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HAIR
TRANSPLANT
I N T E R N A T I O N A L
Volume 18, Number 5
September/October 2008
How to assess scalp laxity
COLUMNS
Parsa Mohebi, MD, Jae Pak, MD, William Rassman, MD Los Angeles, California
162 President’s Message
163 Co-editors’ Messages
165 Editor Emeritus
177 Hair Sciences
183 Scalp Dermatology for the
Hair Restoration Surgeon:
Folliculitis
185 Surgeon of the Month
191 Review of the Literature
194 Letters to the Editors
196 Cyberspace Chat
197 Surgical Assistants
Co-editors’ Messages
198 Classiﬁed Ads
FEATURE ARTICLES
162 Amerinet and the ISHRS:
A great member beneﬁt
169 Laser-assisted hairline
placement
173 Aid to hairline design
(AHD)
175 Intra-operative monitoring
of the follicular transection
rate in follicular unit
extraction
177 An interview with
Professor Valerie Randall
180 Removal of undesired
grafts 5 days after a hair
transplant: How to do it
186 Review of the Asian Hair
Surgery Workshop
188 Review of Made in Italy:
Hair Restoration Live
Video Surgery Workshop
190 Review of the 13th Annual
Meeting of the EHRS
195 The commoditization of
surgical hair restoration—
a cautionary statement
197 Patient welfare
17th Annual Scientiﬁc Meeting
July 22–26, 2009
Amsterdam,
The Netherlands
Laxity: What Is the Problem?
Assessment of scalp laxity prior to hair transplant procedures has been a clinical subjective evaluation
that varies with each surgeon and each visit. Hair transplant surgeons have been traditionally assessing
the laxity of the scalp with manual palpation of the donor area and by moving the scalp horizontally
or vertically and estimating the scalp movement against the occipital bone. Measurements have been
recorded with subjective terms such as very loose, moderately loose, average, moderately tight, and
severely tight. With the exception of the well-known Mayer scale, which provides an estimation of the
percentage of scalp elasticity, there have been no units of measurement available for assessing the
scalp laxity. Thus, there are no standards for measurements of the scalp laxity to reassure the surgeon
regarding his or her judgment.
Strip harvesting yields depend upon two parameters: average density of hair in the donor area,
and surface area of excised strip. Larger transplant sessions require a longer and wider strip size. In
larger hair transplant sessions, the height of the strip depends solely upon the laxity of the scalp.
Removing wide strips will increase tension upon closing the wound. Higher wound tensions cause
the following:
1. Difﬁculty closing the wound and wound dehiscence
2. Widening of the eventual donor scar
3. Wound ischemia and necrosis
4. Telogen efﬂuvium of the surrounding skin
The patients who have a higher risk of donor wound complications include the following:
1. Patients with high ratio of demand to supply.
2. Those who have had repeated hair transplants with diminished scalp laxity after each surgery.
3. Patients with surgical scars on the scalp especially at or below the level of the projected new
strip excision.
4. Patients who naturally have tight scalps.
Laxometer
The laxometer can provide a metric for measurement of the laxity of the donor wound before surgery
when planning a procedure, and a
variation of this same instrument
can be used to estimate tension on
the wound during the hair transplant
while local anesthesia is applied and
before strip removal.
Our clinical prototype was made
Figure 1. Laxometer
of two pads that were able to have a
good grip on the scalp. The laxometer consists of two coarse pads with
a spread of about 5 cm (Figure 1). The lower pad is placed on the scalp
skin just above the occipital bone after parting the hair in the area and
the upper pad follows. The readings on the clinical instrument and its
surgical counterpart were reproducible.
The ﬁrst thing that came to mind after making the laxometer was to
ﬁnd an answer for one of our old questions: Can scalp exercise really
improve the laxity of the scalp? We instructed a few patients to do scalp
exercise and followed them on a monthly basis with laxometer measurements (Figure 2). All patients responded well to this treatment with Figure 2. Scalp exercise improves laxity.
signiﬁcant improvement in scalp mobility. You can see the measured
 page 167
Ofﬁcial publication of the International Society of Hair Restoration Surgery
Hair Transplant Forum International
Hair Transplant Forum International
Volume 18, Number 5
Hair Transplant Forum International is published bi-monthly by the
International Society of Hair Restoration Surgery, 13 South 2nd
Street, Geneva, IL 60134. 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 60134.
Telephone: 630-262-5399, U.S. Domestic Toll Free: 800-444-2737;
Fax: 630-262-1520.
President:
Bessam K. Farjo, MD
Executive Director:
Victoria Ceh, MPA
Editors:
Francisco Jimenez, MD
[email protected]
Bernard P. Nusbaum, MD
[email protected]
Managing Editor, Graphic Design, & Advertising Sales:
Cheryl Duckler, 262-643-4212
[email protected]
Surgeon of the Month: Vance W. Elliott, MD;
Edwin S. Epstein, MD
Cyberspace Chat:
Sharon A. Keene, MD
Pearls of Wisdom:
Robert T. Leonard, Jr., DO
Surgical Assistants Corner Editors:
Laurie Gorham, RN
[email protected]
Betsy Shea, LPN
[email protected]
Basic Science:
Satoshi Itami, MD
Andrew Messenger, MBBS, MD
Ralf Paus, MD
Prof. Mike Philpott, PhD
Prof. Valerie A. Randall, PhD
Rodney Sinclair, MBBS
Scalp Dermatology:
Ricardo Mejia, MD
Scientiﬁc Section:
Nilofer P. Farjo, MD
International Sections:
Asia:
Australia:
Europe:
South America:
Sungjoo Tommy Hwang, MD, PhD
Jennifer H. Martinick, MBBS
Fabio Rinaldi, MD
Marcelo Pitchon, MD
Review of Literature:
Dermatology:
Marc R. Avram, MD
Plastic Surgery:
Alfonso Barrera, MD
Facial Plastic Surgery: Sheldon S. Kabaker, MD
Copyright © 2008 by the International Society of Hair Restoration
Surgery, 13 South 2nd Street, Geneva, IL 60134. Printed in the USA.
The views expressed herein are those of the individual author and are
not necessarily those of the International Society of Hair Restoration
Surgery (ISHRS), its ofﬁcers, directors, or staff. Information included
herein is not medical advice and is not intended to replace the considered
judgment of a practitioner with respect to particular patients, procedures,
or practices. All authors have been asked to disclose any and all interests
they have in an instrument, pharmaceutical, cosmeceutical, or similar
device referenced in, or otherwise potentially impacted by, an article.
ISHRS makes no attempt to validate the sufﬁciency of such disclosures
and makes no warranty, guarantee, or other representation, express or
implied, with respect to the accuracy or sufﬁciency of any information
provided. To the extent permissible under applicable laws, ISHRS
speciﬁcally disclaims responsibility for any injury and/or damage to
persons or property as a result of an author’s statements or materials
or the use or operation of any ideas, instructions, procedures, products,
methods, or dosages contained herein. Moreover, the publication of an
advertisement does not constitute on the part of ISHRS a guaranty or
endorsement of the quality or value of the advertised product or service
or of any of the representations or claims made by the advertiser.
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).
September/October 2008
President’s Message
Bessam K. Farjo, MD Manchester, England
By the time you read this, I will have handed over the
ISHRS presidency to the safe hands of Kentucky’s ﬁnest,
Dr. Bill Parsley. It has indeed been a great privilege and
honour to act as your president this past year.
I would like to thank Dr. Arthur Tykocinski for his
dedication and commitment in chairing this year’s Annual
Scientiﬁc Meeting in Montréal. Arthur’s involvement has
also contributed to my aim of emphasising the international status of our Society by fully involving colleagues
from around the world in this year’s event, such as Drs.
Alex Ginzburg and David Perez. The team was completed
by Drs. Carlos Puig and Paul McAndrews as well as Kathryn Lawson (of the
Gillespie Clinic). My sincere thanks goes to everyone.
The ISHRS has continued to grow rapidly and its achievements over the past
year are testament to that fact. Under the guidance of Drs. Paul Cotterill and
Bob Haber we have achieved ACCME accreditation with commendation. Several
workshops have taken place across the world as well as our popular webinars,
and we continue to develop opportunities for workshops in the U.S., Europe, and
the Middle East. Of particular importance, we co-sponsored a regional workshop
in South East Asia for the second successive year. Our ﬁrst regional workshop
in Europe clearly demonstrated the huge demand and potential for educational
opportunities in this important region.
Our vision continues to be to establish the ISHRS as the leading resource and
unbiased authority on hair loss treatment. Our strategic initiatives over the next
3 years will be to gain ﬁnancial security; increase web- and media-based public
awareness; increase the number of physician members; position the ISHRS as an
integral aspect of emerging technologies; and, ﬁnally, to offer materials and/or
resources for physicians to train new surgical assistants.
As medical professionals, we are not necessarily used to dealing with the
media. However, it’s something that can only be beneﬁcial in our aim of raising
awareness of hair loss solutions and the work of the ISHRS and its members.
We may be unsure of the media, but the impact of news stories over the past
few months—such as hair cell research, genetic screening, and robotics—is
tangible. Stories of patients and their journey through the transplant process
continue to spark interest, particularly high-proﬁle personalities or stories of
human interest such as those under the banner of OPERATION RESTORE. This
is invaluable in raising the positive proﬁle of hair transplantation and something
that should be encouraged and harnessed.
Although the role of President has meant extra work and involvement in
almost all ISHRS issues, I have enjoyed it tremendously but certainly now appreciate why one year is quite enough! I started in this ﬁeld 15 years ago when
I was about 30 and have attended every Annual Meeting since the ﬁrst one in
Dallas back in 1993. You can say I have grown up alongside our Society and I
feel very proud of all its achievements.
Along the years I have been privileged to get to know you as colleagues,
and lucky enough to be able to call many of you dear friends. Thank you all for
your support and trust. Finally, thank you to the support of the ISHRS Executive
Committee and Board of Governors, Victoria Ceh who makes it all tick, Kimberly,
Jule, and the rest of the ad min team in Chicago.
Bessam Farjo, MD
162
Hair Transplant Forum International
September/October 2008
Co-editors’ Messages
Bernard Nusbaum, MD Coral Gables, Florida
Paco Jimenez, MD Las Palmas, Spain
In the designing of the hairline,
we usually measure landmarks such
as the mid frontal point and the
frontotemporal junction, and most of
us still rely on the “eyeball” method
when drawing the hairline. It would
be helpful to have tools to level the
hairline and check for its symmetry.
We have been fortunate to receive
in the last month two articles that
present different tools for aiding in
hairline placement. The ﬁrst article is by Drs. Ng, Pathomvanich, and colleagues from Thailand, who have developed
a portable laser device. The second article is by Dr. Cole,
who uses a template made of a transparent plastic ﬁlm with
vertical and horizontal scales. I think both tools are very
useful and simple to operate, and I am sure that once you
begin using either of them you will never go back to the
“eyeball” method of drawing.
The laxometer, on this issue’s cover, designed by Drs.
Mohebi, Pak, and Rassman, was developed to objectively
measure the laxity of the donor area. An interesting observation is that the laxometer clearly conﬁrms the improvement in laxity following the so called “scalp exercise” for
the donor area.
Dr. Ng and colleagues also present an unusual but real
case that could happen to any of us, namely a patient who
decides to have part of the grafts removed several days after
the transplant. A year ago, Dr. Cooley published a similar
case (Hair Transplant Forum International 2007; 17(5):178)
in which minigrafts were removed using a 20 gauge needle
to hook one edge of the graft and pull upwards. In the
case presented here, Dr. Ng and colleagues removed follicular units 5 days after transplant. It is not as easy as
simply grasping the graft and pulling it out, but involves
what they call a “4-step approach,” which they show in
a detailed diagram.
Dr. Yamamoto from Japan writes on the controversial
topic of the transection rate in FUE, demonstrating that what
he calls the “completely transected graft rate” appears to be
a useful indicator of the follicular transection rate.
In the basic science section, Dr. Nilofer Farjo brings us
an interview with one of the most prominent researchers in
our ﬁeld, Dr. Valerie Randall. She is a world-renown expert
on the inﬂuence of androgens on the hair follicle. We are
very proud to have her in the list of Basic Science Contributors for the Forum, and we hope to enjoy her contributions
in future issues.
When you read this issue of the Forum, the meeting in
Montréal will be over. To those of you who presented talks,
please consider sending those studies to our journal for
publication. Remember that a written article always has
much more impact than a 5-minute presentation. With your
help, we will continue improving the quality of the Forum,
the reference journal of hair restoration surgeons.
You are all aware of the dramatic
evolution in hair restoration throughout the years. From the days of large
round grafts, to donor strips, to follicular unit transplantation and FUE,
the ISHRS has been the platform for
innovators in our ﬁeld to share their
ideas so that colleagues can adapt to
new methods and new technology.
Since its inception in 1993, the Society
has beneﬁted not only its physician
members, but, ultimately, our patients
and the industry as a whole. For those new to the ﬁeld, I encourage you to make use of your membership, learn as much
as you can, and continue to get better. For those of us who
have practiced hair restoration for many years, each transition results in dramatic improvements in our results and, if we
are not careful, we could easily be lulled into complacency,
look back and believe that the “new technique” of the time is
“as good as it gets” or “good enough.” The easy thing to do
would be to get comfortable and perform the procedure at this
“new” level and avoid change. We cannot become complacent,
however, because the remarkable thing about our ﬁeld is that
innovations continue to develop at a rapid pace. If you practice
hair restoration, you might think that you are maintaining
your skill level at a horizontal plateau. In fact, however, you
are either constantly reﬁning and improving your techniques
and you are “on the way up,” or (even if you don’t perceive
it) you are actually on the decline and will be left behind. I
encourage you to keep abreast of new developments in our
ﬁeld. Take advantage of the spirit of friendship and hospitality
that the ISHRS provides and visit different clinics. Attend the
meetings, read the Forum, and beneﬁt from the vast array of
educational offerings that our Society has to offer.
Bernard Nusbaum, MD
ISHRS Afﬁnity Program with
The ISHRS is working with Amerinet, a national group
purchasing organization, to provide ISHRS members
in the U.S. discounts on countless ofﬁce and surgical
products and services. For a membership fee of $375
per quarter per location, ISHRS members can take advantage of the complete product and service agreements
in each area.
Interested in learning more? Contact Emily Hughes,
Regional Manager, Amerinet/HRS at 206-5836516, toll-free at 800-842-6663, or e-mail Emily.
[email protected]. Or visit the ISHRS website,
Members Only section.
Paco Jimenez, MD
163
Hair Transplant Forum International
September/October 2008
Amerinet and the ISHRS: A great member beneﬁt
E. Antonio Mangubat, MD Tukwila, Washington
Last year at the business meeting in Las Vegas, I introduced a group-purchasing beneﬁt that partners the ISHRS
with Amerinet. Amerinet is a company that negotiates large
discounts on behalf of its members. I became a member of
Amerinet in late 2004 after calculating that I would reap at
least a 16% discount in all of my ofﬁce supplies. Considering that my ofﬁce supplies constitute a hefty part of my
surgery center expenses, it seemed like small risk. After
the ﬁrst partial year, I realized a 12% savings, and in the
second full year, the savings were a whopping 42%. This
certainly offsets the full price membership fees that I paid
to Amerinet and far more.
I am surprised to ﬁnd out that very few ISHRS members
have taken advantage of this beneﬁt. Not only do you get a
PRODUCT
Needles
Syringes, 3cc
Syringes, 5cc
Syringes, TB
Syringes, 10cc
Syringes, 20cc
Syringes, 60cc
Staples 35W
Envirocide 1gal.
Cidex 1gal.
Chlorexidine scrub brushes
Surgeon’s gloves
Shoe covers
Masks, tie strings
Masks, ear loop
OLD PRICING
$ 8.05
8.91
16.78
17.51
18.12
20.16
40.53
112.34
26.14
15.58
23.44
25.64
10.00
11.09
12.27
discount on Amerinet fees, the ISHRS receives a royalty for
each member from the ISHRS, and the savings on medical,
surgical, drug, and even ofﬁce supplies can be considerable.
I cannot begin to tell you how much I think you are missing
by not taking advantage of this opportunity. Below is a table
of a few of my best negotiated expenses before and after
Amerinet. These are actual numbers and actual savings. I
believe every ISHRS member deserves to keep more income;
please take another look at the ISHRS/Amerinet beneﬁt.
You’ll wonder why you waited so long.
For a membership fee of $375 per quarter per location,
ISHRS members in the United States can take advantage
of the complete product and service agreements in each
area.
AMERINET
Saved
PRODUCT
$ 4.14
5.31
9.39
11.30
9.71
10.16
17.30
67.09
14.87
10.38
14.28
14.84
6.43
8.01
7.92
-48.57%
-40.40
-44.04
-35.47
-46.41
-49.60
-57.32
-40.28
-43.11
-33.38
-39.08
-42.12
-35.70
-27.77
-35.45
Sterile gowns
Mayo cover
Table cover
3/4 sheet
Light handle covers
Lap sponges
Suction tubing
4×4’s
Lactated Ringers 1ltr.
Lactated Ringers 3ltr.
Suture, 5-0 & 6-0 FAST
Suture, 3-0 Vicryl 3/doz.
Propofol 10mg/mL 20ML
TOTAL
OLD PRICING
AMERINET
Saved
$ 77.46
46.51
52.76
50.96
29.21
51.72
49.36
41.50
25.00
40.25
141.10
200.71
289.50
$ 52.71
28.66
34.68
38.43
18.69
32.60
24.89
37.85
14.90
25.66
72.14
105.40
79.39
-31.95%
-38.38
-34.27
-24.59
-36.02
-36.97
-49.57
-8.80
-40.40
-36.25
-48.87
-47.49
-72.58
$1,462.60
$777.13
-46.87%
Interested in learning more?
