ISHRS 19th ASM Abstract Book 2011 Alaska Final

New Vistas & Trusted Techniques in Hair Transplantation

A B S T R A C T B O O K

INTERNATIONAL SOCIETY OF HAIR RESTORATION SURGERY

19TH ANNUAL SCIENTIFIC MEETING SEPTEMBER 14-18

2011 ANNUAL SCIENTIFIC MEETING COMMITTEE

Melvin L. Mayer, MD Chair

David Perez-Meza, MD Basics Course Chair

Marco Barusco, MD Basics Course Co-Chair

Glenn M. Charles, DO Advanced/Board Review Course Chair

James A. Harris, MD Advanced/Board Review Course Co-Chair

Jean Devroye, MD Workshops Chair

Robert P. Niedbalski, DO Live Patient Viewing Chair

Nina Otberg, MD Live Patient Viewing Co-Chair

Rajesh Rajput, MD Live Patient Viewing Co-Chair

Paul J. McAndrews, MD Immediate Past-Chair

Margaret Dieta Surgical Assistants Chair

Robert T. Leonard, Jr., DO Newcomers Program Chair

How to read this bookAbstracts are included for General Session oral presentations and poster presentations.

The abstracts are listed in this book in the order they are scheduled to present in the General Session. Posters are listed behind the Poster tab.

There is an author index and topic index behind the Index tab. The indices reference the abstract numbers. The oral presentations are numbered in the order they are presenting starting with 001. The posters are numbered starting from P01.

The abstract format is as follows:

Abstract Number

Title of PresentationAuthor Block

The bold name is the presenting author.

Biography ofPresenting Author

Disclosure of Conflictof Interest Block

Abstract

Presenters were given the opportunity to submit their PowerPoint presentations in addition to their abstracts. Where applicable, the presentation is included immediately after a presenter’s abstract.

Disclosures of conflict of interest are included in the introductory pages as well as next to each presenter’s abstract throughout this book.

DisclaimerRegistrants understand that the material presented at the Annual Meeting has been made available under sponsorship of the International Society of Hair Restoration Surgery (ISHRS) for educational purposes only. This material is not intended to represent the only, nor necessarily the best, method or procedure appropriate for the medical situations discussed, but rather is intended to present an approach, view, statement or opinion of the faculty which may be of interest to others. As an educational organization, the ISHRS does not specifically approve, promote or accept the opinions, ideas, procedures, medications or devices presented in any paper, poster, discussion, forum or panel at the Annual Meeting. Registrants waive any claim against ISHRS arising out of information presented in this course.

Registrants understand and acknowledge that volunteer patients have been asked to participate in the Annual Meeting sessions for educational and training purposes. Registrants shall keep confidential the identity of, and any information received during the Annual Meeting regarding, such volunteer patients.

Registrants further understand and agree that they cannot reproduce in any manner, including, without limitation, photographs, audiotapes and videotapes, the Annual Meeting sessions. All property rights in the material presented, including common law copyright, are expressly reserved to the presenter or to the ISHRS. The sessions may be audio, videotaped, or photographed by the ISHRS.

Registrants also understand that operating rooms and health care facilities present inherent dangers. Registrants shall adhere to universal precautions during any Course, Workshop, or Session that they attend that may utilize cadaveric specimens, cadaveric material or sharps, and that any contact they may have with cadaveric specimens or cadaveric material shall conform to all proper medical practices and procedures for the treatment of patients for whom nomedical history is available. In the event that one incurs a needle stick injury, cut, or other exposure to blood borne pathogens, the person shall immediately notify the Course, Workshop, or Session Director and the ISHRS and take such other follow-up measures as deemed appropriate.

By attending this program, in no way does it suggest that participants are trained and/or certified in the discipline of hair restoration surgery. All speakers, topics, and schedules are subject to change without prior notification and will not be considered reasons for refund requests.

Registrants agree to abide by all policies and procedures of the ISHRS. Registrants waive any claim against ISHRS for injury or other damage resulting in any way from course participation.

© 2011 International Society of Hair Restoration Surgery

001

Program Chair Opening RemarksMelvin L. Mayer, MD Bosley Medical, San Diego, CA, USA.

Dr. Mayer has been practicing hair transplant surgery since 1992. He has been awarded research grants by the ISHRS. His special areas of interest have been follicular regeneration of bisected follicles, graft yield at varying densities, classification and surgical techniques of the temporal points, scalp elasticity scale and understanding its importance in maximizing donor width and minimizing donor scars, and techniques to maximize the quality of transplants in patients of African decent. For these efforts he was awarded the Platinum Follicle Award in 2004. He is a Past-President of the ABHRS.

M.L. Mayer: None.

ABSTRACT:Not applicable.

ABSTRACTS

19th Annual Scientific Meeting of the International Society of Hair Restoration Surgery

September 14-18, 2011 Dena’ina Civic and Convention Center

Anchorage, Alaska, USA

Continuing Medical Education Mission Statement CME Purpose The purpose of the International Society of Hair Restoration Surgery’s (ISHRS) CME program is to meet the educational needs of its members and close the gap that exists between current and best practices by providing practice-oriented, scientifically-based educational activities that will maintain and advance skills and knowledge as well as promote lifelong learning for its members. CME activities will result in improvement of physician competence and performance in practice. Content Areas The curriculum of the ISHRS’s CME program includes but is not limited to hair transplantation, alopecia reduction surgery, hair biology and physiology, congenital and acquired alopecias, other hair and scalp related ancillary procedures and disorders, and risk and practice management. (ISHRS Core Curriculum of Hair Restoration Surgery and Core Competencies of Hair Restoration Surgery). Content is determined by the integration of various sources of needs, including gaps in knowledge and/or performance of hair restoration surgeons, national guidelines, emerging research, and expert opinion. Target Audiences The target audiences of the ISHRS are as follows: - The primary target audience is its physician members with varying medical specialty backgrounds from around the world. - Secondary audiences for the CME program include non-member physicians, as well as residents, nurses, surgical assistants and other allied health personnel. The ISHRS recognizes the importance of and encourages international and interdisciplinary exchange of medical knowledge and practice through calls for papers, and invitations to interdisciplinary and international speakers with special expertise. Types of Activities The activities that support the CME mission are diverse and multifaceted, in order to provide multiple approaches for knowledge acquisition. CME offerings include the following: - Annual Meeting, which may include didactic and hands-on courses, live surgery workshops, seminars, scientific sessions, and poster presentations. - Other activities include regional live surgery and didactic workshops, enduring materials, and Internet CME. All CME activities will be cost-effective and will meet the criteria for continuing medical education of the ACCME and the AMA Physician’s Recognition Award. Expected Results The CME program will result in improved performance in practice (such as surgical skills) and competence (medical knowledge and ability) among its participants. All participants will be expected to provide written feedback following all educational activities, and the CME Committee will rely on this feedback as well as other methods to assess the effectiveness of educational efforts and direct changes in its CME Program. Learning Objectives The learning objectives are listed on the adjacent page as well as by each General Session listing within this Abstract Book.

Continuing Medical Education (CME) Credit The International Society of Hair Restoration Surgery is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The International Society of Hair Restoration Surgery designates this live activity for a maximum of 32.75 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. The International Society of Hair Restoration Surgery Annual Scientific Meeting (program #611100) is recognized by the American Academy of Dermatology for 32.75 AAD Recognized Category I CME Credits and may be used toward the American Academy of Dermatology's Continuing Medical Education Award.

Learning Objectives Upon completion of the General Sessions, you will be able to: THURSDAY New Vistas in Hair Transplantation

o Describe ongoing studies involving pharmacologic agents being tested for treatment of androgenetic alopecia.

o Discuss various research projects on the subject of hair and how they may impact therapies or treatments for hair loss.

o Review the role of apoptosis and oxidative stress in hair loss and the effect of therapies aimed at reducing it in the donor and recipient areas.

o Review the results of platelet growth factors and porcine urinary bladder matrix in wound healing and hair growth.

Challenging and Atypical HT Cases

o Recognize surgical limitations in marginal candidates and develop appropriate treatment plans for these patients.

o Discuss challenging and atypical cases and treatment options. Emerging Issues and Treatments

o Describe various studies and emerging issues in hair restoration surgery. FUE

o Better understand various techniques that can be used for FUE and their advantages, disadvantages, and average transection rates.

Gigasessions: High Definition Surgical Theater “Workshop in Brazil” & Free Papers

o Review the treatment plan and observe key components during the procedure for a gigasession (5000 FUs). FRIDAY Breakfast with the Experts

o Discuss various hair restoration surgery topics in-depth in small groups. Female Hair Loss

o Recognize variations in the management of hair loss in women. Advances in Hair Biology

o Assess the latest developments in hair basic science. Medical and Non-Surgical Treatments

o Describe studies related to medical treatments for androgenetic alopecia. Advanced Surgical HD Videos

o Compare and contrast different surgeons’ approaches to various aspects of the hair transplant procedure. Controversy: FUE vs. Strip Harvest FUT

o Compare and contrast the benefits and drawbacks of follicular unit extraction versus strip harvest follicular unit transplantation.

Finasteride Adverse Events Controversies

o Describe recently FDA-added post-marketing possible adverse events relating to the use of finasteride, including claims of persistent sexual dysfunction, concerns relating to prostate and breast cancer, and proposed theories that may explain these controversial adverse events.

o Properly inform your patients about these possible adverse events.

Scientific Free Papers I o Discuss various research projects on the subject of hair and how they may impact therapies or treatments

for hair loss. Body and Beard Used as Donor -- Eyebrow and Eyelash Transplants

o Discuss the results of a variety of free papers and research on topics relating to the use of body and beard hair as donor, as well as surgical treatments of the eyebrow and eyelash.

Scientific Free Papers II

o Discuss various research projects on the subject of hair and how they may impact therapies or treatments for hair loss.

SATURDAY Breakfast with the Experts

o Discuss various hair restoration surgery topics in-depth in small groups. Non-Androgenetic Alopecias

o Discuss the role of hair transplants in non-androgenetic alopecia. o Discuss the diagnosis and treatment of non-androgenetic alopecia.

What’s the Diagnosis?

o Test your diagnostic skills on various hair loss cases. Hairline Design Panel

o Compare and contrast different surgeons’ approaches to designing hairlines and temporal points. Difficult Cases

o Recognize surgical limitations in marginal candidates and develop appropriate treatment plans for these patients.

o Discuss difficult cases and treatment options. o Explain when to consider flaps and expanders over grafting techniques.

New Surgical Instruments and Techniques

o Identify advantages and disadvantages of various surgical techniques and surgical pearls. Donor Management and Closure Techniques

o Compare and contrast methods and techniques relating to donor area management and closure. Unique Issues in Ethnic Transplantation

o Describe techniques and special considerations for achieving optimal cosmetic outcomes in patients of non-Caucasian ethnic origins.

Live Patient Viewing

o Assess the results of real live patients from a variety of cases that utilized different approaches and techniques.

Learner Bill of Rights The International Society of Hair Restoration Surgery (ISHRS) recognizes that you are a life-long learner who has chosen to engage in continuing medical education to identify or fill a gap in knowledge or skill; and to attain or enhance a desired competency. As part of the ISHRS’s duty to you as a learner, you have the right to expect that your continuing medical education experience with the ISHRS includes: • Content that:

Is driven and based on independent survey and analysis of learner needs Promotes improvements or quality in healthcare Is current, peer-reviewed and evidence-based Offers balanced presentations that are free of commercial bias

Is vetted through a process that resolves any conflicts of interests of planners and faculty Is driven and based on learning needs, not commercial interests Addresses the stated objectives or purpose Is evaluated for its effectiveness in meeting the identified educational need

• A learning environment that:

Is based on adult learning principles that support the use of various modalities Supports learners’ ability to meet their individual needs Respects and attends to the special needs of learners with respect to the ADA Respects the diversity of groups of learners Is free of promotional, commercial, and/or sales activities

• Disclosure of:

Relevant financial relationships that planners, teachers, and authors have with commercial interests related to the content of the activity

Commercial support (funding or in-kind resources) of the activity Anecdotal content

Approved by CME Committee, 03/02/05 Approved by Board of Governors, 06/20/05

The ISHRS gratefully acknowledges the following corporate supporters

of the 19th Annual Scientific Meeting for their generosity.

Platinum Merck

Gold Johnson & Johnson Healthcare Products, Division of McNEIL-PPC, Inc.

Silver Bosley

Hair Club Medical Group P&G beauty and grooming

Bronze Restoration Robotics, Inc.

In-Kind A to Z Surgical

Canfield Imaging Systems Ellis Instruments, Inc.

Micro-Vid

Summary of Disclosures of Conflict of Interest

The International Society of Hair Restoration Surgery (ISHRS) assesses conflict of interest with its faculty/instructors, planners and managers of CME activities. Conflicts of interest that are identified are thoroughly vetted by management and the CME Committee via the Content Review and Validation Teams of peer-physicians, for fair balance, scientific objectivity of studies utilized in this activity, and patient care recommendations. The ISHRS is committed to providing its learners with high quality, unbiased and state-of-the-art education. All faculty were required to disclose both via our online abstract submission system and at the podium or on their posters. The disclosures are listed below as well as next to each abstract in this book.

The following faculty have reported real or apparent conflicts of interest that have been resolved through a peer-review process.

Publishing Title Disclosure Block A Prospective Study on the Role of Commercially Available Growth Factors in Hair Growth

S. Caroli: Other Research Support (receipt of drugs, supplies, equipment, or other in-kind support); Recipent of cocktail solutions and dermaroller for the research in healthy volunteer patients. D. Pathomvanich: Other Research Support (receipt of drugs, supplies, equipment, or other in-kind support); Recipent of cocktail solutions and dermaroller for the research in healthy volunteer patients. K. Amonpattana: Other Research Support (receipt of drugs, supplies, equipment, or other in-kind support); Recipent of cocktail solutions and dermaroller for the research in healthy volunteer patients; Off-label use: Mesoline Hair, MD Skin Solutions

Breakfast with the Experts, Table Leader on the Topic of "Body Hair and Beard as Donor Source for FUE"

J.P. Cole: Other; He makes instruments that he sell to other physicians for use in hair transplant surgery and in particular FUE.

Lunch Symposium 213 - Hair Duplication & Other Uses of Extracellular Matrix

J.P. Cole: Other; He makes instruments that he sell to other physicians for use in hair transplant surgery and in particular FUE.

Lunch Symposium 213 - Hair Duplication & Other Uses of Extracellular Matrix (Lunch Symposium Director)

J. Cooley: Other Research Support (receipt of drugs, supplies, equipment, or other in-kind support); discounted product purchases. Off-label use: Acell MatriStem

New Horizons in Storage Solutions and Additive Agents in Organ Transplantation

W.D. Ehringer: Ownership Interest (owner, stock, stock options); Dr. Ehringer is Founder of VitaTech and Vital Solutions who are developing VitaSol (fusogenic lipid vesicles containing ATP). Ownership Interest (royalty, patent, or other intellectual property); Dr. Ehringer is the inventor on U.S. and foreign patents pertaining to VitaSol.

Mastering Clinical Photography In Hair Restoration Surgery

R.S. Haber: Ownership Interest (royalty, patent, or other intellectual property); Ellis Instruments.

Low-Level Laser Therapy for Androgenetic Alopecia: A 24-week Randomized Double-Blind Placebo Controlled Trial

C. Huh: Research Grant (principal investigator, collaborator or consultant); PI of Research Grant. Off label use: OASE, One Technology

Medical Treatments: OTC's M. Leavitt: Ownership Interest (owner, stock, stock options); A-Z Surgical. Consultant/Advisory Board; Merck and Lexington.

Basics Course in Hair Restoration Surgery, Station 2: Anesthesia, Donor Harvesting & Donor Closure

P. Mohebi: Ownership Interest (royalty, patent, or other intellectual property); Yet to be determined. Off-label use: Laxameter I & Laxameter II

New Generation of the Laxometer P. Mohebi: Ownership Interest (royalty, patent, or other intellectual property); Yet to be determined. Breakfast with the Experts, Table Leader on the Topic of "How to Incorporate HRS into Your Current Practice"

C.J. Puig: Independent Contractor (includes contracted research); Independent Consultant for Physicians Interested in Incorperating HRS into thier practice.

Breakfast with the Experts, Table Co-Leader on the Topic of "Use of Staining in Recipient Sites"

M.N. Rashid: Consultant/Advisory Board; Recipient Site Stain by Innovative Surgiquip.

Scoping Scalp Disorders: Updates in Dermatoscopy

N.E. Rogers: Other; I work as a spokesman for J&J for Rogaine, speaking with media outlets and at the AAD.

Embryonic-like Secreted Proteins Enhance Follicular Unit Viability and Improve Donor Site Healing

N.S. Sadick: Other Research Support (receipt of drugs, supplies, equipment, or other in-kind support); Histogen, Inc.. Speakers Bureau/Honoraria (speakers bureau, symposia, and expert witness); Histogen, Inc..

The Role of Inflammation and Immunity in the Pathogenesis of Androgenetic Alopecia

N.S. Sadick: Research Grant (principal investigator, collaborator or consultant); Histogen. Speakers Bureau/Honoraria (speakers bureau, symposia, and expert witness); Histogen; Research Grant (principal investigator, collaborator or consultant): Histogen

(continued)

(continued from previous page)

Publishing Title Disclosure Block Ergo-scope, the New Microscope for Hair Transplant

P.A. Tafoya: Ownership Interest (royalty, patent, or other intellectual property); inventor/royalty.

Beginner Small Team’s Dream Comes True - Mega and Giga Session by Multiple Mini Sessions on Consecutive 3 to 4 Days

S.A. Vasa: Ownership Interest (owner, stock, stock options); Vasa hair Academy, Vasa Surgiart Pvt. Ltd., Vasa Innovations, Vasa Clinic.. Ownership Interest (royalty, patent, or other intellectual property); Dr. Sanjiv Vasa (Consultant, Director, Advisory board); Ownership Interest (owner, stock, stock options): Vasa hair Academy, Vasa Surgiart Pvt. Ltd., Vasa Innovations, Vasa Clinic.

Throw Away Your Loupes: Plantation Under Digital Video Microscope

S.A. Vasa: Ownership Interest (owner, stock, stock options); Vasa hair Academy, Vasa Surgiart Pvt. Ltd., Vasa Innovations, Vasa Clinic.. Ownership Interest (royalty, patent, or other intellectual property); Dr. Sanjiv Vasa (Consultant, Director, Advisory board).

Cell and Gene Therapy K. Washenik: Employment; Bosley/Aderans. Ownership Interest (owner, stock, stock options); Bosley/Aderans. Ownership Interest (royalty, patent, or other intellectual property); Bosley/Aderans.

Moderator Introduction, Non-Androgenetic Alopecias

K. Washenik: Employment; Bosley/Aderans. Ownership Interest (owner, stock, stock options); Bosley/Aderans. Ownership Interest (royalty, patent, or other intellectual property); Bosley/Aderans.

Persistent Sexual Dysfunction Controversy/Case Reports


Update on Cell Therapy and Biotech Research

K. Washenik: Employment; Aderans Research Institute/Bosley. Ownership Interest (owner, stock, stock options); Bosley. Ownership Interest (royalty, patent, or other intellectual property); Aderans Research Institute.

Workshop 103 - Understanding Cell Therapy and Related Follicular Research Advances (Workshop Director)


Two Year Follow Up of the Hair Stimulating Complex Exploratory Clinical Trial and Initiation of Phase I/II Trial

C. Ziering: Consultant/Advisory Board; Histogen Scientific Advisory Board; Consultant/Advisory Board: Histogen Scientific. M. Zimber: Employment; Employee of Histogen. M. Hubka: Employment; Employee of Histogen. D. Perez-Meza: None. J. Mansbridge: Employment; Employee of Histogen.

Planners and managers that have reported real or apparent conflicts of interest:

Name of Planner or Manager Position Reported Areas of Conflict Paul C. Cotterill, MD CME Committee Chair Royalty from Trandermal Cap.

Robert S. Haber, MD CME Committee Ownership interests (royalty, patent, or other I.P.), Ellis Instruments

Matt L. Leavitt, DO CME Committee, LSW Committee Chair

Speakers Bureau/Honorarium, Merck; Ownership interests (royalty, patent, or other I.P.), A-Z; Consultant/Advisory Board, Photomedex, Lexington, Merck

Ken Washenik, MD, PhD CME Committee


In addition, the ISHRS reports the following relationships with commercial interests associated with this activity:

Name of Commercial Interest

Type of Financial Relationship

Merck Provided unrestricted educational grant Johnson & Johnson Healthcare Products, Division of McNEIL-PPC, Inc.

Provided unrestricted educational grant

Bosley Provided unrestricted educational grant Hair Club Medical Group Provided unrestricted educational grant P&G beauty & grooming Provided unrestricted educational grant Restoration Robotics, Inc. Provided unrestricted educational grant A to Z Surgical Provided in-kind support Canfield Imaging Systems Provided in-kind support Ellis Instruments Provided in-kind support Micro-Vid Provided in-kind support

The ISHRS is not owned by an organization with any interests in product manufacturing.

(continued)


Planners and managers that have reported no conflicts of interest: Name of Planner or Manager Position Reported Area of Conflict Marco Barusco, MD CME Committee, Basics Course Co-Chair No COI to report. Victoria Ceh, MPA Executive Director, CME Director No COI to report.

Glenn M. Charles, DO CME Committee, Advanced/Board Review Course Chair No COI to report. Jean Devroyre, MD CME Committee, Workshops Chair No COI to report. Margaret Dieta CME Committee, Surg Asst Chair No COI to report.

James A. Harris, MD CME Committee, Webinars Chair, Advanced/Board Review Course Co-Chair No COI to report.

Francisco Jimenez, MD CME Committee No COI to report.

Sharon A. Keene, MD CME Committee No COI to report (not as a planner) Melvin L. Mayer, MD CME Committee, 2011 ASM Cmt No COI to report. Paul J. McAndrews, MD CME Committee, 2011 ASM Cmt No COI to report. Robert P. Niedbalski, DO CME Committee, LPV Chair No COI to report. Nina Otberg, MD CME Committee, LPV Co-Chair No COI to report. David Perez-Meza, MD CME Committee, Basics Course Chair No COI to report. Carlos J. Puig, DO CME Committee No COI to report. Rajesh Rajput, MD CME Committee, LPV Co-Chair No COI to report. Cam Simmons, MD CME Committee No COI to report.

OFF-LABEL OR OTHER NON-FDA APPROVED, INVESTIGATIONAL USE Additionally, speakers are also required to know and disclose to their audiences the FDA approval status of all medical devices and pharmaceuticals for the uses discussed, described or demonstrated in their educational presentations. Listed below are those who indicated that their presentation will include discussion of an “off-label” or other non-FDA approved, investigational use of a medical device or pharmaceutical product:

Publishing Title Presenting Author Off-label disclosure

Lunch Symposium 213 - Hair Duplication & Other Uses of Extracellular Matrix (Lunch Symposium Director)

Jerry Cooley, MD ACell MatriStem

Prescribing Finasteride at Distance in a Safe Way, Including the Simplified BCS Scoring

Mats Ingers, MD finasteride 5 mg, any generic copy

A Prospective Study on the Role of Commercially Available Growth Factors in Hair Growth

Shobit Caroli, MBBS Mesoline Hair, MD Skin Solutions

Contraindications to Hair Loss Medicines Jeff Donovan, MD PhD FRCPC FAAD

minoxidil 5 %, finasteride, dutasteride, spironolactone, flutamide for treatment of androgenetic alopecia in women

Low-Level Laser Therapy for Androgenetic Alopecia: A 24-week Randomized Double-Blind Placebo Controlled Trial

CHANG-HUN HUH, MD

OAZE, One Technology

A Report On "The Use of Oral Minoxidil That Make Hair Transplant From Impossible Become Possible in the Poor Candidate"

Damkerng Pathomvanich, MD

Oral Minioxidil, Loniten, Pharmacia and Upjohn Company

Is Soy Isoflavones an Alternative Treatment in Perimenopausal Females to Improve Hair Quality and Stop Hair Loss?

Silvana Franzini, MD soy flavones

(continued)


Listed below are those who answered that they DO NOT have a financial interest or other relationship with the manufacturer(s) of any of the products(s) or service(s) they intend to discuss:

Publishing Title Disclosure Block Evaluation and Comparisone of Linear Scar Line in Donor Area After Lower and Upper With Lower Edge Trichophitic Closure

G. Abbasi: None. S. Abbasi: None.

Determining the Efficacy of Supraorbital/Supratrochlear Nerve Blocks in Hair Transplant Surgery

M. Ahmad: None.

Donor Strip Slivering, Submerses in Normal Saline to Avoid Grafts Desiccation K. Amonpattana: None. D. Pathomvanich: None. Basics Course in Hair Restoration Surgery, Station 2: Anesthesia, Donor Harvesting & Donor Closure

J.L. Ballon: None.

FUE vs. Strip Harvest FUT: Panelist for "Pro Strip Harvest" side J.L. Ballon: None. Breakfast with the Experts, Table Co-Leader on the Topic of "Spanish-speaking Table: Our Favorite Pearls in HT Surgery"

A. Barrera: None.

Basics Course in FU Hair Restoration Surgery - Co-Chair M.N. Barusco: None. Breakfast with the Experts, Table Co-Leader on the Topic of "Crown Design and New Techniques"

M.N. Barusco: None.

Breakfast with the Experts, Table Leader on the Topic of "Electronic Medical Records-New U.S. Standards"

M.N. Barusco: None.

Workshop 104 - How to Compile a Patient Record and Proper Patient Photographs - See your workshop director for specifics and format of this workshop

M.N. Barusco: None.

Breakfast with the Experts, Table Leader on the Topic of "Eyelash Transplantation"

A.J. Bauman: None.

FUE vs. Strip Harvest FUT: Team Leader for "Pro FUE" side A.J. Bauman: None. Hair Bundle Cross-Section Trichometry Measurements in 250 Consecutive Cases of Hair Loss

A.J. Bauman: None.

How Dry I Am... Graft Desiccation Prevention During Suction-Assisted FUE A.J. Bauman: None. Lunch Symposium 211 - Hairline Design - See your symposium director for specifics and format of this symposium

M.L. Beehner: None.

Meta-Analysis of All Hair Transplant Survival Studies To Date M.L. Beehner: None. The Forelock Transplant Pattern Still Has a Place M.L. Beehner: None. Informed Consent Issues R.M. Bernstein: None. Panelist for Interactive Hairline Design Panel R.M. Bernstein: None. The Demographics of Male Pattern Baldness in India T. Bhatti: None. Basics Course in Hair Restoration Surgery, Station 3: Graft Slivering & Preparation

T. Carman, MD: None.

Hair Transplantation in Frontal Fibrosing Alopecia: 2 Prospective Cases S. Caroli: None. D. Pathomvanich: None. A.V. Kumar: None. K. Amonpattana: None.

Optimize the Efficiency of Recipient Area Estimation: A Comparative Study S. Caroli: None. D. Pathomvanich: None. K. Amonpattana: None. A.V. Kumar: None.

Trichohexis Nodosa: Unusual Hair Transplant Complication S. Caroli: None. D. Pathomvanich: None. A.V. Kumar: None. K. Amonpattana: None. O. Pathomvanich: None.

Breakfast with the Experts, Table Co-Leader on the Topic of "Japanese & English-speaking Table: Hairline Design in Male & Female; Prevention of Shock Loss; and Painless Anesthesia"

S.C. Chang: None.

Advance Technologies Panel Discussions: Graft Placement Techniques G.M. Charles: None. Advanced/Board Review Course - Co-Chair G.M. Charles: None. Basics Course in Hair Restoration Surgery, Station 2: Anesthesia, Donor Harvesting & Donor Closure

D. Clas: None.

Moderator Introduction, What's the Diagnosis I.S. Cohen: None. What's the Diagnosis?: Case 1 I. Cohen: None. Moderator Introduction, Body and Beard Used as Donor -- Eyebrow and Eyelash Transplants

J.P. Cole: None.

President's Address J. Cooley: None. Breakfast with the Experts, Table Leader on the Topic of "Female Hair Loss" P.C. Cotterill: None. ISHRS Best Practices Project P.C. Cotterill: None. Moderator Introduction, FUE: High Definition Surgical Theater & Free Papers J. Devroye: None. Panelist for Interactive Hairline Design Panel J. Devroye: None. Use of PRP and Extracellular Matrix-UBM in Hair Transplantation J.B. DeYarman: None. Female Hair Loss Work Up & Non Androgenetic Hair Loss D. Didocha: None. Contraindications to Hair Loss Medicines J.C. Donovan: None. Off label discussion: minoxidil 5 %,

finasteride, dutasteride, spironolactone, flutamide for treatment of androgenetic alopecia in women

To Transplant or Not to Transplant: Lessons from 10 Cases J.C. Donovan: None. Powered FUE Hair Transplant - An Analysis of 232 Patients K. Dua: None. A. Dua: None. Breakfast with the Experts, Table Co-Leader on the Topic of "Tissue Storage Solutions"

W.D. Ehringer: None.

Advance Technologies Panel Discussions: Recipient Sites V.W. Elliott: None. Moderator Introduction, Finasteride Adverse Events Controversies E.S. Epstein: None. Prostate and Breast Cancer E.S. Epstein: None. VIDEO: V-Loc Knotless Dermal Wound Closure Suture E.S. Epstein: None.

Publishing Title Disclosure Block Effects of Caffeine on Human Hair Follicles and the Dermal Papilla Cells in Vitro

W. Fan: None. L. Chen: None. N. Guan: None.

Eyebrow Hair Transplant in Dormant Keratosis Pilaris Atrophicans & 7-Year Follow Up

B. Farjo: None. N. Farjo: None.

Importance of Hair Alignment in Disguising the Donor Scar B. Farjo: None. Moderator Introduction, Medical and Non-Surgical Treatments B. Farjo: None. Study Update: Growth Stimulation of Scalp Hair Follicles by Prostaglandins K. Khidhir: None. N. Farjo: None. B. Farjo: None. D.

Woodward: Employment; Researcher. V. Randall: Research Grant (principal investigator, collaborator or consultant); Investigator.

Workshop 103 - Understanding Cell Therapy and Related Follicular Research Advances - See your workshop director for specifics and format of this workshop

B. Farjo: None.

Association of Hair Transplantation and Lichen Planopilaris N.P. Farjo: None. B.K. Farjo: None. M.J. Harries: None. R. Paus: None.

Post-Op Shedding: Female vs Male, Theories of Why? N.P. Farjo: None. Selected Thymic Peptides Directly and Differentially Modulate Human Hair Growth, Stem Cell Activity

N.P. Farjo: None. B.K. Farjo: None. R. Paus: None. N.T. Meier: None. D. Pattwell: None.

The Effects of Holding Solutions on Clinical Outcome Following Hair Transplantation and on the Viability of Isolated Human Hair Follicles As Demonstrated By Their Ability to Grow In Tissue Culture

N.P. Farjo: None. B.K. Farjo: None.

Breakfast with the Experts, Table Leader on the Topic of "Mesotherapy" S. Franzini: None. Intradermotherapy in Scarring Alopecias: Could it be an Alternative Treatment to Delay Their Progress Waiting New Developments?

S. Franzini: None. N. Lusicic: None. A. Susacasa: None.

Is Soy Isoflavones an Alternative Treatment in Perimenopausal Females to Improve Hair Quality and Stop Hair Loss?

S. Franzini: None. N. Lusicic: None. A. Susacasa: None. Off label use: soy flavones.

The Use of Silicone at the End of Graft Placing to Prevent Bleeding, Contamination and Improve Early Scab Removing in Hair Restoration Surgery


The Whole Truth About the PRL and Its Impact on the Hair Growth Cycle. Our Experience.


Treatment of AGA in Patients Under 18 Years Old. A New Approach to an Old Dilemma

S. Franzini: None. N. Lusicic: None.

Basics Course in Hair Restoration Surgery, Station 4: Recipient Sites S.A. Friedman: None. Workshop 104 - How to Compile a Patient Record and Proper Patient Photographs (Workshop Director)

S.A. Friedman: None.

Panelist for Difficult Cases Session J.W. Gaffney: None. Moderator Introduction, Advanced Surgical HD Videos V. Gambino: None. Surgical Transplantation of the Crown: A Video Presentation V. Gambino: None. Finasteride Induced Mood Changes. Case Reports and Literature Review J.I. Gaviria: None. A. Trius-Chassaigne: None. Moderator Introduction, Scientific Free Papers II J.I. Gaviria: None. Myths and Tips for Female Hair Loss (Cosmetic Hair Loss) J.I. Gaviria: None. How to Try to Reduce the Possibility of Over Cutting and Subsequently Piggy Backing or Popping

S. Gholami: None.

Our Experience Utilizing Cellular Therapy in Hair Restoration Surgery and Non-Surgical Treatments of Hair Loss Disease

J.F. Greco: None.

Moderator Introduction, Challenging and Atypical HT Cases R.S. Haber: None. Advance Technologies Panel Discussions: FUE J.A. Harris: None. Advanced/Board Review Course - Co-Chair J.A. Harris: None. Analysis of the Measured Area of FUE Extraction Donor Zones Utilizing Dissecting Punches of Different Sizes

J.A. Harris: None.

Case Study of the Clinical Result of 4100 Beard Graft Transplants to the Scalp J.A. Harris: None. Breakfast with the Experts, Table Leader on the Topic of "Autocloning/Plucking"

G.S. Hitzig: None.

Lunch Symposium 213 - Hair Duplication & Other Uses of Extracellular Matrix - See your symposium director for specifics and format of this symposium

G.S. Hitzig: None.

Advance Technologies Panel Discussions: Donor Removal Techniquess (strip) S. Hwang: None. Breakfast with the Experts, Table Leader on the Topic of "Asian HT" S. Hwang: None. Case 2: Chronic Post-Op Folliculitis S. Hwang: None. Moderator Introduction, Scientific Free Papers I S. Hwang: None. Basics Course in Hair Restoration Surgery, Station 2: Anesthesia, Donor Harvesting & Donor Closure

S.R. Ibrahim: None.

Workshop 102 - FUE: Different Technical Approaches - See your workshop director for specifics and format of this workshop

D. Ilter: None.

Prescribing Finasteride at Distance in a Safe Way, Including the Simplified BCS Scoring

M.G. Ingers: None. Off-label use: finasteride 5 mg, any generic copy

Breakfast with the Experts, Table Leader on the Topic of "Spanish-speaking Table: Our Favorite Pearls in HT Surgery"

F. Jimenez: None.

Clinical and histopathological analysis of Frontal Fibrosing Alopecia F. Jimenez: None. E. Escario: None. E. Poblet: None. Hair Grafting in Non-Healing Chronic Leg Ulcers: A Pilot Clinical Study F. Jimenez: None. A. Izeta: None. C. Garde: None. E.

Escario: None. E. Poblet: None. Moderator Introduction, New Vistas in Hair Transplantation I F. Jimenez: None. My Preferred Method to Make the Recipient Sites: Evolution of Former Method F. Jimenez: None. D. Sosa-Cabrera: None. Magnifying-Aded High-Densed Eyelash Transplantation W. Jing: None. Breakfast with the Experts, Table Leader on the Topic of "Flaps and Expanders" S. Kabaker: None.

Publishing Title Disclosure Block Panelist for Difficult Cases Session S. Kabaker: None. Case 1: Widened Donor Scar Treated with FUE - Resultant Hypopigmentation Scar - Tattoo

S.A. Keene: None.

Follow up from the pilot study to Evaluate Two Independent Cohorts using the X chromosome weighted method of AR-CAG Genotype to Identify Female Hair loss patients who are likely to respond to Anti Androgen Therapy (Finasteride)

S.A. Keene: None.

Panelist for Gigasessions Session S.A. Keene: None. One-Hour Eyebrow Transplantation (Rapid 160 Grafts Placing in 10 Minutes With Choi Implanters)

D. Kim: None.

Transection Rate and Speed of Combining Grafts Dissection (Slivering Under 20x Digital Video Microscope and Graft Cutting Under 2x Loupe )

D. Kim: None.

The Gene Expression Patterns of Transplanted Human Hairs in Nude Mice M. Kim: None. J. Oh: None. J. Kim: None. Is FUE Really a Repair Technique or Small case Technique Rather Than a 1st Option for MPB?

R.G. Knudsen: None.

Moderator Introduction, Hairline Design Panel R.G. Knudsen: None. Analysis of EGFR Expression in Human Hair Follicles in Frontoparietal and Occipital Scalp

J. Kolasinski: None. M. Mackiewicz-Wysocka: None. A. Przybyla: None. A. Mackiewicz: None.

Moderator Introduction, Female Hair Loss J.R. Kolasinski: None. TrichoScan Enhances Patient Selection for Hair Transplantation J. Kolasinski: None. M. Mackiewicz-Wysocka: None. M.

Kolenda: None. Eyebrow Transplantation - Problems & Outcomes M. Kulahci: None. O. Ergun: None. A. Karadeniz: None. FUE vs. Strip Harvest FUT: Panelist for "Pro FUE" side M. Kulahci: None. Hair Transplantation in Psoriasis: To Cut or Not To Cut A.V. Kumar: None. S. Caroli: None. K. Amonpattana:

None. O. Pathomvanich: None. D. Pathomvanich: None. Longitudinal or Horizontal Slivering Instead of Ordinary Method K.-. Laorwong: None. Breakfast with the Experts, Table Leader on the Topic of "Female Hair Loss and Treatment"

M. Leavitt: None.

Lunch Symposium 212 - Top 10 Clinical Pearls to Achieve Best Results and Happy Patients - See your symposium director for specifics and format of this symposium

M. Leavitt: None.

15 Years of Experience with the Use of Cross Hatching Surgical Technique to Improve Naturalness of a Hair Transplant Procedure

M. Leavitt, DO: None. D. Perez-Meza MD: None.

Comparison of Methods & Quality Speed L. Leonard: None. Comparison Placement : FUT vs FUE L. Leonard: None. Comparison Study of FUE Techniques: Sharp vs Dull Punch L. Leonard: None. New Anesthesia Mixture for FUE L. Leonard: None. Workshop 405 - Surgical Assistants Dissecting & Implanting Workshop (Implanting Station)

L. Leonard: None.

Integration of Suction-Assisted FUE in My Practice R.T. Leonard: None. Protection from Free Radical Formation on the Scalp F. Liebel: None. Breakfast with the Experts, Table Co-Leader on the Topic of "Spanish-speaking Table: Our Favorite Pearls in HT Surgery"

J.F. Lorenzo: None.

VIDEO - Efficient FUE Extraction and Implantation with Implanter Pen J.F. Lorenzo: None. Workshop 102 - FUE: Different Technical Approaches - See your workshop director for specifics and format of this workshop

J.F. Lorenzo: None.

Advance Technologies Panel Discussions: Tissue Expansion & Flaps E. Mangubat: None. Breakfast with the Experts, Table Leader on the Topic of "Flaps and Expanders" E. Mangubat: None. Moderator Introduction, Difficult Cases E. Mangubat: None. Breakfast with the Experts, Table Leader on the Topic of "Considerations When Building a Large, Quality Driven, Multinational Practice"

A. Markarian: None.

Breakfast with the Experts, Table Co-Leader on the Topic of "PRP" M. Markou: None. The Hair Clock, Or (To Put It Another Way) Why is Hair Growth Cyclical? A. Marliani: None. Breakfast with the Experts, Table Leader on the Topic of "How to Train Your Staff "

J.H. Martinick: None.

Workshop 101 - Recipient Sites - See your workshop director for specifics and format of this workshop


Advance Technologies Panel Discussions: Trichophytic Closures M. Marzola: None. Breakfast with the Experts, Table Leader on the Topic of "Trichophytic Closures"

M. Marzola: None.

Moderator Introduction, Emerging Issues M. Marzola: None. Panelist for Difficult Cases Session M. Marzola: None. Panelist for Interactive Hairline Design Panel M. Marzola: None. Program Chair Opening Remarks M.L. Mayer: None. Lunch Symposium 211 - Hairline Design - See your symposium director for specifics and format of this symposium

P.J. McAndrews: None.

Medical Treatments: Medical Therapies P.J. McAndrews: None. Overview of BLS and AED W.M. McKenzie: None. Moderator Introduction, Gigasessions: High Definition Surgical Theater & Free Papers

P. Mohebi: None.

Breakfast with the Experts, Table Leader on the Topic of "Beard and Mustache Transplantation"

D.H. Mohmand: None.


P.T. Mwamba: None.

Publishing Title Disclosure Block FUE Donor Harvesting All Over the World, Our Experiences Considering Ethnical Varieties

F.G. Neidel: None. K. Leonhardt: None.

Basics Course in Hair Restoration Surgery, Station 4: Recipient Sites R.P. Niedbalski: None. Workshop 101 - Recipient Sites (Workshop Director) R.P. Niedbalski: None. Female Hair Loss: The Clinical Role of Hair Bundle Cross Section Trichometry B.P. Nusbaum: None. Frontal Fibrosing Alopecia in a Man: Results of Follicular Unit Test Grafting B.P. Nusbaum: None. Moderator Introduction, Advances in Hair Biology B.P. Nusbaum: None. Update on ISHRS Project: Registry for Transplantation Results of Cicatricial Alopecias

N. Otberg: None.

A Simple Way to Isolate and Cultivate Dermal Papilla Cells from Human Scalp Hair Follicle

R. Panchaprateep: None.

Breakfast with the Experts, Table Co- Leader on the Topic of "Surg Asst Topic: Infection Control"

M.W. Parsley: None.

Potpourri: Tissue Management - Panel Discussion M.W. Parsley: None. Workshop 405 - Surgical Assistants Dissecting & Implanting Workshop (Slivering Station)

M.W. Parsley: None.

Basics Course in Hair Restoration Surgery, Station 1: Hairline & Crown Design W. Parsley: None. Breakfast with the Experts, Table Co-Leader on the Topic of "Tissue Storage Solutions"

W. Parsley: None.

Breakfast with the Experts, Table Leader on the Topic of "Lighting & Polarized Lights"

W. Parsley: None.

Case 3: Poor Production W. Parsley: None. Workshop 101 - Recipient Sites - See your workshop director for specifics and format of this workshop

W. Parsley: None.

A Report On "The Use of Oral Minoxidil That Make Hair Transplant From Impossible Become Possible in the Poor Candidate"

D. Pathomvanich: None. O. Pathomvanich: None. Off label use: Oral Minioxidil, Loniten, Pharmacia and Upjohn Company

How Deep Should We Actually Score While Donor Harvesting? D. Pathomvanich: None. S. Caroli: None. A.V. Kumar: None. O. Pathomvanich: None. P. Thienthaworn: None.

How to Manage an Intra-Operative Surprise When We Encounter Slippery Grafts

D. Pathomvanich: None. S. Caroli: None. A.V. Kumar: None. K. Amonpattana: None. O. Pathomvanich: None.

Moderator Introduction, Donor Management and Closure Techniques D. Pathomvanich: None. Panelist for Interactive Hairline Design Panel D. Pathomvanich: None. Basics Course in FU Hair Restoration Surgery - Chair (Introduction & Guide to Hair Restoration for Dummies 9:00AM-9:30AM)

D. Perez-Meza: None.

Breakfast with the Experts, Table Co-Leader on the Topic of "Spanish-speaking Table: Our Favorite Pearls in HT Surgery"


FUE versus Strip Harvest FUT: Fair and Balanced View D. Perez-Meza: None. Breakfast with the Experts, Table Leader on the Topic of "Preview Long Hair Transplants"

M. Pitchon: None.

Preview Long Hair Transplantation, The P Constant, the Patient Maximum Efficiency Equations and Therasession

M. Pitchon: None.

Cicatricial Alopecia Update V.H. Price: None. What's the Diagnosis?: Case 3 V. Price: None. Case 6: Methicillin-resistant Staphylococcus aureus (MRSA) C.J. Puig: None. Lunch Symposium 212 - Top 10 Clinical Pearls to Achieve Best Results and Happy Patients - See your symposium director for specifics and format of this symposium

W.R. Rassman: None.

Moderator Introduction, Controversy: FUE vs. Strip Harvest FUT W.R. Rassman: None. Basics Course in Hair Restoration Surgery, Station 3: Graft Slivering & Preparation

W.H. Reed: None.

Top 10 Clinical Pearls to Achieve Best Results and Happy Patients. W.H. Reed: None. Workshop 101 - Recipient Sites - See your workshop director for specifics and format of this workshop

W.H. Reed: None.

Breakfast with the Experts, Table Co-Leader on the Topic of "PRP" R.J. Reese: None. Pre and Post-op Management R.J. Reese: None. Two Hand Technique F. Reynoso: None. Breakfast with the Experts, Table Leader on the Topic of "Non-Androgenetic Alopecias"

N. Rogers: None.

Moderator Introduction, Unique Issues in Ethnic Transplantation N. Rogers: None. Vitamin D and Hair: Should We Care? N.E. Rogers: None. Basics Course in Hair Restoration Surgery, Station 4: Recipient Sites A. Ruston: None. FUE Learning Curve A. Ruston: None. Lunch Symposium 212 - Top 10 Clinical Pearls to Achieve Best Results and Happy Patients - See your symposium director for specifics and format of this symposium

A. Ruston: None.

Surgical Complications in Hair Transplantation: A Series of 533 Procedures S.N. Salanitri: None. A. Helene Jr.: None. A.A. Jose Gonçalves: None. F. Helena Junqueira Lopes: None.

Regulation in Hair Disorders and Diseases M.E. Sawaya: None. Graft Preparation, Survival, & Growth J. Scannell: None. Advance Technologies Panel Discussions: Hairline Design R. Shapiro: None. Breakfast with the Experts, Table Co-Leader on the Topic of "Use of Staining in Recipient Sites"

R. Shapiro: None.

Lunch Symposium 211 - Hairline Design (Lunch Symposium Director) R. Shapiro: None.

Publishing Title Disclosure Block Scoring-Backhanded Blunt Dissection For Minimal Transection Donor Strip Harvesting With 0 - 1 Assistants And Tools You Already Own

C. Simmons: None.

Lunch Symposium 212 - Top 10 Clinical Pearls to Achieve Best Reults and Happy Patients (Lunch Symposium Director)

D. Stough: None.

Persistent Sexual Dysfunction Controversy Data and Possible Explanations D. Stough: None. What's the Diagnosis?: Case 5 D. Stough: None. FUE vs. Strip Harvest FUT: Team Leader for "Pro Strip Harvest" side E. Suddleson: None. Proposal of Definition of FUE Transection R.H. True: None. Test Taking Strategies R.H. True: None. Workshop 102 - FUE: Different Technical Approaches (Workshop Director) R.H. True: None. Giga Sessions - A Six-Year Perspective A. Tsilosani: None. VIDEO: Planning and Execution of a Gigasession A. Tykocinski: None. Workshop 101 - Recipient Sites - See your workshop director for specifics and format of this workshop

A. Tykocinski: None.

Hairline Refinement Using Leg Hair S.H. Umar: None. Are Analgesics and Sedatives Safe? Hair Transplantation in G6PD Deficiency A.K. Vaggu: None. S. Caroli: None. K. Amonpattana:

None. O. Pathomvanich: None. D. Pathomvanich: None. Oral Tranexamic Acid as a Pre-operative Medication Before Hair Transplant Surgery

D.P. Vaidya: None.

Moderator Introduction, New Surgical Instruments and Techniques S.A. Vasa: None. Comparative Study Between Direct Hair Implantation and Classic FUE. How Can a Minimally Invasive Procedure Affect the Survival of Hair Follicles?

