, temples, and occiput, gives me the best possible density after two sessions (Figures 4 and 5). My favorite instrument for making the slit grafts is a B.P. #11 blade. I create the recipient slits sagittally, angle them forward around 45 degrees, and then perform a slight back-cut with the very bottom of the blade after I have penetrated a depth equal to the hair follicle s previously measured length (Figure 6). All FUs and MFUs are cut under the 10 stereoscope, and the average first-time patient receives around 280 slit MFUs and 800 FUs. The number of slit MFUs usually drops to around 220 for the second session. At each session, approximately 130 FUs are placed in each side temple area, FUs in the front hairline zone, and the rest of the FUs are placed in between the slit MFUs. My last priority for females is the vertex area, as I usually don t have enough grafts left over to place any there. Fortunately, most women with hair loss have slightly better density in the vertex than in the frontal and midscalp areas. The final point is that it is hard to make an improvement in their vertex hair density due to the whorl arrangement of hairs, which doesn t lend itself to much overlapping of the hairs. We have used focal dense packing into the small frontal core behind the front hairline in around 20 females over the past 3 years, usually placing all 3-hair FUs into 19 or 18 gauge needle recipient sites at a density of around 25 30cm 2, using the stick-and-place method. So far, around 15 of these patients have returned and the resulting growth has been disappointing in at least half of them. I am presently retrying this technique in a smaller number of test patients, using only 2-hair FUs and placing them into smaller 20g needle sites. My suspicion and hope is that hair survival will improve and that key areas, such as the frontal core, can be more aggressively filled in at the first session. Figure 6. Spacing of slit recipient sites (made with #11 blade with back-cut ) seen in bottom of photo; Dense packed frontal core area just anterior to slit sites, and frontal hairline FU sites at top of photo and anterior to frontal core. 86

11 that they sweep from one side to the other through the front curved contour, thus creating a denser and more aesthetic appearance (Figures 7 and 8). Figure 7. Patient B: 37-year-old woman, who lost her hair with her 3 rd pregnancy, with no regrowth over 8 years. Figure 8. Patient B: After 3 transplant sessions. Miscellaneous Points Regarding medical therapy, I have not had a lot of success in persuading my female patients to use minoxidil regularly. Many complain of the greasiness of the medicine and several stopped using it at the first sign of facial hair. I have seen three patients present to me who had been on Spironolactone in doses over 200mg a day who had very impressive results, but I have not started any women on this medication, as it appears to work only in these dosage ranges and I have strong reservations about the possible medical side effects of long-term therapy. Before transplanting a female patient, I make sure that recent thyroid and iron level tests have been performed to rule out any etiologic role of a deficiency of either. If the menstrual and fertility history is normal, I do not order any hormone tests. It is important to maintain a high index of suspicion for other etiologies besides hereditary female pattern hair loss and to biopsy whenever one is suspicious. I find that most females presenting for consultation have had extensive workups by dermatologists or endocrinologists before they see me. The one diagnosis in female alopecia that forever keeps me humble and on the watch is diffuse alopecia areata. I have seen photos of two such patients belonging to colleagues, which looked extremely similar to FPHL and were only diagnosed with biopsy. In closely observing the direction of hair in females, cowlicks in various directions are much more commonly seen than in males. A sudden divergence of hair direction to both sides will sometimes be seen in the frontal region. In setting the angle and direction of the grafts, in the hairline area I almost always follow that of the existing hairs. One exception is the frontal hairline region that is particularly sparse. In such patients, I place the FUs so Conclusion Despite the widespread pessimism concerning transplantation of women, I would strongly urge that any hair surgeon reconsider and challenge such a mind-set. Performing female hair transplantation well requires a very trusting doctor-patient relationship. It demands absolute honesty on the part of the physician in the consultation, with emphasis on somewhat understating the density of the final results and clearly outlining the possible bumps in the road along the way. The key to success is to choose the right patients those who are significantly thin on top and who possess reasonably good occipital donor hair and then work only on those who have their sights fixed on the final result two years later after at least two procedures (Figures 9 12). Most of my female patients do return for their second transplant procedure, and I cannot recall a single one of these who wasn t happy with her results a year and a half after her final procedure Figure 9. Patient C: 46-year-old with frontal rim hair loss and thinning behind also. Figure 11. Patient C: Contour of hairline of frontal region and temple areas drawn. Figure 12. Patient D: Black female from Nigeria with traction alopecia hair loss. Hairline drawn for front and side areas. Figure 10. Patient C: Side view of same patient before transplanting ABHRS 2006 Examination Dates: January 20 21, 2006 Location: Marriott George Bush International Airport JFK Blvd. Houston, TX Phone: Deadline for Examination Application: December 1, 2005 Deadline for Hotel Reservations: January 7, 2006 Website: For information: Phone: Fax: abhrs@sbcglobal.net 87

12 Prevention of Forehead Edema and Periorbital Ecchymosis after Hair Transplantation Steven C. Chang, MD Newport Beach, California Figure 1. Figure 2. When informing patients about side effects associated stances of forehead edema and prevent periorbital ecchymosis in nearly all patients in whom post-operative fore- with hair transplantation, we always must mention postoperative forehead edema and periorbital ecchymosis head edema develops. The method has been successfully ( black eyes ). We know that nearly all hair transplant patients are at risk for developing forehead edema, and be- This technique utilizes (1) an elastic headband to fit applied in 120 patients. cause edema may migrate from the scalp to the forehead to just above the orbits, to keep fluid from reaching the orbits, and a plastic plate 13cm long by 4cm wide that is the orbits, a small number of patients 5% 10% may develop periorbital ecchymosis. Generally, the earlier forehead edema develops, the more severe it eventually becomes. from the forehead to the lateral sides of the head (Figures applied under the elastic headband, to direct fluid flow While prevention of post-operative edema for example, 1 and 2), and (2) Triamcinolone 40mg (10mg/ml) mixed by pre- and/or post-operative administration of local or systemic corticosteroids is always our goal, complete or significipient site. with 15ml tumescent solution, injected into the frontal recant prevention is often not realized. The goal then becomes The patient is instructed to apply the elastic headband decreasing the severity of the edema and/or ecchymosis. and plastic plate if and when forehead swelling develops, or Commonly used approaches to prevention or amelioration of forehead swelling include having the patient (1) operative day, whichever comes first. to apply the elastic band and plastic plate on the third post- apply cool packs several times daily to the forehead, (2) The elastic band provides consistent pressure to prevent fluid migration to the periorbital area. The plastic plate apply hand pressure to the forehead to massage fluid away from the forehead to the temple areas, (3) avoid the flat slipped into place under the elastic band opens a channel reclining position when sleeping for several days after surgery, and (4) apply an elastic band low on the forehead, the lateral sides of the head toward the temples. for drainage of accumulated fluid from the forehead area to above the orbits, to prevent fluid from reaching the orbits Application of the plastic plate has been effective even (by Dr. Damkerng Pathomvanich). when the patient has forgotten to apply it before swelling In my practice, I have found that use of a specially designed plastic forehead plate, an elastic headband, and lo- these circumstances, swelling has been seen to decrease in reaches the periorbital area; when applied immediately in cally administered corticosteroid will resolve nearly all in- a matter of hours as fluid drains laterally from the forehead. 88

13 Scalp Dermatology for the Hair Restoration Surgeon Trichotemnomania Bernard P. Nusbaum, MD Miami, Florida A recent case report describes a 28-year-old woman who presented with a completely hairless scalp. 1 The hair loss started one year previously with round bald patches and was followed by the loss of eyebrow, axillary, and pubic hair. At the time of the hair loss, she also developed dysphonia (hoarseness), which was diagnosed as being psychogenic and attributed to the sudden onset of hair loss. What is your #1 diagnosis? Based on the provided information, the obvious diagnosis would be alopecia areata and, in fact, for one year or so, several internists and dermatologists in her native Germany had diagnosed alopecia areata totalis. For the sake of accurate terminology, alopecia areata that results in total scalp hair loss is termed alopecia totalis, and when total body hair loss occurs, it is termed alopecia universalis. As is often the case in evaluating alopecia, however, things are not always as they initially appear to be. Upon close inspection of the scalp, it was observed that all follicle openings were filled with hair shafts, none of which were elevated above the skin surface. The eyebrow and axillary hair were absent but, in the pubic region, all the hair was present at a length of approximately 4mm. The physical examination was consistent with the fact that the scalp had been shaved! The pubic region had not been shaved for several days. Scalp biopsy showed normal histopathology, and microscopy of hair stubs showed clean-cut surfaces at the distal end. A diagnosis of trichotemnomania was made. This term is derived from the Greek: thrix (hair), temneim (to cut), and mania (madness). After a stressful event the patient developed an obsessive-compulsive disorder consisting of dysphonia and the habit of shaving the hair in the involved areas. The diagnosis had been obscured by the patient stating that the hair loss started as round patches, thus dissuading several physicians from undertaking a more detailed examination. Trichotemnomania should be differentiated from trichotillomania, which is a compulsive habit of hair plucking. Trichotillomania presents with bizarre hair loss patterns, often sparing the peripheral scalp areas, possibly because these areas are more painful to pluck. In addition, trichotillomania has distinctive abnormal histopathology. Both disorders occur predominantly in women. This report underscores the need to maintain a high index of suspicion when diagnosing alopecias and to adhere to a systematic approach of obtaining a detailed history, performing a thorough scalp examination, and, when indicated, performing microscopic analysis of hair and or a scalp biopsy. Hair Loss Following Bariatric Surgery As a result of the current obesity epidemic, there is an increasing number of patients undergoing bariatric surgery. Although a literature search failed to reveal the exact incidence of hair loss following this procedure, personal communication with colleagues involved with these patients indicates that it may be around 50%. Hair loss in these patients may be a telogen effluvium precipitated by the surgery itself or the marked weight loss. If this is the case, the expected course would be excessive shedding of telogen hairs beginning 2 3 months after the precipitating event. Spontaneous resolution should occur within 6 months, as long as the stressful factor is eliminated and not repeated. Diffuse hair loss, however, can result from nutritional deficiency. Most patients undergoing bariatric procedures will develop nutrient deficiencies to a degree proportional to the amount of lost absorptive area and to the percentage of weight loss. 2 These patients require mineral, multivitamin, and protein supplementation post-operatively. The main nutrients affected are protein, vitamin B12, folate, iron, and calcium. Iron deficiency is one of the most common, affecting 46% of patients undergoing vertical gastroplasty. 2 Female patients of reproductive age are at particular risk of developing iron deficiency. Anemia and iron deficiency are known causes of hair loss, seen in many women presenting with alopecia. Although zinc deficiency is uncommon after bariatric surgery, there is one report of diffuse hair loss occurring in 47 of 130 patients who underwent vertical gastroplasty. 3 The hair loss began 4 11 months following the surgery. All patients were receiving multivitamins and iron supplementation when they developed alopecia, and the hair loss resolved only with high-dose zinc supplementation. We should be aware of the possible causes of hair loss in these patients. It should be noted that hair transplantation is not indicated in telogen effluvium or nutritional deficiencies, and the mainstay of treatment is correcting underlying factors and reassurance. References 1. Happle, R. Trichotemnomania: Obsessive compulsive habit of cutting or shaving the hair. JAAD. January 2005, Alvarez-Leite, J. I. Nutrient deficiencies secondary to bariatric surgery. Curr Opin Clin Nut Metab Care. September 2004, 7(5): Neve, H. J., et al. Reversal of hair loss following vertical gastroplasty when treated with zinc sulphate. Obesity Surgery 6:

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15 Letters to the Editors I wanted to comment on two articles that have been published in the past two issues of the Forum. What these articles have in common are several things: first, they were well written, obviously thoughtful, and authored by wellrespected peers in the field. However, I feel that both of them made some rather significant statements of fact, yet lacked what I feel were adequate scientific review. The article on The Ziering Tunnel Technique, by Craig Ziering, DO (Vol. 14, No. 6, 2004), made the conclusion that limited tunnels of undermining resulted in reduced wound closure tension of donor sites. While I congratulate Dr. Ziering for developing a technique that potentially maximizes the advantages of wound undermining while minimizing the downsides, does not such a conclusion deserve to be supported by scientific data using tensitometer readings? Such readings are extremely easy to perform, and would make many of us much more likely to incorporate this adjuvant technique to our practice if supported scientifically, not simply anecdotally. The second article, Lateral, Dense, Mega Is This the Future? by Jerry Wong, MD (Vol. 15, No. 1, 2005), described in detail how they are routinely performing extremely large hair transplant procedures. A passing reference was made to the excision of donor strips routinely as wide as 2cm that resulted in narrow donor site scars. While this statement was not directly the main topic of the article, does not such a claim that is largely responsible for making possible the harvesting of as many as 5,000 grafts in a single procedure require some scientific data and elaboration? Similar to Drs. Wong and Hasson, I have 11 hair transplant assistants using microscopes to dissect all follicular unit grafts, and use for making recipient sites blades of 0.6 to 1.1mm that are cut with the Sharper Edge device. Yet, of the 475 procedures I performed last year, in fewer than 40 (out of over 100 in whom I desired to transplant as many grafts as possible) was I able to obtain 3,000 or more grafts, because of concerns of wide donor site scars that I have observed that can potentially result when strips typically wider than 12mm or so are excised. And certainly my experience is shared by other transplant surgeons, where the only limitation to the number of grafts we could maximally perform is in the supply. What is the total number of hairs transplanted in these 5,000-plus graft procedures? Dr. Wong s excellent article could have been significantly improved by the elaboration of the critical point about the safety of excising 2cm wide donor strips, and in fact I welcome his elaborating on this issue. Sincerely, Jeffrey Epstein, MD, FACS Miami, Florida In Response To: Jeffrey Epstein, MD, FACS Is it safe to take a donor strip 2.5cm wide? Sometimes yes, other times no. Dr. Epstein as you are well aware it is difficult to obtain more than 3,000 Follicular Units if we restrict the donor width to 1.5cm. A wider strip does not always generate a tight closure. Prior to surgery we encourage the patient to push their scalp up and down to increase mobility. They do this by placing their palm firmly on the donor scalp and pushing the skin up and down. The palm should not slide on the skin surface; the idea is to loosen the scalp from its underlying attachment. Patients are told that the amount of donor tissue to be harvested is dependent on the laxity they can generate. Patients who are motivated can over a 2 to 8 week interval increase their laxity significantly. As a general rule there is usually more scalp laxity in the temple and mid-occipital region. Therefore the strip taken is often not uniform in width but will vary depending on regional laxity. At the time of surgery, with the patient supine, the scalp laxity at each location is carefully checked to determine the width of the strip. With practice one can determine very accurately the maximum width obtainable. If in doubt, be conservative to avoid excessively tight closure. When laxity allows we ve taken strips as wide 2.5cm and had very acceptable donor scars. Donor scars can be minimized by: 1. Reducing hair shaft transection along the strip edge. 2. Gentle handling of tissue and keeping the edge moist. 3. Accurate wound edge approximation. 4. Avoiding excess suture tension. Jerry Wong, MD Vancouver, BC, Canada In Response To: Jeffrey Epstein, MD, FACS Our recent article about the Ziering Tunnel Technique was intended to provide our colleagues with a brief overview of an adjunctive tool/technique that can be used for the reduction of donor closure tension. Unlike an article presented to a peer reviewed medical journal, this overview was simply submitted in a timely fashion to educate our colleagues about this technique so that it could be implemented into their practice if an appropriate case was encountered. Our study of this tunnel technique is still ongoing with appropriate data being collected and recorded. In a virgin hair transplant patient where no previous scarring is present and all tissues are under equal pulling forces, tensitometry readings are indeed very useful. However, we must keep in mind that open donor tensitometry readings are different throughout the length of the strip incision because of the stretch variability and diffuseness of the scarring. Because of this variability, there are limitations present in comparing tensitometry readings of sides or ends having had the tunnel technique performed vs. sides or ends where traditional undermining with complete disruption of the adhesions was performed. We must continue to question and challenge so that we can obtain the answers that will make us better surgeons for our patients. Respectfully submitted, Craig Ziering, DO Beverly Hills, California 91

16 nce Upon a Time 15 years ago Here in Australia, I am experiencing something of a style revolution. Nearly every new patient requests minigrafts. Even my old regular customers have been influenced by the trend. Doing lots of minigrafts mainly alters the way one approaches the business of hair transplantation. I am still in a learning phase when it comes to quoting the number of operations required. I will have to increase my minigrafts from 100 to 250 per session in order to get comparable final density. This will take more time than the old 60 to 70 plugs. Richard Shiell, MBBS Melbourne, Australia (Vol. 1, No. 1, September 1990) 10 years ago The surgeon should strive to achieve an aesthetic appearance on the patient by using a large number of mini- and microtranpslants in as few sessions as possible. If this development is powered ahead without reflection and the number of transplanted grafts gets higher and higher (megasessions), the following problems, which I am increasingly encountering in my consultations, can occur a wide, unsightly (occipital) scar that is a strong psychological burden for the patient.(and) a very large number of transplants are distributed over a wide surface already in the first session, the donor area will no longer be able to provide sufficient transplants for the second and third sessions to achieve an aesthetic result. Manfred Lucas, MD Grafelfing, Germany (Vol. 5, No. 1, January/February 1995) 5 years ago Since reviewing the literature, I obtained an anesthetic warming system from Premier Dental Products Company (King of Prussia, PA), and have conducted an informal evaluation of the impact of warming on the perception of pain. Nine of ten patients have noted less pain with the injection of the warmed anesthetic, while one patient felt that the warming increased the discomfort. Based on this initial patient survey and the results reported in the literature, warming of the local anesthetic is now standard protocol in my office. James A. Harris, MD Englewood, Colorado (In Heated Lidocaine: Warming Up to an Old Idea. Vol. 10, No. 6, November/December 2000; p. 172) 92