Contact Emily Hughes, Regional Manager, Amerinet/HRS at 206-583-6516, toll-free at 800-842-6663, or e-mail
[email protected].
Or go to the ISHRS website at www.ishrs.org/members/amerinet.php.✧
Guidelines for Submitting an Article to the
Forum
2007–08 Chairs of Committees
2007–08 Board of Governors
 Send submission AND Author Consent Release
Form electronically via e-mail to Bernie Nusbaum,
MD, at [email protected].
2008 Annual Scientiﬁc Meeting Committee:
Arthur Tykocinski, MD
American Medical Association (AMA) Specialty & Service
Society (SSS) Representative:
Paul T. Rose, MD, JD
Audit Committee: Robert S. Haber, MD
Bylaws and Ethics Committee: Robert T. Leonard, Jr., DO
CME Committee: Paul C. Cotterill, MD
Core Curriculum Committee: Edwin S. Epstein, MD
Fellowship Training Committee: Vance W. Elliott, MD
Finance Committee: Jerry E. Cooley, MD
Hair Foundation Liaison: E. Antonio Mangubat, MD
Live Surgery Workshop Committee: Matt L. Leavitt, DO
Media Relations Committee: Robert T. Leonard, Jr., DO
Membership Committee: Marc A. Pomerantz, MD
Nominating Committee: Edwin S. Epstein, MD
Past-Presidents Committee: Paul T. Rose, MD, JD
Pro Bono Committee: David Perez-Meza MD
Scientiﬁc Research, Grants, & Awards Committee:
Marcelo Gandelman, MD
Surgical Assistants Executive Committee: Kathryn M. Lawson
Task Force on Hair Transplant CPT Codes:
Robert S. Haber, MD
Website Committee: Ivan S. Cohen, MD
Evidence Based Medicine (EBM) Task Force:
Sharon A. Keene, MD
Joint Task Force on ABHRS/ISHRS: William M. Parsley, MD
Ad Hoc Committee on Regulatory Issues:
Paul T. Rose, MD, JD
President: Bessam K. Farjo, MD*
Vice President: William M. Parsley, MD*
Secretary: Edwin S. Epstein, MD*
Treasurer: Jerry E. Cooley, MD*
Immediate Past-President: Paul C. Cotterill, MD*
Michael L. Beehner, MD
John D. N. Gillespie, MD
Jerzy R. Kolasinski, MD, PhD
Matt L. Leavitt, DO
Robert T. Leonard, Jr., DO
E. Antonio Mangubat, MD
Jennifer H. Martinick, MBBS
Bernard P. Nusbaum, MD
Damkerng Pathomvanich, MD
Carlos J. Puig, DO
Surgical Assistants Representative:
MaryAnn W. Parsley, RN
 Include all photos and ﬁgures referred to in your
article as separate attachments in JPEG or TIFF
format. Be sure to attach your ﬁles to your e-mail.
Do NOT embed your ﬁles in the e-mail itself.
 An Author Consent Release Form must
accompany your submission. The form can be
obtained in the Members Only section of the
website at www.ishrs.org.
 At the beginning of any article submitted for the
Forum’s consideration, authors must disclose any
ﬁnancial or other commercial interest they possess
in an instrument, pharmaceutical, cosmeceutical,
or similar device referenced in, or otherwise
potentially impacted by, the article.
 Trademarked names should not be used to refer to
devices or techniques, when possible.
Submission deadlines:
October 5, November/December 2008
December 5, January/February 2009
February 5, March/April 2009
164
*Executive Committee
Hair Transplant Forum International
September/October 2008
Notes from the Editor Emeritus
Michael L. Beehner, MD Saratoga Springs, New York
Thoughts on entering our
specialty
Whenever I see a newspaper ad
for Lasik eye surgeries, it seems it is
always accompanied by assurances
to the reader that the doctor has performed over 10,000 procedures; and I
always wonder: How did he or she
ever notch the ﬁrst couple hundred?
Our specialty is very similar. Entering the specialty of hair restoration
surgery and eventually becoming
successful has a number of “Catch-22’s.” How do you get
patients if you haven’t done many procedures? How can you
possibly hire (and train—the hardest part!) ﬁve assistants
when the appointment book is mostly empty? How do you
actually perform your ﬁrst few transplant procedures when
there are virtually no “hands-on,” live patient opportunities
in the clinical world as we know it now? It must seem to the
aspiring newcomer like a very high and fast merry-go-round
that’s tough to get on board and ride.
From my vantage point on the ISHRS Board of Governors
the past few years, I sense our Society is keenly aware of
the problem and is trying hard to answer this need, but it
is a difﬁcult and complicated challenge. Later on I will list
some of the ways the ISHRS is helping in this regard. In recalling my own entry into hair surgery and that of many of
you I have talked with, some common denominators come
to mind: First of all, a large percentage of us were actually
patients before we were hair surgeons. We got “religion” the
hard way and really believed! In my own case, after I had
those ﬁrst three sessions of 90 large grafts each in 1981-82,
I was thrilled beyond measure to look into the mirror each
morning and see hair framing my upper forehead. It had a
profound effect on my self-image and I felt and acted 15
years younger. Having frizzy, multi-hued brown hair helped
me camouﬂage the detectability of my transplants from that
era. I also secretly discovered that committing the big “nono” my wife forbade me to do—using a bar of Ivory soap as
my shampoo of choice—helped increase the frizziness and
fullness of my hair. So, seven years later, when I was looking for something to add to my practice and help me slow
down a little from my busy family practice life, I recalled that
I often had thought it would be neat to learn to do what was
done to me. So I sought out someone to teach me how to
perform hair surgery and in addition I sponged up everything
I could read about the procedures. I am eternally grateful
that the state of the art at the time was fairly primitive—all
neatly summed up in O’Tar Norwood and Richard Shiell’s
wonderful 324-page text, Hair Transplant Surgery. If I were
to fast forward my life 19 years and embark on the same
journey now, I would instead ﬁnd that there was a 1,000
page textbook with innumerable nuances and approaches
to learn, and that I would need 3–6 assistants day one to
help me move the typical 1,500-3,000 grafts most patients
expected. I am pretty sure I would have found the whole
thing a little daunting and may never have set forth.
Another common background feature that a great many
of us shared is that we had some surgical background, many
in dermatology, and others in Emergency Room, family practice, or one of the surgical specialties. I had a year of general
surgery residency along with my family practice residency
and always enjoyed doing procedures with my hands, so
hair restoration surgery was a natural jump for me.
Perhaps the most important starting factor for many of our
members was that they got their start by being recruited in
the course of some serendipitous encounter by either a large
national transplant group or by an individual hair surgeon for
the purpose of helping staff their busy hair surgery ofﬁces.
Many of my colleagues spent several years in such groups,
often having to travel a good deal to cover the geographic
needs of the business. For various reasons, often simply to
be able to practice with more independence and make their
own mark, they would leave the larger group and strike out
on their own. Many individual, established hair surgeons,
like myself, reach a point where they are busy and simply
want another physician to share the load of the practice so
that they can keep their staff fully employed and perhaps
slow down a little themselves. In both of these instances,
in which a newcomer either joins an existing group or solo
practice, there is an inherent self-interest in the motivation
of the party bringing on the new hair surgeon-to-be. The
ISHRS Fellowship Training Program, which was started under
the leadership of Dr. Dow Stough, and then enhanced by Dr.
Carlos Puig a few years ago and continues now under Dr.
Vance Elliott, has been active primarily with doctors who
were seeking to add someone to their practice and who
want to do it in a structured, more prestigious manner that
would enhance the quality of the educational experience. I
functioned in this capacity three years ago. It is a lot of work
and sets a hair surgeon back quite a few dollars, but is worth
it if the goal of training a future partner is realized.
One other very common background most of us share
is that we had another medical career before we switched
over to being a hair surgeon. I practiced family medicine
full-time from 1976 to 1989, and then overlapped the two
specialties for the next 4–5 years before devoting myself
full-time to hair surgery. An exception would be the several
colleagues I can think of, who had some exposure to hair
surgery during their dermatology residencies or spent a
year in fellowship training in either hair surgery or facial
plastic surgery with an emphasis on hair, and were able
to go right out and perform hair transplant surgery at the
beginning of their practice years. But this is deﬁnitely the
minority of our members today, with the cross-over docs
far outnumbering them.
For most individuals who go into hair surgery, if you really sit down and talk to them about the early beginnings
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Editor Emeritus
 from page 165
of their career, it’s like talking with someone about the day
they fell in love with their spouse. It was love at ﬁrst sight!
The creative aspect of what we do is intoxicating. In a very
visible way you have the opportunity to totally change a
person’s self image and outlook on life!
So, putting together the obstacles of needing to have
hands-on experience and then convince some patients to
walk through your door, along with the fact that most of us
make this switch mid-career while still practicing our initial
primary specialty, what is the best way for us to help these
physicians interested in becoming hair surgeons?
The Basics in Hair Restoration Surgery Course at the
ISHRS Annual Scientiﬁc Meeting, the on-line teaching with
instructional CD, and the various live surgery workshops—
especially the wonderful Orlando one each spring—go a long
ways toward introducing the newcomer. Reading the UngerShapiro text, Hair Transplantation (2004), and the similarly
named Haber-Stough text, Hair Transplantation (2006), is a
necessary start. Two new texts, edited by Drs. Marc Avram
and Danny Rousso, respectively, will soon be available
too. Joining the ISHRS, attending the annual meetings, and
reading the Forum are additional great ways to stay current
and keep your ﬁnger on the pulse of the specialty. The ﬁnal,
crucial component to this learning process is visiting as
many doctors’ ofﬁces as you possibly can, observing how
each of them organizes their ofﬁces and staff, and, of course,
how they perform the various steps of the hair transplant
procedure. It’s very hard for the host surgeon to offer much
hands-on experience in this setting because our patients
fully expect us and our trained staff to perform all the steps
of their hair surgery. While it is true that you can view an individual surgeon operating at the live surgery workshops and
on the live video screen at the annual meeting, still the best
setting to view surgery is in the physician’s own ofﬁce. The
big “line in the sand” that is hard to cross and still remains
is the daunting challenge of getting hands-on experience.
The ISHRS Fellowship route is an ideal way to go, but not
many mid-career physicians, who have family and ﬁnancial
obligations, can afford to break away for a one-year fellowship. Having a group or individual take you under their wings
and train you, whether in the formal fellowship structure
or not, is obviously a great way to learn and quickly gain
experience. The last entry method is to gradually transition
over while continuing in your primary specialty. After many
meetings, much reading, and many visits to various ofﬁces,
you hopefully will ﬁnd a small group of trusting patients
willing to let you perform your early procedures, and then
secure a hair surgeon who will let you bring your patient
into his or her ofﬁce where you perform the surgery under
their supervision. Usually the host physician charges his
usual fee for taking this time and trouble. The legal liability
issues are the murkiest aspect to this arrangement, but in a
situation in which the host physician knows of you through
meetings and the obvious evidence of your serious interest in the specialty, this is usually not an obstacle. I would
discourage anyone from recruiting relatives for this role, as
you have to live with them for the rest of your life! If you
do any work in your nearby VA Hospital, the bald patients
September/October 2008
from there are an ideal source of patients looking for an
inexpensive hair transplant.
To the best of my knowledge, no one has a really good
handle on whether the demand for hair surgery is increasing,
on a plateau, or possibly even decreasing. It’s probably safe
to assume that being in an economic recession would tend to
lessen demand. Do we need more hair surgeons? The answer
in the next few years will most certainly be “yes.” None of us
are staying the same age and some members retire each year.
The psychology of human nature would suggest that maybe it
is a better idea to do your principal training and supervisedoperating time in an ofﬁce at least a few hundred miles away
from where you intend to practice. In my own case, I went
through the yellow pages of every city west of the Mississippi to
note possible practices to visit and ended up in San Francisco.
I think we’ve matured a great deal since those earlier, more
competitive times, and most of us share the view of Dr. Tony
Mangubat, our distinguished former president, who described
hair surgery as an unlimited potential market that we’ve barely
tapped, rather than a rigid sized pie that we cut up and keep
getting smaller and smaller pieces as others enter the ﬁeld. I
always recall the story Bill Parcells told when he was asked
on the ﬁrst day of training camp with the New York Jets why
he’d want to take over one of the sorriest franchises in professional sports. “Two guys are sent to Australia to sell shoes to
the Aborigines,” he said. “One calls his boss and says ‘There’s
no opportunity here; the natives don’t wear shoes. The other
calls his boss and says ‘There are a lot of opportunities here;
these people don’t have any shoes!’”✧
State-of-the-art
instrumentation for hair
restoration surgery!
For more information, contact:
21 Cook Avenue
Madison, New Jersey 07940 USA
Phone: 800-218-9082 • 973-593-9222
Fax: 973-593-9277
E-Mail: [email protected]
www.ellisinstruments.com
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September/October 2008
Scalp laxity
 from page 161
Figure 4. Intraoperative use of laxometer
the local anesthesia and before removing the strip. More
studies are needed to compare the correlation between the
two methods of laxometery to the closure tension of the
surgical wound.
Figure 3. Measured mobility of the scalp skin (cm) over time with scalp exercise
laxity of the scalp in one of the patients who was compliant
with the exercise and follow-up visits (Figure 3).
We have started to use the laxometer routinely on almost all patients; however, we continued to seek a method
to decrease human error in measuring the laxity. Thus, we
equipped the laxometer with a spring to provide a constant
pulling force instead of the surgeon’s hand pulling the pads.
The two pads were attached to the skin with ﬁxed needles
(Figure 4) to eliminate slipping of the pads on scalp skin.
Obviously, this method should be performed after applying
Conclusion
The laxometer can determine the laxity (mobility) of the
scalp accurately with reproducible measurements. It can be
used prior to the time of surgery and during surgery, and
the device is able to apply a numerical value on scalp laxity,
augmenting the surgeon’s clinical judgment. In patients with
tight scalps in whom we recommend scalp exercise/massage, the laxometer can follow the change of laxity in the
scalp.✧
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September/October 2008
Laser-assisted hairline placement
Bertram Ng, MBBS, Damkerng Pathomvanich, MD, Kongkiat Laorwong, MD Bangkok, Thailand*
*The authors express ﬁnancial interest in the product they intend to discuss.
Introduction
Hairline placement is important. It frames the face and
has the most impact on a patient’s appearance. The reconstructed hairline bears the signature of the surgeon, giving
the ﬁrst impression of his or her work quality.
Symmetry remains the ﬁrst criteria in proper hairline
placement. Differences in symmetry from one side to the
other as well as differences in height impair facial attractiveness.1,2 The shape of the hairline is also crucial. It should
match the individual face to give the best aesthetic result.
A monotonous “universal” bell-shaped hairline misses the
artistic part of hair restoration.
Proper hairline placement can be very time consuming.
The patient only sees the hairline after it is drawn and may
not accept the design. The surgeon has to rub off the marking
and repeat the whole process. Regardless the time spent during the consultation, it is difﬁcult to record the exact hairline
design on drawings or photographs. The entire procedure
has to be repeated again on the day of the surgery.
Use of Landmarks in Hairline Placement
As not every surgeon is gifted in drawing symmetrical
curves, facial landmarks are commonly used to assist hairline placement.3,4
When drawing the frontal hairline, the glabella and lateral epicanthus are ﬁrst projected vertically to locate the
mid-frontal point (MFP) and the frontotemporal apex (Apex),
respectively. A symmetrical curve is then drawn to connect
these three points. Norwood advised resting the palm on
top of the scalp behind the proposed hairline as the center
point; drawing with a marker somewhat like a compass.5
For the temporal hairline, two pairs of landmarks are used
to trace the nasal tip–pupil line (NTP line) and the MFP–tip
of earlobe line (MFP-E line). The intersection marks the temporal point from which the superior and inferior temporal
hairlines are created.6,8
In real practice it is difﬁcult to project these 2-dimensional straight lines on paper onto a 3-dimensional surface;
the lines bend signiﬁcantly on the forehead. Flexible tape
measure helps but cannot be totally trusted to reach the exact
measurement on both sides.3 Any slight deviation results in
asymmetry. Better tools are therefore needed.
Laser Level
In 2007, Shiao reported the use of a professional-grade
laser level in designing a symmetrical frontal hairline and donor incision.7 The patient was seated in an upright position.
A laser level mounted on a tripod cast a horizontal plane of
light that “turned corners” and followed the contour of the
forehead or occipit. This provided a visual on the potential
position of hairline and donor incision. A perfectly symmetrical guideline was instantaneously created.
The result was impressive; however, there are some practical problems in using a professional-grade laser level:
1. A large room is needed to tripod the device at a certain distance from the patient.
2. The patient has to be maintained in a perfectly horizontal position.
3. The head has to be tilted in different directions and
angles to ﬁnd the desired sloping of the guideline.
4. The level cannot create a feminine hairline in a normal sitting position.
5. The patient has to wear a protective eye-shield or
glasses to prevent accidental laser exposure (see
amendment).
Stimulated by Shiao’s work, we have been working on a
portable laser device that can overcome the above limitations. The ﬁrst prototype was built in March 2008. The objective of this article is to introduce a handheld laser device that
can assist in rapid hairline placement. The device made its
ﬁrst appearance at the ISHRS Asian Workshop in Korea.
Material and Methods
The ﬁrst model consists of a class IIIA horizontal beam laser
module (3 volt, maximum power 5mW, 650nm wavelength)
wired to a battery box. The assistant holds the device directly
in front of the patient and casts a beam on the forehead. The
surgeon tilts the patient’s head in different angles to ﬁnd and
mark a curve most pleasing to the eyes. However, without the
support of a tripod, two problems arise in the use of the handheld device: unsteadiness and tilting with the laser beam.