A. Vekris: None. K. Giotis: None.

Comparative Study of Follicular Unit Extraction Between Different Ethnic Groups With 0.9mm and 1.0mm Punches

A. Vekris: None. V. Desai: None. K. Giotis: None.

Workshop 104 - How to Compile a Patient Record and Proper Patient Photographs - See your workshop director for specifics and format of this workshop

J. Vogel: None.

Basics Course in Hair Restoration Surgery, Station 1: Hairline & Crown Design and Hair Loss, Scarring and Non-Scarring Alopecias

M. Waldman: None.

A Proposal for Standard FUE Nomenclature S.M. Wassebauer: None. FUE Transection Rates S.M. Wassebauer: None. Robotic Assisted Harvest of Follicular Units S. Wasserbauer: None. FUE vs. Strip Harvest FUT: Panelist for "Pro FUE" side K.L. Wililams: None. Breakfast with the Experts, Table Leader on the Topic of "FUE" B. Wolf: None. FUE vs Strip FUT: A Side By Side Comparison B.R. Wolf: None. FUE vs. Strip Harvest FUT: Panelist for "Pro FUE" side B. Wolf: None. Quality & Legal Issues Regarding Surgical Tech Participation in the HT Procedure

B. Wolf: None.


B. Wolf: None.

FUE vs. Strip Harvest FUT: Panelist for "Pro Strip Harvest" side J. Wong: None. Panelist for Gigasessions Session J. Wong: None. Workshop 101 - Recipient Sites - See your workshop director for specifics and format of this workshop

J. Wong: None.

Breakfast with the Experts, Table Leader on the Topic of "Japanese & English-speaking Table: Hairline Design in Male & Female; Prevention of Shock Loss; and Painless Anesthesia"

K. Yagyu: None.

Lunch Symposium 212 - Top 10 Clinical Pearls to Achieve Best Results and Happy Patients - See your symposium director for specifics and format of this symposium

K. Yagyu: None.

Management of Arrhythmia and Updated Guidelines for Perioperative Beta Blockade Therapy in Hair Restoration Surgery

K. Yagyu: None.

Management of Patients with Coronary Artery Disease and Updated Guidelines for Antithrombotic Therapy in Hair Restoration Surgery

K. Yagyu: None.

Additional Intra-epidermal Suture to Trichophytic Closure of Both Wound Edges to Minimize Scarring and Camouflage Donor Scars Effectively

K. Yamamoto: None.

Refinements of Asian Female Hairline Surgerys S. Yi: None. Breakfast with the Experts, Table Co-Leader on the Topic of "Crown Design and New Techniques"

C.L. Ziering: None.

Breakfast with the Experts, Table Leader on the Topic of "Social Media" C.L. Ziering: None. Zones for Hair Restoration C.L. Ziering: None. Hair Restoration For Congenital Etiology Baldness In Occipital Region Of The Head Of 15 Years Old Male Patient Using FUE

G. Zontos: None.

Mathematical Approach of Lateral and Sagittal Incisions G. Zontos: None.

The views and techniques of the presenters are not necessarily those of the International Society of Hair

Restoration Surgery (ISHRS), but are presented in this forum to advance scientific and medical education.

DA

Y-BY-DA

Y PR

OG

RA

MThuRsDAY ➤ sePTeMBeR 15, 20115:30AM-9:15AM; and 4:00PM-5:15PM

Looping, limited shuttle bus service between Hotel Captain Cook and Dena’ina Civic and Convention Center

6:00AM-5:00PM Poster Viewing

6:00AM-5:00PM Registration

6:00AM-5:00PM Speaker Ready Room

6:30AM-8:30AM Workshops 101, 404 (ticket required)

7:00AM-8:30AM Workshops 102, 103, 104 (ticket required)

8:00AM-5:00PM Exhibits

8:00AM-9:00AM Continental Breakfast

9:00AM-5:00PM GENERAL SESSION

9:00AM-9:18AM Opening Session Moderator: Melvin L. Mayer, MD

9:00AM-9:08AM 001

8 Program Chair Welcome Melvin L. Mayer, MD

9:08AM-9:18AM 002

10 President’s Address Jerry E. Cooley, MD

9:20AM-10:50AM New Vistas in Hair Transplantation Moderator: Francisco Jimenez, MD

LEArning obJECtivEs:

• Describe ongoing studies involving pharmacologic agents being tested for treatment of androgenetic alopecia.

• Discuss various research projects on the subject of hair and how they may impact therapies or treatments for hair loss.

• Review the role of apoptosis and oxidative stress in hair loss and the effect of therapies aimed at reducing it in the donor and recipient areas.

9:20AM-9:22AM 003

2 Moderator introduction Francisco Jimenez, MD

9:22AM-9:29AM 004

7 Update on Cell therapy and biotech research

Ken Washenik, MD, PhD

9:29AM-9:36AM

005

7 the Effect of Holding solutions on Clinical outcomes Following Hair transplantation and on the viability of isolated Human Hair as Demonstrated in their Ability to grow in tissue Culture

Nilofer P. Farjo, MBChB

9:37AM-9:44AM

006

7 Embryonic-like secreted Proteins Enhance Follicular Unit viability and improve Donor site Healing

neil s. sadick, MD

9:44AM-9:51AM

007

7 two Year Follow Up of the Hair stimulating Complex Exploratory Clinical Trial and initiation of Phase i/ii trial

Craig L. Ziering, Do

9:51AM-10:05AM Q&A

10:05AM-10:12AM

008

7 Our Experience Utilizing Cellular Therapy in Hair restoration surgery and non-surgical treatments of Hair Loss Disease

Joseph F. greco, PhD, PA/C

10:13AM-10:20AM

009

7 Use of PRP and Extracellular Matrix-UBM in Hair transplantation

James b. DeYarman, Do

10:20AM-10:40AM

010

20 norWooD LECtUrEr

New Horizons in Storage Solutions and Additive Agents in Organ TransplantationFeatured guest speaker: William D. Ehringer, PhD

Associate Professor of Physiology, Biophysics, and Bioengineering, University of Louisville and Founder, VitaTech and Vital Solutions, LLC, Charlestown, Indiana, USA

10:40AM-10:50AM Q&A

10:50AM-11:15AM Coffee Break Generously supported by a grant from Merck

11:15AM-12:25PM Challenging and Atypical HT Cases Moderator: robert s. Haber, MD


• Recognize surgical limitations in marginal candidates and develop appropriate treatment plans for these patients.

• Discuss challenging and atypical cases and treatment options.

11:15AM-11:17AM 011

2 Moderator introduction

robert s. Haber, MD

11:17AM-11:22AM

012

5 Case 1: Widened Donor scar treated with FUE – resultant Hypopigmentation scar – tattoo

sharon A. Keene, MD

11:22AM-11:27AM 5 Discussion of Case 1

11:28AM-11:33AM 013

5 Case 2: Chronic Post-op Folliculitis

Sungjoo Tommy Hwang, MD, PhD


11:39AM-11:44AM 014

5 Case 3: Poor Production

William M. Parsley, MD


11:50AM-11:55AM

015

5 Case 4: Hair transplantation in Psoriasis: to Cut or not to Cut

Anand Kumar, MD

11:55AM-12:00PM 5 Discussion of Case 4

12:01PM-12:06PM

016

5 Case 5: Trichohexis Nodosa: Unusual Hair transplant Complication

shobit Caroli, MD

12:06PM-12:11PM 5 Discussion of Case 5

12:12PM-12:17PM

017

5 Case 6: Methicillin-resistant staphylococcus aureus (MrsA),

Carlos J. Puig, Do

12:17PM-12:22PM 5 Discussion of Case 6

12:25PM-12:45PM Attendee Break & Convention Center prepares tables for lunch

12:45PM-1:45PM ISHRS General Membership Business Meeting Luncheon and Service Awards

1:45PM-3:45PM Surgical Assistant Program Committee Post-Meeting Wrap-Up (invitation only)

2:00PM-2:45PM Emerging Issues and Treatments Moderator: Mario Marzola, Mbbs

LEArning obJECtivE:

• Describe various studies and emerging issues in hair restoration surgery.

2:00PM-2:02PM 018

2 Moderator introduction Mario Marzola, Mbbs

2:02PM-2:09PM

019

7 Mesotherapy - treatment of AgA in Patients Under 18 Years old. A new Approach to an old Dilemma

silvana Franzini, MD

2:10PM-2:17PM

020

7 is FUE really a repair technique or small case technique rather than a 1st option for MPb?

russell Knudsen, Mbbs

2:17PM-2:22PM

021

5 FUE versus strip Harvest FUt: Fair and balanced view

David Perez-Meza, MD

2:23PM-2:30PM

022

7 Quality & Legal issues regarding surgical tech Participation in the Ht Procedure

bradley r. Wolf, MD

2:30PM-2:45PM Q&A

2:50PM-4:00PM FUE Moderator: Jean Devroye, MD

LEArning obJECtivE:

• Better understand various techniques that can be used for FUE and their advantages, disadvantages, and average transection rates.

2:50PM-2:52PM 023


Jean Devroye, MD

2:52PM-2:55PM 024

3 Proposal of Definition of FUE Transection

robert H. true, MD, MPH

2:55PM-3:02PM 025

7 FUE Learning Curve

Antonio s. ruston, MD

3:02PM-3:09PM

026

7 VIDEO – Efficient FUE Extraction and implantation with implanter Pen

Jose Lorenzo, MD

3:10PM-3:17PM

027

7 Analysis of FUE sites and the Measured Area of FUE Extraction Donor Zones Utilizing Dissecting Punches of Different sizes

James A. Harris, MD

3:17PM-3:24PM

028

7 integration of suction-Assisted FUE in My Practice

robert t. Leonard, Jr., Do

3:25PM-3:32PM

029

7 How Dry i Am...graft Desiccation Prevention During suction-assisted FUE

Alan J. bauman, MD

3:32PM-3:39PM

030

7 Powered FUE Hair transplant: An Analysis of 233 Patients

Kapil Dua, MD

3:40PM-4:00PM Q&A

4:00PM-4:15PM Coffee Break Generously supported by a grant from Johnson & Johnson Healthcare Products, Division of McNEIL-PPC, Inc.

4:15PM-5:00PM

032 033

Gigasessions: High Definition Surgical Theater “Workshop in Brazil” & Free Papers Moderator: Parsa Mohebi, MD

Panelists: sharon A. Keene, MD and Jerry Wong, MD

LEArning obJECtivE:

• Review the treatment plan and observe key components during the procedure for a gigasession (5000 FUs).

4:15PM-4:17PM 031


Parsa Mohebi, MD

4:17PM-4:24PM 034

7 Gigasession a Six Year Perspective

Akaki tsilosani, MD

4:24PM-4:44PM

035

20 VIDEO: Planning and Execution of a gigasession

Arthur tykocinski, MD

4:45PM-5:00PM Q&A

7:00PM-9:00PM Welcome Reception: Alaska Native Heritage Center Coach loads at 6:30PM at Hotel Captain Cook.

9:30PM-1:00AM Optional Outing: Chillkoot Charlie’s

001

Program Chair Opening Remarks Melvin L. Mayer, MD Bosley Medical, San Diego, CA, USA.

Dr. Mayer has been practicing hair transplant surgery since 1992. He has been awarded research grants by the ISHRS. His special areas of interest have been follicular regeneration of bisected follicles, graft yield at varying densities, classification and surgical techniques of the temporal points, scalp elasticity scale and understanding its importance in maximizing donor width and minimizing donor scars, and techniques to maximize the quality of transplants in patients of African decent. For these efforts he was awarded the Platinum Follicle Award in 2004. He is a Past-President of the ABHRS.

M.L. Mayer: None.

002

President's Address Jerry Cooley, MD Carolina Dermatology, Charlotte, NC, USA.

Jerry Cooley, MD is President of the International Society of Hair Restoration Surgery.

J. Cooley: None.

003

Moderator Introduction, New Vistas in Hair Transplantation I Francisco Jimenez, MD Private Practice, Las Palmas Gran Canaria, Spain.

Dr. Jimenez is a dermatologist and hair transplant surgeon, working in private practice in Las Palmas de Gran Canaria, Canary Islands, Spain. Author of more than 70 articles in international journals and chapter of textbooks. Past Editor of the Hair Transplant Forum Journal (2008-2010).

F. Jimenez: None.

004

Update on Cell Therapy and Biotech Research Ken Washenik, MD, PhD Bosley, Beverly Hills, CA, USA.

Ken Washenik, MD PhD, is the Medical Director and Chief Medical Officer of Bosley and the Chief Executive Officer of the Aderans Research Institute. Dr. Washenik is the Immediate Past President of the North American Hair Research Society, a faculty member of the Department of Dermatology at the New York University School of Medicine and on the Boards of the Hair Foundation and the Cicatricial Alopecia Research Foundation.


ABSTRACT: The scientific basis of cellular hair follicle regeneration will be reviewed in detail with a focus on the journey from the lab bench top to the clinical trial stage. The current stage of development of this technology will be discussed. In addition, recent hot topics in hair follicle biology and research will be explored including the important discovery that the hair follicles of the bald scalp contain the same number of stem cells as the follicles of the non-balding scalp. The implications of this, and other, scientific findings in relationship to the treatment of hair loss will examined.

005

The Effects of Holding Solutions on Clinical Outcome Following Hair Transplantation and on the Viability of Isolated Human Hair Follicles As Demonstrated By Their Ability to Grow In Tissue Culture Nilofer P. Farjo, MBChB, Bessam K. Farjo, MBChB Farjo Medical Centre, Manchester, United Kingdom.

Nilofer Farjo has been exclusively performing hair restoration since 1993 in Manchester, UK. She is a member of the ISHRS, Co-editor of the Hair Transplant Forum International and diplomat of the American Board of Hair Restoration Surgery. Nilofer is the immediate past President and founder member of the British Association of Hair Restoration Surgeons, Fellow of the Institute of Trichologists, past President of The Trichological Society and member the European Hair Research Society. She currently works with three universities and one public company on basic hair sciences projects.

N.P. Farjo: None. B.K. Farjo: None.

ABSTRACT: Aim: The aim of these studies is to look at finding the optimum solution to use in hair restoration surgery. Although there have been several attempts in the past to look at holding solutions for graft storage prior to re-implantation there has not been a definite conclusion on the type of medium to use. Currently most surgeons use simple normal saline or other IV solution as the storage medium. Other organ grafting procedures use one of several purpose developed solutions. This begs the question of why this has not happened with hair transplantation. The in vivo study was designed to look at clinical outcomes using soltran vs normal saline. The aim of the in vitro study was two-fold. One to find a reliable model for testing holding solutions and secondly to investigate whether Marshall's solution (currently used as an organ holding solution) is a better transport media for isolated human hair follicles than either saline or Williams E medium (the standard used in hair biology research). Methods: In the in vivo study all patients from a selected date had surgery performed with graft storage in Marshall’s Solution(Soltran). Follow-up of the post surgery course looked at healing times and the lag time between transplantation and new hair growth Patients prior to the use of the new medium were also routinely asked for the same information. The in vitro study used human hair follicles isolated for hair transplant surgery from male and female patients which were placed in sterile Sterilin tubes containing either, Williams E Medium, Saline or Soltran and sent to the centre for Cutaneous Research London. On receipt in London isolated hair follicles were maintained at 37oC in an atmosphere of 5% CO2/95% air in individual wells of 24 well multiwell plates containing 500ul of Williams E medium supplemented with 2mM L-glutamine, 10ug/ml insulin, 10ng/ml hydrocortiscone, 100 ug/ml streptomycin and 100U/ml penicillin. Hair follicle measurements were made using Image J software. In addition to hair follicle measurements we also investigated whether, at the end of the experiments any of the hair follicle tissue remained viable. This was carried out by micro dissection of the dermal papilla and plating the isolated DP for explant culture. We then determined the number of DP that showed cell explants and established primary cell cultures. Results: In vivo: For post-op patients completing surveys between September 2009 and February 2010. Surgery dates from March 2008 to October 2009. Graph 1 shows the number of days before scabs came off post-operatively (mean 10.71 days) using soltran.

Prior to this survey we did a preliminary comparative study showing the following results: The normal saline group (N=6): Average for scabs: 12.58 days Marshall’s solution group (N=10): Average for scabs: 7.06 days Graph 2 shows the numbers of weeks before grafted hairs were visibly growing as reported by the patient (mean 11.5 weeks). In the preliminary survey the results were: The normal saline group (N=6): Average for growth: 13.67 weeks Marshall’s solution group (N=10): Average for growth: 13.5 weeks In-vitro: Experiments were carried out using hair follicles from 3 separate patients. The number of hair follicles used per experiment varied per patient although there was never less than 5 follicles per treatment per patient. In total we studied 24 hair follicles from 3 patients for Williams E medium, 17 follicles from 3 patients for Saline and 17 follicles from 3 patients for Soltran. Hair follicles transported in Williams E. retained greater viability in terms of the number of hair follicles that grew in culture 22 out of 24 follicles (91.6%) compared to Saline, 11 out of 17 (64.7%) and Soltran in which only 7 follicles out of 17 (41.1%) grew. This was also confirmed when growth of follicles over 11 days was assessed (Figure 1). From this figure it can clearly be seen that follicles grew better in culture when transported in Williams E. medium compared to Soltran and Saline. Analysis of isolated hair follicles following culture also confirmed the improved morphology of hair follicles transported in Williams E medium compared to Saline and Soltran. Although a more detailed study of hair follicle histology would be required it appears from this study that hair follicles transported in Williams E medium appear morphologically much healthier than follicles transported in Saline and Soltran and this probably explains the greater number of follicles that grew in vitro when transported in Williams E medium compared to saline and Soltran. We managed to isolate 5 DP from follicles transported in tissue culture medium; 4 DP from follicles transported in Soltran and 4 DP from follicles transported in saline. The ability to isolate DP and the number of DP isolated was not influenced by transport media. We then plated these DP in culture and looked at the number of DP that explanted and from which cells grew. This was interesting: 3 out of 5 DP from follicles transported in tissue culture medium explanted and established explant culture 2 out of 4 DP from follicles transported in Soltran explanted and established explant culture. But only 1 DP out of 4 follicles transported in saline explanted and established an explant culture. So from this very very small study tissue culture medium and Soltran give similar results but much better than saline. At present there does not appear to be any difference in quality of DP cells that are growing and so once in culture their means of transport seems to be cancelled out. However, it is important to emphasise that this is a very small study. Discussion: This is only a small pilot study and although some conclusions can be made from this it is important to emphasize the small sample size. These studies do suggest that there are better holding solutions than normal saline but that the alternative solution we used is not the ideal one. The lag phase between hair transplantation and hair growth is not markedly changed and although the post-operative period of recovery (ie until scabs fall) was improved there was greater physician surveillance in these patients suggesting possible errors in patient reporting. The in vitro studies show that we can use some objective methods of assessing hair follicle viability to compare holding solutions. Ongoing studies are assessing alternative solutions. Conclusion: The type of holding solution does impact hair follicle viability. It remains to be seen whether we can significantly improve graft survival by developing the "ideal" holding solution. This study was partially supported by an ISHRS study grant.

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006

Embryonic-like Secreted Proteins Enhance Follicular Unit Viability and Improve Donor Site Healing Neil S. Sadick, MD Sadick Aesthetic Surgery and Dermatology, New York, NY, USA.

Dr. Sadick holds five board certifications in internal medicine, dermatology, cosmetic surgery, hair restoration surgery and phlebology. Dr. Sadick is one of the world’s most respected dermatologists and the medical director and owner of Sadick Dermatology with locations on Park Avenue in New York City and Great Neck, Long Island. Dr. Sadick is also the director of the Sadick Research Group, which runs multiple FDA clinical trials each year.

N.S. Sadick: Other Research Support (receipt of drugs, supplies, equipment, or other in-kind support); Histogen, Inc.. Speakers Bureau/Honoraria (speakers bureau, symposia, and expert witness); Histogen, Inc..

ABSTRACT: Embryonic-like Secreted Proteins Enhance Follicular Unit Viability and Improve Donor Site Healing Neil Sadick1, Michael Zimber3, Craig Ziering2, Jonathan Mansbridge3, and Gail K. Naughton3 1Department of Dermatology, Weill Cornell Medical College, 2Ziering Medical, 3Histogen, Inc. Introduction: Although tremendous progress has been made in the field of hair transplantation over the last few decades, post transplant shock leading to effluvium still remains an issue in seeing immediate cosmetic improvement. Transplant medicine has progressed greatly over the past two decades, in large part due to the creation of transport solutions that maintain the organs and tissues in a more physiologic state and maximize cell viability. New solutions for organ preservation serve to minimize damage and promote graft survival and function. It is therefore logical that by


creating a more natural and hospitable environment for follicles during the period they are outside of the body, the effluvium can not only be lessened, but the final result of the transplant procedure may be more successful by improving the quality and health of the newly transplanted follicles and hairs. The aim of this research was to examine a naturally-secreted, embryonic-like human cell conditioned media (hCCM) as a holding solution (FHS, or Follicular Holding Solution) for follicles from extraction to transplant, and determine if this media may aid in follicle viability and reduced post-transplant shock, as compared to the standard saline solution. This conditioned media is also being studied as a healing promoter at both the donor and transplant sites. Method and Materials : Neonatal cells are grown in suspension cultures in closed bioreactors that closely maintain an environment of 3-5% oxygen. Under these conditions the cells express markers associated with multipotent cells and produce proteins and growth factors, particularly Wnt7a, KGF, VEGF, and follistatin, which have long been associated with hair growth, tissue formation and regeneration. Over 5000 genes are differentially expressed as compared to identical growth conditions with normal oxygen, and cell surface markers are expressed which are normally associated with follicular stem cells, including Lhx2, SOX 21, Nestin, NFATc1, and Krt 15. (Figure 1) FHS was evaluated in laboratory and clinical paradigms to determine its effect on follicular viability, growth and survival. In vitro evaluation of excess human follicles obtained from routine transplant procedures was performed by isolating follicular units in either hCCM or phosphate buffered saline (PBS) at the time of the procedure. Follicles were then cultured at 37°C in either hCCM or PBS and followed out over three days to obtain hair length and follicular cell viability over time. The growth rate of the individual follicles (10 two-haired units in each evaluation group) were measured at 24 hour intervals using the microscopic image analysis, and viability of the follicular grafts was determined using the MTT cell assay at 24 and 72 hours post-explant. Clinical exploratory studies are being conducted to evaluate the use of the hCCM as a holding solution, as compared to a saline control, in a routine hair transplant procedure as well as to assess the ability of the material to support donor site and graft site healing. Results: In vitro evaluation of the hCCM as a follicular holding solution showed significantly greater viability of the explanted human hair follicular grafts as compared to PBS. In addition, the data indicates that the hCCM maintains the capacity of the hair to continue hair growth in vitro, as revealed through measurements at 24 hour intervals over 72 hours. (Figure 2) The results of this experiment suggest that FHS would be a significant improvement in maintaining the viability and growth of human follicular units during the period between explant from donor scalp tissue and transplantation into the recipient region. In exploratory clinical trials to date 50-60% of the transplanted hairs held in PBS were lost to effluvium at the 6 week follow-up whereas 80-90% of follicles held in hCCM remained intact at this follow-up time point. In addition, initial clinical experience with a topical formulation of hCCM at donor sites has shown improved wound closure and reduced scarring. Summary: Although technique plays a crucial role in the successful outcome of a hair transplant procedure, issues such as effluvium, healing and scarring tend to be out of the specialist’s control. In vitro and case study results with hCCM support the use of this naturally-secreted complex of embryonic-like proteins for hair transplant applications as a follicular holding solution and as a topical treatment to promote the healing of post-transplant wounds. Figure 1: The Expression of hair follicle-related stem cell markers in neonatal cells grown under simulated embryonic conditions. Figure 2: The Hair growth and cell viability of follicles in vitro when held in PBS vs. FHS as measured over 72 hours.

007

Two Year Follow Up of the Hair Stimulating Complex Exploratory Clinical Trial and Initiation of Phase I/II Trial Craig Ziering, DO1, Michael Zimber, Ph.D2, Mark Hubka2, David Perez-Meza, MD3, Jonathan Mansbridge, Ph.D2

1Ziering Medical, Los Angeles, CA, USA, 2Histogen, Inc., San Diego, CA, USA, 3Medical Hair Restoration, Maitland, FL, USA.

Dr. Craig Ziering has more than 19 years of specialized experience in hair restoration. In addition to performing over 14,000 hair transplant procedures, he is an author, lecturer, trusted surgeon to physicians, and innovator in the field. As founder and medical director of Ziering Medical, he operates hair restoration centers in Beverly Hills, Newport Beach and Las Vegas. Dr. Ziering is certified by the American Board of Hair Restoration Surgery and the American Osteopathic Board of Dermatology, serves on the advisory board for companies including Merck and Lexington International, and is Surgical Faculty for the Procedural Dermatology Fellowship at UC Irvine. He remains an active participant in research, and serves as an advocate of innovative future treatments for hair loss.

C. Ziering: Consultant/Advisory Board; Histogen Scientific Advisory Board. M. Zimber: Employment; Employee of Histogen. M. Hubka: Employment; Employee of Histogen. D. Perez-Meza: None. J. Mansbridge: Employment; Employee of Histogen.

ABSTRACT: Introduction: Research has shown the importance of stimulating bulge cells and inter-follicular stem cells to induce hair growth. We have developed a human cell-derived formulation, termed Hair Stimulating Complex (HSC), consisting of Wnt 7a, Follistatin, KGF, VEGF and other growth factors and morphogens recognized to be critical in stimulating stem cells and bulge cells to form new follicles and promote hair growth. Method and Materials: Human neonatal cells are exposed to hypoxic conditions (1-5% oxygen) under which they express stem cell markers and proteins associated with multipotent cells. These multipotent cells are seeded on dextran beads and grown in suspension cultures in hypoxic bioreactors during which time they produce HSC. In the initial double-blind, placebo-controlled, randomized single site exploratory trial patients received 4 intradermal injections of HSC and non-conditioned medium in anterior treatment sites of the scalp at baseline only. Safety was assessed at 12 weeks, 5 months, 12 and 24 months and efficacy was formally assessed up to the one year timepoint. Additional exploratory studies have been initiated to test the safety and efficacy of a clinically relevant number of injections (50-100/patient) and a formal phase double-blind, placebo-controlled, randomized multicenter I/II trial is underway to test the effect of eight 0.1cc injections at baseline, with an additional eight injections at 6 weeks. Results: Data analysis indicated that HSC was safe throughout the two year followup. HSC was effective in stimulating hair growth in subjects with male-pattern baldness, with Trichoscan image analysis of the HSC treated sites demonstrating a statistically significant increase in hair shaft thickness (p = 0.046), thickness density (p = 0.028), and terminal hair density (P= 0.029) as compared to the control site at 12 weeks. Although injections were given only at baseline, total number of hairs continued to increase on the HSC-treated site over one year (p=0.032), supporting the role of HSC having a stimulatory affect on native bulge and interfollicular stem cells to produce new hair. Such continued new hair growth (figure 1) was seen on the majority of the regions treated with HSC while several regions treated with the placebo showed continued hair loss over the one year period. Positive effects were seen within a 2 mm distance of the 0.1cc injections, with an average of 25 new hairs being generated per injection. Although there was no formal assessment of efficacy at the 2 year time point, new hairs appeared to persist. In addition, initial results in subjects receiving 50 injections/treatment show safety and efficacy at the initial 6 week timepoint. Conclusion: These results clearly demonstrate that a single intradermal administration of HSC improved hair growth in subjects

with androgenetic alopecia and is a clinical substantiation of previous preclinical research with Wnts, Follistatin, and wound growth factors in inducing new hair formation. Exploratory multiple dose studies will help to demonstrate safety and efficacy in a clinically relevant treatment, while phase I/II results will further assess the number of new hairs induced per injection and the ability to capture more follicles in an inductive state through a second set of injections at week 6. Figure 1: Clinical trial subjects 009 and 027 show continued hair growth in the HSC treated site at 1 year.

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008

Our Experience Utilizing Cellular Therapy in Hair Restoration Surgery and Non-Surgical Treatments of Hair Loss Disease Joseph F. Greco, PhD 3023 Eastland Bvld, Suite 113, Clerarwater, FL, USA.

Joseph F Greco, PhD, PA/C has specialized in Hair Restoration Surgery the past 28 years and completed three Research Grants sponsored by the ISHRS, including two dealing with the effects of growth factors on non transplanted hair in Androgenic Alopecia and Alopecia Areata. Dr Greco is a charter member of the International Society of Hair Restoration and has three patents pending in growth factor technology.

J.F. Greco: None.

ABSTRACT: The purpose of this presentation is to share our experience with cellular therapy in over 1,000 surgical hair restoration and non-surgical cases, including, but not limited to Androgenic Alopecia, Alopecia Areata and Discoid Lupus, since 2007. This will include the results of two research grants sponsored by the ISHRS and results of other hair restoration surgeons utilizing cellular therapy in hair restoration. Regenerative medicine or the ability to, “safely take our own healing capable cells and regenerate damaged soft tissue, ligaments, tendons, muscle and bone,” is the future of medicine. Cell-based therapy focuses on cellular treatments that lead to regeneration by having the body gather the necessary reparative cells and bring them to the damaged site. Over the past fifteen years there is extensive published literature that supports the use of cellular therapy to improve surgical outcomes in multiple medical disciplines. The primary use for platelet rich plasma (PRP) in hair restoration surgery demonstrated an increased yield when utilized as a graft storage medium. (Uebel, 2005) This author publish his preliminary experience in 30 cases and suggested expanding use of Platelet Rich Plasma in hair transplant surgery to “enhance donor site wound healing, to decrease the incidence of infection, to reduce donor scaring, increase donor scar tensile strength, to enhance recipient site healing and to be utilized as an effective treatment protocol in severe cases of wound dehiscence or infection.” in the July/August 2007 issue (Vol.17 Number 4) of the Hair Transplant Forum International. While in its infancy, this author has observed positive outcomes utilizing cellular therapy in surgical hair restoration and non surgical hair loss disease processes and has not had any adverse side effects since 2007. While we are only beginning to understand the interaction of growth factor/ stem cells signaling with hair regeneration so time, scientific study and critical review will determine its eventual outcome, but the future appears promising.

009

Use of PRP and Extracellular Matrix-UBM in Hair Transplantation James B. DeYarman, DO self, LaJolla, CA, USA.

I graduated from medical school in 1973. During my internship I became interested in hair transplant surgery and in 1979 did a preceptor-ship with Dr C.P. Chambers of Atlanta, Georgia. I started a practice in hair restoration in 1980 in San Diego, Ca and over the years have improved my skills by visiting other physicians and attending workshops and the ISHRS annual meetings. In 2005 I passed the exam of the American Society of Hair Restoration Surgery. I received a award at the ISHRS meeting in Peurto Verato for the best practical tip. I have lectured at the meetings on the use of photo shop for the planning of a hair transplant which got excellent reviews.

J.B. DeYarman: None.

ABSTRACT: Presentation: I have almost 2 years of experience in using PRP in hair transplant surgery. I can present my methods of using the PRP and patient results. I have almost one year experience in using PRP with Acell for both surgery and non-surgical treatment for hair loss. I have before and after photos. I will present my method of treatment. I am very excited about the results that I have seen with this treatment and feel strongly that other doctors in hair restoration would benefit from this. The presentation will include dosage and methods for the treatment.

PRP and Extra-cellular Matrix

For

Hair Restoration

Product Disclosure

I have no ownership or Financial interest in

PRP or Intra-cellular Matrix

Production or distribution

PRPI first heard of PRP from Joe Greco and got instructions on how to use PRP

in hair restoration

For medical treatment only, I inject .1 cc of PRP every square centimeter

I follow up with .01 cc of Thrombin every square centimeter

Following local anesthetic a micro-roller is used to stimulate the area

I then massage the area for at least 2 minutes

Surgery use of PRP Only

In hair transplantation I inject .1 cc PRP every square centimeter

in the recipient area of the transplant

I then inject .01 cc of Thrombin every square centimeter

I massage the area for at least two minutes

18 months of PRP Therapy

I feel PRP should be standard of care in Hair Transplant Surgery

1. Faster Healing time

2. Less redness

3. Faster growth

4. Better Growth

5. All patients have done better

No side effects

Only patient that couldn’t use was Jehova’s Witness

Extra-Cellular Matrix

ACell’s MatriStem is the name of the extra-cellular matrix that is available

It comes in powder form or sheets and is created from pigs bladder

The micromatrix fine particles is the best and when put in suspension can

be injected thru a 25 gauge needle

Donor Site Closure

I use the 3cm by 7cm sheets for the donor site

I cut the sheets into 2 mm strips and place 2mmx7cm in the base of the wound

Prior to closure a trichophytic closure in done on the inferior border

I do not use any sub-cu sutures for closing

Staples are used for closing

PRP with the Extra-Cellular Matrix

I mix 100 mg of fine particles with 10 cc of PRP

3 cc of the mixture is put in holding cups

for the graphs to soak in prior to insertion

The remaining mixture is injected into the recipient

area after creating the sites(intra-dermal)

Massage area working up and into center of head

PRP/Extra cellular matrix treatment of Hair loss

After local anesthetic of area for treatment use a

micro roller to activate the tissue

Mix 100 mg of fine particles of extra cellular matrix

with 10 cc of PRP

Inject .1cc of suspension every square centimeter Intra-dermal

Inject .01cc of Thrombin every square centimeter

Massage area for 2 minutes

Before and after photos

Video of injection of PRP and

extra-cellar matrix

Complications

Post-op Swelling

Donor Scar redness

Can not use Extra-cellular Matrix if patient is allergic to Pork

The following Doctors were very kind

in sharing their Treatments and Findings

Dr Joe Greco

Dr Gary Hetzig

Dr Jerry Coley

Dr John Cole

Questions and Concerns

010

New Horizons in Storage Solutions and Additive Agents in Organ Transplantation William D. Ehringer, PhD University of Louisville, Louisville, KY, USA.

William D. Ehringer, PhD Associate Professor of Physiology, Biophysics, and Bioengineering, University of Louisville, and Founder of VitaTech and Vital Solutions, LLC. Dr. Ehringer has published over 135 publications and abstracts, and has been funded by the NIH and NASA. In 2002, Dr. Ehringer invented a method for delivery of adenosine-5’- triphoshate to cells to reduce the affects of ischemia and hypoxia. In 2006 he was awarded 2 U.S. patents for delivery of ATP to cells, tissues, and organs. Using this (VitaSol), Dr. Ehringer has demonstrated that cells or tissues treated with VitaSol are resistant to hypoxia or ischemia.

W.D. Ehringer: Ownership Interest (owner, stock, stock options); Dr. Ehringer is Founder of VitaTech and Vital Solutions who are developing VitaSol (fusogenic lipid vesicles containing ATP). Ownership Interest (royalty, patent, or other intellectual property); Dr. Ehringer is the inventor on U.S. and foreign patents pertaining to VitaSol.

ABSTRACT: Introduction: Since the advent of in vitro tissue culture over 100 years ago, there has been continuous improvement in the culture media used to sustain tissue viability ex vivo. Currently it is well established that hair follicle viability depends on a variety of factors, such as energy charge, pH, specific nutrients, oncotic proteins, growth factors, and hormones. In the present study, the current and future use of these factors in maximizing hair follicle viability will be examined, with specific emphasis on maintaining hair follicle cell high energy phosphate levels. Objective: To explore the necessary storage solution factors that should be considered by hair transplant surgeons during microfollicular hair transplant procedures. In addition, the presentation will consider newly developed additives that could maximize hair follicle viability and maximize newly transplanted follicle hair growth. Materials and/or Methods: Hair follicle transplant storage solutions should contain specific components that will maximize hair graft survival, graft quality (length and width), and graft survival time ex vivo. Hair follicles stored in Hypothermosol supplemented with fusogenic vesicles containing ATP were used during the dissection procedure and as a post-operative spritz. Hair graft survival, quality, and time ex vivo were measured. Discussion/Results: The use of specific agents and temperature during graft harvesting and processing have dramatically increased graft survival, quality, and survival time ex vivo. However, the hypoxic conditions during graft harvesting and graft implantation, and the post-surgical ischemia of the grafts until angiogenesis is complete reduces graft survival. The use of additives that prevent depletion of hair follicle high energy phosphates, and thus blunting hypoxia and ischemia-reperfusion injury, are paramount to increasing graft survival, quality, and survival time ex vivo. Current collaborative studies have indicated that the use of Hypothermosol supplemented with fusogenic lipid vesicles containing ATP markedly improves these observable with no apparent toxicity. Conclusion: To maximize hair graft survival, quality, and survival time ex vivo requires a combination of storage solution additives and conditions. Most importantly, hair grafts have depleted intracellular high energy phosphates prior to the restoration of blood flow to the follicle. Utilizing an ATP delivery system, the loss of high energy phosphates during the hair grafting procedure can be blunted, thus maximizing the efficiency and outcome of hair transplant surgeons.

011

Moderator Introduction, Challenging and Atypical HT Cases Robert S. Haber, MD CWRU School of Medicine, Cleveland, OH, USA.

Listed elsewhere in abstract book

R.S. Haber: None.

012

Case 1: Widened Donor Scar Treated with FUE - Resultant Hypopigmentation Scar - Tattoo Sharon A. Keene, MD 310 North Wilmot, Ste 304, Tucson, AZ, USA.

Dr. Sharon Keene, MD is board certified in general surgery, specializing in follicular unit hair grafting for 16 years. Dr. Keene has taught and lectured on various topics to improve techniques including ergonomics and efficiency, and developed tools/ instruments to effect this. She developed the first multi-recipient site scalpel, a rotating graft reservoir for graft hydration, and created an affordable dissecting video scope microscope. She identified a benefit for methylene blue dye to visualize gray hairs; and performed the first survey to assess normal hair line density in men, to improve naturalness and avoid excess use of donor hairs.

S.A. Keene: None.

ABSTRACT: All forms of hair restoration surgery involve redistribution of permanent donor hairs to areas of hair loss. Harvesting of donor hair can be performed by taking a strip of donor hair and dissecting this into follicular units, or by extracting individual hair bundles with a small punch excision. One method creates a linear incision (strip) and the other diffusely distributes small round holes (follicular unit extraction). A single case report illustrating scarring caused by each method, in a patient who wears his hair shaved will be presented, along with options for dealing with the scars. Currently there is no method to harvest donor hair that does not incise skin, and all methods have the potential to cause visible scarring.

013

Case 2: Chronic Post-Op Folliculitis Sungjoo (Tommy) Hwang, MD 513-1 Shinsa-dong, Gangnam-gu, 4th Floor, Dong-won Building, Seoul, Korea, Republic of.

Sungjoo "Tommy" Hwang, MD Director of Dr. Hwang's Hair Clinic Secretary of Asian Association of Hair Restoration Surgeons Board of Directors, American Board of Hair Restoration Surgery

S. Hwang: None.

ABSTRACT: A patient with Cronic Folliculitis after Hair Transplantation Sungjoo “Tommy” Hwang, MD, Dr. Hwang’s Hair Clinic, Seoul , Korea A healthy 58 year old male with male pattern hair loss received a follicular unit transplantation on August 7th, 2010. Because of numerous gray hairs on the scalp (both donor and recipient), the hair was dyed before surgery. A total of 2,000 follicular units were implanted. At one month after surgery, a simple case of folliculitis developed on the recipient area. At 3 months after surgery, numerous, painful, pruritic erythematous papulopustules developed (Fig. 1). This is the first case of numerous, severe folliculitis to happen to one of my patients during the last 15 years. Laboratory findings showed normal except highly elevated Ig E (1000 IU/ml). ESR and CRP were within normal limits. A culture of the pus material showed coagualse negative Staphyllococcus( methicillin resisitant). No fungal or atypical mycobacterial growth was found. The biopsy showed mixed cell infiltration (neutrophill, eosinopill and plasma cell) with little granuloma formation (Fig.2, 3) Treatment consisted of antibiotics (tetracycline) and steroids for one month and an incision and drainage of the pustules was done. During drainage of the wound, the kinking-growing hair also came out. The lesion waxed and waned for another 3 months but at 6 months after surgery, the severity of the lesions had decreased. A couple of new lesions developed and disappeared and this repeated again and again during follow-up until 7 months after surgery. Conclusion : The possible patho-mechanism is that the transplanted hair follicle was located at a deeper layer of the dermis and the newly growing hair could not puncture the scalp and it became trapped and grew inside and under the skin with a subsequent allergic inflammatory reaction that caused pustules and abscesses.

014

Case 3: Poor Production William Parsley, MD Parsley Waldman Hair Center, Louisville, KY, USA.

William Parsley, MD graduated from Univ of Tennessee Med School (1969) and completed Dermatology at the Univ of Louisville (1975). Positions: Past President- ISHRS ISHRS BOG and EC Past Chair of the ASHRS Past President of the ABHRS Past moderator of the Hair Transplantation Forum for the AAD Past BOT of the American Academy of Cosmetic Surgery Past Editor- Hair Transplant Forum International BOT- Hair Foundation. Past President- Kentucky Dermatologic Society Recipient of the ISHRS Golden Follicle Award (2003). Diplomate: Am Brd of Dermatology, Am Brd of Dermatopathology, ABHRS Awards: ISHRS Golden Follicle Award- 2003

W. Parsley: None.

ABSTRACT: Dr. Parsley will present the case of a patient that had a 3000 graft session with good donor hair. The growth was poor even though surgically the procedure went well.

015

Hair Transplantation in Psoriasis: To Cut or Not To Cut Anand V. Kumar, MD, Shobit Caroli, MBBS, Kulakarn Amonpattana, MD, Oravan Pathomvanich, MD, Damkerng Pathomvanich, MD DHT Clinic, Bangkok, Thailand.

Dr. Anand Kumar Vaggu is a dermatologist from Hyderabad, India. He is presently an ISHRS fellow in Hair Restoration Surgery at DHT Clinic in Bangkok, Thailand.

A.V. Kumar: None. S. Caroli: None. K. Amonpattana: None. O. Pathomvanich: None. D. Pathomvanich: None.

ABSTRACT: Background: Psoriasis is relevant to a hair transplantation surgeon because one would like to avoid incising affected skin in a fear of Koebner phenomenon, worsening of psoriasis lesions at both donor and recipient, increased risk of wound infection and decreased wound healing capacity. Objective: To study the risk of Koebner phenomenon and infection at both the donor and recipient areas, and poor wound healing at donor area in psoriasis patients . Methods: We did hair transplantation in four patients with psoriasis, three cases of scalp hair and one case of eyelash transplantation. In the first case, we intentionally transplanted 525 follicular unit grafts on right frontal area which was prepared from the psoriatic lesion over the donor area. In the second case, psoriatic lesions over the donor area were avoided during strip harvesting. In the remaining two cases, one was scalp and another was eyebrow, no psoriatic lesions were found over the donor area. In all the cases, psoriatic lesions were present on trunk but not on the recipient area. All the patients have been on topical steroids only. These cases have been following up for aggravation of psoriasis and infection at both donor and recipient areas and poor wound healing at donor area. Results: In the first two cases, there was no aggravation of psoriasis at both donor and recipient areas even in the first case where grafts were prepared from a psoriatic lesion. In the third case of scalp hair transplantation where follicular unit grafts were prepared from normal donor area erythema, pustular lesions, crusting and aggravation of psoriasis developed over the recipient area 3 weeks after surgery. In eyelash transplant case, postoperative course was uneventful. None of the patients developed any infection or poor wound healing at donor area. All the cases have been following up and the final results will be presented at the conference. Discussion: The Koebner phenomenon is the development of isomorphic pathologic lesions in the traumatized uninvolved skin of patients who have cutaneous diseases like psoriasis. The reported incidence varies from 11-75%. Incresed risk of infection is due to increased colonization with Staphylococcus aureus in psoriatic skin. There are studies in orthopaedic and podiatric literature regarding incision of the active psoriatic lesions, koebnerization and infection but hardly any studies about hair transplantation in psoriasis. Individual anecdotal experiences are there. Preliminary findings from our study show that there is not much risk of Koebner phenomenon as we anticipated. Conclusion: Hair transplantation can be performed on active psoriatic skin with proper preoperative measures, dermatological treatment and also with prior counseling of the possibility of Koebner phenomenon.

Anand Kumar Vaggu, MD,

Shobit Caroli,MD, Ratchathorn Panchaprateep ,MD, Kulakarn Amonpattana,MD, Oravan Pathomvanich,MD,

Damkerng Pathomvanich, MD,FACS ,

DHT clinic, Bangkok, Thailand.

CONTROL No.2011-G-100-ISHRS

� No relevant financial relationships or conflicts of interest to declare.

� Why it is important?

� What is koebner phenomenon?

� Whether to cut or not to cut the psoriatic lesion ?

One would like to avoid incising affected skin.

� Fear of an increased risk of infection due to compromised skin barrier in psoriasis

� Isomorphic or Koebner phenomenon

� Decreased wound healing ability

� Worsening of the psoriatic lesions.

� The Koebner phenomenon is the development of isomorphic pathologic lesions in the traumatized uninvolved skin of patients who have cutaneous diseases.

� Not known

� But immunologic factors are involved in the pathogenesis of psoriasis

� According to some investigators, capillary changes in the dermis precede all other morphologic changes.

� The reported incidence- varies from 11-75%.

� The latent period is usually 10-14 days, but it may range from 3 days to several years.

� More likely to occur when psoriasis is unstable

� More severe injury may result in more extensive skin lesions.

� No anatomic site preferences.

� More frequently in the winter than in the summer.

� Signifies activity of the disease.

� It guides the clinician to avoid surgical procedures

� Thus, surgeons should be aware of this entity and should warn their patients about its possible occurrence.

Thappa DM. The isomorphic phenomenon of Koebner. Indian J Dermatol Venereol Leprol 2004;70:187-9

� Objective; To study the risk of koebnerphenomenon and infection at both the donor and recipient areas, and poor wound healing at donor area in psoriasis patients .

� We did hair transplantation in four patients of psoriasis, three cases of scalp hair one case of eyelash transplantation.

� In first case, we intentionally transplanted 525 follicular unit grafts on right frontal area which was prepared from the psoriatic lesion over the donor area.

� In second case, psoriatic lesion over the donor area were avoided during strip harvesting.

� In the remaining two cases, one was scalp and another was eyebrow, no psoriatic lesions were found over the donor area.

� In all the cases psoriatic lesions were present on trunk but not on the recipient area.

� All the patients have been on topical steroids only.

� These cases have been following up for aggravation of psoriasis and infection at both donor and recipient areas, and poor wound healing at donor area

� Except case 3, remaining patients did not develop any aggravation of lesions.

� None of the patient developed any infection and poor wound healing at donor area.

� Our study shows that there is not much risk of koebner phenomenon as we anticipated.

� Hair transplantation can be performed on psoriatic skin with proper preoperative measures, dermatological treatment and also with prior counseling of the possibility of koebner phenomenon.

016

Trichohexis Nodosa: Unusual Hair Transplant Complication Shobit Caroli, MBBS, Damkerng Pathomvanich, MD, Anand Vaggu Kumar, MD, Kulakarn Amonpattana, MD, Oravan Pathomvanich, MD DHT Clinic, Bangkok, Thailand.

Dr. Shobit Caroli received his Bachelor’s in Medicine and Surgery from University College of Medical Sciences, University of Delhi, India. He did post-graduation work in dermatology from Maulana Azad Medical College followed by Board certification in dermatology from University of Delhi, India. He is presently participating in an ISHRS accredited fellowship training program under Dr. Damkerng Pathomvanich at DHT Clinic, Bangkok.

S. Caroli: None. D. Pathomvanich: None. A.V. Kumar: None. K. Amonpattana: None. O. Pathomvanich: None.

ABSTRACT: Introduction: Trichohexis nodosa is a abnormality resulting in increased fragility of hair shaft. It has hereditary, metabolic disorder and acquired presentations. We have found this to be a first case as a sequel to hair restoration surgery. Case report: A 42 year male with Norwood III hair loss pattern of receding hairline presented to the clinic. Follicular unit hair transplantation with focal dense packing was performed with a total of 2800 grafts. The patient postoperative period was uneventful. At 2 year post surgery follow-up, the patient complained of patchy poor cosmetic density in the area of hair transplantation. He also complains of breakage of the transplanted hair shafts near to the scalp leaving behind a stump of growing hair. On clinical examination, there were many stumps hair of size 2-4 mm in size with whitish tips. Many hairs have nodular thickening and an acute angled bending at the shafts. On trichoscan examination of hair in the affected area, we observed bulbous nodes on the shaft of hair with longitudinal fracture of the hair shaft exposing the cortical fibers. The existing hairs in the scalp were examined and found to be normal. Patient was screened for any history of excessive or repeated trauma like frequent hair combing, scalp massage, itching, chemical application or hair perming over the area. The diagnosis of trichohexis nodosa affecting the transplanted hair was made. Conclusion: Trichohexis nodosa was found to be an interesting unusual complication and cause of poor result after surgery.

http://files.abstractsonline.com/CTRL/64/7/5b7/b4a/47f/4c2/3ba/185/5de/3a4/38f/d7/g113_1.JPG�





Trichorrhexis nodosa: An unusual

hair transplant complication.

