2011 ISHRS Hair Transplant Forum Newsletter

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orumHAIR TRANSPLANT

I N T E R N A T I O N A L

orumHAIR TRANS

I N T E R N A T I O N A LI N T E R N A T I O N A L

fVolume 21, Number 4 • July/August 2011

Inside this issue

President’s Message ...................106Co-editors’ Messages ..................107Update on proposition of regulations on who can perform HTs in Europe ..............................109Hair loss algorithm ...................... 113Polycystic Ovary Syndrome and hair loss ........................................ 114Safety measures in high-risk patients with cardiovascular disease and elderly patients undergoing hair restoration surgery ......................................... 116Introduction to the use of implanters ....................................121How I Do It: A technique for achieving minimal donor scars ..123Cyberspace Chat: Green tea, iron defi ciency—is there a relationship to hair loss? ............124Epigenetic modifi cations may explain the relative protection of occipital hair follicles fromandrogenetic alopecia in men ....127ISHRS—helping you to help your patients .........................................128Hair’s the Question ......................129Message from the Program Chair of the 2011 Annual Meeting ........130Meetings and Studies: Highlights of the Istanbul Workshop ...........132Review of the Literature ..............133Letters to the Editors ..................134Expanded Newcomers Program set for 2011 ISHRS annual meeting .........................................135Surgical Assistants Corner ........137How to grow a hair ......................137Classifi ed Ads ..............................138

Register Today!

http://www.ishrs.org/AnnualMeeting.html

Candidacy of females for hair transplantation Walter Unger, MD Toronto, Ontario, Canada [email protected]

Last year, in an issue of O, The Oprah Magazine, one of our esteemed colleagues was quoted as saying that “only about 20% of female patients with thinning hair are candidates” for hair transplantation. If I had been asked, I would have said that of the women that I see in consultation, only 20% are not candidates and, at the very least, a majority are.1 More specifi cally, at most, only 20% of the women that I see do not have suffi cient acceptable donor tissue for at least one small session of 800-1,200 FUs. Acceptable donor is hair that is judged to be permanent and that lies in the area of scalp considered to be the donor area for males. Although many of the women we see have more than one such session available in their donor area, if even one procedure is carried out in a well-chosen, cosmetically important area, they can achieve a very satisfying cosmetic result (Figure 1).

There is good reason to believe that this statement in O Magazine could be understood (directly and indirectly) by millions of women with female pattern hair loss (FPHL) as a consensus view of hair restoration surgeons (HRS). What is in fact the consensus of a sampling of expert hair restoration surgeons on this subject? I thought it was important to try to clarify the answer to that question by sending an email to a large group of some of our most experienced colleagues. Each was asked: What percentage of women you see with FPHL has at least enough good donor tissue for one small session of 800-1,000 FUs?

A B C

Out of the 28 physicians who responded to the question, the following was found: 6 thought that 20% to 25% (or fewer) women with FPHL they see are candidates; 2 thought approximately 35%; 7 thought 40 to 50%; 5 thought 60 to 65%; 8 thought 70 to 80% (or more). Included in the lowest percentage group were Drs. Bernstein, Rassman, Wolf, Epstein, Wong and Stough. The 8 members of the group that answered 70% or more included Drs. Limmer, Beehner, Perez-Meza, Leonard, Cooley, Mayer, Jerry Shapiro, and the presenter. Some of the reasoning of members of each of the groups is included below.

It was unanimously agreed that all patients (incidentally men as well as women) should be advised of the likelihood of loss of some transplanted hair over the years. It was, of course, universally agreed upon that none of the respondents would operate on somebody whose donor area might be satisfactory today but he/she thought would most likely be inadequate in the future. Because of this reality, the most cautious of us would pick the lowest percentages of acceptable candidates. Unfortunately, this group would probably never know whether their pessimistic prognosis was valid or not because they would almost certainly never again see a large majority of their rejected patients. On the other hand, surgeons at the optimistic prognostic end of the acceptable scale would be very likely to see their patients again—especially if they were dissatisfi ed—and would therefore be more ap-propriately informed as to whether or not they should change their practice philosophy.

The source of patients for different offi ces is different and this is likely to affect the percentage of “acceptable” patients seen. For example, those doctors whose practice referral source is primarily the Internet or other promo-tional venues are more likely to see a higher percentage of unacceptable individuals than those surgeons whose patients are primarily referred by knowledgeable prior patients, physicians and hairstylists. Moreover, the entire group agreed, for a variety of reasons, that not everyone who is a candidate should or would proceed because of

Figure 1. A: A 52-year-old female patient before hair transplanting in a frontal midline area with low hair density. B: 7 years after a hair transplant consisting of 843 FU and 113 DFU (a total of 1,069 FU). The patient was being seen for possible transplanting posterior to the fi rst recipient area. C: Photo taken at the same time as B, with the hair combed back for critical evaluation. A little hair placed properly and with good hair survival goes a long way cosmetically. The fear of losing transplanted hair is also misplaced if the donor area has been appropriately chosen.

Hair Transplant Forum International July/August 2011

106 www.ISHRS.org

This past January 2011, the leadership of the ISHRS met to conduct a strategic planning meeting, something we do every three years to plan our future. At this meeting, we formulated new Mission and Vision Statements and I would like to share these with you in this column. The Mission Statement describes what business we are in now, while the Vision Statement refers to where we hope to be in the future and serves as a guiding principle or “north star” if you will.

The mission of the ISHRS, according to our new statement, is: To achieve excellence in patient outcomes by promoting member education, international collegiality, research, ethics, and public awareness. A great deal of effort went in to deciding what to include and what to exclude. As this statement makes clear, our top priority is our patients. Our methods to achieve excellent outcomes includes first and foremost, member education, meaning all aspects of hair restoration surgery from beginning to advanced. The annual scientific meeting is our largest educational offering, but we also put significant time and energy into regional workshops, the Hair Transplant Forum, Internet webinars, and other audiovisual materials.

Our second purpose, international collegiality, refers not only to the makeup of our Society but also the conscious effort on our part to promote relations between members from different countries and regions of the world. At our annual meeting, a convenient venue exists to meet, socialize, and network with physicians in this field from all parts of the globe. By composing boards and committees with members from different countries, we ensure that our leadership reflects our membership. We are also putting effort into translating our website into other languages.

As with most medical societies, we promote re-search as an inte-gral part of who we are. Nothing stays the same and we facilitate scientific, evidence-based research activities within the realm of hair restora-tion surgery to ensure continued evolution of our field. We have since our inception provided research grants to worthy projects and recently I participated in a webinar on biostatistics to improve the quality of the research that we do fund. Research find-ings are discussed at meetings and in the Hair Transplant Forum and Dermatologic Surgery.

This brings us to ethics. In the medical realm, this refers to how we interact with our patients and our colleagues. By putting our patients’ interests above all else, and treating our colleagues as we would want to be treated, we become known as moral people and we safeguard the reputation of our specialty and the ISHRS. Let’s face it, hair restoration surgery has an imperfect past in terms of ethics, when financial concerns were placed above the best interests of the patient. We must keep ethics on the front burner because we all need frequent reminders.

Finally, we get to public awareness. As a non-profit society, we have a duty to educate the public about hair loss and what treatments and procedures are available. This is an end in itself and is not designed primarily to drive patients into our offices. As we educate each other at the professional level, we in turn educate the public. And this brings us to our new Vision Statement: To establish the ISHRS as the leading unbiased authority in hair restoration surgery. In my opinion, the best way for us to achieve our vision is by doing our mission, over and over, every day, and to the best of our abilities.

President’s MessageJerry E. Cooley, MD Charlotte, North Carolina, USA [email protected]

Hair Transplant Forum International Volume 21, Number 4

Hair Transplant Forum International is published bi-monthly by the International Society of Hair Restoration Surgery, 303 West State Street, Geneva, IL 60134 USA. 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, 303 West State Street, Geneva, IL 60134 USA. Telephone: 630-262-5399, U.S. Domestic Toll Free: 800-444-2737; Fax: 630-262-1520.

President: Jerry E. Cooley, MD [email protected]

Executive Director: Victoria Ceh, MPA

Editors: Nilofer P. Farjo, MBChB William H. Reed, II, MD [email protected]

Managing Editor, Graphic Design, & Advertising Sales: Cheryl Duckler, 262-643-4212

[email protected]

Cyberspace Chat: Sharon A. Keene, MD

Controversies: Russell Knudsen, MBBS

How I Do It: Bertram Ng, MBBS

Hair’s the Question: Sara M. Wasserbauer, MD

Surgical Assistants Corner Editor: Patrick A. Tafoya [email protected]

Basic Science: Francisco Jimenez, MD Ralf Paus, MD Mike Philpott, PhD Valerie A. Randall, PhD Rodney Sinclair, MBBS Ken Washenik, MD, PhD

Review of Literature: Marco Barusco, MD Nicole E. Rogers, MD

Meeting Reviews and Studies: Timothy P. Carman, MD David Perez-Meza, MD

Copyright © 2011 by the International Society of Hair Restoration Surgery, 303 West State Street, Geneva, IL 60134 USA. 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).

The best way for us to achieve our vision is by doing our mission, over and over, every day,

and to the best of our abilities.


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Co-editors’ MessagesNilofer P. Farjo, MBChB Manchester, United Kingdom [email protected]

William H. Reed, MD La Jolla, California, USA [email protected]

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In this issue we have discussion on some very important topics. There are several that cover issues to do with female hair loss. Dr. Walter Unger’s thought-provoking article and the replies by experts show the diversity of opinions that exist in dealing with women’s hair loss. But it also points out how, no matter what our experience we, can sometimes get it wrong. The main thing to keep in mind is that we should

be getting it right the majority of the time. We have guidelines but there are always exceptions. There are two other articles by eminent surgeons looking at the issues of diagnosis of female hair loss, an often complicated issue that is not as straightforward as in men. Dr. Paul McAndrews shares with us his hair loss algorithm and Dr. Edwin Suddleson gives his advice on the treatment for polycystic ovarian syndrome. Dr. Sharon Keene’s Cyberchat touches on some dietary issues that may lead to iron deficiency, a condition we mainly see in women.

Improving the quality of what we do is what the ISHRS is all about. It attempts to do this by providing venues for fellow surgeons to meet to exchange ideas and to develop friendships. In addition to the meetings that it sponsors throughout the year, the ISHRS offers a Fellowship Training Program that has turned out some of the best surgeons in our field. However, the Fellowship, since it offers

no remuneration and requires the fellow to live where the Fel-lowship is offered, fulfills the needs of relatively few physicians. It is with these limitations in mind that two new ISHRS efforts are useful: Listserv+ and the Extended Newcomers Program at the upcoming Anchorage meeting.

As described by the ISHRS, Listserv+ “is a convenient way to contact more than one person at a time” and “the topics and the threads will be archived on the ISHRS website for future reference.” Listserv+ discussion groups are open to members only. This can be a great format for sharing opinions and asking questions on a wide variety of subjects relating to hair restora-tion. It should be live about the time of this issue’s coming to print and can be accessed via the “Members Home Page” at ISHRS.org. LISTSERV+ URL: http://www.ishrs.org/members/member-index.php#

The Listserv+ is a good forum for discussions resulting from the second ISHRS effort to educate: the Extended Newcomers Program. This program enables newcomers to be paired with experienced surgeons at the meeting in Anchorage with the possibility of extending their relationship beyond the meeting for two years. (See page 135 for more details.)

Those of you who have read my earlier editorials know that

I believe diversity is an important element in the remarkable progress of our field over the past 15 years. Large organiza-tions such as Bosley and, in days past, MHR make and have made critical contributions to this progress. Just as critical, however, are the contributions, including the very formation of the ISHRS itself, of the individual surgeon. While the large organizations train their own well, these two new programs from the ISHRS offer the germ that can make significant con-tributions to the training of the individual practitioner whose life circumstances prevent him or her taking advantage of the Fellowship Program.

Unlike “Top Down” methods of development where the executive level dictates direction, how these germs of “Bottom Up” organization offered by the ISHRS will grow to fruition are less well defined here at their outset. Nevertheless, their possibilities are exciting. The Listserv+ forum is an opportunity waiting to discuss a wide range of topics. Individuals partici-pating in a discussion can share their opinions as well as write emails to authorities who may not have begun participating to ask them to join the discussion to share their expertise to the whole group of participants.

Although not its main purpose, Listserv+, by its very ex-istence, will be an informal marketplace where, for example, surgeons can ask for or offer services such as providing as-sistance in getting a newcomer’s practice started. I know how important that was to me when the late Dr. Jim Arnold and his capable technicians visited to help me get started. What services are offered matters not as much as the existence of the Listserv+ forum, which allows our needs to be defined and addressed.

The ISHRS, arguably threatened by its success and age alone

Emergency preparedness for high-risk cardiac patients is dis-cussed in Dr. Kuniyoshi Yagyu’s article. As we see more elderly patients seeking hair restoration, he reminds us of the vigilance required in dealing with this age group and the management required in treating these patients. Many of us would turn these patients away but Dr. Yagyu gives us the pointers to manage these high risks in a safe way. As a former cardiac surgeon, Dr. Yagyu has the benefit of experience with cardiac management that many of us do not have, and therefore we may not feel the same level of confidence. Be sure to attend Dr. Yagyu’s session at the annual meeting in Alaska where he will speak on some of these cardiac issues.

Genetic research into AGA is an exciting area of study being conducted in several centers around the world. In this issue, Prof. Rodney Sinclair and his group discuss the concept of epigenetics and how this may relate to the genetics of hair loss in male pat-tern hair loss by DNA-methylation.


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Reed Message from page 67

Bernard Nusbaum, MDEditorial Guidelines for Submission and

Acceptance of Articles for the Forum Publication

1. Articles should be written with the intent of sharing scientific information with the purpose of progressing the art and science of hair restoration and benefiting patient outcomes.

2. If results are presented, the medical regimen or surgical tech-niques that were used to obtain the results should be disclosed in detail.

3. Articles submitted with the sole purpose of promotion or marketing will not be accepted.

4. Authors should acknowledge all funding sources that supported their work as well as any relevant corporate affiliation.

5. Trademarked names should not be used to refer to devices or techniques, when possible.

6. Although we encourage submission of articles that may only contain the author’s opinion for the purpose of stimulating thought, the editors may present such articles to colleagues who are experts in the particular area in question, for the pur-pose of obtaining rebuttal opinions to be published alongside the original article. Occasionally, a manuscript might be sent to an external reviewer, who will judge the manuscript in a blinded fashion to make recommendations about its accep-tance, further revision, or rejection.

7. Once the manuscript is accepted, it will be published as soon as possible, depending on space availability.

8. All manuscripts should be submitted to [email protected]. A completed Author Authorization and Release form—sent as

a Word document (not a fax)—must accompany your submis-sion. The form can be obtained in the Members Only section of the Society website at www.ISHRS.org.

10. All photos and figures referred to in your article should be sent as separate attachments in JPEG or TIFF format. Be sure to attach your files to the email. Do NOT embed your files in the email or in the document itself (other than to show placement within the article).

11. We CANNOT accept photos taken on cell phones.12. Please include a contact email address to be published with

your article.Submission deadlines:

August 5 for September/October 2011 issueOctober 5 for November/December 2011 issue

2010–11 Chairs of CommitteesAmerican Medical Association (AMA) House of Delegates (HOD) and Specialty & Service Society (SSS) Representative: Carlos J. Puig, DO (Delegate) and Robert H. True, MD, MPH (Alternate Delegate)Annual Giving Fund Chair: John D.N. Gillespie, MDAnnual Scientific Meeting Committee: Melvin L. Mayer, MDAudit Committee: Robert H. True, MD, MPHBylaws and Ethics Committee: Robert T. Leonard, Jr., DOCME Committee: Paul C. Cotterill, MDCore Curriculum Committee: Edwin S. Epstein, MDFellowship Training Committee: Robert P. Niedbalski, DOFinance Committee: Carlos J. Puig, DOHair Foundation Liaison: E. Antonio Mangubat, MDLive Surgery Workshop Committee: Matt L. Leavitt, DOMedia Relations Committee: Robert T. Leonard, Jr., DOMembership Committee: Marc A. Pomerantz, MDNominating Committee: Vincenzo Gambino, MDPast-Presidents Committee: William M. Parsley, MDPro Bono Committee: David Perez-Meza, MDScientific Research, Grants, & Awards Committee: Michael L. Beehner, MDSurgical Assistants Committee: Margaret DietaSurgical Assistants Awards Committee: Marilynne Gillespie, RNTask Force on Hair Transplant CPT Codes: Robert S. Haber, MDWebsite Committee: Arthur Tykocinski, MDAd Hoc Committee on Database of Transplantation Results on Patients with Cicatricial Alopecia: Nina Otberg, MD Ad Hoc Committee on FUE Issues: Paul T. Rose, MD, JDAd Hoc Committee on Regulatory Issues: Paul T. Rose, MD, JDSubcommittee on European Standards: Jean Devroye, MD, ISHRS Representative to CEN/TC 403Evidence Based Medicine (EBM) Task Force: Sharon A. Keene, MDTask Force on Physician Resources to Train New Surgical Assistants: Jennifer H. Martinick, MBBSTask Force on Finasteride Adverse Event Controversies: Edwin S. Epstein, MD

2010–11 Board of GovernorsPresident: Jerry E. Cooley, MD*Vice President: Jennifer H. Martinick, MBBS*Secretary: Vincenzo Gambino, MD*Treasurer: Carlos Puig, DO*Immediate Past-President: Edwin S. Epstein, MD*John D.N. Gillespie, MDAlex Ginzburg, MDSharon A. Keene, MDJerzy R. Kolasinski, MD, PhDBernard P. Nusbaum, MDDavid Perez-Meza, MDArthur Tykocinski, MDKuniyoshi Yagyu, MDPaul C. Cotterill, MDRobert S. Haber, MD

*Executive Committee

of becoming “An Institution” (see Dr. Paul Straub’s informa-tive historical review in last month’s Controversies), revitalizes itself with ideas such as Listserv+ and the Expanded Newcomer Program. It balances its “Top Down” Fellowship Program now with these two new “Bottom Up” programs. With these ideas the ISHRS has provided us the opportunity. Keeping our profession

vital with diversity from the “Top” as well as the “Bottom,” from the Big and Small, from the Corporate and the Individual, is up to its members. I encourage you to be active in these new programs from the ISHRS. Register for the Extended Newcom-ers Program when you register for the Anchorage meeting and watch for, participate in, and enjoy the Listserv+ format for enhancing our knowledge and collegiality.