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18 By Jerry E. Cooley, MD Charlotte, North Carolina Hair Transplant Forum International May/June 2005 Pioneer of the Month Pioneer of the Month Michael L. Beehner, MD Michael & Harrilyn Beehner Saratoga Springs, New York Fortunately, in our specialty not everyone thinks the same. Over the years, Michael Beehner, MD, the 1999 Platinum Follicle Award winner and recipient of four research awards from the ISHRS, has given us a unique and valuable perspective on a number of issues important to us. Whether it is in favoring larger graft sizes or performing studies that question some of our closely held assumptions, he has never been afraid to go against the tide and voice his opinion. Moreover, he has participated in our debates with calm civility and much needed integrity. Mike was born in East St. Louis, Illinois, the first of ten children. His family moved to Marcellus, New York, outside Syracuse, where he spent his childhood. His father worked as a factory manager. Mike waxes nostalgic about growing up near the Adirondack Mountains, where he went camping, canoeing, and enjoyed the natural beauty. He always planned to raise his own family here. For high school, he went to the preparatory seminary with the intention of training to be a Catholic priest. While attending college at Loyola University in Chicago, he decided he could help people better as a physician, and headed to the University of Illinois medical school. While there he met a young occupational therapy student, Harrilyn, who he has been happily married to for 35 years. His post-graduate work was spent getting training in general surgery and completing a family practice residency, including a stint in the National Health Service Corps in remote upstate New York. Following residency, Mike set up practice as a family doctor in Rice Lake, Wisconsin, a town of 7,000 people. As he recalls, he did it all, from general medicine to obstetrics, and even the occasional complicated gall bladder surgery. During this time, Mike missed his native New York and returned in 1981 to be a family doctor in Ticonderoga in the Adirondack Mountains. He spent the next five years busy and successful until tragedy changed his life. In 1986, while driving with his wife along a mountain road near Lake Placid, he was involved in a head-on collision with an 18-wheel truck. Mike managed to come out of this without a significant injury, but his wife was paralyzed and was now confined to a wheelchair. This caused him to reevaluate his career, especially the commitments of his busy general practice that required so much time away from his family. Over the next several years, Mike continued his family practice, but looked for a way to make a switch. He had often thought of hair transplantation as an intriguing surgical procedure, but it remained just a thought. The final impetus was his second daughter wanting to attend private boarding school and the financial demands this entailed. As he recalls it, he went running one night and in his mind, visualized all the steps necessary to make the jump to hair restoration a reality. This included reading textbooks cover to cover, attending conferences, and finding someone willing to train him. He notes how all of these steps were completed in exactly the way he imagined them, as if it were destiny. Mike began performing hair transplants in 1989, with this side of his practice gradually growing until he set up a full-time hair restoration practice in 1992 in Saratoga Springs. The early days were spent performing mostly central scalp reductions and standard sized plugs. In 1993, Mike heard Emanual Manny Marritt, MD, speak at a meeting of the American Hair Loss Council. Manny spoke about the frontal forelock design and the importance of planning hair restoration in relation to the progressive nature of hair loss. Later, at the ISHRS meeting in Toronto, Mike was astonished that this concept wasn t even mentioned during the whole four-day conference. He wrote to the editor of the Forum, O Tar Norwood at that time, to ask whether this concept shouldn t be emphasized more among surgeons. O Tar responded with a request for Mike to write something for the Forum, which he did. After this, Mike became inextricably linked to the concept of the frontal forelock design and its benefits in light of the uncertainty of future hair loss. He notes that only a minority of his cases are pure isolated forelock design, but that nevertheless this idea has had a profound impact on his practice. In our current era of megasessions of skinny single follicular units, Mike continues to be a tremendous advocate of double and triple follicular unit grafts, largely because of the high survival rate and visual density they can contribute over the large central areas of the frontal and mid-scalp regions. He usually places these in 1.3mm holes or small 3 4mm slits. Mike has made significant contributions to our field in the area of research. Over the years, he has researched questions of graft growth in different sized grafts and the effect of incision depth on growth. He guesses that most people in actual practice probably obtain about 85 92% growth with follicular units compared to about % with carefully prepared multi-follicular unit grafts. His research has continued on bottom of page 95 94

19 Vance W. Elliott, MD Edmonton, Alberta, Canada Hair Transplant Forum International May/June 2005 Surgeon of the Month Ramon Vila-Rovira, MD Ramon Vila-Rovira, MD Barcelona, Spain Ramon Vila-Rovira, MD, was born in Barcelona, Spain, on May 14, 1948, the second-eldest in a family of two sons and two daughters. Ramon s father worked very hard crafting jewelry instruments, inspiring his son to also develop good work habits. Ramon credits his mother s positive attitude and his father s example as his greatest inspirations in life. Ramon attended Catholic primary school and enjoyed sports such as sailing, skiing, roller-hockey, and motorcycling, choosing a medical career over architecture at age 18. From 1965 to 1971, he attended the Facultad de Medicina de la Universtidad de Barcelona, and completed residency in Plastic and Reconstructive Surgery in He began work in the Department of Plastic Surgery and Burns of Valle Hebron Hospital in Barcelona, becoming interested in hair transplantation for burn patients in the early 1980s. Ramon feels fortunate to have met and visited Dr. Walter Unger in Toronto, Ontario, Canada, in 1987; he began performing micrograft transplants shortly afterward. Without much success in his first few cases, Ramon visited more colleagues and attended more hair transplant meetings. He feels that his hair surgery then progressed at the same pace as his plastic and other aesthetic surgery. In 1992, Ramon founded the Sociedad Española de Transplante de Pelo (The Spanish Society for Hair Transplantation). As its first president, he organized courses for medical doctors, helping to spread and promote hair transplantation surgery throughout Spain. In 1997, Ramon introduced the CO 2 Laser for hair transplantation, only to discontinue it three years later as he realized its disadvantages. In 1997, he also organized the Live Surgery portion for the 5 th Annual Meeting of ISHRS, at the Centro Medico Teknon in Barcelona. He served as President of the European Society of Hair Restoration Surgery in 2001 and 2002, organizing the 4 th Annual Congress of ESHRS in Barcelona, Spain. Ramon has five children, aged 31, 28, 26, 10, and 5, the last two with his wife of ten years, Montse. His parents, aged 89 and 86, continue to provide him with motivation and inspiration. In addition to still practicing wind sports, and recently taking up golf, his main hobby is painting. He has had three art shows in the past few years. Pioneer of the Month continued from page 94 also focused on the critical importance of the vascular net to support grafts. He believes the difference in the vascular insult of an 18- vs. a 20-guage needle is huge. He also thinks that is why thicker scalps have better growth than those with thinner skin. Mike is perhaps best known to us as co-editor of the Forum from 2002 to He currently serves as president of the American Board of Hair Restoration Surgery, and also serves on the Board of Directors of the ISHRS. He has, of course, given countless lectures and authored numerous papers and textbook chapters in our field. Mike s personal life is centered on enjoying the Adirondacks with his wife. He is active in his church and volunteers for a nearby Catholic prison ministry. He has also been a lifelong avid runner, competing in over 38 marathons. Harrilyn often competes with him, doing the races in her racing wheelchair and, according to Mike, has no problem leaving him in the dust. He is also a selfconfessed baseball nut, and attends a fantasy baseball camp with the Chicago Cubs every year in Arizona. Golf and downhill skiing are other interests of his. He has four children and three grandchildren. 95

20 Cyberspace Chat Edwin S. Epstein, MD Richmond, Virginia Please send your comments/questions to: THOUGHTS ON MINIMUM AGES FOR TRANSPLANTS FRONTAL HAIRLINE Bill Parsley, MD Louisville, Kentucky If we transplant the frontal forelock zone of a 20-yearold, we are not just transplanting a barely balding young man; we are transplanting an advanced balding young man. Our experience with newer grafts for these patients is less than 10 years for most of us. The difference between 10 years and our goal of about 60 years is enormous. We can only guess how these will hold up with time. Can a distressed 20- year-old really make a level-headed decision? Most of them would sell out tomorrow for distress relief today. It is my opinion that the severe distress of MPHL fades with time, while the distress of an inappropriate transplant does not. It is a serious decision with serious consequences, and is one of the hardest judgment calls we have as transplant surgeons. BUT, this decision, if delayed for 8 10 years, can be made with much more knowledge and therefore less risk Paul Rose, MD Tampa, Florida I think that most if not all of us have been doing this long enough to know that good decisions years ago can come back to haunt us now or in the future.. Avoiding the crown is often good advice, but thinking that one can get away with treating the frontal area in a young patient can also prove to be a poor decision. Recently I saw a 26-year-old who underwent an HT at age 22. He had approximately 1,200 1,500 transplants along the frontal hairline. The grafts grew in pretty well and in pictures taken a year or two post-transplant, his scalp looked full. Today he has marked thinning throughout the crown and parietal areas as well as the area previously transplanted. The transplanted hairline is far too broad for his current situation and appears significantly too low. The patient is distraught. I think that we all feel for these patients and want to be empathetic. There is an urge to want to fix the problem, but fixing the problem may not be possible. In such cases we need to stick to telling them something they don t want to hear: The best I can offer is medication, support, and encouragement. Bill Rassman, MD Beverly Hills, California Transplanting a young patient in today s modern view of the progressive hair loss phenomenon is not that much different than transplanting any person of any age. Yes, the young man is often too early in the hair loss process, too immature to understand what he is getting into, too financially strapped to understand the meaning of a lifetime commitment to a transplant process. But there are 40- and 50- year-olds that fit these cautionary characteristics as well. I generally don t like rules, but I pay attention to my historical choices for those I have agreed to transplant and those who I have not. I have rarely transplanted people under the age of 24, let alone 22 or less. In 1993 I transplanted a 19- year-old Class 7, and in hindsight, this may have been premature. While his results were good, I am sure that the yield was not as good as it could have been with today s better techniques. Had he waited, he would have had more hair to move around. That being said, I recently saw a 22-year-old Class 6 who had been on Propecia for 2 years, and although it stabilized the hair loss, there has been little regrowth. He was very mature, well educated, fully informed about this field, and his focus was upon framing his face (with less care about the balding crown at this time), making him quite realistic in my opinion. One 3,500 graft session should give him enough density to create a reasonably full appearance of the frontal areas of his scalp. I have advised against transplanting the crown at this time, and I believe that he is actually a good candidate for a hair transplant despite his age. Russell Knudsen, MBBS Sydney, Australia I believe in treating each and every patient as an individual, and each assessment is therefore unique to his or her situation. I have no absolute rules as to age or degree of balding. That said, I do have firm guidelines that form the basis of my decision making. Some of these guidelines have shifted over the years, usually as the (unhappy) result of experience. Patients who are desperate will often not accept your philosophy and seek more amenable help. I had two teenage patients who were adamant about surgery. Both started Propecia, and while I tried to delay acting on their committed view that they needed surgery, both eventually sought second opinions and were operated on. Both were unhappy with the result of the surgery (average-poor technique and average-poor planning) and required corrective surgery by me as my hand had been forced (so to speak). I think they were more disappointed with the quality of the result rather than their decision to have surgery. The moral of the story? Your conservative, ethical view will not necessarily be reflected by another surgeon (or his/her consultant). You can only absolutely control what you do and try to act in the patient s best interests. You are going 96