Shobit Caroli MBBS,DDVL; Damkerng Pathomvanich MD FACS;

Kulakarn Amonpattana MD; Oravan Pathomvanich MD; Anand

Kumar MD; Ratchathorn Panchaprateep MD.

Damkerng Hair Transplant Clinic, Bangkok, Thailand

The authors have indicated no significant

interest with commercial supporters.

Case report

• 42 year male with Norwood II pattern hair loss withreceding hairline and deep fronto-temporal anglespresented in year 1990 with a curvilinear scar along thehairline.

• Four sessions of hair transplantation was done over 5years duration with:

– 28 grafts (4.25 mm punch)

– 196 grafts (quarter punch)

– 70 mini grafts (1.25 mm size)

– 86 (2 hair grafts)

– 80 (1 hair grafts).

Postoperative 15 years back after hair

transplantation

• Examination of patient in 2009 shows:

– Good growth of grafts

– But, there was thinning in-between the previouslytransplanted grafts along the fronto-temporal area.

• Follicular unit hair transplantation with focaldense packing was planned and performed:

– A total of 628 grafts with 108 one hair, 304 two hair,65 three hair and 151 four to five hair grafts.

– The postoperative period was uneventful.

At 2 year post surgery follow-up in 2011:

• Patient complained of patchy poor cosmetic density in thearea of hair transplantation than before.

• Patient’s main concern:– Transplanted hair breaks off near to the scalp leaving behind a

stump of growing hair.

• Increased hair fragility was observed for past 1½ years sincetransplanted hairs grew after the surgery.

• Patient has history of excessive repeated rubbing of scalp inthe affected area.

• No history suggestive of habitual tic, aggressive hair combing,scalp massage, chemical application or hair perming.

Clinical Gross Examination

• Cosmetic density was found to be less than expected.

• Growth of hairs in the area was found to be normal.

• We observed thinning of lateral 1/3rd of both eyebrows.

• The skin of the affected area was normal with no signs

of excoriations or lichenification.

Postoperative 2 year, hairline thinning

Under 3 X magnification

– Transplanted and resident hairs in the area were found tohave nodular thickening and an acute angled bending at thehair shafts.

– Stumps of hair sized 2-4 mm in size with whitish tips wereobserved in the area of hair transplant.

– Similar picture was observed among the normal residenthairs in the transplanted area and the lateral 1/3rd ofeyebrows.

– Other areas of the scalp were examined and found to havenormal hair growth.

Close up snap showing broken hair stumps, acute angled bending of hair shaft

(A) Normal Dense Eyebrow Preoperative 20 years back

(B,C,D) Postoperative follow up with marked loss and thinning snaps

Trichoscan Examination

• Done with Magic-i 20X CCD Camera fixed to LCD monitor.

• Findings:– The affected hairs in the frontal and eyebrows have single or

multiple bulbous nodes along the shaft.

– Few hairs have longitudinal fracture of the hair shaft with acuteangled bending leading to exposure of the cortical fibers.

– Stumps of broken hairs were also observed.

– The native resident hairs and eyebrows are also similarly affected.

– The hairs in the other scalp areas (i.e. donor and mid scalp) of thescalp were examined and found to be normal.

Close up snap showing broken hair stumps, acute angled bending of hair shaft RESIDENT NON TRANSPLANTED HAIRS IN THE AFFECTED ZONE

Trichoscan snaps of eyebrows

A = Broken hair stumps

B= Nodulations along hair shaft

Clinical Diagnosis

Trichorrhexis nodosa

Skin Biopsy finding


Final Diagnosis


Discussion

• Trichorrhexis nodosa, also known as trichonodosis, was first described by SamuelWilks of Guy’s hospital in 1852.2

• It is the most common of hair dysplasias associated with increased hair fragility.3

• It is considered as an anomalous response of the hair shaft to external trauma andis clinically characterized by dry, dull, and brittle hairs of different lengths withvarying numbers of small grayish white or yellowish nodules distributed irregularlyalong the shaft.4

• Trichorrhexis nodosa has congenital and acquired presentations.

• Congenital disorder may present as an isolated autosomal dominant defect, or itmay be associated with genodermatoses5.

• Acquired type has 3 major groups:– proximal (predominantly among blacks)

– distal (common in Asian and white individual’s esp. Spain)

• Localized TN is usually associated with pruritic dermatoses,trichotillomania, and other disorders that lead to the persistentmanipulation of the area, scratching, and lichenification.10

• In cases with acquired variety, there is no specific treatmentexcept the effective measures to avoid repeated traumas whichvary from person to person.2

• We found the case to be interesting because most of times thecause of poor cosmetic density is thought to be poor growth but inthis case even though the transplanted hair grew well the net haircosmetic density was poor.

• Such condition should be identified, discussed and treated toavoid further distress among such patients.

Conclusion

• Trichohexis nodosa was found to be an

interesting unusual complication and cause of

poor cosmetic result after surgery.

References1. 2009 Practice Census Results. International Society of Hair Restoration Surgery. June 2009. p. 4.

2. Jackson GT, MacMurtry CW. A treatise on the diseases of the hair. London: Kimpton; 1913. p. 131-7.

3. Lagrán ZM, Hermosa MRG, Pérez JLD. Localized Trichorrhexis Nodosa. Actas Dermosifiliogr. 2009; 100: 522-

24.

4. Whiting DA. Structural abnormalities of the hair shaft. J Am Acad Dermatol. 1987;16:1-25.

5. Cheng AS MD, Bayliss SJ MD. The genetics of hair shaft disorders. J Am Acad Dermatol 2008; 59: 3.

6. Serra-Guillén C, Torrelo A, Drake M, Armesto S, Fernández- Llaca H, Zambrano A. Síndrome de Netherton.

Actas Dermosifiliogr. 2006; 97: 348-50.

7. Jiménez-Puya R, Moreno-Giménez JC, Camacho-Martínez F, Ferrando-Barberá J, Grimalt R. Tricotiodistrofia:

syndrome PIBIDS. Actas Dermosifiliograf. 2007; 98: 183-7.

8. Lurie R, Hodak E, Ginzburg A, David M. Trichorrhexis nodosa: a manifestation.

9. Francisco Camacho-Martinez MD. Localized trichorrhexis nodosa. J Am Acad Dermatol, 1989; 20, 696 – 697.

10. Whiting DA. Localized trichorrhexis nodosa. J Am Acad Dermatol. 1989;20:854.

11. Messenger AG, Berker DAR, Sinclair RD. Disorders of hair. Abnormalities of the hair shaft. Rook Textbook of

Dermatology. Edn 8th p. 66.67-68.

Thank you

017

Case 6: Methicillin-resistant Staphylococcus aureus (MRSA) Carlos J. Puig, DO Suite G205, 6029 Skyline Drive, Houston, TX, USA.

Since 1973 Dr Puig has been actively involved in the practice of hair restoration surgery. A founding Member of the ISHRS, Dr Puig has presented papers and surgical demonstrations on many topics: diagnostic and surgical techniques, practice ethics, marketing, management and continuous quality improvement. Dr. Puig is a Fellow of the American Academy of Cosmetic Surgery, and a Diplomate, and Past President of the American Board of Hair Restoration Surgery. Dr. Puig has served as chair of the ISHRS Fellowship Training Committee, Basic HRS Training Workshop, Board Review Programs, Core Curriculum Committee, and is currently the Treasurer if the ISHRS.

C.J. Puig: None.

ABSTRACT: An unusual case of post operative wound infection of the recipient area of a follicular unit hair restoration surgery caused by MRSA. The case presentation is followed by a brief review of the incidence and current treatment strategies recommended for MRSA infections.

018

Moderator Introduction, Emerging Issues Mario Marzola, MBBS Norwood Day Surgery, Adelaide, Australia.

Hair Restoration Surgery is such a dynamic field with so many lateral thinkers who work with us. Every year there are developments that challenge us but every now and again there are real paradigm changes which turn our beleifs upside down. We are on the verge of stem cell knowledge which may completely demolish surgical hair restoration. In the meantime robotic FUE is enough of a challenge. The only way to stay on the pace is to attend conferences and workshops every year and enjoy all these challenges.

M. Marzola: None.

019

Treatment of AGA in Patients Under 18 Years Old. A New Approach to an Old Dilemma Silvana Franzini, MD, Nicolas Lusicic, MD Hair Recovery Argentina, Buenos Aires, Argentina.

Silvana Franzini MD: Certified internal medicine, and certified cardiologist. Nicolas Lusicic MD: Certified general surgeon and certified plastic surgeon. Alejandra Susacasa MD: Certified general surgeon and certified cosmetic surgeon has been active member of ISHRS for the last 14 years. She has more than 16 years of experience in hair restoration surgery. Sixteen year ago Dr. Lusicic & Dr. Susacasa have founded a hair restoration center in Argentina with 16 offices including other Latin American countries. In 2006 they started with their innovative technique, intradermotherapy.

S. Franzini: None. N. Lusicic: None.

ABSTRACT: The goal of this study was to evaluate different alternatives of treatments in those patients with severe scalp balding at very early years of puberty. We compared medical treatment against intradermotherapy Abstract: Puberty is a period of life where self-esteem is very important to socialize with their fellows. - Puberty is a transition period in life. - Puberty occurs at different ages in different individuals - The age of puberty can be influenced by external factors. - In this period of life, as well as in adults, hair loss can affect the quality of life and self esteem. Not to mention if it is associated with many other disorders of this age. Changing the type of hair Like many other mammals , human hair are produced all over the skin.- So, as many mammals do ,humans change the type of hair produced in different areas of the body on maturity like the development of the “ lion´s mane”. Paradoxically , during puberty androgens afect human follicles in two different ways: Androgens stimulate the gradual production of pigmented terminal hairs in many regions of the body such as beard,axillae and pubis. Other follicles producing terminal hair in children remains unaffected, such as eyelashes. In genetically predisposed individuals, androgens may cause, simultaneously, the opposite gradual transformation, of terminal hair into vellus follicles, leading to balding ( randall ) Caucasian men develope some recession of the frontal hairline at the temples during their teens. Deep frontal recession and /or vertex balding may also start shortly after puberty almost in most men the onset is later. 15-20 % of men do not show balding apart from postpubertal temporal recession, even in old age Evaluation and treatment: Following with our orthomolecular approach, we have evaluated and treated 38 patients under 18 years with a 3 years follow up. We practice a double blind randomized treatment. All patients were males between 13 to 18 years old, mean age 16.3 All of them presented shedding, miniaturized hair, and a strong genetics hair loss pattern. A) 17 of them, with oral vitamins and amino acids and topical Minoxidil al 5%. B) 21 of them with intradermotherapy treatment Conclusión: In our population the prevalence of AGA in young man is near 30%.

As soon as we can start treatment it will have better results in terms of hair quality and quantity, to prepare the patient to future surgeries , arriving to an appropiate age with better donor and recipient areas. Intradermotherapy result better in terms of time to see improvements and in terapeutical response in all the patients.

020

Is FUE Really a Repair Technique or Small case Technique Rather Than a 1st Option for MPB? Russell G. Knudsen, MBBS The Knudsen Clinic, Sydney, Australia.

Dr Russell Knudsen practises full-time in hair restoration surgery in Australia and New Zealand. He is a Past-President of ISHRS, Immediate Past-President of the Australasian College of Cosmetic Surgery and Past Editor of the Hair Transplant Forum.

R.G. Knudsen: None.

ABSTRACT: IS FUE REALLY A REPAIR TECHNIQUE OR SMALL CASE TECHNIQUE RATHER THAN A 1ST OPTION TECHNIQUE FOR MPB? RUSSELL KNUDSEN MBBS Sydney Australia FUE = micro-punch grafting. It is undoubtedly a superior technique to traditional punch grafting and has been greeted by many patients and some physicians with enthusiasm. It has had 10 years of publicity and usage so it is time to review its role, effectiveness and success in correcting hair loss. It is worth remembering that all techniques have both benefits and “costs”. No technique is perfect or fully suited to all patient situations. Thus the exclusive use of any technique is sub-optimal therapy in some instances. The introduction of any new treatment paradigm traditionally follows a well-known path. Initial resistance to the new treatment. Acceptance followed by enthusiastic uptake. The single session limits of the treatment are expanded by constantly evolving variations or aggressive application of the technique. Treatment shortcomings or complications appear as a result of overuse of the technique. A backlash occurs against the use of the technique till a more nuanced view appears that identifies its proper, optimal use. This has certainly been the case for traditional punch grafting, scalp reduction surgery, maxi-session FUT and its requirement for maxi-donor strips. Why should we not expect the same for FUE? It is part of what I term the normal “pendulum” of technique advancement.

It is perhaps unfortunate that the term FUE is in common use. I contend that the name itself has (inadvertently) caused patient confusion, aided and abetted by (deliberate) slick marketing that minimizes the recognition that any surgery is involved. How many times have we each experienced potential patients that believe there is no cutting involved in FU extraction, just plucking of the donor hairs, which then regrow in the donor area? Marketing goals are to firstly increase markets thereby increasing the number of patients seeking surgery and secondly, to increase market share (competitive marketing) which distinguishes between techniques and between practitioners. This is good if marketing is both accurate and honest. I am, however, personally troubled by the exaggerated claims of some practitioners (e.g. “scarless technique”) which seek to play on general public fears about any form of surgery as well as fears of excessive scarring via strip surgery. Comparison of Strip FUT VS FUE: Strip = open technique (visually) that optimally uses a single strip to minimize transection of follicles at the edge of the strip. FUE = blind technique that produces a higher mathematical risk of transected follicles (also true in practice) and is a more difficult technique to master. It is worth noting that mechanization is of NO help in this regard. It merely increases speed. Advantages of FUE Avoidance of linear donor scarring. No suture/stapling. Less postoperative discomfort. Ability to harvest further grafts between previous strip scars for top ups. Ability to combine strip and FUE for bigger single session numbers. (Bob True). Ability to minimize staff numbers to assist the procedure (with or without mechanization). Ability to wear hair very short. Disadvantages of FUE Higher follicle transection rates (in most hands). Reduced growth rates (especially for inexperienced practitioners). Slower technique (except for mechanization and several extremely skilled practitioners). Requires larger donor area for equivalent graft numbers. Potential use of “non-safe” donor hairs, especially in younger patients. Overuse in any area can produce “white-walling” (see through effect). White dot speckled donor scarring. Another tricky issue is the potential delegation of surgery to assistants. Plucking the cut FU graft by assistants is legal, but harvesting of the graft in FUE is likely illegal in some jurisdictions for non-physicians. Most, if not all, physicians who perform strip FUT do this surgery themselves. Some, but not many, clinics perform stick-and-place graft insertion by assistants. Recent promotion of mechanized FUE appears to be encouraging techs/assistants to perform the whole FUE procedure under “physician supervision”. This will likely result in loss of physician control of the procedure from over-delegation and will soon mimic the performance of synthetic hair implantation where the physicians only role is to perform the local anesthetic administration.

Summary: Current assessment of FUE outcomes suggests that many of the potential pitfalls of overuse of the procedure are now appearing in practice. The backlash will soon appear on the internet. Points 4, 5,6 and 7 of the Disadvantages list have great potential to harm the reputation of FUE. These disadvantages can be minimized by judicious application of the technique for small sessions and for repair cases. I believe that, over time, applying these principles to the proper selection of patients and use of the technique will confirm that its most appropriate use is in small sessions and repair cases.

RUSSELL KNUDSEN M.B., B.S.

Sydney Australia

19thASM of ISHRS

Anchorage September 14-18 2011

IS FUE A REPAIR TECHNIQUE, OR SMALL

CASE TECHNIQUE, RATHER THAN A 1ST

OPTION FOR MPB?

CONFLICT OF INTEREST

• I have no conflict of interest to disclose.

FUE = MICRO-PUNCH GRAFTING

• Clearly superior to traditional punch grafting

• High patient enthusiasm

• Some physicians highly enthused (approx 10% surgeries)

• Over 10 years of publicity and usage:

time to evaluate its role, effectiveness and success in correcting hair loss

FUE

• ALL techniques have both benefits and costs

• NO technique is perfect or fully suited to ALL patient situations

• EXCLUSIVE use of any technique is sub-optimal therapy in some instances

EVOLUTION OF NEW TREATMENTS

1. Initial resistance to the new treatment (longest phase)

2. Acceptance followed by enthusiastic uptake

3. Single sessions limits of treatment expanded by evolving variations or aggressive

application of the technique

4. Treatment shortcomings or complications appear as a result of overuse of the technique

5. A backlash occurs against the use of the technique until a more nuanced view appears

that identifies it’s proper, optimal use

EXAMPLES OF THIS EVOLUTION

• TRADITIONAL PUNCH GRAFTING

• SCALP REDUCTION SURGERY

• MAXI/GIGA-SESSION FUT (= MAXI/GIGA STRIPS)

• Why should FUE be any different?

• The outcome is what I call the PENDULUM of technique advancement

FUE

• The name has caused (unintended) patient confusion (EXTRACTION)

• Confusion not helped by deliberately slick advertising that minimizes recognition that any

surgery is involved

• Some patients believe that it just involves plucking of donor hairs, no incisions, and that

new hairs regrow in the donor area

• Marketing is good if it increases the market size, market share and promotes honest,

accurate competition between practitioners and between techniques

• Is this what is happening with FUE marketing?

• Exaggerated claims of “scarless surgery” play to patient fears about any form of surgery

and to fears of excessive scarring via strip surgery

COMPARISON OF STRIP FUT VS FUE

• STRIP = open technique that optimally uses a single strip to minimize transection of

follicles at the edge of the strip

• FUE = blind technique that produces a higher mathematical risk of transection, also

generally true in practice, because it is a harder technique to master

• N.B. Mechanization of no help in this regard, it merely increases speed

ADVANTAGES OF FUE

• Avoidance of linear donor scarring

• No suture/stapling

• Less post-operative discomfort (? in some cases)

• Ability to harvest extra grafts between strip scars for “top ups”

• Ability to combine strip and FUE to harvest greater single session numbers

• Ability to minimize staff numbers to assist the procedure (with/without mechanization)

• Ability to wear hair very short (in most cases)

DISADVANTAGES OF FUE

• Higher follicle transection rates (in most hands, especially beginners)

• Reduced growth rates (especially inexperienced surgeons)

• Slower technique (excluding mechanization and several extremely skilled surgeons)

• Requires larger donor areas for equivalent graft numbers

• Potential use of “non-safe” donor hairs, especially in younger patients

• Over harvesting in any areas can produce “white walling” (see-through effect)

• White dot speckled scarring

POTENTIAL PROBLEM OF DELEGATION

• Plucking the cut grafts via assistants is legal BUT harvesting the graft by assistants in

FUE is likely illegal in some jurisdictions

• Most, if not all, surgeons performing strip FUT do the harvesting themselves.

• Some clinics allow “stick and place” by assistants.

• Recent promotion of mechanized FUE appears to encourage techs/assistants to perform

the entire procedure “under physician supervision”. This will likely result in loss of

physician control of the procedure from over-delegation.

• This will mimic the performance of synthetic hair implantation where the doctor’s role is to

administer the local anesthetic.

SUMMARY

• Current assessment of FUE outcomes suggests that many potential pitfalls of overuse of

the procedure are now appearing in practice.

• The backlash will soon appear on the internet

• Overuse, poor growth rates and harvesting of non-safe donor hairs have great potential to

harm the reputation of FUE

• These disadvantages can be minimized by judicious application of the technique for small

sessions and for repair cases.

• Over time, applying these principles to patient selection and optimal use of the technique

suggests that the most appropriate use of FUE is in small sessions and in repair cases.

021

FUE versus Strip Harvest FUT: Fair and Balanced View David Perez-Meza, MD Permanent Hair Solutions, Mexico City, Mexico.

Dr. Perez Meza is graduated from the Military Medical School in Mexico City. He specialized in Plastic and Reconstructive Surgery. He was an active member of the Presidential Medical Corps. He retired with Lt. Colonel Status in 1996 after serving in the Mexican Army for 26 years. He was trained in hair restoration surgery under Drs. Leavitt, Mayer and Ziering. In 2001, he was the first Hispanic Diplomate of the ABHRS. He has been active member of the ISHRS as speaker, moderator and Course Director. He had received nine Research Grant Awards. In 2007, he received the Platinum Follicle Award.


ABSTRACT: My presentation is related to FUE (follicular Unit extraction) versus Classical Donor Strip Harvest FUT: Fair and Balanced View.

Taken from the ISHRS website: http://www.ishrs.org/articles/strip-harvesting-vs-fue.htm

August 2010 Comparison between Strip Harvesting and Follicular Unit Extraction: A Fair and Balanced View ISHRS Position Statement on Qualifications for Scalp Surgery Ten years ago the use of follicular unit extraction (FUE) was advocated as an alternative to traditional strip harvesting of the donor tissue. The use of the technique has been slow to be accepted as a new standard. Many physicians have, in fact, tried the technique but with markedly varying success. The recent promotion of mechanical devices and powered follicular extraction devices has sparked renewed interest and controversy regarding this method of harvesting. A great deal of discussion by physicians, ancillary personnel, and the general public has occurred on the Internet and multiple media sources about the value of FUE versus strip harvesting and vice versa. Sadly, many of the claims of “superiority” of the newer technique seem more related to marketing and self-promotion rather than a clear scientific evaluation. This article discusses advantages and disadvantages of both techniques to provide a more accurate and balanced view of the two approaches. The Donor Area and Scar Formation Strip harvesting produces a linear scar. The appearance of the donor strip scar can be a significant concern for patients who wish to wear their hair very short. The vast majority of patients who undergo strip harvesting have minimal scars that are easily concealed by the hair above the scar. And in many instances the scar may not be evident at all except on careful inspection. There are, however, some patients who have scars that have widened, and there are also patients who have several scars from multiple procedures. In some instances the apparent widened appearance of a scar may actually be due to damage to follicles along the incision line during harvesting rather than true scarring. Judicious planning on the part of the surgeon can largely diminish the problems associated with strip scars. By limiting the width of the strip to be taken and avoiding tension on the wound, the surgeon can minimize the donor scar. To avoid multiple scars many physicians who use strip harvesting employ a single scar technique even if multiple procedures are performed. By utilizing careful dissection along the incision line, damage to hair follicles can be diminished. The use of the trichophytic method of closure for strip harvesting can also be extremely helpful in improving the appearance of the strip harvest scar. As noted above closing under minimal or no tension can help to avoid the widening of a scar. This allows hair to camouflage the scar and the hair growing through the scar can limit the stretching. Avoiding damage to the hair follicles along the incision lines is crucial in preventing the appearance of a prominent scar. Some physicians advocate the use of a layered closure and undermining as techniques to minimize scars. Other surgeons feel that undermining and layered closures do not seem to alter the healing except in situations where tension is a problem. There are patients such as those with Ehlers Danlos syndrome, who because of alterations in collagen deposition, are prone to widened scars and poor wound healing. There is little that can be done to prevent such scars in these patients. The circular scars produced by FUE may suffer the same fate and be stretched in these patients. The primary rationale for the use of FUE is that a linear scar is avoided. Several proponents of FUE market the procedure as a technique that does not involve cutting, is less invasive and does not result in scars (i.e., “scarless”). While a linear scar is not created with FUE, circular scars are created. The length of incision is greater with FUE than with strip harvesting. This is apparent when one calculates the circumference of a 1mm punch (1mm x pi = 3.14) and then multiplies this by the number of grafts, for instance, 1000 grafts (1000x3.14 =3140mm which equals 31.4cm). In comparison, a strip harvest of 1000 grafts assuming an average density of 80 FUs per sq cm and a 1cm strip width the length of the scar created would be 12.5cm (1000/80 = 12.5). "Cutting" is clearly involved when using a punch. Although a linear scar is not produced with FUE, scars are created and evidenced by virtue of the fact that hypopigmented or hyperpigmented "dots" may be visible when the hair is cut very short. These “dots” may be a scar reaction or actual post inflammatory pigment changes, particularly in darker skinned individuals. Also the human eye may pick up “spaces” where follicular units are missing in the normal pattern. The depth of the incisions with FUE is usually shallower as compared to strip harvesting. The punch depth is to the level of the fat or at the fat-dermis junction. With strip harvesting the depth of incision is into the fat. Some physicians cut to the deeper fat or just above the fascia.

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When using FUE it is important to recognize that as more and more grafts are harvested the area may appear moth eaten. If grafts are taken too close together there may be an appearance of a scar. In some patients as large numbers of grafts are removed there can be a clear demarcation between the areas that have been harvested and areas left alone. This is opposed to the strip technique where hair of similar density is brought back together at the suture line. Opponents of strip harvesting would note that if hair does not grow well in a strip scar and the scar widens, then the scar might be apparent if the hair above it is short or otherwise thin. Some promoters of FUE have stated that nerves and veins are not cut. This claim is untrue. By entering the skin with the punch arteries, veins and nerves are cut. It is important to point out that with FUE the patient’s hair usually must be trimmed quite short for harvesting. This is the case especially when large numbers of grafts are required. A way to avoid trimming all of the donor hair is to set up rows of short hair between rows of long hair. The short hair grafts can be harvested within the existing long hair. But again, this is only suitable when relatively small numbers of grafts are needed. Graft Survival Debate exists as to the rate of survival regarding FUE versus strip grafts. There is some concern that because the FUE grafts may have very little tissue surrounding them that they are less likely to survive. Such grafts are more prone to dehydration, which has been shown to be a major cause of diminished graft survival. The lack of perifollicular tissue is often a result of “pulling” on the graft to remove it. Because there is added manipulation in trying to remove a graft this may also contribute to diminished survival. Sometimes the ends of the bulbs are splayed or unusually far apart. This makes the bulbs more susceptible to trauma, as a result of increased graft manipulation during implantation. As of this time there are not adequate studies to compare survival rates. Clearly there are patients who have undergone the FUE procedure and have excellent results. Some physicians might argue that less successful results may be due to technical surgical skill rather than the nature of the more fragile graft created with FUE. With FUE there is a greater chance of transection of hairs as compared to strip harvesting and this could result in poor growth or lack of growth depending on the level of transection. The rates of transection seem to vary widely with FUE. Conversely, with strip harvesting, grafts may be damaged in making the initial skin incisions and subsequent dissection of the tissue, but this is considered minimal. The use of the microscope for dissection of the donor strip should limit transection rates to 1-2%. Grafts created with strip harvesting generally have a greater amount of surrounding tissue and fat. This may decrease the chance of dehydration and allow for greater leeway in manipulation of the grafts during placing and hence, better graft survival. Placing of Grafts When manual placement of grafts is utilized there is no difference in regard to the technique of placement of strip harvested or FUE harvested grafts. There may be some concern about the fragility of the FUE grafts and the fact that they may be more susceptible to drying and over manipulation. When a machine that uses pneumatic pressure is used it is the contention of the manufacturer/distributor that the machine places the graft with less manipulation. Some surgeons who have used the machine have indicated that the graft placing capability of the machine is limited at times and not always reliable. Perfectly harvested grafts may be damaged during the placement phase and fail to grow. Trauma and graft drying are well known factors that may occur in inexperienced hands and will effect graft survival. Regardless of how grafts are harvested, there is a considerable amount of artistry and technical expertise necessary to place them to produce an excellent or even acceptable result. The surgeon must be able to create an aesthetic "blueprint" for graft placement, determining the distribution of 1, 2, and 3 hair grafts. Hairline design is obviously important, as is the grafting plan over the rest of the scalp. The experienced hair surgeon will create gradients of density to achieve natural looking results with adequate density. In addition, the incisions must be made at the proper angle and direction. Even single hair grafts will look unnatural if placed at the wrong angle. Technical Expertise A somewhat different skill set is required for FUE harvesting. The surgeon must be able to align the small punch correctly, find the right depth and adjust the punch to account for changes in direction of the hair. The primary concern with FUE is the rate of transection. That is, if the hairs in a follicular unit are transected they are less likely to grow. This is in part dependent on the level of transection. The reports from physicians performing FUE indicate that the rate of transection is higher than with strip harvesting.



As noted above, the physician must be able to adjust the punch to account for change in hair direction. Patients with curly or very wavy hair may be difficult to treat when FUE is used. In comparison, strip harvesting is suitable for all types of hair. The use of the blunt punch can be helpful in harvesting curly or wavy hair with the FUE technique. FUE can be a tedious process and both patient and physician may experience fatigue. This can limit the amount of grafts that can be harvested in a single session. Because of the time usually involved in harvesting and the possible strain on the surgeon performing the harvesting one has to wonder if less emphasis is placed on the recipient area. The learning curve for FUE can be slow for physicians who are used to excisions with scalpels and unaccustomed to the use of punches for harvesting. The physician may need to use high power loupes 4x-6x. Working at a shorter focal distance can be tiresome and lead to neck problems. Some physicians have used ophthalmic microscopes to facilitate the surgery. An important issue associated with a particular mechanized FUE is the marketing to physicians that unlicensed personnel may be able to perform the harvesting. This raises significant legal issues in many countries, including the U.S. There are states where it is clearly illegal to have a non-physician, non Physician Assistant (PA) or Nurse Practioner (NP) perform such surgery. The laws in other countries may present similar medico legal problems regarding who can harvest tissue. For example, in Austria, Israel, Italy, Korea, Georgia, Thailand, Turkey, and Japan, only physicians are allowed to make incisions, and regulations vary as to the role of assistants in graft insertions. In some countries including the US, entrepreneurial nurses and medical assistants are setting up hair transplant clinics, and hiring physicians as medical directors who may have limited or no hair transplant experience, but who “supervise” the procedure. Many U.S. states allow the physician to delegate responsibilities to staff under supervision, but both the degree of supervision, and the extent of staff responsibilities is not clearly defined. To date, this issue has not been challenged or reviewed by any state medical board. The following is the position of the International Society of Hair Restoration Surgery: ISHRS Position Statement on Qualifications for Scalp Surgery The position of the International Society of Hair Restoration Surgery is that any procedure that involves tissue removal from the scalp or body, by any means, must be performed by a licensed physician in the field of medicine. Physicians who perform hair restoration surgery must possess the education, training, and current competency in the field of hair restoration surgery. It is beyond the scope of practice for non-licensed personnel to perform surgery. Surgical removal of tissue by non-licensed medical personnel may be considered practicing medicine without a license by state, federal or local governing boards of medicine. The Society supports the scope of practice of medicine as defined by a physician's state, country or local legally governing board of medicine. Number of grafts per session In general most physicians who perform FUE are not able to do as many grafts in a single session as can be done with strip harvesting. With strip harvesting, sessions of 2000-3000 grafts are very common and some physicians frequently perform sessions in excess of 4000 grafts. There are, however, exceptions and some physicians, routinely performing motorized FUE, report similar in excess of 2000 grafts. Unfortunately, the rates of graft transection in these larger FUE sessions has not been studied or reported. Cost The cost of FUE is usually significantly more than that for strip harvesting on a per graft basis. The costs may exceed double the price of strip harvesting. Body Hair FUE can be very useful for harvesting body hair. In such situations the majority of follicular units are single hairs. Evidence of the surgery is often visible as hypo or hyperpigmented “dots” in these non-scalp donor areas. Small number of grafts When small numbers of grafts are needed FUE may be an excellent choice of technique. Using the technique where narrow rows of trimmed hair are used it would be relatively easy to camouflage the work and avoid creating a linear scar. On the other hand using a 2.5 cm long and 1.2 cm wide strip a surgeon could easily obtain 240 or so grafts. (2.5 x 1.2 =3.0 sq cm) assuming a density of 80 FU per sq cm (80 x 3 = 240 grafts). Thus, evidence of removal of 240 FUE grafts would be a 2.5cm long scar. FUE into scars FUE can be used to try to camouflage linear donor scars. This is considered by many hair restoration surgeons to be another excellent use of the technique. Some surgeons have suggested that a combination of strip harvesting and FUE is the optimal use of the techniques.


http://www.ishrs.org/�


Instrumentation The cost of instrumentation for strip harvesting and non-mechanized FUE is modest. With the advent of mechanization the cost for machines that can be used for FUE can be expensive. Powered or motorized devices can cost several thousand dollars and one system currently sells for approximately $80,000 (USD). With the motorized systems there is debate as to the rate of transection. Some physicians who perform FUE but do not use the motorized systems feel that the rate of transection is higher with such devices. Other surgeons indicate that transection rates are the same or lower. This may depend on the training and skill of the physician performing the work. Increased donor supply Advocates of FUE have stated that FUE expands the donor area in the scalp. With FUE the surgeon can harvest in the nape of the neck more easily as well as the areas superior and more anterior to the ear. This apparent advantage is somewhat negated because the area can become moth eaten in appearance as more and more graft are obtained. In addition going into the nape of neck area or high onto the scalp can be a problem later in life for the patient as some men lose hair in this area as a result of male pattern hair loss. Complications Some of the surgeons who prefer FUE feel that patients experience less pain and there is a shorter recovery time. There is little data to support this view. One would need to compare the pain associated with comparable numbers of grafts harvested per session. For instance one would want to compare, for example, 1000 grafts harvested with strip vs. the same number harvested with the FUE technique. The fact that pain is very subjective complicates such studies. Telogen effluvium can occur in the donor area with FUE or strip harvesting, but this is uncommon. Infection is a very rare complication with hair restoration surgery. Dehiscence with strip harvesting can occur but this is quite rare and would be associated with surgical error. Similarly, necrosis of tissue should not occur unless the area harvested is too wide and/or closed under excessive tension. This could also occur if the arterial supply was already compromised. Patients may complain of altered sensation but this can occur with strip harvesting or FUE as small nerves are cut in both procedures. Years ago some strip-harvested patients may have experienced significant dysesthesia as a result of damaging the occipital nerves. As dissection should be at the level of the fat or perhaps at the level of the fascia these nerves should not be damaged. Bleeding occurs with both techniques but more significant bleeding occurs with strip harvesting. That said, bleeding is not considered a problem with strip harvesting and in most cases bleeding is nominal. A complication that is specific to FUE harvesting is the burying of grafts. This happens when the punch pushes the graft into the subcutaneous tissue. The grafts can be difficult to recover and can lead to a foreign body reaction and cyst formation. Hypertrophic scars and keloids should also be rare with FUE or strip harvesting. If patients have a predilection for keloids making punch excision will not limit such scar formation. In general hair must be cut short to be harvested with FUE. At times layers can be created allowing hair to cover the harvested areas but this places a limit on the amount of hair that can be removed at the session. Staffing Strip harvesting requires a larger staff than FUE. For FUE the surgeon can get by with just one or two assistants but if the surgeon has to alter course and use a strip harvest having only one or two assistants could be problematic. Summary Strip harvesting and FUE are both acceptable techniques for harvesting donor grafts. Each technique has advantages and disadvantages. On a cost-benefit ratio strip harvesting would seem to provide the most cost effective procedure. FUE is well suited for patients who insist on not having a linear scar. It may be an excellent choice for young patients seeking small procedures. FUE may be the ideal choice for harvesting trunk, leg and arm hair, and it is an excellent way to camouflage strip scars. It is important that objective data continue to be collected regarding graft survival with FUE. Similarly, it would be beneficial to obtain more information as to the degree of discomfort experienced with the two techniques and the healing times.



No matter the technique employed, the surgeon must be well versed in the technical and aesthetic components of performing the surgery in order to produce consistently good results. A single course or training session on one aspect of the hair restoration procedure such as harvesting is inadequate training for a physician to learn how to perform hair restoration procedures. The surgeon must acquire a sense of the aesthetic and technical components of the procedure. He or she must be able to develop a plan for patients with various clinical scenarios and know when to refer to a surgeon with more expertise. The goal of hair restoration seems simple enough, namely to move hair from one part of the scalp to the other. However, any experienced physician will tell you how complex this seemingly simple task is. For example, one of the most important concepts the physician must appreciate is that hair loss is progressive and that any restoration plan must be made with this in mind. When a patient comes to the physician with a given stage of hair loss, the physician must be able to assess the donor area for hair density and quality, calculate the number of grafts needed, give the patient a reasonable expectation for what the result will be, and plan this result with the possibility of future hair loss in mind. The physician must be able to discuss the pros and cons of medical treatments designed to stop or slow future hair loss, such as oral finasteride and topical minoxidil. All of these elements require considerable training and expertise to implement for each patient. Successful graft harvesting is only one small component of surgical hair restoration. Without attention to all of the other aspects, there is a very real possibility of a bad outcome. Finally, the incision of skin and tissue, whether using instruments that create a linear or circular incision, is legally considered surgery and should only be performed by a licensed physician with adequate training and expertise in hair restoration.


022

Quality & Legal Issues Regarding Surgical Tech Participation in the HT Procedure Bradley Wolf, MD Wolf Medical Enterprises, Cincinnati, OH, USA.

Dr. Wolf has practiced hair restoration surgery exclusively for almost 20 years. He is interested in all aspects of hair restoration surgery and performs strip excision surgery as well as FUE. He lives and practices in Cincinnati, Ohio.

B. Wolf: None.

ABSTRACT: Surgical techs or medical assistants are usually involved in hair restoration procedures. In some practices they perfrom a majority of the procedure. These assistants are commonly unlicensed and are under the supervision of the delagating physician. This talk will define the practice of medicine, delegation of tasks, and other pertainent terms. It will also explore state codes for the legal constraints and ramifiacations of using unlicensed assistants. As well the issues of quality results in hair restoration when using unlicenced assistants will be discussed. Outline

1. Discussion of US state medical boards rules governing assistants- administrative codes a. Licensed assistants b. Unlicensed assistants (techs)

2. Roles of assistants in hair restoration surgery: Strip and FUE 3. Model of a Corporation offering automated FUE

a. Role of assistants (techs) contracted by client physician b. Examination of contract (Technicians services agreement)

4. Discussion of quality issues in hair restoration surgery with respect to above.

023

Moderator Introduction, FUE: High Definition Surgical Theater & Free Papers Jean Devroye, MD Brussels, Belgium.

Jean Devroye is a "Doctor in Medicine and Surgery"(MD). He completed his studies at the University of Liège, in Belgium. In 1999, he decided to move to the United States and dedicated his time to Hair Transplant Surgery. He only performs hair transplants. Dr Devroye works in Belgium, Brussels. • 2009 : Amsterdam Chairman LPV (live patient viewing) ISHRS Congress. • 2008 : Rome, Live Surgery Demonstration FUE ISHRS and ISHR Congresses. • 2008 : Montreal 2nd Award for the best poster ISHRS Congress. • 2005 : Sydney Australia ISHRS Meeting Award for the best Poster, 3rd.

J. Devroye: None.

024

Proposal of Definition of FUE Transection Robert H. True, MD True & Dorin Medical Group, P.C., New York, NY, USA.

Dr. Robert True practices hair restoration surgery full time in New York City. He is the immediate past President of the American bBoard of Hair Restoration Surgery. He is one of the pioneers in developing FUE techniques and has given numerous lectures and workshops on FUE over the past 8 years. He has developed a unique approach to motorized FUE

R.H. True: None.

ABSTRACT: When we talk about transection in FUE are we suing the same definituion or are we comparing apples with oranges. I preparing for our workshop on different techniques of FUE for this meeting all presenters agreed to a common definition so that we could compare our results more accurately. After consider at we agreed upo these two simple definitions: Missed graft - no follicles in extracted tissue Transection - any microscopically visible disruption of any portion of the follicle Moreover, we agreed that FUE cases should uniformly be documented as follows: Total number of punch insertions Total number of extractions Total number of grafts by size (1’s, 2’s, 3’s, and 4 or more) and total Total number of missed extractions (extracted tissue contains no follicles) Total number of grafts with one transection by size (1’s, 2’s, 3’s, and 4 or more) and total Total number of grafts with two transections by size (1’s, 2’s, 3’s, and 4 or more) and total Total number of grafts with 3 or more transections by size (1’s, 2’s, 3’s, and 4 or more) and total We would suggest that these become a standard usage by members of our society

025

FUE Learning Curve Antonio Ruston, MD Clinica Ruston, Sao Paulo / SP, Brazil.

Dr. Antonio Ruston - Plastic Surgeon Medical director of Clinica Ruston Has been working with Hair restoration surgery for 16 years. Member of ISHRS since 1999. Member of:

- Brazilian Society of Plastic Surgery. - American Society of Aesthetic Plastic Surgery. - International Society of Aesthetic Plastic Surgery

A. Ruston: None.

ABSTRACT: Introduction: After 15 years of doing FUT I never thought that I would have the opportunity to learn something “from scratch” in hair transplant surgery. With FUE I had the same feeling and excitement that I had 15 years ago, the feeling that just beginners have. Objective: Show the learning curve in FUE field and all of its difficulties from the perspective of an experienced hair transplant surgeon. Materials and/or methods: In 2002, after the New York meeting, I decided to try the FUE technique. Because of my high transsection rate (around 25%) and the difficulty of the technique I stopped. I confess that I was not convinced about the technique until last October when I visited Dr. Bob True in New York and Dr. James Harris in Denver. Since then, I've been doing FUE EVERY DAY using the motorized blunt system. Each day, after the donor closure I extract from 50 to 100 FUE above the suture. At first I was not so enthusiastic because my transsection rates, even using the correct tools, were around 20% or more (fig. 1). So I decided to study each case. That is to say I started by looking under the microscope at each individual follicular unit that I had removed using FUE, placing them on a spatula and photographing each group of FUEs removed from each patient (fig. 2). I also took pictures of the donor area removed and some slivers. Afterwards, with those pictures and patient notes (angle of hairs, density, hair type, percentage of 1, 2 and 3s and depth variation of each case and areas) I was able to more thoroughly study the causes of the variation in transsection rates (fig. 3). With this study I began to deeply understand why some cases are much more difficult, in terms of transsection, than others. The main factor is depth control, which not only varies from patient to patient but also within the same patient. This means that the same patient can have different depths in the same or different donor areas (fig. 4). The second most important factor is the angle, not only above but also below the scalp surface. The more acute the angle of the hair in relation to scalp, the more difficult the case is in terms of transsection (and vice-versa). Further, in cases in which the angle of the hair inside the skin changes abruptly there is a greater the chance of transection (fig. 5). Understanding this is the first key to reducing the transsection rates. So I started to remove a few grafts and measure the depth. If I noticed that the depth was less than 4mm (the depth of the punch), I used a depth control system and removed a few more and checked again until certifying that I was using the correct punch depth. Because the depth sometimes varies from area to area, each time that I moved to a different area I repeated this process. Other cases that are more difficult than the others: cases in which the majority of the follicular units splay outward as depth increased (fig. 6), cases with very low density in which the majority of the follicular units have one hair, cases with little fat tissue in the donor (usually with low depth of the bulbs), wavy hairs (more difficult than curly).

I also did a study about the scabbing period: maintaining the grafts exactly as they were removed (with the skin) versus after trimming (without skin) - figure 7 Discussion/results FUE is a very difficult technique requiring training, patience and a huge learning curve. Even after around hundred procedures, in some difficult cases my transsection rates were still around 15 - 20% and I consider a good transection rate to be around 10% or less. Having just done my first “big”case of FUE (around 1000 FUs) after six months of “training” every day, I can guarantee that FUE is much more difficult than many colleagues and I had thought. I am going to show in the presentation different types of FUE uses such as: correction of donor spread scars, patients with a depleted donor area, patients who do not accept linear scars, small procedures, and young patients type VII to frame the face and allow for wearing the hair shaved. I will also present a short video of using a power system FUE technique - figure 8. My concern about FUE: Many professionals with no experience whatsoever in HTS will start in this field mainly because FUE requires a much smaller team (one of the bigger obstacles in our field). For this reason we will see a large amount of publicity about this technique in the next years. But are they prepared? Do they know enough about the progression of the baldness for each patient and the safe zone for removing the grafts? Do they know how to indicate FUE and how to indicate FUT, and will they do it? (as they are not prepared for FUT) These are just a few questions that will appear in the next years. Conclusion FUE is a technique that has come to stay in the hair transplant field but it is not as easy to do as many professionals think. As with all kinds of new techniques and strategies in the beginning we have the tendency to over indicate a “new” technique and after few years this technique will occupy its definitive space in the field.

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026

VIDEO - Efficient FUE Extraction and Implantation with Implanter Pen Jose F. Lorenzo, MD Centro Cirugia Capilar Avanzada, Madrid, Spain.

Dr. Lorenzo born in the Canary Islands, Spain. Graduated in 1991 in the Universidad Complutense of Madrid. Diplomated in General Surgery in 1997. Exclusively practicing FUE Technique since 2003. Currently, he is the director of his own HT clinic in Madrid, injertocapilar.com

J.F. Lorenzo: None.

ABSTRACT: Introduction: This is a new handing of different maneuvers that can facilitate and optimize the harvest of follicles by manual FUE technique in order to maximize the quality of the grafts. We will focus on different movements that we use to delivery the units after the dermis has been cut by the punch. In a second part we will introduce the use of the implanter to achieve high density without tumescence neither previous design of the recipient sites.


Technique: FUE is a slow extraction technique. Making more than 3000 extractions per day requires experience, a well coordinated team, and a detailed knowledge of the technique. This video continues with the description of some of the tricks we use regularly to facilitate the extraction and accelerate implantation. Discussion: The extraction in FUE technique is complex. Every patient is different, there’re also variations in the different areas of the head: the depth, angle, the anchor systems... Even our daily disposition or humor influences in the quality of extraction. Specializing in FUE would be desirable in order to standardize the procedures. We try to show our usual practice and some details that can improve both quality and speed, in the extraction and implantation.

027

Analysis of FUE Sites and the Measured Area of FUE Extraction Donor Zones Utilizing Dissecting Punches of Different Sizes James A. Harris, MD, FACS University of Colorado, Greenwood Village, CO, USA.

James A. Harris, MD, FACS, received his medical degree with honors from the University of Colorado School of Medicine in 1989. He is a Diplomate of the American Board of Otolaryngology, Fellow of the American College of Surgeons, member of the American Academy of Otolaryngology and the International Society of Hair Restoration Surgery. He is a Clinical Instructor of Hair Transplantation at the University of Colorado Health Sciences Center in Denver, Colorado. Dr. Harris has developed a surgical methodology and instrumentation for performing follicular unit extraction that ensures graft safety and integrity called the Harris SAFE System®.

J.A. Harris: None.

ABSTRACT: Introduction: There is some controversy among doctors and patients regarding the importance of utilizing FUE punches of the smallest size inner diameter to limit trauma and minimize scarring. There are no studies to examine the effect of punch size on the visual appearance of the resulting extraction site scar or the measured post operative area of the donor zone. A significant change in the area may either increase or decrease the density of the remaining hair affecting the visual density of the remaining hair. Methods and Materials: A powered FUE device utilizing 1mm, .9mm, and .8mm inside diameter dissecting punches will be used to create FUE sites in three patients. Three adjacent 1 cm2 grids marked with black tattoos will be subjected to FUE with 20 extractions per grid with each punch size. The areas will be calculated to assess post operative area changes as related to punch size. Photographs taken prior to surgery will be compared to post operative photographs after a 4-6 month delay to subjectively evaluate the FUE site scars. The scars will also be measured and the results presented. Results: Pending final analysis Conclusion: Pending final analysis

Analysis of FUE Sites and the Measured Area of FUE Extraction Donor Zones

Utilizing Dissecting Punches of Different Sizes

James A. Harris, MD, FACS

Assistant Clinical Professor – Hair Transplantation

Department of Otolaryngology/ Head and Neck Surgery

University of Colorado Health Sciences Center

and

The Hair Sciences Center of Colorado

Denver, Colorado

No COI to report

Introduction♦Controversy - does the diameter of

an FUE punch make a significant

cosmetic difference

♦Does tissue removal from FUE

change the area of the extraction

zone and impact follicular unit

density

Methodology

♦ Tattoo three 1cm2 grids in each of three

patients

♦ Extract 20 skin plugs from each grid using a

0.8mm, 0.9mm and 1mm punches

♦ Evaluate and measure scars in each grid and

compare within and between patients

♦ Measure the areas of each grid and compare

.8 mm .9 mm

1 mm

Results -

♦ Analysis and photos of donor sites pending

♦ Measurement of donor are pending

Conlusions -

♦ Pending analysis of data

028

Integration of Suction-Assisted FUE in My Practice Robert T. Leonard, DO Leonard Hair Transplant Associates, Cranston, RI, USA.