INTERNATIONAL SOCIETY OF HAIR RESTORATION SURGERY

Vision: To establish the ISHRS as the leading unbiased authority in hair restoration surgery.

Mission: To achieve excellence in patient outcomes by promoting member education, international collegiality, research, ethics, and public awareness.


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Update on proposition of regulations on who can perform HTs in EuropeJean Devroye, MD, ISHRS Representative to CEN/TC 403, Brussels, Belgium [email protected]

In Europe, the practice of hair trans-plant surgery is in danger. Actually, for one and a half years, a “normalization” group has been created under the aegis of European aesthetic surgeons. The aim of this group is to define precisely, on the European level, the general rules that must apply to the practice of medicine and aesthetic surgery. The practice of hair transplants is, of course, tackled, too.

The main problem is to define the competences. In the current project, only the general surgeons, the maxil-lofacial surgeons, and the aesthetic surgeons can practice micro hair transplants. Moreover, there is not a single mention about the difference between FUT and FUE. It is logical that flap surgeries and scalp reductions can be per-formed only by surgeons, but it is absurd to forbid non-surgeons from performing FUT or FUE procedures.

On the European level, the directive is managed by the CEN (Comité Européen de Normalisation) and by national organiza-tions of normalization. The secretary of the European Commit-tee named CEN403 is Dr. Grün based in Austria. The different representatives meet with each other periodically to discuss the amendments to the text. The last meeting took place in Austria, Vienna, at the end of May 2011. The next one will take place in Florence, Italy, on the 23rd of September 2011.

The national groups of the CEN403 have met for the past year and a half. At the beginning, CEN403 was created by aes-thetic surgeons. This explains that most of the positions in the different national mirror committees of each European country are held by them.

Commissions work in this way: During these Europeans CEN meetings, each European country is represented by one to three delegates chosen among the members of the entire com-mission. One of them only can speak and vote on behalf of the whole commission: he is supposed to reflect the opinion of all the members of the mirror committees. Those national com-

missions are created in each European country by the national organizations, which are in charge of the norms; for example, the AFNOR in France, the Din in Germany, the UNI in Italy, the BSI in England, and the AENOR in Spain

In two years, the directive would be definitively approved by the CEN. At this moment, the directive, which is normally non-restrictive and volun-tary, would be available for all states. It will probably happen that, despite the appeasement given by the members of the CEN, this norm (which will be

associated to a European directive) will become a law. In the past, we have seen that it is easier for a state to refer

to a European directive instead of wasting energy and time to create its own norms.

Since May 2011, what have we already done?On one hand, a letter was sent on behalf of the ISHRS to

Dr. Grün, which led to the ISHRS being accepted as a liaison society “observer.”

I am the official representative of the ISHRS among the CEN, thus, thanks to this, we can have access to all documents in relation to the CEN403 directive and also can attend the CEN international meetings.

On the other hand, I am registered in the “mirror commis-sion” of the Belgian branch of the CEN, represented by the NBE in Belgium. I have had the opportunity to better understand the functioning and the history of this commission.

It would be a good idea to have an ISHRS hair transplant mem-ber in each national commission. The member would have to attend the meetings of the national commission a few times a year.

It would also be good idea to get together to set up a common line of arguments and propose concrete solutions regarding the qualification of the doctors who practice hair transplants.

I invite every person interested in this topic to contact me as soon as possible.

ISHRS Ad Hoc Committee on Regulatory Issues Paul T. Rose, MD, JD, Chair

Patricia Cahuzac, MD (France)Nilofer K. Farjo, MD (U.K.)

John D.N. Gillespie, MD (Canada)Melike Kuelahci, MD (Turkey)William H. Reed, II, MD (USA)Ken Washenik, MD, PhD (USA)

Subcommittee on European StandardsJean Devroye, MD, ISHRS Representative to

CEN/TC 403Bessam K. Farjo, MBChBVincenzo Gambino, MD

Claudia Moser


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Candidacy of females from front page

information they should always be given about the procedure, the postoperative sequelae—especially the temporary recipient area hair loss that occurs in approximately 50% of women—and their personal likely outcomes. For example, in a subsequent review I conducted on 471 consultations I had with women from 2003 to 2009, who I thought could proceed with surgery, only 36% did so. In comparison, more than 60% of men I have “accepted” in the last year have proceeded with surgery. (This is probably a higher percentage than in most practices because most of my patients come to me via prior patient, physician or hairstylist referrals.)

A surgeon’s view of the likely success of a hair transplant will quite reasonably always be affected by his or her prior pa-tient results. Some of the experts in the 20-25% group said that minimal hair density gain was the rule rather than the exception in the women they had operated on. It is worthwhile remembering that risk tolerance tends to go down much faster with negative experience than up with positive experience. Those in the higher percentage acceptability group (and certainly in my experience) have found that both of the often suggested threats of 1) possibly accelerating hair loss when transplanting into still hair-bearing areas, or 2) achieving minimal improvement in such sites, are avoidable. A randomly selected group of 50 female patients I treated from 2003 to 2009 who were asked in a mailed question-naire: Knowing what you know now, would you do it again? and Would you recommend it to a friend? resulted in only one of them answering “no” to the first question and another one “no” to both. The latter patient was seen for reassessment and changed her mind when she was shown her “before” photos—she subsequently had another transplant. Interestingly, the other patient who did not come in for re-assessment answered “yes” to the second question.

Having observed many hair restoration surgeons operate over the years, I believe the most common cause for poor results in hair-bearing areas (whether in women or men) is the operator in-cising recipient area sites too quickly and therefore not optimally following the angle and direction of the existing hair. A video of the author making recipient site incisions at typical speed can be found at: http://www.youtube.com/watch?v=xmeYfHh4z_E.

The second most common cause of poor results—especially in women—is an FU/cm2 density that is too high. It should be remembered that lower graft densities than in men are advanta-geous for women who generally have the aforementioned smaller donor areas than those usually found in men, and that high graft densities are not necessary to produce very satisfying results in women. This is because women have more hairstyling options than men, long hair optimizes hair coverage for any given number of hairs, and women very rarely lose all of the hair in an affected area. Therefore, the potential cosmetic benefit from any given number of transplanted hairs or FU/cm2 in an area—typically 20-25 FU/cm2—is greater (both short-term and long-term) than in men.

Two of the respondents found that only 20% of the women they do magnified trichoscopic exams on during consultations have acceptably low levels of donor area “hair miniaturization.” In my opinion, the potential donor areas of women tend to be incorrectly assessed in many cases. Trichoscopy should not be carried out in 4 to 6 “standard” fringe areas as is commonly done

in men. Rather, the donor areas are virtually always properly limited to occipital and parietal areas (virtually never temporal areas) and they are often more inferior than the usual locations in men. Twenty women with worse than average donor areas but who the author deemed acceptable for hair transplanting, had satisfactory donor areas at approximately the level of and/or inferior to the occipital protuberance. Those areas are shown in violet and blue in Figure 2, as compared to the typical donor area in men, which is shown in the yellow and violet areas. This female donor area would virtually never be assessed during consultations with magnification for miniaturization if the same areas used for male assessments were sampled with trichoscopy. Thus, the patients would be incorrectly rejected. As an example, a patient came to our office one month after having been rejected by a physician in the 20% female candidacy group. “Confused” and “hopeless” were her stated emotions after being informed of her poor candidacy based ostensibly on her poor donor/recipient area ratio. A folliscope exam of 9 regions both within and at the border of her potential donor area revealed an average prospec-tive donor area density of 118 FU/cm2 and a terminal to osten-sible vellus hair ratio of 96:4 (Figure 3). With her well-defined recipient area, this is an example of how an overly conservative approach can be as damaging to the quality of patient care as an overly aggressive one.

Figure 2. The violet and blue areas represent the acceptable donor area found in 20 women with worse than average female donor areas. The typical donor area in men is represented by the yellow and violet areas.

Figure 3. A representative folliscope photo taken in a woman who had been rejected on the basis of an inadequate donor area one month earlier, by one of the 20% group physicians. The average FU density was 118 FU/cm2 and she had a terminal to ostensible vellus hair ratio of 96:4.


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I agree with Dr. Unger’s concept of going lower with the donor area. Because you are confined to a smaller available zone, in order to get sufficient length of donor, you inevitably have to take the donor from a lower site. Dr. Bob Leonard is quite right that women often want the option of tying their hair up, which means we have to avoid going too low. —NF

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A direct visual search for good potential donor areas should be done before any trichcoscopic examination, and if the latter is unfavorable, it should be repeated, for example, 12 weeks later, to see if some “miniaturized” hairs were actually early anagen hairs that could not initially be morphologically distinguished from truly miniaturized hairs. At the 2010 ISHRS Annual Sci-entific Meeting in Boston, before I presented a lecture on hair transplanting in females, I asked three widely respected hair experts, Drs. David Whiting, Marty Sawaya, and Jerry Shapiro, if they thought that a single trichoscopic examination could re-ally tell an observer whether somebody had a disproportionate percentage of miniaturized hairs in the area they are examining, or whether they couldn’t. Dr. Whiting in essence said he thought the whole exercise was so “useless” that he never (he emphasized the word) used that method to study miniaturization. Instead, he uses biopsies with transverse sectioning. Dr. Sawaya agreed that unless you did a second examination, you could not deduce anything from a single one, and Dr. Shapiro said the same thing (I spoke to him by phone because he wasn’t at the meeting). I asked these acknowledged world experts in the study of hair diseases specifically because I wanted to prepare for what I expected to be a vigorous assault on my view. Nobody in the audience at-tempted to contradict their replies. Let me be clear, however: If a physician is doing more than one examination, I do believe it could be helpful. It’s just a single examination that is not nearly as definitive as too many would like to believe.

ConclusionA substantial majority view of expert hair restoration sur-

geons (20 of 28) is that at least 40% of patients they see with FPHL have acceptable donor area reserves for at least one session of hair restoration surgery. (Six of 28 thought only 20-25% are acceptable while 8 of 28 thought 70% or more are candidates.) Not all of them should or will proceed because of what the patient (not the physician) views as the cosmetic limitations of a single session, or because of the short-term potential sequelae of the surgery, most commonly in the author’s experience the approxi-mately 50% incidence of some degree of temporary recipient area hair loss. Donor areas in women are not only more limited than in men but they tend to be lower in the occipital and parietal areas than in men. A single folliscope exam in clinically acceptable potential donor areas is not definitive; a negative one should be repeated approximately after three months or later.

Reference1. Unger, W.P., and R.H. Unger. Hair transplanting: an im-

portant but often forgotten treatment for female pattern hair loss. J Am Acad Dermatol. 2003(Nov); 49(5):853-860.

Editor’s note: Dr. Unger has brought up a very important topic that illustrates that even the most experienced hair transplant surgeons can disagree. What is apparent, though, no matter which group you fall into, is that as the doctor you must do your best to act in the patient’s interest. In spite of this, however, we sometimes will “get it wrong.” I probably fall into the 50% group with women’s surgical recommendations because my patients come from a combination of referrals (e.g., patients, other physicians) and other sources (e.g., Internet). Of the refer-ral sources, those women recommended by dermatologists and plastic surgeons will fall into the 80% group, and of the others it entirely depends on the source. Therefore, when reviewing the figures in Dr. Unger’s article, it is important to be cautious and not just take them at face value.

The principle of small operations for women confined to an area just behind the hairline is one that we use in almost all of our female patients with FPHL. It is often quite remarkable the difference in hair styling achieved by a small operation (Figures 1 and 2).

Figure 1. Patient 1: A: Pre-op; B: 1 operation of 850 FUs.

A B

Figure 2. Patient 2: A: Pre-op; B: 2 operations of 1,300 FUs each.

A B

A note from Robert T. Leonard, Jr., DO Cranston, Rhode Island, USA [email protected]

I would like to comment on Dr. Walter Unger’s excellent ar-ticle discussing the candidacy of women for hair transplantation. As was mentioned, I am a surgeon in the group who believes that more, rather than fewer, women are candidates for this often life-altering procedure.

We must never minimize the fact that we are physicians first and that these female patients are usually suffering—badly—be-cause of the loss of their hair. Evaluation for hair restoration in

these patients needs to be carefully, honestly, realistically, and compassionately undertaken.

One of the most important things we must consider is how little hair will be enough to make them feel better about their condition: • To make them be able to more easily prepare for their day. • To allow them to not have the “think about their hair all the

time,” which is a common comment made to me by these girls and women.


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• To offer what physicians are supposed to do for their pa-tients—provide relief of suffering, if at all possible for their patients.

Therefore, it is critically important for the doctor during the consultation process to provide honest and realistic expecta-tions to these women so that they can then make the appropriate decision as to whether or not to undergo the transplant. Tell them what the limitations are with regard to donor availability. Explain to them how large (or small) a surgical session can be to achieve a desired result.

Bigger (or more) is often not better for these patients: • Often a small session in the area immediately posterior to

the hairline will offer them enough hair to style in order to decrease the “see-through” concern about which many complain.

• Too large of a session will cover more area, but often at the expense of density.

• Sadly, (and I sincerely mean this), it is not uncommon for me to see patients who were recommended to have a large number of grafts to cover a large area of thinning. The moti-vation, I am sure, is monetary and not in the best interest in the patient’s well-being.

• A huge number of tiny grafts can do more harm than good. Think about it logically: very often a woman’s hair loss is more of a thinning problem versus a balding one. If a surgeon makes a very large number of very small incisions very close to one another within an area that has follicles providing hair coverage to the patient, regardless of how carefully and slowly one creates these incisions, this will damage/destroy existing follicles. This approach greatly increases shock hair loss, does damage to follicles that could have continued to produce hair for the remainder of the patient’s life, and provides final results that still are quite thin.

Another point I want to offer, especially since the membership of the ISHRS has grown significantly since the days of larger grafts, is that bigger, in some aspects, may, indeed, be better for our female patients.

One of the most wonderful aspects of medical practice is

Candidacy of females from page 111

that it takes practice. And, practice does, indeed, make perfect. The longer you are in this magnificent profession, the more you will realize that everything you learned in the past need not and should not be put on the shelf as being no longer useful.

In my experience over these last 25 years in the field of hair restoration surgery, I have seen techniques that have come and gone and then have returned. I also have seen individuals who embrace a particular surgical method and use it all the time in every patient. Some actually, either quietly in the confines of their consultation room or loudly on the Internet, lambaste colleagues who do not agree with their point of view!

I strongly believe that surgeons in this field should utilize any technique that they have in their experience to provide their patients with the best possible results.

So, in my humble opinion, transplanting larger, rather than smaller, grafts in our female patients offers them a fuller, thicker result. Larger grafts, away from the hairline, give these patients more hair with which to style without damaging as many existing follicles and existing growing hair.

The bottom line in evaluating these patients is to understand and to manage their expectations. I, like Dr. Unger, have seen many women who have been rejected as surgical candidates who then go on to have a procedure with me and become extremely happy and satisfied patients. Unfortunately, I also observe the opposite: Women who come in after having huge numbers of minuscule grafts that have destroyed existing hair and have provided very little resultant density—pretty much kicking her while she was down.

In conclusion: • Be realistic in your evaluations of these vulnerable pa-

tients.• Remember that even a little hair—strategically transplant-

ed—will be therapeutic and satisfying to them.• Don’t be cemented into using only one technique for all of

your patients.• Respect the body’s ability to heal. • First look out for your patients’ best interests and not for your

deposit slips.• Thank you, Dr. Unger, for your expertise and mentorship

through the years. • Continue to be excited and feel blessed to be a part of this

exceptional Society and profession!