21 to be disappointed by patients ignoring your advice but this is inevitable. Each patient is different with unique concerns and history, therefore, it is difficult to adhere to a set minimum age for surgically treating hair loss. For the 18- to 29-year-old patient who is taking Propecia but insists on a hairline that is too low, I will try to dissuade the patient from this expectation. I would recommend that we fortify the existing hairline (provided it is conservative enough) rather than lower the hairline. This is frequently successful and manages the patient s expectations. Very rarely does a patient insist we lower the hairline at a later time. CROWN Dow Stough, MD Hot Springs, Arkansas In the 1980s, I stopped transplanting the crown area. At the same time, I chose not to transplant anyone under the age of 25. The debate then was whether or not we should transplant anyone before the age of 21. The consensus among the hair transplant community was that it is certainly safe and should not be discouraged. The bottom line is we are only now grasping the progressive nature of male pattern hair loss, and questioning whether or not we should transplant someone in their mid 20s. Prior to this, they were certainly open game. Matt Leavitt, DO Orlando, Florida If we are going to treat a patient with crown hair loss, I insist the patient take Propecia and/or Rogaine, realizing that there is no way to guarantee the patient will be compliant for an extended period of time. My approach to the crown in a patient in their 30s is to transplant the anterior portion of the area. This allows the patient to use creative styling to hide the spot with a minimal number of grafts, while making the patient feel better. More conservative doctors would treat the crown much later, but every patient deserves a thorough evaluation and consultation to express his or her desires and needs. I encourage and request they seek a second and/or third opinion from other physicians prior to their treatment if necessary. The longer we are able to stall these patients, the greater certainty we have in how to treat their hair loss situation long term. Samir Ibrahim Abu Ghoush, MD Riyadh, Saudi Arabia Usually I transplant the crown when the patient is over 30, and when I am almost sure he will not lose the frontal hairline. If there is clinical evidence suggesting potential future loss in the hairline, I will not do the surgery, regardless if the patient is taking Propecia or not. It is me, and not the patient, who decides about the hairline. I may lose many of these young patients because they insist on low hairlines. POST-OPERATIVE SWELLING Dow Stough, MD Hot Springs, Arkansas Dr. O Tar T. Norwood has previously stated that he can eliminate postoperative swelling with adding triamcinolone to lidocaine. Others simply give a shot of kenalog immediately post-operatively. While these techniques both work fine, we have found that prednisone, 40mg a day post-op for five days, plus a postoperative wrap worn like a turban, does a very good job of preventing any swelling. Caution is given to take the prednisone with food to prevent nausea. The inherent value of postoperative dressings is to minimize swelling and to maximize wound healing. We utilize these dressings not out of any concerns for post-op bleeding, but have found them to eliminate postoperative swelling and facilitate wound healing. Some of our hair transplant patients do not wish a post-operative dressing. We do warn these individuals, however, that the risk of swelling is greater without the use of a postoperative turban wrap. WORKUP FOR FEMALE HAIR LOSS Eric Eisenberg, MD Toronto, Ontario, Canada Most cases of female hereditary hair loss are easily diagnosed with a thorough history and clinical examination. The presence of a widened central part, increased interfollicular spacing, and reduced density in the frontal area that often extends into the temporal zones and crown area, is a fairly characteristic presentation. The presence of random 2 4mm macular alopecia within the frontal area is commonly seen. Typically, the frontal hairline is preserved, but there is occasionally a male pattern component with a bilateral and sometimes symmetrical rounding and thinning at the frontotemporal junctions. The hair loss and thinning are generally slowly progressive over time, and the telogen hair pull test is in the normal range. It is important to distinguish the presence of female hereditary hair loss from chronic telogen effluvium (with which it may sometimes overlap), or even the presence of acute telogen effluvium. The presence of a significant and ongoing telogen shedding should preclude hair transplantation and should trigger appropriate questioning to identify possible causes. When warranted, and to exclude the possibility of a scarring alopecia or alopecia areata, a biopsy (usually a minimum 3 4mm punch excision) read by a Dermatopathologist (often with horizontal sectioning) is often helpful. Lab investigations, when clinically indicated, should exclude iron deficiency, thyroid disease, and polycystic ovary syndrome. I would not do any testing in the absence of any clinical signs or symptoms of thyroid disease. I have diagnosed new cases of thyroid disease simply on the basis of hair loss in association with mild lethargy. I agree that we often have poor results with idiopathic scarring alopecia, but scarring alopecia secondary to discoid lupus or lichen planopilaris can often be arrested with early intervention. My experience with correction of iron deficiency tends to be more positive. If caught in a relatively early stage, the continued on page 98 97

22 Cyberspace Chat continued from page 97 increased telogen shedding tends to slow down, and patients will often notice a return toward baseline. An objective hair pull test done after a few months of iron replacement will usually show a reduction in the number of easily extractable telogen hairs. Richard Shiell, MBBS Melbourne, Australia I find myself doing less lab work over the years because even if you discover something (e.g., low serum iron), there is no convincing evidence that restoration to normal produces any improvement. PCOS is generally easily diagnosed from the history. Thyroid disease is another relatively common problem, but would you do tests in the absence of lethargy and a low pulse rate? Does the hair loss ever precede the more common symptoms and signs of hypothyroidism? I think I do tests to CONFIRM my diagnosis rather than as a screening test for possible causes. With the cicatricial alopecias it is comforting to have a biopsy to back up your clinical diagnosis, but it is rarely necessary as there is no successful treatment for these conditions. Be very careful about taking 4mm biopsies in the central thinning area of women with androgenetic alopecia. Sometimes they worry more about the new white scar than about the thinned parting. Bob Haber, MD Cleveland, Ohio As a Dermatologist, I perform a more aggressive workup, as I see women with hair loss from many causes and with no expectation of surgery. If I had a practice devoted exclusively to HT, I would prefer that these patients be evaluated elsewhere prior to being sent to me. My laboratory workup is intended to identify subtle problems not detected by physical exam and history and includes: Estradiol, FSH, LH, Prolactin, T4, TSH, Free and Total Testosterone, ANA, Iron, TIBC, and Ferritin. Over the years I have detected pathologic abnormalities of most of the labs above. Although correction of the underlying abnormality rarely results in significant hair regrowth, they nonetheless should be identified and corrected. I obtain a scalp biopsy only when there is inflammation or a suggestion of a scarring process, and then obtain two 4mm punch biopsies from an active area of hair loss, one for routine, and one for horizontal sectioning by a Dermatopathologist. Bernard Nusbaum, MD Miami, Florida I perform two 4 6mm punch biopsies that include the subcutaneous tissue. One specimen is for vertical sections and the other is for horizontal sections; the latter allows accurate follicular counts. If scarring alopecia is suspected, I biopsy an area of inflammation (erythema, scaling) or, if no inflammation is present, I biopsy the periphery of the alopecia. In alopecia areata, I biopsy an area of most recent hair loss. In female pattern hair loss or telogen effluvium, select an area of thinning that will not be too close to the frontal hairline where the small scar may be visible. I find it helpful to the Dermatopathologist to submit a clinical photograph along with the specimen. There is one study that suggests that the diagnostic accuracy of biopsy in telogen effluvium is increased significantly by performing 3 punch specimens, all submitted for horizontal sections. Marc Avram, MD New York, New York My approach is as follows: 3 4mm punch biopsies in a representative region, horizontal sections by a Dermatopathologist, thyroid function tests, iron studies and ANA, referral to a Gyn/endocrinologist, if the history reveals an irregular menses or hirsutism, and I emphasize appropriate hair care. STOPPING ANTICOAGULANTS Jerry Wong, MD Vancouver, British Columbia, Canada I have my patients stop aspirin for at least 7 days and will do a small test strip to make sure the grafts stay put before taking out a large strip. Carlos Puig, DO Houston, Texas The only two bleeding complications I have had in the past 15 years have been in patients who were taking clopidogrel bisulfate (Plavix). I would have the cardiologist decide if they can be moved to an alternate anticoagulant. 98