1. Unsteadiness. The device can be easily used to locate
landmarks. To trace a line, however, is difﬁcult. It is
impossible to hold the device completely still. Slight
tremor of the assistant’s hands turns the projected
thin line into jerky wave. Adding weight to the device
and holding it in different ways are unlikely to maintain steadiness. Some kind of support other than a
tripod is needed to maintain stability. We solved the
problem by mounting the laser on one end of a 15 cm
supporting frame (Figures 1 and 2). The other end
of the frame rests ﬁrmly on the patient’s forehead.
By changing its position along the midline and angle
of beam projection, different hairline shapes can be
visualized. This new design also makes it necessary
to maintain the patient in a rigid sitting position.
2. Tilting. When the laser beam is cast to join the
glabella and the nasal tip, more than one possible
centerline can be seen when the device is moved
sideways. While 2 points can deﬁne a straight line in
a 2-D plane; 3 points are required to deﬁne a unique
projection in a 3-D setting. For this reason, we added
the philtrum as the third point. Also, we replaced the
single-beam module to a cross-beam laser. By aligning its vertical beam with the three mentioned points,
a non-tilted horizontal hairline can be ensured.
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Laser-assisted hairline design
 from page 169
Placing a Feminine Frontal Hairline
The term “feminine” is used instead of “female” as this
pattern can sometimes be desired by men. The feminine
frontal hairline is characterized by an inverted U as opposed
to the horizontal or upward U
in the male pattern. The patient
is seated in front of a mirror
and asked to mark the lowest
point of the desired hairline as
point A (Figure 1). Its position is
adjusted according to the age,
budget, preference, and available donor hair. The centerline
is then checked by aligning the Figure 1. The patient sits in front
of a mirror.
vertical beam with the glabella,
nasal tip, and philtrum. The intersection of the centerline
and point A marks the MFP. The device is then positioned
on the frontal region behind the MFP to cast a downward
beam. Different shapes of hairline can be created by 4 simultaneous steps (Figure 2):
1. Moving the device along the centerline;
2. Tilting the device forward or backward;
3. Keeping the center of the crossed beam on the
MFP;
4. Joining the lateral extension of the beam with
the anterior border of
the sideburns.
As the device is positioned
above eye-level, the patient can
actually look into the mirror to
choose amongst the different
Figure 2. A feminine hairline in the
visualized curvatures (Figure 3). shape of an inverted U is deﬁned.
The selected hairline is traced
after it is inspected from different angles to ensure symmetry.
For those requesting a round mound in the center, the device
can be repositioned on the forehead to trace a second line
(Figure 4).
The patient re-examines the completed drawing.
The shape of the hairline
is changed accordingly to
suit the overall appearance.
Finally, in order to create a
natural looking irregular hairline, “macro-irregularities,”
“micro-irregularities,”3 or “V”
Figure 3. The patient provides immediate
entrances6 are added.
feedback about the hairline.
September/October 2008
Placing a Male Frontal Hairline
The centerline and MFP are ﬁrst located in the same
manner. The device is then positioned on the forehead below the MFP to cast a horizontal or upward beam. Different
shapes of hairline can be created by three simultaneous
steps (Figure 5):
1. Moving the device along the centerline;
2. Tilting the device forward or backward;
3. Keeping the center of the crossed beam on the
MFP.
The selected hairline is
inspected from the front
to ensure symmetry, and
from the sides to confirm
that the lateral portions do
not fall below horizontal.3
Figure 5. A male frontal hairline
The frontal hairline and the
is deﬁned.
temporoparietal fringes can
then be related in two different ways:
1. Connected with or without ﬂare, or
2. Remain unconnected as a frontal forelock.
On completion, symmetry of the apices is best checked
by inspecting from behind the patient. Once again the laser
can be used in a similar fashion (Figure 6 ).
Temporal
Existing vellous hair can guide to locate the temporal
points.7 For Mayer Class P
and R, and those demanding a low frontal hairline,
temporal hairline reconstruction is required. The
laser device can be used
either from a distance or
positioned on the patient
face. With the eyes closed, Figure 6. The symmetry of the apexes is
checked from behind the patient.
the NTP line and the MFP-E
line are marked (Figure 7). Intersection of these two lines
locates the temporal point (TP). The laser is then positioned
along the centerline to conﬁrm that both TPs lie along its
horizontal beam. They should also be equidistant from the
centerline. The superior temporal hairline is deﬁned by
drawing an up-sloping line from the TP and parallel to the
nasal bridge. The inferior temporal hairline is deﬁned by a
down-sloping line parallel to the lateral eyebrow.6
Eyebrows and Moustache
The device is ﬁrst positioned along the centerline to
cast a horizontal beam. Onto the supraorbital ridges, the
A
B
Figure 7. A: The NTP line is deﬁned.
B: The MFP-E line is deﬁned.
Figure 4. A compound hairline is deﬁned.
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eyebrows uppermost points
are checked. As the shape
of an eyebrow is an inverted
“U,” the device should be positioned to cast a downward
beam: the symmetrical lateral
extensions trace the outer
curvatures of the eyebrows
(Figure 8). The moustache
can be created in a similar
way.
September/October 2008
accepts the design before the line is traced.
6. Reproducible hairline design. Three points identify
one line in a 3-D setting. On recording three selected
measurements (e.g., glabella to MFP, lateral canthus
to apex), the original hairline can be retraced on
subsequent visits.
7. Individual design. Traditionally, there is no rule how
to shape the hairline. The surgeon simply draws
an arbitrary curve according to his or her artistic
imagination. On the other hand, the laser device
describes a hairline predetermined by the individual
facial contour. Every point along the hairline carries
the same transit angle where the sagittal plane of
the skull changes from horizontal to vertical. This is
unique in each individual.
8. Laser. Patients are impressed just by hearing the word
“laser.”
Figure 8. The eyebrows are deﬁned.
Donor Site
Some patients demand revision of donor scars. They prefer to show a symmetrical wound when wearing very short
hair. Scar revision, however, is difﬁcult. Attempt should be
made in marking a symmetrical strip in the ﬁrst place. This
can easily be achieved by using the laser device.
The limitations of the laser device are as follows:
1. The laser beam loses sight amongst hair, thus, it is
unable to outline a hairline on areas with plenty of
existing hair.
2. Not all our tested laser modules can produce an
accurate 90-degree cross-beam. Even a slight deviation can affect the overall symmetry of the described
hairline. The beam calibration of each module should
therefore be checked before use.
3. Aligning the vertical beam with the centerline is
a good idea to outline a symmetrical hairline, as
long as the facial contour is symmetrical. In some
patients, the hairline placed using the normal
protocol just looks out of place. The most likely
explanation is an asymmetrical forehead. Under
this circumstance, the vertical beam should best
be ignored, or a single horizontal beam module is
used instead.
Other Applications of the Laser Device
The laser can assist in the classiﬁcation of male pattern
baldness. For example, in Norwood Type II, early recession
in both temporal regions should be at least 2cm anterior to
a vertical coronal plane drawn through each external auditory canal. This 2cm vertical line can be visualized with the
laser for a more accurate diagnosis.
The device can also be used in other medical and cosmetic ﬁelds when symmetrical bodily parts reconstruction is
required, such as eyebrow tattooing, nipple reconstruction,
and forehead lift.
Discussion
Laser-assisted hairline placement is simple and timesaving in creating symmetrical hairlines. However, this is
just a tool. No device can replace the human perception
of beauty. At times, an asymmetrical hairline can be more
natural looking. The surgeon’s artistic judgment is still
the most crucial in the design and placement of hairlines.
Since the ﬁrst prototype was developed in March 2008, the
device is used in our daily practice on all patients. We are
happy with the results and have become dependent on it.
Modiﬁcation and reﬁnement have continuously been made,
both in the device and the technique.
The advantages of using the laser device are as follows:
1. Portable. The device can be carried in a briefcase for
use in our clinic, hospital, and operating theatre.
2. Simple to operate. It can be operated by just one
person and no training is required. The device can
be used regardless of the position of the patient.
3. Affordable. The basic components are simple and the
device can be reused hundreds of times. The running
cost is just the replacement of batteries.
4. Less danger of direct exposure to laser. The device is
operated above or below eye level. The patient can
open his or her eyes throughout the procedure and
provide immediate feedback.
5. Time saving. We usually mark a symmetrical hairline in less than a minute. Time is further saved by
reducing “draw and rub”; the patient visualizes and
A More Artistic Level of Hair Transplantation
Hair transplantation is also called Hair Restoration Surgery, with the objective to restore the patient’s previous look
before loss of hair. With the recent advance in follicular unit
transplantation, we should be able to upgrade our work
from restoration to enhancement. The patient can be more
attractive than he or she ever was.
The perception of beauty follows certain patterns, depending on how the different parts (eyes, nose, hairline,
lips) are proportionally positioned on the face. Da Vinci
introduced the Golden Rule of Three. Greco has an excellent article in the use of “phi” and the “Golden Rectangle” to
deﬁne the focal points. Art and mathematical principles can
become part of facial framing and hair restoration design.10
Pictures of celebrities can also be studied to search for the
“pattern of beauty.” The laser device can deﬁne landmarks
instantly and facilitate the transfer of the complicated 2-D
design onto the face.
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September/October 2008
Laser-assisted hairline design
 from page 171
AMENDMENT: Safety Precautions in Using a Class 3A Laser Pointer11
Lasers are classiﬁed into four main classes—1, 2, 3A & 3B, 4—to identify the associated risk. Class 3A has a
power output less than 5mW and can damage the eye in a time less than the blink reﬂex. Exposure of a person’s
eyes to a momentary sweep of the laser beam can result in temporary ﬂash blindness, afterimage, and glare,
which can be particularly dangerous if the individual is engaged in a vision-critical activity. There are documented
cases of retinal damage following multi-second exposures.
Safety precautions must be taken in its use:
1. Only purchase pointers where the output power, laser hazard classiﬁcation, and a warning about potential
eye hazard are shown on a label or included in the instructions for use.
2. Never look directly into the laser beam.
3. Never aim the pointer at people or at reﬂective surfaces such as a mirror. The assistant should not stand
behind the patient in case of accidental exposure.
4. Wear a protective eyeshield or glasses if the patient cannot be trusted to close his or her eyes when facing
a laser beam.
References
1. Rose, P. Hairline design. Hair Transplant Forum International September/October 2002; 12(5).
2. Springer, I.N., et al. Facial attractiveness. Visual impact
of symmetry increases signiﬁcantly towards the midline.
Annals of Plast Surg August 2007; 59(2):156-161.
3. Rose, P., and W. Parsley. Science of Hairline Design. In
R. Haber and D. Stough, editors. Hair Transplantation
2006. Elsevier Saunders; 55-71.
4. Simmons, C. Five old lines and three new lines that can
help when designing a male temporal hairline or when
transplanting the frontotemporal apex. Hair Transplant
Forum International November/December 2004; 14(6).
5. Norwood, O.T., and B.J. Taylor. Hairline design and placement. J Dermatology Surg Oncol June 1991; 17(6):510-8.
6. Mayer, M., and D. Perez-Meza. Temporal points: Classiﬁcation and surgical techniques for aesthetic results.
ESHRS Journal 2003; 3(2):6-7.
7. Shiao, T.K., and I.S. Shiao. Laser-guided hairline design
and donor strip marking. Hair Transplant Forum International March/April 2007; 17(2):53-54.
8. Basto, F.T. Irregular and sinuous anterior hairline: Prior
technique reﬁnement and male and female trace parameters. Hair Transplant Forum International January/February 2005; 15(1):15.
9. Brandy, D.A. A method for evaluating and treating the
temporal peak region in patients with male pattern
baldness. Dermatol Surg May 2002; 28(5):394-400.
10. Greco, J. Facial framing: “It’s not all about the hair, it’s
about the eyes”! Utilizing art and mathematic principles in facial framing and hair restoration design. Hair
Transplant Forum International January/February 2005;
15(1):11.
11. Statement on the use of laser pointers source of information: University of Toronto, Environmental Health and
Safety. http://www.ehs.utoronto.ca/services/laserpg/
laserptr.htm.✧
Editors’ note: The authors of this article noted that
this laser device is not yet commercially available.
They have designed a few models, tried over the past
6 months, and now have a design ready for production. It will be sold over the Internet by mail order in
the near future. Further information can be found at
www.hairtransinter.com.
Bertram M. Ng, MBBS, is currently
a trainee in the ISHRS Accredited
Fellowship Training Program under
director Dr. Damkerng Pathomvanich. He was initially practicing
hair transplantation in Hong Kong
using exclusively FUE and the implanter-insertion technique. His
main interest is eyebrow transplant in females. Dr. Ng
was born in Hong Kong and received his MBBS from the
University of New South Wales—Australia, holding also
a Master’s Degree in Pain Medicine and Fellowship in
Family Medicine.
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Aid to hairline design (AHD)
John Cole, MD Atlanta, Georgia
*The author expresses a ﬁnancial interest in the device discussed.
The principal factors to consider when designing the
hairline that frames the face or forehead are the mid-frontal
height of the hairline, the width of the frontal hairline between the recession points, the irregularity of the hairline,
the temple point location, the temple angle, the hairline
symmetry, and the hair growth direction.
Hairline location is often described at a single point, a
certain number of centimeters above the glabella, at the
mid-sagittal line (e.g., “the patient desires a 6cm hairline”).
Although this is the simplest point to initially create, as one
focuses more laterally, hairline location generally becomes
more subjective and less readily reproducible. In my experience, most physicians, including the author, pride themselves
on their ability to create a symmetrical hairline from eyesight
alone. The question, as with all subjective evaluations, remains the degree of accuracy (and aesthetic potential).
A builder would never begin construction without using a
level and providing for accurate measurement. Why should
physicians construct hairlines without tools to assist them
in producing and maintaining accuracy?
Dr. Paul Rose taught me a simple trick using a ﬂexible
ruler. He made several level, equidistant points, at and
lateral from the glabella. He then measured up from each
of these to deﬁne symmetrical points on or near each side
of the frontal edge of the hairline. The problem with this
method was time consumption and reproducible accuracy.
It is dependent on:
1. Creating a true horizontal line lateral from the glabella;
2. Creating another horizontal line somewhere between
the hairline and the glabella, since two points are
required to create a straight and level line to measure
symmetrical vertical distances above line #1.
The Aid to Hairline Design
To assist in creating a symmetrical hairline quickly,
we developed a template called the “Aid to Hairline Design” (AHD) (Figure 1). This is a simple, straightforward
method of drawing the hairline, and is also a tool that can
be used to assist in the design of the temple and areas of
the recession.
The AHD template is made up of a clear plastic ﬁlm capable of bending to partially conform to the facial curvature.
The transparency of the ﬁlm allows one to see and review the
designed hairline. It has horizontal and vertical scales spaced
appropriately, to measure and mark points. The template,
at its mid-section, has a feature extending downward that
may be aligned with the vertical nasal axis to secure the
horizontal symmetry. The template is then placed with the
horizontal reference line set along the glabella on a level line.
Numerous additional equidistant lines inferior to this allow
the physician to ensure that the above-mentioned baseline
is truly horizontal.
One may orient
these inferior lines
so that they are
symmetrical with
respect to their
location at the
outer canthus or
numerous other
landmarks such
Figure 2. AHD Positioning with respect to
as the pupil, the
facial features.
medial canthus, or
the orbital margins above or below as shown in Figure 2.
Once the alignment is done, the template is secured in
position around the head.
We created two versions: one is disposable and utilizes
double-sided tape in the frontal area, and the other is reusable featuring an elastic band and a Velcro locking system
that extends around the head. The disposable version is best
used if the patient has already had any donor harvesting
done, as that would potentially contaminate the elastic band
of the reusable version.
Once the AHD is secured properly with respect to the
facial landmarks, the hairline mid-frontal point is marked on
the central scale. Additional symmetrical points are marked
on the lateral sides (Figure 3, A and B).
B
A
Figure 3. A: Hairline marking with AHD. B: Hairline marked with AHD.
The head position or orientation of the patient does not
affect the hairline design because the AHD is secured with
respect to the facial features as shown in Figure 2. This is
deﬁnitely an advantage over non-contact techniques, such
as laser projection, which prohibit any motion of the patient
until the hairline design is ﬁnalized.
Figure 1. Design of the AHD.
 page 174
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Aid to hairline design
 from page 173
AHD helps also to reproduce or copy the temple point
and recession point from one side to the other. Determine
the point on one side using any of the available methods
or by visual inspection. Identify the horizontal and vertical
coordinates x and y, respectively, to the template point, T.
The horizontal, or x, coordinate is measured from the center
of the nose at the glabella and may be a certain distance
from the lateral canthus or the lateral orbital bone. The
vertical, or y, coordinate is measured from the reference
line through the glabella upwards to the temple point. The
respective coordinate points are reproduced on the other
side as shown in Figure 4.
The frontotemporal recession point (R)
may be the virtual intersection point of the
frontal hairline and
the inclined temporal
line. The temple angle
(θ), shown in Figure
5, may be between
55º and 75º from the Figure 4. Copying/reproducing points from one
side to the other.
horizontal plane. The
vertical and horizontal projections of the temporal line may
be given by TRsin θ and TRcos θ, respectively. The same
principle used to reproduce the temple point to a symmetric
September/October 2008
position may be applied to reproduce the
horizontal and vertical coordinates x and
y, respectively, of the
recession point.
Conclusion
In summary, it is of
great value to produce
a useful, reproducible Figure 5. Representation of coordinate points
hairline template during the surgical construction of what is probably the single
most important feature of a hair transplant. The AHD may
actually be placed on the patient, so that the individual,
anatomical variations of the facial, skull, and scalp structures are honored and taken into account during the creation
of the hairline. This is offered as a superior alternative to
the less objective and less reproducible technique of visual
inspection and freehand drawing. The AHD method saves
signiﬁcant time and consistently produces a natural, aesthetically pleasing and symmetric result.✧
Editors’ note: For those interested in this device, the
cost is US$48.00 for 12 disposable units and US$48.00
for 6 reusable units. The contact information is www.
device4hair.com.