A note from Ed Epstein, MD Virginia Beach, Virginia, USA [email protected]

Recently I participated in a survey by Dr. Walter Unger in which I responded that only 20-25% of women with FPHL in my practice were HT candidates. Ten percent of hair transplants in my practice are women, as I tend to be more conservative in the selection process. While the donor areas of most women can support a single 800-1,200 graft session, many have donor sup-plies limited to the occipital area, average or sub-optimal density, and/or fine texture, which either excludes them from higher graft number sessions, or may provide results that, while an improve-ment, may fall short of patient expectations, even when those potential less dense results are thoroughly discussed. Dr. Unger’s

observation of higher density below the occipital protuberance is interesting, but I have concerns about scar widening in this area as well as potential scar visibility when the hair is pulled up and worn on top of the head. The phenomenon of post-procedure shedding, despite slow and deliberate site placement and reduced use of epinephrine, is disconcerting to both patient and doctor, and, in my hands, contributes to a more conservative approach in patient selection.


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Hair loss algorithmPaul J. McAndrews, MD Pasadena, California, USA [email protected]

Not all hair loss is the same. Hair loss, like stomach pain, is a symptom, and not a diagnosis. There are many things that can cause stomach pain and the treatments are all different. Similarly, there are multiple causes for hair loss and the treatments are all different. The most common form of hair loss is androgenetic alopecia; however, in order to offer the best care to our patients, we must evaluate for other potential causes. Once the cause of hair loss is established, we can then discuss the ideal medical and surgical approaches for this patient.

I use the following algorithm in Figure 1 to show the patient how I came up with a specific diagnosis for his or her hair loss. This algorithm is somewhat simplistic and there is some overlap (e.g., a specific disease can fall into two different categories), however, it can help a provider to simply and effectively assign and explain a diagnosis to a patient’s hair loss.

It is important to first establish whether there is true hair loss or if the hair shaft is breaking. It is important to examine the hair that is falling out with a handheld microscope and determine if there is a bulb. If there is no bulb on the end of the hair, the hair is breaking. Hair breakage can be secondary to genetic defect of the hair shaft, which usually presents in infancy or childhood; however, usually hair breakage is caused by outside, environmen-tal damage to the hair (i.e., blow drying, straightening, perming, dying, bleaching, sun exposure, hair styling, etc.). Remember, the hair is essentially a dead piece of protein string, and the more trauma it experiences, the more likely it will break. The treatment for hair breakage is to avoid the trauma, and the hair follicle will produce a new healthy new hair with time.

If the hair is not breaking, the next step is to determine whether the hair loss is due to scarring. There are several derma-tologic diseases that cause scarring of the scalp and may destroy the hair follicles, such as the following:

• Pseudopelade of Brocq • Dissecting Cellulitis • Lichen Planopilaris • Radiation• Sarcoid • Collagen Vascular Diseases• Folliculitis Decalvans • Follicular Degeneration Syndrome• Folliculitis Keloidis Nuchae • Neoplasm • Infection• Trauma

A visual examination of the scalp can show some of the char-acteristic features of certain cicatricial alopecias. An examination with a handheld microscope will, for example, show obliteration of the follicular orifices. Ultimately, a scalp biopsy at the active border of the alopecia may be needed to determine which type of hair loss is occurring. If it is a scarring hair loss disorder, the disease needs to be treated promptly because once the hair fol-licle is destroyed the hair will never grow back. After the disease process is stopped, hair transplants can be used to fill in the bald spot created. However, there is no guarantee that the disease process will not reactivate to destroy the transplanted hair.

If the hair loss is not caused by a scarring disorder, then the next step in the diagnostic process is to determine if the patient is experiencing a significant increase in shedding (more than 100 scalp hairs per day). An examination of the shed hair with a microscope or handheld microscope will determine if it is anagen or telogen hair. If it is an anagen hair, the diagnosis is either loose anagen syndrome (usually seen in young females) or anagen ef-fluvium (which usually the history will elucidate that the patient is undergoing chemotherapy). If it is excessive shedding of telogen hairs, the diagnosis is telogen effluvium. It is usually caused by a preceding traumatic event (2-3 months prior), whether physical or psychological. A thorough medical history will often pinpoint the trigger. Laboratory testing may be necessary to rule out chronic trauma (thyroid disease or iron deficiency). In either case, the normal shedding cycle will return when the cause is identified and treated. In any case of shedding hair loss, hair transplantation is not an appropriate treatment option.

If examination reveals a non-breaking, non-scarring, and non-shedding hair loss disorder, then we need to determine through a careful physical examination if the hair loss is diffuse or if it is patterned. Diffuse hair loss can be caused by a deficiency of zinc or biotin, however, there is usually other dermatologic manifestations (peri-oral dermatitis and acral dermatitis). It can also be caused by alopecia totalis or universalis.

There are several forms of patterned hair loss. Traction alopecia is usually seen at the peripheries of the hairline and a good history will help in the diagnosis. This typically leads to destruction of the hair follicles. Trichotillomania usually presents with patches of alopecia across the scalp. The appearance is uneven because there are different lengths of broken hair. Alopecia areata presents with annular patches of alopecia. Many times, a handheld microscope will show exclamation point hairs, broken off hairs close to the follicular orifice (exclamation point hairs break at their thinnest point), and follicular orifices without hair. Androgenetic alopecia is the most prevalent type of hair loss presenting typically with a Norwood or Hamilton pattern. A handheld microscope will show miniaturization of the hairs in the areas of thinning.

This algorithm is useful in reassuring patients that there is a thought process going into how I came up with the specific diagnosis for their hair loss. It also helps patients understand why certain treatments for hair loss will not help their specific cause of hair loss.

Figure 1- Hair Loss Algorithm

HAIR LOSS

HairBreakage

TrueHair Loss

Scarring(See List)

Non-Scarring

Shedding Non-Shedding

Patterned Diffuse Telogen Effluvium Loose

Anagen Syndrome

Anagen Effluvium

TraumaGenetic Defect

Traction Alopecia

Trichotillomania Alopecia Areata

Androgenetic Alopecia

Figure 1. The hair loss algorithm.


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Polycystic Ovary Syndrome and hair lossEdwin Suddleson, MD Beverley Hills, California, USA [email protected]

Polycystic Ovary Syndrome (PCOS) is one of the most preva-lent endocrine abnormalities in women.1 This fact, simply stated, came as a surprise to me when I interviewed a patient with PCOS and hair loss and followed up with some study. I guess I just had not given it much thought. Some of my colleagues were surprised as well. So this communication is intended to increase awareness of PCOS and its implications in the hair loss patient.

Three similar but distinct definitions of PCOS exist and are in common use. The earliest definition, from the National Insti-tutes of Health (NIH) ca. 1990, consists of a common disorder associated with chronic anovulatory infertility and hyperandro-genemia with clinical manifestation of oligomenorhhea, hirsut-ism, and acne. Polycystic ovaries by ultrasound were added to the definition in a subsequent refinement in 2003, the Rotterdam Consensus. In this definition, 2 of 3 diagnostic criteria must be positive: hyperandrogenism, oligoamenorhhea, and/or polycystic ovaries by ultrasound diagnosis. In 2006, the Androgen Excess Society defined PCOS as a syndrome of hyperandrogenism with oligoamenorhhea and/or polycystic ovaries by ultrasound diagnosis.

Although there is still no clear universally accepted definition of PCOS, several consequences of PCOS are well known and well documented. PCOS is associated with numerous dermato-logic conditions including hirsutism, acne, and patterned hair loss. PCOS has the potential of substantial metabolic sequelae including an increased risk of obesity, diabetes, and cardiovas-cular disease.

Depending upon the diagnostic criteria used, the prevalence of PCOS in women falls between 8.7% (NIH criteria), 10.2% (Androgen Excess Society criteria), and 11.9% (Rotterdam criteria).2 To me, that’s a surprising number of women affected. A Google search of PCOS gives 9 million hits, which is to be expected for something so common. The prevalence is so high that the “For Dummies” series of books has a Managing PCOS edition.

Again, it is not surprising given the high prevalence that a professional society exists to support research and disseminate information. The Androgen Excess and PCOS Society is an in-ternational organization dedicated to promoting knowledge and original clinical and basic research in every aspect of androgen excess disorders such as polycystic ovary syndrome, non-clas-sic adrenal hyperplasia, idiopathic hirsutism, and premature adrenarche. Members include basic and clinical scientists, and clinicians, whose major interest is the etiology, diagnosis, treat-ment, and prevention of androgen excess disorders (see website below). The prevalence of dermatologic features in PCOS pa-tients were described in 2010 as: hirsutism, 73.9%; acne, 53%; seborrhea, 34.8%; androgenetic alopecia, 34.8%; and acanthosis nigricans, 5.2%.3

Treatment of female hair loss associated with PCOS begins with accurate diagnosis. The clinical findings listed above are essential in the diagnosis of hyperandrogenism. In addition, measurement of androgen levels (free and total testosterone and dehydroepiandrosterone sulfate) may be helpful. One must also rule out other causes of elevated androgens. Genetic testing has

recently been suggested as a helpful adjunct to predict the ef-fectiveness of anti-androgen therapy in women with hair loss.

Treatment of hair loss in women with PCOS may be medical, surgical, or a combination. Anti-androgens are not FDA approved in the United States for the treatment of hair loss in women, but are often prescribed off-label. Spironolactone and flutamide are commonly used. Cyproterone4 is available in Canada and Europe, not in the U.S. Finasteride is also enjoying some popularity as an anti-androgen. Response rates to these medications are not well documented. Oral contraceptives are used to suppress the ovarian androgen output. Minoxidil also is useful in female hair loss and should be advised.

Hair transplantation is indicated for women with PCOS and hair loss. Standard evaluation protocols of the scalp with respect to grafts needed and a reliable donor supply should be followed. In my personal experience, patients are satisfied with their results when goals and expectations are realistic.

PCOS can have significant metabolic sequelae including the so-called metabolic syndrome. Metabolic syndrome consists of elevated blood pressure, increased waist circumference, elevated fasting glucose levels, reduced HDL levels, and elevated tri-glyceride levels. Hair loss associated with PCOS and metabolic syndrome can be treated but may or may not be amenable to transplantation depending upon the availability of adequate donor hair.

In conclusion, PCOS is a remarkably common condition and is undoubtedly under-appreciated in our practices. Hair loss as-sociated with PCOS and other causes of elevated androgens are treatable medically and, in many cases, with transplantation.

For more information see:1. Shapiro, J. Hair loss in women. N Engl J Med. 2007;

357:1620-1630.2. http://www.ae-society.org/3. Mason, H., et al. PCOS trilogy: a translational and clinical

review. Clinical Endocrinology. 2008; 69:831-844.

References1. Mason, H., et al. PCOS trilogy: a translational and clinical

review. Clinical Endocrinology. 2008; 69:831-844.2. March, W.A., et al. The prevalence of polycystic ovary

syndrome in a community sample assessed under contrasting diagnostic criteria. Hum Reprod. 2010(Feb); 25(2):544-551. Epub 2009 Nov 12.

3. Ozdemir, S., et al. Specific dermatologic features of the poly-cystic ovary syndrome and its association with biochemical markers of the metabolic syndrome and hyperandrogenism. Acta Obstet Gynecol Scand. 2010; 89(2):199-204.

4. Karrer-Voegeli, S., et al. Androgen dependence of hirsut-ism, acne, and alopecia in women: retrospective analysis of 228 patients investigated for hyperandrogenism. Medicine (Baltimore). 2009(Jan); 88(1):32-45.


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Safety measures in high-risk patients with cardiovascular disease and elderly patients undergoing hair restoration surgery Kuniyoshi Yagyu, MD Tokyo, Japan [email protected]

Patients with cardiovascular disease and cerebrovascular disease could be eliminated from candidates waiting for hair transplantation; however, at the consultation before surgery, a busy physician might not gather a detailed history of the patient including ischemic heart disease and ischemic cerebral stroke. Other patients with systemic atherosclerosis might not have ever been diagnosed with latent coronary artery disease, cerebrovas-cular disease, or aortic aneurysm.

Sometimes, elderly patients visit our clinic for treatment of male pattern hair loss and some of them may have cardiovascu-lar disease. Hair transplantation is generally considered a safe procedure; however, the physician must consider and prevent possible life-threatening events during surgery. The most seri-ous complications in such high-risk patients is the new onset or recurrence of myocardial infarction, cerebral ischemia, or rupture of aortic aneurysm, which need immediate and precise diagnosis and treatment.

It is imperative that physicians anticipate systemic arterial sclerosis including stenosis in the coronary artery and cerebral artery and have knowledge of basic treatments for the prevention and avoidance of cardiovascular events.

Our Study Fifty-two hair transplantation operations were performed over

eight years in 44 male patients at mean age of 52.4±14.4 years old with diagnosed coronary artery disease, aortic disease, and/or cerebrovascular disease. The disorders included ischemic heart diseases (n=24), such as myocardial infarction, angina pectoris, and unstable angina. Patients had chest pain without coronary angioplasty in 14 operations, percutaneous coronary intervention (PCI) procedures and PCI stenting treatment in 9, and coronary artery bypass graft (CABG) surgery in 2. Arrhythmias (n=18) included frequent multifocal premature ventricular contraction in 7 operations, Wolff-Parkinson-White syndrome with episodes of dangerous tachycardia in 2, paroxysmal atrial fibrillation with tachycardia and syncope in 2, as well as sick sinus syndrome and others. Vascular disorders included dissecting thoracic aor-tic aneurysm and cerebral infarction in 4 operations, transient ischemic attack in 2, and stenosis of carotid artery and cerebral artery. Other disorders included valvular heart disease before and after prosthetic valve replacement in 2 sessions, hypertrophic cardiomyopathy in 2, pulmonary embolism, chronic renal failure under regular hemodialysis for 9 years, ventricular septal defect in an adult, and obliterative arteriosclerosis.

Among these disorders, ischemic heart disease, cerebral in-farction, dissecting aortic aneurysm, chronic renal failure under hemodialysis, and obliterative arteriosclerosis indicate existence of systemic atherosclerosis including latent stenosis in the coro-nary artery and cerebral artery. These patients are candidates for heart attack and stroke.

Presentation of Cases Case 1 was a 78-year-old male with type VII male pattern

baldness and a history of poorly controlled hypertension and permanent atrial fibrillation. His systolic blood pressure some-times was over 180-200mmHg. He had experienced a dissecting thoracic aortic aneurysm requiring repair 20 years prior, which meant that he had remains of the aortic dissection and aneurysm. Five years prior, he experienced cerebral infarction. He had recovered from speech disturbance and right hemiplegia after rehabilitation. He underwent two operations of gastrectomy for gastric cancer one year prior.

The patient needed maintenance medicines including 1mg warfarin, 100mg aspirin, beta blocker, alpha blocker, calcium channel blockers, angiotensin II receptor blocker, and diazepam. All drugs were continued before surgery.

In this patient, risk factors included the remaining dissecting aortic aneurysm, atherosclerotic cardiovascular disease, uncon-trolled hypertension, and atrial fibrillation. To prevent the risk of recurrent dissection of the aorta and rupture of the aortic aneurysm, high blood pressure had to be avoided during the surgery. As for the other risk factor, systemic atherosclerosis indicated latent ste-nosis in the coronary artery and cerebral artery. Emotional stress, hypotension, and hypoxemia had to be avoided during the surgery to prevent myocardial infarction and cerebral infarction.

Four sessions were performed in this patient between the ages of 78 to 81, and a total of 4,824 grafts were transplanted in his bald area from the front to the vertex. Oral chlorpromazine was given for sedation before operation. Nitroglycerin tape was applied on his chest skin for coronary vasodilatation and 3-4 liter/minute nasal oxygen was given during the surgery. Fentanyl and midazolam were used for analgesia and sedation. Precordial electrocardiogram (ECG) in lead II, blood pressure, heart rate, and pulse oximeter (SpO2) were monitored. Blood pressure was measured every 2.5 minutes. Heart rate, SpO2, and ECG were monitored continuously during the sessions. His blood pressure was 168-180/90-110mmHg with atrial fibrilla-tion before surgery. Heart rate was 78-82 beats per minute and SpO2 was 95-96%. Blood pressure decreased after sedation and was kept around 100-120/70-80mmHg during the surgery. Heart rate was around 67-84 beat/minute, and SpO2 was kept around 98-100% using nasal oxygen. There was no significant change of ST segment on the precordial ECG during the surgery (Figure 1). Four sessions were performed safely and successfully without any complication.

Case 2 was a 64-year-old male with type VII male pattern hair loss whose history revealed he had suffered from chronic renal failure and hypertension for 30 years, and that he had been under regular hemodialysis for 9 years. He had suffered

Figure 1. Case 1, 78-year-old male with atrial fibrillation and slight ST segment depression on the ECG during surgery.


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from angina pectoris for 7 years. He underwent CABG surgery 5 years before and he needed four PCI procedures thereafter; however, there still remained several stenoses in his coronary artery and he sometimes needed sublingual nitroglycerin to relieve chest pain.

The patient needed 10 maintenance medicines including 200mg ticlopidine, 81mg aspirin, coronary vasodilators, ni-troglycerin, calcium channel blockers, angiotensin II receptor blocker, etc. Ticlopidine was discontinued for one week and other drugs were continued before surgery.

In this patient, risk factors were chronic renal failure under hemodialysis and angina pectoris, which suggested systemic atherosclerosis including stenosis in the coronary artery and cerebral artery. To prevent acute myocardial infarction and cerebral infarction, hypotension, and hypoxemia was avoided during the surgery.