23 Pearls of Wisdom Robert T. Leonard, Jr., DO, FAACS Cranston, Rhode Island Thank you for participating in this section to date. We have initiated a new means of obtaining input from our worldwide membership. Using the wonders of the cyberspace, we shall be ing requests on a totally random basis on a particular topic to be published in an upcoming Pearls column. This issue, Drs. Jerzy Kolasinski, Martin Tessler, and Robert True have graciously offered us their pearls. If you haven t already made your plans for Sydney get going!! What tricks do you have for quicker or more efficient placement? Jerzy Kolasinski, MD, PhD Swarzedz, Poland 1. Patient positioning should provide good access to two planters. For central alopecia, the patient is placed in the ventral decubitus position only such a position allows for restoration of the natural growth direction. For frontal alopecia, the patient is placed in a semireclining position. 2. Tumescent technique significantly reduces intra-operative bleeding. The solution is prepared immediately prior to use. 3. The grafts are placed in incisions made with a No. 65 scalpel blade using our own technique, called fourhands-stick-and-place. In this technique, the scalpel is used not only to make incisions in the skin but also to open the incision by pressing on its wall and immediately placing the graft in the incision. A jeweler s forceps is only used for transferring the grafts close to the incision. Keeping grafts to be planted close to the recipient area substantially simplifies and shortens this maneuver. The four-hands-stick-and-place technique is based on harmonious cooperation of four hands working together: those of the surgeon and the assistant, who makes incisions and places grafts, too. The mirror position of their hands enables the procedure to be carried out very efficiently. Marty Tessler, MD Southfield, Michigan 1. The use of Dumont forceps, style #5, 45 degree angled tips. 2. Designs By Vision surgical glasses for the doctors and nurses (which have replaced other magnifiers). The nurses use either 3.5 or 2.5. They are custom fitted for eye width and working distance. They open up a whole new realm in visual acuity and comfort, which in turn, translates into more efficient placement of grafts. They cost between $1,050 and $1,650 a pair, but are well worth the cost. My nurses love them! 3. I have used a 3 for many years and have changed to the 6 a few months ago for making recipient incisions. I dealt with some dizziness until I became used to them. They are so far superior to the 3 that I actually felt guilty when I didn t use them. I can see things that I didn t even realize I couldn t see (e.g., very fine hairs and gray hairs). There is no question that I can do superior work with them (as could anyone). Robert H. True, MD, and Robert J. Dorin, DO New York City, New York 1. Knowing the angle of the receptor site is hands-down the most important factor in speed of graft placement. Grafts slip in quickly and easily along the angle of the receptor site. Conversely, they resist placement and pop easily when they are inserted contrary to the site angle. In a team where the doctor and staff are used to working together, the techs can anticipate the site angles the doctor usually makes. Site orientation may vary from case to case and in different recipient areas. Gentle probing with a forceps is a quick way to determine site angles. The angles are usually consistent within an area, so once angle is determined, grafts can be placed rapidly following the same angle, repeating this process when moving into a new zone. Each technician has to be positioned correctly, and holding the forceps correctly in order to be able to place along the site angle accurately. 2. Having proper forceps is critical to placement speed. The forceps need to have fine tips, but not sharp tips (which cut tissue). Our current favorite is the Leavitt Bonn forceps. Each technician needs to have their own straight and angled forceps and be proficient in using both. A right-handed person is generally quicker with an angled forceps when working on the left side and vice versa. Conversely, lefties are quicker on the left side with a straight forceps and righties on the right side with a straight. All of this comes back to being in the best position to place the grafts along the site angle. When recruiting staff it s not a bad idea to ensure a mix of left- and right-handed people as the combination often produces the most efficient placing teams. continued on page

24 Pearls of Wisdom continued from page 99 Handedness can also be overcome by holding the forceps vertically in the hand rather than with the usual pencil grip. When three or four people are working, placement will be quicker if those in the rear use an angled forceps. 3. Cutting quality grafts speeds placement. Grafts that have too much fat are hard to insert and keep in place. Grafts that have irregular margins, particularly at the epidermis, have the same problems. Well-cut grafts with smooth margins and just the essential amount of fat at the bottom below the follicle for the forceps to grasp go in quickly. 4. Careful pre-op patient screening and planning makes for quicker placement. Patients that bleed take longer to place. 99% of bleeding problems can be avoided by screening patients pre-operatively for medications that promote bleeding and eliminating these in the pre-op period. Over-the-counter medications can be easily overlooked, and we are always amazed how many patients who say no when asked if they are taking any medications, will say yes when they are specifically asked about aspirin and vitamins and supplements. 5. Keeping the patient relaxed and comfortable speeds placement. Patients who move around or who need frequent breaks will take longer. Adequate sedation needs to be maintained. Anticipate. Avoid hunger, full bladders. Use supportive cushions to change position. Give planned stretch breaks. Give booster anesthesia before discomfort becomes pain. 6. Make receptor sites the right depth. Nothing slows placement down more than receptor sites that are too shallow. 7. Clean and adjust as you go. Fully inserted grafts are less likely to pop. Popping slows down placement. Spraying and blotting frequently improves visualization and helps things move along faster. 8. Start placing before all of the grafts are cut. We make our recipient sites based on a preliminary estimate of the number of grafts and have one or two people start placing while the remaining grafts are cut. Any further recipient sites are added and the rest of the team joins in placing. We want to thank our excellent staff Rita Kordon, Aleks Krasnozhen, Jose Salvador, Jose Crisanto, Ruel Adajar, Lisa Mastando, Ana Rios, and Yelena Shprit and for their input to these tips and for their daily dedication to producing great results for each patient. 100

25 Focus on Protecting the Tools of the Trade Richard Himelhoch, Esq. Chicago, Illinois Richard is an Intellectual Property attorney at Wallenstein Wagner & Rockey located in Chicago, Illinois. Questions or comments concerning this article can be directed to or The difference between a successful procedure and one having poor results ultimately depends on the skill of the doctor. However, the use of specialized techniques and cutting-edge technology the instruments and devices employed in the procedure often play an important role in such success. The development and refinement of the techniques and technology utilized generally involve an inventive process. Where Does an Invention Come From? Invention occurs in every field on a random yet continuous basis. Sometimes it comes from a sudden flash of inspiration, while at other times it is the result of years of painstaking research and development. Most often, it is somewhere between these extremes. Invention typically results from identifying a problem, and then finding a solution to that problem. In most cases, the solution is something of value worthy of protection. How Can an Invention Be Protected? A patent allows the owner to exclude anyone from making, using, selling, or offering to sell the patented invention anywhere in the United States or its territories. The right to exclude is regardless of whether another independently creates the same invention. These exclusive rights can be enforced when the patent issues and until it expires 20 years from the filing of an application seeking grant of a patent. How Does One Get a Patent? Patent protection can be sought for any new and useful process, machine, device, apparatus, article of manufacture, or composition of matter. Moreover, protection can also be sought for any improvement to such items. The improvement just has to be new and useful in and of itself. The process for obtaining a patent begins with preparing and filing a patent application with the Patent and Trademark Office. The application contains a detailed description including drawings when necessary of the invention. This description must be sufficient to enable or teach one of ordinary skill in the art to practice the invention. Additionally, it must also disclose the best mode of practicing the invention known to the inventor at the time of filing. The application also includes a series of claims that define the scope of protection being sought. The claims map out the metes and bounds of the invention and act as the KEEP OUT sign to the inventor s property. Once filed, the Patent and Trademark Office examines the application to determine whether a patentable invention is being claimed. In addition to ensuring the application meets a variety of technical requirements, an Examiner from the Patent and Trademark Office will perform a search of the prior art that is, a search of what has come before the invention and make a determination as to whether the claimed invention is new or non-obvious from the prior art. The Examiner details his or her findings in an Action that is mailed to the inventor, or to the inventor s attorney or agent of record. The Examiner can allow some or all of the pending claims, and/or reject some or all of the Claims. In the case of a rejection based on prior art relied upon by the Examiner, the inventor can respond to the action by amending the claims to include additional elements of the invention that distinguish it from the prior art and/or submit arguments as to why such art does not disclose or show the claimed invention. This process continues until only allowable claims remain in the application. At this point, the Examiner will issue a Notice of Allowance, and a patent will be granted. Although not required, the inventor can perform a prior art search before filing an application. This can act as an insurance policy that, depending on the results, may cause an inventor to not take on the usually more significant costs of preparing and filing the application. These costs can range on average from a few thousand dollars to two or three times that amount depending on the complexity of the invention, the completeness of the invention disclosure or lack thereof provided to the patent attorney or agent, and possibly the extent and content of the prior art known to the inventor. A similar amount can be expected to cover responding to the Patent and Trademark Office until issuance of a patent. Even if the invention is not shown in the search results, the search can also be useful in preparing the application by assisting the patent attorney or agent in drafting claims having sufficient detail to be patentable over the art discovered. This may save costs down the road by avoiding rejections that would require adding such detail further on in the process. The patent laws encourage an inventor to file an application sooner rather than later. In the United States, the clock starts running from a public disclosure of the invention or an offer to sell the invention. From that point, the inventor has one year to file a patent application; otherwise, any potential rights to a Patent may be forfeited. Many foreign countries call for even faster filing, often requiring an application be filed prior to any public disclosure. Accordingly, consideration of whether to file a patent application should be done as soon as possible. Once a patent has been issued, the owner can treat it as an asset that can be sold, licensed either exclusively or non-exclusively or otherwise transferred in whole or in part to another entity. Moreover, there is no requirement to enforce the patent against any and all infringers. The owner can pick and choose who to sue. However, if the patent continued on page