Dr. Robert Leonard is Founder and Chief Surgeon of Leonard Hair Transplant Associates with offices in New England. Founding Secretary and a Past President of the ISHRS, Dr. Leonard has specialized in the field of HRS for the last 25 years. He added Power-Assisted FUE, using the NeoGraft device to his practice in the spring of 2010. He lives in Rhode Island with his wife and three children.

R.T. Leonard: None.

ABSTRACT: I shall relate the reasons for and my experience in adding the NeoGraft device to my well-established practice of hair restoration surgery.

029

How Dry I Am... Graft Desiccation Prevention During Suction-Assisted FUE Alan J. Bauman, MD Bauman Medical Group, Boca Raton, FL, USA.

Dr. Alan J. Bauman received his MD degree from New York Medical College and served as a resident in surgery at Beth Israel Medical Center and Mt. Sinai Medical Center in New York. For the past 13 years, he has specialized exclusively in hair transplantation as a full-time Hair Restoration Physician. In 2002 he began to offer FUE Follicular Unit Extraction to his patients and was the first to demonstrate the manual FUE technique in a Live Surgery Workshop in Orlando in 2003. In 2007 Dr. Bauman began using powered FUE devices in his practice. Today, of the 250+ hair transplants he personally performs annually in his practice, over 90% of them are FUE.

A.J. Bauman: None.

ABSTRACT: Introduction: Past research supports the concern that graft desiccation during hair transplantation may significantly impact graft viability. During either traditional strip harvesting or FUE, follicular-unit grafts spend many hours outside of the body being sorted, dissected, awaiting implantation in petri dishes, as well as during the implantation process. One only needs to examine follicular-unit grafts sitting on a technician’s gloved fingertips for more than several minutes during the implantation phase of a hair transplant to see how quickly exposure to the air changes their hydration status.

Suction-assisted FUE using the device manufacturer’s suggested set-up utilizes a “dry” graft collection canister with constant negative pressure and airflow. Collected grafts are subject to this potentially desiccating environment. At the time of this writing, the manufacturer offers no written protocols or recommendations as to how often irrigation or graft canister emptying should be performed and leaves this to the discretion of the operating surgeon. Purpose: Our 9-month long investigation was designed to explore several variations in protocol, technique and/or device setup which may minimize the potential desiccation of FUE grafts specifically during the harvesting process. Over the course of 150 consecutive cases, options were evaluated for their impact on graft-desiccation risk as well as graft collection efficiency (grafts/hour), technical difficulty, ease of quality-control as well as equipment and personnel requirements. Methods, materials & results: A contra-angle, foot-pedal actuated handpiece with a depth-adjustable rotational 0.8mm punch was used in each FUE case. Option A: (Manufacturer’s recommended setup) Dry canister, suction-assisted FUE. This technique/setup requires consistent irrigation every few minutes and frequent collection canister emptying to reduce desiccation risk. An assistant can aid graft-harvesting efficiency by swapping an empty canister with the operator, then transferring the grafts to chilled 0.9% saline. Graft quality is easily monitored during each graft’s extraction from the skin as well as by directly examining the collection canister which is attached to the extraction handpiece. We observed that the frequent irrigation and emptying process to reduce graft drying required the operator to interrupt the rhythmic extraction process. This ‘breaking stride’ seemed to reduce efficiency somewhat compared to the other techniques. Option B: Single “Wet” Canister/Flask, Suction-Assisted FUE. A modified set-up allows the collection of grafts directly into a single flask which contains 0.9% chilled saline (or other storage solution). Literally hundreds of grafts may be collected consecutively without having to empty the flask or ‘break stride’ except for occasional brief irrigation/flush to keep the collection tubing clear of harvested grafts and debris. Grafts are therefore immersed in the saline during the collection process, virtually eliminating the risk of dehydration during this phase. Grafts are then removed/decanted from the ‘wet canister’ after long intervals reducing interruptions which diminish harvesting speed. Because the larger flask is located slightly farther away than the standard handpiece-mounted “dry” collection canister, immediate feedback to the operator regarding graft quality by direct observation is slightly impaired. Option C: “Two-Step” FUE (without suction-extraction), No Canister. During “Two-Step” FUE, the operator first makes a minimal-depth incision around the follicular unit with the blunt 0.8mm punch. Then, the grafts are manually extracted using forceps by an assistant and/or the handpiece operator without suction. Grafts remain ‘in situ’ until removed and are immediately transferred to 0.9% chilled saline or other storage solution of choice, protecting them from dehydration during harvesting. This harvesting technique can be performed with a single operator, but speed certainly improves with the help of an assistant armed with forceps. Immediacy of feedback regarding graft quality is a function of the time between the two steps of harvesting (incision and graft extraction). If graft extraction is performed with the help of an assistant, communication with the handpiece operator is essential to ensure timely feedback regarding graft quality. In our hands, two-step FUE using a blunt 0.8mm punch provided slightly higher hair/graft counts than suction-extraction techniques. Conclusion: During my surgical training, my chief resident used to say to junior residents “The walls are sabotaging you...” What he meant was that in medicine and surgery oftentimes there are many factors that could work against you, potentially disrupting the beneficial outcomes that you are so desperately working to achieve. In the increasingly complicated and technical ‘symphony of detail‘ which is modern hair transplant surgery, this concept seems to be more true now than ever. Changes in instrumentation or protocol which are supposed to make the process ‘simpler’ or ‘better’ often introduce new potential problems, risks or challenges which then require modifications, work-arounds or other solutions. Examining a follicle’s potentially perilous journey from donor area

to recipient area and minimizing areas of possible trauma or injury is the tireless role of any successful hair transplant surgeon and his team. In our comparison of evolving FUE techniques and devices which has taken place over more than seven years, we still feel that we are “moving up the learning curve” as new plateaus of graft quality, speed and/or efficiency are being reached approximately every ninety days. When it comes to surgical techniques there is never a ‘best’ way or a ‘best’ instrument, only what works best ‘in your hands.’ A careful comparison of the manufacturer-recommended set-up and technique with some minor modifications to protocol and procedures brings to light the fact that there are potentially several options that reduce the chances of graft dehydration. It is the author’s hope that future research and input from other practices will help elucidate further the pros and cons of these various techniques and device setups.

Three FUE Setup Options For Graft Harvesting

Option A: Dry Canister + Suction

Option B: Wet Canister + Suction

Option C: Two-Step, Forceps Extraction

Dehydration Risk Medium Low Low

Speed (grafts/hr) Medium High Medium to High

Quality (follicles/graft)

Good Good Good to Excellent

Personnel Two One One or Two

Technical Difficulty

Varies Varies Varies

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Powered FUE Hair Transplant - An Analysis of 232 Patients Kapil Dua, MD, Aman Dua, MD A K Clinics Pvt Ltd, Ludhiana, Punjab, India.

Dr. Kapil Dua, MBBS,MSc (ENT and Head Neck Surgery) Consultant Hair Transplant Surgeon, A K CLINICS pvt ltd Ludhiana, Punjab, INDIA Member ISHRS Founder Member AHRS (India) Special interest in FUE Hair Transplant Performed more than 500 FUE surgeries

K. Dua: None. A. Dua: None.

ABSTRACT: Introduction: FUE Hair transplant is an emerging technique of hair extraction which is still in its infancy. A number of different techniques and instrumentation are being employed for better results. The manual methods are being supplemented by motorized techniques. Powered FUE is yet another novel method of extraction. In this study, we are going to assess and present our experience of Powered FUE and the results. Premise: A total of 232 patients were enrolled in the study over 1 year 3 months. During surgery various parameters which were evaluated were: speed of extraction of grafts, follicular transection rate, number of false attempts and number of hair per graft and time of extraction. The results are under compilation and will be presented in the meeting. Discussion: Powered FUE is a faster and definitely better option than the traditional manual method. Newer options are being looked for in FUE and have the promise of making FUE hair transplant faster and easier than ever.

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Moderator Introduction, Gigasessions: High Definition Surgical Theater & Free Papers Parsa Mohebi, MD US Hair Restoration, Los Angeles, CA, USA.

Parsa Mohebi, MD, is the medical director of US Hair Restoration (USHR). Dr. Mohebi did his surgical residency at the University of New Mexico and York, Pennsylvania. Dr. Parsa Mohebi pursued an interest in surgical research at Johns Hopkins School of Medicine, Department of Surgical Sciences. At Johns Hopkins, he performed several studies on wound healing and hair growth, using growth factors and gene therapy methods. In addition, Dr. Mohebi

completed a fellowship in surgical hair restoration at New Hair Institute (NHI). Dr. Mohebi is a Diplomate of the American Board of Hair Restoration Surgery.

P. Mohebi: None.

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Panelist for Gigasessions Session Sharon A. Keene, MD 3940 North Campbell Ave, Tucson, AZ, USA.


S.A. Keene: None.

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Panelist for Gigasessions Session Jerry Wong, MD Hasson & Wong, Vancouver, BC, Canada.

Dr. Jerry Wong, MD graduated from the University of Alberta Medical School with a background in general practice. He has been involved in hair transplants since 1992. He is a graduate of the Marzola School of Hair Surgery and is currently working at Hasson & Wong in Vancouver, Canada. Dr. Wong developed the Lateral Slit Technique. He has attended every ISHRS meeting thus far.

J. Wong: None.

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Giga Sessions - A Six-Year Perspective Akaki Tsilosani, MD, PhD Talizi Hair Transplantation Clinic, Tbilisi, Georgia.

Akaki Tsilosani was born in Tbilisi, Georgia in 1966. After graduation from Tbilisi Physico-Mathematical public school in 1983, he entered Tbilisi State Medical University. After passing residency in the department of General Surgery of Tbilisi 4th Clinical Hospital, he worked as a general surgeon in several clinics in different regions of Georgia. Since 1999 he works in Talizi Hair Transplantation Clinic as a hair transplant surgeon where he already performed more than 3,000 hair transplant sessions. In 2003 he was appointed to the position Director of the clinic. He is the author of 22 scientific works and 6 inventions in the field of hair transplantation. He is married and has 3 children.

A. Tsilosani: None.

ABSTRACT: Giga Sessions - A Six-Year perspective Introduction: At the ISHRS Meeting in Amsterdam in 2009, giga sessions were defined as transplantation of more then 3500 FU’s. Giga sessions have many advantages: patient gains time as long as the optimal cosmetic result hair transplant surgery obtained earlier; he benefits by undergoing all the discomfort related operation only one time; obtains better final donor scar (even the donor strip being wider, the final result will be better than after 2 or 3 incisions in the same place); there is no previous scar deforming the anatomy, so less risk to damage nerves and arteries; and finally the first session in many cases grows better. After 6 year experience we achieved reduction of giga session’s duration to five hours. Using small (less than 1.0 mm) and sharp micro blades for recipient sites creation with depth limiter allowed us to avoid compromising of blood supply and decreasing grafts survivability; nevertheless, the main problem with performing large sessions is poor donor supply in the patient with low donor density and poor flexibility. In order to reduce strip width without decreasing the number of grafts transplanted during an operation, in 2006 we decided to combine FU strip excision with FUE. This method not only provides the ability to harvest the necessary quantity of grafts, but also substantially decreases tension on the donor wound closure. The purpose of this study was to compare and analyze scalp tension forces while closing donor wounds immediately following strip excision and before and after additional FUE extraction in patients with low donor density and poor laxity. Materials and Methods: Twenty patients with poor scalp laxity and with low or average donor density underwent hair transplantation with the purpose of correcting male pattern alopecia of high degree (Norwood IV-VII). In all subjects, scalp tension during donor wound closure was measured. To achieve this, retention sutures involving the dermis at equidistant points 5-8cm from the wound center were placed. Retention sutures placed on the upper wall of the wound were attached to one dynamometer, and sutures put on the lower wall of the wound were attached to another. Next, the assistant accurately moved the dynamometers in one plane at right angles to the wound in different directions, stretching the wound edges until the moment of contact. Readings of both dynamometers were registered. The sutures were then removed. Scalp tension forces during donor wound closure were determined as the sum of forces applied to the upper and lower ends of the wound necessary for adjoining its edges. The obtained data was statistically processed. The wound was then temporarily packed and we proceeded with the FUE extraction of grafts above and below the strip donor area to try to obtain at least 30% additional grafts than was generated through strip excision. We used 0.75 and 1.0mm punches for graft extraction. The quantity of grafts obtained with FUE varied from 450-1,500 FUs. At the completion of the FUE procedure, scalp tension was measured a second time as

described above. Next, a lower edge trichophytic closure of the wound with one-layer continuous 5-0 monocryl was performed. Results: The power required to approximate the donor wound edges without the additional FUE procedure varied from 3.4-8.8 kg-f depending on scalp flexibility and the number of obtained grafts (strip width). The average tension power in cases of transplantation of 2,505-3,544 FUs was 4.92±0.09kg-f. After FUE extraction of 450-1,500 FUs, the necessary power for approximation was 2.1-5.3kg-f, average 2.95kg-f, p<0.001%. It was observed that if, through FUE, at least 30% additional grafts are generated, then compression forces decreased by half during wound closure. For example, if a patient had 1,200 FUs extracted above and below the excised strip (which generated 3,306 grafts), this would decrease scalp tension power from 6.4kg-f to 3.1kg-f. If FUE would generate less than 30% of the quantity of strip grafts (e.g. 450 FUs per 2,512-graft strip), then the compression force during wound closure did not decrease significantly. On average, after FUE, scalp tension power varied from 4.92-2.95kg-f, which accounts for a 40% decrease. Donor wounds in all patients healed as cosmetically acceptable scars. On average, after FUE, scalp tension power varied from 4.92-2.95kg-f, which accounts for a 40% decrease. Donor wounds in all patients healed as cosmetically acceptable scars. Conclusion: The combination of strip surgery and FUE increases the duration and the cost of the operation; nevertheless, we believe this is the optimal option to perform large sessions in patients with poor donor laxity and density.

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VIDEO: Planning and Execution of a Gigasession Arthur Tykocinski, MD Tykocinski Medical Group, Sao Paulo, Brazil.

Dr. Tykocinski is a dermatologist from Brazil exclusively dedicated to hair restoration. He was one of the pioneers of the Follicular Unit Transplantation, since 1996, learning the principles of the technique from Dr. Ron Shapiro. He wrote several papers and book chapters on hair restoration. He has also been in leading positions on the ISHRS Annual Meetings: Workshop Chair (2005), Advanced Review Course (2007) and Program Chair (2008). He is actually member of the “Board of Governors” and Chair of the Website Committee from the ISHRS.

A. Tykocinski: None.

ABSTRACT: Tykocinski’s HT Technique Despite of doing HT since 1993, I started as a professional HT surgeon just after visiting and learning the fundamental good techniques from Dr. Paul Cotterill back in 1995. In 1996 I moved to FUT, after learning it from the yet undiscovered HT hero Dr. Ron Shapiro. In 1998 I moved to 100% FUGs and to Stick & Place. In 2002 I moved to the coronal technique influenced by Dr. Jerry Wong and in 2005 I’ve brooked the 4.000 FUs barrier and this year I reached 7.000 FUs in one session. Bellow the highlights of my technique.

Pre-op scalp massage - As proposed by Dr. Wong, ads a lot of laxity to the donor area, allowing extra grafts. I modified this concept adding a Shiatsu massage on scalp twice a week for 8 weeks prior HT. In my experience, it ad not just more FU grafts (15-30%), but also aloud a better healing and for most patients an almost painless post op. Mayer-Paul’s Caliper - I use this technique since I learned from Dr. Melvin Mayer in 2005. Forget removing the strip with all the same width. You should adjust it cm by cm based on the local laxity. It is a must if you want to go Giga. Laxity evaluation Chart - After one year using the caliper, I started creating my own chart based on the new vertical concepts proposed by Dr. Bill Rassman in 2006. Two years after I got the first version and in 2010 we reached a very reliable relation between the donor laxity and the donor strip width. This all together combined allowed me to consistently produce sessions on the 4.000 FUs range, on average, and closing with almost no tension at all. Not published yet. Sandoval Scoring Technique - Another simple, but yet genius concept, that allows a donor strip removal without almost any transection. You first score the skin superficially parallel to the hair shaft and than make a blunt dissection with the mosquito. Intruder - After learning the great concept proposed by Dr. Bob Haber with his Spreader, and using it for an year I tried some improvements unsuccessfully. So I decided to create something new, simple to use and reliable. I designed the intruder that was so great for me that I decided to share it with friends and finally with all. This device should be used after the superficial scoring and before the use of mosquito for donor strip blunt dissection. In fact it facilitates that job and also avoid trauma. Presented in 2010. Intra-operatory scalp massage - Sometimes could be hard dealing with tissue fluids. In fact the fluid can make our lives miserable sometimes. This concept was presented in 2009 and is an easy way to remove the excessive tissue fluid before the suturing. Using the tip of the fingers you just massage the galea and the surgical wound. Trychophytic closure - An old Iuri concept that was revitalized by Drs. Marzola, Fretchet and Rose. It is basically a camouflage technique that allows the hairs to grow in trough the forming scar. Sometimes it could ad tension to the superficial closure - because the 1-2mm extra removal - markedly when using it on the inferior border (Fretchet and Rose), and less frequently when used on the superior border (Marzola) - just my experience - no study yet. Two layers closure - Trying to get the best donor scar possible, I’ve been using the double layer technique for more than 10 years. Thinking of Giga session, I believe the double layer closure is a must because it holds all the tension into the deep suture, and allows closing the superficial suture without any tension. This is especially important when performing the trichophytic closure, allowing the hairs to grow into the forming scar. It also decreases the fibrosis along the suture, markedly into the sub-Q, when coming for the next session. Presented at Orlando 2008 and Boston 2010. Diagonal Slivering - Instead of performing the slivering perpendicular to the strip, we search for the diagonal lines of natural FUs pattern. This allow us to keep the FUGs intact instead of creating sub-follicular units, resulting in less hair per FU that way decreasing the final density. Presented in 2007. Follicular Grouping - Using the concept proposed by Dr. David Seager - described as follicular family unit - we expand it for getting extreme densities in tuff area. Follicular groupings (FG) are two follicular units so close together that can be placed as just one FU in a yet small incision - very different from a regular double FU, where the distance in-between is 1 mm. But in fact there are two FUs per site, doubling the final density. Placing 30-35 FGs per cm2 will produce 120-140 hairs/cm2 - a lot of density. Published on the Forum in 2003. Organic 3-D Hairline design - Starting from the artistic design of Ron Shapiro’s hairline I have incorporated some new aspects on it, as the face/skull shape, the Da Vince facial proportions and the Sandoval shingling point. Also, instead of triangles I moved to a flame pattern for the hairline design. Finally I started restoring the temporal area in almost every patient, after seeing an amazing result from Bill Rassman, many years ago. It in fact adds to the hairline a real 3-D aspect. Presented in 2008.

Coronal Technique - Moving to the coronal sites and the small incisions made from the custom blades was love at the first site. I was missing an instrument that allows small incisions for a while. Not just density, the coronal technique ad sharp angles for the FUT that is especially valuable for the temporal area. Published in the Forum in 2006. Stick & Place - This is a Brazilian specialty. Introduced by the Brazilian pioneer Dr. Carlos Uebel, it adds many advantages to FUT as: speed, design/pattern control, less trauma, less bleeding, no missing holes, no piggy back. For sure there is a learning curve. Presented annually at the ISHRS whorkshops since 2005. Giga session - All the donor area aspects combined will aloud sessions of more than 4.000 FUs, and sometimes over 5.000 FUTs. Considering that most patients will need around 8.000 FUTs or less in total, this mission could be accomplished in maximum 2 sessions. I think this is more than reasonable for most.

FRiDAY ➤ sePTeMBeR 16, 20115:45AM-9:00AM; and 3:30PM-6:00PM


6:00AM-7:00AM Global Council of Hair Restoration Surgery Societies Meeting (invitation only)





6:30AM-8:30AM Continental Breakfast Generously supported by a grant from Merck

7:00AM-8:00AM Breakfast with the Experts

No extra fee. Open to all attendees on a first-come, first-served basis. This is an informal session for small groups to discuss a specific topic. Come with your questions. round banquet tables will be set in the back of the general session room. Each table will be labeled with a topic and expert’s name. Get your breakfast and then sit at the table of your choice to have “breakfast with an expert.”

LEArning obJECtivE:

• Discuss various hair restoration surgery topics in-depth in small groups.

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tAbLE toPiCs

1. Social Media Craig L. Ziering, Do

2. Eyelash Transplantation Alan J. bauman, MD

3. How to Train Your Staff Jennifer H. Martinick, Mbbs

4. Female Hair Loss and Treatment Matt L. Leavitt, Do

5. Flaps and Expanders sheldon s. Kabaker, MD

6. Trichophytic Closures: The Cream on the Cake Mario Marzola, Mbbs

7. Tissue Storage Solutions William M. Parsley, MD & William D. Ehringer, PhD

8. Use of Staining in Recipient Sites ron shapiro, MD & Muhammad nasir rashid, MD

9. Beard and Mustache Transplantation Mohmmad H. Mohmand, MD

10. How to Incorporate HRS into Your Current Practice Carlos J. Puig, Do

11. Mesotherapy silvana Franzini, MD

12. Electronic Medical Records-New U.S. Standards Marco barusco, MD

13. Surg Asst Topic: Infection Control MaryAnn Parsley, rn

14. Surg Asst Topic: Pre-Op & Post-Op Care Laureen gorham, rn

15. Japanese & English-speaking Table: Hairline Design in Male & Female; Prevention of Shock Loss; and Painless Anesthesia Kuniyoshi Yagyu, MD & steven Chang, MD

16. Spanish-speaking Table: Our Favorite Pearls in HT Surgery (Nuestras "Perlas" Favoritas en el Transplante de Pelo)Francisco Jimenez, MD, Alfonso barrera, MD, Alex Ginzburg, MD, Jose Lorenzo, MD, David Perez-Meza, MD

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8:15AM-9:00AM Female Hair Loss Moderator: Jerzy r. Kolasinski, MD, PhD

LEArning obJECtivE:

• Recognize variations in the management of hair loss in women.

8:15AM-8:17AM 058


Jerzy r. Kolasinski, MD, PhD

8:17AM-8:24AM

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7 Myths and tips for Female Hair Loss (Cosmetic Hair Loss)

Jorge gaviria, MD

8:24AM-8:31AM

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7 Follow up from the pilot study to Evaluate two independent Cohorts using the X chromosome weighted method of Ar-CAg genotype to identify Female Hair loss patients who are likely to respond to Anti Androgen therapy (Finasteride)

sharon A. Keene, MD

8:32AM-8:39AM

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7 Female Hair Loss: the Clinical role of Hair bundle Cross section trichometry

bernard P. nusbaum, MD

8:39AM-8:46AM

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7 Post-op shedding: Female vs Male, theories of Why?


8:46AM-9:00AM Q&A

9:05AM-10:00AM Advances in Hair Biology Moderator: bernard P. nusbaum, MD

LEArning obJECtivE: • Assess the latest developments in hair basic

science.

9:05AM-9:07AM 063



9:07AM-9:14AM

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7 study Update: growth stimulation of scalp Hair Follicles by Prostiglandins

Bessam K. Farjo, MBChB

9:14AM-9:21AM

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7 The Role of Inflammation and Immunity in Pathogenesis of Androgenetic Alopecia

neil s. sadick, MD

9:22AM-9:42AM

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20 ADvAnCEs in HAir bioLogY LECtUrEr

Regulation in Hair Disorders and Diseases Featured guest speaker: Marty E. sawaya, MD, PhD

Chief Medical Officer, InflamaCORE, University of Miami & the Miami Project to Cure Paralysis, Ocala & Miami, Florida, USA

The Advances in Hair Biology Lectureship is generously supported by a grant from BOSLEY.

9:42AM-10:00AM Q&A

10:00AM-10:30AM Coffee Break

10:30AM-11:20AM Medical and Non-Surgical TreatmentsModerator: Bessam K. Farjo, MBChB

LEArning obJECtivE: • Describe studies related to medical

treatments for androgenetic alopecia.

10:30AM-10:32AM 067



10:32AM-10:39AM

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7 A Report On “The Use Of Minoxidil that Makes Hair transplantation from impossible become Possible in the Poor Candidate”

Damkerng Pathomvanich, MD

10:39AM-10:46AM 069

7 Contraindications to Hair Loss Medications

Jeff Donovan, MD

10:47AM-10:54AM

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7 the Whole truth About PrL and its impact on the Hair Growth Cycle. Our Experience

silvana Franzini, MD

10:54AM-11:01AM

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7 Finasteride induced Mood Changes- Case reports and Literature review

Jorge gaviria, MD

11:01AM-11:08AM

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7 Low-Level Laser therapy for Androgenetic Alopecia: A 24-week randomized Double-blind Placebo Controlled trial

Chang-Hun Huh, MD, PhD

11:08AM-11:20AM Q&A

11:23AM-12:15PM Advanced Surgical HD Videos Moderator: vincenzo gambino, MD

LEArning obJECtivE: • Compare and contrast different surgeons’

approaches to various aspects of the hair transplant procedure.

11:23AM-11:25AM 073


vincenzo gambino, MD

11:25AM-11:31AM 074

6 viDEo: surgical transplantation of the Crown

vincenzo gambino, MD

11:31AM-11:37AM

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6 viDEo: My Preferred Method to Make the recipient sites: Evolution of former Method

Francisco Jimenez, MD

11:37AM-11:43AM

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6 viDEo: trichoscan Enhances Patient selection for hair transplantation

Jerzy r. Kolasinski, MD, PhD

11:43AM-11:49AM

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6 viDEo: throw Away Your Loupes: Plantation Under digital video Microscope

Sanjiv Vasa, MD

11:49AM-11:55AM

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6 viDEo: scoring – blunt dissection for Minimal transection Donor strip Harvesting with 0-1 Assistants and tools You Already own

Cam simmons, MD

11:55AM-12:01PM

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6 viDEo: transection rate Comparison of Combination vs. video Microscopic graft-Dissecting Method

Dae-Young Kim, MD, PhD

12:01PM-12:15PM Q&A

12:30PM-1:45PM Lunch Symposia 211, 212, 213 For all registered attendees except exhibitors. No extra fee required, but you must sign-up for the symposium of your choice during the registration process so we can properly plan for food and room size.

2:00PM-2:28PM

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Controversy: FUE vs. Strip Harvest FUT Moderator: William r. rassman, MD

Panelists:

Pro FUE tEAM:

Alan J. bauman, MD, Melike Kuelahci, MD, Ken L. Williams, Do, bradley r. Wolf, MD

Pro striP HArvEst tEAM:

Edwin suddleson, MD, Jonathan L. ballon, MD, Jerry Wong, MD

LEArning obJECtivE: • Compare and contrast the benefits and

drawbacks of follicular unit extraction versus strip harvest follicular unit transplantation.

2:00PM-2:02PM 080


William r. rassman, MD

2:02PM-2:07PM 081

5 Pro FUE, team leader presentation

Alan J. bauman, MD

2:08PM-2:13PM

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5 Pro strip Harvest FUt, team leader presentation

Edwin suddleson, MD

2:13PM-2:28PM Panel Discussion and Q&A

2:30PM-2:58PM Finasteride Adverse Events ControveriesModerator: Edwin s. Epstein, MD

Panel: Dow b. stough, MD, robert M. bernstein, MD, Ken Washenik, MD, PhD

LEArning obJECtivEs: • Describe recently FDA-added post-

marketing possible adverse events relating to the use of finasteride, including claims of persistent sexual dysfunction, concerns relating to prostate and breast cancer, and proposed theories that may explain these controversial adverse events.

• Properly inform your patients about these possible adverse events.

2:30PM-2:32PM 088


Edwin s. Epstein, MD

2:32PM-2:37PM

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5 Persistent Sexual Dysfunction Controversy/Case reports


2:38PM-2:43PM

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5 Persistent Sexual Dysfunction Controversy Data and Possible Explanations

Dow b. stough, MD

2:43PM-2:46PM 091

3 Prostate and breast Cancer


2:46PM-2:48PM 092

2 informed Consent issues

robert M. bernstein, MD

2:48PM-2:58PM Panel Discussion and Q&A

3:00PM-3:30PM Scientific Free Papers I Moderator: Sungjoo Tommy Hwang, MD, PhD

LEArning obJECtivE:

• Discuss various research projects on the subject of hair and how they may impact therapies or treatments for hair loss.

3:00PM-3:02PM 093


Sungjoo Tommy Hwang, MD, PhD

3:02PM-3:09PM

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7 Meta Analysis of All Hair transplant studies to Date

Michael L. beehner MD

3:09PM-3:16PM

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7 15 Years of Experience With the Use of Crosshatching surgical technique to improve naturalness of Hair transplantation

Matt L. Leavitt, Do

3:17PM-3:24PM

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7 Mastering Clinical Photography in Hair restoration surgery

robert s. Haber, MD

3:24PM-3:30PM Q&A

3:30PM-4:00PM Coffee Break & Poster Inquiry Session

4:00PM-4:45PM Body and Beard Used as Donor – Eyebrow & Eyelash TransplantsModerator: John P. Cole, MD

LEArning obJECtivE: • Discuss the results of a variety of free

papers and research on topics relating to the use of body and beard hair as donor, as well as surgical treatments of the eyebrow and eyelash.

4:00PM-4:02PM 097


John P. Cole, MD

4:02PM-4:09PM

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7 viDEo: one-Hour Eyebrow transplantation (rapid Placing 150 grafts in 10 min with Choi implanter)

Dae-Young Kim, MD, PhD

4:09PM-4:16PM 099

7 Hair Refinement Using Leg Hair

sanusi H. Umar, MD

4:17PM-4:24PM

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7 Case study of Clinical result of 4100 beard graft transplants to the scalp

James A. Harris, MD

4:24PM-4:31PM

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7 Eyebrow transplantation – Problems and outcomes

Melike Kulahci, MD

4:32PM-4:39PM

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7 Magnifying-aided High Density Eyelash transplantation

Weiming Jing, MD

4:39PM-4:55PM Q&A

5:00PM-5:45PM Scientific Free Papers II Moderator: Jorge gaviria, MD

LEArning obJECtivE: • Discuss various research projects on the

subject of hair and how they may impact therapies or treatments for hair loss.

5:00PM-5:02PM 103


Jorge gaviria, MD

5:02PM-5:09PM

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7 A simple Way to isolate and Cultivate Dermal Papilla Cells from Human scalp Hair Follicle

ratchathorn Panchaprateep, MD

5:09PM-5:16PM

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7 Management of Arrythmias and Updated guidlines for Perioperative b-blockade therapy

Kuniyoshi Yagyu, MD

5:17PM-5:24PM 106

7 vitamin D and Hair: should We Care?

nicole E. rogers, MD

5:24PM-5:31PM

107

7 Hair grafting in non-healing Chronic Leg Ulcers: A Pilot Clinical study


5:31PM-5:45PM Q&A

6:00PM-10:15PM Optional Group Excursion: Alaska Railroad Dinner Excursion Coach loads at 5:15PM at Hotel Captain Cook.

036

Breakfast with the Experts, Table Leader on the Topic of "Social Media" Craig L. Ziering, DO Ziering Medical, Beverly Hills, CA, USA.

CEO and Medical Director of Ziering Medical. Practicing Hair Restoration for 20 years.

C.L. Ziering: None.

037

Breakfast with the Experts, Table Leader on the Topic of "Eyelash Transplantation" Alan J. Bauman, MD Suite 102, Bauman Medical Group, Boca Raton, FL, USA.

Alan J. Bauman, MD received his MD degree from New York Medical College and served as a resident in Surgery at Beth Israel Medical Center and Mt. Sinai Medical Center in New York before specializing in Hair Restoration. He is the Medical Director of Bauman Medical Group located in Boca Raton, Florida since 1997. Dr. Bauman is a Diplomate of the American Board of Hair Restoration Surgery.

A.J. Bauman: None.

038

Breakfast with the Experts, Table Leader on the Topic of "How to Train Your Staff " Jennifer H. Martinick, MBBS Salvado Medical, Nedlands, Australia.

Dr Martinick is a past Program Chair of the ISHRS, past editor of Cyberspace Chat and currently serves as Vice President of the ISHRS. She is deeply committed to its mission of promoting the highest ethical standards in professional hair restoration. In 2003 she received the Platinum Follicle award, the society’s highest award for her contributions to the hair transplantation industry. She has gained international prominence for her studies on transected hair and devising the very natural looking snail track hairline. Dr Martinick has developed a Technician Training System. She is renowned for her restorative work.


039

Breakfast with the Experts, Table Leader on the Topic of "Female Hair Loss and Treatment" Matt Leavitt, DO 120 International Parkway, Medical Hair Restoration, Maitland, FL, USA.

Matt Leavitt, DO, FAOCD, is a Board-Certified Dermatologist and Diplomate of the ABHRS, of which he was a founder and vice president. He currently serves as ISHRS Chairman of the Live Workshop Committee and is the Chairman of the Live Workshop, now in its 18th year in 2012. He has been president of the American Osteopathic College of Dermatology and received numerous awards, chief among which is the Golden Follicle from the ISHRS which he received in 2002. Dr. Leavitt has authored numerous chapters in several textbooks on hair restoration and published a book on Hair Loss in Women.

M. Leavitt: None.

040

Breakfast with the Experts, Table Leader on the Topic of "Flaps and Expanders" Sheldon Kabaker, MD Oakland, CA, USA.

Dr. Kabaker is one of the founding members of the Board of Governors of the ISHRS and its 5th president. He was instrumental in introducing pedicle flap surgery, tissue expansion and surgical hairline lowering to the US hair transplant community . His present areas of interest and expertise are in hairline lowering, follicular unit hair transplantation and reconstructive scalp surgery with scalp expansion.

S. Kabaker: None.

041

Breakfast with the Experts, Table Leader on the Topic of "Trichophytic Closures" Mario Marzola, MBBS Norwood Day Surgery, Norwood, Australia.

Over 30 years of Hair Restoration, seeing all the changes in that time.

M. Marzola: None.

042

Breakfast with the Experts, Table Co-Leader on the Topic of "Tissue Storage Solutions" William Parsley, MD Parsley Waldman Hair Center, Louisville, KY, USA.

William M. Parsley, MD William Parsley, MD graduated from Univ of Tennessee Med School (1969) and completed Dermatology at the Univ of Louisville (1975). Past President- ISHRS ISHRS BOG and EC Past President of the ABHRS Past moderator of the Hair Transplantation Forum for the AAD Past BOT of the American Academy of Cosmetic Surgery Past Editor- Hair Transplant Forum International BOT- Hair Foundation. Past President- Kentucky Dermatologic Society Recipient of the ISHRS Golden Follicle Award (2003). Diplomate: Am Brd of Dermatology, Am Brd of Dermatopathology, ABHRS

W. Parsley: None.

043

Breakfast with the Experts, Table Co-Leader on the Topic of "Tissue Storage Solutions" William D. Ehringer, PhD Suite 104, University of Louisville, Louisville, KY, USA.

Associate Professor of Physiology, Biophysics, and Bioengineering, University of Louisville and Founder, VitaTech and Vital Solutions, LLC, Charlestown, Indiana, USA. Dr. Ehringer is a graduate of Indiana University, where he received his PhD in Medical Biophysics in 1993. Dr. Ehringer’s postdoctoral work in the area of human microcirculation from 1993- 1995 focused his interest in ischemia and potential interventions to combat this pathophysiological state.

W.D. Ehringer: None.

044

Breakfast with the Experts, Table Co-Leader on the Topic of "Use of Staining in Recipient Sites" Ronald Shapiro, MD 5270 West 84th Street, Bloomington, MN, USA.

Dr. Shapiro is founder of Shapiro Medical Group in Minneapolis, Minnesota, USA. He is on the Faculty of the Department of Dermatolgy at the University of Minnissotta and has beeen active in the field of Hair Restoration for over 20 years. In 2005 he recieved the Golden Follicle Award. He co-edited the 2005 and 2011 releases of the medical textbook,"Hair Transplantation". He served on the Board of Governors for the ISHRS for 8 years and currently serves on the Board for the ABHRS. He has published numerous articles on the subject of follicular unit hair transplantation and hairline design.

R. Shapiro: None.

045

Breakfast with the Experts, Table Co-Leader on the Topic of "Use of Staining in Recipient Sites" Muhammad N. Rashid, MBBS 60 - C MODEL TOWN, LAHORE, Pakistan.

Dr. Rashid is a member of the ISHRS. He introduced the most advanced method of Hair Transplant called NO TOUCH SURGERY which gives most NATURAL HAIRLINE with 0 % damage risk due to the use of a Special HAIR IMPLANTER DEVICE instead of forceps.He holds exclusive rights for this TECHNOLOGY.He has done Hair Transplant for all the leading Public figures & celebrities of Pakistan. He uses state of the art computerized Local Anaesthesia called Compumed.He is also the President of HAIR CLUB INTL, Pakistan's largest chain of Hair transplant clinics.

M.N. Rashid: Consultant/Advisory Board; Recipient Site Stain by Innovative Surgiquip.

046

Breakfast with the Experts, Table Leader on the Topic of "Beard and Mustache Transplantation" Mohammad H. Mohmand, MD International Laser Hair transplant surgery Center, Islamabad, Pakistan.

Dr. Humayun Mohmand is a Plastic Surgeon by speciality. He has been actively involved in the teaching of Hair Transplant surgery. He has been presenting his work at the ISHRS forum since 2002. He has been awarded the best technique of the year in 2006, he was selected as the Surgeon of the month in 2009. He runs a one to one hands on training courses on all aspects of hair transplant surgery including the FUE.

D.H. Mohmand: None.

047

Breakfast with the Experts, Table Leader on the Topic of "How to Incorporate HRS into Your Current Practice" Carlos J. Puig, DO Physicians Hair Restoration Center, Houston, TX, USA.

Since 1973 Dr. Puig has been actively involved in the practice of hair restoration surgery. A founding Member of the ISHRS, Dr Puig has presented papers and surgical demonstrations on many topics: diagnostic and surgical techniques, practice ethics, marketing, management and continuous quality improvement. Dr. Puig is a Fellow of the American Academy of Cosmetic Surgery, and the Diplomate, and a Past President of the American Board of Hair Restoration Surgery. Dr. Puig has served as chair of the ISHRS Fellowship Training Committee, Basic HRS Training Workshop, Board Review Programs, Core Curriculum Committee, and is currently the Treasurer if the ISHRS.

C.J. Puig: Independent Contractor (includes contracted research); Independent Consultant for Physicians Interested in Incorperating HRS into thier practice..

048

Breakfast with the Experts, Table Leader on the Topic of "Mesotherapy" Silvana Franzini, MD Hair Recovery, Buenos Aires, Argentina.

Silvana Franzini MD: Certified internal medicine, and certified cardiologist.

S. Franzini: None.

049

Breakfast with the Experts, Table Leader on the Topic of "Electronic Medical Records-New U.S. Standards" Marco N. Barusco, MD Tempus Hair Restoration, Port Orange, FL, USA.

Marco N. Barusco, MD is the founder and Medical Director of Tempus Hair Restoration in Port Orange, Florida. Serves as: ISHRS Workshop Committee, Examination Committee of the American Board of Hair Restoration Surgery (ABHRS), Chief Section Editor in Hair Restoration for the American Journal of Cosmetic Surgery (AJCS), Advisory Council of the American Society of Hair Restoration Surgery (ASHRS), teaching faculty for Expert to Expert Europe and expert consultant for REUTERS Insight, among others. Served as Co-Chair, Scientific Co-Chair and Scientific Coordinator in the various annual editions of the Orlando Live Surgery Workshop.

M.N. Barusco: None.

050

Breakfast with the Experts, Table Co- Leader on the Topic of "Surg Asst Topic: Infection Control" MaryAnn W. Parsley, RN Parsley Waldman Hair Center, Louisville, KY, USA.

Mary Ann Parsley is a registered nurse who has worked in the field of reconstructive surgery for over 30 years. She has lectured and demonstrated in workshops her skills of slivering, cutting and placing. She has attended all of the ISHRS meetings except for the first one.

M.W. Parsley: None.

051

Breakfast with the Experts, Table Leader on the Topic of "Surg Asst Topic: Pre-Op & Post-Op Care" Laurie Gorham, RN BOSLEY, Boston, MA, USA.

Laurie Gorham has been the National Nursing Manager for 5 years at Bosley and has been with the company for 15 years. She began her career in Hair Restoration in 1995 as a staff nurse in the Bosley Boston office. In 1998 she became the Clinical Supervisor of the Boston team and in 2005 assumed the role of the National Nursing Manager. She has lectured at the ISHRS meetings in San Diego, Las Vegas and Montreal and has been active in the Tissue Prep Team for the meetings in San Diego and Las Vegas.

L. Gorham: None.

052

Breakfast with the Experts, Table Leader on the Topic of "Japanese & English-speaking Table: Hairline Design in Male & Female; Prevention of Shock Loss; and Painless Anesthesia" Kuniyoshi Yagyu, MD 4-1 Kioicho, Chiyoda-ku, Kioicho Clinic, 7F New Otani Business Court, Tokyo, Japan. Kuniyoshi Yagyu, MD, has been exclusively practicing hair transplantation in Tokyo. He serves on the Board of Governors of the International Society of Hair Restoration Surgery. He is a Diplomate of the American Board of Hair Restoration Surgery, Past President and Board Governor of the Japan Society of Clinical Hair Restoration, and a Winner of the ISHRS Research Award in 2010. He has authored 44 research and clinical publications in books and journals. He had specialized in the field of cardiac surgery for 22 years. He is a board certified Cardiac Surgeon, Cardiologist and Respiratory Physician as well.

K. Yagyu: None.

053

Breakfast with the Experts, Table Co-Leader on the Topic of "Japanese & English-speaking Table: Hairline Design in Male & Female; Prevention of Shock Loss; and Painless Anesthesia" Steven C. Chang, MD 1000 Dove Street, # 250, Newport Beach, CA, USA.

Former Anesthesiologist. Believe safe and painless Anesthesia for hair transplantation is not difficulty to achieve.

S.C. Chang: None.

054

Breakfast with the Experts, Table Leader on the Topic of "Spanish-speaking Table: Our Favorite Pearls in HT Surgery (Nuestras “perlas” favoritas en el Trasplante de Pelo)” Francisco Jimenez, MD Angel Guimerá, 2, Las Palmas Gran Canaria, Spain.

Francisco Jimenez, MD is a dermatologist and hair transplant surgeon working in private practice in Las Palmas, Canary Islands, Spain. Dr. Jimenez is the author of more than 70 scientific articles and various chapters in textbooks, and has been coeditor of the Hair Transplant Forum Journal (2008-2010).

F. Jimenez: None.

055

Breakfast with the Experts, Table Leader on the Topic of "Spanish-speaking Table: Our Favorite Pearls in HT Surgery (Nuestras “perlas” favoritas en el Trasplante de Pelo)” Alfonso Barrera, MD 915 Gessner # 825, Houston, TX 77024, Houston, TX, USA.

He is a Clinical Assistant Professor of Plastic Surgery at Baylor College of Medicine in Houston, Texas. Dr. Barrera has been in private practice as a Plastic Surgeon in Houston, Texas since 1985 and has a unique practice now devoted exclusively to follicular unit hair transplantation and Aesthetic Plastic Surgery. He has lectured and presented extensively on state of the art hair transplantation techniques at major cosmetic surgery meetings around the world. He is a Diplomate of the American Board of Plastic Surgery and The American Board of Otolaryngology-Head & Neck Surgery.

A. Barrera: None.

056

Breakfast with the Experts, Table Leader on the Topic of "Spanish-speaking Table: Our Favorite Pearls in HT Surgery (Nuestras “perlas” favoritas en el Trasplante de Pelo)” Jose F. Lorenzo, MD Madrid, Spain.

Dr. Lorenzo born in the Canary Islands, Spain. Graduated in 1991 in the Universidad Complutense of Madrid. Diplomated in General Surgery in 1997. Exclusively practicing FUE Technique since 2003. Currently, he is the director of his own HT clinic in Madrid, injertocapilar.com

J.F. Lorenzo: None.

057

Breakfast with the Experts, Table Leader on the Topic of "Spanish-speaking Table: Our Favorite Pearls in HT Surgery (Nuestras “perlas” favoritas en el Trasplante de Pelo)” David Perez-Meza, MD Permanent Hair Solutions, Mexico City, Mexico.

Dr. Perez Meza is graduated from the Military Medical School in Mexico City. He specialized in Plastic and Reconstructive Surgery. He was an active member of the Presidential Medical Corps. He retired with Lt. Colonel Status in 1996 after serving in the Mexican Army for 26 years. He was trained in hair restoration surgery under Drs. Leavitt, Mayer and Ziering. In 2001, he was the first Hispanic Diplomate of the ABHRS. He has been active member of the ISHRS as speaker, moderator and Course Director. He had received nine Research Grant Awards. In 2007 he received the Platinum Follicle Award.


058

Moderator Introduction, Female Hair Loss Jerzy R. Kolasinski, MD, PhD Klinika Kolasinski - Hair Clinic Poznan, Swarzedz, Poland.

Dr. Jerzy Kolasinski, a member of the American Academy of Cosmetic Surgery, and American Society for Hair Restoration Surgery is the founder and director of Klinika Kolasinski Hair Clinic Poznan in Swarzedz, Poland. He is a Board member of the International Society of Hair Restoration Surgery. Dr. Kolasinski is an author of 100 articles and presentations concerning hair restoration surgery.

J.R. Kolasinski: None.

059

Myths and Tips for Female Hair Loss (Cosmetic Hair Loss) Jorge I. Gaviria, MD Gaviria & Trius Hair Transplant Surgery Center, Boca Raton, FL, USA.

Dr. Jorge Gaviria, is licensed to practice medicine and surgery in USA, Spain, Colombia and Puerto Rico, he is in private practices at the Gaviria & Trius Hair Transplant Surgery Center in Barcelona, Spain and Miami Beach, Florida. He has completed two accredited fellowship programs in Hair Restoration, both with world renowned physicians: Dr. Walter Unger and Dr. Matt Leavitt. Dr. Gaviria is the principal investigator and has authored several protocols, on the topics of: evidence based medicine, donor site closure, dense packing and survival rates, digital medical hair, and hair cloning.

J.I. Gaviria: None.

ABSTRACT: Fancy hairstyles, new hair colors, the latest procedures and new hair products, they all may look great but they are the source of irreversible hair damage, affecting the appearance and leading to hair loss. Myths: Female pattern baldness needs a comprehensive evaluation, from its different genetic origen to its subtle clinical manifestations. Real facts are presented to clarify some aspects of hair loss. Myth: Hair is a live organ Truth: Hair is a nonliving and does not heal itself once is damaged Myth: Hair has the capability to repair itself Truth: Hair does not have an auto repair capability and needs to grow again to be repair

Myth: Hair drying is safe and causes no hair damage Truth: Heat damages hair, wet hair when in touch with heat becomes steam creating hair bubbles Myth: Ceramic flat irons will straighten the hair without side effects Truth: Heat applied directly to hair will destroy its natural moisturizers and become dull in appearance Myth: Keratin hair straighten the hair in a safe way Truth: Combining chemicals and heat using keratin with gluteraldehyde or formaldehyde will damage hair Myth: Hair wash done daily will injured hair Truth: Hair and scalp need to get clean on a daily basis. Myth: All shampoos are made equal Truth: Shampoos are made for different hair conditions, shapes and types. Myth: Will special diets and oil treatments make my hair look lustrous Truth: No special diets needed unless you have gastric bypass surgery or dietary deficiencies Myth: Stress triggers hair loss Truth: Yes, stress exacerbates or triggers hair loss Myth: Excess androgens or hormones causes hair loss Truth: Yes, androgens and hormones causes hair loss Tips for women with hair loss /Practical tips on how to avoid hair loss Tips: Avoid hair tints that contain ammonia Cover your hair while swimming in a pool or avoid it Use microhighlites instead of highlights Hair cut should be done in layers Avoid using direct heat to your hair and blow drying Do not touch scalp while tinting No capillary treatments with greasy products Clean your hair and scalp on a daily basis Control greasy scalp with special serums Use conditioners to improve hair appearance and reduce tangling Dimethicone in hair products gives a shine look and easy manageability Avoid pulling your hair and rubbing your scalp Do not use pony tails or tie backs

060

Follow up from the pilot study to Evaluate Two Independent Cohorts using the X chromosome weighted method of AR-CAG Genotype to Identify Female Hair loss patients who are likely to respond to Anti Androgen Therapy (Finasteride) Sharon A. Keene, MD Tucson, AZ, USA.