One session was performed and a total of 1,528 grafts were transplanted in his frontal and central area. During the operation, monitors for blood pressure, heart rate, SpO2, and precordial ECG in lead II were used. Fentanyl and midazolam were adminis-tered for analgesia and sedation. Nitroglycerin tape was attached on the chest skin for coronary vasodilatation and 3 liter/minute nasal oxygen was given during the surgery. Nitroglycerin spray was prepared for sublingual usage under sedation. As the patient had an internal shunt for hemodialysis on his left forearm, the blood pressure monitoring cuff and an injection catheter were attached on his right arm.

At the beginning of the operation, his blood pressure was 116/68mmHg, heart rate was 83 beats per minute, and SpO2 was 97%. During the donor suture, the author noticed 0.1 mil-livolt elevation of the ST segment on the ECG (Figure 2). Blood pressure was 92/53mmHg and heart rate was 76 beat/minute. The patient was under sedation without chest pain. The author increased nasal oxygen from 3 to 4 liter/minute and put the patient in the supine position. SpO2 increased to 99%. In a few minutes, blood pressure recovered to 110/70mmHg, heart rate was 72-76 beat/minute, and ST segment on the ECG recovered to the preoperative state. The patient was kept in the supine position during the session and hemodynamic parameters were stable until the end of the operation. The operation was completed without any complication.

meant myocardial ischemia (Figure 3). A nitroglycerine tape was applied on his chest skin, and 3 liter/minute nasal oxygen was given during the surgery. Hemodynamic parameters were kept stable until the end of the operation. ST segment depression on the ECG was improved gradually. The patient complained of no chest pain during the surgery and the operation was completed without complication.

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Figure 2. Case 2, 64-year-old male with mild ST segment elevation on the ECG during surgery.

Case 3 was a 70-year-old male with type VI baldness with a history of left lung tuberculosis and who had undergone a left upper lobectomy and thoracoplasty operation when he was 20 years old. He had no history of coronary artery disease, diabetes, or hypertension. He needed no maintenance medicine.

One session was performed and a total of 1,476 grafts were transplanted in his frontal and central area. Blood pressure was stable around 130-150/80-100mmHg, heart rate was 70-86 beats per minute, and SpO2 was kept around 96-97% during the surgery. However, the author noticed 0.3 millivolt depres-sion of the ST segment on the precordial ECG in lead II, which

Figure 3. Case 3, 70-year-old male with significant ST segment depression on the ECG during surgery.

Case 4 was a 66-year-old male with type V baldness who had a history of hypertension and hyperlipidemia and no other disease. The first session was performed without any complica-tions, and 1,920 grafts were transplanted.

One year later, however, he was diagnosed with severe coro-nary artery stenosis and he needed a PCI procedure with PCI stenting treatment. Because coronary artery stenosis advances gradually over many years, this indicated that the patient already had latent coronary artery stenosis at his first session. He did not realize that his chest discomfort was the result of coronary artery disease, and he never consulted a cardiologist. It could be said that the author was simply lucky to have performed his first session without a cardiac event. It is important to note that some elderly patients may have latent coronary artery disease, even if they don’t have chest pain or specific past history.

ResultsAll patients underwent safe and successful operations. Precor-

dial ECG, blood pressure, SpO2, and heart rate were monitored during the procedure. Usage of analgesics and sedatives was important as was prophylactic usage of a nitroglycerin tape.l Nasal oxygen was supplied to prevent hypoxemia during surgery. Nitroglycerin inhalation spray, anti-arrhythmic drugs, and other drugs were prepared for emergencies.

DiscussionPerioperative cardiac events include cardiac ischemia and

arrhythmia, which could cause angina pectoris, myocardial infarction, and other cardiac complications. Once a patient has suffered a coronary event, the risk of recurrence is high. Some arrhythmias may be a sign of myocardial ischemia. To prevent cardiovascular events during surgery, it is important to predict latent coronary artery disease before the surgery. Systemic ath-erosclerosis indicates existence of latent arterial sclerosis in the coronary artery and cerebral artery, which may increase the risk of perioperative myocardial ischemia and cerebral ischemia in patients who undergo non-cardiac surgery.1

Systemic atherosclerosis can be anticipated by the patient’s history and age. Even if a patient has no specific past history, you should consider the existence of latent arterial sclerosis in patients over 60 years old and also in patients with risk factors such as diabetes, cigarette smoking, hypertension, hyperlip-idemia, obesity, and hyperuricemia, which contribute to the


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progression of systemic atherosclerosis. In patients with the possibility of latent systemic atherosclerosis, it is essential to be prepared for any complication.

Usage of prophylactic drugs is crucial to stabilize the patient’s hemodynamic state. Anticipation of the catastrophic complica-tions means monitoring to detect early hemodynamic changes.

Blood pressure. If systolic blood pressure goes lower than 70mmHg during surgery, the patient is in danger of sudden car-diac arrest. It is important to elevate the patient’s feet and put the patient in the supine or the Trendelenburg position as soon as possible. If systolic blood pressure goes higher than 90mmHg, we can continue the operation.

If systolic blood pressure is higher than 180mmHg before surgery, the patient is in danger of cerebral bleeding. The patient should be given a sedative and vasodilator as soon as possible. When the systolic blood pressure goes lower than 160mmHg, the operation can begin. In a patient with aortic aneurysm, systolic blood pressure should be kept lower than 140mmHg.

Change of diastolic blood pressure is usually a secondary issue of the systolic pressure and is unimportant. Chronically persisting high or low diastolic blood pressure is another subject, which relates to systemic atherosclerosis, stiffness of the large artery, aortic valve regurgitation, diastolic dysfunction of the heart, and chronic hemodialysis.

Heart rate. If the heart rate on the ECG drops below 40 beats per minute, enough oxygen is not being pumped out of the heart. Sinus bradycardia and bradyarrhythmia may cause too slow heart beat, which sometimes results in dizziness, syncope, shortness of breath, chest discomfort, low cardiac output syndrome, cir-culatory failure, and cardiac arrest. Trained athletes and some healthy individuals may have a slow resting heart rate of under 50 beat/minute. Resting bradycardia without symptoms is often considered normal.

A heart rate of greater than 140 beats/minute is unusual. Check the ECG if atrial tachycardia is caused by paroxysmal supraventricular tachycardia, atrial flutter, and atrial fibrillation, or ventricular tachycardia. Excessive tachycardia causes less ef-ficient pumping, decreased cardiac output, increased myocardial oxygen demand, relative cardiac ischemia, and heart failure.

A heart rate between 120-130 beats/minute is usually not seri-ous tachycardia, which may be a normal physiological response to exercise and stress, and the heart rate will decrease after some rest. If you feel a strong pulse on the radial artery even in tachy-cardia, it means that the peripheral perfusion is preserved and there is enough time to treat the tachyarrhythmia. If the pulse rate is less than the heart rate, the pulse deficit means that tachycardia has caused insufficient filling in the cardiac cycle. Management of tachyarrhythmia is mandatory. If you feel only a weak pulse on the radial artery, it suggests that enough blood is not being expelled out of the heart by each contraction and the patient is in low cardiac output. You should treat the tachyarrhythmia as soon as possible.

Permanent atrial fibrillation without extreme tachycardia or bradycardia is not dangerous. Safe operation is possible as usual in patients with permanent or established atrial fibrillation.

Cardiac ischemia. In patients with coronary artery stenosis, hypotension, hypoxemia, and tachyarrhythmia might trigger

myocardial ischemia and therefore must be prevented. Chest discomfort and angina are prevented by analgesia, sedative, oxy-gen, nitroglycerin, and avoidance of hypotension. Hemodynamic stability is most important.2

Risk stratification of cardiac ischemia. There are different phases for myocardial ischemia. The first phase is a preclinical phase, which means a state before the onset of chest pain. ST segment change on ECG, hypotension, hypoxemia, and arrhyth-mia are early signs of myocardial ischemia. It is important to detect the signs before the onset of clinical symptoms. Treat-ment should be commenced at this preclinical phase. The second phase is a clinical phase, which means onset of chest pain, chest discomfort, cold sweat, nausea, and shortness of breath. In this phase, treatment of myocardial ischemia is mandatory and hair transplant surgeons should send the patient to an emergency room. The third phase is the hemodynamic deterioration phase with acute circulatory failure and cardiogenic shock, which is dangerous.

It is important to begin treatment in the preclinical phase be-fore the onset of chest pain. You should always ascertain during surgery if a patient is in a stable hemodynamic state and judge whether to continue or discontinue the surgery.

Severe symptoms of myocardial ischemia never come out suddenly. Before the onset of clinical symptoms and hemody-namic deterioration, there is always a preclinical phase with early signs of myocardial ischemia. If you check ST segment change on ECG, hypotension, hypoxemia, and arrhythmia every several minutes, you will notice the early signs of cardiac ischemia. Hy-potension, hypoxemia, and emotional stress are the factors that can be treated and eliminated. Arrhythmia can also be treated. Coronary vasoconstriction can be prevented and treated using a coronary vasodilator. If you begin effective treatment at the preclinical phase, patients will recover from cardiac ischemia and will not proceed to the clinical phase and the deterioration phase of cardiac ischemia, thus preventing cardiovascular events during surgery.

Sympathetic nerve activity. Sympathetic nerve activity is important for patients with coronary artery disease and cerebral artery disease. Mental and emotional stress and high blood pres-sure means increased sympathetic nerve activity, which may trigger arrhythmia and coronary artery spasm, and could lead to heart attack and stroke. Therefore, avoidance of pain, anxi-ety, distress, hypertension, hypoxemia, and arrhythmia during the procedure is crucial. Frequent monitoring of hemodynamic parameters is helpful. Blood pressure should be measured at least every 1-2 minutes. Usage of analgesics and sedatives be-fore surgery is very important to alleviate anxiety and distress, to decrease sympathetic nerve activity, and to treat high blood pressure and arrhythmia.3

Nitroglycerin. Prophylactic usage of a nitroglycerin tape or patch is safe and very useful. Absorption of nitroglycerin through the skin is relatively rapid. Stable therapeutic effect of nitroglyc-erin can be obtained 30 minutes after application of a tape on the skin, and one hour after usage of a patch. Dosage of continuous infusion of nitroglycerin is 0.2-0.5 microgram/kg/minute for pre-vention of myocardial ischemia, and 1-2 microgram/kg/minute for treatment of angina pectoris. This means that one or two tape or patches will be enough for prophylactic usage. In a patient of about 40-60kg body weight, one tape will be enough to achieve a therapeutic nitroglycerin level.

Safety measures from page 117


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Maximal blood nitroglycerin concentration will be achieved at 3.6 hours after application of a tape on the skin and the effec-tive nitroglycerin level can be maintained for 12 hours using a tape. Nitroglycerin absorbed through the skin enters the systemic circulation in an active state. This is in contrast to oral medicine, which is absorbed through the intestine and passes the liver through the portal vein, which results in initial inactivation.

Possible side effects of nitroglycerin are palpitation, hypoten-sion, and headache. These side effects seldom occur with usage of only one tape or patch on the skin. If you suspect that low systolic pressure is caused by a nitroglycerin tape, blood pressure will recover easily after removal of the tape. Prophylactic usage of a nitroglycerin tape is safe and effective for patients with coronary artery stenosis. Therefore, the author recommends prophylactic usage of a nitroglycerin tape or patch for elderly patients with the possibility of latent coronary artery disease.

For sublingual usage of nitroglycerin, an inhalation spray is more convenient than a tablet for patients with dry oral cavity under sedation. One push spray provides 0.3mg nitroglycerin, which is equivalent to one sublingual tablet. Maximal blood nitroglycerin concentration can be obtained 4 minutes after sublingual usage. You can repeat sublingual nitroglycerin every 5 minutes up to 3 times, if necessary.

Maintenance medicines. The requirements for acceptance of patients with cardiac, vascular, and cerebrovascular disorders are as follows. Patients should be on medication with stable doses under the care of experienced cardiologists at outpatient clinics. Therapy optimized for more than three months without hemodynamic and electrocardiographic complications is crucial. All maintenance medicines should be continued on the day of operation. Anti-hypertensive, anti-arrhythmic, vasodilator, seda-tive, anti-allergic, and other kinds of drugs should be continued in the same maintenance doses before surgery. Nitrates and calcium channel blockers for prevention of vasospastic angina should be continued. In addition to these maintenance medicines, analgesic, sedative, nitroglycerin, oxygen, and anti-arrhythmic drugs should be given during surgery, if necessary.

Beta-blocker. Patients with hypertension, arrhythmia, or ischemic heart disease sometimes take beta-blocker as one of their maintenance medicines. If the patient is in a stable state with daily per oral intake of beta-blocker, it must be continued in the maintenance dose before the surgery.4 If it is discontinued before the hair transplantation, it will result in uncontrollable hypertension, increase of ventricular arrhythmia, and increased risk of ischemic heart attack.

Anti-thrombotic therapy. Patients with cardiac, vascular, and cerebrovascular disorders sometimes take anti-coagulant drugs and anti-platelet drugs as maintenance therapy. You should talk to the patient’s physician about control of these medicines. If the cardiologist doesn’t mind stopping the anti-coagulant drug for several days, warfarin should be discontinued 3 days before surgery and restarted after the surgery. If the cardiologist doesn’t allow you to stop warfarin for a few days, it should be continued. If allowed, warfarin should be reduced to 1/2-2/3 of the maintenance dosage for 3 days before the surgery. To de-termine the optimal dose of warfarin, prothrombin time should be measured.5

You should also talk to the patient’s physician regarding anti-platelet drugs. If the cardiologist doesn’t mind stopping anti-platelet drugs, the drugs can be discontinued for 3-7 days

before the surgery and restarted after. If the cardiologist doesn’t agree to stop anti-platelet drugs, anti-platelet drugs should be continued.6,7

Epinephrine (adrenaline). Usage of epinephrine in patients with cardiac diseases is not dangerous for patients with cardiac disor-ders, if not injected directly into the vessels. The amount of epi-nephrine in the tumescence can be reduced to 1/2-1/3 of the usual dose without problem of uncontrollable bleeding from slits.

Bronchial asthma. In patients with bronchial asthma, main-tenance drugs including bronchodilator and steroid should be continued on the day of the operation. The author usually applies a tape or patch of beta 2 stimulant in order to prevent an asthma attack during the surgery. For an adult patient, 2mg tulobuterol (editors note: this is a long acting beta2 agonist available mainly in Germany and Japan) tape works effectively for prevention of an asthma attack and has no serious side effects. Usage of a tape on the chest skin should make the operation safe and eventless. After the surgery, the tape should be removed.

You can also use an inhalation spray of beta 2 stimulant (salbutamol, etc.) for the treatment of an asthma attack in drowsy patients under sedation. One or two push sprays can be repeated every 5-10 minutes.

In patients with a history of aspirin asthma, discuss and select a safe painkiller before the surgery. Prophylactic oral intake of an anti-allergic drug before the session and usage of beta 2 stimulant tape or patch during the surgery should be effective to prevent an allergic asthma attack.

Fever. High body temperature suggests dehydration, hypo-volemia and metabolic acidosis which may result in circulatory collapse and brain damage. If the resting body temperature is higher than 38 degrees Centigrade (100 degrees Fahrenheit), the operation should be postponed a few days until the body temperature becomes normal.

Physiological Change and Organ Dysfunction The possibility of latent cardiovascular disorders and cere-

brovascular disorders is very high in patients over 75 years old. Even if the patient has no symptom or specific past history, you should consider that the patient over 75 years old has some cardiovascular disease and cerebrovascular disease. ECG should be monitored in every patient over 60 years old. The author recommends prophylactic usage of a nitroglycerin tape or patch in patients over 60 years old.

Furthermore, elderly patients have the possibility of impaired liver and kidney function. Metabolism of medicines in elderly patients is not the same as with young people. The effect of medi-cines may be different even in the same plasma concentration. For example, in elderly patients there is a decreased response to beta blocker and tolbutamide, whereas their response to calcium channel blocker, warfarin, diazepam, morphine, and pentazocine is increased. Thus, it is important to carefully select and dose medicines in elderly patients.

ConclusionThe above guidelines allow for safe surgery in high-risk

elderly patients with coronary artery disease, cardiovascular disease, or cerebrovascular disease. Anticipation of possible emergency situations, monitoring of parameters, and usage of prophylactic drugs are crucial.


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Safety measures from page 119

In patients with cardiac, vascular, and cerebrovascular disor-ders, anticipation of catastrophic situations, careful preparation for management of the possible situations, and usage of prophy-lactic drugs are crucial to stabilize hemodynamic states during the surgery. The following helps break down the management of elderly hair transplant patients:1. In patients over 60 years old or patients with history of car-

diovascular disease, monitoring of electrocardiogram, pulse oximeter (SpO2), blood pressure (every 2-3 minutes), and heart rate are mandatory during surgery.

2. If the systolic blood pressure before surgery is 180mmHg or higher, you should wait after using sedative and vasodilator until systolic blood pressure becomes 160mmHg or lower.

3. Anemia should be corrected before surgery to decrease the risk of cardiovascular ischemia and heart failure.

4. Prophylactic usage of a nitroglycerin tape or patch is safe and useful to prevent cardiovascular events in a patient over 60 years old, who has a possibility of latent coronary artery stenosis.