26 Protecting Tools of the Trade continued from page 101 owner refuses to sue a known infringer, certain actions or omissions to act can possibly create defenses for the infringer for any future action against it. Patents in the Medical Field Patent protection in the medical field has limitations not encountered in other technical areas. While medical devices, apparatuses, instruments, and compositions of matter can be protected by a patent, it is not possible to enforce a patent to prevent a medical practitioner (or the health care entity the practitioner works for) from performing a medical or surgical procedure on a body. That is, an inventor of such a procedure cannot prevent medical practitioners from performing it, and cannot obtain monetary damages or an injunction against the practitioner. Focus on the Business Side When Deciding If Patent Is Right for You William R. Rassman Los Angeles, California Mr. Richard Himelhoch has given us a good overview of the patent process. My comments, however, focus on the business side of the inventive process, which should be analyzed before beginning the expensive and time-consuming process of obtaining a patent in the first place. Don t be so thrilled with the solution that your invention provides that you become blind to the real value and costs of a patent as a business. My best case in point is the patent I obtained for the Hair Densitometer (U.S. Patent #5,331,472), the visual device that is used to measure hair density and hair thickness. When I invented it, I did not think a great deal about the value of owning a patent on this device, so I filed a U.S. Patent application and obtained one in a reasonably short period of time. Unfortunately, by the time the patent was issued, Radio Shack was already selling a hand held microscope for $12 that worked well enough to replace the Densitometer. So, with a device on the market being priced so low and created for another use (the There is an exception to this limitation. Medical or surgical procedures that utilize a patented device, apparatus, instrument, or composition of matter do not qualify as medical activities that avoid liability under the patent laws. However, the patent on the device, apparatus, instrument, or composition of matter already provides the right to exclude anyone from using it. What does this all mean for the medical practitioner who becomes an inventor? Well, for one thing, regardless of which form of protection is best for the invention at issue, guard against any public disclosure or offer for sale of the invention. At least until some decision has been made about whether and how you are going to protect the invention. Next, take steps to secure that protection. In the case of a trade secret, put in place and follow procedures for limiting access and keeping the secret confidential. For a patent, prepare and file an application as soon as possible (and in no case no more than a year from the first public disclosure or offer for sale). toy market), attempting to enforce a patent for my device made no business sense. How could anyone who purchased it from Radio Shack as a child s toy be restricted from using it to measure hair density? This example underscores the importance of assessing the business side of inventing, which should have produced an analysis of the product, the marketplace, the production costs, the marketing costs and a detailed competitive analysis including (as in this case) the presence of the Radio Shack toy as a threat to my exclusive monopoly that U.S. Patent law granted. The requirement for the inventor is to balance creative output against the business case for creating a profitable business or product. In conclusion, I would suggest that prior to investing substantial amounts of money and time into obtaining a patent for your invention, that you think through the business case for the use of a commercial device in great detail first. With all of my warnings on this subject above, I still continue to obtain patents on many technologies, but now I spend considerable time thinking through the business case. Editor s Note: Advances in our field would be severely limited if we kept our techniques and devices to ourselves. Many ISHRS members have invented devices that have deliberately not been protected by patent. This is to be encouraged. We have published this article not to encourage our members to make their contributions profitable, but to educate us regarding the process of protecting intellectual property. RSH The Annual ISHRS Practice Census Have you ever wondered How many hair transplants are done in the world annually? How many transplants are done on men versus women? Is the number increasing or decreasing? How many scalp reductions are done annually? What is the average cost of a hair transplant? What is the average number of hairs transplanted per patient? Help us obtain reliable statistics in HRS. One of our strategic initiatives is to increase the public s awareness and perception of HRS. To properly do public relations and work with the media, who can help promote our profession, we need reliable statistics. We are beginning our annual formal effort to collect meaningful and useful statistics on hair restoration surgery. We have hired an independent survey firm to assist us in developing a questionnaire, conducting the survey, collecting the data, and analyzing the results. In the months to come you will be receiving an asking you to take part in this survey. Please take the time to complete it. The data we compile from this effort will be invaluable in helping understand our profession and in helping the media understand the hair restoration community and the ISHRS. 102

27 Scalp REPORT Dermatology FROM THE for AD the HOC Hair COMMITTEE Restoration ON AMA Surgeon MEMBERSHIP FOR ISHRS As Committee Chairman, I am pleased to report on Committee findings to date with regard to the possibility of the ISHRS becoming a member of the House of Delegates of the American Medical Association (AMA). For the ISHRS to gain full AMA membership, there is a two-step process. The first step is for the ISHRS to submit an Application for Membership in the Specialty Societies Section (SSS) of the AMA, and for that application to be accepted firstly by the SSS Credentials Committee and secondly by the voting members of the SSS. There are nine criteria that are considered with regard to membership in the SSS, and at the present time, the ISHRS does meet most, but not all, of these criteria. One of the most important criteria will be discussed in the next paragraph. The second step for full AMA membership is to file a formal application for delegate status after at least two years of membership in the SSS, and all Societies seeking delegate status in the AMA House of Delegates must be members of the SSS for a minimum of three years and be recommended by the SSS Governing Council. One of the most important criteria in order to submit an Application for Membership in the SSS, is that specialty organizations with a total of 500 or more physician members must have 35% of their USA members also be members of the AMA personally. With the assistance of Ms. Victoria Ceh, our Executive Director, and her staff, we were able to compare the membership rosters of the two organizations for our 342 American members. At the present time, only 95 (28%) American members of the ISHRS are also members of the AMA. It is believed that the ISHRS can meet the other eight criteria also required, if the dual membership percentage criteria can be achieved. In order for the ISHRS to become a member of the AMA, at least 25 more American members of the ISHRS must join the AMA personally. Once a 35% dual membership status is in place, at least 35% of our American members must continue to be members of both organizations in order for AMA membership of the ISHRS to continue in the future. The Ad Hoc Committee has reported this information to the ISHRS Board and they are presently considering the information carefully. Respectfully submitted on behalf of myself and the other Committee Members, Martin G. Unger, MD Committee Chairman, Ad Hoc Committee on AMA Membership for ISHRS Other Ad Hoc Committee Members Paul J. McAndrews, MD Daniel E. Rousso, MD Neil S. Sadick, MD James E. Vogel, MD 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 103

28 Reports on Orlando 2005 William M. Parsley, MD Louisville, Kentucky Friday, March 4 Day 3 began at 8AM after a pleasant night of cocktails at Disney s Pleasure Island Park. Normally these sessions start slowly with some brief informative talks until the coffee kicks in. No one was prepared for this one. Early risers were treated to one of the best lectures we have ever heard. Scott Lucia, MD, from Aurora, Colorado, was flown in as one of the guest lectures. He was the lead investigative pathologist for the large Prostate Cancer Prevention Trial (PCPT); the study that had the hair restoration surgeons around the world wondering if our favored hair-loss therapy was indeed safe. With precision, he reported studies that dissected the PCPT parameters and results, with his conclusions backed by solid data. The lecture was presented in a fashion that nonurologists could understand. It now appears that: 1) finasteride is not tumorgenic; 2) Gleason scores on blind needle biopsies are unreliable; 3) these higher Gleason numbers can be explained by prostatic shrinkage; 4) pathologists are unable to accurately recognize hormonally induced prostatic changes; 5) rather than being worrisome for prostatic cancer, finasteride appears to aid early detection of a pre-existing tumor via digital rectal exam; and 6) checking PSA levels before beginning treatment and at 3 months could aid early detection of a preexisting prostatic cancer. Attendees gave a sigh of relief concerning their continued use of finasteride. This topic is of major importance to us and will be addressed in the Forum and also will be presented in Sydney. Details will not be given until the study is published. Panelists included Ed Epstein, MD, Ken Washenik, MD, Tony Mangubat, MD, Matt Leavitt, DO, and Byron Hodge, MD (a Pathologist). It was concluded that more guidance is needed as to the hair restoration surgeon s responsibility in the follow-up of patients on finasteride and in the need for informed consent (or as Dr. Washenik called it, confused consent ). Wonderful lecture no coffee necessary. The next panel, related to special cases, was moderated by Ken Washenik, MD. Marco Barusco, MD, lectured on temporal points. He stated that while results can be quite rewarding, if the restoration is improperly done or performed on someone with inadequate donor supply for future temporal recession, the results could result in a serious cosmetic problem. He states that it usually takes about 250 grafts to restore each temporal point and that only 1- and 2-hair grafts should be used. Dr. Barusco uses 22g needles for 1-hair grafts and 18g needles for 2-hair grafts. This was followed by Tony Mangubat, MD s lecture on repair cases. He presented some cases that included a large alopecic scar from a tumor and another with a large burn scar. The use of expanders led to impressive results unobtainable by other methods. Dr. Mangubat finished by pleading to the audience that we don t lose these skills in our Society. Gabriel Krenitsky, MD, discussed the vertex, describing the natural patterns and their prevalence. The patterns observed were: diffusion pattern (no defined whorl), S pattern, Z pattern, double SZ, and double SS. No double ZZ pattern has been reported yet. Matt Leavitt, DO, then moderated a panel on hair loss in women. Bernie Nusbaum, MD, noted that the two most common indications for surgery in women are female pattern hair loss and post-cosmetic surgery, with traction alopecia also common. He pointed out that more investigation is often needed than in men, and that doctors need to prepare patients PCPT Panel (L-R): Drs. Matt Leavitt, E. Antonio Mangubat, Ken Washenik, Byron Hodge, Scott for the possibility of Lucia, Edwin Epstein post-operative effluvium. Dr. Nusbaum stated that he likes to pretreat patients for 2 4 weeks with minoxidil to reduce the incidence of this effluvium. Surgically he reduces epinephrine use, creates sites slowly to reduce shedding, and packs less densely. Sara Wasserman, MD, pointed out that hair loss in women is less socially acceptable than in men and that the psychological impact is much greater. This impact is in the form of loss of self-confidence and self-esteem, embarrassment, and depression. In the final lecture session of the morning, Paul McAndrews, MD, led a panel discussion on hairline design. The panelists were Ron Shapiro, MD, Jennifer Martinick, MBBS, and Bill Parsley, MD. Two live patients were presented for discussion. Using the vertical lateral epicanthal line to help locate the frontotemporal apex was discussed, along with techniques to locate the midfrontal point of the created frontal hairline. Many individual opinions were given on this all important design. Everyone agreed that it is best to be conservative on the design to allow for future hair loss. 104