S.A. Keene: None.

ABSTRACT: Background: Last year results of a 6 month pilot study regarding the use of Androgen Sensitivity (Androgen Receptor Genotype using X weighted CAG repeat number)to identify female patients with hair thinning who would respond to finasteride, indicated an association between greater androgen sensitivity and finasteride response. However, additional patient numbers were needed to confirm this association. Since that time a second published study has been reported in the medical literature on a female cohort in Japan that reportedly identified finasteride responders, but was unable to confirm an association with CAG repeat numbers (androgen sensitivity), but also did not use a weighted method to determine which of the X alleles was activated. Additional limitations of that study will be reviewed (lack of hair counts in their response assessment). Furthermore, 2 additional patient cohorts are being currently evaluated, independently, using the method of X weighting in order to insure that androgen sensitivity is most accurately assessed, and whether this can be used to predict which women will benefit from finasteride treatment. Finally, data will be presented to compare the DNA of buccal mucosa with hair follicle DNA to determine if there is concordance in allele activation between androgen target tissues(hair follicles) and non androgen target tissues (buccal mucosa). Results/conclusion: Data gathering is underway and final results will be available by August

061

Female Hair Loss: The Clinical Role of Hair Bundle Cross Section Trichometry Bernard P. Nusbaum, MD Hair Transplant Institute of Miami, Coral Gables, FL, USA.

Past President, American Board of Hair Restoration Surgery Board of Governors, International Society of Hair Restoration Surgery Co-Editor Hair Transplant Forum International

B.P. Nusbaum: None.

ABSTRACT: Introduction: The evaluation of females with hair loss can be confusing and time consuming. By using bundle cross section trichometry (BXST), important diagnostic parameters can be rapidly established and measured. Objective: BXST was added to the routine protocol that we use for evaluating women with hair loss Material and Methods: On initial visit, the medical history, gross scalp exam, photography, video microscopy, pull test, etc. were all performed as usual. In addition, the hair bundle cross section (Hair Mass Index) was measured in the occipital and mid-scalp region of each patient. The two values were compared. A working diagnosis was rapidly established and only the appropriate blood work and additional testing were performed. Discussion: With BXST we were able to quickly establish the following: - Differentiation between pattern (AGA) and diffuse (shedding) hair loss - The actual severity of the hair loss - The presence of significant hair breakage contributing to the loss On the basis of these findings, appropriate, and non-wasteful blood work was ordered. The baseline BXST parameters were of significant value on return visits because we could easily determine if the condition had improved, worsened, or remained stable. Conclusion: By adding BXST to our routine female hair loss evaluations, we discovered that we could often arrive at a working diagnosis on the first visit. We were able to track the patient’s progress and detect changes that would have not been seen using photography. We could determine how effectively treatments like minoxidil, laser, spironolactone, iron supplement, thyroid supplement, biotin, etc. were working. The continued activity or stabilization of telogen affluvium could be easily established. Those patients with significant breakage were identified and given educational material for proper hair care habits, and referred to salons for appropriate restorative treatments. Because the BXST measurement was performed by a medical assistant, its addition to our protocol required no additional physician time.

062

Post-Op Shedding: Female vs Male, Theories of Why? Nilofer P. Farjo, MBChB Farjo Medical Centre, Manchester, United Kingdom.

Nilofer Farjo has been exclusively performing hair restoration since 1993 in Manchester, UK. She is a member of the ISHRS, Member of the Fellowship Training Committee, Co-editor of the Forum International and diplomat of the American Board of Hair Restoration Surgery. Nilofer is the immediate past President and founder member of the British Association of Hair Restoration Surgeons, Fellow of the Institute of Trichologists, past President of The Trichological Society and member the European Hair Research Society. She currently works with three universities and one public company on basic hair sciences projects.

N.P. Farjo: None.

ABSTRACT: Postoperative shedding or shock loss is anagen effluvium which is temporary or permanent loss of hair that is in the anagen phase of the hair growth cycle as a result of an operative procedure. Here we discuss the theories on causative mechanisms of this shedding following hair transplantation and look at the differences in incidence between female and male patients. Although there is a lack of literature on this subject there are common strategies that are used by hair restoration surgeons to prevent the occurrence of this common post operative complication. These preventative measures are based on the following causes¹: direct mechanical injury chemical injury dense packing tissue response to injury peri-operative disruption of hair loss maintenance medications Based on these concepts preventative measures used include: 1.making incisions that avoid native hairs using tumescence and depth control to avoid disruption to deep vasculature using minimal possible doses of anaesthetic and vasoconstrictive medications avoiding drug usage wherever possible directly in the recipient areas but instead use field blocks avoid dense packing in areas not completely bald using intralesional steroid to decrease tissue response continue hair loss medications prior to surgery. Only stop minoxidil for a short period after surgery and continue with finasteride throughout. commence hair loss medications at least one month prior to surgery. Occurrence rates are difficult to determine because of the lack of scientific data on this subject. However, it is generally agreed that it is a common clinical problem 1,2 with a higher incidence in those patients with thinning/miniaturizing hair and is especially prominent in women. References: True R, Dorin R. A Protocol to Prevent Shock Loss. Hair Transplant Forum International 2005 (Nov/Dec);15(6) Shiell,R. Notes from the Editor Emeritus. Hair Transplant Forum International 2002 (March/April); 12(2).

Post operative effluvium/shock

loss

Nilofer Farjo, MBChB

Manchester UK

Definition

• anagen effluvium which is temporary or

permanent loss of hair that is in the anagen phase of the hair growth cycle as

a result of an operative procedure.

• Causes

• Prevention

• Incidence

– Male vs Female

Mechanism

• direct mechanical injury

• chemical injury

• dense packing

• tissue response to injury

• peri-operative disruption of hair loss maintenance medications

Prevention

• making incisions that avoid native hairs• using tumescence to avoid disruption to deep

vasculature• using minimal possible doses of anaesthetic and

vasoconstrictive medications• avoiding drug usage wherever possible directly in the

recipient areas but instead use field blocks• avoid dense packing in areas not completely bald• using intralesional steroid to decrease tissue response• continue hair loss medications prior to surgery. Only

stop minoxidil for a short period after surgery and continue with finasteride throughout.

• commence hair loss medications at least one month prior to surgery

Incidence

• lack of scientific data

• generally agreed that it is a common

clinical problem with a higher incidence in

those patients with thinning/miniaturizing hair and is especially prominent in women.

• “50% female patients” (W.Unger)

References

• True R, Dorin R. A Protocol to Prevent

Shock Loss. Hair Transplant Forum

International 2005 (Nov/Dec);15(6)

• Shiell,R. Notes from the Editor Emeritus. Hair Transplant Forum International 2002

(March/April); 12(2).

063

Moderator Introduction, Advances in Hair Biology Bernard P. Nusbaum, MD Coral Gables, FL, USA.

Dr. Nusbaum has been widely published in the fields of dermatology and hair transplantation and has been extremely active in research and professional societies. He is in demand as a lecturer and has presented numerous programs, research findings, and clinical reports at medical conferences.

B.P. Nusbaum: None.

064

Study Update: Growth Stimulation of Scalp Hair Follicles by Prostaglandins Karzan Khidhir, PhD1, Nilofer Farjo, MBChB2, Bessam Farjo, MBChB2, David Woodward, PhD3, Valarie Randall, PhD1 1University of Bradford, Bradford, United Kingdom, 2Farjo Medical Centre, Manchester, United Kingdom, 3Allergan, Irwin, CA, USA.

Bessam Farjo, MBCHB, graduated in 1988 from the Royal College of Surgeons in Ireland. After general surgery training, in 1993, he trained in hair surgery in Canada and co-founded the Farjo Medical Centre in Manchester and London exclusively practicing hair restoration surgery. Past President of ISHRS (07-08), Past President and co-founder of the British Association of Hair Restoration Surgeons, Diplomate and Board Director of the American Board of Hair Restoration Surgery, Fellow, Board Governor & Medical Director of the Institute of Trichologists, Fellow of the International College of Surgeons.

K. Khidhir: None. N. Farjo: None. B. Farjo: None. D. Woodward: Employment; Researcher. V. Randall: Research Grant (principal investigator, collaborator or consultant); Investigator.

ABSTRACT: Introduction: A prostaglandin F2α analogue, bimatoprost, used as a treatment for patients with glaucoma (ocular hypertension) stimulated eyelash growth as a side effect. This is licenced in the USA for eyelashes under the name, latisse. Our original study in 2008 showed human hair follicles responded positively to in vitro stimulation by PGF2α, and contain target receptors for bimatoprost which would allow them to respond directly to the drugs. In order to prove direct action by the drug, the study was repeated after adding a PGF2α antagonist agent.

Objective: To confirm that the stimulatory effects of PGF2α are working via PGF2α receptors (FP) by demonstrating that these effects are blocked by an antagonist to FP. Materials & method: Occipital and parietal scalp skin samples were collected and the hair follicles were individually microdissected and pooled for each sample and poly(A) RNA extracted. RT-PCR was performed to detect the prostanoid FP receptor gene in the human hair follicle. RT-PCR analysis showed expression of the appropriate sized product, 1080bp for the prostanoid FP receptor gene, and sequence analysis showed 99% homology with the expected gene sequence. Isolated follicles were also incubated within 4 groups constituting Vehicle control, PGF2α , PGF2α + FP antagonist and FP antagonist on its own. Discussion/results: We previously demonstrated that RT-PCR analysis showed expression of the appropriate sized product, 1080bp for the prostanoid FP receptor gene, and sequence analysis showed 99% homology with the expected gene sequence. Human hair follicles also showed significant in vitro improvement in terms of prolonged anagen phase, faster growth rate and total hair shaft length. The introduction of the FP antagonist has now showed significant abolition of all stimulatory effects of PGF2α on scalp hair follicles. Conclusion: Scalp hair follicles respond biologically to PGF2α in a dose-responsive manner in organ culture, while FP antagonist blocked the stimulatory effects of PGF2α. Also isolated scalp hair follicles express the PGF2α receptor gene. This suggests that PGF2α can act on receptors within human hair follicles to stimulate growth.

065

The Role of Inflammation and Immunity in the Pathogenesis of Androgenetic Alopecia Neil S. Sadick, MD Sadick Aesthetic Surgery and Dermatology, New York, NY, USA.

Dr. Sadick holds five board certifications in internal medicine, dermatology, cosmetic surgery, hair restoration surgery and phlebology. Dr. Sadick is one of the world’s most respected dermatologists and the medical director and owner of Sadick Dermatology with locations on Park Avenue in New York City and Great Neck, Long Island. Dr. Sadick is also the director of the Sadick Research Group, which runs multiple FDA clinical trials each year.

N.S. Sadick: Research Grant (principal investigator, collaborator or consultant); Histogen. Speakers Bureau/Honoraria (speakers bureau, symposia, and expert witness); Histogen.

ABSTRACT: Female pattern hair loss affects many women; its pathogenetic basis has been held to be similar to men with common baldness. 52 women with androgenetic alopecia (AA) underwent scalp biopsies for routine light microscopic assessment and direct immunofluroescent studies. In 18 patients serologic assessment for antibodies to androgen receptor, estrogen

receptor and cytokeratin 15 was conducted. A lymphocytic folliculitis targeting the bulge epithelium was observed in many cases. Thirty-three of 52 female patients had significant deposits of IgM within the epidermal basement membrane zone consistent with a positive lupus band test. Biopsies from men with androgenetic alopecia showed a similar pattern of inflammation and immunoreactant deposition. The serologic assessment for antibodies to androgen receptor, estrogen receptor or cytokeratin 15 were negative. A lymphocytic microfolliculitis targeting the bulge epithelium along with deposits of epithelial basement membrane zone immunoreactants are frequent findings in androgenetic alopecia and could point toward an immunologically driven trigger.

The Role of Inflammation and The Role of Inflammation and Immunity in the Pathogenesis of Immunity in the Pathogenesis of

Androgenic AlopeciaAndrogenic Alopecia

Neil Sadick MDNeil Sadick MD FAAD FAACS FACP FACPhFAAD FAACS FACP FACPhNeil Sadick, MD, Neil Sadick, MD, FAAD, FAACS, FACP, FACPhFAAD, FAACS, FACP, FACPh

Clinical Professor Department of Dermatology Weill Medical College of Cornell University

Cynthia Magro, MDCynthia Magro, MD

Professor of Pathology and Laboratory MedicineDirector of Dermatopathology

Weill Medical College of Cornell University

BackgroundBackgroundMale AGA Female Pattern Hair Loss (FPHL)

AGA etiology is hormonal alteration of hair cycle –• ↑ 5-α-reductase in the hair follicle = ↑ levels of DHT • DHT binds to follicular based AR and results in ↓ of the anagen phase

FPHL is multifactorial – anti-androgen therapy is not as efficacious as in AGA

BackgroundBackgroundMale Androgenic Alopecia Female Pattern Hair Loss

presentation frontoparietal / vertex diffuse in centroparietal regions

classification Norwood Ludwig

genetics

polygenic: Xq12 - androgen receptor20p11 - P450 aromatase

3q26 - familial component

polygenic: not established; androgen receptor not a biomarker

Hair follicle is an endocrine Multifactorial;

pathophysiology

Hair follicle is an endocrine target: ↑ central / peripheral

androgens and androgen sensitivity

Multifactorial; androgen elevation and increased sensitivity not seen in all patients

histopathology

Follicular miniaturization ↓ Terminal : Vellus ratio ↓ Anagen : Telogen ratio microinflammation and

perifollicular fibrosis

Follicular miniaturization ↓ Terminal : Vellus ratio ↓ Anagen : Telogen ratio microinflammation and

perifollicular fibrosis

immunoreactant deposition unknown unknown

Materials and MethodsMaterials and Methods Review of 52 female subjects with clinical diagnosis of non Review of 52 female subjects with clinical diagnosis of non

scarring AGA/FPHLscarring AGA/FPHL•• 2X 4 mm punch biopsies of scalp (H&F,DIF)2X 4 mm punch biopsies of scalp (H&F,DIF)•• Retained frontal hairline with frontoparietal thinningRetained frontal hairline with frontoparietal thinning•• All other etiologies of alopecia were ruled outAll other etiologies of alopecia were ruled out

Controls: 10 female (nonControls: 10 female (non--FPHL) and 7 male (AGA)FPHL) and 7 male (AGA)

Laboratory / Histology EvaluationLaboratory / Histology Evaluation•• CBC, DHEAS, FT, ANA, TSH, free T4, free T3, Ferritin, RPRCBC, DHEAS, FT, ANA, TSH, free T4, free T3, Ferritin, RPR•• H&E light microscopyH&E light microscopy•• DIF (rabbit antiDIF (rabbit anti--human fluoresceinhuman fluorescein--conjugated monoclonal conjugated monoclonal

antiodies)antiodies) C3, C3d, C4d, C5bC3, C3d, C4d, C5b--99 IgA, IgG, IgMIgA, IgG, IgM

Materials and MethodsMaterials and Methods All 52 subjects separated into 2 distinct groups of :All 52 subjects separated into 2 distinct groups of :

Positive Lupus Band Test (‘+’ LBT) Positive Lupus Band Test (‘+’ LBT) VsVs Negative Lupus Negative Lupus Band Test (‘Band Test (‘--’ LBT)’ LBT)

‘ ’ LBT i ifi t i d it l th DEJ‘ ’ LBT i ifi t i d it l th DEJ ‘+’ LBT = significant immunodeposits along the DEJ‘+’ LBT = significant immunodeposits along the DEJ

Materials and MethodsMaterials and Methods‘+’ Lupus Band Test ( 33/52 subjects)‘+’ Lupus Band Test ( 33/52 subjects)

Age range 24Age range 24--82 (mean 55.1 years)82 (mean 55.1 years)

Hair loss Hair loss –– diffuse in 32/33, localized frontal accentuation in 1diffuse in 32/33, localized frontal accentuation in 1

Ludwig classification:Ludwig classification: Ludwig classification:Ludwig classification:

•• Mild Mild –– 44•• Moderate Moderate –– 2222•• Severe Severe –– 77

Duration of loss 1.0 years Duration of loss 1.0 years –– 50 years (mean 9.35 years)50 years (mean 9.35 years)

21/33 + family history of genetic hair loss21/33 + family history of genetic hair loss

Materials and MethodsMaterials and Methods‘‘--’ Lupus Band Test (19/52 subjects)’ Lupus Band Test (19/52 subjects)

Age range 23Age range 23--82 (mean 46.6 years)82 (mean 46.6 years)

Hair loss Hair loss –– diffuse in 17/19, localized frontal parietal in 2diffuse in 17/19, localized frontal parietal in 2

Ludwig classification:Ludwig classification: Ludwig classification:Ludwig classification:

•• Mild Mild –– 55•• Moderate Moderate –– 1212•• Severe Severe –– 22

Duration of loss 2 months Duration of loss 2 months –– 25 years (mean 7.17 years)25 years (mean 7.17 years)

17/19 + family history of genetic hair loss17/19 + family history of genetic hair loss

Serology of Immune Based Serology of Immune Based TargetsTargets

In addition, 18 patients with classic AA underwent In addition, 18 patients with classic AA underwent serologic assessment for antibodies to :serologic assessment for antibodies to :

•• Androgen receptorsAndrogen receptors –– localized to this area and localized to this area and involved in hair cyclinginvolved in hair cycling

•• Estrogen receptor Estrogen receptor ββ –– influences AR function and influences AR function and transition to anagen and expressed in follicletransition to anagen and expressed in follicle

•• Cytokeratin 15Cytokeratin 15 –– expressed in portion of HF that expressed in portion of HF that exhibits targeted inflammationexhibits targeted inflammation

Treatment ProtocolTreatment Protocol Determined by levels of hair loss classification ie. Determined by levels of hair loss classification ie.

inflammatory diffuse FPHL vs noninflammatory diffuse FPHL vs non--inflammatory diffuse FPHLinflammatory diffuse FPHL

The dosing of the medication and the amt of RLT was The dosing of the medication and the amt of RLT was standardized for each patientstandardized for each patient

•• Minoxidil 5%Minoxidil 5% -- applied twice daily applied twice daily

OROROROR

•• Minoxidil 5% additionalMinoxidil 5% additional Retinoic Acid 0.025%Retinoic Acid 0.025% --applied twice daily applied twice daily

•• additional additional Betamethasone 0.05%Betamethasone 0.05% -- applied twice dailyapplied twice daily

•• additional additional red light LED therapyred light LED therapy (RLT) (RLT) –– once/wk for 8 once/wk for 8 wks then once a month wks then once a month

•• additional titrated dosages of 50 mg to 250 mg/day oral additional titrated dosages of 50 mg to 250 mg/day oral SpironolactoneSpironolactone –– once dailyonce daily

Treatment ProtocolTreatment ProtocolTx determined on the severity of hairloss based on levels of Tx determined on the severity of hairloss based on levels of

hair loss classification for each individual patient, ie. non hair loss classification for each individual patient, ie. non inflammatory diffuse FPHL vs inflammatory diffuse FPHLinflammatory diffuse FPHL vs inflammatory diffuse FPHL

Non Inflammatory diffuse FPHLNon Inflammatory diffuse FPHL Minoxidil + Retinoic AcidMinoxidil + Retinoic Acid +/+/-- Red Light Therapy Red Light Therapy +/+/-- SpironolactoneSpironolactone

Inflammatory diffuse FPHLInflammatory diffuse FPHL Minoxidil +/Minoxidil +/-- Retinoic AcidRetinoic Acid BetamethasoneBetamethasone +/+/-- Red Light TherapyRed Light Therapy

Results Results –– Light MicroscopyLight Microscopy

All cases showed typical changes of AGAAll cases showed typical changes of AGA

•• ↓↓ of terminal/vellus hair ratio, elastotic fibrous tracts, some degree of of terminal/vellus hair ratio, elastotic fibrous tracts, some degree of involutioninvolution

40/52 showed focal lymphocytic folliculitis40/52 showed focal lymphocytic folliculitis40/52 showed focal lymphocytic folliculitis40/52 showed focal lymphocytic folliculitis

•• Inferior portion of the infundibulum, superficial isthmus, follicular Inferior portion of the infundibulum, superficial isthmus, follicular bulge epithelium, germinative epithelium, and the trochanteric bulgebulge epithelium, germinative epithelium, and the trochanteric bulge

•• Reaction concentrated around main repository of stem cells critical to Reaction concentrated around main repository of stem cells critical to formation of new anagen hair formation of new anagen hair –– may be of pathological significancemay be of pathological significance

•• T cell nature of infiltrate was highlighted by CD3 stainT cell nature of infiltrate was highlighted by CD3 stain

Postulate Postulate –– lymphocytic follicular reaction may alter lymphocytic follicular reaction may alter dynamics of hair cyclingdynamics of hair cycling

Light Microscopy ResultsLight Microscopy Results

Classic histologic changes of Androgenetic Alopecia: miniaturized hairs and elastotic tracts


The biopsy shows a lymphocytic folliculitis (arrow is at a site of inflammation). Lymphocytes appear to preferentially target the superficial isthmic region of the follicle in the region of the stem cell repository (i.e. bulge epithelium)

Arrow at bulge epithelium in the region Of the superficial isthmus)


Bulge epitheliumwith admixed lymphocytes

Lymphocytes permeate the “trochanteric” bulge epithelium in the superior isthmic region the follicle, the putative source of new anagen hairs

CD3 - a PAN T cell marker in the region of the sebaceous gland, (another site of lymphocyte infiltration)

Results Results –– Light MicroscopyLight MicroscopyOut of the 40/52 patients demonstrating lymphocytic Out of the 40/52 patients demonstrating lymphocytic

perifolliculitis, perifolliculitis, 7 showed perifollicular fibroplasia localized to the 7 showed perifollicular fibroplasia localized to the

superior isthmic portion of the hair follicle superior isthmic portion of the hair follicle corresponding to the sites of follicular inflammationcorresponding to the sites of follicular inflammation

Perifollicular fibroplasia correlates with the severity of Perifollicular fibroplasia correlates with the severity of h i l hi t l i llh i l hi t l i llhair loss histologicallyhair loss histologically

Perifollicular fibrosis

Results Results –– DIFDIF 33/52 granular deposits of IgM along DEJ and follicular BMZ 33/52 granular deposits of IgM along DEJ and follicular BMZ

to qualify for a +Lupus Band Test (LBT)to qualify for a +Lupus Band Test (LBT)

•• All 33 also demonstrated significant deposits of C5bAll 33 also demonstrated significant deposits of C5b--9 9 along DEJ and other components of complement along DEJ and other components of complement activationactivation

IgG / IgA were not observedIgG / IgA were not observed

52/52 Negative ANA52/52 Negative ANA

A positive LBT of pure IgM isotype is not specific for LE but A positive LBT of pure IgM isotype is not specific for LE but strongly correlated with underlying autoimmune diathesis. strongly correlated with underlying autoimmune diathesis. •• SLE/DLE = all three classes of Ig along the DEJ rather SLE/DLE = all three classes of Ig along the DEJ rather

than IgM in isolation than IgM in isolation

19/52 19/52 -- focal IgM and C5bfocal IgM and C5b--9 along DEJ was noted but not 9 along DEJ was noted but not sufficient to warrant designation as a positive LBTsufficient to warrant designation as a positive LBT

Results Results –– DIFDIF

IgM along the DEJIgM within the BMZ of the

Hair follicle

This specific DIF profile appears to be part of routine histologic findings in FPHL

In addition to the lymphocytic folliculitis seen under H&E, immunologically driven inflammation could be of pathogenetic significance

Controls Controls

10 female control alopecia cases10 female control alopecia cases –– other established other established etiologies, 4 with Discoid Lupus Erythematosus (DLE)etiologies, 4 with Discoid Lupus Erythematosus (DLE)

•• All underwent DIFAll underwent DIF•• +LBT in all LE cases, nonspecific immunoreactant profile in +LBT in all LE cases, nonspecific immunoreactant profile in

other casesother cases

7 male control cases with classic AGA, no different 7 male control cases with classic AGA, no different than FPHL suggesting a similar pathogenesisthan FPHL suggesting a similar pathogenesis

•• 5/7 cases showed +LBT of IgM isotype with significant 5/7 cases showed +LBT of IgM isotype with significant deposits of C5bdeposits of C5b--99

DIF Results and FPHL SeverityDIF Results and FPHL Severity Cases with more extensive deposits of IgM within the BMZ had Cases with more extensive deposits of IgM within the BMZ had

increased severity of FPHL, i.e. greater tendency toward involution increased severity of FPHL, i.e. greater tendency toward involution and hair miniaturization in cases with +LBTand hair miniaturization in cases with +LBT

•• Terminal to vellus hair ratio Terminal to vellus hair ratio –– normal cutnormal cut--off is 8:1off is 8:1 + LBT 3.84 : 1+ LBT 3.84 : 1 -- LBT 3.88 : 1LBT 3.88 : 1

+ LBT has traditionally been associated with nuclear based + LBT has traditionally been associated with nuclear based antigen of epithelial derivation bound to antibodyantigen of epithelial derivation bound to antibody

The epithelial structures targeted in FPHL include bulge The epithelial structures targeted in FPHL include bulge epithelium, sebaceous cells including the precursor germinative epithelium, sebaceous cells including the precursor germinative cellscells

Estrogen Receptor (ER)Please note staining of the germinative epithelial cells of the sebaceous gland (nuclear stains brown)

ER expression is in the germinative sebaceous gland epithelium and hair bulge.

Androgen Receptor (AR)Please note the staining of the mature sebaceous cells (nucleusstains brown)

AR is expressed in the sebaceouscells, germinative epithelium of the sebaceous gland and the hair papillae

Results of Western Blot for Results of Western Blot for Immune Based TargetsImmune Based Targets

In addition 18 subjects with classic features of In addition 18 subjects with classic features of AA were assessed:AA were assessed:

No immunoreactivity was detected to cytokeratin 15, No immunoreactivity was detected to cytokeratin 15, estrogen receptor, and or androgen receptorestrogen receptor, and or androgen receptor

4/5 had good response to standardized tx 4/5 had good response to standardized tx protocolprotocol

Results Post TreatmentResults Post Treatment‘+’ LBT‘+’ LBT 25/33 subjects 25/33 subjects –– marked decrease in shedding on marked decrease in shedding on Tx ProtocolTx Protocol

•• 7/25 patients in addition to shedding experienced 7/25 patients in addition to shedding experienced regrowthregrowth

7 pts not responding to tx had a reduction in the terminal to vellus 7 pts not responding to tx had a reduction in the terminal to vellus ratio of 3:1ratio of 3:1

‘‘--’ LBT’ LBT 11/1911/19 subjectssubjects -- marked decrease in shedding on marked decrease in shedding on Tx ProtocolTx Protocol

•• 2/11 patients in addition to shedding experienced 2/11 patients in addition to shedding experienced regrowthregrowth

7 pts not responding to tx had a reduction in the terminal to vellus 7 pts not responding to tx had a reduction in the terminal to vellus ratio of 3:1ratio of 3:1

STATISTICAL RELEVANCE : “+” LBT subjects had STATISTICAL RELEVANCE : “+” LBT subjects had a greater response to Tx protocol (p=0.039)a greater response to Tx protocol (p=0.039)

ConclusionsConclusions Critical events summaryCritical events summary

1. Superficial folliculitis targeting bulge epithelium1. Superficial folliculitis targeting bulge epithelium2. Basis of inflammation is likely triggered by antigen in 2. Basis of inflammation is likely triggered by antigen in

inflamed portion of follicleinflamed portion of follicle3. Inflammation interferes with repository of cells that 3. Inflammation interferes with repository of cells that

normally differentiate into anagen hairnormally differentiate into anagen hairnormally differentiate into anagen hairnormally differentiate into anagen hair

63% cases showed significant immunoreactant deposits 63% cases showed significant immunoreactant deposits •• Prominent IgM / complement activation within the Prominent IgM / complement activation within the

epidermal and follicular BMZepidermal and follicular BMZ•• Findings equivalent to + LBTFindings equivalent to + LBT•• IgM / complement within DMJ correlates to more IgM / complement within DMJ correlates to more

advanced AGAadvanced AGA

ConclusionsConclusions We show that lymphocytic folliculitis is a very common We show that lymphocytic folliculitis is a very common

finding in FPHL (40/52) finding in FPHL (40/52) •• Appears in superficial region Appears in superficial region –– follicular bulge, follicular bulge,

germinative epitheliumgerminative epithelium•• Perifollicular fibrosis is the presumptive sequelae of Perifollicular fibrosis is the presumptive sequelae of

lymphocytic reactionlymphocytic reaction

Partial etiology of FPHL attributable to immune drivenPartial etiology of FPHL attributable to immune driven Partial etiology of FPHL attributable to immune driven Partial etiology of FPHL attributable to immune driven inflammationinflammation•• Incipient phase Incipient phase –– distinctive superficial lymphocytic distinctive superficial lymphocytic

folliculitisfolliculitis May interfere with stem cell entry into anagen or May interfere with stem cell entry into anagen or ↓↓

anagen durationanagen duration Possibly targeting basilar sebocytes, bulge epitheliumPossibly targeting basilar sebocytes, bulge epithelium The precise localization of folliculitis implies a very The precise localization of folliculitis implies a very

select antibody targetselect antibody target

ConclusionsConclusions The combination of lymphocytic folliculitis and deposits of The combination of lymphocytic folliculitis and deposits of

IgM / C5bIgM / C5b--9 suggest an immunologically driven process 9 suggest an immunologically driven process possibly due to a follicular based antigenpossibly due to a follicular based antigen

No concrete hypothesis for exact basis of lymphocytic No concrete hypothesis for exact basis of lymphocytic microinflammationmicroinflammation

d f dd f d•• Antigen target not yet identifiedAntigen target not yet identified•• Inflammation in bulge region Inflammation in bulge region –– location known to location known to

contain estrogen receptor contain estrogen receptor ββ

Determinant in response to tx :Determinant in response to tx :•• The cases with the positive LBT had a tendency toward The cases with the positive LBT had a tendency toward

a greater involutional tendency however the severity of a greater involutional tendency however the severity of the hair loss was not greaterthe hair loss was not greater

Treatment Treatment –– Clinical ResultClinical Result

Post 8 Tx : Patient treated with Minoxidil 5%, Diprolene lotion 0.05% and OmniLux Red Light LED

POST 7 Tx : Ominlux Red Light – Combination of Minoxidil 5% with Retinoic Acid 0.025% POST 8 Tx : Omnilux Red Light, Minoxidil 5% , Betamethasone 0.05%

066

Regulation in Hair Disorders and Diseases Mary (Marty) E. Sawaya, MD, PhD University of Miami School of Medicine, Ocala, FL, USA.

Marty E. Sawaya, MD, PhD Dr. Sawaya obtained PhD in Biochemistry in 1983, and MD in 1986 from the University of Miami School of Medicine. Completing internship and postdoctoral training, she joined the faculty at the University of Miami’s Departments of Dermatology & Biochemistry, with dermatology residency training at SUNY Brooklyn, and University of Florida in 1996. For over 30 years Dr. Sawaya has published extensively in steroid biochemistry in skin, especially the androgen receptor, 5a-reductase in human hair follicles and androgenetic alopecia. Current investigations focus on the influence of steroids in the inflammatory/apoptosis pathways, especially inflammasome in hair disorders/diseases.

M.E. Sawaya: None.

ABSTRACT: “Inflammasome Regulation in Androgenetic Alopecia”, Investigators: Juan Pablo de Rivero Vaccari, Bernard P. Nusbaum, Alan J. Bauman, Robert W. Keane, Marty E. Sawaya, Department of Physiology and Biophysics, University of Miami Miller School of Medicine, Miami, FL The inflammasome is a multiprotein complex that controls the activation of caspase-1 in the innate (front door, early steps) immune system that regulates inflammation. Vigorous inflammatory responses are induced in hair and skin diseases, but the intracellular pathways regulating innate immunity are poorly defined. In the present study, we examined the expression of NLRP1 inflammasome proteins in adult 24 men with androgenetic alopecia (AGA) and individuals treated with finasteride (4 months to 10 years). We show that human subjects with AGA express key components of the NLRP1 inflammasome, the proinflammatory cytokine interleukin-1β (IL-1β) and androgen receptors (AR). Individuals who responded well to finasteride treatment showed a significant decrease in levels of these proteins, whereas patients who responded poorly to finasteride had protein levels similar to untreated AGA males. Further, in vivo studies with human keratinocytes treated with dihydrotestosterone (DHT) expressed significantly elevated levels of caspase-1 indicating that DHT induces inflammasome activation in these cells. Our study is the first to show that the NLRP1 inflammasome is involved in AGA and may be considered “the” initial indicator of inflammation in this and other hair diseases such as cicatricial alopecia’s where key inflammatory steps regulate the hair cycle. These studies support the concept that NLRP1 inflammasome contributes to the innate immune response in AGA and provides the basis for development of novel treatments of inflammatory skin and hair diseases.

067

Moderator Introduction, Medical and Non-Surgical Treatments Bessam Farjo, MBChB Farjo Medical Centre, Manchester, United Kingdom.

Graduated in 1988 from the Royal College of Surgeons in Ireland. After general surgery training, in 1993, he trained in hair surgery in Canada and co-founded the Farjo Medical Centre in Manchester and London exclusively practicing hair restoration surgery. Past President of ISHRS (07-08), Past President and co-founder of the British Association of Hair Restoration Surgeons, Diplomate and Board Director of the American Board of Hair Restoration Surgery, Fellow, Board Governor & Medical Director of the Institute of Trichologists, Fellow of the International College of Surgeons.

B. Farjo: None.

068

A Report On "The Use of Oral Minoxidil That Make Hair Transplant From Impossible Become Possible in the Poor Candidate" Damkerng Pathomvanich, MD, Oravan Pathomvanich, MD DHT CLINIC, Bangkok, Thailand.

Dr. Damkerng Pathomvanich is a diplomate of American Board of Hair Restoration Surgery, American Board of Surgery and Fellow of American College of Surgeons. He received Golden Follicle award 2010 at ISHRS Annual Scientific meeting, Boston. He completed a cosmetic surgery fellowship sponsored by American Academy of Cosmetic Surgery and trained in hair restoration surgery at Stough Medical Associates, Arkansas. He is an active member of ISHRS and served on its Board of Governors. He is Director of the fellowship training program in hair restoration surgery at DHT clinic and editor of a new textbook entitled “Hair Restoration Surgery in Asians” by Springer. He is also founder and president of Asian Association of Hair Restorative Surgeons.

D. Pathomvanich: None. O. Pathomvanich: None.

ABSTRACT: Background: The FDA approved medical treatment for hair loss include Finasteride and minoxidil lotion. Minoxidil tablet has also been used in many Asian countries for more than 30 years to grow hair with good result but no report available regarding its use. Objective: To report on the use of oral minoxidil that make hair transplant that seemed impossible become possible in the poor candidate for hair transplantation.

Material and method: 5 patients with extensive hair loss who were not candidate for hair transplantation were evaluated at our clinic. Minoxidil tablets were prescribed till the hair grown and planned for surgery or given post op to enhance hair transplantation out come. This was found to be very useful especially when given pre-op at least 4 months till the miniaturized hair start to growth, making hairline design and recipient site planning easier. Result: All the patients have good hair growth and the miniaturized hair become thicker, enhance the outcome of hair transplantation. All patients have good and pleasing cosmetic result with no side effect to date. Discussion: Minoxidil is a vasodilator uses for the treatment of hypertension.Its side effect is hypertrichosis and hair growth on the scalp, I haven't seen patients complaint of libido as in those who took finasteride. It is not the first line of drug for the treatment of hair loss. Oral minoxidil is not approved by FDA to treat hair loss.However for those who have, I call " terminal hair loss"poor donor hair, failed finasteride and minox lotion but still want to go on with any treatment that might be able to bring back his hair. These patients should have an option to consider low dose oral minoxidil and see the result in 4-6 months. Side effect of oral minoxidil includes sodium retention and also the concern of its long term used.If swelling occur diuretic especially Spironolactone when given in conjunction with oral minoxidil can further enhance hair growth. What is appropriate dose for oral minoxidil to grow hair is not known since no study regarding this subject? However most doctors who prescribed believed that 5 mg per day is effective without blood pressure changed. Those who opt to take this drug must be informed of the non FDA approved drug and its side effect.

1919thth ISHRS Annual Scientific MeetingISHRS Annual Scientific Meeting

Anchorage ,AlaskaAnchorage ,Alaska

1414--1717thth June June 20112011

�� A Report on "The Use Of A Report on "The Use Of Oral MinoxidilOral Minoxidilthat Makes Hair Transplantation from that Makes Hair Transplantation from Impossible become Possible Impossible become Possible in the Poor in the Poor

CandidateCandidate""

D.Pathomvanich MD FACSDHT clinic,Bangkok,Thailand

DisclosureDisclosure

�� I have no significant interest with commercial I have no significant interest with commercial supporterssupporters

BackgroundBackground

�� The FDA approvedThe FDA approved medical treatment for hair medical treatment for hair loss include Finasteride and minoxidil lotionloss include Finasteride and minoxidil lotion

�� Minoxidil tablet has been used in many Asian Minoxidil tablet has been used in many Asian countries for more than 30 years to grow hair countries for more than 30 years to grow hair

with good result and minimal side effectwith good result and minimal side effect

�� However there is no report available regarding However there is no report available regarding

its used. its used.

What is minoxidilWhat is minoxidil

�� 2,42,4--Pyrimidinediamine, 6Pyrimidinediamine, 6--(1(1--piperidinyl)piperidinyl)--, 3, 3--oxide oxide

��Minoxidil is vasodilatorMinoxidil is vasodilator

�� by widening blood vessels and opening by widening blood vessels and opening

potassium channels potassium channels

�� allows more oxygen, blood, and nutrients to allows more oxygen, blood, and nutrients to

the follicle the follicle

Absorbtion and MetabolismAbsorbtion and Metabolism

� At least 90% absorbed from the Gl tract in experimental animals and man

�� Plasma levels reach maximum within the first Plasma levels reach maximum within the first hour and decline rapidly thereafter. hour and decline rapidly thereafter.

�� The average plasma halfThe average plasma half--life in man is life in man is 44..2 2 hourshours. .

�� Metabolized by conjugation with glucuronic acid Metabolized by conjugation with glucuronic acid

at the Nat the N--oxide position in the pyrimidine ring oxide position in the pyrimidine ring ��excreted principally in the urineexcreted principally in the urine

Usage of MinoxidilUsage of Minoxidil

�� It is used to treat hypertension by decreasing It is used to treat hypertension by decreasing peripheral vascular resistance peripheral vascular resistance

�� Minoxidil (Minoxidil (22..55, , 55, , 1010mg) has little effect on mg) has little effect on blood pressure in normotensive subjects. blood pressure in normotensive subjects.

Fleishaker JC, et al.. J Clin Pharmacol. 1989 Feb;29(2):162-7.

DosageDosage

�� Effective doseEffective dose

�� 1010--40 mg per day for antihypertensive40 mg per day for antihypertensive

�� The maximum recommended amountThe maximum recommended amount

�� 100 mg a day100 mg a day

Side effectSide effect

1.1. Salt and water retention Salt and water retention �� Increase plasma and interstitial fluid volume Increase plasma and interstitial fluid volume �� Rapid weight gain (five or more pounds within a Rapid weight gain (five or more pounds within a few days)few days)

�� Local or generalized edemaLocal or generalized edema�� Diuretic treatment in conjunction with restricted Diuretic treatment in conjunction with restricted salt intake salt intake

2.2. Rapid heart rate Rapid heart rate �� Increase of 20 beats or more over normal pulse rateIncrease of 20 beats or more over normal pulse rate�� Controlled by BetaControlled by Beta--adrenergic blocker adrenergic blocker

Side effectSide effect

3.3. Interaction with Guanethidine Interaction with Guanethidine �� Result in serious orthostatic effects (↓BP)Result in serious orthostatic effects (↓BP)

�� I.V. administration of normal saline I.V. administration of normal saline

4.4. Pericarditis, Pericardial Effusion, and TamponadePericarditis, Pericardial Effusion, and Tamponade

5.5. OtherOther�� Difficulty in breathingDifficulty in breathing

�� Worsening chest pain (angina) Worsening chest pain (angina)

�� Severe indigestion Severe indigestion

�� Dizziness, lightheadedness or faintingDizziness, lightheadedness or fainting

�� Nausea and vomitingNausea and vomiting

General PrecautionsGeneral Precautions

1.1. Monitor fluid and electrolyte balance and body weight Monitor fluid and electrolyte balance and body weight

2.2. Observe patients for signs and symptoms of Observe patients for signs and symptoms of pericardial effusion pericardial effusion

3.3. Should not been used in patients who have had a Should not been used in patients who have had a myocardial infarction within the preceding month myocardial infarction within the preceding month

�� limit blood flow to the myocardiumlimit blood flow to the myocardium

4.4. Hypersensitivity Hypersensitivity �� skin rash less than skin rash less than 11% %

5.5. Renal failure or dialysis patients may require smaller Renal failure or dialysis patients may require smaller doses of Minoxidildoses of Minoxidil

��FDA didn’t approve oral minoxidil FDA didn’t approve oral minoxidil

to use for hair growthto use for hair growth

ObjectiveObjective

�� To report onTo report on the use of oral minoxidil that the use of oral minoxidil that make hair transplant from impossible become make hair transplant from impossible become

possible in the poor candidate for hair possible in the poor candidate for hair

transplantation. transplantation.

Material and methodMaterial and method

�� Retrospective review of Retrospective review of 5 5 patients with extensive patients with extensive hair loss who were not candidate for hair hair loss who were not candidate for hair

transplantation at DHT clinic, Bangkok, transplantation at DHT clinic, Bangkok,

Thailand.Thailand.

�� Minoxidil tab was prescribed till the hair grown Minoxidil tab was prescribed till the hair grown

and planned for surgery or given post op to and planned for surgery or given post op to enhance hair transplantation outcome. enhance hair transplantation outcome.

MethodMethod

�� This was found to be very useful especially when This was found to be very useful especially when given pregiven pre--op at least op at least 4 4 months till the months till the

miniaturized hair start to grow, making hair line miniaturized hair start to grow, making hair line

design and recipient site planning easier design and recipient site planning easier

ResultResult

�� All the patients have good hair growth and the All the patients have good hair growth and the miniaturized hair become thicker, enhance the miniaturized hair become thicker, enhance the

outcome of hair transplantation.outcome of hair transplantation.

�� All patients have good and pleasing cosmetic All patients have good and pleasing cosmetic

result with no side effect to dateresult with no side effect to date

Patient CharacteristicsPatient Characteristics

SexSex AgeAge DxDxNumber of HT Number of HT

(# of grafts)(# of grafts)

MedicationMedicationDurationDuration

Oral MinoxOral Minox FinasterideFinasteride

Pt1Pt1 MM 4040 NW VINW VI HTHT--I (2,672)I (2,672) 5 mg/day5 mg/day 1 mg/day1 mg/day1 4/12 yrs1 4/12 yrs

(after HT(after HT--I)I)

Pt2Pt2 MM 3838 NW VINW VI HTHT--III (4,264)III (4,264) 5 mg/day5 mg/day --10 yrs10 yrs

(after HT(after HT--II)II)

Pt3Pt3 MM 4242 NW IVNW IV HTHT--II (2,617)II (2,617) 5 mg/day5 mg/day --9 yrs9 yrs


Pt4Pt4 MM 3030 NW VNW V HTHT--III (4,611)III (4,611) 5 mg/day5 mg/day --5 yrs5 yrs


Pt5Pt5 MM 3131 NW VNW V HTHT--I (1,951)I (1,951) 5 mg/day5 mg/day --6 yrs6 yrs


Pt1: Minox 5 mg + Finas 1 mgPt1: Minox 5 mg + Finas 1 mg

Pre-Op 7 mo Post HT-I (2,672)

PtPt11: Minox : Minox 5 5 mg + Finas mg + Finas 1 1 mgmg


PtPt22: Minox : Minox 5 5 mgmg

Pre-Op 9 mo Post HT-III (4,264)

Pt2: Minox 5 mgPt2: Minox 5 mg

Pre-Op 9 mo Post HT-III (4,264)

PtPt33: Minox : Minox 5 5 mg mg

9mo Post-Op HT-I Pre-Op HT-II 5 yr Post HT-II (2,617)Pre-Op


9mo Post-Op HT-I Pre-Op HT-II 5 yr Post HT-II (2,617)Pre-Op


9mo Post-Op HT-I Pre-Op HT-II 5 yr Post HT-II (2,617)








Pre-Op 4 yr 8 mo Post HT-I (1,951)









DiscussionDiscussion

�� Minoxidil is a vasodilator uses for the treatment Minoxidil is a vasodilator uses for the treatment of hypertension.of hypertension.

�� Its side effect is hypertrichosis and hair growth Its side effect is hypertrichosis and hair growth

on the scalp, I haven't seen patients complaint on the scalp, I haven't seen patients complaint of libido as in those who took finasteride. of libido as in those who took finasteride.


�� It is not the first line of drug for the treatment It is not the first line of drug for the treatment of hair loss.of hair loss.

�� Oral minoxidil is not approved by FDA to treat Oral minoxidil is not approved by FDA to treat hair loss.hair loss.

�� However for those who have, I call " However for those who have, I call " terminal terminal hair loss”hair loss”,, poor donor hair, failed finasteride poor donor hair, failed finasteride and minoxidil lotion but still want to go on with and minoxidil lotion but still want to go on with any treatment that might be able to bring back any treatment that might be able to bring back his hair. his hair.


�� These patients should have an option to These patients should have an option to consider low dose oral minoxidil and see the consider low dose oral minoxidil and see the

result in result in 44--6 6 months. months.

�� Side effect of oral minoxidil includes sodium Side effect of oral minoxidil includes sodium retention and also the concern of its long term retention and also the concern of its long term

used. used.


�� If swelling occur diuretic especially If swelling occur diuretic especially SpironolactoneSpironolactone when given in conjunction with when given in conjunction with

oral minoxidil can further enhance hair growth. oral minoxidil can further enhance hair growth.


�� What is appropriate dose for oral minoxidil to What is appropriate dose for oral minoxidil to grow hair ? grow hair ?

�� It is nIt is not known since there are no study ot known since there are no study regarding this subjectregarding this subject

ConclusionConclusion

�� Most doctors who prescribed believed that Most doctors who prescribed believed that 5 5 mg mg per day isper day is effective for hair growth without effective for hair growth without

blood pressure changedblood pressure changed

�� Those who option to take this drug must be Those who option to take this drug must be informed of the non FDA approved drug and informed of the non FDA approved drug and

its side effectits side effect

069

Contraindications to Hair Loss Medicines Jeff C. Donovan, MD, PhD University of Toronto, Toronto, ON, Canada.

Dr. Donovan received his MD degree from the University of Ottawa; his post-graduate clinical training in Dermatology and PhD studies in cell biology and were conducted at the University of Toronto. In 2007-2008, Dr. Donovan pursued a post doctoral research fellowship in hair immunology at the Mount Sinai School of Medicine. During the Fall of 2009, he trained in the Hair Diseases Program at the University of California San Francisco under Dr. Vera Price before returning to Canada in 2010 to complete training in hair transplantation under Dr. Walter Unger, Dr Donovan is currently an Assistant Professor of Dermatology at the University of Toronto.

J.C. Donovan: None.