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Intra-operative monitoring of the follicular transection
rate in follicular unit extraction
Kazuhito Yamamoto, MD Osaka, Japan
It is well known that follicular transection is the most
common problem encountered with the follicular unit
extraction (FUE) technique. In order to maintain the reliability of FUE, it is indispensable to remain within a
permissible level of follicle transection rate (FTR), at least
comparable to the standard technique of strip harvesting
and microscopic dissection, which has a transection rate
of approximately 2%.
When performing FUE for scalp hair, it is difﬁcult to
determine the transection rate of 2- or 3-hair follicular
units (FUs) as opposed to body hair transplantation (BHT)
in which almost all FUs are composed of only 1 hair. For
instance, if we extract a 2-hair FU and it actually contains
an intact 1-hair follicle plus a transected 1-hair follicle, the
transection rate is already 50%, causing a low survival rate
and the miniaturization of the transected follicles. Therefore, if we become aware of a difﬁcult case during FUE, we
should be able to measure the transection rate in a timely
manner so that we could change to more effective devices
and techniques intra-operatively.
We have managed to evaluate the FTR intraoperatively
by measuring the completely transected graft rate (CTGR),
which is deﬁned as the rate of grafts containing only follicle
transection divided by the total number of grafts extracted.
CTGR is very easy to calculate as we simply need to count
the number of grafts in which all the follicles are transected
(Figure 1).
Figure 2. Correlation between CTGR and FTR
Relationship between Surgical FUE
Technique and Transection Rates
We differentiated three techniques for FUE as following:
1. Manual one-step technique. This technique is performed by scoring and dissecting the FU simultaneously using a sharp punch.
2. Manual two-step technique. This technique uses two
types of punches to perform scoring and dissecting
separately. We use a serrated punch with or without
suction to dissect the grafts (Figure 3).
3. Modiﬁed mechanical technique. Although we use a
mechanical removal punch, this technique is carried
out while paying adequate attention to the depth
control and hair exit angle and orientation in three
dimensions compared to the simple, mechanical
one-step technique.
Figure 3. Device with the serrated punch and suction for two-step technique;
the serrated punch (left) and our device (right).
Figure 1. CTGR measurement
We examined the correlation between FTR and CTGR in
24 consecutive cases (36-536 grafts/session, average, 330
grafts), and investigated CTGR in 100 cases (34-536/sessions, average, 310 grafts), observing a linear correlation
between CTGR and FTR. We found that 10%, 30%, and
50% CTGRs indicated more than 30%, 50%, and 70%
FTRs, respectively (Figure 2). Therefore, in order to achieve
a permissible level of FTR of 30% or less, the CTGR measured should be less than 10%. However, it is necessary to
keep the FTR around 10%, which is 0% CTGR, in order to
obtain results equivalent to those obtained by conventional
strip harvesting.
This study used the rotating removal tool with suction,
which is part of the Automatic Restoration System® (OMNIGRAFTTM), our own novel device. The removal punch
consisted of a cilyndrical punch of 1.0 to 1.25mm in internal
diameter, which is suitable for the size of the average FU
in Asians (Japanese). This technique involved a simple mechanical FUE, which extracted grafts at non-selective and
densely regular intervals, considering extraction speed as
the most important issue.
Using the simple one-step mechanical FUE technique in
100 Japanese patients, we found that one-fourth of the cases
had a CTGR between 0 and 10% (classiﬁed as easy type),
half of the cases had between 10%-30% (difﬁcult type),
and about one-fourth had more than 30% CTGR (dangerous type) (Figure 4). These results indicate that easy cases
 page 176
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Intraoperative monitoring of FTR
 from page 175
for FUE comprise onefourth of the total, so
we realized that we
had to use alternative
devices or techniques
for the remaining 75%
of cases in which it was
difﬁcult to extract the
grafts.
In Figure 5, we
demonstrate the different techniques in
the same patient. First,
we evaluated the level
of difﬁculty using the
manual one-step technique (test extraction).
CTGR was 25.8% and
this patient was considered to be a difﬁcult
type. It is important
to record not only the
patient’s type but also
Figure 5. Manual FUE technique (left) and mechanical FUE technique (right).
the characteristics of the skin. Next, we performed the
manual two-step technique followed by the modiﬁed mechanical FUE technique. For both techniques, the CTGR
was 0%. The FTRs for the manual one-step, two-step, and
modiﬁed mechanical FUE technique was 45.5%, 9.5%, and
13.6%, respectively.
In conclusion, the estimation of the CTGR facilitates the
determination of FTR intraoperatively. We should choose
the ideal FUE technique based on individual patient characteristics and differences in donor sites in order to keep the
FTR below 10%, using a 0% CTGR as a guideline. The FTR
for the manual one-step technique is, in our hands, higher
than for the other techniques. Based on this fact, we should
not choose this method except in easy cases, even though
it has the advantage of saving time.✧
Figure 4. CTGR in 100 cases. Based on the degree
of difﬁculty, patients were divided into three types:
easy, difﬁcult, and dangerous.
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176
Hair Transplant Forum International
September/October 2008
Hair Sciences
Nilofer Farjo, MD Manchester, England
This issue’s guest contribution is by Professor Valerie
Randal, one of the world’s leading researchers in hair biology. She has a particular interest in hormone regulation in
skin and hair so she was asked to discuss androgen action
in the hair follicle. We have asked Professor Randall to stick
to basics so apologies to those of you who feel the topic is
over simpliﬁed. What it does serve to point out is that we
have a long way to go in our understanding of the complex
mechanisms in hair follicle growth.
We have changed the layout for this
edition to a question and answer style
to give a more easily readable format. For future editions,
if anyone has questions that they would like to ask any of
our research panel please email me and we will publish
their answers.
An interview with Professor Valerie Randall
1. What is your academic background and how did you ﬁrst
get involved in hair research?
My ﬁrst degree is a B.Sc. in Zoology from the University
of Shefﬁeld, England. I was fortunate to be taught by Professor John Ebling, a renowned endocrinologist focusing on the
skin, the coauthor of the Rook’s Textbook of Dermatology.
During his exciting course on Biology of Skin, I became fascinated by the hair follicle’s regenerating capacity and the
dermal papilla’s ability to induce a whisker to grow out of a
rat’s ear! I stayed in Shefﬁeld to do my PhD with John Ebling
on hormonal regulation of the sebaceous glands and postdoctoral research on the use of antiandrogens in hirsutism
and seasonal variation in human hair growth. As soon as I
had my own academic position, I started to focus on how
androgens affect human follicles.
2. In the last decade, the hair follicle has attracted the attention of many researchers from different areas. What makes
this miniorgan so interesting to basic researchers?
Zoologists have appreciated the hair follicle for a long
time because of its essential roles for mammalian survival in
maintaining body temperature and camouﬂage. Recently, cell
biologists have realized its fantastic regenerating powers, the
complex interactions between epithelial, mesenchymal- and
neural crest-derived cells, and the presence of stem cells for
the various cell types. The follicle also has the exceptional
advantage of being on the body surface, allowing it to be
manipulated/observed in a living mammal. In the future, this
may allow its use as a non-invasive source of stem cells that
could be manipulated to replace diseased cells or organs,
which would not be rejected if put back into the same person.
Pharmaceutical scientists have also become interested since
drugs such as minoxidil stimulated some hair regrowth in
balding for the ﬁrst time. For endocrinologists, the follicle
offers a unique paradox: it is the only organ that responds
differently to the same hormone, androgen, depending on its
body site. Androgens stimulate many areas like the beard,
have no effect on the eyelashes, and can inhibit follicles on
the scalp, causing balding.
Figure 1. Model of androgen action
Figure 2. Testosterone and dihydrotestosterone acting with
the same receptor
3. As an expert on the inﬂuences of hormones in the hair
follicle, what is the basis for the paradoxical effects of
androgens on hair follicles of different body sites?
Because follicles respond differently despite receiving the
same level and types of androgens, the variations must be
due to their differing capacity to respond to the same signal.
This is, of course, the basis for hair transplant surgery as the
transplanted follicle responds on the frontal scalp as it did
at the base of the neck. The transplanted follicles ability to
produce terminal hair, while any existing follicles continue
to miniaturize around them, conﬁrms the response is within
the hair follicle itself and does not involve factors from the
surrounding skin.
4. How do androgens act on the hair and what is the role
of the androgen receptors?
Androgens act on the follicle via intracellular androgen
177
 page 52
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September/October 2008
Interview with Prof. Valerie Randall
used to treat eye conditions, or the identiﬁcation of stimulatory
paracrine factors that could be applied topically.
receptors; if individuals have deﬁcient androgen receptors,
they retain children’s hair patterns. Androgens enter every
cell, but only those with receptors can respond. Once the
receptor binds the hormone it changes shape, enabling it
to bind to hormone response elements of the DNA, triggering the synthesis of speciﬁc mRNA and proteins. Several
androgens can bind the receptor, particularly testosterone
and its more potent metabolite, 5α-dihydrotestosterone.
Whether or not testosterone is metabolized intracellularly
to 5α-dihydrotestosterone by the enzyme 5α-reductase
depends on the type of follicle. Male distinguishing hair
follicles, like the beard, and also balding scalp follicles form
5α-dihydrotestosterone, while androgen-dependent follicles,
like the axilla in both sexes, don’t. This dual route is not fully
understood, but testosterone also acts in muscle and testis,
and 5α-dihydrotestosterone in the prostate.
The current model for androgen action involves testosterone or 5α-dihydrotestosterone binding to receptors in the
dermal papilla, altering the production of paracrine factors
that inﬂuence the activity of other follicular cells like keratinocytes and melanocytes. Some factors already identiﬁed
stimulate keratinocyte growth (e.g., IGF-1) or melanocytes
(stem cell factor), while others inhibit (TGF-β).
7. We are very grateful for your collaboration as part of the
Basic Science Contributors of this Forum journal. The collaboration between hair transplant surgeons and hair researchers is important for the future of our specialty. Are
there speciﬁc actions that you would advise to strengthen
these bonds?
An important way to strengthen the relationship between
hair transplant surgeons and researchers is for surgeons to
facilitate access to hair follicle samples. The best way for
this is when the scientist and the surgeon collaborate in a
project of mutual interest like my group is doing with Nilofer
and Bessam Farjo working on the possible mechanism of
action of minoxidil in the hair follicle, but simple donations
of skin tissue are also very useful. I am particularly keen to
obtain androgen-affected samples.
I also think that your Basic Science Contributors concept
for the Forum is an excellent way to enhance this link; the
editorial team should be congratulated on this!
 from page 177
5. How can we block androgen effects?
Androgen effects on hair follicles can currently be blocked
in two ways. Firstly, by antiandrogens, like cyproterone
acetate or spirolactone, which compete with the hormone
for the receptor. Unfortunately, antiandrogens block all androgen responses, including libido, making them unsuitable
for men, unless they could be introduced topically. Fortunately, the second approach, inhibiting the metabolism of
testosterone, gives more selective blocking of male-speciﬁc
follicles and fewer side-effects. Finasteride, a 5α-reductase
type 2 inhibitor, is used successfully for balding in men. In
women, both types of blockers must be given with oestrogen in women of child-bearing age to ensure prevention of
feminization of a male fetus.
In the future when we understand more about how the
follicle works, it may also be possible to block androgen
effects more selectively by inhibiting the proteins that they
alter to carry out their effects.
8. Which are currently your main research projects?
My current projects fall into three main areas: 1) androgen action in hair follicles; 2) understanding the role of
ATP-sensitive potassium channels in hair follicles (these are
what minoxidil acts on); and 3) hormonal regulation of hair
pigmentation. All of these have potential beneﬁts for future
development of therapeutics for hair conditions that cause
psychological distress, balding, hirsutism, and hair greying.
If anyone is interested in reading further about how androgens affect hair follicles, Professor Randall has recently
published a major review:
Randall, V.A. (2007) Hormonal regulation of hair follicles
exhibits a biological paradox. Seminars in Cell & Developmental
Biology 18:274-285.✧
Valerie Anne Randall (Val Randall)
is currently Professor of Biomedical
Sciences at the University of Bradford, UK. She leads a research team
investigating the biology of human
hair follicles, particularly androgen action, and is also involved in
undergraduate and post-graduate
teaching. She carried out her PhD
with Professor John Ebling at the University of Shefﬁeld,
UK. Professor Randall is currently on the Council of
the Institute of Biology and formerly was the Secretary
and President of the European Hair Research Society,
Editorial Board member for the Journal of Endocrinology, Editor of The Endocrinologist, Council Member
for the Society for Endocrinology and for the Heads of
University Centres of Biomedical Sciences.
6. Besides ﬁnasteride and minoxidil, are there other products under investigation that could show efﬁcacy in the
treatment of AGA?
Dutasteride has recently been shown to stimulate hair regrowth possibly more effectively than ﬁnasteride. Dutasteride
inhibits both 5α-reductase types 1 and 2, being a more potent
5α-reductase type 2 inhibitor than ﬁnasteride. Less clearly
established exciting alternatives include the isolation and
culture of dermal papilla cells to reimplant into balding scalp
to induce new follicles to develop. One problem with this or
implanting other parts of the follicle would be ensuring that
the new follicles developed at a cosmetically beneﬁcial angle.
Other possible approaches in the future could include a prostaglandin F2α analogue, which stimulates eyelash growth when
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Removal of undesired grafts 5 days after a hair transplant:
How to do it
Bertram Ng, MBBS, Damkerng Pathomvanich, MD, Kongkiat Laorwong, MD Bangkok, Thailand
Many articles describe different ways of preventing
post-surgical graft dislodgement. This paper addresses the
opposite scenario: how to dislodge unwanted grafts postoperatively, leaving them intact for reimplantation.
Hairline design is an important aspect of hair restoration
surgery. The surgeon identiﬁes minimum and maximum
safe limits of hairline placement and the patient chooses
the design within those limits.1 A mutually agreed-on plan
must be arrived at before surgery.
On occasion, soon after a procedure, the patient may
change his or her liking of the new hairline after being
bombarded by comments from friends and family, leaving
the following questions to be answered:
What are the surgeon’s options?
Should the undesired grafts be removed?
When and how should they be removed?
We would like to share our experience on these issues and
present a case report to study the different ways of removing
undesired grafts 5 days after a hair transplant.
Case Description
A 27-year-old Asian female was disturbed by her “big
face,” and requested to lower her frontotemporal hairline
to make her face appear “smaller.” She was pleased with
the new hairline design before signing the pre-operative
consent.
In one session, 2,898 grafts (4,665 hairs) were transplanted. A 22G needle was used to create 300 lateral slits
for the one-hair FUs, while a 20G was used to make 950
slits for the two-hair FUs. Needles of the same gauge were
used to stick-and-place the remaining grafts for dense
packing.
Two days later, the patient returned in distress. She was
told by friends that the new hairline did not match her face.
On day 5, she insisted on removing the ﬁrst centimeter of the
transplanted hairline. We complied
and the procedure was carried out
the same day.
Materials and Methods
The patient lied supine with
eyes covered. The area was marked
(Figure 1A) and anesthetized with
8cc of 1% xylocaine with adrenaline. A nurse skilled in forceps graft
insertion and a doctor trained in
FUE were assigned to extract the
follicles side by side. Jeweler’s
forceps, straight and curved, were Figure 1A. Before graft removal
used under 2× loupe magniﬁcation. Different techniques were attempted and compared.
All removed grafts were examined and counted.
Results
Crusts were seen embracing the grafts in the recipient
site. There was no inﬂammation or swelling. Gentle ﬁnger
rubbing freed the crusts from the skin but did not dislodge
any implanted grafts. Jeweler’s forceps were required for
graft removal.
Four techniques were tried in sequence:
1. The tip of the hair shaft was simply grasped and
pulled. This method was abandoned after a few trials
as most hairs removed were without bulbs.
2. The graft was grasped by the crust just above the
skin surface. On pulling, the crust came off together
with the hair. The result was slightly better but over
half still had no bulbs.
3. Our usual FUE grasping technique (without using
a punch) was tried using two pairs of forceps. The
curved forceps pressed on the skin around the graft;
the straight one was waiting to grasp the popped up
follicle. Nothing popped out. Not a single graft was
removed by this method.
4. The crust behaved like a sheath. It could be moved
up and down along the hair shaft but was difﬁcult to
shatter. The tips of the forceps were therefore inserted
under the crust to separate it from the skin and lift
it up along the hair. The forceps then pressed and
dimpled the skin, grasped the upper infundibulum,
and gently pulled out the graft. Almost all the pulledout grafts had intact follicles. This 4-step approach
was subsequently used to remove all remaining grafts
(Figure 2).
Post-extraction bleeding was minimal and controlled
by direct pressure. A total of 286 intact grafts were removed, including 258 one-hair and 28 two-hair follicular
units. They were reimplanted more posteriorly into the
anesthetized frontal and temporal regions to add density
(Figure 1B). The 28 hairs removed mainly by method 1 or
2 had no dermal papilla and
were discarded.
No dressing was applied.
The patient was asked to follow
the usual postoperative protocol
(Table 1). Regular visits have
been arranged to assess any
change of skin pigmentation
after extraction.
Discussion
Drs. David Perez-Meza, Matt
Figure 1B. After graft removal
Leavitt, and Melvin Mayer reported that the coordinated process of acute tissue healing
starts right after making slits in the recipient area. They
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September/October 2008
Table 1. Our Postoperative Protocol (Recipient Site)
Shampooing (using baby shampoo)
Head Band
Day 1: By our staff
Days 2 to 5: By patient, using gentle stream of room-temperature water. Shampoo is lathered up on the palms and patted
onto the area without rubbing.
After 5 days the grafts can be gently rubbed to remove crust
during washing.
To be worn continuously from
discharge to day 3 (except when
shampooing), or longer if there is
sign of forehead swelling.
Dressing
Usually no, except when popping and
oozing are expected, or when the temporal areas are transplanted (to avoid
rubbing by the head band).