29 The participants then traveled to the surgery center where a corrective case was performed by Ron Shapiro, MD, Sharon Keene, MD, and Tony Mangubat, MD; temporal points were restored by Alan Bauman, MD, Jennifer Martinick, MBBS, and David Perez-Meza, MD; a vertex case was performed by Marco Barusco, MD, Alex Ginsburg, MD, Paul McAndrews, MD, Marc Avram, MD, and Gabriel Krenitski, MD; a female case was demonstrated by Matt Leavitt, DO, Bernie Nusbaum, MD, James Harris, MD, and Melike Kuelahci, MD; and eyelashes were restored by John Porcaro, MD, and Marcelo Gandelman, MD. After a long day in lectures and in the operating room, dinner at Wolfgang Pucks in Pleasure Island (Downtown Disney) was very welcome. Welcome Reception (L-R): Drs. Paul McAndrews, Ron Shapiro, Alan Bauman, Melike Kuelahci Welcome Reception (L-R): Drs. Paul McAndrews, Ron Shapiro, Alan Bauman, Melike Kuelahci Bessam K. Farjo, MD Manchester, United Kingdom Saturday, March 5 Live Surgery (L-R): Drs. David Perez-Meza, Jennifer Martinick, William Parsley, John Porcaro There was one didactic session on the morning of the last day of the Live Surgery Workshop. Patrick Frechet, MD, presented a new and improved Frechet Extender, enabling him to eliminate 12 15cm of baldness in one procedure, but it must remain in place for 6 weeks. In a second presentation, he talked about a new mystery technique for suturing the donor area where he consistently gets very fine scars. He did not discuss the details of the technique. Ramon Vila Rovira, MD, discussed scalp expanders for injuries while Bessam Farjo, MD, presented some disturbing study results that led to the creation of new decontamination regulations in the United Kingdom. Clinics now will be forced to either outsource the sterilization process or rely totally on single-use instruments for hair restoration. Sharon Keene, MD, presented her experience with consecutive day surgery performing up to 5,000 grafts over two consecutive days on the same patient. She performed a study on 4 patients over 8 months showing good results and an alternative option for clinics with limited staff. Finally, Mohammed Humayun Mahmood, MD, showed his practice of evaluating the donor area pre-operatively for mobility. He measures vertical mobility at 4 different areas. This enables him to predict how much width he can remove without risk of tension and allowing closure of the donor incision in a single layer. After the lectures, there were four surgeries at the Surgery Center. In the first case, Drs. Frechet and Marco Barusco performed a midline scalp reduction with ellipse design in a patient with previous scalp reduction. Dr. Leavitt, in a surgery team with Melike Kuelahci, MD, and Tony Mangubat, MD, performed a second surgery in a female case with hair loss in the occipital area after a brain tumor removal and radiotherapy more than 20 years ago. The temporal area was used as donor area for the case. This was done as an Operation Restore patient. Ed Suddleson, MD, and Dr. Farjo were the surgery team for a case of frontal follicular unit grafting (1,300) on a past MHR patient. Finally, David Perez-Meza, MD, with William Parsley, MD, and Jennifer Martinick, MBBS, initiated a study comparing recipient site orientation and dense packing. FUs were planted in densities of 30, 40, and 50cm 2 in both sagittal (parallel) and coronal (perpendicular) orientation in the same scalp. A preliminary report will be presented in Sydney. The ISHRS Online Forum Archives at Search for articles Download the latest issue (PDF) Reference a past issues 105

30 Call to All Experts! & Announcement of ASK THE EXPERTS Feature Are you an expert in any of the following HRS categories? If yes, please consider volunteering as an Expert in our Ask the Experts feature on the ISHRS Website. This new feature provides a mechanism for members to ask questions and seek advice from other members. It s easy to use. Members who want to ask a question: ❶ ❷ ❸ ❹ Simply go to the Ask the Experts section in the Members Only section of the Website. Select the topic category. Choose as many (or as few) names from the list of Experts for that particular topic of whom you want to ask your question. Fill in your name, address, and your question. ❺ Then hit Send. Done. Your question will be ed to the Experts who you chose. Experts are kindly asked to respond within one week. Members who want to sign up as an Expert: ❶ ❷ ❸ ❹ ❺ Go to the Add/Edit Profile feature in the Members Only section. Go to the Ask the Expert Volunteering section (i.e., 3 rd section). Check the subject areas in which you consider yourself an expert and are willing to answer questions from other members. At any time you may check or uncheck topics. Then hit Submit Changes. Be ready to receive s with questions from other ISHRS members. (Note: messages will indicate that they are coming from the Ask the Experts program.) Do you consider yourself and all-around Expert? If yes, please check the Other topic area in addition to specific topics. TOPICS Anesthesia Aesthetics Avoiding Poor Growth Basic Science Brow Lift Complications Consultations Density Issues Dermatologic Aspects of Scalp & Hair Disorders Donor Harvesting & Closure (strip technique) Endocrinology of Hair Loss Ethnic Variations Eyebrow Restoration Eyelash Restoration Facelift and Scar Treatment Female Hair Loss FIT, FUE Flaps, Reductions, Extenders, Expanders Follicular Unit Transplantation (FUT) Graft Preparation Hair Cloning, Culturing Hairline Design Hair Transplantation into Scars Instrumentation Marketing & Internet Medical Therapy Mixed Grafting Recipient Site Preparation Other 106

31 Submit Your Patients Hair Stories The second most viewed section of the ISHRS Website is the Patient Stories section. has well over 10,000 visitors a month. Prospective patients want to hear about other patients experiences, and they want to view before and after photos. The ISHRS is expanding and reorganizing the Patient Stories section, and we are seeking more stories from your patients! This is your chance to show your work and let your patients describe how their hair restoration surgery has changed their lives. We encourage you to invite your patients to share their personal hair restoration stories. As their physician, you will be identified by name with a link to your ISHRS Physician Profile. Photos and essays will be reviewed by a selection committee on the basis of the following criteria. Selected pieces will: Exhibit high-quality photos showing authentic before and after results. Describe an experience from the patient s perspective. Advance the understanding of the patient-physician relationship. Provide creative insight or illumination about an experience. Raise issues in a compelling way. This is an opportunity for you to share your great results! A prepared flyer and Patient Story Form is available that you may give to your patients. The ISHRS may edit the patient s story, but the story will remain in the patient s voice. Please send us your patients stories for consideration. Submissions must include the essay, labeled before and after photos, and completed and signed Patient Story Form signed by both the patient and surgeon. Essay must be in Word format. Photos must be JPEG format untouched, in color, and 300dpi. Photos must be labeled with patient name, date, and whether before or after. For after photos, indicate the number of months post-op and, if applicable, provide additional description. Patient Story Form must be faxed or scanned/ ed. SUBMISSION STEPS 1. Essay and Photos. to: info@ishrs.org 2. Patient Story Form. Fax signed form to: (Or scan and to: info@ishrs.org) International Society of Hair Restoration Surgery 13 South 2 nd Street, Geneva, IL USA Phone: or ; Fax: ; info@ishrs.org 107