ABSTRACT: A variety of topical and systemic medications are used to treat hair loss in men and women. These treatments compliment surgical strategies and patients may wish to start or continue these medications even if they proceed with hair transplantation. Hair restoration surgeons need to be knowledgeable about the use of minoxidil, finasteride, dutasteride, spironolactone, flutamide and oral contraceptives. Using a case-based approach, the author will present cases from his hair loss practice where one of the above medications presented an absolute or relative contraindication. These included patients with a history of psychiatric disorders, ischemic heart disease, malignancy, liver disease, gastrointestinal problems, concurrent use of other specific medications, and elevated thromboembolic risk. The hair transplant surgeon needs to be familiar with the contraindications to topical and oral hair loss medicines to ensure the highest level of patient safety.

Jeff Donovan MD PhD FAAD

Assistant Professor, University of Toronto

Friday, September 16, 2011 10:39AM-10:46AM

� Speaker has no relevant financial relationships or conflicts of interest to declare

� To discuss contraindications to topical and

oral medications for hair loss

� Current Treatment:

� Minoxidil 2 % for 3 years

� No improvement

� PMHx:

� Mycocardial infarction (age 61 & 64)

� Angioplasty (age 64)

� Severe angina

� Hypersensitivity to any ingredient in the product � Cardiovascular disease

� Pregnancy/ breast feeding � Use of occlusive dressings � Inflamed or infected scalp

� Minoxidil stopped

� Angina improved significantly

� PMHx:

� Mild Depression (8 yr)

� Medications

� Citalopram 40 mg daily (2 yr)

� Finasteride 1 mg daily (1 yr)

� Finasteride crosses blood brain barrier � May contribute to or exacerbate depression

� In December 2010, side effect of depression added to finasteride product monograph

Rahimi-Ardabili et al, 2006

Altomare et al, 2002

� Current Medications

� Finasteride 2.5 mg/d for 2 yr

� PMHx:

� Liver disease NYD

� AST = 61

� ALT = 94

� Finasteride metabolized by the liver

� Caution needed in those with liver dysfunction

YEAR ALT

2006 31

2009 61

2011 94

� Medications

� Finasteride 1 mg daily

� Minoxidil 5 % daily� PMHx

� None� Family Hx

� Mother – breast cancer

� Maternal Grandmother – breast cancer

� 1 of 3 Maternal Aunts – breast cancer

� 5 mg finasteride

� At least 50 case reports

� Median time to onset about 36 months

� 1 mg finasteride

� At least 3 case reports

� Median time to onset too short to conclude

anything about association

Thompson et al, 2003McConnell et al, 2003McConnell et al, 1998

� Pregnancy (class X) and breast feeding

Use Caution with

� Depression� Liver Disease� Elevated Breast Cancer Risk

� Under 18

� Pregnancy women (class D)/breast feeding� Anuria, hyperkalemia, renal failure, diabetes, liver disease

Use caution with:� Depression� Liver Disease� Elevated Breast, Ovarian, Endometrial Cancer� Elderly � Medicines which increase potassium

� Cyclosporine, tacrolimus, potassium supplements, ACE inhibitors, ARBs,

steroids, lithium

� Treatment

� Minoxidil 2 % lotion

� Spironolactone 100 mg bid

� PMHx

� Osteoarthritis

� Duodenal ulcer and significant GI bleed

� Verhamme K et al, BMJ 2006

▪ 2.7 fold increased risk of GI event

� Gulmez S et al, Br J Clin Pharm 2008

▪ 2.7 fold increase risk of upper GI bleeding

� Russo et al. Pharmacoepidemiol Drug Saf 2008

▪ 1.94 fold increased risk of upper GI bleeding

� Pregnancy (class D)/ breast feeding� Anuria, hyperkalemia, renal failure, diabetes, liver disease

Use Caution with � Depression� Liver Disease� Elevated Breast, Ovarian, Endometrial Cancer� Elderly � Medicines which increase potassium� Those with increased propensity to GI bleeding

Jeff Donovan MD PhD FAAD

Assistant Professor, University of Toronto

Friday, September 16, 2011 10:39AM-10:46AM

070

The Whole Truth About the PRL and Its Impact on the Hair Growth Cycle. Our Experience Silvana Franzini, MD, Nicolas Lusicic, MD, Alejandra Susacasa Hair Recovery Argentina, Buenos Aires, Argentina.

Nicolas Lusicic MD: Certified general surgeon and certified plastic surgeon. He has more than 16 years of experience in hair restoration surgery and is active member of ISHRS since last 14 years. Alejandra Susacasa MD: Certified general surgeon and certified cosmetic surgeon has been active member of ISHRS for last 14 years. She has more than 16 years of experience in hair restoration surgery. Dr Lusicic & Dr Susacasa have founded 16 years ago the most important hair restoration center in Argentina with 16 offices including other Latin American countries. In 2006 they started with their innovative technique, intradermotherapy. Silvana Franzini MD:certified internal medicine,certified cardiology, works with Dr Lusicic and Dr Susacasa as medical director since 2007.


ABSTRACT: The goal of this study is to consider the dermatological dimensions of PRL and the prevalence of hyperprolactinemia in patients with hair loss disorders. We evaluate over 10,000 patients between 2007- 2010. Ages between 18 to 75 years old, both males and females. We practiced a complete hormonal test twice a year with circadian rhythm . We distribute them into four differents groups: Males /Females - Surgical treatments / Non surgical treatments Different authors mention that the prevalence of Hyperprolactinemia is about 0.5% in adult population. In our population , we've found near 8 % of prevalence of hyperprolactinemia in patients with hair loss disorders Conclusion: Hyperprolactinemia is most frecuently found in females ( 57.7% / 42.3% males).

1) Chronic telogen effluvium is the most frecuent presentation. 2) Patients with high PRL levels + AGA undergoing hair transplant surgery ,results may be low densities

more than patients without high prolactine levels PRL. 3) In our reports, we observed that patients with high PRL levels generally not improve with medical

treatments (finasteride + minoxidil). 4) Alopecia Areata may occur with hyperprolactinemia and it could be more aggressive more studies must be

done to correlate this findings. 5) We suggest to take this hormone in account every time you have a different result to yours in surgery or

medical treatments in your patients.

071

Finasteride Induced Mood Changes. Case Reports and Literature Review Jorge I. Gaviria, MD1, Ana Trius-Chassaigne, MD2 1Gaviria & Trius Hair Transplant Surgery Center, Boca Raton, FL, USA, 2Gaviria & Trius. Hair Transplant Center, Barcelona, Spain.

Dr. Jorge Gaviria, is licensed to practice medicine and surgery in USA, Spain, Colombia and Puerto Rico, he is in private practices at the Gaviria & Trius Hair Transplant Surgery Center in Barcelona, Spain and Miami Beach, Florida. Dr. Ana Trius Chassaigne is a medical doctor and surgeon in private practice at the Gaviria & Trius. Hair Transplant Center in Barcelona, Spain.

J.I. Gaviria: None. A. Trius-Chassaigne: None.

ABSTRACT: Finasteride is a competitive inhibitor of 5 alpha-reductase enzyme, and is used for treatment of benign prostatic hyperplasia (5 mg/day) and androgenetic alopecia (1 mg/day). Finasteride is one of three FDA approved medication for the treatment of androgenetic alopecia. Adverse effects reported by manufacturer are sexually related, in general Finasteride has a safe profile. We report four cases of atypical mood changes induced by finasteride that altered personal and family routines in patients with no personal histories of psychiatric disorders. In all cases Propecia® was prescribed for the treatment of androgenetic alopecia after hair transplant surgery. Keywords: Androgenetic alopecia, finasteride, atypical

072

Low-Level Laser Therapy for Androgenetic Alopecia: A 24-week Randomized Double-Blind Placebo Controlled Trial Chang-Hun Huh, MD, PhD 300 Gumi-dong Bundang-gu, Seongnam/Gyeonggi, Korea, Republic of.

Chang-Hun Huh, MD, PhD Assistant Professor(2004~present) Department of Dermatology, Seoul National University Bundang Hospital Education Seoul National University(SNU), College of Medicine(1989-1995), Master course in SNU(2001-2003), Ph.D. Course in SNU(2004-2007) Postgraduate Training Internship in SNU Hospital(1995-1996), Military service as an Army Doctor(1996-1999), Residency in SNU Hospital(1999-2003), Clinical Instructor of SNU Hospital(2003-2004) Society Activity Treasurer of the Korean Dermatologic Laser Association(2006-present), Treasurer of the Korean Hair Research Society(2006-2010), Treasurer of the Korean Society for Aesthetic and Dermatologic Surgery(2008-2010)

Research Interests Stem Cell Biology, Hair & Scalp Disease, Dermatologic Surgery, Laser/Photomedicine, Wound healing

C. Huh: Research Grant (principal investigator, collaborator or consultant); PI of Research Grant.

ABSTRACT: Low-level laser therapy(OAZE) for androgenic alopecia : an 24-week randomized double-blind placebo controlled trial Jee-Woong Choi, Jun-Young Kim, Jung-Bok Jung, Se-Young Na, *Seok-Jong Lee, Jung-Im Na, *Weon-Ju Lee, Sang-Woong Youn, *Do-Won Kim, Kyoung-Chan Park, and Chang-Hun Huh. Seoul National University Bundang Hospital and *Kyungpook University Hospital, Korea Androgenetic alopecia(AGA) is a common disorder affecting both men and women. The incidence rate of AGA seems to be gradually increasing. Recent works have attempted to find effective and safe agents for hair loss treatment. Low-level laser therapy (LLLT) in hair restoration has been used to stimulate hair growth and reduce shedding of hair. OAZE(WON Technology, Daejeon, Korea) is a helmet type home use LLLT device with 69 LD and LED. The present study was made to see the efficacy of LLLT using OAZE for regrowth of hair in AGA. 38 Korean patients with AGA were enrolled, and used randomly assigned device, OAZE or dummy for 18 minutes daily for 24 weeks. Efficacy was measured by changes in hair density and mean hair diameter, which was calculated by phototrichogram. After 24 weeks of application, mean hair density of the OAZE group(n=20) was significantly grow compared with dummy group(n=18). (16/cm2 Vs. 0.2/cm2). Mean hair diameter also greatly increase in OAZE group than dummy group(n=18). (11μm Vs. 3.4μm). No serious adverse reactions were observed in both groups. In summary, LLLT with OAZE is an effective treatment for regrowth of AGA. But, long term evaluation and research regarding basic mechanism is still needed.

Jee-Woong Choi, Jun-Young Kim, Jung-Bok Jung, Se-Young Na, *Seok-Jong Lee, Jung-Im Na, *Weon-Ju Lee, Sang-Woong Youn, *Do-Won Kim, Kyoung-Chan Park, and Chang-Hun Huh.

Seoul National University Bundang Hospital and *Kyungpook University Hospital, Korea

Low-level laser therapy for

androgenic alopecia : an 24-week randomized double-

blind placebo controlled trial

� Medication- Oral Finasteride/Dutasteride- Topical Minoxidil/Alphatradiol

� Surgery- Scalp Reduction- Autologous Hair Transplantation

� Others- Mesotherapy- Device : Laser/Light, Magnetic, etc.

Androgenetic Alopecia Treatment

� Low Level Laser Therapy- Home use- Clinic based

� Pulsed Electrostatic Fields- Electromagnetic

� Non-ablative Fractional Laser

� Excimer Laser – Alopecia AreataIR diode Laser – Alopecia Areata

Current Alopecia Treatment Devices

[Dermatol Surg. 2002;28:1131–4.]

Paradoxical Hair Growth

[Dermatol Surg. 2002;28:1131–4.]

� Unclear

� Suboptimal fluence activate HF

- stimulate hair follicle stem cells

- release of certain mediators and cytokines

� Direct light synchronized hair growth cycles

: Overall hair density appear to be greater compared to previous asynchronous hairs.

Mechanisms of Paradoxical Hair Growth

� Developed in 1962

� Generally smaller, less expensive, and operate in

the mW range, (1–500 mW)

� Do not produce heat, photochemical effect only

� Therapeutic laser, Low-intensity level laser, Soft laser, Cold laser, Bio-stimulator,

Bio-modulator

� No S/Es were recorded from the biostimulativelight energy directed to the body cells

[J Am Acad Dermatol. 1984;11:1 142–50.]

LLLT (Low-Level Laser Therapy) Light Source

� HeNe lasers (632.8 nm)

� Light emitting semiconductor diodes

(630 nm – 980 nm)

- Diode lasers : resonator contained- LEDs

� Recent : longer wavelengths (~800 to 900 nm)higher output powers (to 100 mW)

� Endre Mester in Semmelweis University,

Budapest, Hungary, in 1967

� low powered ruby laser (694 nm)

� to test if laser radiation cause cancer in mice

� the hair on the treated group grew back more quickly than the untreated group.

[Kiserl. Orvostud., 1967;19: 628-31]

First report of Hair Growth by LLLT

� 890 nm diode laser (5 mW)

20 min/day[J Clinical Otolaryngol 2004;15:167-173]

Mice experiment of LLLT for hair

� Pinheiro AL, GerbiME. Photoengineering of bone repair processes. [Photomed Laser Surg 2006; 24: 169-78]

� Liu X, Lyon R, Meier HT, et al. Effect of lower-level laser therapy on rabbit tibialfracture. [Photomed Laser Surg 2007;25: 487-94]

� Yu W, Naim JO, LanzafamRJ. Effects of photostimulation on wound healing in diabetic mice. [Lasers Surg Med 1997; 20:56-63]

� Reddy GK, Stehno-Bittel L, Enwemeka CS. Laser photostimulation accelerates wound healing in diabetic rats. [Wound Repair Regen 2001; 9: 248-55]

� Reddy GK. Comparison of the photostimulatory effects of visible He-Ne and infrared Ga-As lasers on healing of impaired diabetic rat wounds. [Lasers SurgMed 2003; 33: 344-51]

� ByrnesKR, Barna L, Chenault VM, et al. Photobiomodulation improves cutaneous wound healing in an animal model of type II diabetes. [PhotomedLaser Surg 2004; 22: 281-90]

� de Carvalho PT,Mazzer N, dos Reis FA, et al. Analysis of the influence of low-power He-Ne laser on the healing of skin wounds in diabetic and non-diabetic rats. [Acta Cir Bras 2006;21: 177-83]

� Neiburger E J. Rapid healing of gingival incisions by the helium-neon diode laser. [J Mass Dent Soc 1999;48:8-13.]

Effect of LLLT : Pro-proliferation

� Unclear

� Cytochrome c oxidase(Cox) in Mitochondria is the primary photoacceptor for the red-NIR range in mammalian cellsmore than 50% of the absorption greater than 800 nm. [Dokl Akad Nauk 1995;342:693-5.]

� Activation of the mitochondrial electron-transport chainIncreased ATP production[J Photochem Photobiol B 1989;3:642-3.][Int J Radiat Biol 2000;76:863-70. ]

Mechanisms of LLLT

� Anti-inflammation

� Vasodilatation : Increase production of NO

� Improved blood circulation

� Stimulated secretion of bFGF and IGF-1 by Fb

� Increased NGF production and release- anagen-promoting/-supporting role. [J Am Acad Dermatol. 1984;11:1 142–50.][J Invest Dermatol. 2003;120:56–64.][Lasers Surg Med 2000;27:427-37.][Eur J Oral Sci 2000;108:29-34.][Lasers Surg Med 1998;22:294-301.][J Photochem Photobiol B 2002:66;195-200.][J Histochem Cytochem 2006:54;275–288]

LLLT

� Midwest RF LLC of Hartland, Wisconsin.

� FDA Clearance in March 2010 for female

pattern baldness treatment

� 20-minute treatments for 18 weeks(X2/week)

MEP-90 Hair Growth Stimulation System

� KPDA approved laser device for hair loss Tx.

OAZE™

� LD 650nm : 27- Wavelenghth : 650 nm- Output Power: 4mW- Irradiation diameter : 0.5mm

� LED 630nm : 24- Wavelenghth : 630nm- Output Power: 3.5�

� LED 650nm : 18- Wavelenghth : 660nm- Output Power : 2.5�

OAZE™

� Clinical Trial for KPDA approval: 2009.5-2010.5

� Seoul National UniversityKyoungbook National University

� Regulated and inspected by KFDA.

� AGA- Male : N-H III,IIIv, IV, IVa, V, Va, VI, VII - Female : Lodwig I-III

� 40 enrolled - OAZE:20, Dummy:20

� 38 complete - 2 drop out (Dummy)

� Once per day for 18 min treatment

� 6mo F/U

Clinical Trial for KPDA approval :OAZE™

� Primary Parameter- Hair Density (/cm2) Change after 24 weeks

� Secondary Parameter- Hair Diameter (μm) Change after 24 weeks- Patient evaluation- Photo evaluation

� Compliance evaluation by counter- PP : regular visit

more than 50% use per protocol

Design

� Hair Density (/cm2) : ITT

� Hair Density (/cm2) : PP

Results

DummyDummyDummyDummy(N=14)(N=14)(N=14)(N=14) OazeOazeOazeOaze(N=15)(N=15)(N=15)(N=15) pppp----valuevaluevaluevalueMeanMeanMeanMean±S.D.S.D.S.D.S.D. ----2.142.142.142.14±18181818....30303030 17.2017.2017.2017.20±12121212....15151515 0.00270.00270.00270.00271)1)1)1)Median[Median[Median[Median[Min,MaxMin,MaxMin,MaxMin,Max]]]] ----0.50.50.50.5[[[[----38383838,,,, 33333333]]]] 12121212[[[[5555,,,, 50505050]]]]DummyDummyDummyDummy((((N=18)N=18)N=18)N=18) OazeOazeOazeOaze(N=20)(N=20)(N=20)(N=20) pppp----valuevaluevaluevalueMeanMeanMeanMean±S.DS.DS.DS.D.... 0.250.250.250.25±18181818....04040404 16.516.516.516.5±12121212....65656565 0.00210.00210.00210.0021 1)1)1)1)Median[Median[Median[Median[Min,MaxMin,MaxMin,MaxMin,Max]]]] 1111[[[[----38383838,,,, 39393939]]]]12.512.512.512.5[[[[----5555,,,, 50505050]]]]

� Hair Diameter (μm)

ResultsDummyDummyDummyDummy OazeOazeOazeOaze pppp----valuevaluevaluevalueITTITTITTITT nnnn 18181818 20202020MeanMeanMeanMean±S.D.S.D.S.D.S.D. 3.443.443.443.44±6666....95959595 11.5511.5511.5511.55±8888....79797979 0.00350.00350.00350.0035 1)1)1)1)Median[Min,Max]Median[Min,Max]Median[Min,Max]Median[Min,Max] 3.53.53.53.5[[[[----9999,,,, 14141414]]]] 10.510.510.510.5[[[[----1111,,,, 37373737]]]]ITTITTITTITT ((((LOCF)LOCF)LOCF)LOCF) nnnn 20202020 20202020MeanMeanMeanMean±S.D.S.D.S.D.S.D. 3.103.103.103.10±6666....66666666 11.5511.5511.5511.55±8888....79797979 0.00150.00150.00150.0015 1)1)1)1)Median[Min,Max]Median[Min,Max]Median[Min,Max]Median[Min,Max] 2222[[[[----9999,,,, 14141414]]]] 10.510.510.510.5[[[[----1111,,,, 37373737]]]]PPPPPPPP nnnn 14141414 15151515MeanMeanMeanMean±S.D.S.D.S.D.S.D. 3.863.863.863.86±7777....34343434 12.6012.6012.6012.60±9999....44444444 0.01000.01000.01000.0100 1)1)1)1)Median[Median[Median[Median[Min,MaxMin,MaxMin,MaxMin,Max]]]] 3.53.53.53.5[[[[----9999,,,, 14141414]]]] 13131313[[[[----1111,,,, 37373737]]]]� Patient Evaluation

ResultsDummyDummyDummyDummy OazeOazeOazeOaze pppp----valuevaluevaluevalueITTITTITTITT nnnn 18181818 20202020MeanMeanMeanMean±S.D.S.D.S.D.S.D. 3.893.893.893.89±2222....91919191 5.705.705.705.70±2222....49494949 0.08160.08160.08160.0816 1)1)1)1)Median[Min,Max]Median[Min,Max]Median[Min,Max]Median[Min,Max] 5555[[[[0000,,,, 9999]]]] 5.55.55.55.5[[[[1111,,,, 10101010]]]]ITTITTITTITT ((((LOCF)LOCF)LOCF)LOCF) nnnn 20202020 20202020MeanMeanMeanMean±S.D.S.D.S.D.S.D. 3.793.793.793.79±2222....86868686 5.705.705.705.70±2222....49494949 0.03210.03210.03210.0321 1)1)1)1)Median[Median[Median[Median[Min,MaxMin,MaxMin,MaxMin,Max]]]] 5555[[[[0000,,,, 9999]]]] 5.55.55.55.5[[[[1111,,,, 10101010]]]]PPPPPPPP nnnn 18181818 20202020MeanMeanMeanMean±S.D.S.D.S.D.S.D. 3.433.433.433.43±3333....13131313 5.135.135.135.13±2222....33333333 0.10600.10600.10600.1060 1)1)1)1)Median[Min,Max]Median[Min,Max]Median[Min,Max]Median[Min,Max] 3333[[[[0000,,,, 9999]]]] 5555[[[[1111,,,, 9999]]]]� Photo Evaluation (ITT)

Results

0

10

20

30

40

50

60

70

80

90

Excellent Good Slight No Change Worse

Dummy

Oaze

� Photo Evaluation (PP)

Results

0

10

20

30

40

50

60

70

80

90

Excellent Good Slight No Change Worse

Dummy

Oaze

Results Conclusion

� LLLT with OAZE™ is beneficial to alopecia patient in

terms of increasing hair density and hair diameter.

073

Moderator Introduction, Advanced Surgical HD Videos Vincenzo Gambino, MD Milano, Italy.

Doctor Gambino is Secretary Board of Governors ISHRS. A member and past president of the Italian Society and a founding member of S.I.Tri. (Società Italiana di Tricologia) currently serving a three year term as the president. He heads the surgical hair restoration section of the Cosmetic Dermatology department of San Raffaele University Hospital, Milan and also the hair restoration section of S.I.E.S.having written the Hair Restoration section of their medical text book- Medicina e Chirurgia Estetica Viso e Collo. He currently teaches the surgical hair restoration section of the University of Florence’s Masters program, Scienze Tricologiche Mediche e Chirurgiche.

V. Gambino: None.

074

Surgical Transplantation of the Crown: A Video Presentation Vincenzo Gambino, MD Milano, Italy.

Doctor Gambino is Secretary of the ISHRS Board of Governors. He is a member and past president of the Italian Society of Hair Restoration and a founding member of S.I.Tri. (Società Italiana di Tricologia) currently serving a three year term as the president. He heads the surgical hair restoration section of the Cosmetic Dermatology department of San Raffaele University Hospital, Milan and also the hair restoration section of S.I.E.S.having written the Hair Restoration section of their medical text book- Medicina e Chirurgia Estetica Viso e Collo. He currently teaches the surgical hair restoration section of the University of Florence’s Masters program, Scienze Tricologiche Mediche e Chirurgiche.

V. Gambino: None.

ABSTRACT: Transplantation of the crown is especially challenging because the hair continuously changes direction in a natural whorl or vortex. This video will demonstrate a surgical approach that successfully and naturally recreates the crown area.

075

My Preferred Method to Make the Recipient Sites: Evolution of Former Method Francisco Jimenez, MD, Darío Sosa-Cabrera, MD Private Practice, Las Palmas Gran Canaria, Spain.

Dr. Francisco Jimenez is a dermatologist and hair transplant surgeon working in private practice in Las Palmas, Canary Islands, Spain. Dr. Jimenez is former coeditor of the Hair Transplant Forum International (2008-2010).

F. Jimenez: None. D. Sosa-Cabrera: None.

ABSTRACT: Introduction: In 2007 at the meeting in Las Vegas, I presented my personal technique to create recipient sites at consistent densities using templates created with custom made stamps. At that time I used to paint the templates on Micropore surgical tape, which were then stuck to the recipient area of the scalp, and the slits were made through the Micropore tape. Now I would like to present a video showing a modification of the former technique. I still use templates created using custom made stamps, but I prefer to paint the pattern of the dots directly onto the scalp using gentian violet 2% as the staining product. The slits are made introducing the desired tool (needles or blades) through the dots marked with gentian violet. Technique: Each stamp recreates a triangular pattern of 3 cm x 3 cm with different densities of 25, 30, 35, 40, 50 or 60 dots /cm2. The pattern of dots painted onto the scalp reproduces the specific density of sites per square centimeter. The triangular pattern mimics the natural distribution of follicular units in the scalp. Discussion: This method offers the following advantages to the hair transplant surgeon: first and most importantly, the pattern of dots painted on the recipient scalp enables the surgeon to estimate how close the recipient sites need to be made in order to achieve the desired density; and secondly, it allows better visualization of the recipient sites as these will have retained the gentian violet staining product.

076

TrichoScan Enhances Patient Selection for Hair Transplantation Jerzy Kolasinski, MD, Malgorzata Mackiewicz-Wysocka, MD, Malgorzata Kolenda, MD Klinika Kolasinski - Hair Clinic Poznan, Swarzedz, Poland.

Dr. Jerzy Kolasinski, a member of the American Academy of Cosmetic Surgery, and American Society for Hair Restoration Surgery is the founder and director of Klinika Kolasinski Hair Clinic Poznan in Swarzedz, Poland. He is an author of 100 articles and presentations concerning hair restoration surgery.

J. Kolasinski: None. M. Mackiewicz-Wysocka: None. M. Kolenda: None.

ABSTRACT: Introduction: Hair miniaturization is a hallmark of androgenetic alopecia (AGA). Miniaturization and then baldness occurs in frontoparietal region of a scalp but there are also miniaturized hair in occipital scalp. Since occipital area is the donor site, hair localized in that region are supposed to be a good quality hair to guarantee a good hair growth in recipient site. Optimal patient selection for hair transplant procedures is one of the elements of a correctly performed reconstructive scalp treatment. Until 2006 the qualification for surgery was only based on physician’s experience, macroscopic and videomicroscopic (Micro-VID Digital Hand Held Microscope) evaluation of the donor site in patients with AGA. There was also no objective method for evaluation of hair growth in androgenetic alopecia patients. For the last 3 years TrichoScan method has been used for diagnostic purposes, patient selection for surgical treatment and also for monitoring pharmacological treatment. Materials and methods: One hundred patients (both men and women) with hair loss selecting for surgical treatment were analyzed by TrichoScan. In each patient, 1 area of 1.8 cm2 in occipital region was chosen, shaved, dyed and then a picture of prepared area was taken. The study was performed with a digital imaging system combined with epiluminescence microscopy - the TrichoScan method. The miniaturization grade was expressed as percentage of vellus hair to terminal hair. Results: A number of miniaturized hairs in donor site not higher than 10% is a good prognosis, 10% to 15% of miniaturized hairs should indicate caution on selecting patients for surgical treatment and miniaturization exceeding 15% to 20% should suggest other type of treatment for this patient. Conclusions: Trichoscan proved to be a good diagnostic tool for enhanced patient selection for hair restoration surgery. There are several advantages of this method such as simplicity and speed of photographic processing, lack of pain associated with the procedure and what is the most important - the quantitive results. TrichoScan has many advantages not only in supporting diagnosis but also in monitoring hair loss and treatment response. However, the latter applications still need final validation.

077

Throw Away Your Loupes: Plantation Under Digital Video Microscope Sanjiv A. Vasa, MD Vasa Hair Academy, Ahmedabad, Gujarat State, India.

He has been active member of ISHRS for last 15 years, founder and president of Association of Hair Restoration Surgeons of India, Director of Vasa Hair Academy. He has devoted last 16 years exclusively to hair restoration and performed procedures in more than four figures. His major research interests has been to find out pitfalls of current hair restoration practice and resolve them by innovating specially designed instruments, equipments and techniques.

He has the ownership of many patents, design registry, trademarks. He has also innovated unique training system on simulators for hair restoration.


ABSTRACT: Introduction / background: Conventional magnifying tools used in hair transplantation include magnifying lens (2X), loupes (2.5 to 6X), stereo microscope (10X) and digital video microscope (25 to 50X). Higher the magnification more is the accuracy. Different tools are used by different centers for different steps but use of microscopes has not been mentioned for plantation. Objective: Accurate plantation at desired angle, direction and orientation with close proximity can be achieved with higher magnification. Material and method: Custom made digital video microscope is focused over plantation area. The images are transmitted to the tv screen with adjustable magnification from 10X to 25X suitable for the desired field of vision. Plantation is performed in the usual way with more accuracy and close packing achieving higher density. Video will be presented. Discussion / results: Occupational cervical spine problems produced by Prolong plantation through traditional loupes can easily be avoided. Conclusion: Most natural results can be achieved with use of higher magnification using digital video microscope.

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078

Scoring-Backhanded Blunt Dissection For Minimal Transection Donor Strip Harvesting With 0 - 1 Assistants And Tools You Already Own Cam Simmons, MD Canadian Hair Transplant Centre, Toronto, ON, Canada.

Cam Simmons MD ABHRS is the founder and medical director of the Canadian Hair Transplant Centre (CHTC) in Toronto, Canada. He received his medical degree from Queen’s University in Kingston in 1985 and his CCFP in 1987 and practiced family and emergency medicine before working as an associate with Dr. David Seager from 1999 -2005. In 2004, he became a diplomate of the ABHRS. Dr. Simmons is currently a member of the ISHRS website committee and the CME committee.

C. Simmons: None.

ABSTRACT: Introduction: In this surgical video, a new technique for donor strip harvesting with minimal transection will be demonstrated. Technique: This is a 3-step donor strip harvesting technique that is similar in concept to the manual SAFE system technique for FUE. In the first step, a scoring incision is made with a depth-controlled #15 blade. In the second step, blunt dissection with the back of a #10 scalpel blade frees the strip edges. In the third step, blunt dissection with the back of a #10 blade is used to free the strip from the underlying tissues. Discussion: The primary goal of minimal transection donor strip harvesting is to save as many hair follicles as possible so that more hair will grow in the recipient area and more hair will grow in and near the donor scar. Secondary goals are to minimize trauma to vessels and nerves. Careful depth-controlled, single-blade sharp donor strip dissection works well in the majority of patients. It is relatively fast, doesn’t require special instruments, and can be done with minimal assistance. However, simple sharp dissection can cause transection of hair follicles along the edges of the donor strip; particularly for patients with very curly hair, white hair that is hard to see, or when follicle angles change naturally or due to previous scarring. Techniques to minimize transection have been developed with 2 basic approaches. Dr. Damkerng Pathomvanich developed and Dr. Dow Stough further described the Tension Donor Dissection technique. In this first approach, 2 assistants apply traction to pull apart the skin edges while the surgeon performs sharp dissection under direct vision. In the second approach, a scoring incision is made then the skin is spread to tear through the tissues without cutting hair follicles. Dr. Arturo Sandoval uses a hemostat in his Triple S technique, Dr. Bob Haber modified an iconoclast to create the Haber spreader and Dr. Paul Rose modified a Kelly clamp to create the Rose spreader. Dr. Arthur Tykocinsky introduced a perforating device in Boston 2010 so the tissues would tear more easily. The presented technique represents a third approach with sharp then dull dissection as done in the manual SAFE system for FUE. The idea to use the back of the scalpel blade for dull dissection resulted from observation of a backhanded technique while assisting at a hernia surgery. The surgeon, Dr. A. De La Roche, used backhanded dissection to protect vessels while dissecting through scar tissue and had employed this technique regularly while working as a cardiothoracic surgeon. Every technique has advantages and disadvantages. The Tension-Dissection Technique creates neat edges and uses inexpensive and readily available tools but is slower than other techniques and requires 2 surgical assistants. The presenter has used a modified technique whereby traction is applied with toothed forceps by one assistant to the upper edge while the surgeon pulls on the lower edge with toothed forceps and undertakes sharp dissection. The presenter has used the Haber spreader frequently but has not used the other spreading techniques. The Haber spreader can be used blindly, minimizes transection, does not require assistance, and most often is easy and fast to

use. It is harder to use with tough skin and patients sometimes dislike the pressure sensation. If not inserted or angled properly the spreader can pop out and a tooth can cut the skin. The Haber spreader has a mechanical advantage over other spreaders but seems quite big at first. The more force required to spread the tissues, the more uneven the torn edges can be. Suturing may be interrupted to remove or manipulate partially- dissected follicular unit grafts. The Scoring-Backhanded technique creates clean edges, can be done blindly or with thumb and finger traction on the edges, does not require special tools, and does not require 2 assistants. It is faster to perform than Tension-Dissection and may be faster or slower than spreading depending on the patient. In tough or scarred skin, more pressure and multiple strokes may be required. It is sometimes faster to use backhanded sharp dissection to separate the strip from the deep tissue. Caution must be employed because there is a greater risk to staff and surgeon from the exposed sharp blade. Conclusion: The Scoring-Backhanded Donor Dissection technique provides another reliable option for minimal transection donor strip harvesting.

079

Transection Rate Comparison of Combination vs. Video Microscopic Graft-Dissecting Methods Dae-Young Kim. MD, PhD Yonsei Hair Center, Seoul, Korea, Republic of.

Dr. Dae-young Kim is a board certified plastic surgeon and ABHRS, and had been practicing hair restoration surgery since 2000 in Seoul. He presented 3 papers about "Pustules-Free Trichophytic Closure" at the 16th and 17th ISHRS annual meetings in Montreal and Amsterdam. These papers were also printed in the FORUM of ISHRS and the 5th edition of Walter Unger's text book. At the 18th annual meeting in Boston he presented "20x digital microsopic dissection" and "Placing 1500 grafts per hour with Choi implanters."

D. Kim: None.

ABSTRACT: Transection Rate Comparison of Combination vs. Video Microscopic Graft-Dissecting Methods Dae-young Kim, MD, PhD Apkujung Yonsei Hair Transplantation Center, Seoul, Korea Backgrounds: In 1988, Limmer introduced the optic binocular microscope, and Sharon Keene, in 2004, introduced a video microscope, to the hair transplant field. Sharon discussed about ergonomics, quality assurance, and easy teaching of a video microscope. In 2004, Rose and Shapiro published on a combination method with its benefits and advantages.

Introduction: In 2009, our clinic set up digital video microscope systems. CCD-chip-loaded hand-held digital video camera, 19-inch HD (high definition) LCD monitor, an LED ring-light source, and a multi-stand were the instruments as a complete system. Objective: Our purpose is to evaluate the transection rates and productivity of graft dissection under two graft-dissecting methods to prove which one would be more efficient. Methods: 0.5cm-length strip sections were obtained from all 6 ethnic Korean patients. Digital video microscopic graft-dissecting method and combination method of digital video microscopic slivering and graft cutting with loupes were compared for transection rates and graft-producing time. All the procedures were recorded on an HD video camera for each patient. For digital video microscopic slivering and graft-cutting, works of both technicians were recorded by a single shot. And graft-cutting with loupes was separately recorded with an HD video camera for cross-checks. Results: The transection rate of digital video microscope use was 2.2% while the combination method with 1.6%. For the results of digital video microscope, the average graft-producing rate was about 348 grafts/hour. For the combination method, the average graft-producing rate was about 588 grafts/hour. For comparison of graft-producing time, producing nearly equivalent number of grafts, the combination method performed in about 186% faster the time with 0.6% less the transection rate. Discussion: Our definition of transection restrictively stands for the transection level of hair shaft below epidermis. The visual quality of a digital video microscope system is comparably good to binocular optic microscopes. Lacked feature of a digital video microscope is its less 3D effect. Our technicians took about 3 months to adapt to its less 3D effects. Conclusions: The data showed that the work efficiency was about double greater with the combination method. The combination method showed equivalent transection rates with the two-fold faster graft-cutting time than the digital video microscopic method. The author has indicated no significant interest with commercial supporters. Figure 1 20x digital video microscopic slivering and graft-cutting procedures. Figure 2 20x video microscopic slivering and 2.5x graft-dissecting with loupes. Figure 3 CCD-loaded hand-held digital video camera, 19” HD LCD monitor, a LED ring-light source, and a multi-stand as a full set.

080

Moderator Introduction, Controversy: FUE vs. Strip Harvest FUT William R. Rassman, MD NHI, Los Angeles, CA, USA.

Dr. William Rassman received his MD from the Medical College of Virginia. He was stationed as a surgeon in Vietnam and was certified by the American Board of Surgery in 1976. He holds multiple patents in medical devices, computer software and biotechnology. He has published chapters in text books on cardiac surgery and hair transplantation. Included in his published work in the field of hair restoration have been pioneering articles in megasessions, follicular unit transplantation and follicular unit extraction. He recently released a highly ranked consumer book “Hair Loss & Replacement for Dummies” available on Amazon.com and in major bookstores.

W.R. Rassman: None.

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081

FUE vs. Strip Harvest FUT: Team Leader for "Pro FUE" side Alan J. Bauman, MD Suite 102, 6861 SW 18th Street, Boca Raton, FL, USA.

Dr. Alan J. Bauman is a diplomate of the American Board of Hair Restoration Surgery and a full-time Hair Restoration Physician in private practice in Boca Raton, Florida since 1997. He has performed FUE procedures since 2002 and was the first to demonstrate the FUE technique in a live surgery setting at the ISHRS Orlando Live Surgery Workshop in 2003. Up until 2007, FUE remained only 10% of all of his surgeries. Today, 90% of all hair transplants performed by Dr. Bauman include the transplantation of over 1500 FUE grafts.

A.J. Bauman: None.

ABSTRACT: The purpose of this panel discussion is to highlight the major differences between FUE and linear harvesting procedures. While there is never a 'one size fits all' surgery, the patient-demand for less invasive procedures and treatments is a well-known growing trend in all areas of cosmetic surgery. As techniques and technology continue to improve the speed and quality of FUE hair transplant harvesting, it is inevitable that more surgeons will adopt this technology.

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082

FUE vs. Strip Harvest FUT: Panelist for "Pro FUE" side Melike Kulahci, MD Transmed, Istanbul, Turkey.

Founder and Medical Director of Transmed since 1994, Current Ad Hoc Committee Member and Former Board Member of International Hair Restoration Surgery (ISHRS), 2000-2004. Former Board Member and Co-Founder of European Society of Hair Restoration Surgery (ESHRS) Recipient of various ISHRS research grants.

M. Kulahci: None.

083

FUE vs. Strip Harvest FUT: Panelist for "Pro FUE" side Ken L. Williams, DO Suite 390, Irvine Institute of Medicine and Cosmetic Surgery, Irvine, CA, USA.

Ken L. Williams, Jr., D.O. , is a board certified primary care physician practicing hair restoration and cosmetic surgery in Orange County, California since 2009. In his hair restoration practice, the primary surgical procedure utilized is automated FUE using the NeoGraft device. Dr. Williams is a member in good standing with the ISHRS, American Society for Laser Medicine and Surgery, and the American Academy of Cosmetic Surgery.

K.L. Wililams: None.

084

FUE vs. Strip Harvest FUT: Panelist for "Pro FUE" side Bradley Wolf, MD Wolf Hair, Cincinnati, OH, USA.

Dr. Wolf has practiced hair restoration surgery exclusively for almost 20 years. He is interested in all aspects of hair restoration surgery and performs strip excision surgery as well as FUE. He lives and practices in Cincinnati, Ohio.

B. Wolf: None.

085

FUE vs. Strip Harvest FUT: Team Leader for "Pro Strip Harvest" side Edwin Suddleson, MD East Tower Penthouse, BOSLEY, Beverly Hills, CA, USA.

Edwin A. Suddleson, MD, is Assistant Medical Director of Bosley, practicing in Beverly Hills. Dr. Suddleson joined Bosley in 1999 following a distinguished career as Assistant Professor of Clinical Surgery at the University of Southern California, Keck School of Medicine, and surgical instructor and practicing general surgeon at Huntington Hospital in Pasadena, California. Dr. Suddleson is a Diplomate of the ABHRS. Dr. Suddleson attended USC Keck School of Medicine. He completed training in surgery at Huntington Hospital in Pasadena, California where he was chief surgical resident. Dr. Suddleson is a member of the American Medical Association and the ISHRS.

E. Suddleson: None.

ABSTRACT: The quality of a hair restoration procedure is judged by the naturalness of the patients' final appearance. Factors included in patient satisfaction are the appearance of the hairs themselves, the apparent density of the hair and the absence of tell tale scars. Position, shape and density of the hairline are key, as are angle, direction and position of each transplanted hair. Make no mistake, success is judged from the front. Having an adequate supply of grafts is critical to success. In obtaining the necessary supply of grafts for an excellent result, Strip Harvest has been, and continues to be, the Gold Standard by which other harvest methods are measured. It is the technique in most common use today by far. Other methods of harvesting available, increasingly utilized for specific indications include various punch methods. Under which scenario's would patients benefit from alternative methods of donor harvesting?

For men who want to shave or very closely crop their hair, strip harvesting is of limited use. Does this patient want a hair transplant to show off the stubble? Some patients wish to preserve the option of shaving their heads in the future (presumably if the hair transplant does not meet expectations). This is more sales pitch than useful result. The operated scalp always shows some scar and the transplanted hairs show to the trained observer when closely cropped. On the other extreme, when patients have exhausted their available scalp by the strip method, punch harvesting can be used to generate a modest amount of additional hair from the scalp or body. This is done at great expense because there is no other harvest alternative. Donor area pain following harvest is clearly less with fine punch methods. There are no stitches to remove or dissolve. These minor advantages come at a cost. Patients must lie still in the prone or decubitus position for the laborious extraction process. In many cases sedation is needed due to discomfort and boredom. Accurate dissection of grafts under direct visualization to include vital structures is only accomplished via strip harvest, hence the reduced and random amount of loose connective tissue included in FUE grafts. Gentle handling of tissues is sacrificed to traction for extraction of grafts. In some scenarios, travel along suction powered tubing gives the grafts a good tumbling. Evidence of graft abuse is contained in the new language developing to describe the negative effects of punch extraction ie: Capping, Buried Grafts, Partial Transection, etc. It's no wonder graft survival rates are lower in punch harvest methods even in the most experienced hands. Strip harvest methods allow for rapid dissection of large numbers of grafts. Punch harvest is limited to one operator on the scalp, generating individual grafts one at a time. Although robot operated punches have been approved in the United States, this is not true everywhere. In no state or country is the use of surgical punches on live patients approved for non-licensed medical personnel, including commercially available punch/suction extraction devises, robots, or motorized punch systems. This means the physician must incise the skin with the punch, each and every time. In my practice and the practices of my colleagues, Drs. Ballon and Dr. Wong, a 2000+ graft case is average. To my understanding, FUE surgeons are charging $8 to $12 a graft, occasionally up to $30 a graft. This would certainly make most people think twice about a 2000+ graft procedure. Not many of our patients feel the cost yields a good value over strip harvest. Personally, I have a crisis of conscience offering a procedure that does not justify that kind of price tag. "Training" is non-existent for this procedure. Opportunities to develop skills are hard to come by as well so the learning curve is at the expense of the paying patient and the learning curve is long. It is a technically demanding procedure, even in experienced hands. Strip harvesting is less demanding on the surgeon and patient. It is far easier to master. The yields are predictable and far less dependent on uncontrollable factors like hair texture, color and curl. The use of punch harvest systems to generate large numbers of grafts is limited. Cost is double or triple to the patient and the result is still judged in the same way, that is, "How does it look with the hair grown in?" In my experience, the strip harvest is the superior method for most patients.

1) Efficiency of harvest better in Strip

a. Single operator v multiple trimmers at work station b. Doctors time (assuming the current medical model of licensed physicians operating on patients)

2) Graft Survival rates/Transection rates better in Strip a. capping, partial transection, inadequate connective tissues b. rough handling during extraction c. rough handling due to use of suction devises

3) Cost better in Strip a. Increased demands on physician time b. Expensive equipment which needs to be purchased cleaned and maintained c. 2x to 3x cost to patient or more

4) Availability better in Strip a. Training of FUE transplanters, long learning curve, even for experienced although occasional FUE

operators. b. Fewer cases can be done by each trained physician

5) Head shave for procedure not necessary for Strip 6) Complications in both Strip and FUE

a. Buried grafts b. Hypertrophic scarring c. Unappreciated long term effects on surrounding hairs d. Mottling or denuded areas from over-harvest e. Infections complications from tissue transfer from mechanical devises eg: drills

086

FUE vs. Strip Harvest FUT: Panelist for "Pro Strip Harvest" side Jonathan L. Ballon, MD 2615 Clubside Terrace, Alpharetta, GA, USA.

Dr. Ballon practiced neurosurgery for 16 years before discovering that hair transplantation could provide both a solution to his hair loss and a more relaxing second career. He works with Hair Club in their Atlanta, Charlotte and D.C. locations. In his free time, Dr. Ballon enjoys riding his motorcycle, hiking with his wife and Doberman, and reading. J.L. Ballon: None.

087

FUE vs. Strip Harvest FUT: Panelist for "Pro Strip Harvest" side Jerry Wong, MD Hasson & Wong, Vancouver, BC, Canada.

Dr. Jerry Wong, MD graduated from the University of Alberta Medical School with a background in general practice. He has been involved in hair transplants since 1992. He is a graduate of the Marzola School of Hair Surgery and is currently working at Hasson & Wong in Vancouver, Canada. Dr. Wong developed the Lateral Slit Technique. He has attended every ISHRS meeting thus far.

J. Wong: None.

088

Moderator Introduction, Finasteride Adverse Events Controversies Edwin S. Epstein, MD Suite 1, 60th St, Virginia Beach, VA, USA.

Edwin S. Epstein, MD, has been practicing hair restoration since 1990. He has served on the Board of Governors of the International Society of Hair Restoration Surgeons (ISHRS) since 2004, and was President for 2009-2010. He is a Diplomate of the American Board of Hair Restoration Surgery.. [[Unsupported Character -  ]]Dr. Epstein earned his B.A. degree from Duke University and his MD from Georgetown University. He completed internships and residency at Duke University Medical Center, and Washington University, Barnes Hospital. He is a Diplomate of the American Board of Urology, and a Fellow of the American College of Surgeons.

E.S. Epstein: None.

089

Persistent Sexual Dysfunction Controversy/Case Reports Ken Washenik, MD, PhD BOSLEY, Beverly Hills, CA, USA.

Ken Washenik, MD, Ph.D., is the Medical Director of Bosley and the Chief Executive Officer of the Aderans Research Institute, a biotechnology firm involved in researching tissue engineered hair follicle neogenesis and cellular based hair restoration. The former director of the Dermatopharmacology Unit at the New York University School of Medicine, Dr. Washenik continues to serve as a clinical investigator and faculty member in the Department of Dermatology. His Ph.D. is in Cell Biology and focused on hormone metabolism. He frequently lectures on the effects of hormones on the skin including their effects on hair loss and growth.


ABSTRACT: For more than a decade, finasteride has been prescribed for the treatment of male pattern hair loss. A discussion of the uncommon possibility of sexual side effects (e.g., decreased libido, erectile dysfunction, etc.) has been part of that process since its approval for this indication. However, the clinical trial data that revealed the possibility of these side effects indicated that, should they occur, these side effects are temporary and will resolve if the medication was discontinued. The data also indicated that, for most men who experienced one of these side effects, these side effects would also resolve if a patient continued to take the medication. Recently, however, the presence of a number of post-marketing reports of persistence of sexual side effects, despite discontinuation of the medication, has led to the addition of a notification of these reports to the package insert of finasteride in the United Kingdom, Sweden and, most recently, the United States. This presentation will review the controversy that has arisen concerning the post-marketing reports of persistent sexual side effects secondary to finasteride use. The definition of post-marketing reports will be covered as will two recent publications in the Journal of Sexual Medicine that highlighted the topic of possible persistence of finasteride related side effects and a survey of patients reporting persistent sexual side effects. This discussion will be part of a session that examines the side effect profile of finasteride from clinical trial data, physician clinic experience, post marketing reports and the occurrence of these types of complaints in the general male population.

090

Persistent Sexual Dysfunction Controversy Data and Possible Explanations Dow Stough, MD The Stough Clinic, Dallas, TX, USA.