Post-surgical shampooing is important in removing crusts.3 Most clinics
start washing the area the next day. Diverse opinions exist whether the grafts
should be rubbed while shampooing.
Some regard this as one of the main
causes of dislodged grafts,5 and note
that it should be avoided for the ﬁrst 10
days.4 Dr. Alex Ginzburg recommended
massaging the recipient area with olive
oil as early as day 4.6
Gentle rubbing after day 5 to prevent the build-up of crusts has been
part of our protocol for years (Table 1).
Its minimal risk for dislodging transplanted grafts has been conﬁrmed by
this study.
Conclusion
Figure 2. Illustration of the 4-step process
documented the following histological features on day 5
after surgery:2
1. Subsiding tissue edema
2. Overlapped inﬂammatory and proliferative phases
characterized by clot formation; deposition of ﬁbrin;
and inﬂux of ﬁbroblasts, epithelial cells as well as
inﬂammatory cells to the areas
3. Early revascularization
4. An increasing level of multiple cytokine growth factors (GF), such as platelet-derived GF, transforming
alpha GF, transforming beta GF, epidermal GF, and
vascular endothelial GF; as well as Factor VIII, Collagen III and IV, and CD 31
Even though our observation was based on a single
report, the number of grafts removed (314 grafts) was signiﬁcant. By day 5 graft-tissue adherence from the acute
wound resisted dislodgment. Grafts did not pop out by gentle
rubbing or forceps compression. Even simple grasp-and-pull
removed only hair shafts. A 4-step technique was required
to obtain intact follicles. It is reasonable to expect that graft
removal will become more difﬁcult with progressive healing. Any undesired grafts should therefore be removed as
soon as possible whenever the patient expresses the need
after surgery.
There is another implication in post-surgical recipient site
shampooing. Crusts3 are coagulated serum and blood that
seep around the grafts in the ﬁrst 24–48 hours after surgery.4
Mingled with the hair, they may dislodge a graft if caught
on a ﬁngernail or comb. Dislodged follicular unit grafts dry
quickly and do not survive long enough to be reimplanted.
Transplanted grafts settled well in
the recipient site on day 5 if not earlier. Any undesired grafts should be
removed as soon as possible following the 4-step technique
that was described.
Gentle ﬁngertip massage after day 5 is unlikely to dislodge
grafts and should safely be included in the post-surgical
shampooing protocol after a hair transplant.
References
1. Rose, P., and W. Parsley. Science of Hairline Design. In
R. Haber and D. Stough, editors: Hair Transplantation.
2006; 55-71.
2. Perez-Meza, D., M. Leavitt, and M. Mayer. The growth
factors, part I: Clinical and histological evaluation of
the wound healing and revascularization of the hair
graft after hair transplant surgery. Hair Transplant Forum
international 2007; 17(5):173.
3. Draelos, Z. The Scientiﬁc Basis and Use of Hair Care
Products Related to Hair Transplantation. In D. Stough
and R. Haber, editors: Hair Replacement—Surgical and
Medical. Mosby, 1996; 387.
4. Parsley, W. Management of the Postoperative Period. In
W. Unger and R. Shapiro, editors: Hair Transplantation,
4th Edition. Marcel Dekker Inc., 2004; 555-566.
5. Appendix H—Patient Instruction for Hair Replacement
Surgery. In D. Stough and R. Haber, editors: Hair Replacement—Surgical and Medical. Mosby, 1996; 437-438.
6. Ginzburg, A. Tips for the hair transplant surgeon. Hair
Transplant Forum international 2004; 14(2).✧
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Hair Transplant Forum International
September/October 2008
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182
Hair Transplant Forum International
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Scalp Dermatology for the Hair Restoration Surgeon
Folliculitis
Ricardo Mejia, MD Jupiter, Florida
Folliculitis is a condition that occurs in hair-bearing
regions of the body. Clinically, it is characterized by erythematous papules or
pustules surrounding
a hair follicle. Lesions
of folliculitis are often grouped, occurring
most commonly on
the scalp, legs, buttocks, axilla, and face.1
Folliculitis is typically asymptomatic but
1. Folliculitis of the hairline. Photo courtesy
may be associated with Figure
of DermnetNZ.net.
mild pruritus and pain.
Scalp folliculitis is characterized by small, very itchy pustules
within the scalp, often most troublesome on the frontal hairline (Figure 1). There may be only a small number of lesions
or they may be very numerous. They typically become sore
and crusted because they itch, and patients usually scratch
the lesions.
Various conditions predispose a patient to getting folliculitis, such as the following: diabetes mellitus, infrequent
washing or poor hygiene, and friction. Diabetics are more
prone to developing Candida folliculitis in intertriginous
areas. Certain medications, such as oral steroids and sirolimus, a drug that is used in renal transplant patients, has
been reported with a 26% increased rate of scalp folliculitis.2
Although folliculitis is often a clinical diagnosis, a culture
may be taken to determine the causative organism. True
pathogens are rarely cultured. Folliculitis has a variety of
different etiologies and treatment may vary according to the
causative organism.
One etiology of folliculitis includes bacterial infections
of the hair follicle. The most common bacterial pathogen is
staphylococcus aureus (S. aureus). Although S. aureus lives on
our skin, they generally only cause problems through cuts
or abrasions. Hair transplantation would represent a risk
of this type of infection although it is rarely seen. Factors
that can predispose to mild cases of scalp folliculitis include
wearing dirty hats or helmets, or preexisting inﬂammatory
scalp conditions and acne.3
Most infections are superﬁcial and often clear on their
own in a few days. Treatment will depend on the severity
of the disease. Typical therapies include chlorhexidine gluconate (hibiclens), hexachlorophene (phisohex), povidoneiodine (betadine) shampoo, topical antibiotics, long-term
systemic antibiotics, warm compresses, and improving
poor hygiene. Even with the best treatment, folliculitis can
be a recurrent condition. Mupirocin ointment in the nasal
vestibule twice a day may eliminate the carrier state of S.
aureus for these recurrent cases.
Methicillin-resistant S. aureus (MRSA) is an emerging
bacteria that is resistant to the drug penicillin. In the past,
this form of “staph” was predominantly isolated in hospital
patients and injection
drug users, but has
recently become more
prevalent in the general
population.4 A medical
pearl and clue to the
diagnosis of Staphylococcus is the presence
of a rim of desquamation surrounding the
Figure 2. Rim of desquamation. A Clue to S.
infected hair follicle aureus.5
(Figure 2). There may
be one or, less commonly, multiple circles of desquamation
arranged in a lamellar fashion around the infected hair follicle.5 The presence of this sign should alert the physician
to culture the lesion.
Deep or recurrent
folliculitis may need
treatment to prevent
bacterial spread and
hair loss. Deep folliculitis usually manifests as
a large swollen lump or
mass. Severe deep folliculitis cases may lead Figure 3. Dissecting cellulitis in Caucasian male.
Photo courtesy of K. Lane. www.priory.com/
to dissecting cellulitis medicine/dissecting_cellulitis.htm
with permanent scarring alopecia (Figure 3). Dissecting cellulitis (also known as
perifolliculitis capitis abscedens et suffodiens), is a chronic,
progressive, inﬂammatory disease similar to cystic acne. Lesions are suppurative with interconnecting sinus tracts that
can be ﬂuctuant and express a serosanguineous ﬂuid.6 It is a
rare disease, typically occurring between 18 and 40 years of
age. African American men are affected almost exclusively,
although there have been case reports of dissecting cellulitis in
Caucasian patients.7 These lesions are progressive, resistant to
therapy, and complicated by bacterial superinfection. Extensive scarring of the scalp develops and may be hypertrophic
or keloidal. Treatment of this disease can be very resistant.
Signiﬁcant improvement can be obtained with a combination
of isotretinoin 80mg once daily and dapsone 100mg once
daily.8 Potassium hydroxide preparations and fungal and
bacterial cultures should be completed to rule out more common conditions such as kerion (a scalp abscess secondary
to a fungal infection with secondary bacterial infection) and
folliculitis. Tinea capitis due to Trichophyton soudanes, which
is endemic in Africa, has been reported to mimic bacterial
folliculitis.9 It is becoming more frequent in Europe because
of immigration and has been seldom isolated in Italy.
183
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Hair Transplant Forum International
Scalp Dermatology: Folliculitis
 from page 183
Pseudomonas aeruginosa is another bacteria that causes
“hot tub folliculitis,” typically found in hot tubs where the
pH levels or chlorine content are poorly regulated. This
rash commonly develops between 8 hours and 5 days after
exposure, and is worse in areas covered by a swimsuit.10 It is
usually a self-limiting infection and clears within 2–10 days.
No treatment is necessary, but patients may be relieved with
5% acetic acid compresses for 20 minutes four times a day.
Ciproﬂoxacin may be indicated in cases of immunosuppression. Additional bacterial causes of gram-negative folliculitis
also include Enterobacter, Proteus, and Klebsiella.
Pityrosporum folliculitis (PF) is a pruritic, papulopustular
eruption, characterized by uniform, pinhead sized pimples,
which typically occurs in young to middle-aged adults.11 It
is caused by Malessezia, a yeast that is a normal inhabitant
of the skin over- proliferating, often due to factors such as
a hot, humid environment or chronic antibiotic usage. PF is
typically seen on body locations where Malessezia is most
abundant, such as the back, chest, neck, shoulders, and
scalp. It is occasionally seen on the arms, and rarely on the
face. Treatment includes topical 2.5% selenium sulﬁde, and
in severe cases may require systemic antifungal therapy with
oral ketoconozole.
Viral etiologies of folliculitis include herpes simplex virus and molluscum contagiosum.12 This form of folliculitis
is often spread by shaving over an infected area. Irritant
folliculitis can occur from chemical exposure to substances
such as tar and oil. This is more common in roofers, mechanics, and oil workers. Other rare causes
include syphilitic folliculitis and eosinophilic
folliculitis, which is more
common in HIV patients.
The cause of eosinophilic
folliculitis is not known.
Figure 4. Traction folliculitis complicated by S.
It is characterized by aureus. Photo courtesy of B. Cohen. dermatlas.
recurring patches of in- org
ﬂamed pus-ﬁlled sores, primarily on the face and sometimes
on the back or upper arms. It is not always associated with
the hair follicle. Topical and systemic corticosteroid therapy
is the treatment of choice depending on the disease severity. Another cause of resistant scalp folliculitis is Demodex
(mite) infestation.13 Traction folliculitis can also presents as
perifollicular erythema and pustules on the scalp, often in
areas where hairstyles produce tension on the hair shaft
(Figure 4).14
In hair transplantation patients, folliculitis may be a
frustrating and concerning phenomenon. Many patients
may experience a mild folliculitis one month following
surgery, which typically develops in the recipient area, and
rarely lasts for over six months post-operatively. Warm
compresses to the area several times a day can improve
the condition. Patients must be reassured because although
these eruptions can potentially delay hair growth, they
rarely reduce growth. Certain factors during the surgical
procedure make folliculitis more likely, such as piggy-back-
September/October 2008
ing of hairs (one graft on
top of the other) or burying of grafts (Figure 5)
by making the recipient
holes too deep.15
In summary, there are
many causes of folliculitis. After hair transplan- Figure 5. Folliculitis as result of burying grafts
tation, physicians should too deep.
properly evaluate the condition to rule out any treatable
causes and prevent progression to deeper infections, which
may affect hair loss.
References
1. Bolognia, J.L., J.L. Jorizzo, and R.P. Rapini. (2007). Dermatology Vol 2. St. Louis, Mo: Mosby.
2. Mahe, E., et al. (2005). Cutaneous adverse events in
renal transplant recipients receiving sirolimus-based
therapy. Transplantation 79:476-482.
3. Unger, W., and R. Shapiro. (2004). Hair Transplantation,
4th edition. New York, NY: Marcel Dekker, Inc.
4. Cathel, K. (2006). Community acquired MRSA: an underrecognized problem. The Lancet Infectious Disease 6(5).
5. Levy, A.L., G. Simpson, and R.B. Skinner. (December
2006). Medical pearl: circle of desquamation—a clue
to the diagnosis of folliculitis and furunculosis caused
by Staphylococcus aureus. JAAD 55(6).
6. Monroe, M., and C. Crutchﬁeld. (2005). Dissecting cellulitis of the scalp. Dermatol Nurs 17(3):208.
7. Stites, P.C., and A.S. Boyd. (2001). Dissecting cellulitis in
a white male: a case report and review of the literature.
Cutis 67:37–40.
8. Bolz, S. (January 2008). Successful treatment of
perifolliculitis capitis abscedens et suffodiens with
combined isotretinoin and dapsone. J Dtsch Dermatol
Ges 6(1):44-7.
9. Ghilardi, A. (March 2007). Tinea capitis due to Trichophyton soudanese mimicking bacterial folliculitis. Mycoses 50(2):150-2 (from NIH/NLM Medline).
10. Baruchin, A.N., et al. (1996). Pseudomonas folliculitis
acquired from hot tubs and whirlpools: an overview.
Annals of Burns and Fire Disasters Vol. IX.
11. Gupta, A.L., et al. (2004). Skin diseases associated with
Malassezia species. Journal of the American Academy of
Dermatology 51(5): 785-798.
12. Foti, C. (April 2005). Recalcitrant scalp folliculitis: a possible role of herpes simplex virus type 2. New Microbiol
28(2):157-9.
13. Sanfilippo, A.M. (November 2005). Resistant scalp
folliculitis secondary to Demodex infestation. Cutis
76(5):321-4 (from NIH/NLM MEDLINE).
14. Fox, G.N. (January 2007). Traction folliculitis: an underreported entity. Cutis 79(1):26-30.
15. Haber, R.S., and D.B. Stough. (2005). Hair Transplantation.
Philadelphia, PA: Elsevier Saunders.✧
184
Hair Transplant Forum International
September/October 2008
Surgeon of the Month: Tseng-Kuo Shiao, MD
Vance W. Elliott, MD Edmonton, Alberta, Canada
Tseng-Kuo Shiao (also known as
T.K.) was born in Taipei, Taiwan. He
is the oldest of three children, and
lived with his maternal grandmother
until high school started. It was not
uncommon for Chinese grandparents
to help raise their grandchildren, and
he felt lucky to have had the undivided attention of his grandmother.
T.K. immigrated with his family to
the suburbs of Kansas City (United
Tseng-Kuo Shiao, MD
States) in December 1977 and
Overland Park, Kansas
completed high school in Overland
Park, Kansas. Subsequently, he went to the University of
Kansas and received his bachelor’s and master’s degrees in
Computer Science. He proceeded to work a few years in the
computer industry before going to the University of Kansas
School of Medicine. The ﬁrst ten years in the United States
were difﬁcult for his parents; his mother stayed here with the
children while his father worked in Taiwan, but they willingly
sacriﬁced themselves so their children could receive better
educations and have better career opportunities.
T.K. was ﬁrst introduced to hair restoration by his father
and attended his ﬁrst ISHRS meeting at Barcelona in 1997.
Hair restoration, however, did not get his full attention until
he started working extensively with him at his clinic in 2004.
After working with his father for several years, T.K. found
it a fascinating ﬁeld with many great people, and started
his own clinic, United Hair Restoration, in Overland Park,
Kansas in 2007.
T.K.’s father, I-Sen Shiao, MD,
graduated from the National Defense
Medical College, the oldest allopathic
medical school in China with over a
hundred years of history. He was a research fellow for artiﬁcial kidney in the
department of Urology at University
Hospital of Michigan during the early
1960s and later started the Pediatric
department at the largest hospital in T.K.’s father, I-Sen Shiao, MD
Taiwan. He started practicing aesthetic
surgery in the 1980s and was the founder of the now 1,000member strong Chinese Society of Cosmetic Surgery and
Anti-Aging Medicine in Taiwan.
While seeking new developments in aesthetic surgery,
Dr. Shiao had a chance encounter with hair restoration
surgery during the International Hair Replacement Surgery
Symposium at Hot Springs, Arkansas, in February 1986.
T.K. can still remember the hundreds of turns through the
winding mountain roads in Arkansas when they drove there
from Kansas City: “My father was very impressed by the
symposium’s faculty and director, Dr. Bluford Stough.” A
comment made by the co-director, Dr. Richard Webster, on
how techniques were taught freely, without reservation, how
a father would teach his son, also made a lasting impression
on his father. Incredibly, this has been the tradition at the
ISHRS. The willingness of our members to teach and share
experiences is unparalleled by any other ﬁeld.
“Such novel experiences and dedicated teaching made
my father focus his efforts on hair restoration. At an annual
meeting in Los Angeles, Dr. O’Tar T. Norwood convinced
my father to devote his efforts to mini-grafts and later to
follicular unit transplantation. He became the ﬁrst physician
specialized in hair transplantation in Taiwan and has been
exclusively doing hair restoration at his clinic since 1992.”
“My father and I share similar philosophies in hair restoration. For my father, hair restoration is his hobby. It is
personally rewarding when he creates art in every case and
knows that he is helping people feel better. We see it as a
form of art but we also explore what science and technologies have to offer to help better the art creation process.
“On a personal note, I have been married to a wonderful person, Chin-Hui Tseng, for over 20 years. We have one
daughter, Jessica, who is 18 and a sophomore at Johns
Hopkins University. My primary hobby is to explore the
diversities in cultures and people through various types of
personal encounters.”✧
185
25 Plant Ave. Hauppauge NY 11788
The leader in
Hair Restoration Surgery
for instruments and accessories
Please call
800-843-6266
or visit our web site at
www.atozsurgical.com or
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E-mail: [email protected]
Hair Transplant Forum International
September/October 2008
Review of the
Asian Hair Surgery
Workshop
Paul C. Cotterill, MD Toronto, Ontario, Canada
while at the same time including the audience in the decision
process. This format worked very well and proved to coax
This past May, Dr. Sungjoo Tommy Hwang hosted a very much participation from the attendees. Another morning
successful ISHRS Asian Hair Surgery Workshop in Seoul, highlight was on the second day when Dr. Hwang, during a
Korea. This was the third Asian workshop and the second session entitled Live Patient Viewing, brought back the surgiKorean workshop. The ﬁrst Korean workshop was held in cal patient from the day before for all to inspect along with
Daegu, Korea, in 2001 hosted by Dr. Jung-Chul Kim. The six other of Dr. Hwang’s previous transplant patients.