5. Mental and emotional stress and high blood pressure mean increased sympathetic nerve activity, which may trigger ar-rhythmia, coronary artery spasm, anginal pain, and cerebral ischemic stroke.

6. Usage of analgesics and sedatives is important to avoid pain, anxiety, and distress during surgery.

7. Epinephrine in tumescence can be used in usual does or in a half dose.

It is also imperative to consider medications the patient may be taking prior to surgery: 1. Patients should be on medications with stable doses under

the care of experienced cardiologists at outpatient clinics. 2. Therapy optimized for more than three months without he-

modynamic complications is crucial to the safe operation. 3. Anti-hypertensive, anti-arrhythmia, vasodilator, sedatives, and

other drugs should be continued in the maintenance doses. 4. Maintenance dosage of beta-blocker should be continued.

Finally, there are contraindications to surgery that should be followed. The following are physiologically unstable states. You should wait for a while, keeping the patient at rest, until circulation and respiration become stable. If the patient is still unstable in spite of the treatment, postpone the operation. Pay close attention to the following: 1. Resting heart rate of under 40 beats per minute or more than

130 beat/minute 2. Resting systolic blood pressure lower than 90mmHg or

higher than 180mmHg 3. Effort angina with chest pain 4. Atrial fibrillation with extreme bradycardia or tachycardia 5. Shortly after acute myocardial infarction with unstable

hemodynamic state 6. Tachyarrhythmia or frequent ventricular premature contrac-

tion 7. Chest pain at rest 8. Symptoms of palpitation, cold sweat, and shortness of

breath

9. Dizziness, syncope, and nausea at rest 10. Resting body temperature higher than 38 degrees Centigrade

(100 degrees Fahrenheit) 11. Hypoxemia: SpO2 at rest lower than 90%

References 1. Poldermans, D., et al. A clinical randomized trial to evaluate

the safety of a noninvasive approach in high-risk patients undergoing major vascular surgery. The DECREASE-V pilot study. J Am Coll Cardiol. 2007; 49:1763-1769.

2. Kushner, F.G., et al. 2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percu-taneous coronary intervention (updating the 2005 guideline and 2007 focused update). A report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. Available at http://circ.ahajour-nals.org. Circulation 2009. Accessed November 19, 2009.

3. Gulliksson, M., et al. Randomized controlled trial of cog-nitive behavioral therapy vs standard treatment to prevent recurrent cardiovascular events in patients with coronary heart disease: Secondary Prevention in Uppsala Primary Health Care project (SUPRIM). Arch Intern Med. 2011; 171:134-140.

4. Fleischmann, K.E., et al. 2009 ACCF/AHA focused update on perioperative beta blockade. A report of the American College of Cardiology Foundation/American Heart Associa-tion task force on practice guidelines. Available at http://circ.ahajournals.org. Circulation. 2009. Accessed November 4, 2009.

5. Hirsh, J., et al. American Heart Association/American Col-lege of Cardiology Foundation guide to warfarin therapy. J Am Coll Cardiol. 2003; 41:1633-1652.

6. Fuster, V., et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation. A report of the American College of Cardiology/American Heart As-sociation task force on practice guidelines and the European Society of Cardiology Committee for practice guidelines (writing committee to revise the 2001 guidelines for the management of patients with atrial fibrillation). J Am Coll Cardiol. 2006; 48:e149-246.

7. Pignone, M., et al. Aspirin for primary prevention of cardio-vascular events in people with diabetes. A position statement of the American Diabetes Association, a scientific statement of the American Heart Association, and an expert consensus document of the American College of Cardiology Founda-tion. Available at http://circ.ahajournals.org. Circulation. 2010. Accessed June 5, 2010.



Introduction to the use of implantersJosé Lorenzo, MD, Ximena Vila, MD Madrid, Spain [email protected]

Since Yung Chul Choi began using the first types of implant-ers in the early 1990s, there have been many opinions written both for and against their use in hair transplantations. Only a very few hair transplant surgeons use implanters, and improvements made in the design and material used have not succeeded in gaining any interest. The reason for this is because the implanter requires in-depth knowledge and precise techniques for it to be beneficial to the surgeon. Without this technique, any professional who may have tried the implanter would probably soon have abandoned it due to the extra effort involved, complications, and lack of adequate preparation.

We have been using the implanters every day since 2003 and have learned from self-experience, evolving and changing in such a way that the implanter has become an indispensable tool for us during follicular unit implantation.

The ImplanterThe implanter

consists of an ex-ternal recyclable plastic shell, with an internal dis-posable grooved needle (Figure 1). The needle is changed before or during every procedure, whenever we notice that it has be-come blunt.

We first need to open the plastic shell to change the needle and, after changing, attach the needle using the external circular clip. Always check that the internal guide is at the same level as the point of the implanter. If incorrectly positioned, the insertion of the units will be more difficult.

Once the implanters are correctly assembled, they are then sterilized. In our case, we use conventional and authorized chemical sterilization.

There are two main sizes of needles that we use: 0.80mm (for units of 1 and 2 hairs) and 1mm (for units of 2, 3, and 4 hairs). As we explained in the previous edition of this publica-tion (Hair Transplant Forum Int’l. 2011; 21(3):82), we place a lot of importance on the quality of the needle: the internal and external diameter, the groove width, the edge, the point, and the surgical steel are all fundamental factors when it comes to working without complications. The measurements of our cur-rent implanters are:Item number External diameter Internal diameter Channel width Body length

Lion HT 08 0.8mm 0.6mm 0.30mm 104.0mm

Lion HT 10 1.0mm 0.8mm 0.37mm 104.0mm

Circulation of the ImplanterOur position at the table when it comes to loading the implant-

ers has evolved notably during these past few years. We regularly work with 2 techs and 4 implanters (two of 0.80mm and two of 1mm). Their task is to load the implanters; the left side nurse acts as the table leader and is the person in charge of placing the im-

planters in the exact posi-tion so that the surgeon can take them without looking at the table. The technician on the right side of the table is in charge of keeping the follicles left on the gloves completely hydrated, the anesthesia, and the gauze. The table is flanked on the right-hand side by the Petri dishes and on the other sides by compressed tissues that act as small barriers so that the implanters can roll without the risk of falling off (Figure 2).

The circuit of the im-planters should be very strict and coordinated to avoid accidents. The sur-geon must be positioned at the head of the patient; if right–handed, the table must be on his right-hand side at a distance no longer than half the length of the surgeon’s arm (Figure 3).

Operating with magnifying glasses, the surgeon’s vision should be fixed on the area that is being operated on. The sur-geon never looks at the auxiliary table but knows automatically where the instruments are. The loaded implanters are always on the front part of the table, on the right, with the point facing outwards (the technician always keeps an eye on its correct position). The unloaded implanters are left on the internal part, against the Petri dishes, with the point facing to the front. The surgeon’s hand, as it is blind, dominates the surgical site and always has preference over the nurse’s hands. As in all surgical sites, there is never anything passed from hand-to-hand and no one can access the site while the surgeon’s hand is present there. The implanter has to roll on the table in a controlled fashion. The “rolling” is very important because it helps the dynamism and rapidness of the procedure.

Lastly, the position of the patient is more inclined than that used for the forceps technique, particularly when operating on the frontal section. We must take care not to over-stretch or over-exert the neck, to avoid compromising the blood flow return and increase bleeding.

Technique Used to Place the Units in the Grooved NeedleOur team performs only the FUE

technique. As we mainly use punches of 0.75/0.80mm for the extraction, it is not necessary to use a microscope to trim the borders (Figure 4). This implies that all of the units are surrounded with epidermis above the sebaceous gland. This is fundamental as it plays an important part in: • Depth control: the units always stay at the

Figure 1. Implanter assembly.

Figure 2. Circulation of the implanter.

Figure 3. Positioning of the surgeon, patient, tray, and technicians.

Figure 4. Graft with and without epidermis.


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Figure 6. Loading the implanter.

same level and avoid getting buried (Figure 5). With practice, the movements with the implanter can be very quick. The absence of a limit can cause many units to be inserted to an incorrect depth, which results in a lower survival rate.

• Hemostasis: as the surgical area is not predesigned, the epidermis of the follicular unit acts as a plug when inserted into the hole made by the needle, and thus avoids bleeding (Figure 5).

Introduction to implanters from page 121

• The nurses always handle the units touching the epidermis only, thereby avoiding traumatizing the follicle.

Any skeleton units (without epidermis) are separated and left until the end of the procedure, with greater attention paid

Figure 5. Depth control.

to their insertion, or are used as part of multiple units. The nurse holds the implanter in her left hand supporting the edge of the needle with her fifth finger (Figure 6).

• The right hand supports the unit by the epidermis, places it in the bevel, and turns the head of the unit upwards. Only in this moment can we gently slip the unit through the canal. It is a delicate action that must not be forced, and as mentioned, the unit is never touched in critical sites but only on the epidermis. The grafts stay completely inside the needle and therefore remain protected until placed. As noted, there are always 2 to 4 implanters on the table; this way, the units are not af-fected by dehydration. Grafts are held in saline solution until loaded and then quickly implanted, the whole process takes seconds. In experienced hands, the velocity of implantation can reach up to 700 units per hour (500-900 depending on the characteristics of the dermis, elasticity, and hemostasis).


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How I Do ItBertram Ng, MD Hong Kong, China [email protected]

Here is an excellent article from Dr. Muhammad Ahmad regarding his donor wound closure. Yes, we all have our own favourite techniques, but learning how others do the same job always shines light into our search for perfection.

After taking a strip width of 2.2cm, there is often a mismatch in the superior and inferior flap edges. I usually take deeper bites in the lower flap to bring it up to level with the upper one. Dr. Ahmad, on the other hand, advocates taking more superficial bites in the lower flap to elevate the skin of the upper flap for more overlapping.

I am an obsessively neat surgeon and always lay the stitches at regular depth and spacing. Here, Dr. Ahmad raises the idea that the stitches should be irregularly placed to avoid a uniform constricting effect.

What do you think? Please share your thoughts and comments with us.

A technique for achieving minimal donor scarsMuhammad Ahmad, MD Islamabad, Pakistan [email protected]

BackgroundThere are 2 major goals for every hair transplant surgeon: 1)

a natural looking anterior with good density, and 2) a minimally visible donor scar. Various methods have been described in the literature regarding personal techniques and their results.1-3

Technique and DiscussionIn my hair transplant procedures, I always perform the vertical

skin mobility test. I tape the hair upwards to look for the best site for donor harvesting.4 The width of the strip usually ranges from 1.5-2cm, and in a few cases may be more than 2cm. With the patient in a prone position, I excise the strip using a no. 10 surgical blade, taking great care to remain above the aponeurosis at all times. Good haemostasis is achieved by using bipolar cautery. The lower and upper flaps are then undermined up to 0.5-1cm depending on the width of the strip. I always grasp the edges with two forceps and repeat the vertical mobility test until there is an overlap of 2-3mm. This is followed by lower trichophytic closure with 1-2mm de-epithelization. The wound is then closed in a single layer using 3-0 non-absorbable monofilament suture (polypropylene). Special care is taken to avoid any tension on the suture line.

I prefer to vary the distance between the suture bites. This variation prevents a uniformly constrict-ing effect along the wound margins, and better protects the underlying circula-tion. I also vary the depth of the bites but ensure that the bite on the upper flap is always about 1mm deeper than the lower flap (Figure 1). This helps to elevate the skin of the upper flap. A deeper bite in the upper flap produces a “lift-effect,” and allows proper overlapping of the trichophytic edges (Figure 2). More follicles growing within the scar definitely reduces the distance between hairs.

The sutures are removed on the 10th or 11th postoperative day. The use of topical steroid cream is not recommended. We then routinely assess the scars after 6 and 12 months.

ConclusionI have been using this technique for the last two years, producing

good donor scars (Figure 3). The extra “lift” of the stitch provides extra skin at the wound margins. This technique has produced fine scars (1mm or even less), and has also helped to avoid a “step-de-formity” in the scar, which is usually due to tight closure.

References1. Neidel, F.G., and K. Leonhardt. The invisible scar—a pro-

spective randomized study on 100 patients comparing clas-sic suture technique with Frechet suture technique. ESHRS Journal. 2006; 6(1):6-7.

2. Frechet, P. Scalp surgery with invisible scars. ESHRS Jour-nal. 2005; 5(1):10-11.

3. Gaviria, J., and A. Trius. Invisible or minimal scar closure versus standard subcutaneous closure: progress report. ESHRS Journal. 2008; 8(1):6-7.

4. Mohmand, M.H. Invisible donor scar in wedge closure: a way forward or an alternative to FUE? Presentation at the 14th Annual Scientific Meeting of the ISHRS. 2006 (October 18-22). San Diego, California, USA.

Figure 1. Suturing technique.

Figure 2. Details of the technique.

Figure 3. Case 1: donor strip width 2.1cm, 9 months post-op; case 2: donor strip width 2.3cm, 8 months post-op; and case 3: donor strip width 2.4cm, 7 months post-op.


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Cyberspace ChatSharon A. Keene, MD Tucson, Arizona, USA [email protected]

The following discussion regarding the issue of green tea, and its efficacy to treat iron overload by impeding iron absorption, is based on a clinical case I encountered in my practice. I raised the question of whether this might also cause iron deficiency, which could impact hair loss. This led to a discussion on the evidence supporting the relationship between iron deficiency and hair loss, which remains controversial, and which will be reviewed in the column as well.

Green tea, iron deficiency—is there a relationship to hair loss?I began the discussion with this comment:I enjoy learning about novel medical management from my

patients. I was surprised to learn that one of my patients, who was diagnosed with hemochromatosis, was able to control his over absorption of iron by consuming a daily combination of green and black tea extracts, which obviated a need for phlebotomy. Natu-rally, I was curious to know if there was any medical literature to support this therapeutic approach—and found at least one abstract on the subject.1 It is great to know there is a non-phlebotomy treat-ment for hemochromatosis. However, on the flip side, we know that iron deficiency and non-anemic low ferritin levels are thought to be a cause of hair thinning. Thus, should we be counseling patients against the consumption of green tea, etc.?

Bob Haber quickly responded:I would not jump to counseling against the consumption

of green tea in the absence of evidence that it causes anemia. Reducing utilization of dietary iron does not equate to anemia or depleted iron stores. There are populations that consume vast quantities of green tea, but I’m not aware of widespread anemia in those populations. I think a more reasonable question is: Does consumption of green tea cause anemia? If that were to be proved, then perhaps for our patients with low iron and ferritin, it would be appropriate to counsel against excessive green tea consumption.

I countered:Given that Dr. Hugh Rushton published a paper in 1992 in-

dicating that treatment of hair loss is impacted with non-anemic serum ferritin levels < 40ug/l—we may not have to see anemia.2 In fact, I reviewed labs on a woman patient this week with mild hair thinning, completely normal Hgb/Hct and a ferritin of 30, which is within normal range. I will still recommend iron supplements, and to avoid green tea with meals. The young man I mentioned had very high levels of ferritin that were completely normalized by green tea and black tea extracts. In the case of a normal baseline ferritin, wouldn’t a similar drop in ferritin be potentially detrimental to iron stores? When I see male patients with thinning, I recommend finasteride, but I don’t usually evaluate them for other contributory causes of hair loss and thin-ning—I never check labs unless I am doing preoperative labs for surgery. We previously discussed the fact that hairs affected by AGA may be at greater risk for the effects of stress, and that this may be a cause for acceleration of hair loss. This raises the question of whether factors such as iron deficiency may inhibit the benefit of medical therapy such as finasteride.

Dr. Haber responded:I’m simply encouraging scientific thinking and evidence

based decision making. While we all “know” that anemia, low iron, and low ferritin are associated with hair loss, there is pre-cious little, if any, scientific evidence that correcting anemia, iron stores, and ferritin levels produces predictable reversal of hair loss. Certainly some anecdotal experiences exist, but I’ve identified these lab abnormalities in hundreds of women, at least tried to correct all of them, and cannot honestly state that any of them reported significant hair recovery. These lab changes might be secondary to some other process, so correcting the lab abnormality may not be the right fix.

Regarding green tea, there are areas of Japan where 80% of the population consumes large quantities of green tea on a daily basis. Surely these populations should be ferritin depleted and balding if indeed green tea causes the stated problems. These populations have been studied to find evidence of the health ben-efits of green tea, and I am not aware of any detrimental effects. So I don’t believe there is any evidence to support restricting green tea consumption in people with hair loss, particularly with the well-studied health benefits of green tea. I need better data to support such a recommendation.

Nilofer Farjo shared:Attached is an article on patients with haemochromatosis

treated with tea. My understanding of the subject is that iron ab-sorption is mainly affected by iron stores. There are a few things that increase (e.g., Vitamin C) and a few things that decrease iron absorption (e.g., tea) when taken at the same time as food. The effect is different for heme and non-heme (plant source) iron.3 The only time that I saw the consumption of tea with food causing iron deficiency was in infants and toddlers given bottles of tea to drink. Their iron requirements being much higher than adults, it caused a problem. As adults, it’s mainly women who lose iron and need higher iron uptake so perhaps the advice to women who are iron deficient should be to avoid drinking tea with their meals.

Pertinent to the issues posed by Dr. Haber, Ed Epstein asked:Just curious, in women who you may have treated for low

ferritin levels, when returned to normal, did their hair loss im-prove?