Dr. Stough is a co-founder and past president of the International Society of Hair Restoration Surgery. He was presented the Golden Follicle Award in 1999 from the ISHRS for his continued innovation and research in the field

of hair transplantation. In 2010, he was awarded the Manfred Lucas Lifetime Achievement award by his peers. Dr. Dow Stough began hair transplanting under the tutelage of his father in 1985. He joined his father in private practice after becoming a diplomate of the American Academy of Dermatology. He has written more than 150 articles and given more than 100 scientific presentations. Dr. Dow Stough has over 26 years’ experience as a hair transplant surgeon and has performed thousands of hair transplant procedures.

D. Stough: None.

ABSTRACT: There was no published abstract at the time of printing the abstract book.

091

Prostate and Breast Cancer Edwin S. Epstein, MD Bosley, Virginia Beach, VA, USA.

Edwin S. Epstein, MD, has been practicing hair restoration since 1990. He has served on the Board of Governors of the International Society of Hair Restoration Surgeons (ISHRS) since 2004, and was President for 2009-2010. He is a Diplomate of the American Board of Hair Restoration Surgery, and the American Board of Urology, and is a Fellow of the American College of Surgeons.

E.S. Epstein: None.

ABSTRACT: Merck and Co. has recently made changes in the product information insert for Proscar® and Propecia® in response to reported post- marketing adverse events. In December 2009 the Medicines and Healthcare Products Regulatory Agency reviewed 53 cases of breast cancer in men using finasteride, and concluded that an increase in male breasts cancer associated with finasteride could not be excluded. The MHRA recommended a breast cancer warning in product information. Placebo controlled double blind studies in the US involving finasteride 5mg and 1mg were reviewed. In approximately 29,000 men studied, 8 cases of breast cancer were reported: 5 in the finasteride group and 3 in placebo. In 17000 men using dutasteride, 3 cases were reported; 2 in the dutasteride group and 1 in placebo. In December 2010, the US Food and Drug Administration held a hearing to discuss the efficacy and safety of Proscar® and Avodart® in prostate cancer risk reduction. The Prostate Cancer Prevention Trial (PCPT) reported a 26% lower risk of being diagnosed with medium grade prostate cancer in men in the Proscar® arm compared to the placebo arm. An unexpected finding was that men in the Proscar® arm had a 26 percent relative increase in high-grade (Gleason score 7 - 10) prostate cancers.

In the REDUCE trial, Avodart® was randomized in men considered to be at high risk for prostate cancer. Similar to the findings from the PCPT, the REDUCE trial found a 23 percent lower risk of being diagnosed with Gleason score 6 or less prostate cancer when compared to placebo. There was a notable increase in Gleason score 8 to 10 prostate cancers with Avodart®. The FDA rejected both requests by Merck and Co. and GlaxoSmithKline to respectively change product information reflecting Proscar®’s efficacy in reducing prostate cancer, and a new indication for Avodart® in the reduction of prostate cancer in men at risk for its development. Reasons of the panel were best summarized by this comment: “I voted no. There is no doubt that finasteride reduces the amount of early-grade prostate cancer that was detected. At the same time, there’s also no doubt that the rates of high-grade prostate cancer were increased, and that’s an unacceptable risk in a population of men who don’t have prostate cancer.” * The issue remains controversial: the detection of high Gleason grade cancer is higher in men using 5 ARI’s, while the detection of low-medium grade prostate cancer is significantly reduced. Biases inherent to the study designs may explain a large percentage of this increase. Because 70% of Gleason grade 6 and below may be at low risk for progression, it has been argued that 5ARI’s may be reducing cancer that may never cause significant morbidity or mortality, and surveillance may be a treatment option, without potential side effects associated with 5 ARI’s. However, 90% of these diagnosed patients will seek definitive therapy, which have significant morbidity potential. Concerning chemo-prevention, informed consent discussions with patients should qualify this potential therapy to patients at risk for prostate cancer: including age, African-American ethnicity, family history, and clinically suspicious disease. Annual PSA and DRE should be obtained according to the guidelines of the American Urological Association, and a PSA multiplier of 2.5 should be factored for men using 5 ARI’s over 7 years. While this class of drugs has been successfully used for over 14 years in the treatment of BPH and Androgenetic Alopecia with a relatively low adverse event profile, there remains a lack of understanding of their biology in terms of prostate cancer in the long-term setting. *www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/OncologicDrugsAdvisoryCommittee/UCM237499.pdf

092

Informed Consent Issues Robert M. Bernstein, MD Bernstein Medical, New York, NY, USA.

Robert M. Bernstein, MD, F.A.A.D. is Clinical Professor of Dermatology at Columbia University and founder of Bernstein Medical - Center for Hair Restoration in New York. He is a member of the ISHRS Task Force on Finasteride Adverse Events and co-author of Update on the pathogenesis, genetics and medical treatment of patterned hair loss.

R.M. Bernstein: None.

ABSTRACT: Informed Consent Issues The use of finasteride is associated with a number of uncommon, but significant, side effects that include sexual dysfunction, gynecomastia, lowering of PSA, and potential birth defects if ingested by a pregnant woman carrying a

male fetus. Since the approval of finasteride 1mg for the treatment of hair loss in 1997 new, but as yet unproven, concerns have arisen regarding this medication. These include; an increased risk of being diagnosed with a higher grade prostate cancer and persistent sexual dysfunction after discontinuing the medication. In order to insure that full disclosure of the possible adverse reactions of finasteride have been communicated to the patient, we have used a detailed consent form in our practice since 1997. This presentation will discuss the salient features of our present consent form and some significant changes we have made to its content over the years.

093

Moderator Introduction, Scientific Free Papers I Sungjoo (Tommy) Hwang, MD Dr. Hwang's Hair Hair Clinic, Seoul, Korea, Republic of.


S. Hwang: None.

094

Meta-Analysis of All Hair Transplant Survival Studies To Date Michael L. Beehner, MD Saratoga Hair Transplant Center, Saratoga Springs, NY, USA.

Michael Beehner, MD has practiced hair transplant surgery full-time since 1989 in Saratoga Springs, NY. He is a diplomate of the American Board of Hair Restoration Surgery and formerly the American Board of Family Practice. He served as president of the ABHRS in 2005, was co-editor of the Forum (2002-2005), received the Platinum Follicle Award in 1999 and the Manfred Lucas Lifetime Achievement Award in 2007, along with four research grants from the ISHRS. He has written over 50 clinical articles on hair transplantation and has written several textbook chapters.

M.L. Beehner: None.

ABSTRACT: Introduction: The main purpose for this talk is to take an overall view of all studies to date on hair growth and survival in various size grafts. The great majority of these studies have been done with FU's, and these will be looked at with regard to both planting density and whether they are 1-hair, 2-hair, or 3-hair FU's. This talk will confine itself mainly with grafts planted without any undue stress factor present. If time permits, I will look at those as a group and make appropriate comments, comparing how various grafts did in the face of these stress factors. This author has completed approximately 20 hair growth studies over the years of various types which will be included. Studies on FU growth by researchers such as Jung Chul Kim, Mel Mayer, Sharon Keene, Walter Unger, David Perez-Meza, William Reed, and Jennifer Martinek will be included. Premise: There is no one objective I am out to prove, other than to see if the trends found by other researchers are somewhat similar to the conclusions I have found in my own research. A number of conclusions I have reached over the years in my own research are the following:

- Two-hair FU grafts survive better than one-hair FU grafts, and three-hair FU's likewise do better than two-hair FU's.

- Multi-FU grafts ("mini-grafts") survive at a higher percentage than FU grafts - "Chubby" FU grafts result in more hairs being present than "skinny" or "skeletonized" FU grafts. - Stress-factors, such as drying, time-out-of-body, partial transection of the graft, graft handling trauma, and

hydrogen peroxide result in decreased graft survival percentages. - FU grafts planted in the 30/cm2 range predictably survive with high percentages near 90-95%, while those

in the 50/cm2 or above vary in various studies and are not as predictably good.

Discussion: All of the raw numbers for "large" grafts, "mini-grafts," and FU grafts from all available studies will be aggregated and presented. The only ones that will be excluded will be those grafts from studies in which a stress factor was deliberately introduced into the study. With regards to FU grafts, where possible, these numbers will be presented separately and compared for FU grafts with one, two, and three hairs per graft.

095

15 Years of Experience with the Use of Cross Hatching Surgical Technique to Improve Naturalness of a Hair Transplant Procedure Matt Leavitt, DO1, David Perez-Meza MD2 1Bosley, Maitland, FL, USA, 2Permanent Hair Solutions, Mexico City, Mexico.

Matt Leavitt, DO, FAOCD is a Board-Certified Dermatologist and Diplomate of the American Board of Hair Restoration Society. He currently serves as ISHRS Chairman of the Live Workshop Committee and previously served on the Board of Governors. He is also Chairman of the Live Workshop 2011. He was a founder and vice

president of ABHRS. He was president of the American Osteopathic College of Dermatology and received numerous awards, chief among which is the Golden Follicle from the ISHRS which he received in 2002. Dr. Leavitt has authored numerous chapters in textbooks on hair restoration and published a book on Hair Loss in Women.

M. Leavitt, DO: None. D. Perez-Meza MD: None.

ABSTRACT:

As hair restoration surgeons, we are all aware that the most important areas from a cosmetic point of view are the hairlines (anterior, laterals and posterior). We must create and restore hairlines that are undetectable and appropriately located to provide the best result for the patient. General consensus is that only one-hair grafts should be used for the first rows of the hairlines followed by a transition zone of two and three-hair grafts. It is also generally accepted that the anterior hairline has to be irregular and random to achieve a natural look. Many different instruments can be used to create the recipient sites in the hairlines with each instrument varying in angles and directions of the hair. In order to achieve a more natural-looking effect, a new approach of “cross-hatching” hairs has been performed in thousands of patients in a 15-year period Objective: To present our 15 year experience with the cross hatching technique in hair restoration which increases naturalness by crossing hairs using oblique angles crossing each other. This technique has been used in all areas of the scalp but especially in the anterior, laterals (temple) and posterior (crown) hairlines.

096

Mastering Clinical Photography In Hair Restoration Surgery Robert S. Haber, MD CWRU School of Medicine, Cleveland, OH, USA.

Robert Haber, MD is a Board Certified Dermatologist specializing in Hair Restoration Surgery. He is a Clinical Associate Professor at Case Western Reserve University School of Medicine and faculty member of University Hospitals of Cleveland. Dr. Haber has co-authored two textbooks in the field of hair restoration surgery: "Hair Replacement - Surgical and Medical" in 1996, and “Hair Transplantation” in 2006. He has authored ten textbook chapters, 18 original reports, and has presented over 130 papers at meetings throughout the world. Dr. Haber has served as President of the ISHRS, as Co-Editor of the Hair Transplant Forum International, and was honored as a winner of the Golden Follicle Award in 2009.

R.S. Haber: Ownership Interest (royalty, patent, or other intellectual property); Ellis Instruments.

ABSTRACT: Introduction: In spite of many lectures over the years, photographs and videos presented at our meetings are frequently of poor quality. The availability of high quality, simple digital cameras has actually worsened this situation by allowing the photographer to remain ignorant of basic photographic principles. This lecture is intended to clearly identify some of the most frequent errors and their solutions. Premise: Every surgeon who wishes to share his or her results or techniques has an obligation to master clinical photography. Showing poor quality images and videos is not only an insult to the audience, but often makes the results themselves seem questionable. Every office has space to devote to photography, and with minimal expense, excellent photographic results can be assured. Substantiating data: Take a critical look at the photos and videos at this conference. Are they properly focused? Is there distracting background activity? Are before and after series presented in identical fashion? Do faces appear distorted? The reasons for these problems are simple, as are the solutions. Discussion: Quality photography begins with equipment. Simple as well as advanced cameras can be used, but the best results require studio strobes, and these only work best with more advanced equipment. Creating a small studio is easy, and requires very little room. Photographic technique involves an understanding of aperture settings and magnification. Intraoperative still or video photography requires additional technique adjustments. Mastering clinical photography is the best way to showcase a surgeon’s results, and is well worth the effort.

097

Moderator Introduction, Body and Beard Used as Donor -- Eyebrow and Eyelash Transplants John P. Cole, MD International Hair Transplant Institute, Alpharetta, GA, USA.

Physician

J.P. Cole: None.

098

One-Hour Eyebrow Transplantation (150 Grafts-placing in 10 minutes with Choi Implanters) Dae-young Kim, MD, PhD Yonsei Hair Clinic, Seoul, Korea, Republic of.

Dr. Dae-young Kim is a board certified plastic surgeon and a Diplomate of ABHRS, practices hair restoration surgery since 2000 in Seoul. He presented 3 papers about "Pustule-Free Trichophytic Closure" at the 16th and 17th ISHRS annual meetings in Montreal and Amsterdam. These papers were also printed in the FORUM of ISHRS and the 5th edition of Walter Unger's text book. At the 18th annual meeting in Boston he presented "20X digital microsopic dissection" and "Placing 1500 grafts per hour with Choi implanters."

D. Kim: None.

ABSTRACT: One-Hour Eyebrow Transplantation (150 Grafts-placing in 10 minutes with Choi Implanters) Dae-young Kim, MD, PhD Apkujung Yonsei Hair Transplantation Center, Seoul, Korea Background: Eyebrow hair transplantation requires 3 to 4 hours for about 100-300 single-hair grafts on each side. The knowledge of anatomy and hair direction is essential for eyebrow transplantation. Introduction: The ability to direct control of Choi implanter is very useful. However, since graft-placement using the device is still time-consuming, so that we introduce an original technique which would effectively shorten the operating time. Objectives: It would be beneficial to find out an effective way of using Choi implanters for reducing the operation time. We introduce "Rapid placement technique with Choi implanters in eyebrow transplantation” which would change a 3-to-4-hour operation into speedy one-hour surgery. Methods: For eyebrow transplantation, we exclusively utilize one-hair grafts or longitudinally dissect all multi-hair grafts into one-hair FUs. We first grab 10-15 loaded implanters in left hand and then transfer them to right hand, one by one. After the grafts are placed, empty implanters remain in right hand. When empty implanters are gathered until a number of 5 to 7, they are handed over to technicians for reloading. Discussions: Two conditions that we must care after the insertions are that empty Choi implanters which pre-loaded grafts are accidentally and fully slided-out and partially slided-out (half-loaded) implanters which cause hair follicles bent or crushed. We should remove and replace the grafts consecutively. Conclusions: With the both-hand technique of “Rapid eyebrow transplant,” we could place 150 grafts in 10 minutes with assistance of 4 technicians. As we minimized unnecessary physical movements, we could more easily concentrate on the magnified visual fields and place more grafts in rapid succession of original both-hand technique. An effective use of choi implanters for eyebrow hair transplantation is advantageous for both speedy and accurate operation Figure 1. Ten to 15 loaded Choi implanters are first grabbed in left hand. Figure 2. Ten loaded implanters in left hand and then transfer them to right hand, one by one to place the grafts. Figure 3. When the grafts are placed, empty implanters are left in right hand until 5-7 empty implanters are gathered, then passed to and reloaded by technicians.

http://files.abstractsonline.com/CTRL/f1/b/e9e/5b5/90e/420/f9e/ca0/146/9bd/f4d/00/g42_1.JPG�





099

Hairline Refinement Using Leg Hair Sanusi H. Umar, MD FineTouch Dermatology Inc, Redondo Beach, CA, USA.

Dr. Umar is a board certified dermatologist and a fellow of the American Academy of Dermatology. He is faculty at UCLA dermatology department. He has been performing non head hair to head transplants at his clinic (FineTouch Dermatology Inc.) for the past 6 years and has published in the subject. He has presented on the same subject at past ISHRS meetings.

S.H. Umar: None.

ABSTRACT: Background: Follicular unit techniques in hair transplantation traditionally use head hair derived from the safe donor area. However, the inherently large caliber of safe donor area hair imparts a coarse hairline. Natural hairlines are typically softer especially in the slight recessed hairlines that hair transplants aim to mimic. Objective: To demonstrate that in hirsute individuals the use of leg hair in hair transplantation to the hairline results in a superior aesthetic appearance. Methods: Two case reports are described. One patient received grafting of 1,025 leg hair follicles to an area covering 0.5-1.0 cm in front of and 0.5-1.0 cm internal to the original vanguard hair of the original hairline and temporal recesses; the other patient received grafting of approximately 1,000 leg hairs and 600 head hairs to advance and soften his hairline, and to create a custom widow’s peak with more leg hair in the vanguard area. Results: Transplantation resulted in a fully grown and soft-looking hairline after 9 months in the first patient. Mean length of the transplanted hair was slightly longer than that of the original leg hair with less curliness but similar hair width. However, transplanted hair width was significantly finer compared to existing head hair width. After 4 years, sustained results were achieved, minimizing concerns that hair loss might result from leg hair cycle variations. In the second patient, similar results were sustained at 3 years. Limitations: This technique is limited to individuals with sufficient donor leg hair. Conclusion: The use of leg hair in hair transplantation provides more options in those cases in which hairlines need to be refined or reworked.

100

Case Study of the Clinical Result of 4100 Beard Graft Transplants to the Scalp James A. Harris, MD University of Colorado, Greenwood Village, CO, USA.

James A. Harris, MD, FACS, received his medical degree with honors from the University of Colorado School of Medicine in 1989. He is a Diplomate of the American Board of Otolaryngology, Fellow of the American College of Surgeons, member of the American Academy of Otolaryngology and the International Society of Hair Restoration Surgery. He is a Clinical Instructor of Hair Transplantation at the University of Colorado Health Sciences Center in Denver, Colorado. Dr. Harris has developed a surgical methodology and instrumentation for performing follicular unit extraction that ensures graft safety and integrity called the Harris SAFE System®.

J.A. Harris: None.

ABSTRACT: Introduction: A 34 year old male with a history of transplants in his 20’s now desires additional density and a more appropriate location for his frontal hairline. The patient also has a widened donor area scar that is visible with the hair cut at his preferred length. On examination the patient has a low frontal hairline, cosmetic tattoos in a 3-4mm wide donor area scar and significant miniaturization of the scalp donor hair. The patient has what appears to be very dense beard hair in the submental and neck areas. Methods and Materials: A powered blunt FUE device utilizing primarily the .9mm inside diameter dull dissecting punch was used for the beard FUE. A 1mm inside diameter manual blunt FUE punch was used to extract 233 of the previously planted grafts in order to reshape the frontal hairline. The protocol for the beard extraction was the extraction of approximately 1000 grafts from unilateral submental and neck areas on each of 2 consecutive days. Two weeks later the same protocol was followed. The frontal hairline FUE revision was performed at the first visit. Results: Photos to be taken to show the recipient and donor areas. Conclusion: Pending final outcome.

Case Report: 4000 Graft Beard FUE

James A. Harris, MD, FACS

Clinical Instructor – Hair Transplantation

Department of Otolaryngology/ Head and Neck Surgery

University of Colorado Health Sciences Center

and

The Hair Sciences Center of Colorado

Denver, Colorado

No COI to report

Treatment Objectives

• FUE to correct the position of the

FHL

• FUE to harvest from the beard to

enhance scalp coverage

Clinical Plan• Raise hairline

• Move fronto-temporal angle posteriorly

• Obtain grafts from beard using FUE

• Increase frontal density

Immediate post-op frontal hairline

revision by FUE and 2000 beard grafts

Brief Beard FUE Video

Pre-op 2 Weeks after 2000 graft FUE

2 Weeks following second session of 2000 grafts

Thank You

101

Eyebrow Transplantation - Problems & Outcomes Melike Kulahci, MD, Ozge Ergun, MD, Ali Emre Karadeniz, MD Transmed Hair and Cosmetic Surgery Clinic, Istanbul, Turkey.

Founder and Medical Director of Transmed since 1994, Current Ad Hoc Committee Member and Former Board Member of International Hair Restoration Surgery (ISHRS), 2000-2004. Former Board Member and Co-Founder of European Society of Hair Restoration Surgery (ESHRS) and recipient of various ISHRS research grants.

M. Kulahci: None. O. Ergun: None. A. Karadeniz: None.

ABSTRACT: Introduction: There has been a big rise in demand for eyebrow transplantation in Istanbul, Turkey. With almost three patients per week, there has been many improvements to the technique and approach of the physician to eyebrow cases. Maximizing growth rate and site creation techniques will be the focus of this presentation. Premise: The author of this presentation argues that high growth rate can be retained only until a certain FU-amount trashhold. The author will also show her approach to site creation directions and sizes. Substantiating data: A series of 20+ patients' before & after photos. Discussion: Do you agree with sticking to a threshold of FU's for eyebrow cases? What is your approach to site creation for eyebrow patients?

102

Magnifying-Aded High-Densed Eyelash Transplantation Weiming Jing, MD Plastic Surgery Hospital, Beijing 100143, China.

Dr. Jing is a plastic surgeon trained in Shanghai, Beijing, Hong Kong University, and Paris (French College of Plastic Reconstructive and Aesthetic Surgery), who's work is mainly plastic and cosmetic surgery.

W. Jing: None.

ABSTRACT: As reviewed in different data and papers, as few as 6 to 20 or more hairs are generally transplanted for cosmetic purposes of enhancing eyelashes. In the author's practicing experiences, this is not enough for each upper lid to satisfy the patient's expection. They request more and need more. With the aid of magnifying (3 x), author has transplanted as many as 50-70 single FUs, which is twice or triple the general transplanting, on each upper eyelid for ornament. The hairs take well. Patients are satisfied with the results although and are informed to do some postoperative work such as cutting and curling to ornament. Indications and preoperative precautions are discussed in the paper. Magnifying-aided high-densed eyelash transplantation is a satisfying cosmetic procedure to those who like to enhance their eyes. The use of magnifying transplanting helps to choose the skin spaces between the original eyelash and makes sure more natural direction of the transplanted hairs is achieved. Compared with the other techniques or lower transplanting density choices, magnifying-aided high-densed eyelash transplantation could achieve better cosmetic results. But more densed, say, than 70 FUs for each upper lid or on lower lid has not yet been done and it needs more investigations.

Magnifying-Aided

High-DensedEyelash

Transplantation

Dr Weiming JING,

Hair Transplantation Centre of Plastic Surgery Hospital, Beijing, China

Introduction

• Eyelash

-Function

-Ornament

perhaps more important

Introduction

• Surgery Techniques Review

-’Pluck –and- Sew’ Technique

Caputy & Flowers(1994)

-Choi Implanter Technique

(1992)

Surgical Technique

• HIGH-DENSED EYELASH TRANSPLANTATION (HDLT)

• Mini-Scalp strip(as small as 1.5 x 1.0cm) harvest with long clipped hair(as long as 4cm) in SDA

• SINGLE hair grafts( as many as 50-70 on demand) isolated

• ‘Sewing’ technique is used

Surgical Technique

• Step One

- hair harvest

- grafts praparation

with magnifying (3x)

Surgical technique

• Step Two

Transplant

-under LA

-with manigfying (3x)

-with asistant’s help

‘ready to sewing’

Surgical Technique

• Step Three

Sewing Technique

PERSONAL PREFERENCE

- from the MIDIUM to LATERAL in order to keep appropriate directions

- chilly sponge cover on the finished side for 15-20 mins and

antibiotic ointment applied

RESULT

• Twenty cases (40 upper lids )

• 19 /20 satisfied, only one

complained the fast growth( even though informed

preoperatively)

DISCUSSION

• ‘Pluck and Sew’ and Choi Implanter techniques are the creative ones,

but limited in the 20-30 grafts on each upper lid (50 grafts) generally. Those are not enough to all

‘patients’, EVEN THOUGH the oprative results are acceptable.

• More ‘patients’ ask more densedeyelash for ornament, ‘the more the better’ they ask usually in my

personal experiences.

DISCUSSION

• ABOVE AFORMENTIONED

push and persuade us to explore more efforts.

• Magnifying-aided High-densed

Eyelash Transplantation (HDELT) provides us evidences

to meet that challenge.

DISCUSSION

Though some complications

such as uncomfortable , growth

postoperatively, potential inflammation and reoperation,

HDELT STILL makes it possible

to have a path to get more beautiful eyelash and eyes.

CASES

103

Moderator Introduction, Scientific Free Papers II Jorge I. Gaviria, MD Miami Beach Hair Institute, Miami beach, FL, USA.

Dr. Jorge Gaviria is in private practices at the Miami Beach Hair Institute in Miami Beach, Florida and Gaviria & Trius in Barcelona, Spain. Has completed two ISHRS accredited fellowship programs in Hair Restoration. Brings research, surgical and artistic background to our profession, is the principal investigator and has authored several protocols on the topics of evidence based medicine: donor site closure, dense packing and survival rates, ciclopirox vs. clindamycin in folliculitis, digital medical hair, hair cloning and stem cell research. Well known study on trichophytic closures. Evidence based medicine should be our philosophy

J.I. Gaviria: None.

104

A Simple Way to Isolate and Cultivate Dermal Papilla Cells from Human Scalp Hair Follicle Ratchathorn Panchaprateep, MD Chulalongkorn University and DHT Clinic, Bangkok, Thailand.

Ratchathorn Mornchan, MD

Address: Division of Dermatology, Chulalongkorn University and DHT Clinic, Bangkok, Thailand Email Address: [email protected] Education: 2003: Medical degree (First Class Honours), Chulalongkorn University, Bkk, Thailand 2005-2007: Master degree of Science in dermatology, Chulalongkorn University 2007- 2008: Clinical fellow in Dermatologic Surgery, Ramathibodi Hospital, Mahidol University 2008- : PhD in dermatology, Chulalongkorn University(research on hair and skin stem cells) March 2011-: Fellow in Hair Restoration Surgery, DHT Clinic, Bkk, Thailand Qualification

Doctor of Medicine (MD) (First Class Honours) Medical License, Thai medical council Master of Science in Dermatology 2008: Fellowship in Dermatologic Laser Surgery

Professional Memberships The Medical Council of Thailand The Dermatological Society of Thailand The Thai Cosmetic Dermatology and Surgery International Society of Hair Restoration Surgery

R. Panchaprateep: None.

ABSTRACT: A Simple Way to Isolate and Cultivate Dermal Papilla Cells from Human Scalp Hair Follicle background: The past few years have seen significant developments in hair follicle research including hair multiplication and regeneration. It is a basic necessity for healthy dermal papilla cells to be isolated and cultured. The most commonly used method to isolate dermal papilla cells is microdissection technique which requires significant skill, is time-consuming and has several limitations regarding cell adhesion and low growth-out rates. Objective: To simplify and improve the method of isolation and culture of human hair DP cells. Material and method: By combining a simple dissection technique with one-step enzyme digestion, we easily obtained these cells on a large-scale in rapid time. The DP from each hair follicle was easily obtained by simple transection at the level of upper papillae with ophthalmic corneal blade under a stereomicroscope. The isolated DP was then digestion with Liberase DH (dispase high) research grade (Roche, Basel, Switzerland) at 37ºc for 2 hours. After enzymatic dissociation, the DP was cultured in a plastic plate under normal condition. Result and discussion: We used the activity of a new mixture of purified enzymes, dispase and collagenase, to proteolysis the membrane and extracellular matrix of dermal papilla. Our cultured DP cells showed high adherent and growth-out rate than microdissection alone. The DP cells in the culture condition grew well without the need of collagen-coated plate, showed and stained positive with specific markers. Summary: In this study, we developed a more simple, rapid and efficient method for the isolation and culture of DP cells from a human scalp hair follicle. Optimistically, our results will provide some useful cell culture information in the field of hair study. Keywords: isolation, dermal papilla cells, hair follicles

A Simple Way to Isolate and

Cultivate Dermal Papilla Cells

from Human Scalp Hair Follicle

Ratchathorn Panchaprateep, MD.

DHT Clinic, Bangkok, Thailand

Disclosures

• Speaker has no relevant financial relationships or conflicts of interest to declare

1. Epidermal (epithelial)

compartments

– CTX+ORS (stem cells in bulge)/

IRS+cuticle/ cortex+medulla

2. Dermal (mesenchymal)

1. Dermal papilla (DP)

– Like a tear drop, located at the base

of HF with its own blood supply

2. Dermal sheath (DS)

– Connective tissue sheath lines

epithelium

Hair Follicle Structure

• Cluster of special fibroblasts embedded in ECM (collagen type I, III, IV and laminin)

• Direct correlated to the size of HF and the fiber produced

• DPCs is a niche of bulge cells

• DPCs function as “inducers” send signals to regulate the hair growth and renewal of neighboring tissues

Dermal Papilla (DP) Cells

Background

• Most therapeutic efforts to date have concentrated on the idea of expanding the number of inductive dermal cells and establish a hair reconstitutional assay that could eventually have therapeutic implications

• It is basic necessary for healthy DP cells to be isolated and cultured in every hair follicle research

Surgical microdissection

• The most commonly used method to isolate dermal papilla (DP) cells is “Microdissection technique”

• Requires significant skill

• Time-consuming

• Have several limitations

• Poor cell adhesion

• Low growth-out rates

Enzymatic Digestion

• Proximal portion of HF was digested with dispase for 16-18 hrs at 4ºC and then with collagenase for 4-6 hrs in the incubator

Dispase Collagenase

Objective

• To simplify and improve the method of isolation and culture of human hair DP cells.

Material and Method

• Excess normal hair follicles or scalp specimens were obtained from hair transplantation surgery

• The specimens were transported in Williams’E serum free media with 2% antibiotic-antimycotic at 4°C, not over than 48 hrs

Isolation of DPC

• The specimens were repeated washed with phosphate-buffered saline (PBS)

• To isolated DPC, we used simple microdissection with one-step enzyme digestion technique

Surgical Microdissection

• DP from each hair follicle was obtained by simple

transection at the level of papilla with ophthalmic

corneal blade under a stereomicroscope.

The isolated DP after dissection

Isolation of DPC

• After dissection, the isolated DP were digested

with Liberase DH (dispase high) research grade

(Roche, Basel, Switzerland) at 37 ºC for 2 hours

or until the capsule sheath of DP were digested

Cultivation of DPC

• After the enzymatic dissociation, DPC are cultivated in a 6-well plate in DMEM (Sigma Co) supplemented with nutrient Ham F12 (3 parts of DMEM, 1 part of Ham’s F12), 10% fetal bovine serum (FBS), 200 mmol/L L-glutamine and 1% antibiotic-antimycotic

Cultivation of DPC

• The cultures are incubated at 37˚C in a humid atmosphere containing 5%CO2

• The culture plates were kept untouched for 3 days, allowing cells to adhere.

• The medium changes every 2 days

Cultured DPC by simple dissection and

one-step enzyme digestion

DP after digestion was in spherical shape. It attached quickly within one day

on the plastic plate with higher attached rate ∼∼∼∼ 90%

×100×100



One day after, the cells initially outgrowth from the DP explants and spread

out like sunflower

×100×100



One day after, the cells initially outgrowth from the DP explants and spread

out like sunflower

×100×100



DP after digestion was in spherical shape. It attached quickly within one day

on collagen coated plated with higher attached rate ∼∼∼∼ 90%

×100×100

Difference from the dermal fibroblasts and dermal sheath cells, DP cells

proliferate quickly and form multilayer aggregation and clump.



About 2 weeks , the DP cells reached confluence and can be subcultured.

×100×100

Cultured DPC by Microdissection alone

DP isolated by microdissection was very hard to adhere even using little

medium , covered by a coverslip or needle scratch technique .

×100×100

About 5-10 days after, DP began to attached and the cells outgrowth from

the explant in about 1-3 weeks

The cultured DPC showed positive with immunohistochemical staining

Toluidine Blue

VimentinSMA

AB-PAS

Immunohistochemical staining of DPCcompared to DS and DF

Cell Type AB AB-PAS Toluidine blue Vimentin SMA

DP Cells + ++ + + +

DS Cells + +- - + +

Fibroblasts - -- - + -

• The cultured DP cells were identified by positive immunohistochemistry which were similar to the staining results of in situ hair follicle and consistent with published report.

Arch Derm Res 2005, 297: 60-67.

Discussion

• Our Method combined the simple microdissection with one-step enzymatic digestion, by using the activity of a new mixture of purified dispase and collagenase I + II enzyme (Liberase DH (dispase high))

– Collagenase activity 14 Wunsch unit/ ml

– High dispase (neutral protease) from Bacillus Polymyxa

– Endotoxin < 50 EU/mg

Discussion

1. Main advancement of this method is the reduction

of the former two-step enzymatic digestion of 20-24

hours to one incubation step of only 2 hours using

mixture of purify enzyme

2. Combined with simple microdissection first to

separate DPs out from DS under microscope

– Decrease possibility of DS cells contamination

when using enzymatic digestion alone

Discussion

3. Higher cell yield and viability

� Most of out DP attached within 1-3 days (90% attachment

rate) and the cells can spread out more quickly

• The reason is the use of Collagenase type I+ II directly

digest the capsule sheath and proteolysis the extracellular

matrix � facilitate cell attachment and migrate out more

freely

• The dispase act synergistically with collagenase

Comparison of 3 method of DPC Isolation

MethodSurgicaldissection

Enzymatic digestion Our Method

Description Cut DS to expose DP � release DP by pressure or cutting stalk

Two-step enzymeUsing dispase and then collagenase treatment of lower hair follicle

Simple microdissection(Cut DS to isolate DP )One-step enzyme(LiberaseDH: collagenase+dispase)

Adventage Preserve the intact DP Reduced labor, more efficient

Time saver, Efficient with high purity

Time use Require significant skill, Time-consuming

16-18 hours for dispase6-8 hours for collagenase

3 hours

Cultureoutcome

Low product, poor cell adhesion, low growth-out rates

Better yield, but possible contamination of DSC

Better cell attachment + cell yield and viabilityLess DSC contamination

Conclusion

• In this study, we developed more simple, rapid and efficient method for isolation and culture of DP cells from human scalp hair follicle.

• Hopefully, our results will provide some useful cell culture information not only in he basic of hair biology but also in the field of hair folliculogenesis and tissue engineering.

Thank you for your attention

105

Management of Arrhythmia and Updated Guidelines for Perioperative Beta Blockade Therapy in Hair Restoration Surgery Kuniyoshi Yagyu, MD Kioicho Clinic, Tokyo, Tokyo, Japan.

Kuniyoshi Yagyu, MD, has been exclusively practicing hair transplantation in Tokyo. He serves on the Board of Governors of the International Society of Hair Restoration Surgery. He is a Diplomate of the American Board of Hair Restoration Surgery, past president and board governor of the Japan Society of Clinical Hair Restoration, and a winner of the ISHRS Research Award in 2010. He has authored 44 research and clinical publications in books and journals. He had specialized in the field of cardiac surgery for 22 years. He is a board certified cardiac surgeon, cardiologist and respiratory physician as well.

K. Yagyu: None.

ABSTRACT: Introduction and Objective: Sometimes patients with arrhythmia visit our clinic for hair restoration surgery. Some arrhythmias are life-threatening causing sudden cardiac arrest and others need careful monitoring during surgery. There are other types of arrhythmias which are relatively safe. Knowledge and control of arrhythmia and prevention of arrhythmia are crucial for a safe operation. Patients with arrhythmia or coronary artery disease often need treatment with beta blockers. Beta blockers are widely used for management of cardiac arrhythmias and hypertension. Is a beta blocker a dangerous drug and should it be stopped before hair transplantation? Would a beta blockers cause hypotension, bradycardia and heart failure during surgery? Beta 1 selective blockers reduce perioperative mortality and non-fatal heart attacks in patients undergoing non-cardiac vascular surgery. Beta blockers have revolutionized the medical management of angina pectoris considered to be one of the most important contributions to clinical medicine pharmacology in the 20th century. Updated knowledge about guidelines for perioperative control of beta blockers will be summarized in this study. Material and Methods: The subjects of this study were patients with cardiovascular disease who visited our clinic for hair transplantation. The patients underwent up to four sessions. Arrhythmia included Burgada syndrome, Wolff-Parkinson-White (WPW) syndrome with tachycardia and ventricular premature contraction (VPC). Other disorders included supraventricular tachy-arrhythmia, atrial flutter, atrial fibrillation, ischemic heart disease with myocardial infarction, angina pectoris and valvular heart disease. Patients with ischemic heart diseases were under the treatment by percutaneous coronary intervention (PCI), coronary artery stents and coronary artery bypass grafting. Results: Patients underwent up to four sessions without complications under hemodynamic monitoring. Precise diagnosis of arrhythmia offered us a choice of treatment for cardiovascular patients. A patient with Burgada syndrome needed an implantable cardioverter defibrillator before hair transplantation. Patients with WPW syndrome and VPCs underwent safe operations under careful management. Maintenance dose of a beta blocker and other drugs were continued during hair transplantation. Epinephrine in tumescence solution was used as usual or in a lower dose. Discussion: Life-threatening irregular heartbeats, especially those that cause sudden cardiac arrest, should be controlled before surgery. Conditions predisposing towards arrhythmias and sudden cardiac death should be treated before surgery. Special attention should be paid to serious arrhythmias such as Burgada syndrome and WPW syndrome. Burgada syndrome should not be considered as a surgical candidate unless the patient receives implantation of a defibrillator. WPW syndrome with tachycardia episodes is a dangerous arrhythmia. Patients with arrhythmia should be under the care of experienced cardiologists with stable doses of drug therapy optimized for more than three months without

hemodynamic and electrocardiographic complications at an outpatient clinic. A beta blocker is widely used for management of cardiac arrhythmias and hypertension. It is also used for cardioprotection after myocardial infarction. Beta blockers have revolutionized the medical management of angina pectoris and are considered to be one of the most important contributions to clinical medicine pharmacology in the 20th century. Therefore, updated knowledge about guidelines for perioperative control of beta blockers is crucial in hair restoration surgery. There are three known types of beta receptors. Beta 1 adrenergic receptors are found in the heart and kidney. Stimulation of beta 1 receptors induces a positive chronotropic and inotropic effect on the heart and increases cardiac conduction velocity and automaticity. Stimulation of beta 1 receptors on the kidney causes renin release. Beta blockers are indicated in supraventricular arrhythmias such as sinus tachycardia, supraventricular tachyacrdias and WPW syndrome with orthodromic atrioventricular tachycardias. Beta blockers are also used for rate control in atrial flutter, atrial fibrillation, and ventricular arrhythmias. Beta blockers are used for conditions predisposing towards arrhythmias and sudden cardiac death in acute myocardial infarction. There is some recent surprising information about beta blockers. Beta blockers significantly reduce mortality in stable ischemic and non-ischemic heart failure. Beta selective blockers are effective in reducing morbidity and mortality in type II diabetics with hypertension. Beta 1 selective blockers reduce perioperative mortality and non-fatal heart attacks in patients undergoing non-cardiac vascular surgery. There are many kinds of beta blockers with or without intrinsic sympathomimetic action and membrane stabilizing effects. Among them, esmolol, sotalol, and landiolol will be chosen for cardiac arrhythmia. Bisoprolol, carvedilol, metoprolol and nebivolol will be used for congestive heart failure. Atenolol, metoprolol and propranolol will often be chosen for myocardial infarction. According to the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) guidelines in 2009, a maintenance beta blocker during hair transplantation is classified into class I indication on the level of evidence B or C. It is highly recommended to continue the maintenance beta blocker perioperatively in order to minimize cardiac risk during surgery according to the ACCF/AHA 2009 guidelines. However, we should be cautious about the initial usage of a beta blocker in hair transplantation. New usage of a beta blocker is a quite different issue. It is not recommended for non-cardiologists or non-anesthesiologists. Especially, the intravenous administration of beta blocker is often dangerous. It is the other legitimate uses of beta blockers only for anesthesiologists and cardiologists. Conclusion: Arrhythmias during surgery could be prevented by careful management and a maintenance dose of anti-arrhythmic drug therapy. According to the ACCF/AHA 2009 guidelines, maintenance beta blockers should be continued in hair transplantation. A safe operation will be possible under maintenance beta blocker therapy even in patients with arrhythmia, hypertension, and heart failure.

Kuniyoshi Yagyu, MD, ABHRS

Kioicho Clicic

Management of Arrhythmia

and Updated Guidelines

for Perioperative

Beta Blockade Therapy

in Hair Restoration Surgery

Management of Arrhythmia

and Updated Guidelines

for Perioperative

Beta Blockade Therapy

in Hair Restoration Surgery

DISCLOSURESDISCLOSURES

Speaker has no relevant financial

relationships or conflicts of interest to

declare.

BETA BLOCKERBETA BLOCKER

�Beta blocker is widely used for management

of cardiac arrhythmia, hypertension and

coronary artery disease.

�Beta blocker has been believed to impair

cardiac function. It has been discontinued

before hair transplantation.

� Is beta blocker really dangerous or safe

during surgery?

PATIENTS & METHODS PATIENTS & METHODS

� 52 hair transplantation in 44 patients with cardiovascular

disease

� Ischemic heart disease (n=24):

without percutaneous coronary intervention (PCI) (n=14),

PCI+coronary stenting (n=9), and CABG (n=2)

� Arrhythmia (n=18): PVC (n=7),

Wolff-Parkinson-White syndrome with tachycardia (n=2),

Paroxysmal atrial fibrillation with tachycardia (n=2),

Sick sinus syndrome, etc. (n=1)

� Aortic aneurysm (n=4), Valvular heart disease (n=2),

Cerebral infarction and TIA (n=2)

RESULTSRESULTS

�Maintenance dose of beta blocker was

continued before surgery.

�Beta blocker did not have an unfavorable

effect on the patients.

�All patients went through safe surgery

without complications.

�All anti-arrhythmic drugs were continued

before surgery.

DISCUSSIONDISCUSSION

�Patients with arrhythmia should be under

stable optimized drug therapy by

experienced cardiologist

for more than 3 months before surgery.

�PVC, and permanent atrial fibrillation are

not dangerous.

�CAD patients after PCI, coronary stenting,

and CABG are safe.

DANGEROUS ARRHYTHMIADANGEROUS ARRHYTHMIA

�Burgada syndrome

�WPW syndrome with tachycardia & syncope

These arrhythmia may cause sudden cardiac death

and quite dangerous. Special attention should be paid.

�Ventricular tachycardia (VT)

BURGADA SYNDROMEBURGADA SYNDROME

� Disorders of sodium channel and calcium channel of the myocytes

� Genetic disease, Autosomal dominant,

� One of the most common cause of sudden cardiac

death in young men without underlying cardiac disease

� ECG of Brugada syndrome: persistent ST elevation in leads

V1-3 with a RBBB appearance

� A patient with Burgada syndrome should not be considered as

a surgical candidate unless the patient receives implantation of

a cardioverter defibrillator (ICD).

� Asymptomatic, idiopathic Ventricular Fibrillation,

Sudden cardiac death with the 1st VF attack

� Management of cardiac arrhythmias, cardioprotection

after myocardial infarction (heart attack), and

hypertension

� It revolutionized the medical management of angina

pectoris.

(van der Vring JA, 1999, WCN research)

� It is considered to be one of the most important

contributions to clinical medicine and pharmacology of

the 20th century.

(Stapleton MP, 1997)

BETA BLOCKERBETA BLOCKERBeta-blockers are indicated in:

Beta-Blockers in ArrhythmiasBeta-Blockers in Arrhythmias

Supraventricular arrhythmias

Rate control for:

Ventricular arrhythmias

Acute myocardial infarction

Atrial Fibrillation (AF)

Supraventricular tachycardias

Wolff-Parkinson-White syndrome (WPW) with orthodromic AVRTs

Sinus tachycardia

Atrial Flutter

Conditions predisposing towards arrhythmias and sudden

Long QT Syndrome (LQTS)

Catecholaminergic polymorphic ventricular tachycardia

cardiac death

Beta-Blockers: Beta-Blockers:

In contrast to enalapril, beta-blocker was renoprotective in patients

with mild heart failure.

3.

Beta-blockers significantly reduce mortality in stable ischemic and

non-ischemic heart failure.

1.

Beta1 selective blocker was at least as effective as ACE inhibitor in

reducing morbidity and mortality in type II diabetics with hypertension.

2.

Beta1 selective blocker reduced peri-operative mortality and non-fatal

heart attacks in patients undergoing non-cardiac vascular surgery.

4.

(Cruickshank JM, Eur Heart J 21, 354-364, 2000)

Some Recent Surprising InformationSome Recent Surprising InformationISA MSA agents

I Non-selective + + alprenolol, penbutolol, oxprenolol,

penbutolol

+ - pindolol, carteolol

- + propranolol, bufetolol

- - timolol, nadolol, nipradilol, tilisolol

II β1-selective + + acebutolol

+ - celiprolol

- - metoprolol, atenolol, bisoprolol,

betaxolol

III α-blocking + + labetalol

- + carvedilol

- - arotinolol, amosulalol

Beta BlockerBeta Blocker

ISA: Intrinsic Sympathomimetic Activity,

MSA; Membrane Stabilizing Activity

Beta Blocker: Indication DifferencesBeta Blocker: Indication Differences

Cardiac Arrhythmia: esmolol, sotalol, landiolol●Myocardial Infarction: atenolol, metoprolol, propranolol ●Migraine Prophylaxis: timolol, propranolol ● Glaucoma: betaxolol, carteolol, levobunolol, metipranolol, timolol● Congestive Hart Failure: bisoprolol, carvedilol, metoprolol, ●

nebivolol

Agents Specifically Indicated for Each Disorder

Perioperative Beta Blocker TherapyPerioperative Beta Blocker Therapy

� Hair Transplantation in usual patients:

ACCF/AHA guideline: Class I indications

On the Level of Evidence B or C

� Maintenance Beta Blocker should be continued in

patients undergoing surgery.

(ACCF/AHA 2009 Guidelines)

prophylactic use of beta blockers minimize

perioperative cardiac risk

� Maintenance beta blocker: highly recommendable

� New usage of beta blocker: not recommendable

other legitimate uses of beta blockers

Anesthesiologist: intraoperative control of heart rate or

(ACCF/AHA 2009 Guidelines)

Cardiologist: heart rate control in common tachyarrhythmia

high blood pressure

BETA BLOCKERBETA BLOCKER

106

Vitamin D and Hair: Should We Care? Nicole E. Rogers, MD Old Metairie Dermatology (Private Practice), Metairie, LA, USA.

Dr. Nicole Rogers is a board certified dermatologist and fellow of the American Academy of Dermatology. She is in private practice in the New Orleans area where she specializes in hair loss and hair restoration for both men and women. She completed an ISHRS fellowship in hair transplantation with Dr. Marc Avram in New York City. Together, they co-edited a textbook on hair transplantation and have authored numerous papers on medical and surgical treatments for hair loss. She is assistant clinical professor of dermatology at Tulane and enjoys teaching the residents about various forms of alopecia.

N.E. Rogers: None.

ABSTRACT: Vitamin D is an essential fat soluble vitamin necessary for normal body function. It traditionally has been linked to bone health. Recently there has been increased interest in Vitamin D in the role of skin and hair disorders. This talk will focus on whether we should consider checking vitamin D, based on basic science, and where possible include clinically relevant data as well. A comparison of Vitamin D levels in women with FPHL will be reviewed, discussing the results and comparing them with Vitamin D levels in age-matched controls (study underway in author's office).

107

Hair Grafting in Non-Healing Chronic Leg Ulcers: A Pilot Clinical Study Francisco Jimenez, MD1, Ander Izeta2, Carmen Garde3, Eduardo Escario4, Enrique Poblet4 1Private Practice, Las Palmas Gran Canaria, Spain, 2Instituto Biodonostia, San Sebastian, Spain, 3Hospital Donostia, San Sebastian, Spain, 4Hospital Universitario de Albacete, Albacete, Spain.

Francisco Jimenez, MD is dermatologist and hair transplant surgeon working in private practice in Las Palmas, Canary Islands, Spain. His is the author of 70 scientific articles and various chapters in textbooks of hair transplantation, and has been the coeditor of the Hair Transplant Forum (2008-2010).

F. Jimenez: None. A. Izeta: None. C. Garde: None. E. Escario: None. E. Poblet: None.

ABSTRACT: Introduction: It has long been observed that, when the hair follicle is still relatively intact post injury, epidermal sheets spread centrifugally from the hair folicle infundibulum to reepithelialize the wound bed. Wound healing also happens faster in skin áreas rich in terminal hair follicles.