At the end of each morning we were bused to Dr. Hwang’s
faculty this year included Drs. Paul Cotterill (Toronto, Ontario,
Canada), Alex Ginzburg (Raanana, Israel), Kenichiro Imagawa state-of-the-art surgical facilities. Dr. Hwang’s ofﬁces were
(Yokohama, Japan) (last year’s host of the Yokohama Asian perfect for hosting two simultaneous surgeries where attendees could observe bedside or in
Workshop), Jung-Chul Kim (Daegu,
an adjoining lounge with live video
Korea), Seok-Jong Lee (Daegu,
feed. Dr. Hwang’s attention to detail
Korea), Damkerng Pathomvanich
was very evident.
(Bangkok, Thailand), as well as our
On the ﬁrst day, Drs. Kim and
Korean host, Dr. Hwang.
Hwang transplanted a 29-year-old
The focus of the meeting, similar
male with Norwood type II male
to last year’s meeting in Japan, was
pattern baldness (MPB) that had an
to give Asian doctors exposure to
unnatural hairline done in a previcurrent hair restoration techniques
ous ﬁrst session elsewhere. Using
and advances as well as to showthe KNU implanter, 1,500 grafts,
case the differences in approach to
(L to R) Drs. Sungjoo Tommy Hwang, Jung-Chul Kim,
approximately 2,700 hairs, were
Asian patients while incorporating
Alex Ginzburg, Kenichiro Imagawa,
transplanted. This is where the bigthe best from the West. Dr. James
Damkerng Pathomvanich, Paul Cotterill, Seok-Jong Lee
gest difference between the surgical
Arnold, who passed away last year,
was at last year’s Asian meeting in Yokohama and wrote treatment of Asian and Caucasian hair is readily apparent.
a very insightful description of the meeting and covered Due to the unique Asian hair characteristics of lower density,
many of the differences in the approach to Asians that were larger diameter, and dark, straight hair, grafts are quickly and
highlighted this year. I would urge the reader to revisit Jim’s efﬁciently trimmed without magniﬁcation and loaded into
write up in last year’s Forum (Vol. 17, No. 3; p. 94) as his Choi or, in this case, KNU implanters. I am always amazed
coverage, in typical James Arnold fashion, was eloquent and and impressed at how this particular technique of working from front to back and left to right, in fairly rigid rows,
comprehensive.
Both mornings began with didactic lectures. In my lec- achieves a consistently natural result. In the next room, Drs.
tures, I covered many of the essentials of the consultation, Imagawa and Pathomvanich used the western method to
jointly transplant a 49-year-old male
including the approach to the younger
with MPB. 1,400 grafts, about 1,800
patient as well as the management of
hairs, were obtained with microscopic
the female patient, while Dr. Ginzburg
dissection. Dr. Pathomvanich employed
covered key points on how to deal
his meticulous and time-consuming
with the recipient area. Similar to last
follicle saving technique of carefully
year, comprehensive presentations
excising a donor ellipse by visualizing
on the differences of Asian hair and,
every follicle. Traction, 3-4 skin hooks,
correspondingly, the differences in
2 assistants, tumescent ﬂuid, and a
the approach and surgical treatments
Live surgery operation performed at Dr. Hwang’s ofﬁce
bloodless ﬁeld with suctioning are all
of the Asian patients were given by
Drs. Imagawa, Pathomvanich, Hwang, and Kim. Dr. Lee’s components. On day 2, Dr. Hwang transplanted a female
presentation on mimickers of androgenetic alopecia, and with female pattern hair loss with 1,500 grafts (around
on scalp diseases that are not to be treated with surgery, 2,850 hairs). As well, a scar revision employing about 400
provided important points to cover for physicians of any grafts was performed by Drs. Hwang and Pathomvanich. Dr.
Ginzburg demonstrated his w-plasty technique on the donor
level of expertise.
Highlights of the morning sessions included patients that scar. After that, Dr. Ginzburg attempted FUE just superior
the faculty selected for discussion on the management of to the donor revision incision. However, the yield was less
Norwood types II–IV. This was followed the next day with than expected, likely due to the poor tissue turgor and local
discussions on Norwood type V–VII patients. The faculty effects created by the revision. Another highlight was Dr.
was put to the task as to how they would treat each patient Hwang bringing back the 2 patients from the day before to
186
Hair Transplant Forum International
September/October 2008
see how the patients were doing, inspect their grafts, and
wash their hair. This generated much discussion.
All surgeries were very well received. Dr. Hwang was a
gracious host who really went out of his way to ensure a
quality learning experience. In attendance at the meeting
were 46 participants, not including faculty, from 14 countries: Korea (24), and the rest from Japan, China, Hong
Kong, Singapore, Israel, Georgia, Turkey, Taiwan, Thailand,
Canada, USA, India, and Malaysia. There were 22 ISHRS
members and 24 nonmembers. The experience level ranged
from 17 physicians at the advanced level, 18 intermediate,
and 11 novice. I have had the privilege of being able attend all
three ISHRS/Asian workshops and experience ﬁrsthand the
incredible amount of talent and expertise our Asian members
have to offer. I have also seen the great amount of interest
and enthusiasm the attendees bring to the workshops. The
facts that 1) over half the attendees were non-ISHRS members; 2) almost half of the attendees were from outside of
Korea; 3) the meeting was over-sold; and 4) this is the second Asian meeting in 12 months, indicate that there is a big
draw from Asia and surrounding countries with continued
interest. Due to the logistics and costs of holding our large
annual ISHRS meeting, North American venues are favorable
for a meeting of that size; however, there are many doctors
from around the world who appreciate the ISHRS bringing
the educational activities to them. These smaller, more intimate workshops are unique opportunities for physicians
to learn new techniques, and to also learn about the ISHRS.
Hopefully, with more doctors like Dr. Hwang, who has put
a tremendous amount of time and effort into ensuring a
successful workshop, more ISHRS/Asian regional meetings
will be available in the future.
Melike Kuelahci, MD Istanbul, Turkey
Dr. Jung-Chul Kim presented FU transplantation using
the KNU implanter. The device is not new, but is widely
The best thing about living in a world that’s round is used among Korean surgeons. I, on the other hand, prefer
reaching the East if you continue going West. While the West not to use the implanter because in the last few years, in
promises a new world of opportunities and gold, the East my patient population, I tend to apply dense packed megasessions, with a regular density of 40
is a symbol of wisdom, the traditional
FUs per cm2, which, in my opinion, is
and the peaceful—and, in a world that’s
difﬁcult to achieve with the implanter.
round, that should be the ﬁnal destinaDr. Kim gave two other lectures; one on
tion for you to reach. Having attended
good and bad candidates for HTS and the
the Orlando and Europe workshops for
other on the approach to young patients.
years, I decided that it was time for me
I think that the number of presentations
to go to the East. To the Asian Hair Suron the latter topic constituted an all-time
gery Workshop, hosted by Dr. Sungjoo
high at this workshop—maybe there is
Tommy Hwang.
a generation gap that we have to deal
Dr. Hwang opened the meeting, folwith, after all.
lowed by Dr. Paul Cotterill, who gave a
Attendees of the Asian Hair Surgery Workshop
Next, Dr. Alex Ginzburg, my good
speech on behalf of the ISHRS. Founded
in 1993, this Society, with its 746 members, is the biggest as- friend and neighbor from Israel in my part of the world, gave
sociation in its ﬁeld and its purpose is to promote professional a wonderful summary of recipient sites with different kinds
excellence. Having served as a board member for six years, I of instruments currently available in the market.
The best presentation for me was that of Dr. Pathomlistened to Dr. Cotterill with great pride. Even if we are heading towards the East in a personal state of peace, the idea of vanich explaining the technique of donor harvesting with
minimal transection using skin hooks, a technique that
belonging to Western institutions is nevertheless assuring.
Next, Dr. Kenichiro Imagawa spoke on the differences I would deﬁnitely try in my own surgeries. I think this
between Asian and Caucasian patients; primarily that method would diminish most patients’ complaints about
Asians usually have coarse black hair; mostly two-hair scalp hypoesthesia after surgery due to sparing of nerves
units (50-64%) and some three-hair units (13-17%). In my and vasculature.
The last speaker of the day, Dr. Hwang, gave a presentaopinion, these numbers don’t differ much from the typical
tion on complications and their prevention in hair surgery.
Caucasian.
Dr. Cotterill then followed with comments on consulta- For the purpose of increasing awareness of potentially ditions and the approach to young patients, as well as non- sastrous results, this talk was absolutely necessary.
During the course of the day, we went to Dr. Hwang’s
surgical treatments and female hair loss. He pointed out that
cyproterone acetate is not available in the United States. This ofﬁce and observed two live surgery operations. Dr. Hwang
bewildered me. In a country where estrogens are still being and his two assistants organized everything—the cameras
sold despite their carcinogenic effects being well known, and the sound system worked in perfect harmony.
The last day of the meeting we toured Seoul and exwhy are antiandrogens forbidden?
Dr. Damkerng Pathomvanich next gave a presentation on plored its famous Korean treasures. This city, with its 15
optimal hairline placement for Asians and showed us a laser million people and its metropolitan skyscrapers that have
device, described by him as the “instrument of the century.” only been created in the past 35 years, is nothing less than
Applied ﬁrst by Dr. Bertram Ng, it emits a criss-cross laser impressive.
On the ﬂight home, I felt grateful for being a part of this
beam to create a variety of hairlines. Unfortunately, it is
not yet on the market, but Damkerng, whose name was so round world. ✧
difﬁcult for me to pronounce (but I ﬁnally got it at the end),
says that it should soon be available.
187
Hair Transplant Forum International
September/October 2008
Review of
Made in Italy: Hair Restoration
Live Video Surgery Workshop
Rome, Italy • Msy 30–June 1, 2008
cell biology and tissue engineering for Aderans Research Laboratories, described recent updates. Dr. Bessam Farjo reported
Dr. Piero Schiavazzi opened the meeting with a talk on on the” dermal papilla (DP) alone strategy”, where DP cells
the 10-year history of hair restoration meetings in Italy and are used to recruit keratinocytes from interfollicullar epidermis.
emphasized the importance of public awareness in state-of- Keratinocytes can form follicle cell aggregates—“proto-hairs”.
the-art hair restoration. Dr. Schiavazzi’s title is not from a The expected next step is to make use of proto-hairs in human
volunteers. Next, Drs. Liudmila G. Korkina,
medical degree, rather, he is a prominent
a cell-biologist, and Walter Krugluger prejournalist, interviewing leading politicians
sented their own concepts on how to induct
all over the world. His enthusiasm for hair
new follicles. Speciﬁcally, Dr. Korkina imtransplantation began 10 years ago when
proved the expectation of clinicians with her
he was the recipient of a hair transplant,
enthusiastic “very soon” promises.
which made him strive for getting the word
After the coffee break, Dr. Schiavazzi
out about this ﬁeld.
moderated a panel with three journalists:
Dr. Robert Leonard, in his speech
one from Men’s Health USA, one from the
“Transitions to the Latest Trends in Hair
Rome Workshop Program Co-Directors:
London Times, and one from the most
Restoration Surgery,” reviewed the history
Drs. Ciro De Sio and Robert T. Leaonard, Jr.
widely read Japanese newspaper, Shimbun
of our ﬁeld, beginning in the late 1930s
with the work of Dr. Okuda in Japan, and chronicled hair (18 million copies). This panel was paid for personally by Dr.
transplantation through the past 70 years. Dr. Leonard then Schiavazzi because of his strong conviction that hair restoradescribed the “plug” technique followed by “split grafting” tion doctors are producing the best and most undetectable
and donor area closure. Next he described follicular unit (FU) transplants but the public has no idea of what we can achieve.
transplantation and follicular unit extraction techniques. He In fact, we are our own worst enemies—because the results
concluded with discussion of non-surgical treatments of male are so good and patients don’t talk about the fact they’ve
had a hair transplant, so the public thinks that we still do
and female pattern hair loss as well as hair cloning.
On the ﬁrst day, two surgeries were performed. Dr. Franco plugs as they only see bad, outdated results.
The panel directed by Dr. Leonard, “Overview on Current
Buttafaro started with a frontal baldness case with approximately 2,300 FUs. He worked with his own team and used Non-Surgical Treatments,” discussed the current treatments
of male or female pattern hair loss including Propecia®,
a density of about 20 FUs/cm2.
Rogaine® Solution and Foam, and Low
Next, Dr. Ronald Shapiro’s surgery was
Level Laser Light Therapy. Desanka Rasstructured on a basic density of 30–35 twokovic described also the use of serenoa
to three-hair FUs per square centimeter with
repens—which is simply the Latin name for
spikes on a wavy hairline. His mixture of
saw palmetto. Two things about minoxidil
two hairs with ones was worth mentioning.
were “off record” but important observaIn the center of each irregular-sized spike,
tions: 1) at the 5th week of treatment hair
Dr. Shapiro inserted a bunch of two-hair
shedding peaks for a couple of days, and
FUs and than spread one-hair FUs around
2) minoxidil is more effective than thought
using stick-and-place. Using 0.7–0.8mm
in the frontal area and temples. The next
blades obtained from custom cut razor
Rose performing surgery, assisted by speaker was Dr. Joe Greco, who disblades, he made sagittal slits, except in the Dr. Paul
Veselina Jelisavac and Karl Moser of the
cussed platelet therapy and presented his
temples where he turned to coronal again.
Moser Clinic.
evidence-based study with nice pictures
Both surgeries were broadcast to a press
conference where Dr. Schiavazzi moderated a question-and- showing faster healing of scalp crusting and erythema.
After lunch, half of the attendees viewed the live surgery
answer session. The aim was to give more information to the
media about reﬁnements in hair restoration surgery and an via video connection in the conference hall while the other
half rotated through the surgery rooms. Five procedures were
idea about future therapies such as hair cloning.
After lunch, Dr. Ciro DeSio and Dr. Leonard removed a done in parallel, covering such topics as vertex, hairline,
Frechet Extender after 3 weeks and performed a triple ﬂap. FUE combined with FUT, hairline correction, and hairline
In the second operation theater, Dr. Robert Haber excised a thickening in a second operation. With respect to the FUE
strip in 10 seconds using the Haber extractor, and worked combined with FUT case, note that it would be very difﬁcult
to do both on the same day because of the edema and the
with SAG slits on a female patient.
Saturday included two panel sessions. First was “Hair Re- hair roots changing direction.
search: A Growing Topic,” moderated by Dr. Kenneth Washenik.
Dr. Washenik, who has been working actively in recent years for
Melike Kuelahci, MD Istanbul, Turkey
188
Hair Transplant Forum International
September/October 2008
Robert T. Leonard, Jr., DO Cranston, Rhode Island
Following the typical Italian traditions of hospitality and
generosity, the workshop began with a special guided visit to the
Capitol Museums and a welcome at the Pietro da Cortona Hall
on Rome’s Capitol Hill. Next, the entire delegation of attendees
was hosted to an unforgettable dinner at the home of Dr. and
Mrs. Ciro DeSio, offering several courses of delicious dishes
prepared by Cinzia DeSio. A huge grazie mille to the DeSios!
A highlight of Friday’s program was the simultaneous video
transmission from the operating rooms of Drs. Ron Shapiro
and Franco Buttafarro both to the audience of medical attendees and to a group of journalists from throughout Italy
and the world during a Press Conference organized by Dr.
Piero Schiavazzi. The afternoon’s live video feeds were from
the operating rooms of Drs. DeSio and Leonard (triple ﬂap
procedure) and Dr. Robert Haber (female restoration). The
evening was topped off by a marvelous dinner, al fresco, in
the Travestere neighborhood of Rome.
Highlights of Saturday’s program included the Surgical Assistants and Nurses Program, organized by Dr. Maurice Collins
with the invaluable assistance from Joanne Scannell, RN, and
Dr. Jennifer Martinick. A packed house of hair transplant assistants received an overview of anatomy, vocabulary, transplant
and graft preparation techniques, common medications, and
emergency management in hair restoration surgery by this
most capable faculty. The other portion of the day’s program
was the Panel on Media Training, where roles were reversed
with the journalists in that they took questions from the physicians about topics important to a hair restoration surgical
practice. The afternoon allowed attendees to directly observe
and interact with surgeons performing their procedures in
state-of-the-art operating rooms of the IDI and it included the
following surgeons: Drs. Marco Toscani, Kenichiro Imagawa,
Paul Rose, Robert Leonard, Jean Devroye, Jerzy Kolasinski, and
Luigi Belliazzi. The evening concluded with the elegant Gala
Dinner at the Casina Valadier in Villa Borghese Park.
Sunday brought together many physicians who put into
practice the topics of the lectures given in the morning on the
subject of the hair loss consultation by Drs. Jennifer Martinick, Robert Leonard, Ciro DeSio, and Salvatore Marrocco. Ap-
proximately
50 Italian
citizens came
to the IDI to
be examined
by our faculty, which
included Drs.
Devroye, BelAttendees and staff at St. Peter’s Basilica
liazzi, Imagawa, Koher, Marrocco, Mollura, Rose, Niedbaldski, M. Unger,
Buttafarro, Farjo, Haber, Leonard, Kolasinski, Martinick,
Shapiro, Toscani, and DeSio. These complimentary consultations on men, women, and children suffering from
hair loss offered the opinions of world-renowned hair restoration surgeons as well as provided a hands-on learning
experience for attendees—both novice and experienced
in the ﬁeld. Immediately following the adjournment of the
conference, Dr. Piero Schiavazzi arranged a “cook’s tour of
the kitchen” with a guided tour of the magniﬁcent St. Peter’s
Basilica as well as a moving experience beneath the church
into the grottos and burial place of Pope John Paul II and
many other popes.