Mel Mayer shared his experience in treating women with low ferritin levels:

Over the past 19 years, I have diagnosed many low ferritin


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women—I can’t remember one who with correction over 1-2 years had significant improvement in hair density. This would be a great “hair mass” study.

In contrast, Arthur Tykocinski commented:Usually, iron deficiency is not the cause of hair loss, but

causes additional shedding when hair loss is present. Not just that, but it can also decrease the effect of anti-androgen therapy. The iron supplement should be continued for at least 6 months, and must be taken 1 hour before or 2 hours after meals.

Richard Shiell responded with this counterpoint:It must be 40 years since I read the first report in the literature

associating iron deficiency with hair loss in females. I got quite excited about it and did a lot of iron studies and suggested iron supplements for the ladies, but I do not recall EVER seeing any improvement. I gave up on it by about 1975 when I became convinced that low iron levels are so common in women that the association with hair thinning may be purely coincidental. People keep bringing up this old research without any evidence of a causal relationship or evidence that the condition can be reversed by restoring iron levels.

Finally, Jerry Cooley shared these thoughts:The literature on iron levels and hair loss are confusing

and contradictory, as described in a recent meta-analysis in the Journal of the American Academy of Dermatology (JAAD).4

My experience over the years has been that iron is a necessary but not sufficient factor in optimal hair growth. There certainly seems to be a strong connection between low iron and telogen effluvium in my patients. I always check and correct. For female pattern hair loss, correcting iron alone does nothing (except prevent chronic effluvium), but it is important to do this before expecting a response to medical therapy and a successful trans-plant. I agree with Arthur.

DiscussionThe importance of normal iron stores in human health is

underscored by the fact that iron is vital for all living organisms because it is essential for multiple metabolic processes, including oxygen transport, DNA synthesis, and electron transport.5 Iron deficiency is known to be the most common nutritional deficiency in humans worldwide, and has been shown to cause developmen-tal delay, intellectual dysfunction, and immune compromise—to name only a few of the adverse physiologic responses to this mineral deficiency.6 In light of these facts, maintaining healthy iron homeostasis is important as a general health concern. The incidence of iron deficiency is higher in pre-menopausal women than men, relative to blood loss from the menstrual cycle and pregnancy. In men, iron deficiency is usually secondary to GI tract blood loss, or malabsorption. The discovery of the protein, hepcidin, produced in the liver and which suppresses enterocyte absorption of iron, appears to be the critical factor in charge of iron absorption from enterocytes as well as tissue distrubution.7 Hepcidin levels appear influenced by signals from molecules reflective of iron stores as mentioned by Dr. Farjo. However, hepcidin can also be stimulated by factors such as inflammation and hypoxia, leading to the “anemia of chronic disease,” as well as by reduced levels in the presence of liver disease, leading to iron overload. Interestingly, a mouse model with “over expres-

sion” of hepcidin not only expressed iron deficiency anemia but also experienced hair loss.8 For a convenient in-depth discussion on the diagnosis and treatment of iron deficiency I refer readers to the online medscape reference link.5

The Centers for Disease Control and Prevention (CDC) recommends that all pre-menopausal women be evaluated for iron deficiency anemia every 5 years, and annually for those at high risk or previously anemic. For men and post-menopausal women, there are no routine recommendations except as clini-cally indicated.

There are many known dietary inhibitors to impede iron absorption from the small bowel, for instance, proton pump inhibitors used to treat gastric acid reflux can impede Vitamin C (ascorbic acid) excretion in gastric fluid. Without Vitamin C in the gastric fluid, less iron is absorbed. In addition there are a number of other dietary constituents that impede absorp-tion, among them the polyphenols in green tea. As a medical principle it is useful to know if there are foods or drink that may inhibit iron absorption, especially for patients who are or should be treated for this condition. According to researchers, it is the polyphenols in tea that impede absorption of non-heme (plant based) iron. Nutritionists at Pennsylvania State University revealed that polyphenols bind to iron in intestinal cells creat-ing a non-transportable complex that is not absorbed, and is subsequently excreted in feces.9 Apparently, there are numerous dietary constituents that render non-heme iron nonabsorbable such as phytates (bran, cereal grains, flour, legumes, nuts, and seeds), phosphates (food additive in the EU), tannates (tea and coffee), oxalates (rhubarb, nuts, tea, cocoa), and carbonates (antacids). Non-heme (plant) iron has 10% bioavailability, in contrast to heme (meat) iron with a 30% bioavailability.6 The latter has a different chemical structure and is not chelated by these constituents. Therefore, diets higher in meat portend less risk for iron deficiency; and the aforementioned iron inhibitors are a focus of attention in low-income countries where diets are largely plant based.

Although there are published articles to discuss the effect of tea extracts in treating hemochromatosis by impeding iron absorption, there were no prospective studies that assessed iron concentrations before and after a period of tea consumption—as Dr. Haber had suggested was needed to draw a conclusion. In-stead, at least one unpublished study in South Africa concluded that black tea consumption did not have an effect on iron absorp-tion and that the population evaluated had no greater incidence of anemia.10 Nevertheless, general recommendations in the nu-tritional literature are to avoid iron inhibitors for patients being treated for iron deficiency anemia.

As an issue for specialists in the treatment of hair loss, the more pertinent question may be: How important is correcting iron deficiency in the treatment of hair loss? As Dr. Cooley mentioned, a meta analysis reviewing a myriad of published studies on the relationship between iron deficiency and hair loss was reported in a recent JAAD.4 This was an update on the article written by the same authors in 2006.6 The findings of this group from the Cleveland Clinic conclude there are contradictory reports in the medical literature that make it impossible to draw evidence based conclusions about the im-portance of evaluating or treating iron deficiency in patients with hair loss to improve outcomes. Although iron deficiency

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anemia always warrants treatment, the authors did not support treatment of non-anemic iron deficiency to maximize anti-an-drogen therapy, unless the patient was at high risk to develop anemia. This raises the question: What is the risk or prevalence of iron deficiency in our hair loss patients? Prevalence varies from country to country, and is related to local diets. It may be of interest to note a recent 2005 published survey of 121 recreationally active adults in the United States who were tested for iron deficiency; based on low ferritin levels it was found that 29% of pre-menopausal females and 4% of males were iron deficient without anemia (serum ferritin < 16ug/l).10 Clearly, the issue is one that affects more women than men. Despite the conclusions of the JAAD article, it seems likely that a systemic deficiency of iron can contribute to systemic physiologic stress—which is a well-documented cause of accelerated telogen hair loss, even if there is no direct link to hair growth.12 Nevertheless, a direct link to hair follicle growth was suggested by Hordinsky’s group from the University of Minnesota, based on the identification of 6 genes in the bulge region of the follicle that are influenced by iron.13

Based on the adverse impact that iron deficiency has on a patient’s general health, and the prevalence in women, there seems little harm to including this in an evaluation of female patients with hair loss. While the incidence of iron deficiency in men is much lower, unexplained telogen may be an appro-priate indication for at least an Hgb/Hct. Now that hepcidin has been identified as an important molecular modulator for iron homeostasis, it is likely we will learn more molecular details about the physiologic effects of iron, and whether this has a direct impact on hair growth/loss or whether the previous stud-ies indicating this association in some but not all patients are a general reflection of variable responses to systemic stress. For now, I will continue to evaluate women patients for anemia and low ferritin levels, and provide dietary recommendations for the latter, including the suggestion to avoid iron inhibitors, such as green tea, at mealtime.

References1. Samman, S., et al. Green tea or rosemary extract added to

foods reduces nonheme-iron absorption. Am J Clin Nutr. 2001; 73(3):607-612.

2. Rushton, D.H., and I.D. Ramsay. The importance of ad-equate serum ferritin levels during oral cyproterone acetate and ethinyl oestradiol treatment of diffuse androgen-de-pendent alopecia in women. Clin Endocrinol (Oxf). 1992; 36(4):421-427.

3. Kaltwassera, J.P., et al. Clinical trial on the effect of regular tea drinking on iron accumulation in genetic haemochroma-tosis. Gut. 1998; 43:699-704.

4. Trost, L.B., W.F. Bergfeld, and E. Calogeras. The diag-nosis and treatment of iron deficiency and its potential relationship to hair loss. J Am Acad Dermatol. 3 Feb 2011. Retrieved from http://www.eblue.org/article/S0190-9622%2805%2904745-6/abstract.

5. Conrad, M., and E. Besa. Iron deficiency anemia. Medscape Reference. 2011. Retrieved from http://emedicine.medscape.com/article/202333-overview#a0104.

Cyberspace Chat from page 125

6. Trost, L.B., W.F. Bergfeld, and E. Calogeras. The diagnosis and treatment of iron deficiency and its potential relationship to hair loss. J Am Acad Dermatol. 2006; 54:824-844.

7. Nemeth, E., and T. Ganz. Regulation of iron metabolism by hepcidin. Annual Review of Nutrition. 2006(Aug); 26:323-342.

8. Sasu, B., et al. Antihepcidin antibody treatment modulates iron metabolism and is effective in a mouse model of inflam-mation-induced anemia. Blood. 2010; 115:3616-3624.

9. Han, O. Polyphenol antioxidants inhibit iron absorption. Science Daily. 23 Aug 2010.

10. Bophirima, Y. The Association between black tea consump-tion and iron status of African women in the North West Province: THUSA study. Mini dissertation, 2005.



Epigenetic modifications may explain the relative protection of occipital hair follicles from androgenetic alopecia in menMansi Patel, MBChB, Prof. Rod Sinclair, MBBS, MD Melbourne, Australia [email protected]

IntroductionThe mode of inheritance of male pattern baldness (MPB) is

presently unclear, however, it is most likely polygenic with an androgen-dependent pathogenesis.

Androgen receptor (AR) is the key factor that mediates androgen action by its molecular effects on transcription and translation of cellular proteins.3 It has been suggested that an-drogen receptor levels are likely to be important in MPB. Frontal scalp of balding men has been found to have higher expression of androgen receptors compared to the occipital scalp and this is thought to be a major contributing factor to the site-specific follicular miniaturisation seen in androgenetic alopecia.2,3

Recent work has suggested that the reduced expression of androgen receptor in occipital scalp compared to the vertex may be explained by the increased DNA methylation of the androgen receptor gene in occipital follicles.4 This article briefly discusses this epigenetic process of DNA methylation in the context of this recent work.

Role of Androgen Receptor (AR) Gene in MPBThe actions of androgens are regulated by the androgen re-

ceptor that modulates the transcription of androgen-responsive genes thought to play a major role in the processes of follicular miniaturisation and androgenetic alopecia.3 It has been dem-onstrated that dermal papilla cells from balding scalps of men contain significantly higher androgen receptor levels than the non-balding follicles.2

The AR gene is located on the X chromosome indicating the importance of the maternal line in the inheritance of MPB.5 A number of studies have demonstrated the association between MPB and the AR gene.1,5,6 Ellis, et al. found an association between polymorphism in this gene and MPB, which was con-firmed by another association study.6 A recent study investigat-ing around the AR locus found two non-coding regions either side of the AR gene, both independently associated with MPB.7 These functional variants in and around the AR gene region have not been identified, but it is thought that they may in some way influence the site-specific and tissue-specific expression of the AR gene. It has been suggested that functional mutations in the upstream promoter regions of the AR gene lead to increased transcription and translation in the affected scalp of balding men.1 Recent work points towards a role of epigenetic processes that regulate gene expression in the pathogenesis of MPB.4

Mechanisms That Determine Gene ExpressionEpigenetics is the study of heritable changes in phenotype

or gene expression caused by mechanisms other than changes in the underlying DNA sequence. These non-genetic factors that alter gene expression are inherited from cell to daughter cell or from generation to generation.8 The term “epigenetics” was coined by C.H. Waddington towards the middle of the 20th century from the Greek word “epigenesis,” to term a theory of development.9 The process of cellular differentiation during

morphogenesis is an example of epigenetic change that results in a zygote giving rise to many different cell types as it divides by mechanisms that determine transcriptionally active and silent states of genes.10 Differentiated cells maintain their phenotype through subsequent cell divisions. Epigenetics includes a number of biochemical processes that regulate gene expression and make it possible for the same genome to execute numerous expression patterns specifying structural and functional cellular diversity. These processes affect chromatin structure leaving the underly-ing genomic sequence unaltered. One of these processes is called DNA methylation, and gene expression states generated from this are inherited through successive cell generations.

DNA MethylationDNA methylation is the longest known and most extensively

studied form of epigenetic modification. It is a postreplicative modification where a methyl group is covalently added to the 5 position of the cytosine pyrimidine ring mostly at CpG sites.10 CpG sites are regions of DNA where a cytosine nucleotide oc-curs next to a guanine nucleotide in the linear sequence of bases along its length, separated by a phosphate, which links the two nucleotides together. DNA methylation is a crucial part of cellular differentiation in higher organisms as it alters the gene expression pattern in a stable manner. At the 5 position of cytosine it has the specific effect of reducing gene expression.10

The short, dispersed regions of unmethylated DNA that have a high frequency of CpG dinucleotides, called CpG islands, are considered useful landmarks in the genome for identifying genes.11 They have been found to be associated with the 5’ pro-moter sites of genes, thus potentially having the ability to regulate gene expression. DNA methylation of such regions can alter the ability of regulatory proteins to bind DNA, key to silencing the expression of the associated downstream gene.8,10

Cobb, et al. recently compared DNA methylation patterns at the AR gene between hair follicles from the occipital and vertex scalp of 24 men with MPB.4 They found a significantly greater proportion of occipital hair follicles exhibited higher degrees of methylation in the CpG island located in the promoter and across the transcription start site of the AR gene compared to the vertex.4 These findings suggest that the reduced expression, and therefore reduced levels of AR in the occipital follicles, may be due to the epigenetic effects of increased DNA methylation.

ConclusionAlthough the functional DNA variant of the AR gene is un-

known, a number of studies have demonstrated an association between the AR gene and MPB. Further work into identifying these variants in and around the AR locus that affect gene expres-sion of the AR gene may help elucidate the pathophysiology of MPB. The recent work discussed here highlights the importance of a role of epigenetic processes such as DNA methylation in the tissue-specific gene expression that underlies the pathogenesis


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of MPB. One benefit of understanding these mechanisms is the reversible nature whereby changes to DNA methylation can alter throughout life as a response to the local cellular and external environment, with methyl groups being added or removed from CpG dinucleotides. It is possible that increases in DNA methylation at the AR CpG islands may be protecting occipital hairs from miniaturisation and hair loss. The potential to take advantage of the plasticity of DNA methylation, and accessibil-ity of scalp hair to topical applications, makes this an enticing area for the development of therapeutic and preventive strate-gies for AGA. The processes through which DNA methylation at the AR CpG island may result in reduced gene expression is unknown but further analysis of the role of DNA methylation in AGA is important.

Editor’s note: The full article, “Evidence of increased DNA methylation of the androgen receptor gene in occipital hair follicles from men with androgenetic alopecia” (J.E. Cobb, et al.) has been accepted for publication in the British Journal of Dermatology.

References1. Ellis, J.A., M. Stebbing, and S.B. Harrap. Polymorphism of

the androgen receptor gene is associated with male pattern baldness. J Invest Dermatol. 2001; 116(3):452-455.

2. Hibberts, N.A., A.E. Howell, and V.A. Randall. Balding

Epigenetic modifications from page 127

hair follicle dermal papilla cells contain higher levels of androgen receptors than those from non-balding scalp. J Endocrinol. 1998; 156(1):59-65.

3. Sawaya, M.E., and V.H. Price. Different levels of 5alpha-reductase type I and II, aromatase, and androgen receptor in hair follicles of women and men with androgenetic alopecia. J Invest Dermatol. 1997; 109(3):296-300.

4. Cobb, J.E., et al. Evidence of increased DNA methylation of the androgen receptor gene in occipital hair follicles from men with androgenetic alopecia. Br J Dermatol. 2011.

5. Hillmer, A.M., et al. Genetic variation in the human an-drogen receptor gene is the major determinant of common early-onset androgenetic alopecia. Am J Hum Genet. 2005; 77(1):140-148.

6. Levy-Nissenbaum, E., et al. Confirmation of the association between male pattern baldness and the androgen receptor gene. Eur J Dermatol. 2005; 15(5):339-340.

7. Cobb, J.E., et al. Evidence for two independent functional variants for androgenetic alopecia around the androgen receptor gene. Exp Dermatol. 2010; 19(11):1026-1028.

8. Fazzari, M.J., and J.M. Greally. Epigenomics: beyond CpG islands. Nat Rev Genet. 2004; 5(6):446-455.

9. Holliday, R. Epigenetics: a historical overview. Epigenetics. 2006; 1(2):76-80.

10. Rottach, A., H. Leonhardt, and F. Spada. DNA meth-ylation-mediated epigenetic control. J Cell Biochem. 2009; 108(1):43-51.

11. Larsen, F., et al. CpG islands as gene markers in the human genome. Genomics. 1992; 13(4):1095-1107.

ISHRS—helping you to help your patientsE. Antonio Mangubat, MD Tukwila, Washington, USA [email protected]

The 2011 ISHRS Annual Meeting in Anchorage is shaping up to be another great event full of information and new skills that we hope will be valuable in your practice. One of the most important services the ISHRS provides is expert opinions from world-class, experienced hair surgeons.