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33 AUSTRALIA: A Little Political History and Anthropology Richard C. Shiell, MBBS Melbourne, Australia Europeans were skirting around the Australian continent for a couple of hundred years before Lt. James Cook finally planted the flag in 1776 and claimed the entire fertile Eastern seaboard in the name of King George. Earlier contact had been made on the West coast by William Dampier, an English privateer working for the Dutch in the 1600s and other seafarers en-route to the Dutch East Indies. There is even some interesting evidence that the Spanish and Portuguese were here briefly in the 16 th century as well, but the latter had to keep their discoveries quiet because of a deal they had made with the Pope to confine themselves to the other side of the globe and leave our bit to the Spanish. They were all singularly unimpressed by the barren nature of the coasts and its skinny, naked inhabitants who had nothing whatsoever to trade and seemed too miserable even to capture and sell as slaves. Why Britain decided to make a grab for Australia was more to deny it to the French, who were a dominant naval and Scientific power in Europe at the time, than because of any expectations of riches. It was also a convenient dumping place for British convicts now that most of the former North American colonies were now barred to them following the War of Independence. We now know that Australia is home to the world s oldest surviving culture. The aborigines seem to have arrived in several waves coinciding with the falls in sea level resulting from the various ice ages of the past 100,000 years. Anthropologists have been able to identify three distinct bone structures in the aboriginals over this period. The first to arrive seem to have been the Tasmanoids who, by the time of European settlement, had been cut off on the island of Tasmania since the last rise in water level some 10,000 years earlier. On the mainland the present inhabitants were known as the gracile as opposed to an earlier robust race. All were of the species Homo sapiens, which, we are told, came out of Africa some 200,000 years ago and moved gradually across the planet and entirely displaced earlier species of homo in Africa, Europe, and Asia. Why did the early Australian inhabitants stay as huntergatherers and not progress to a village culture with houses, gardens, domestic animals, and pottery? This is a very interesting question and it has been well covered in the excellent book Germs, Guns, and Steel by Jarryd Diamid. Time they had aplenty but the arid climate and unpredictable water supply was a problem in most of Australia. In addition there was no native cereal that could be cultivated (no equivalent of the wheat, barley, millet, rice, or maize of other lands). Furthermore, there were no large domestic mammals such as the cow, horse, donkey, yak, camel, llama, or water buffalo that could be domesticated. All our large animals were marsupials and hopped, and although we occasionally see kangaroos pulling Santa s sleigh on Australian Christmas cards, it has never been achieved in real life. Even the dog was only a recent arrival to aboriginal life during the past 5,000 years or so and never seemed to be used by the aborigines for hunting purpose. It was used to guard the camp at night and as an additional source of body heat on the cold inland nights ( a three dog night was a particularly cold one for the entirely naked aborigines). Aborigines seldom settled in one spot for long but lived in small bands of a dozen or so and moved along a stretch of river or coast and fought fierce hand-to-hand battles with neighboring bands or tribes over territory or women, their only valued possessions. Contact with Europeans proved disastrous and brought death from smallpox, measles, and other European diseases to which the aborigines had no natural resistance. Once graziers spread into the interior in search of permanent water and good pasture, they came into direct conflict with the aborigines who needed the same land. It was a one-sided battle with an occasional white settler speared and in retaliation entire aboriginal bands were sometimes wiped out by shooting or by poisoning bags of flour with strychnine. This genocide continued in certain remote parts of Australia until the early 1930s. Aboriginal numbers are now somewhere around 600,000, but the number of full-blood native Australians is probably only one-tenth of this figure. As occurs in many other countries where there has been culture clash and dispossession of the original inhabitants, these unfortunate souls occupy a disproportionate percentage of the unemployed and jail inhabitants. On the other side of the coin there are now many fine aboriginal sportsmen, singers, and actors, and a few politicians, lawyers, and doctors. Politics While Australia has always had a fair sprinkling of racial mixtures, it was predominantly an Anglo-Saxon enclave until after WWII, when a large number of southern Europeans were admitted. For 70 years we had a deliberate White Australia Policy designed in 1900 to keep out the Asian hoards who, it was supposed, would work for cheap wages and undermine the efforts of the Labor movement who had by 1888 achieved an 8-hour day and an adequate minimum wage for workers. From the 1970s onwards migration policies were changed and we receive large numbers of refugees from Vietnam, Cambodia, Lebanon, Afghanistan, Iraq, and Iran. Politics in Australia is run on the Westminster system of Britain with an upper and lower house, two main parties, Labour and Conservative (known as the Liberal Party), and a number of smaller parties. The Queen of England is still nominally the Head of State, but she is represented by a Governor General who is appointed every 3 years by the party in power at the time. His is an almost entirely ceremonial role but he does have the constitutional right to dismiss a government, appoint a stand-in government, and call for fresh elections as happened in The Government of the day is led by the Prime Minister who is elected from amongst his parliamentary colleagues and not directly by the people. For this reason he can be both poor and bald as he does not need sex appeal nor to run an expensive campaign to become elected. Talent and political savvy is all that is required. 109

34 Make plans to attend The Big One, Down Under! Working Towards a Sustainable Industry for the Future MESSAGE FROM THE PROGRAM CHAIR Dear Colleagues: Too often we forget about the diamonds and wealth of knowledge in our own backyard. I have been working on establishing the General Session of the Program for the ISHRS Conference in Sydney: August 24 28, I am impressed by the offerings from Society members. All are willing to share their research, technical and medical expertise, tips, and practical experience. The Society is rich in knowledge, skills, and innovative ideas. You will reap the rewards by being part of this Annual Meeting. The conference opens by highlighting the theme and outlining the steps Towards a Sustainable Industry for the Future. The speakers in this session, as in every session throughout the conference, need to meet the learner objectives set for the topic to ensure professional growth, promote excellence in practice, and provide support for the membership. Every effort has been made to address professional requests and ensure that the program offers highquality information relevant to your needs in running your practice. The Media Panel is a first for the Society. We have been able to attract eminent speakers who will offer their perspective of our industry and hopefully engage the debate, and offer a way forward to a better informed and more supportive press. The Featured Speakers, Elise Olsen, MD, Andrew Messenger, MBBS, MD, Rodney Sinclair, MBBS, FACD, MD, Satoshi Itami, MD, and Piero Schiavazzi, PhD, have been carefully chosen as leaders in their field and will cover a wide range of topics from female hair loss to cell biology, cloning, and media coverage. There are basic courses in hairline design, graft preparation, techniques in grafting, donor area harvesting, Asian pearls from those practicing in the Orient, scalp dermatology, and marketing. Lectures at an advanced level are included to assist the physicians in honing their skills in the subtleties in patient evaluation and hair loss diagnosis, surgical planning, anesthesia, emergency situations, donor site management, and the use of different types of grafts. The General Session provides medical updates; panels on corrective work, female hair loss, new concepts in harvesting, density and growth, graft preparation and storage, hairline creation and artistry, conflict resolution; and a live surgery and video workshop. The social life includes a dinner cruise on Sydney Harbor, a night at the Sydney Opera House for a symphonic performance, and an optional reef and rainforest trip to Cairns in tropical North Queensland. This conference has everything you have ever wanted plenty of ideas, inspiration, science, artistry and style, a magnificent setting full sail in Sydney Harbor, and, of course, jolly good company! You must come to see some of the diamonds in Australia s backyard. Register now: 1. Online at: 2. Mail to: ISHRS, 13 South 2nd Street, Geneva, IL USA 3. Fax to: Do come to Australia. Relax and enjoy. Cheers, Jennifer H. Martinick, MBBS Program Chair, 2005 Annual Scientific Meeting Committee " REMINDER: Make your hotel and airline reservations! As always, visit the ISHRS Website for continually updated information on the meeting! 110

35 Classified Ads Original Mangubat Cutter for Sale Original Mangubat cutter, nine simple 5 4 cutting boards, three deluxe cutting boards with wells, hundreds of Havel No. 67 blades, 16 plastic cutting blade holders, over 200 Personna prep blades, three graft chilling wells and over 20 used microforceps. Contact Thomas J. Hubbard, MD Hair Restoration Clinics for Sale Group offices in Virginia. Huge client base with 11 years experience in Hair Restoration. 1.3 million gross per year. Inquiries kept confidential. Roxydani@aol.com ; Fax: 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: International Laser Hair Transplant Surgery Center Is looking for a trained Hair Transplant Surgeon/Hair Technicians to help devoted doctor with over 25 years experience in the field at busy offices located in San Diego and Chicago. All inquires confidential. ilhts@aol.com or call Aubrey at : Fax Experienced Medical Hair Restoration Technician Medical Hair Restoration was founded by Dr. Matt Leavitt in 1989 and has experienced approximately 30% growth rate over the past two years. MHR has offices in Chevy Chase, Washington D.C., Boston, Cleveland, Columbus, Miami, Grand Rapids, Hartford, Orlando, Philadelphia, San Francisco, Tampa and Atlanta. Experienced Medical Assistant needed immediately for elective surgery medical office. Use your skills to assist physician in all aspects of providing quality patient care. Duties to include: *Anesthesia Administration (*Depends on location) Assisting physician in surgery Preparation of donor tissue utilizing microscopic techniques Cutting and preparation of hair grafts utilizing magnification Patient pre and post operative instructions Post surgery instrument/room clean-up Medical records charting Requirements: Travel to other surgical clinics -25%-50% Flexible/varying work hours, occasional weekends BLS or CPR certification Able to work utilizing microscope and magnification Daily use of PPE (gown, masks, gloves, hats, glasses, shoe covers) Able to sit/stand for periods up to 3-4 hours Ability to communicate complex medical instructions to patients Ability to work as a team member Respect and recognition of cultural diversity Able to lift up to 25lbs. Professionalism, excellent attendance and attention to detail Knowledge of: aseptic and sterile techniques, phlebotomy, injections (SQ, IM, IV), Medical terminology, Computer literacy, Vital signs are required Competitive pay and benefits including: Medical, Dental, 401K, LTD, STD, Paid Vacation & Holidays. For consideration, please contact Mel Rappleyea, Director of Human Resources, Leavitt Management Group, Inc. via at melr@leavittmgt.com 111

36 Advancing the art and science of hair restoration Upcoming Events Following is a guide to upcoming meetings and workshops related to hair restoration. For more information, contact the appropriate sponsoring organization at the number listed. Meeting organizers are reminded that it is their responsibility to provide the Forum Editors with advance notice of meeting dates. Date(s) Venue Sponsoring Organization(s) Contact Information June 2 4, th ISHR International Conference Modena, Italy Italian Society of Hair Restoration Euromeeting Tel: Fax: emeet@tin.it June 2 5, th Annual Congress and Live Workshop of ESHRS Brussels, Belgium European Society of Hair Restoration Surgery Congress Host: Dr. Jean Devroye ESHRS Headquarters: Tel: (33) Fax: (33) eshrs@eshrs.com August 24 28, th Annual Meeting of the ISHRS International Society of Hair Restoration Surgery Tel: ; Sydney, Australia Fax: January 20 21, 2006 ABHRS Board Exams Houston, Texas American Board of Hair Restoration Surgery Tel: Fax: abhrs@sbcglobal.net 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 112