I also want to thank the faculty who traveled from near
and far to participate and make this workshop a resounding
success. A great big grazie to all at the IDI from the President
to Dr. Piero Schiavazzi and their excellent team including Dr.
Giuseppe Aleo, Dr. Alessandro Franconetti, Ann Anthony,
Flavia Sinatra, Agnese Cacciana, Alessandra Cacciani,
Linda Fioroni, Giorgia Lattanzi, and Debora Bora. Thank
you, too, to Liz Rice-Conboy and Kimberly Miller from the
ISHRS headquarters. Much gratitude also goes to all of the
assistants and nursing staff who helped to make the surgical
portion of this meeting so great, with special thanks to the
Moser Group who provided a large number of assistants for
this meeting. To our patients, we must offer our humble and
sincere thanks for being available to teach us all. Finally, from
the bottom of my heart, I wish to congratulate and thank
our own Victoria Ceh for organizing and triple-checking all
aspects of this meeting allowing it to be as wonderful as it
was. Mamma mia, what a meeting!✧
Surgical Assistants and Nurses Program
Jennifer H. Martinick, MBBS Perth, Australia
Almost 30 attendees participated in the Surgical Assistants and Nurses Program
in Rome, which was chaired by Dr. Maurice Collins, assisted by his registered nurse,
JoAnne Scannell, and Dr. Jennifer Martinick. The program was an excellent introduction to the basics of hair transplantation, such as planning and organization, graft
preparation, keeping grafts alive, and patient management, including emergencies,
medications, use of oxygen, and avoidance and management of complications.
Dr. Martinick spoke on the training methods used in her practice, including Dr. Jennifer Martinick addressing the Surgical
Assistants & Nurses Program, chaired by
using her training boards and the importance of teaching staff to use the minimum
Dr. Maurice Collins.
number of movements to cut and place grafts. At the end of the program, Dr. Collins introduced a novel approach to learning, where he asked questions of the audience—a great way to reinforce the
participants’ learning experience. Dr. Collins pointed out that after being taught something, we only retain 50% by the
next day, and only 5% after a month! A sobering thought.
Unfortunately, continuous translation was not available, so the workshop took longer than expected. However, this
did not detract from the content and given the answers from the participants, much was learned.
As all the faculty was Irish born and bred, it was truly an Irish-Italian affair.
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Hair Transplant Forum International
September/October 2008
Review of the
Fabio M. Rinaldi, MD Milan, Italy
The 13th Annual Meeting of European Hair Research synthesis itself is a rather toxic business, generating much
Society (EHRS), held in Genoa, Italy, July 3–5, 2008, was oxidative stress via oxidation of tyrosine/dopa.
organized by Alfredo Rebora and Marcella Guarrera. The
Jae-Yoon Jung (Korea) presented a study about the
meeting offered scientiﬁc presentations by researchers from efﬁcacy of dutasteride in AGA recalcitrant to ﬁnasteride.
Europe, Asia, and America, and included much useful infor- He showed the clinical efﬁcacy of 0.5mg a day orally of
mation related to the biological and clinical understanding dutasteride in 31 men suffering from AGA who did not
of hair diseases and hair transplants.
respond to conventional ﬁnasteride treatment. In 24 of
In the ﬁeld of hair follicle biology, Michael Philpott (United these subjects, there was a signiﬁcant improvement in hair
Kingdom) presented very interesting data about premature density and thickness (p<0.001). No serious side effects
senescence of balding dermal papilla cells (B-DPC) caused were reported, but 6 patients complained of transient
by loss of proliferative capacity of Bsexual dysfunction.
DPC in vitro associated with decreased
In the hair restoration session, Marco
expression of proliferating cell nuclear
Toscani (Italy) described a modified
antigen and up-regulation of p16INK4a
method to harvest intact hair follicles. He
and nuclear expression of markers of
subdivides the single unit into two parts
oxidative stress and DNA damage. Preby microdissecting the follicle in the upmature senescence of B-DPC in vitro and
per area to leave the bulge, and the lower
the expression of these markers in DPC
containing the dermal papilla. These data
suggest that B-DPC are more sensitive
support the evidence of the possibility
to oxidative stress and to environmental
to duplicate in vivo human hair follicles.
stress than healthy DPC, and that this
This behaviour is likely due to the potenPhoto from www.destination360.com
mechanism may be involved in androtial of the bulge cells to regenerate the
genetic alopecia.
lower portion of the follicle, whereas the dermal papilla is
Informed by these results, I proposed a clinical trial on inﬂuenced by the surrounding environment through stimuli
the impact of air pollution and oxidative stress on the hair that still need to be identiﬁed. Duplicative surgery permits
follicle and scalp. In this study, involving 450 volunteers, us to obtain a larger number of grafts, a natural appearance,
we evaluated the effect of oxidative stress, mediated by and to reduce the scar in the donor site. The disadvantages,
ROS (reactive oxygen species) generated directly from in the opinion of the author, are slower growth of hair and
particulate matter (PM 10, PM 2.5—speciﬁc environmental a longer procedure.
pollutants), which may be a mechanism of chronic inﬂamAndreas Finner (Germany/Canada) presented a study to
mation of the scalp and generate a particular scalp disease standardize the surgical procedure of hair transplants using
called “sensitive scalp.” In Milan, 41.3% of the 350 people a digital imaging technique. In two different randomized pilot
living there (a polluted urban area) suffer from sensitive studies, he investigated hair growth in a target area before
scalp, versus 13.6% of the 100 people living in a country and after hair transplant, measuring donor hair density and
area in North Italy (unpolluted area). This scalp condition calculating transection rates. Increasing the evidence in hair
may be an etiological factor for hair loss, and may present restoration will scientiﬁcally substantiate and validate the
a problem for patients who undergo a hair transplant.
quality of hair transplants, improving this technique and
These data, together, can identify new pathways that thus beneﬁting the patient when they undergo the surgical
could lead to alternative therapeutic strategies.
procedure.
Desmond Tobin (United Kingdom) presented an update
If you’d like more details on this educational meeting,
on melanocyte aging in the hair follicle: Is the hair bulb please see the EHRS website at www.ehrs.org.✧
melanocyte the body’s ultimate age sensor? The relevance
of canities in humans remains unclear, as it occurs after
reproductive peak age, suggesting it has no evolutionary
selective advantages. He suggested that canities may be
a threshold response to a combination of reactive oxygen species—associated damage to sensitive hair follicle
melanocytes, impaired anti-oxidant status, and failure of
melanocyte stem cell renewal. Tobin reported that melanin
190
Hair Transplant Forum International
September/October 2008
Review of the
Literature: Facial Plastic Surgery
Sheldon S. Kabaker, MD, Sumit Bapna, MD Oakland, California
The Transgender Patient
Citation
Spiegel, J. H. Challenges in care of the transgender patient seeking facial feminization surgery. Facial Plastic Surgery Clinics
of North America. 2008; 16(2):233-238.
Jeffrey H. Spiegel describes the characteristics of the
transgender patient and the challenges associated with
surgically treating this difﬁcult population. Facial feminization surgery (FFS) encompasses several procedures offered
by facial plastic surgeons, including rhytidectomy, brow lift,
cheek implantation, lip augmentation, scalp advancement,
frontal cranioplasty, and reduction mandibuloplasty. Most
commonly, transgendered women (women born as men but
diagnosed with gender identity disorder) seek FFS. These
patients lead difﬁcult lives battling depression, rejection by
family and friends, and alienation at work. Their ultimate
goal is to pass as a woman 100% of the time, or achieve
“stealth” status in order to live their lives as women without
being identiﬁed as transgendered.
One of the challenges faced with patients seeking FFS is
the expectation that the newly created face will not only pass
for a woman but also have feminine beauty. They frequently
desire a fantasy outcome. Emphasis must be made that the
goal of the ﬁrst surgery is to feminize and that future surgery
can address beautiﬁcation. Computer simulation of surgical outcome can be problematic also. Frequently, computer
artists change facial features that cannot be surgically corrected, increasing expectations.
Other situations can also present difﬁculties in dealing
with FFS patients. The Internet has allowed the transgender
community to share unlimited information including when
they are having surgery and with whom, who else they
Location:
Marriott Houston @
George Bush International Airport
18700 John F. Kennedy Blvd.
Houston, TX 77032
1-800-228-9290
consulted, pricing, and pre-operative and post-operative
pictures that are not taken by the surgeons. Physicians often
hear comments about other patients’ surgeries but privacy
issues prevent them from discussing this. Also, the private
chat rooms and online communities are password-protected,
preventing access by surgeons. Physicians offering FFS must
also learn to expect that patients possess a high level of information regarding the procedures. Variation in technique
or philosophy from the two or three preeminent physicians
in this ﬁeld will be strongly questioned.
The use of names and pronouns can be sensitive to patients. The majority are deeply offended if called anything
but their chosen female name or are referred to by “he” or
“him.” Education of the ofﬁce, operating room, and hospital
staff can be helpful for the environments that these patients
will be in. Another challenge for dealing with patients
seeking FFS includes the great distance that patients must
travel for surgery. Finally, Spiegel describes that caring for
transgender patients carries a high risk for physician and
staff burnout.
The hair restoration surgeon is often consulted by these
FFS patients. Most are on female hormone replacement
therapy and some have had sex reassignment surgery. They
are at low risk for further hair loss but unless they are Norwood Class I–III patterns, they are likely to be unhappy with
a surgical hair restoration to achieve feminization.✧
ABHRS 2009 Examination
Saturday, January 24, 2009
Deadline for Examination Application: December 1, 2008
Deadline for Hotel Reservations: December 31, 2008
For information, contact the ABHRS Website
at www.abhrs.org
Phone: 708-474-2600; Fax: 708-474-6260
E-Mail: [email protected]
191
Hair Transplant Forum International
September/October 2008
Review of the
Literature: Dermatology
Marc Avram, MD, Nicole Rogers, MD New York, New York
A Hairy Hypothesis
Citation
Stenn, K.S., Y. Zheng, and S. Parimoo. Phylogeny of the hair follicle: The sebogenic hypothesis. J of Invest Dermatol 2008;
128:1576-1578.
A recent publication in the Journal of Investigative Dermatology set forth an interesting hypothesis for how hair follicles
came into existence. Stenn et al. propose that the original
purpose of the hair follicle was to serve as a wick to deliver
lipid components from the sebaceous glands to enhance the
overlying epidermal permeability barrier. As amphibious
creatures made the transition to a predominantly terrestrial
lifestyle, they required a more sophisticated epidermal barrier to protect against water loss. The sebogenic hypothesis
proposes that organisms that could augment their epidermal
barrier, using lipids produced by underlying glands, were
better able to survive the harsh, dessicating environment on
land. That primordial “wick” may have been a simple keratin
plug, which over time has developed many layers. And as
the hair grows out, it pushes the surrounding secreted lipids
toward the surface.
There is evidence that the formation of the hair follicle
and the sebaceous gland are very closely related. A weak
hair-inductive signal will produce sebaceous glands without
hair follicle formation, while a strong hair-inductive signal
gives rise to both sebaceous glands and a hair follicle. With
time, animals bearing this adaptation were better able to
withstand a drying environment, through the use of this wick
to deliver lipids to the surface. Furthermore, the modern-day
hair follicle is also able to help protect animals from trauma,
heat loss, and radiation.
Comment
The head continues to be an important source of heat
and water loss. We wear hats during the wintertime to help
protect us, and notice sweating when we are overheated. Our
hair also protects us, not only from the sun’s radiation but
also to retain heat for our bodies. It is interesting to think that
perhaps the hair was only a functional adaptation, allowing
delivery of sebaceous lipids to the skin surface to prevent
heat and water loss. Since then, it has grown to serve so
many other functions, not the least of which is the cosmetic
framing of the face and enhancement of our appearance!
Counting Hairs
Citation
Wasko, C.A., et al. Standardizing the 60-second hair count. Arch Dermatol 2008; 144:759-762.
When patients come in complaining of increased shedding, dermatologists and other hair experts reassure them
that it is normal to lose around 100 hairs per day, but this
value is theoretical, based on the theory that 10% of our
100,000 hairs are in telogen, and divided by the average
length of the telogen phase (100 days), which equals 100
hairs shed per day. However, as Wasko, et al. point out, it is
difﬁcult for patients to accurately count hairs lost throughout
the day. It is far easier to make a one-time, 60-second collection of hairs and to compare these to expected averages
for other normal patients.
In this study, 60 men without alopecia, aged 20-60,
were asked to use standardized combs, under standardized
conditions, to assess their total hair count. They washed
their hair on three consecutive days with T/Sal shampoo
(Neutrogena). On the fourth day, before shampooing, they
combed their hair for 60 seconds and recorded the number
of shed hairs. The comb used was 15cm long and with teeth
separated by 1mm on one half and 2mm on the other half.
The men repeated this technique over 3 days, and then again
6 months later to account for any seasonal variation. Overall,
the study found that subjects aged 20-40 shed an average of
10.2 hairs (range 0-78) per session, and patients aged 40-60
shed an average of 10.3 hairs (range 0-43). Patient-reported
counts were conﬁrmed by investigators.
Comment
Patients with hair loss can be further evaluated with the
use of this simple technique. It may not be applicable to
persons of different ethnicities, because African Americans
were not included in the study; however, Caucasian patients
with hair loss may ﬁnd this helpful to diagnose telogen efﬂuvium. Also, there may be some need to further reﬁne the
study using combs with similar spacing of teeth. Patients
who consistently used the end of the comb with narrower
teeth may have collected more hairs. Finally, it is difﬁcult
to extrapolate from these 60-second results what the total
hair loss per day is. It is difﬁcult to know whether vigorous
combing would eliminate hairs that might have been lost
later that day, or two days later.
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Hair Transplant Forum International
September/October 2008
A Peroxide Paradox
Citation
Wasserbauer, S., D. Perez-Meza, and R. Chao. Hydrogen peroxide and wound healing: a theoretical and practical review
for hair transplant surgeons. Dermatol Surg 2008; 34:745-750.
An important controversy in both the dermatology and
hair transplantation communities is the question of whether
hydrogen peroxide (H2O2) enhances or inhibits wound healing. Hydrogen peroxide is helpful in hair transplantation
for its effervescent effects of dissolving clotted blood and
mechanically removing tissue debris both at the donor and
recipient sites. It is frequently used as a 1-3% solution, diluted in various ways such a 1 part saline, 1 part H2O2 to 3 or
4 parts saline with 1 part H2O2. In this paper, Wasserbauer,
et al. performed a literature search to investigate the in vivo
and in vitro effects of hydrogen peroxide.
The authors found four studies demonstrating the beneﬁcial effects to include stimulation of vascular endothelial
growth factor (VEGF) release from macrophages, activation
and mediation of transforming growth factor (TGF-β1), and
induction of ﬁbroblast proliferation/collagen formation.
These mostly in vitro studies suggest that hydrogen peroxide
may enhance wound repair and revascularization of the hair
graft after transplant surgery. Four other studies, also mostly
in vitro, found numerous adverse effects of H2O2 on wound
healing. These found cytotoxic effects on ﬁbroblast cultures,
inhibition of human keratinocyte migration, and induction of
apoptosis of epithelial cells. These studies suggest that when
hydrogen peroxide is converted by neutrophils to more reactive oxygen species (ROS), such as superoxide and hydroxyl
radicals, it may adversely affect wound healing.
Only two in vivo studies have been performed investigating the effects of H2O2 on graft viability during hair transplantation. Both were small studies that involved immersing the grafts directly in hydrogen peroxide at increasing
concentrations. Although the numbers were few, they found
that using solutions of 1-1.5% H2O2 caused no problems,
but that decreased growth rates were found using the 3%
concentration of hydrogen peroxide.
Comment
It is clear that the hair transplant community needs to
perform more in vivo studies with higher power to investigate the effects of hydrogen peroxide on graft viability. This
review, while thorough, only serves to underscore the lack
of clear evidence supporting the use of hydrogen peroxide
in hair transplantation or other settings that require wound
healing, such as dermatologic surgery.✧
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Hair Transplant Forum International
September/October 2008
Letters to the Editors
Gaetano Agostinacchio, MD Porto Recanati, Italy and estrone as active ingredients dissolved in ethyl alcohol
Re: Response to Michael L. Beehner’s “Focal to 75 degrees (the author refuses to reveal the exact percentage of the composition since he has this lotion under patent
dense-packing in hair transplantation”
Our colleague Dr. Michael Beehner explains in his article
(Forum January/February 2008; 18(1):5-13) how to surgically treat the problem of thinning behind the front hairline
both in male and female patients. However, in my opinion,
it is not always right to intervene surgically when a precise
diagnosis has not been made and when we are unaware of
how the problem will develop.
An accurate diagnosis at the beginning is vital in determining the medical or surgical therapy to be adopted.
Considering that the mechanism responsible for hair
loss in these patients is not an excess of androgen but an
estrone deﬁciency, a hair transplantation may not solve the
problem, and in fact the transplanted hair may fall out due
to a lack of estrone. Therefore, I consider these patients not
candidates for hair transplantation.
In my experience, both male and female patients with hair
thinning problems similar to those published in Beehner’s
article (which are classiﬁed as Ludwig female pattern hair
loss), beneﬁt from a topical therapy that consists of a cocktail of medicines that include hydrocortisone, progesterone
pending) (see Figures 1 and 2).