Most hair restoration surgeons at some time in their practice encounter difficult cases, such as those that:

1. Have complications that were not expected.2. Have iatrogenic problems that were created.3. We wish did not walk in our door.4. We have no idea what to do with.

Here’s your opportunity to harness the power of the ISHRS: Bring your tough cases to Anchorage for the Difficult Cases session!

We care about our patients and want to help them, but sometimes the problems are so significant that we are overwhelmed or do not know how to proceed. If you have a case like this, let us help.

At the Anchorage Annual Meet-ing, you will have the world’s best hair surgeons available to help on your spe-cific cases, so I encourage all attendees

to submit your tough cases now. Send your patient’s history and photos to me and Mel Mayer at [email protected] and [email protected].

The Difficult Cases session will provide you with the added benefit of learning how to treat your own difficult patients in addition to listening and learning from your colleagues’ dif-ficult cases.

See you in Anchorage!

Here’s your opportunity to harness the power of the ISHRS:

Bring your tough cases to Anchorage for the

Difficult Cases session!


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Hair’s the Question Sara Wasserbauer, MD Walnut Creek, California, USA [email protected]

page 130

1. It is the morning of surgery. The density of your patient’s do-nor area is 65 FU/cm2 and you estimate the length of the strip to be 24cm. If the width of the planned strip is estimated to be 1cm wide, what will the estimated number of grafts be?a. 1,560b. 1,872c. 2,340d. 3,120

2. Your patient wants to cover an area at his crown that is completely bald and about the size of an average man’s palm (assume 10cm × 10cm). If you typically cover an area to a density of 30 FU/cm2, and his crown is shaped more like a circle than a square, approximately how many grafts will you need to cover this area?a. 500b. 1,000c. 2,000d. 3,000

3. Your patient requires at least 1,500 grafts. If your patient’s density is 70 FU/cm2, his donor area is 20cm wide, his elastic-ity is 20%, and you plan to take the maximum width available according to the Mayer-Pauls elasticity scale, will you have enough grafts to meet your patient’s goals?a. Yesb. Noc. No patient needs fewer than 1,500 grafts.d. Every patient needs more than 1,500 grafts.

4. If your patient’s native hairline density is 60 FU/cm2, and as-suming that hair loss only becomes noticeable when 30% or less of the hair remains, approximately what density should be your goal in this patient’s hairline?a. 10 FU/cm2

b. 20 FU/cm2

c. 30 FU/cm2

d. 40 FU/cm2

5. If your patient loses 10% of his absolute hair density per year, in approximately how many years would you expect him to need a hair transplant based on the first noticeable appearance of baldness?a. 1-2 yearsb. 2-3 yearsc. 7-8 yearsd. 9-10 years

I find that all those old high school math skills come in handy in hair surgery! Test your memory and your mental math capabilities!

Hair calculationsThe next three questions come from the same case:

6. You are working with 3 staff members on a traditional “strip” method hair transplant. The strip has been slivered and each of them has 32 slivers yielding an average of 10 grafts per sliver. If 40% of the slivers have been cut into grafts, which of the following is the best estimate of how many grafts you have cut so far?a. 128b. 384c. 500d. 960

7. What is your best estimate of how many sites to make?a. 128b. 384c. 500d. 960

8. Your surgery is complete and your estimates turned out to be perfectly accurate. Your patient asks you how many actual hairs were transplanted into his scalp that day. Since you have tracked and counted every graft, you noted that 519 of his grafts were 2-hair FUs, and the remainder was evenly split between 1-hair FUs and 3-hair FUs. One graft was a 4-hair FU. How many hairs were transplanted? a. 1,478 hairsb. 1,918 hairsc. 1,922 hairsd. 2,802 hairs

9. Your patient has Norwood Class VI male pattern hair loss that has left him with a completely hairless area 15cm wide and 30cm from front to back (conservative potential frontal hairline to posterior crown fringe). He wants to cover the entire bald area to a density of at least 20 FU/cm2. His donor density is 100 FU/cm2, his elasticity is 30%, and the area is 10cm high and 25cm wide. How many traditional “strip” surgeries should you tell him he needs to meet his goals as-suming you take the maximum amount of donor each time based on his scalp’s elasticity? (Assume virgin donor each time for simplicity)a. One surgery b. Two surgeriesc. Three surgeriesd. This patient’s goals are unrealistic.


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Hair’s the Question from page 129

Answers1. A. 65 FU/cm2 × 24cm × 1cm = 1,560 FUs.2. C. The formula for the area of a circle is πr2. Since the di-

ameter is 10cm, the radius would be 5cm: π(3.14) × (5)2 = 2,355 grafts needed (approximately 2,000).

3. A. 10cm × 2cm × 70 FU/cm2=1,400 FUs; 10cm × 1.5cm × 70 FU/cm2 = 1,050 FUs; 1,400 FUs + 1,050 FUs = 2,450 FUs, which is more than enough.

4. B. 30% of 60 FU/cm2 = 18 FUs.5. C. Assuming that hair loss only becomes noticeable when

30% or less of the hair remains, C is the answer.6. B. 32 slivers × 3 techs = 96 slivers; 96 slivers × 10 grafts per

sliver = 960 grafts; 40% of 960 = 384 grafts already cut.7. D.

8. C. If you have 960 total grafts (from the previous answer’s calculation) and 519 two-hair grafts × 2 hairs per graft = 1,038 hairs; 220 one-hair graft × 1 hair per graft = 220 hairs; 220 three-hair grafts × 3 hairs per graft = 660 hairs; 1 four-hair graft × 4 hairs per graft = 4 hairs; Total: 1,038 + 220 + 660 + 4 = 1,922 hairs.

9. B. To cover an area of 15cm × 30cm to a density of 20 FU/cm2 you would need 9,000 grafts. With the given elasticity and donor area measurements you would have: 12.5cm × 2.2cm × 100 FU/cm2 = 2,750 FUs; 12.5cm × 1.5cm × 100 FU/cm2 = 1,875 FUs; 2,750 + 1,875 = 4,625 FUs from the entire 25cm strip. Thus, he would need at least two surgeries to reach the 9,000 grafts needed to cover the whole area to that density.

MESSAGE FROM MELVIN L. MAYER, MD, PROGRAM CHAIR OF THE 2011 ANNUAL MEETING

“New Vistas and Trusted Techniques in Hair Transplant Surgery”

If you haven’t registered for the 19th Annual Scientific Meeting of the ISHRS, NOW is the time. Courses and workshops are filling up fast. Don’t be disappointed because many of these have limited registration.

As you plan your trip, be sure to include at least one of the Alaska Scenic tours. The 26 Glaciers Cruise & Wild-life Conservation Center Excursion leaves the Hotel Captain Hook early Tuesday, September 13, for an all day tour. Another option is to venture out whale watching on Kenai Fjords National Park Cruise all day Sunday, September 18. This excursion will not conflict with meetings because the meeting concludes with the Gala Saturday night. Of course, there are many other vaca-tion options to complement this meeting.

In addition to the previously announced topics and sessions, we have added an optional Satur-day noon session, “Mechanization of HRS.” Restoration Robotics and Neograft technology will be featured in a non-CME format with plenty of time for Q&A.

Highly recommended for the beginner is the “hands-on” Basics Course in hair restoration surgery using human cadaver scalps. Also for these new attendees is the expanded Newcomers Program to orient to the ISHRS annual meeting by pairing newcomers with hosts (see page 137 for a full description). We want to introduce you to other colleagues so you maximize the benefit of this excellent experience.

The learning and social interaction is continuous, starting at 7 AM Friday and Saturday mornings with “Breakfast with the Experts,” which allows you to choose from 16 different table topics in a casual setting. We are introducing two non-English-speaking tables: one featuring Japanese and the other Spanish. You’ll enjoy an interactive educational experience with offerings that include a full-day Board Review Course, several morning Workshops, an FUE-FUT Controversy Panel, Live Patient Viewing, High Definition Surgical Video Theater, and a Hairline Design Panel. The use of the Audio Response System is dynamic and great for audience participation.

We look forward to you being part of this outstanding opportunity for learning, networking, socializing, and exploring the beautiful State of Alaska!

Sincerely,

Melvin L Mayer, MD, 2011 Program Chair www.ISHRS.org/AnnualMeeting.html


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Meetings and Studies(L) Timothy P. Carman, MD La Jolla, California, USA [email protected]; (R) David Perez-Meza, MD Mexico City, Mexico [email protected]

In this issue we present an interesting summary by Dr. Bessam Farjo of the ISHRS Regional Workshop “The Next Big Thing” held in Istanbul, Turkey. This workshop included a Hair Research and Advanced Live Surgery Workshop with a focus on FUE Method.

Highlights of the Istanbul Workshop: The Next Big ThingBessam Farjo, MBChB Manchester, United Kingdom [email protected]

On May 13-15, 2011, Dr. Melike Kulahci hosted the ISHRS-sponsored Regional Workshop: The Next Big Thing: Hair Research and Advanced Live Surgery Workshop.

After welcome and introductory talks by our host, Dr. Kulahci, and ISHRS President Dr. Jerry Cooley, the scientific presentations com-menced. Dr. Ilker Apaydin gave an overview on FUE demand in Turkey and how it forms 70% of their work. This was followed by a density definition panel involving the entire guest surgical faculty of Drs. Ron Shapiro, Robert Haber, Bessam Farjo, Jerry Cooley, Jennifer Martinick, and Jerry Wong.

Attendees were transported to the Transmed surgical center where 2 procedures were observed by the delegates. In the first case, Dr. Apaydin harvested the grafts by FUE, followed by hairline design and recipi-ent site creation by Dr. Shapiro. Simultane-ously, in a second case, Dr. Ozge Ergun of Transmed performed harvesting by FUE while Dr. Farjo continued with the hairline design and site creations. A third case was done where strip harvesting was performed by Dr. Cooley and hairline and site creations by Dr. Wong.

Day 2 of the workshop began with discus-sion of the previous day’s surgery. This was followed with a series of scientific lectures. Prof. Valarie Randall presented the latest in research supporting the positive effect of prostaglandins on scalp hair growth. Partly based on this study, Allergan is commencing clinical trials soon. Dr. Cooley talked about extracellular matrix effect on wound healing and his obser-vation of smoother and flat donor scars when ACell strips were left in. Another way he uses the product is in adding a few drops to graft clusters before placing where he has observed enhanced growth and quality. Dr. Gerd Lindner showed us his results with organ culture–based hair follicle generation from cultured hair cells. This is what Intercytex was working on before its financial collapse, and Dr. Lindner appears to have succeeded in growing hair in vitro. The next step is to take this into clinical trials.

Dr. Haber updated his latest studies using the lasercap LLLT system. He demonstrated data showing the light restored hair shaft diameter and he is planning imminent clinical trials. Dr. Farjo presented for the first time the effect of thymic peptides on

hair growth in organ culture. Inter-estingly, they may play a balancing role as some are promoters while others act negatively. Dr. Martin-ick rounded off the invited faculty lectures by discussing the effect of such advances clinically and from a business point of view. There were two more non-faculty presenta-tions, one by Dr. Larry Shapiro on his positive findings using whey protein concentrate for transplant

patients, and the other by Dr. Silvana Franzini with an update on her talk from Boston about the concept of intradermotherapy on hair loss and growth injecting a variety of factors including minoxidil and finasteride.

The delegates were taken in the afternoon to the surgical center once more where two more operations were performed.

Again the harvesting was done by FUE by Transmed’s Drs. Ergun and Kan, while Drs. Martinick and Haber performed the hairline design and recipient site creation, respectively.

The highlight of the half day on Sunday morning was the scientific panel involving all the invited faculty discussing the future of hair restoration and hair biology, and how scientists and clinicians can cooperate. We debated everything from medications to cells, growth factors, techniques, and robotics. The

conclusion was that the future of our field is bright but that new therapies have to be evidence-based. Having said this, some colleagues were concerned about the difficulty of doing such research in private practice. Dr. Cooley assured the delegates that the ISHRS is working towards a blueprint that can be used by members to conduct such studies simply within their facilities yet attain reasonable credibility. Another message was that we should all be encouraged to communicate and cooperate with local scientists to understand each other and accelerate potential advancements.

Dr. Kulahci and her team, in particular her daughter and clinic manager, Melis, organised an outstanding event attended by nearly 100 delegates including faculty. Everyone was looked after and the hospitality could not have been better. The Friday night dinner was enjoyed by all, and the Saturday gala cruise and entertainment over the Bosphorus will live long in the memory.

(left to right) Jennifer Martinick, Ron Shapiro, Jerry Wong, Harold Ma, Bessam Farjo, Bob Haber, Melike Kulahci, Jerry Cooley, and Valerie Randall

Jennifer Martinick placing with assistants.


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Review of the LiteratureNicole E. Rogers, MD Metairie, Louisianna, USA [email protected]

Yassa, M., et al. Male pattern baldness and the risk of prostate cancer. Annals of Oncology 2011; epub ahead of print.

French researchers investigated whether early male pattern hair loss (MPHL) could be linked to an increased risk of prostate cancer later on. This question has been answered in previous studies in both the affirmative and the negative. A case control study was performed on a total of 669 patients (388 with a his-tory of prostate cancer) wherein they were asked to score their balding pattern at ages 20, 30, and 40. Prostate cancer patients were recruited from a radiation oncology follow-up clinic in France. Controls were chosen from the same hospital database but with no history of prostate cancer or hormone pathologies. Starting in 2004, all patients were contacted by mail and asked to grade their balding using four diagrams: Stage I (no bald-ing), Stage II (frontal hair loss), Stage III (vertex hair loss), and Stage IV (complete frontal and vertex balding). For prostate

cancer patients, additional data was collected to include age at diagnosis, initial stage of disease (T-N-M), Gleason score, and initial PSA. Data revealed patients with prostate cancer were twice as likely to have any form of hair loss (Stages II-IV) at age 20 (odds ratio 2.01, P=.0285). The pattern of hair loss was not predictive of the development of prostate cancer and there was no association between early-onset MPHL and an earlier diagnosis of prostate cancer or with the development of more aggressive tumors.

Although this study is limited by its retrospective nature, including recall bias, the results are worthy of consideration and discussion with patients presenting at an early age. Further gene studies are necessary to better investigate the exact relationship of these two conditions.

REGISTRATION OPENING SOON!

ISHRS “On Demand” WebinarsEnduring Material, Online Format

The ISHRS is pleased to announce its new On-Demand Webinars. The recorded webinars are 60 to 90 minutes in length. You can listen to the webinars 24/7/365. In other words, you can listen to them whenever it is convenient for you. Below is list of the latest recorded webinars. Additional programming is under development.

Going Viral: Unlocking the Secrets of Social Media for Hair Transplant Patient Education and Beyond 60 Minutes; 1.0 CME Credit

Faculty: Alan Bauman, MD

Description: The On-Demand Webinar Program titled Going Viral: Unlocking the Secrets of Social Media for Hair Transplant Patient Education and Beyond is an enduring material created by the International Society of Hair Restoration Surgery (ISHRS). This On-Demand Webinar Program is intended for an audience of all levels. This enduring material was de-veloped first as a symposium offered at an ISHRS Annual Scientific Meeting in 2010. Dr. Alan Bauman, a well-known and distinguished expert in the field of hair restoration and self-proclaimed “techno-geek,” developed the materials and content based on the pre-determined learning objectives and with the guidance of the CME Committee.

Intro to Biostatistics & Evidence Based Medicine 90 Minutes; 1.5 CME Credit

Faculty: Jamie Reiter, PhD and Jerry E. Cooley, MD

Description: This webinar will provide basic information regarding proper research design and statistics for investiga-tors in hair restoration surgery, through didactic lecture and dialogue between presenters. It is intended to address the needs of the more common research questions in hair restoration surgery. Specific research questions may require more advanced instruction.


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of the arrector pili muscles.” Needless to say, primary and secondary follicles should not be confused with terminal or vellus follicles.

3. We share with the authors a special interest in the anatomy of the arrector pili muscle and its relationship with the hair follicles. In 2002, we published an anatomical drawing of the arrector pili muscle as a single muscular unit that divides into branches that are finally inserted into each of the follicles contained in the follicular unit.3 Before that paper, the arrec-tor pili muscle had always been drawn and represented as a single muscle attached to a single follicle, and not as a single unit associated with a single follicular unit. Our anatomical model was basically confirmed by the works of Song, et al., using a three-dimensional reconstruction.4 Patel, et al. note that “as terminal hairs miniaturize into vellus hairs, they lose their arrector pili muscles.” As we did not look into the anatomy of arrector pili muscles in vellus follicles, this is a question that interests us greatly. We would like to know if the authors could show photomicroscopic evidence of this fact (disappearance of the arrector pili muscle as the terminal hair miniaturizes into vellus hair) or whether perhaps there is a paper on this subject pending publication.

References 1. Patel, M., A. Perez, and R. Sinclair. An update on the

pathophysiology of female pattern hair loss. Hair Transplant Forum Int’l. 2011; 21:(2)42-43.

2. Headington, J.T. Transverse microscopic anatomy of the human scalp. Arch Dermatol. 1984; 120:449-456.

3. Poblet, E., F. Ortega, and F. Jimenez. The arrector pili muscle and the follicular unit of the scalp: a microscopic anatomy study. Dermatol Surg. 2002; 28:800-803.