B
A
Figure 1. A: 54-year-old female patient;
B: same patient after 1 year of topical treatment
B
A
Figure 2. A: 35-year-old male patient;
B: same patient after 1 year of topical treatment
IN REPLY
Mike Beehner, MD Saratoga Springs, New York
Re: Reply to Dr. Agostinacchio
I think Dr. Agostinaccio missed the intent of my concept
of “focal dense packing.” It was not meant in any way to
shortcut the process of being certain of the presenting diagnosis of alopecia in the patient before you. For the most
part, my use of this modality has been almost exclusively
in hereditary androgenetic alopecia in males and hereditary
female pattern hair loss in females. I keep as wary an eye as
anyone looking for diagnostic or physical exam clues that the
diagnosis may be something else, and am quick to biopsy
if that thought even occurs. My article was mainly about
marking out a relatively small key area within the overall
transplant pattern, most commonly in the “frontal core”
area, and simply placing as many hairs in that small area
as you humanly can. In my hands, the method that works
best is to use the stick-and-place method with 2-hair FUs
placed into 21, 20, or 19g needle sites, usually in a density
of around 50 FU/cm2 or 100 hairs/cm2. I am still dealing
with the rest of the larger transplant pattern also, but just
not in as dense a fashion as this special area. It’s simply
a way to “jump-start” a key, visible area and perhaps get
two sessions’ worth of density in that spot, while planting
the remaining area in the usual manner, which respects the
blood supply of the scalp.
To the contrary, when I see small, isolated areas of alopecia, that is often an unlikely area for this technique, as
many of them turn out to be burned out scarring alopecias,
in which I want to temper my planting density to allow for
adequate vascular support to the grafts planted. Barring
an obvious diagnosis, such as hairpiece clip bald spots or
trauma, I agree with Dr. Agostinacchio that all such areas
should be biopsied.
As to his comments on the hormonal cause of female hair
loss, I am quite certain it is in fact different from the male
hormonal situation, but am not aware that the answer is
as worked out and simplistic as he implies. I am certainly
impressed with the photos and the results he shows, and
would be interested to see this therapy performed on a
number of female patients who all responded similarly. If
such was true, this would be a major breakthrough. Barring
such evidence forthcoming, I would have to remain skeptical
of his basic premise.
 More Letters to the Editors on page 195
194
Hair Transplant Forum International
September/October 2008
The commoditization of surgical hair restoration—a
cautionary statement
Jeffrey Epstein, MD Miami, Florida
The other day, I was contacted by a patient, a law student low on cash, who asked if I could match a quoted fee
of $3,000 for a 1,300 follicular unit transplant procedure
provided by a reputable New York City surgeon—to be performed in the peak of the summer season. After informing
this patient that I would not be able to come even close to
this price, I then asked myself, how could that surgeon make
any amount of reasonable money on this case? And this leads
me to the more important concern, What is happening to
our wonderful specialty?
To anyone involved in this ﬁeld, it is known that, overall, hair transplants have continually gone down in price.
Perhaps when surgeons were charging $8 to $10 a graft,
there was an indication for fee reduction, but now, fees are
consistently going to $3 and less per graft by some of our
colleagues. This trend is concerning, for there is essentially
no end to how low it can go.
In the widely accepted “guerrilla marketing” approach,
in order to successfully compete against others in the marketplace, it is recommended that any business, or for that
matter, any physician, should pick one attribute or feature
with which one can stand out. For example, FedEx—guaranteeing the package arrives the next day (“when it absolutely,
positively has to be there the next day”). In the automobile
industry: Cadillac—the smoothest ride; BMW—top German
engineering; Ferrari—prestigious Italian passion; and Volvo—the safest. All of these attributes, in all very successful
companies, promise some type of value, and for a competitor
to surpass them, they have to further “up the ante” on that
value. While quality can continue to slowly rise, there is some
limiting ceiling as to how “high” that value can go.
Not so with price, however. Once companies, or for that
matter, hair transplant surgeons, choose to compete on price,
there is no limit to how low that price can go. There is always
someone who can charge less, and once one chooses to play
that game, the only way to compete is to further lower fees.
This practice is so destructive to any industry, for at some
point, providers have no choice but to start cutting corners,
leading to poorer and poorer quality results. I know: Some
of you are saying to yourselves or each other “Boy, that Epstein, doesn’t he know that it is in fact possible to combine
top quality with low fees—I do it every day.” But the reality
is, at some point in the future, by competing with lower and
lower fees, eventually there will be many losers—including
the “winners” of the lowest fee competition.
Essentially, by these efforts to attract patients with lower
and lower fees, what I believe is happening is the commoditization of hair transplantation. Similar to how Kmart, Target,
and the “winner” in the price wars, Wal-Mart, led customers
to believe that the only thing that matters is getting the very
lowest price, more and more of our prospective patients are
developing the mind-set that a hair transplant is just a hair
transplant, and the goal is to seek out the lowest price per
graft. We, as a specialty in general, are fostering this mentality, and should attempt to learn a lesson from such industries
and businesses as department stores, automobiles, and our
physician colleagues competing for HMO contracts. To stay
the price leader, as there is always someone willing to lower
their proﬁt margins, prices can only get lower and lower.
Hair transplantation is an art. It is a cosmetic surgical
procedure, with risks, as well as tremendous variability in
outcomes largely dependent upon technical and aesthetic
skills. I call on my colleagues to not participate in the commoditization of our specialty, and rather regard your work
with pride and respect.✧
Jim Vogel, MD Owings Mills, Maryland
Re: It’s a small world—of friendship
sharing of information. Never are these tenants of our cherished Society more realized than when we travel beyond our
own boundaries and we are welcomed by our colleagues in
a different country.
We just returned from a terriﬁc few weeks in Eastern
Europe. We visited with the Karl and Claudia Moser in
Vienna who were incredible hosts and also got to know a
newer member of the Society, Tomas Mantse,
in Budapest.✧
One of the most special aspects to the ISHRS is the international friendships we develop over the years and even the
friendships our children make with other members’ kids in
our Society as well. We should keep this in mind and never
forget that the foundation of our Society is friendship and
Dr. Vogel spending an educational morning with
Dr. Hugeneck ( left) and Karl Moser (right) at the
Moser Clinic in Vienna.
Tomas Mantse (an IHRS member from
Budapest) and Jim Vogel
195
At dinner with the Vogel family with Karl and
Claudia Moser
Hair Transplant Forum International
September/October 2008
 Cyberspace Chat 
Sharon A. Keene, MD Tucson, Arizona
Rogaine foam in women: Precautions for use
The following discussion took place in regard to a woman
patient inquiry about the use of Rogaine to treat her hair
thinning.
Bob Leonard reported this conversation: “I had a woman
come into the ofﬁce today who was concerned about using
Rogaine foam. It has been my practice to recommend this
product to men and women alike since it became available
early last year. I think it is far easier and much less messy
for patients to use than the liquid formulations. She indicated
that she read on a medical website that Rogaine Foam can
cause cardiac problems in women. Anybody hear anything
about this issue?”
Bill Parsley responded: Apparently topical minoxidil causes
cardiac arrhythmias in about 1/1,000 patients. I have been
using 5% on both women and men and have not seen a
problem in women yet. It was my impression that the main
worry was a higher incidence of facial hypertrichosis.
Bill Rassman added: Don’t forget that minoxidil was originally used for the treatment of hypertension and can reduce
the blood pressure if absorption is high enough. I have seen
patients complain of lightheadedness with the drug, which I
always believed was caused by systemic absorption.
Shelly Kabaker also recalled: I had a physician patient 13
years ago who had a pharmacist compound minoxidil and
increasing the concentration in hopes of a greater effect.
At 15% concentration he had a hypotensive episode while
driving and wrecked his car (fortunately no physical injuries
occurred). He subsequently had a transplant.
Editorial Review
In brief review of this commonly used, over-the-counter
medication, minoxidil is a potassium channel agonist. It
contains the chemical structure of nitric oxide (NO), a blood
vessel dilator, and may be a nitric oxide agonist. This appears
to explain its activity as a vasodilator but may also be related
to its mechanism of hair growth, too. The following information was available from medscape.com regarding systemic
absorption and side effects. One that isn’t mentioned is
facial hair in some women (reported incidence 3–5%)!
Percutaneous absorption of minoxidil after application of 1
or 5% minoxidil solutions to the scalp generally averaged
1.6–3.9% of the applied dose, based on urinary recovery
of radiolabeled drug. Increasing serum concentrations were
observed in cases of scalp irritation. Following cessation of
topical minoxidil dosing, approximately 95% of systemically absorbed drug is eliminated within 4 days. A list of
infrequent, and then rare, side effects is provided.
Less frequent: Dermatitis due to topical drug, Dry skin,
Erythema, Pruritus of skin, Skin rash, Urticaria
Rare: Alopecia, Angioedema, Body ﬂuid retention, Chest pain,
Conduction disorder of the heart, Decreased sexual function,
Dizziness, Eczema, Edema, Folliculitis, Headache disorder,
Head sensation disturbance, Hypotension, Neuralgia,
Reduced visual acuity, Tachyarrhythmia, Vasodilation of
blood vessels, Visual changes
Notwithstanding this information, however, the results
of a multi-center, randomized, placebo-controlled trial are
reported here. A total of 381 women (18–49 years old) with
female pattern hair loss applied 5% topical minoxidil solution (n = 153), 2% topical minoxidil solution (n = 154),
or placebo (vehicle for 5% solution; n = 74) twice daily.
At week 48, the 5% topical minoxidil group demonstrated
statistical superiority over the 2% topical minoxidil group
in non-vellus hair counts as well as investigator and patient
assessment of treatment beneﬁt. Both concentrations of topical minoxidil were well tolerated by the women in this trial
without evidence of systemic adverse effects.1
It is important to remember that minoxidil, while very
helpful and safe in most cases, is still a drug. Currently it
remains a mainstay of therapy for women, who still have
few medical options for achieving hair regrowth.
Reference
1. Lucky, A.W., et al. A randomized, placebo-controlled
trial of 5% and 2% topical minoxidil solutions in the
treatment of female pattern hair loss. J Am Acad Dermatol
2004; 50:541-53.✧
196
Hair Transplant Forum International
September/October 2008
Surgical Assistants Co-editors’ Messages
Betsy S. Shea, LPN Saratoga Springs, New York
Laurie Gorham, RN Boston, Massachusetts
Dear Assistants,
Recently, I read an article in
a paper about the benefits of
teamwork, written by best-selling
author Harvey Mackay. The article
spoke about how there is strength
in numbers. Working as a team will
not only accomplish more, but will
also improve the quality of what’s
being done. Mr. Mackay made reference to the great redwood
trees of California. How despite the fact that some of them
are over 300 feet tall and thousands of years old, their root
systems are very shallow; but the reason they have survived
for so long despite is because they exist together and their
root systems intertwine. They work together: holding each
other up and protecting each other when the storms come
through. We can learn a lesson from these trees:
Stand together, proud and tall. • Work as a team.
Intertwine your roots. • Protect each other from the storms.
Work hard as a team and much can be accomplished.
Bonjour Assistants!
The year has ﬂown by and I
can’t believe it’s time for us to
meet again. I’m looking forward
to our meeting, sharing ideas and
catching up with everyone. It’s so
important for our group to be able
to impart wisdom and guidance
to new comers to our ﬁeld so they
can grow and develop as we have
over the years. Safe travels everyone!
J’attends avec impatience voir tout le monde dans
Montréal.
Warmest regards,
Laurie
Betsy
Patient welfare
Marina Rovdo, Hair Restoration Ltd. Dublin, Ireland
Upon arriving for surgery, a patient is often both excited
and worried. This is why, in our clinic, we have a dedicated
staff member who is responsible for our patient’s welfare each
day. Let me share my experiences, as I do this most often.
My main objective is to create a relaxing and comfortable
feeling for the patient. This involves:
 Reducing pre-operative stress
 Establishing a friendly and professional relationship
with the client
 Creating a positive image of the clinic and trust in
what we are doing
 Creating a relaxed environment for the patient
through small creature comforts, such as preparing
tea/coffee, breakfast and lunch, etc.
I read the patient’s notes in advance and meet the patient
on arrival. As I bring him to the surgery rooms, I like to chat
and try to assess his anxiety level by observing his gestures
and listening to his voice. This helps me gauge the tone and
manner I should use with him. For example, with nervous
patients, I speak more slowly and gently.
I stay with the patient during the preparation stage to
ensure he will recognise me easily during the day. It’s important that he has a familiar face among the staff, as various
people will be around him during the day.
I attach the ECG leads to the patient and explain the
details of the procedure, including:
 The importance of being still, and that if he wants to
move to tell us ﬁrst.
 When breaks are scheduled and that he can ask for
breaks, drinks, etc.
 What to expect during the next stages including
design and donor strip removal.
When speaking with a patient, avoid words like “needle”
or “blood,” which might distress the patient.
After the donor strip removal, I bring the patient from the
operating table to the patient’s room. I ask how he is feeling
and if he needs anything. Sometimes patients need a little
more time to talk just to ensure they feel understood.
In the surgery, the patient should never be left alone.
In contrast, at break time, most patients prefer some time
to themselves. I check every ﬁve minutes that the patient
is content. In our clinic, we have a large DVD library, so I
offer each patient his choice of movies and what he would
like to eat for lunch.
After the break, I bring the patient back to the operating
table, reattach the ECG leads, and switch on the monitor.
I will then tidy the patient’s room. During the surgery it’s
important to observe the patient and from time to time to
ask if he needs water or a short break. Simply being there
is very important as it reassures the patient.
The best indicator that I have done a good job is when
the patient calls me by my name and refers to me when he
needs something. Empathy, courtesy, and patience make
for good patient welfare—and never underestimate the importance of a smile!✧
197
Hair Transplant Forum International
September/October 2008
Classiﬁed Ads
Hair Transplant Surgeon Wanted
ADAMA Hospital & Clinics, a specialized dermatology and plastic surgery hospital located in Saudi Arabia, as an expansion of our Hair Transplant facility, we are looking for an HT Surgeon with:
1. ABHRS or Equivalent
2. 5+ years experience
To apply:
Email: [email protected] or Fax: 00 9966 1 4631589
Independent Hair Technician Available
Denise Kernan is a 14 year experienced hair transplant tech who’s available per diem or training.
If you’re starting, adding or just short handed, please contact
Denise Kernan at 612-751-4657 or [email protected]
Hair Transplant Physician Wanted
Nu/Hart Hair Clinics, the world leader in hair restoration, is seeking a HAIR TRANSPLANT PHYSICIAN
for both their London and Manchester clinics.
Surgical experience or aesthetic training is a plus, with a minimum two-year commitment.
Applicant should e-mail CV to: [email protected]
Clinics for Sale
Well-established Hair Restoration Clinics (2 locations: North Italy and Switzerland).
23 years in practice. Exceptional equipment and staff in place.
Inquiries Conﬁdential Fax: 00041-91-91150051
Hair Transplant Physician Wanted
Excellent Opportunity for Physician in Busy Florida Hair Restoration Practice
Send Inquiries to: [email protected]
To Place a Classiﬁed Ad
To place a Classiﬁed Ad in the Forum, simply e-mail [email protected]. In your e-mail,
please include the text of what you’d like your ad to read—include both a heading, such as “Tech
Wanted,” and the speciﬁcs of the ad, such as what you offer, the qualities you’re looking for, and
how to respond to you. In addition, please include your billing address.
Classiﬁed Ads cost $60 plus 60 cents per word per insertion. You will be invoiced for each issue
your ad runs.
198
Hair Transplant Forum International
September/October 2008
199
A d va n c i n g t h e a r t a n d
science of hair restoration
Upcoming Events
Date(s)
Event/Venue
Sponsoring Organization(s)
Contact Information
Academic Year
2007–2008
Diploma of Scalp Pathology & Surgery
U.F.R de Stomatologie et de
Chirurgie Maxillo-faciale; Paris, France
Coordinators: P. Bouhanna, MD, and
M. Divaris, MD
Director: Pr. J. Ch. Bertrand
Tel: 33 +(0)1+42 16 12 83
Fax: 33 + (0) 1 45 86 20 44
[email protected]
October 16–18, 2008
III Congress of Brazilian Association of
Hair Restoration Surgery
Pestana Rio Atlantica Hotel, Copacabana Beach
Rio de Janeiro, Brazil
Brazilian Association of Hair Restoration Surgery
(ASSOCIAÇAO BRASILEIRA DE CIRURGIA DA
RESTAURAÇAO CAPILAR - A.B.C.R.C.)
President: Marcelo Gandelman, MD
Chairman: Henrique N. Radwanski, MD
[email protected]
International Society of Hair Restoration Surgery
www.ishrs.org
Tel: 630-262-5399;
Fax: 630-262-1520
www.registration123.com/ishrs/07WEBINARS/
November 8, 2008
10:00AM–1:00PM Central Time
Advanced Webinar: Advanced Hair Transplant
Principles and Planning (online seminar)
November 15–16, 2008
January 24, 2009
10:00AM–1:00PM Central Time
14th Annual Scientiﬁc Meeting &
Video Surgery Workshop
JAL Resort Sea Hawk Hotel Fukuoka
Advanced Webinar: Quality Assurance and
“Six Sigma” Strategies in Hair Transplantation
(online seminar)
Japan Society of Clinical Hair Restoration
www.jschr.org/
International Society of Hair Restoration Surgery
www.ishrs.org
President: Masahisa Nagai, MD
Tel: 81+ 92-483-7575
Fax: 81+ 92-483-7580
[email protected]
Tel: 630-262-5399;
Fax: 630-262-1520
www.registration123.com/ishrs/07WEBINARS/
 Make note!
Dates and locations for future ISHRS Annual Scientiﬁc Meetings (ASMs)
2009: 17th ASM, July 22–26, 2009, Amsterdam, The Netherlands
2010: 18th ASM, October 20–24, 2010, Boston, Massachusetts, USA
2011: 19th ASM, dates to be determined, Anchorage, Alaska, USA
2012: 20th ASM, October 17–21, 2012, Paradise Island, Bahamas
HAIR TRANSPLANT FORUM INTERNATIONAL
International Society of Hair Restoration Surgery
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Geneva, IL 60134 USA
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