4. Song, W., et al. A new model for the morphology of the arrector pili muscle in the follicular unit based on three dimensional reconstruction. J Anat. 2006; 208:643-648.

Letters to the EditorsFrancisco Jimenez, MD Las Palmas, Spain [email protected] Poblet, MD Albacete, SpainRe: Pathophysiology of female pattern hair loss

We have read with great interest the article by Patel, Perez, and Sinclair on the pathophysiology of female pattern hair loss.1 The hypothesis of a hierarchical organisation of human follicles into primary and secondary follicles is daring and intriguing, but difficult to reconcile with our current knowledge of the anatomy of the follicular unit.

We would like to add the following comments:1. In one part of their article the authors state that a “follicular

unit typically consists of a larger, central primary follicle surrounded by smaller secondary follicles.” We, as hair transplant surgeons, are used to dissecting thousands of hair follicles and have not noticed such an arrangement. Is it pos-sible that this hierarchical arrangement would be noticeable only at an optical microscopic level? If that is the case, it is important that the authors clarify the histomorphological criteria that they are using to classify a follicle as primary or secondary. Is there any morphometric data (measurements) data available?

2. In the second paragraph of their article, it is stated that “the concept of the follicular unit in humans was first described by Headington in 1984 with the observation that in utero central primary follicles are surrounded by smaller secondary fol-licles.” Unless the authors are referring to a different paper, in his seminal article published in the Archives of Dermatology, Headington described the follicular unit after analyzing trans-verse (horizontal) sections of human adult scalp biopsies.2 As far as we know, Headington did not observe the existence of a primary and secondary follicles, but rather defined the fol-licular unit as a “well-circumscribed structure composed of two to four terminal follicles, and one or, rarely, two vellus follicles, the associated sebaceous lobules, and the insertions

Rod Sinclair, MBBS, MD Melbourne, Australia [email protected]: Response to Jimenez/Poblet

We thank Drs. Francisco Jimenez and Enrique Poblet for their comments relating to our article on the pathophysiology of female pattern hair loss.1

We would like to respond to their comments:1. The hierarchi-

cal arrangement of hair follicles in humans is in-ferred from that seen in o ther mammalian spe-cies (Figure 1). His tomorpho-logical criteria or markers to

classify human follicles into pri-mary and second-ary hair follicles have not been identified.

2. We stand correct-ed. The observa-tion that, in utero, hair follicles grow in groups of three or more, with a central primary follicle surrounded by smaller secondary and tertiary follicles, was made by Montagna, et al. in their illustration (Figure2) and not Headington as we suggested. Indeed, Headington defined the follicular unit as a “well circumscribed structure composed of two to four terminal Figure 1. Photograph showing a compound follicular

unit in a goat with a single large primary follicle and multiple smaller secondary follicles.

Figure 2. Illustration showing developing groups of hair follicles with each group consisting of a primary follicle (P) surrounded by secondary follicles (arrows)

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www.ISHRS.org 135

follicles, and one or, rarely, two vellus follicles, the associ-ated sebaceous lobules, and the insertions of the arrector pili muscles.”2

3. We do have a paper in press on the anatomy of the arrector pili muscle and its relationship with the hair follicle that shows loss of contact of AP muscle with miniaturised hair follicle within a follicular unit (Yazdabadi, A., et al. Minia-turized hairs maintain contact with the arrector pili muscle in alopecia areata but not in androgenetic alopecia: A model for reversible miniaturization and potential for hair regrowth).

References1. Patel, M., A. Perez, and R. Sinclair. An update on the

pathophysiology of female pattern hair loss. Hair Transplant Forum Int’l. 2011; 21(2):42-43.

2. Montagna, W., A.M. Kligman, and K.S. Carlisle. Atlas of normal human skin. Berlin: Springer-Verlag, 1992; 314-315.

Expanded Newcomers Program set for 2011 ISHRS annual meetingRobert T. Leonard, Jr., DO Cranston, Rhode Island, USA [email protected]

I am very excited to chair the Expanded Newcomers Pro-gram, a unique offering in Anchorage this year. This event exemplifies one of the founding tenants of our Society, which is to welcome colleagues from all specialties to participate in the world’s premier educational conference in the field of hair restoration surgery. Since its inception in 1993, the ISHRS offers its members an opportunity to create and grow friendships that can last throughout one’s lifetime.

And…it all begins at the Newcomers Reception!

How It WorksThis program is designed to help our newest ISHRS meeting

attendees become acquainted with the Society, its members, and the field. “Newcomers” will be paired with volunteer member “hosts” prior to the meeting. We encourage longstanding mem-bers to sign up as hosts. All physician and surgical assistant registration types may participate in the program. We expect that non-members who wish to participate for the longer term program apply for membership.

New, Expanded ProgramIn its third year, the Newcomers Program is expanding its

role into an informal mentorship relationship intended for a term of 2 years. This longer period of time will allow the new person to ask questions and become more closely acquainted with the Society, its members, and the field. In addition, the Host may allow the Newcomer to visit his or her practice.

Active Members

If you plan to attend the Anchorage meeting, please consider signing up! Active members will be paired with 2-3 Newcomers. The plan is that your Newcomers will also meet and talk with each other, sit together, and hang out at the meeting.

Guidelines1. Host contact the Newcomer prior to the meeting and answer

questions.2. Host and Newcomer must attend the Newcomers Orien-

tation & Reception on Wednesday/September 14, 2011, 5:30PM–6:30PM, Quarter Deck, Hotel Captain Cook, Anchor-age, Alaska. Meet and greet!

3. Host and Newcomer check in with one another; sit together during opening session.

4. Host and Newcomer communicate with each other through-out a 2-year term via email, phone, or face-to-face. Newcom-ers are encouraged to email and call their host with questions or for advice regarding hair restoration surgery matters.

5. Neither the Host nor the Newcomer may claim that they “trained” as a result of this Host-Newcomer relationship. Neither may advertise this relationship in their promotional materials, on their website, or in their curriculum vitae.

During the registration process, please select the option (New-comer or Host) if you would like to sign up for this program.

If you have any questions, please contact Liz Rice-Conboy at ISHRS Headquarters, [email protected], or me at [email protected]. We shall be in contact with you once you sign up for the program.

See you in Alaska!

For more information, contact:

21 Cook AvenueMadison, New Jersey 07940 USA

Phone: 800-218-9082 • 973-593-9222 Fax: 973-593-9277

E-mail: [email protected]

www.ellisinstruments.com

State-of-the-art instrumentation for hair

restoration surgery!

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Assistant Faculty Tina LardnerKathryn MorganKasia MuzykaCharlene Smith Janna ShaferCarol Wade

Course Director Samuel Lam, MD

Physician FacultyPaul Cotterill, MDVance Elliott, MDRobert Haber, MDJames Harris, MDPaul McAndrews, MD Robert Niedbalski, MD Lawrence Samuels, MDRonald Shapiro, MD James Vogel, MD

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An offering through Practical Anatomy & Surgical EducationSaint Louis University School of Medicine

Seminar InformationPractical Anatomy & Surgical Education 3839 Lindell Blvd., St. Louis, MO 63108

Phone: (314) 977-7400 E-mail: [email protected]

Website: http://pa.slu.edu


www.ISHRS.org 137

Patrick Tafoya Orlando, Florida, USA [email protected] Assistants Corner

Surgical Assistants: Get Involved in the ISHRSWe would love to hear from you. There are many ways you can contribute:

Write an article or present an idea to the Forum Serve on the Surgical Assistants Executive Committee Help in the planning of our educational events Teach at our meetings and workshops

Contact [email protected] today!

Greetings from Orlando where we are all melting from the never ending heat of the summer. I hope everyone is looking forward to the cooler weather in Alaska as I am and, of course, the educational ex-perience of the meeting, too. I hear from the grapevine that there will be quite a few ground breaking presentations there and a few grizzly bear sightings, too. That should be a unique experience. Hope to see everyone there!

How to help grow a hairLiana Voitiul HRBR Ltd, Samson House, Blackrock, Co. Dublin, Ireland [email protected]

When carrying out a hair transplant, a number of wounds are deliberately infl icted on the patient’s scalp; often a large wound that regularly stretches from ear to ear, held together by a foreign body, a stitch. Next, approximately 500 to 6,000 holes are made in a separate part of the scalp. After “damaging” the scalp, a live organ is placed into each of the small holes that have been cre-ated. We then step back and expect the body to heal the wounds without any complications.

We then assume that the body will make new blood vessels and attach them to the hundreds, sometimes thousands, of live organs we’ve left behind. And, presto, a hair grows!

Maybe we should help. But how can we?I have found many ways assistants can help to facilitate the

healing process:1. Take the donor strip in two phases; the longer the hair

stays in the body the better the growth is. 2. Use a sharp, sterilised blade/needle to make the incisions.

Change it regularly.3. Do not damage the native hairs when making incisions. 4. The incisions must be of the correct size and angle to

prevent damaging too much the skin’s surface. 5. Test that incisions will ensure a snug fi t for the graft and

prevent damaging it.6. Use a sharp blade when cutting and slivering. Change it

regularly.7. Tumescence will prevent transection of blood vessels,

nerves, and surrounding hairs. 8. Trim the epithelium (top outside layer of skin) from the

grafts. This will prevent scarring around each individual graft (including pitting and tenting).

9. Trim excess tissue from the graft. Each clinic will set its own standard, so trim to your clinic’s standard. (Re-member, it’s a hair transplant not a scalp transplant.)

10. Limit the number of cuts per graft. This will ensure the grafts are not damaged and are out of the holding solution for a minimal amount of time.

11. Cut one graft at a time and leave the rest in the holding solution.

12. Leave a little fatty tissue below the follicle so that you can hold onto this to plant the graft.

13. Handle the graft with care. Do not touch the follicle when cutting or planting.

14. Do not pile grafts up on your fi nger when you are plant-ing, just take around 10 at a time and get someone to pass them to you. It is faster to plant this way, and the grafts remain hydrated.

15. Emphasize to the patient how important the post-opera-tive care is for the healing process, and ensure that the patient understands this.

16. Hydration! The grafts must be kept moist at all times. Dry grafts are dead grafts.

Remember: The body will heal a wound before it will grow a hair. The more damage you infl ict on the scalp and the graft, the longer time it will take the body to heal the damage. Only when the damage is healed will the body attach a blood supply to the graft.


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Classifi ed Ads

SEEKING DOCTORS TO SUBMIT DIFFICULT CASESThe Diffi cult Cases session moderated by Dr. Tony Mangubat with a stellar panel of hair transplant experts has become

one of the most interesting and educational forums at our Annual Meeting. You are invited to submit a “diffi cult case” that you request help with or that you have performed that could be presented for the education of others. Submitted cases with the most educational value will be selected.

Send your brief case summary with pictures to [email protected] and [email protected].

SEEKING DOCTORS TO BRING PATIENTS FOR LIVE PATIENT VIEWINGThis is an excellent opportunity for you to show off your work! If you are not familiar with the format, physicians bring

a patient with a completed result for the attendees of the meeting to see, touch, inquire of, etc. The doctor displays a poster that outlines the details of the case. This is not the format to show off the typical follicular unit transplant.

We are looking to showcase interesting and unusual cases such as:• FUE (full restoration)• Megasessions• Eyebrows/eyelashes• A new technique• Scalp surgery/fl aps• Reconstruction—trauma, radiation, etc.• Repair—plugs, donor scars• Operation Restore cases• Complications• A challenging restoration on a patient who was in a hair system previously

The ISHRS does not reimburse physicians for the expenses involved in bringing patients to this event. It is seen as a privilege to serve as faculty for this event and present your patient’s surgical results to your colleagues.

If you think you would like to participate, please email Dr. Robert Niedbalski at [email protected]. If you are unsure if the case is what we are looking for, please ask!

Hair Transplant Physicians WantedEstablished hair transplant centers in London, Dubai and other exciting international markets seek

licensed hair transplant physicians. Some experience preferred. Will provide advanced training.

Email CV to: [email protected]

To Place a Classifi ed AdTo place a Classifi ed Ad in the Forum, simply e-mail [email protected]. In your email, please include the text of what you’d like your ad to read—include both a heading, such as “Tech Wanted,” and the specifi cs 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.

Classifi ed Ads cost $60 plus 60 cents per word per insertion. You will be invoiced for each issue in which your ad runs.


www.ISHRS.org 139

New Vistas & Trusted Techniques in Hair Transplantation

International Society of Hair Restoration Surgery303 West State Street, Geneva, IL 60134 USA ß Tel 630 262 5399 or 800 444 2737 ß Fax 630 262 1520 ß [email protected] ß www.ISHRS.org

PLAN TO ATTEND: www.ISHRS.org/AnnualMeeting.html

Surgeons and staff will not want to miss this robust conference of thought leaders on the frontiers of best practices. The refreshing and friendly atmosphere of Alaska will invigorate each day of the conference. Pristine waters and breathtaking views of the Chugach Mountains and Mt. McKinley are the backdrop for up close wildlife adventures and glacier excursions, visionary lectures, hands-on workshops and networking events. Inspired by nature’s wild beauty and the highest caliber of educational presentations, this year ’s event promises to be a trip of a lifetime!

Newcomers Are Welcome! As a result of the positive feedback from the past two annual meetings, we will again offer a “Meeting Newcomers Program” to orient those who are new to the ISHRS annual meeting. Newcomers will be paired with hosts. We want to welcome you, introduce you to other colleagues, and be sure you get the most out of this meeting.

Many exciting formats and topics are being planned for the 19th Annual Scientific Meeting, including a full day, hands-on Basics Course in Hair Restoration Surgery utilizing cadaver scalp, a full day Advanced/Board Review Course, a full day Surgical Assistants Program, several morning workshop on specific topics, a Surgical Assistant Cutting/Placing Workshop utilizing cadaver scalp, lunch symposiums, Breakfast with the Experts table discussion

groups, Live Patient Viewing, several controversy panels, a high definition surgical video theater, a hairline design panel, use of an audience response system to keep the sessions exciting and dynamic, a full exhibits program, and many opportunities for socializing and networking.

Plan Your Pre- And Post-Meeting Activities Early! Wildlife and Glacier Cruises ß Flight seeing – glaciers, Denali ß Sea kayaking, River rafting, float trips • Dog sledding ß Rainforest and alpine hiking, glacier hiking ß Bear viewing ß ATV tours ß Fishing ß Canyoneering, rock climbing, ice climbing

Anchorage, a modern city set amidst the vast expanse of Alaskan wilderness, will host this year’s premier international conference on hair transplant surgery.

SEPTEMBER 14-18, 2011

ISHRS ANCHORAGE FullPg.Forum.indd 1 1/31/11 12:33:44 PM


140 www.ISHRS.org

HAIR TRANSPLANT FORUM INTERNATIONALInternational Society of Hair Restoration Surgery303 West State Street Geneva, IL 60134 USA

Forwarding and Return Postage Guaranteed

FIRST CLASSUS POSTAGE

PAIDCHICAGO, IL

PERMIT NO. 6784

Date(s) Event/Venue Sponsoring Organization(s) Contact Information

Dates and locations for future ISHRS Annual Scientifi c Meetings (ASMs)

Academic Year 2011–2012

Tel: 33 +(0)1+42 16 13 09Fax: 33 + (0) 1 45 86 20 44

[email protected]

Diploma of Scalp Pathology & SurgeryU.F.R. de Stomatologie et de

Chirurgie Maxillo-faciale; Paris, France

Coordinator: Pr. P. GoudotDirectors: P. Bouhanna, MD, and M. Divaris, MD

January 2012 For instructions to make an inscription or for questions:

Yves Crassas, MD [email protected]

International European Diploma for Hair Restoration Surgery

Coordinator: Y. Crassas, MD, University Claude Bernard of Lyon, Paris, Dijon (France), Torino (Italy), Barcelona

(Spain). Department of Plastic Surgerywww.univ-lyon1.fr

2011: 19th ASM, September 14-18, 2011 Anchorage, Alaska, USA

2012: 20th ASM, October 17-21, 2012 Paradise Island, Bahamas

2013: 21st ASM, October 23-27, 2013 San Francisco, California, USA

September 14-18, 2011 Tel: 630-262-5399Fax: 630-262-1520

19th Annual Scientifi c Meetingof the International Society of Hair Restoration Surgery

Anchorage, Alaska, USA

International Society of Hair Restoration Surgery www.ISHRS.org

DIPLOMAS

November 12-13, 2011 Tel: [email protected]

3rd Annual Meeting of the Association of Hair Restoration Surgeons of India (HAIRCON-2011)

Mumbai, India

Association of Hair Restoration Surgeons of India

www.ahrsindia.org

October 14-16, 2011 http://pa.slu.edu3rd Annual Hair Restoration SurgeryCadaver Workshop

St. Louis, Missouri, USA

Practical Anatomy & Surgical Education, Center for Anatomical Science and Education, Saint Louis University School of Medicine

in collaboration with the International Society of Hair Restoration Surgery

http://pa.slu.edu

Upcoming Events

Advancing the ar t and science of hair restoration

Documents

2011 ISHRS Hair Transplant Forum Newsletter