These observations are easily reconciled with the current appreciation of the HF as a major local reservoir for several different progenitor cell populations known to play key roles in wound healing. Punch full thickness skin grafting have been reported as a therapy for chronic leg ulcers. The grafts are harvested from the buttocks where most of the tissue transplanted is interfollicular epidermis and dermis. Given the abundant research studies showing the hair follicle as the main source of adult skin stem cells, and its key role as a wound healing promoter, it would make sense to consider the scalp as the ideal source to obtain full thickness grafts for transplantation into non-healing ulcers. Objective: This is a pilot study in which we have evaluated the feasibility and potential healing capacity of scalp follicular grafts transplanted into the wound bed of chronic leg ulcers. Material and Methods: 10 volunteer patients with chronic leg ulcers of more than 4 months duration that have failed healing in spite of standard medical therapy were included in the study. The ulcers included diabetic, decubitus, mixed and venous insufficiency ulcers. Within each ulcer there was a 2 cm x 2 cm “experimental” area that received 20 hair grafts and an area of 2 cm x 2 cm area that served as “control”. These two areas were randomly selected. The follicular grafts were harvested from the occipital scalp using 1 or 2 mm punches (Miltex) in a similar manner as the technique know as “follicular unit extraction”. The grafts were inserted in the wound bed by the “stick and place” technique method using hypodermic needles with variable gauge according to the size of the grafts. Patients were followed for a total of 18 weeks. The main variable to evaluate is the mean percentage of reduction in the area of the ulcer 18 weeks after the transplantation. Results: At present 4 out of 6 patients have completed the study. In all 4 patients, we have observed a higher reduction in the “experimental” area that received the hair grafts in comparison with the “control” area. The average area reduction in the ulcerated “experimental” zone was 45%. The rest of the patients are still under evaluation and final data will be presented. Discussion: The potential use of hair grafts in wound healing needs to be evaluated. We have performed a randomized controlled pilot study using scalp hair grafts implanted in chronic leg ulcers. Preliminary results have shown a reduction in the implanted area compared to the control zone.

Francisco Jiménez

Las Palmas, Canary Islands, SPAIN

A pilot study evaluating Hair

Grafts in Chronic Leg Ulcers

Disclosure Relationships with Industry

I do not have any relevant relationships

with industry

Hair Follicle-Wound Healing

connection

– Granulation tissue regenerates most rapidly from theconnective tissue around hair follicles (Bishop in Am J Anat 1945;76: 153)

– Reepithelialization occurs from the remaining hairfollicle

– Hair follicle is the source of epithelial and dermal stemcells

– Cutaneous wound healing is accelerated duringanagen stage of the hair cycle (Ansell et al. J InvDermatol 2011; 131: 518)

HairHair TransplantTransplant GraftsGrafts: Can be : Can be usedused toto treattreat

DifficultDifficult toto HealHeal CutaneousCutaneous WoundsWounds??

ClinicalClinical ReportsReports

Plast Reconst Surg 2004; 113: 978-81

Patient with scarring alopecia post-radiotherapy and Mohs surgery wound

that was covered with a skin graft received a hair transplant…

Case Report presented by Dr. Richard Keller in 2008 International Society of Hair

Restoration Surgery meeting in Montreal

14 days after transplant

1 month later, remodelling of the depressed skin graft

HypothesisHypothesis

Hair follicles harvested from scalp and

transplanted to the bed of chronic leg

ulcers will induce healing of the ulcer

ChronicChronic LegLeg UlcersUlcers

ImportanceImportance of of thethe problemproblem

• In Europe, 1% of the population have venous leg ulcers

• Type II diabetes (2% prevalence): 15% of this group have

foot ulcers.

• As the percentage of elderly people rises, chronic leg

ulcers will increase over the next 20 years

• Significant cost associated with chronic ulcers

The mean total cost of

the ulcer per year and

patient was

Material & Material & MethodsMethods

• RCT with 18 weeks follow up (10 w presented here)

• Participants: 10 patients with chronic leg ulcers (3/10 not analyseddue to technical problems for measurements)

– Mean Age: 72.2 years (range 50-83)

– Mean Ulcer Area at baseline: 36.9 cm2

– Mean ulcer duration at baseline: 11.1 years (range 3-30)

– Etiology of ulcers: 4 venous, 2 mixed, 1 pressure

Onset 2007 Onset 2003



Experimental 2 x 2 cmControl zone 2 x 2 cm

20 hair grafts transplanted in the experimental area

Experimental 2 cm x 2 cm

Hair follicle grafts extracted by punch harvesting from scalp

hair graft (extracted with 1 mm punch)

ResultsResults

EvaluationEvaluation of of HealingHealing

• Weekly photographs.

• ImageJ®

– Total ulcer area measurements

– Area of the experimental vs control zones

% Reduction in ulcer area

(experimental vs control)

Case 1 Case 2 Case 3 Case 4 Case 5 Case 6 Case 8

Experimental 66.7 29.6 54.9 14.5 28.1 1.7 0

Control 21.9 -2.5 7.2 -11.6 7 -1.6 0

Greater reduction in experimental vs control area in 5/7 ulcers

Area (total) of the UlcersWeek Case 1

(cm2)Case 2 Case 3 Case 4 Case 5 Case 6 Case 8

0 35.6 38.8 13.3 80.2 29.5 21.4 39.5

0 (+2 days)

28 26.7 12.4 56.2 28.7 23.3 38.1

1 19.6 21.4 8.5 68.3 26.2 19.7 35.9

2 10.5 19.5 9.3 49.7 24.3 21.3 32.6

3 7.8 18.6 8 47.5 20.7 22 29.1

4 10.2 18.1 7.5 34.2 12.5 20.4 28.7

8 9.9 18.1 9.9 38.3 11.4 22.1 32.1

10 18.8 11.4 46.6 6.5 22.5 42

% Reduction in

Total Ulcer Area

Case 1

72.2

Case 2

51.5

Case 3

14.3

Case 4

41.9

Case 5

78

Case 6

-5.1

Case 8

-6.3

Evolution of ulcers after 10 w

Me

an

Ulc

er

Are

a (

cm

2)

Me

an

A

rea

Re

du

cti

on

(%

)

Weeks after intervention

1 week 2 weeks

4 weeks 8 weeks

1 week 2 weeks

3 weeks 18 weeks

1 week 2 weeks

4 weeks 8 weeks

ConclusionsConclusions of of thispilotstudythispilotstudy

1. Safety/Factibility: PunchHair Grafting in

chronic ulcers is an ambulatory procedure;

cheap, safe and relatively simple to perform.

2. Hair grafting seems to induce healing of

chronic ulcers. Further studies need to be

performed (second clinical study currently

undergoing ethical review board examination).

Hospital Donostia, San SebastianHospital Donostia, San SebastianOutpatient Care UnitOutpatient Care Unit

CARMEN GARDEBEGOÑA JIMENO

JESÚS ORTIZCORINA NAVEDA

Dept. Vascular SurgeryDept. Vascular SurgeryJOSÉ LUIS HIGUERA

Instituto Biodonostia, San SebastianDept. Bioengineering

ANDER IZETAARAIKA GUTIÉRREZ-RIVERA

VIRGINIA PÉREZ-LÓPEZUSUE ETXANIZ

Methodological Support UnitNEREA EGÜÉS

Hospital Universitario de AlbacetePathology

ENRIQUE POBLET

DermatologyMARÍA LUISA MARTÍNEZ

EDUARDO ESCARIO

Funds:

ISHRS (2010 research grant)

ISHRS/IHRF (International HairResearch Foundation) JointResearch Grant 2010

sATuRDAY ➤ sePTeMBeR 17, 20116:15AM-9:00AM; and 3:30PM-6:00PM






6:30AM-8:30AM Continental Breakfast

7:00AM-8:00AM Breakfast with the Experts

No extra fee. Open to all attendees on a first-come, first-served basis. This is an informal session for small groups to discuss a specific topic. Come with your questions. round banquet tables will be set in the back of the general session room. Each table will be labeled with a topic and expert’s name. Get your breakfast and then sit at the table of your choice to have “breakfast with an expert.”

LEArning obJECtivE:

• Discuss various hair restoration surgery topics in-depth in small groups.

108

109

110

111

112

113

114

115

116

117 118

119

120 121

122

1. Asian HT Sungjoo Tommy Hwang, MD, PhD

2. Non-Androgenetic Alopecias nicole E. rogers, MD

3. Flaps and Expanders E. Antonio Mangubat, MD

4. FUE bradley r. Wolf, MD

5. Female Hair Loss Paul C. Cotterill, MD

6. Preview Long Hair Transplants Marcelo Pitchon, MD

7. Autocloning/Plucking gary Hitzig, MD

8. Body Hair and Beard as Donor Source for FUE John P. Cole, MD

9. Lighting & Polarized Lights William M. Parsley, MD & Dae-Young Kim, MD, PhD

10. PRP Michael Markou, Do & robert J. reese, Do

11. Considerations When Building a Large, Quality-Driven, Multinational Practice Armen Markarian

12. Crown Design and New Techniques Marco barusco, MD & Craig L. Ziering, Do

13. Surg Asst Topic: Tech Recruitment tina Lardner


8:15AM-9:20AM Non-Androgenetic AlopeciasModerator: Ken Washenik, MD, PhD


• Discuss the role of hair transplants in non-androgenetic alopecia.

• Discuss the diagnosis and treatment of non-androgenetic alopecia.

8:15AM-8:17AM 123



8:17AM-8:22AM

124

5 Update on ISHRS Project: registry for transplantation results of Cicatricial Alopecias

nina otberg, MD

8:22AM-8:42AM

125

20 Cicatricial Alopecia Update Featured guest speaker: vera H. Price, MD, FrCP(C)

Professor, Department of Dermatology, University of California, San Francisco, USA

8:43AM-8:50AM

126

7 Clinical and Histopathological Analysis of Frontal Fibrosing Alopecia


8:50AM-8:57AM

127

7 Association of Hair transplantation and Lichen Planopilaris


8:58AM-9:05AM 128

7 Evidence based Practice in Hair restoration

Mysore n. venkataram, MD

9:05AM-9:20AM Q&A

9:25AM-10:10AM What’s the Diagnosis? Moderator: ivan s. Cohen, MD

LEArning obJECtivE:

• Test your diagnostic skills on various hair loss cases.

Each case has 5’ case presentation and then 3’ discussion.

9:25AM-9:27AM 129


ivan s. Cohen, MD

9:27AM-9:35AM 130

8 Case 1

ivan s. Cohen, MD

9:35AM-9:43AM 131

8 Case 2


9:44AM-9:52AM 132

8 Case 3

vera H. Price, MD

9:53AM-10:01AM 133

8 Case 4


10:02AM-10:10AM 134

8 Case 5

Dow b. stough, MD

10:15AM-10:30AM 135

ISHRS Best Practices Project Facilitator: Paul C. Cotterill, MD

10:30AM-11:00AM Coffee Break

11:00AM-11:45AM 136137 138 139 140

Hairline Design Panel Panel Moderator: russell Knudsen, Mbbs

surgeon Designers: robert bernstein, MD; Jean Devroye, MD; Mario Marzola, Mbbs; Damkerng Pathomvanich, MD

LEArning obJECtivE:

• Compare and contrast different surgeons’ approaches to designing hairlines and temporal points.

The ISHRS gratefully acknowledges CANFIELD IMAGING SYSTEMS for its generosity in helping with this session.

11:50AM-12:30PM 141

142 143 144

Difficult Cases Moderator: E. Antonio Mangubat, MD

Panelists: Jon Gaffney, MD, Alex Ginzburg, MD, sheldon s. Kabaker, MD, Mario Marzola, Mbbs

Many HRS surgeons encounter challenging cases and often times lack the education, training, and experience to handle these tough patients. The goal of this session is to present patients actually treated by the panel and discuss available options. The target audience is physicians of all experience levels who have encountered challenging patients. Participants are also encouraged to bring PowerPoint slides of difficult patients they would like to discuss. Please present these to the Moderator in advance of the session.


• Recognize surgical limitations in marginal candidates and develop appropriate treatment plans for these patients.

• Discuss difficult cases and treatment options. • Explain when to consider flaps and

expanders over grafting techniques.

11:50AM-11:52AM

141


E. Antonio Mangubat, MD

11:52AM-12:30PM Case Presentations and Discussion

12:30PM-2:00PM Lunch on your own (lunch concessions for purchase in exhibit area)

12:30PM-2:00PM Ancillary Meeting: Asian Association of Hair Restoration Surgeons (AAHRS) Board of Governors Meeting (invitation only)

1:00PM-1:45PM Optional Non-CME Session: Mechanization of HRS

All attendees are invited to attend. You may bring your lunch to eat during this session. Taking place in the main General Session room. No CME will be issued for this session.

Moderator: Carlos J. Puig, Do

Panelists: Miguel g. Canales, MD, James A. Harris, MD, Mario Marzola, Mbbs, sara M. Wasserbauer, MD, Michael W. vories, MD, Ken L. Williams, Do

1:00PM-1:02PM 2 Moderator introduction

Carlos J. Puig, Do

1:02PM-1:14PM 12 neograft technology: rebirth of Previous technology

Michael W. vories, MD

1:15PM-1:27PM 12 restoration robotics: ArtAs

Miguel g. Canales, MD

1:27PM-1:45PM 18 Panel Discussion and Q&A

1:30PM-4:30PM Posters Dismantle

2:00PM-2:40PM New Surgical Instruments and TechniquesModerator: Sanjiv A. Vasa, MD

LEArning obJECtivE:

• Identify advantages and disadvantages of various surgical techniques and surgical pearls.

2:00PM-2:02PM 145


Sanjiv A. Vasa, MD

2:02PM-2:09PM 146

7 New Generation of the Laxometer

Parsa Mohebi, MD

2:09PM-2:16PM

147

7 Hair bundle Cross section trichometry Measurements in 250 Consecutive Cases of Hair Loss

Alan J. bauman, MD

2:17PM-2:24PM

148

7 Longitudinal or Horizontal slivering instead of ordinary Method

Kongkiat Laorwong, MD

2:24PM-2:31PM 149

7 robotic Assisted Harvest of Follicular Units

sara M. Wasserbauer, MD

2:31PM-2:40PM Q&A

sAT

2:45PM-3:30PM Donor Management and Closure TechniquesModerator: Damkerng Pathomvanich, MD

LEArning obJECtivE:

• Compare and contrast methods and techniques relating to donor area management and closure.

2:45PM-2:47PM 150

2 Moderator introduction Damkerng Pathomvanich, MD

2:47PM-2:54PM

151

7 How Deep should We score While Actually taking Donor strip? Damkerng Pathomvanich, MD

2:54PM-3:01PM

152

7 Evaluation and Comparison of Linear scar Line in Donor Area After Lower and Upper Lower Edge trichophytic Closure gholamali Abbasi, MD

3:02PM-3:07PM

153

5 viDEo: v-Loc Knotless Dermal Wound Closure suture


3:07PM-3:14PM

154

7 the importance of Hair Alignment in Disguising the Donor scar


3:15PM-3:22PM 155

7 FUE vs. strip FUt: A side by side Comparison

bradley r. Wolf, MD

3:22PM-3:30PM Q&A

3:35PM-4:15PM Unique Issues in Ethnic TransplantationModerator: nicole E. rogers, MD

LEArning obJECtivE:

• Describe techniques and special considerations for achieving optimal cosmetic outcomes in patients of non-Caucasian ethnic origins.

3:35PM-3:37PM 156


nicole E. rogers, MD

3:37PM-3:44PM

157

7 Comparative study of Follicular Unit Extraction between Different Ethnic Groups with 0.9 mm and 1.0 mm Punches

Anastasios verkris MD

3:44PM-3:51PM

158

7 FUE Donor Harvesting All over the World, Our Experience considering Ethnical variations

Frank g. neidel, MD

3:52PM-3:59PM

159

7 Demographics of Male Pattern baldness in india

Tejinder Bhatti, MD

3:59PM-4:06PM 160

7 Refinements of Asian Female Hairline Surgery

sung-Jae Yi, MD

4:06PM-4:15PM Q&A

4:15PM-5:30PM Live Patient Viewing Chair: robert P. niedbalski, Do

Co-Chairs: nina otberg, MD, Rajesh Rajput, MD

LEArning obJECtivE:

• Assess the results of real live patients from a variety of cases that utilized different approaches and techniques.

4:15PM-5:15PM Visit Exhibits (Final Hour) & Coffee Break

4:45PM-5:45PM CME Committee Meeting (invitation only)

7:00PM-12:00AM Gala Dinner/Dance & Awards Ceremony (ticket required)

108

Breakfast with the Experts, Table Leader on the Topic of "Asian HT" Sungjoo (Tommy) Hwang, MD Dr. Hwang's Hair Hair Clinic, Seoul, Korea, Republic of.


S. Hwang: None.

109

Breakfast with the Experts, Table Leader on the Topic of "Non-Androgenetic Alopecias" Nicole Rogers, MD Old Metairie Dermatology, Metairie, LA, USA.

Dr. Nicole Rogers is a board-certified dermatologist who completed an ISHRS fellowship with Dr. Marc Avram in 2007-8. Together they have published extensively, including several review articles and a textbook on Hair Transplantation. She is currently in private practice in the New Orleans metropolitan area where she specializes in the surgical and medical treatment of hair loss for both men and women. She also volunteers her time in the Tulane Dermatology Clinic, instructing residents and medical students about various scarring alopecias such as lichen planopilaris, frontal fibrosing alopecia, and traction and chemical alopecias.

N. Rogers: None.

110

Breakfast with the Experts, Table Leader on the Topic of "Flaps and Expanders" E. Antonio Mangubat, MD Southcenter Cosmetic Surgery, Tukwila, WA, USA.

Dr. Mangubat has been an ISHRS member since 1995. He was graduated from the University of Washington Medical School, studied general surgery at the University of Kentucky and received his cosmetic surgery training from Dr. Richard C. Webster. Dr. Mangubat performs all HRS surgeries, including hair transplantation, scalp flaps, and expanders, in his Seattle, Washington office. He is the recipient of the Golden Follicle Award in 2007. He has a long history of service to the ISHRS including serving as president 2004-2005 and he works tirelessly to promote the positive influence HRS can play in our patients’ lives.

E. Mangubat: None.

111

Breakfast with the Experts, Table Leader on the Topic of "FUE" Bradley Wolf, MD Cincinnati, OH, USA.

Bradley R. Wolf MD has performed hair transplantation surgery for 20 years, including FUE for 8 years. He lives on a farm in Ohio with his wife and son.

B. Wolf: None.

112

Breakfast with the Experts, Table Leader on the Topic of "Female Hair Loss" Paul C. Cotterill, MD Toronto, ON, Canada.

Dr. Cotterill is a past president of the ISHRS and is the current chair of the CME Committee.

P.C. Cotterill: None.

113

Breakfast with the Experts, Table Leader on the Topic of "Preview Long Hair Transplants" Marcelo Pitchon, MD Belo Horizonte, M.G., Brazil.

Dr. Marcelo Pitchon is a Plastic Surgeon exclusively dedicated to hair restoration surgery.

M. Pitchon: None.

114

Breakfast with the Experts, Table Leader on the Topic of "Autocloning/Plucking" Gary S. Hitzig, MD Suite 302, New York Hair Loss, New York, NY, USA.

Dr. Hitzig has over 35 years of expertese in the Hair Transplant field. He is the author of numerous papers, a mass market paperback published by the Hearst Corporation as well as Patents for Hair Transplant instrumentation. He began working with Matristem (ACell) when the FDA approved its use in wound healing in September of 2008. His staff of several Board Certified Plastic Surgeons have employed it in well over 50 diverse cases.

G.S. Hitzig: None.

115

Breakfast with the Experts, Table Leader on the Topic of "Body Hair and Beard as Donor Source for FUE" John P. Cole, MD Cole Hair Transplant Group, Alpharetta, GA, USA.

John Cole, MD is in private practice in Alpharetta, GA. He resides in Islamorada, Florida. He has been involved in hair transplant surgery for over 20 years. His practice is almost exclusively devoted to FUE. He calls his particular method of FUE the Cole Isolation Technique (CIT). Dr. Cole has performed well over 2800 FUE cases. Dr. Cole manufactures and designs his own line of instruments to perform FUE.

J.P. Cole: Other; He makes instruments that he sell to other physicians for use in hair transplant surgery and in particular FUE..

116

Breakfast with the Experts, Table Leader on the Topic of "Lighting & Polarized Lights" William Parsley, MD Parsley Waldman Hair Center, Louisville, KY, USA.

William M. Parsley, MD William Parsley, MD graduated from Univ of Tennessee Med School (1969) and completed Dermatology at the Univ of Louisville (1975). Positions: Past President- ISHRS ISHRS BOG and EC Past Chair of the ASHRS Past President of the ABHRS Past moderator of the Hair Transplantation Forum for the AAD Past BOT of the American Academy of Cosmetic Surgery Past Editor- Hair Transplant Forum International BOT- Hair Foundation. Past President- Kentucky Dermatologic Society Recipient of the ISHRS Golden Follicle Award (2003). Diplomate: Am Brd of Dermatology, Am Brd of Dermatopathology, ABHRS Awards: ISHRS Golden Follicle Award- 2003

W. Parsley: None.

117

Breakfast with the Experts, Table Co-Leader on the Topic of "PRP" Michael Markou, DO Markou Medical Center, Clearwater, FL, USA.

Dr. Markou owns and directs the Markou Medical Clinic and Markou Hair Restoration in Clearwater, Florida. He has been in practice since 1994 and specializes in hair restoration surgery, family medicine and cosmetic surgery. His current research includes Post Op Hair Transplant Surgery Wound Healing with Low Level Laser, Topical Dutasteride treatment in hair loss, Weekly Low Level Laser Therapy, and Autologous Platelet Rich Plasma In Hair Restoration in Men and Women.

M. Markou: None.

118

Breakfast with the Experts, Table Co-Leader on the Topic of "PRP" Robert J. Reese, DO Suite 305, Reese Hair Restoration, PLLC, Edina, MN, USA.

Dr. Reese is a Diplomate of the American Board of Hair Restoration Surgery, (ABHRS) and currently serves the ABHRS on it's Executive Committee as Secretary of the organization, as well as an Examining Physician.

R.J. Reese: None.

119

Breakfast with the Experts, Table Leader on the Topic of "Considerations When Building a Large, Quality Driven, Multinational Practice" Armen Markarian Bosley, Beverly Hills, CA, USA.

Armen Markarian is President and CEO of Bosley. Prior to joining Bosley, he had more than 15 years of leadership experience in marketing and administrative management in a variety of health care settings including major medical institutions, nationwide medical groups, and clinical laboratories. With 23 surgical offices, 25 physicians, 50 consultation offices, and 400 employees, Armen presides over the largest hair restoration practice in the world. He oversees Bosley's business development and strategic alliance initiatives, sales, marketing and finance strategies, operations protocols, -- all designed for the enhancement of Bosley's high quality patient care and service standards.

A. Markarian: None.

120

Breakfast with the Experts, Table Co-Leader on the Topic of "Crown Design and New Techniques" Marco N. Barusco, MD Tempus Hair Restoration, Port Orange, FL, USA.

Marco N. Barusco, MD is the founder and Medical Director of Tempus Hair Restoration in Port Orange, Florida. Serves as: ISHRS Workshop Committee, Examination Committee of the American Board of Hair Restoration Surgery (ABHRS), Chief Section Editor in Hair Restoration for the American Journal of Cosmetic Surgery (AJCS), Advisory Council of the American Society of Hair Restoration Surgery (ASHRS), teaching faculty for Expert to Expert Europe and expert consultant for REUTERS Insight, among others. Served as Co-Chair, Scientific Co-Chair and Scientific Coordinator in the various annual editions of the Orlando Live Surgery Workshop.

M.N. Barusco: None.

121

Breakfast with the Experts, Table Co-Leader on the Topic of "Crown Design and New Techniques" Craig L. Ziering, DO Ziering Medical, Newport Beach, CA, USA.

CEO and Medical Director of Ziering Medica. lPracticing Hair Restoration for 20 years.

C.L. Ziering: None.

122

Breakfast with the Experts, Table Leader on the Topic of "Sug Asst Topic: Tech Recruitment" Tina Lardner Hair Sciences Center of Colorado, Denver, CO, USA.

Tina Lardner is the Surgery Coordinator for James A. Harris, MD in Denver, Colorado. She has been involved in hair restoration for 15 years. She has served on the SA Executive Committee since 2007. She has served as faculty for the St. Louis Cadaver Workshop for the past three years. She authored the Surgical Assistants chapter in Hair Transplantation, 5th Edition and contributed to Hair Transplantation 360 for Surgical Assistants. She has worked with Restoration Robotics trained to operate the ARTAS System. She currently is on the ISHRS Task Force to develop training materials for physicians to train surgical assistants.

T. Lardner: None.

123

Moderator Introduction, Non-Androgenetic Alopecias Ken Washenik, MD, PhD Bosley, Beverly Hills, CA, USA.

Ken Washenik, MD, Ph.D., is the Medical Director of Bosley and the Chief Executive Officer of the Aderans Research Institute, a biotechnology firm involved in researching tissue engineered hair follicle neogenesis and cellular based hair restoration. The former director of the Dermatopharmacology Unit at the New York University School of Medicine, Dr. Washenik continues to serve as a clinical investigator and faculty member in the Department of Dermatology. His Ph.D. is in Cell Biology and focused on hormone metabolism. He frequently lectures on the effects of hormones on the skin including their effects on hair loss and growth.


124

Update on ISHRS Project: Registry for Transplantation Results of Cicatricial Alopecias Nina Otberg, MD Hair Transplant Center Berlin - Potsdam, Potsdam, Germany.

Since 2010 Founder and Director Hair Transplant Center Berlin - Potsdam, Germany Since 2009 Medical Director, Hair Clinic, Skin and Laser Center Potsdam, Germany 2006 -2009Clinical and Research Fellow, UBC, Vancouver, Canada, (Prof. Dr. J. Shapiro) 2007Board Certification in Dermatology, Germany 2002 - 2006Residency in Dermatology , Humboldt-University Berlin, Germany 2003 Research Training, UCSF, University of California, San Francisco, Dept. of Dermatology, (Prof. Dr. H. I. Maibach) 2003 Doctoral thesis, Follicular drug delivery, (summa cum laude) 2001Medical Training, Department of Dermatology, Mount Sinai School of Medicine, New York, USA 1993Training as Certified Medical Laboratory Technician, University of Essen, Germany

N. Otberg: None.

ABSTRACT: The ISHRS has founded a committee for the registration of hair restoration results on patients with cicatricial alopecia and hair diseases other than androgenetic alopecia. The committee consists of 6 members: Nina Otberg (chair), Jeffrey S. Epstein, Valerie Callender, William Parsley, Ken Washenik and Jerry Shapiro. Together we

created a registration form for the outcome of hair restoration surgery in patients with hair diseases other than androgenetic alopecia. The form comprises 4 pages (figure 1-4) and is designed to collect general patient information (age, gender, ethnicity), information on the underlying cause of hair loss (primary cicatricial alopecia with subtype, secondary cicatricial alopecia, temporal triangular alopecia, aplasia cutis congenita and alopecia areata), information on previous or ongoing medical treatment for the hair loss, histopathological reconfirmation via biopsy, disease duration, area of involvement, information on the procedure (scalp reduction, hair transplantation), information on treatment outcome, complications and patient satisfaction. We would like to give a summary of the activities of the committee and the progress of the database.

1 | P a g e

For office use: Case No. Date Received:

International Society of Hair Restoration Surgery

Registration and Consent Form for the Outcome of Hair Restoration Surgery in Patients with Hair Diseases other than Androgenetic Alopecia

Dear Physician, We highly value your contribution to our database of information of transplantation results. Every registered case helps to improve our treatment outcome and patient satisfaction. The form does not have to be filled out completely. Please fill in only such information that you are authorized to provide, and return the form to ISHRS Headquarters at: [email protected] or faxed to: 630-262-1520. Thank you. Nina Otberg, MD, Chair ISHRS Ad Hoc Committee on Database of Transplantation Results on Patients with Cicatricial Alopecia and Hair Diseases Other than Androgenetic Alopecia

Physician Name: Physician’s Email: 1. Patient’s year of birth: 2. Gender

Male Female

3. Ethnicity

Caucasian Asian Hispanic/Latino East Indian African American Native American Other, please specify:

4. Diagnosis

Primary cicatricial alopecia

Specifiy if possible: Discoid lupus erythematosus Lichen planopilaris Frontal Fibrosing alopecia Psedopelade of Brocq Central Centrifugal Cicatricial Alopecia Folliculitis decalvans Dissecting Cellulitis Other, please specify:

2 | P a g e

Secondary cicatricial alopecia

Specify the cause if possible:

Temporal triangular alopecia Aplasia cutis congenital Alopecia areata

5. Medical treatment

a. Medical treatment for the hair disease while the condition was active:

b. Current medical treatment, if any:

6. Was a biopsy taken?

Yes No

If you answered yes to question 6, did the biopsy confirm the diagnosis?

Yes No

7. Disease duration

a. Before the first surgery?

b. Was the disease inactive at the time of the first surgery? If so, for how long?

8. Area of involvement

a. Approximate area of involvement in cm2

b. Location frontal temporal parietal occipital

c. Areas affected by the condition other than the scalp

Yes, please specify: No

9. Procedures other than transplantation (e.g., scalp reduction)

Please specify:

Please give a brief description of the outcome:

3 | P a g e

10. Hair transplant procedures

a. Number of transplant procedures

b. Specifics of each surgery

Month and year

of surgery

Location of donor area

Total number of grafts planted

Approximate number of hairs

planted/cm3

Procedure 1 Procedure 2 Procedure 3 Procedure 4

c. Additional information: Size of grafts, size and type of the instruments used to make the recipient site, the presence of adrenaline in the tumescent solution, the quality of the scar into which grafts were transplanted (e.g., atrophic, sclerotic)

11. Treatment outcome

a. Surgical treatment outcome after one year Excellent graft survival (90-100%) Moderate graft survival (70-89%) Sparse graft survival (50-69%) Poor graft survival (<50%) No graft survival

b. Surgical treatment outcome after two years or more

Excellent graft survival (90-100%) Moderate graft survival (70-89%) Sparse graft survival (50-69%) Poor graft survival (<50%) No graft survival

c. Reactivation of the disease post-surgery

Within one month after surgery Within one year after surgery After more than one year after surgery No reactivation

If reactivated, please explain the treatment and further outcome:

12. Complications (e.g., necrosis, problems with wound healing, infections, keloids, etc.)

Please specify:

4 | P a g e

13. Patient satisfaction

Excellent Good Moderate Poor

14. Patient photo and biopsy results

Important: Do not send any photographs or information that could identify or suggest the identity of, or present a reasonable likeness of, any patient or other individual or that you otherwise are not authorized to provide. If you are authorized to provide a photo of the patient and biopsy results, please attach them or send to [email protected].

15. Please read and sign:

PHYSICIAN CONSENT

I represent and warrant that I have complied with any and all patient privacy laws applicable to the provision of my submitted information. Without limiting the generality of the foregoing, I further represent and warrant that I have not provided any photographs that suggest the identity of, or present a reasonable likeness of, any patient or other individual, or that I am otherwise not authorized to provide. I consent to the publication, distribution, and other use of my submitted information, along with the publication and/or use of my name in connection with such information. I further represent and warrant that my submission, including photographs if applicable, does not violate any copyright, proprietary or personal rights of others, that I have not previously granted any rights to other parties that are inconsistent with this Consent, and that I have the authority to grant this Consent.

I understand that this information is being submitted for educational purposes only, and neither the ISHRS’s publication, distribution, or use of the information and/or use of my name constitutes the ISHRS’s endorsement, approval, or recommendation of me or any products, processes, or services I have provided to the patient. I further understand that ISHRS undertakes no obligation to publish the information or my name. I hereby indemnify and hold the ISHRS, its directors, officers, members, and agents harmless from and against any and all claims, expenses (including reasonable attorneys’ fees), and liabilities whatsoever arising, directly or indirectly, from any breach of my representations herein. I further waive any and all rights I may have against the ISHRS its directors, officers, members, and agents, and release and discharge them from any claim relating to my submission.

I grant this Consent as a voluntary contribution in the interest of public education and waive any claim for payment in connection with such Consent. I certify that I have read the above Consent and fully understand its terms. Physician signature: Date:

Completed forms should be sent to ISHRS Headquarters at: [email protected] or faxed to: 630-262-1520

Rev. 10/13/09

Thank you!

125

Cicatricial Alopecia Update Vera H. Price, MD University of California, San Francisco, San Francisco, CA, USA.

Vera H. Price, MD, FRCP(C) Professor, Department of Dermatology, University of California, San Francisco After moving to California, Dr. Price spent three years doing basic research on human hair with the wool chemists at the USDA in Berkeley. This led to her expertise and subspecialty in hair and hair biology. Dr. Price has described several new hair disorders, and recently co-authored a book, Cicatricial Alopecia: An Approach to Diagnosis and Management. Her research interests include studies in cicatricial alopecia, alopecia areata, hormonal regulation of hair follicle, quantitative methods of estimating hair growth, structural hair shaft anomalies, and Afro-American hair.

V.H. Price: None.

ABSTRACT: Introduction: The scarring or cicatricial alopecias comprise a group of hair disorders that cause permanent destruction of the pilosebaceous unit. The primary cicatricial alopecias are characterized by a folliculocentric inflammatory attack specifically directed at the hair follicle with ultimate destruction and replacement of the follicle with fibrous tissue and progressive, permanent hair loss. Clinically the hallmark is the loss of follicular orifices. New research suggests that in some primary cicatricial alopecias, the perifollicular inflammation may be secondary to lipid-metabolic changes in the sebaceous gland. Specifically, a loss of function of the peroxisome proliferator activated receptor gamma (PPAR-gamma) in the sebaceous gland leads to the abnormal processing and buildup of lipids, which triggers inflammation and eventuates in scarring and destruction of the follicle. A working classification of primary cicatricial alopecia is based on pathological changes and the predominant cellular infiltrate, whether lymphocytic, neutrophilic/plasmacytic, mixed, or end stage, as follows: Lymphocytic group: lichen planopilaris (LPP), frontal fibrosing alopecia, central centrifugal alopecia, pseudopelade (Brocq), Neutrophilic group: folliculitis decalvans, tufted folliculitis, Mixed group: dissecting cellulitis, folliculitis keloidalis End stage (non-specific) Premise: Although histologic findings do not distinguish the various clinical forms beyond separating the predominantly lymphocytic group and the predominantly neutrophilic/plasmacytic group, the nature of the inflammatory infiltrate provides a practical guide for selecting treatments. Recent molecular research has shown that PPAR-gamma expression is significantly decreased in lichen planopilaris. For this reason, PPAR-gamma agonists or glitazones are listed as a new treatment option for lichen planopilaris. Substantiating data: We have published our treatment outcomes with many of the following therapies (1,2,3,4,5), and they are what we use in our practice. It is essential to explain that the goal of treatment is to alleviate the symptoms and clinical signs, and to retard or slow the progression of the disease. Hair regrowth is not possible at this time, and activity may recur after months or years. Treatment of predominantly lymphocytic cicatricial alopecia: Oral: hydroxychloroquine 200 mg twice daily for 6 to 12 months, or doxycycline 100 mg twice daily for 6 to 12 months, or mycophenolate mofetil 0.5 gm twice daily for 1st month, then 1 gm twice daily for 5 months, or cyclosporine 3 to 5 mg/kg per day or 300 mg/day for 3 to 5 months. If after 3 months there is no improvement, then

a 3 month course of an alternative systemic drug is prescribed. Intralesional injection of triamcinolone acetonide 10 mg/cc to inflamed, symptomatic sites. Topicals and intralesional injections are used at the active margins, not in the central bare areas; this contrasts with alopecia areata where topicals and intralesional injections are used in the bare areas as well as the margins. Topical: high potency corticosteroids, topical tacrolimus or pimecrolimus DermaSmoothe/FS scalp oil is useful particularly for scaling and for temporary relief of severe itching. Should these diseases be treated as metabolic disorders instead of primarily inflammatory disorders? Glitazones: PPAR-gamma agonists or glitazones are medications that are widely used for the treatment of type 2 diabetes mellitus. Rosiglitazone and pioglitazone are the currently available glitazones in the United States. In diabetics, these medications lower blood glucose by improving insulin sensitivity. In non-diabetics, these medications do not affect blood glucose and can be safely used. The main side-effects of these medications include: dosage-dependent weight gain due to fat accumulation and fluid retention/peripheral edema as a result of renal sodium reabsorption. This fluid retention may pose a cardiovascular

risk in patients predisposed to congestive heart failure. Check liver function tests before initiating therapy and periodically thereafter. Pioglitazone induces cytochrome P450, increasing the possibility of drug interactions (e.g. oral contraceptives). When compared to other oral medications used for treatment of LPP and other cicatricial alopecias, the glitazones have a comparable side effect and safety profile. Dosage: pioglitazone 15mg PO daily or rosiglitazone 4mg PO daily. Response in reduction of symptoms and signs occurs in 1-2 months. The duration of treatment may be many months. Treatment of predominantly neutrophilic/plasmacytic cicatricial alopecia: Repeated culture and sensitivities of pustules, and oral antibiotics geared to predominant pathogen cultured. - For staph aureus: oral rifampin 600 mg daily and clindamycin 300 mg BID for 10 weeks. May substitute ciprofloxacin 750 mg BID, or cephalexin 500 mg QID, or doxycycline 100 mg BID, given with rifampin. - Culture nostrils. If staph carrier, topical mupirocin ointment QD for 1 week, then once per month - For dissecting cellulitis, folliculitis keloidalis: isotretinoin is helpful in some patients. Starting dose must be small. Discussion: After laying out a systematic approach to the management of the patient with cicatricial alopecia, we have to add that in a few patients the cicatricial alopecias do not respond as hoped and prove to be challenging. Clinical and histologic findings may change over time: a neutrophilic cicatricial alopecia may become lymphocytic, and the failure to respond indicates the need for a rebiopsy. At other times, the histology may not correlate with response to treatment: the predominant infiltrate may be neutrophilic, but the patient does not respond to antimicrobials and does respond to an immunomodulating drug. Another difficulty is that many patients present with late stage disease, which is problematic both for diagnosis and treatment; only acute phase lesions are diagnostic. We need improved therapies for cicatricial alopecia, and continued study of the clinical variants on a molecular level will hopefully identify differences in possible environmental or genetic triggers, and lead to specific therapies. Publications: 1) Mirmirani P, Willey A, Price VH. Short course of oral cyclosporine in lichen planopilaris. J Am Acad Dermatol 49: 667-71, 2003. 2) Mimirani P, McCalmont T, Price VH. Band-like frontal hair loss in a 62 year old woman. Arch Dermatol 139(10): 1363-8, 2003. 3) Chiang C, Sah D, Cho BK, Ochoa BE, Price VH. Hydroxychloroquine and lichen planopilaris: efficacy and introduction of lichen planopilaris activity index (LPPAI) scoring system. J Am Acad Dermatol 62:387-392, 2010. 4) Cho BK, Sah D, Chwalek J, Roseborough I, Ochoa BE, Chiang C, Price VH. Efficacy and safety of mycophenolate mofetil for lichen planopilaris. J Am Acad Dermatol 62(3):393-7, 2010. 5) Price VH, Mirmirani P. Cicatricial Alopecia: An Approach to Diagnosis and Management. Springer, NY, 2011.

ISHRSISHRS19th Annual Scientific Meeting19th Annual Scientific Meeting

September 17, 2011September 17, 2011

Cicatricial Alopecia UpdateCicatricial Alopecia Update

Vera H. Price, MD, FRCPCVera H. Price, MD, FRCPC

DISCLOSURE OF RELEVANTDISCLOSURE OF RELEVANT

RELATIONSHIPS WITH INDUSTRYRELATIONSHIPS WITH INDUSTRY

ConsultantConsultant

J&J, Follica, Allergan, HairDx, AndroScienceJ&J, Follica, Allergan, HairDx, AndroScience

I have no conflict of interest.I have no conflict of interest.

Cicatricial AlopeciaCicatricial Alopecia

A group of inflammatory disorders characterized by A group of inflammatory disorders characterized by

permanent destruction of the pilosebaceous unit:permanent destruction of the pilosebaceous unit:

•• PrimaryPrimary: The hair follicle is the primary target of : The hair follicle is the primary target of

destruction: “folliculocentric”destruction: “folliculocentric”

•• SecondarySecondary: Follicular destruction is incidental to : Follicular destruction is incidental to

nonnon--follicular process: infection, tumor, burn, follicular process: infection, tumor, burn,

radiation, tractionradiation, traction

Recent molecular research suggests a new model for pathogenesis of Recent molecular research suggests a new model for pathogenesis of cicatricial alopecia cicatricial alopecia

Perifollicular inflammation may be secondary to lipidPerifollicular inflammation may be secondary to lipid--metabolic changesmetabolic changes

Loss of peroxisome proliferator activated receptor gamma (PPARLoss of peroxisome proliferator activated receptor gamma (PPARγ) γ) in hair in hair follicles & sebaceous glands follicles & sebaceous glands in LPP & FFAin LPP & FFA

PPARPPARγγ = transcription factor that regulates gene expression= transcription factor that regulates gene expression

Loss leads to abnormal processing & buildup of toxic lipids that trigger Loss leads to abnormal processing & buildup of toxic lipids that trigger inflammation, eventuate in scarring & destruction of the follicleinflammation, eventuate in scarring & destruction of the follicle

Hair follicle stem cellHair follicle stem cell--specific PPARspecific PPARγγ deletion causes scarring alopeciadeletion causes scarring alopecia

Karnik P, Tekeste Z, McCormick TS, Gilliam AC, Price VH Cooper KD, Mirmirani P.Karnik P, Tekeste Z, McCormick TS, Gilliam AC, Price VH Cooper KD, Mirmirani P.

JID 129:1243JID 129:1243--57, 200957, 2009

PPARPPARγγ storystory

Why is cicatricial alopecia permanent?Why is cicatricial alopecia permanent?Working classification of primary Working classification of primary

cicatricial alopecia*cicatricial alopecia*

LymphocyticLymphocytic

NeutrophilicNeutrophilic

MixedMixed

EndEnd--stagestage

Lichen planopilaris Lichen planopilaris

Frontal fibrosing alopeciaFrontal fibrosing alopeciaCentral centrifugal cicatricial alopecia Central centrifugal cicatricial alopecia

Pseudopelade (Brocq) Pseudopelade (Brocq)

**Chronic cutaneous lupus erythematosus **Chronic cutaneous lupus erythematosus **Keratosis follicularis spinulosa decalvans**Keratosis follicularis spinulosa decalvans

Folliculitis decalvansFolliculitis decalvansTufted folliculitisTufted folliculitis

**Dissecting cellulitis **Dissecting cellulitis **Folliculitis keloidalis **Folliculitis keloidalis

* Olsen et al. JAAD. 48: 103* Olsen et al. JAAD. 48: 103--10, 2003 (modified) 10, 2003 (modified) ** Not a primary cicatricial alopecia ** Not a primary cicatricial alopecia

Cicatricial alopeciaCicatricial alopecia

Hallmarks of cicatricial alopeciaHallmarks of cicatricial alopecia

•• Loss of follicular orificesLoss of follicular orifices

•• Pull test: Pull test: looselyloosely anchored anagen hair*anchored anagen hair*

clinical sign of activity, but not always presentclinical sign of activity, but not always present

*Mirmirani et al. JID. 128: 285, 2008*Mirmirani et al. JID. 128: 285, 2008

Management of cicatricial alopeciaManagement of cicatricial alopecia

If time is limited on initial visit:If time is limited on initial visit:

•• Biopsy Biopsy

•• Margin of early active, Margin of early active, hairhair--bearingbearing areaarea

•• Labs: None relevantLabs: None relevant

•• Culture: If pustular, crustedCulture: If pustular, crusted

Dermpath cannot distinguish clinical phenotypesDermpath cannot distinguish clinical phenotypes

Dermpath can describe:Dermpath can describe:

Type, location, extent of infiltrateType, location, extent of infiltrate

Presence/absence of sebaceous glandsPresence/absence of sebaceous glands

Dermpath can distinguish the predominantly lymphocytic Dermpath can distinguish the predominantly lymphocytic group and the predominantly neutrophilic group, group and the predominantly neutrophilic group, notnot the the clinical phenotypesclinical phenotypes

1. Mirmirani P, Willey A, Headington JT, Stenn K, 1. Mirmirani P, Willey A, Headington JT, Stenn K,

McCalmont TM, Price VH. JAAD 52: 637McCalmont TM, Price VH. JAAD 52: 637--43, 200543, 2005

2. Pincus LB, Price VH, McCalmont TH. J Cutan Patho38:12. Pincus LB, Price VH, McCalmont TH. J Cutan Patho38:1--4, 20114, 2011

3. Bormate AB Jr, Price VH, McCalmont TH. ( In preparation)3. Bormate AB Jr, Price VH, McCalmont TH. ( In preparation)

Dermpath cannot distinguish clinical phenotypesDermpath cannot distinguish clinical phenotypes

1. Mirmirani P, Willey A, Headington JT, Stenn K, 1. Mirmirani P, Willey A, Headington JT, Stenn K,

McCalmont TM, Price VH. JAAD 52: 637McCalmont TM, Price VH. JAAD 52: 637--43, 200543, 2005

2. Pincus LB, Price VH, McCalmont TH. J Cutan Patho38:12. Pincus LB, Price VH, McCalmont TH. J Cutan Patho38:1--4, 20114, 2011

3. Bormate AB Jr, Price VH, McCalmont TH. ( In preparation)3. Bormate AB Jr, Price VH, McCalmont TH. ( In preparation)

LymphocyticLymphocytic Lichen planopilaris Lichen planopilaris

Frontal fibrosing alopeciaFrontal fibrosing alopecia

Central centrifugal cicatricial alopecia Central centrifugal cicatricial alopecia

Pseudopelade (Brocq) Pseudopelade (Brocq)

NeutrophilicNeutrophilic Folliculitis decalvans Folliculitis decalvans

Tufted folliculitis Tufted folliculitis

EndEnd--stagestage

Therapy for predominantly lymphocytic group: Therapy for predominantly lymphocytic group:

Immunomodulating agentsImmunomodulating agents

If symptomatic, clinically active, hair loss progressive:If symptomatic, clinically active, hair loss progressive:

•• Hydroxychloroquine 200 mg BID. After 3 months, if symptoms & signs persist, Hydroxychloroquine 200 mg BID. After 3 months, if symptoms & signs persist, consider next therapyconsider next therapy

•• Doxycycline 100 mg BIDDoxycycline 100 mg BID

•• Mycophenolate mofetil 0.5 gm BID for 1 mo, then 1 gm BID for 5 mosMycophenolate mofetil 0.5 gm BID for 1 mo, then 1 gm BID for 5 mos•• Cyclosporine* 3 to 5 mg/kg per day, or 100 mg TIDCyclosporine* 3 to 5 mg/kg per day, or 100 mg TID

•• Intralesional triamcinolone acetonide 10 mg/cc to inflamed, symptomatic sitesIntralesional triamcinolone acetonide 10 mg/cc to inflamed, symptomatic sites

(inject (inject marginsmargins not bare center)not bare center)•• High potency topical corticosteroids, topical tacrolimus, pimecrolimus,High potency topical corticosteroids, topical tacrolimus, pimecrolimus,

DermaSmoothe/FS scalp oilDermaSmoothe/FS scalp oil

Price VH. Semin Cutan Med Surg 25: 56Price VH. Semin Cutan Med Surg 25: 56--9, 2006 9, 2006

*Mirmirani et al. JAAD 49: 667*Mirmirani et al. JAAD 49: 667--71, 200371, 2003

•• Repeated C & S of pustulesRepeated C & S of pustules

•• Oral antibiotics per pathogen culturedOral antibiotics per pathogen cultured

•• For staph aureus*: cephalexin 500mg QID x 10 weeks with oral rifampinFor staph aureus*: cephalexin 500mg QID x 10 weeks with oral rifampin600mg x 10 days 600mg x 10 days

•• Or clindamycin 300mg BID, or trimethoprimOr clindamycin 300mg BID, or trimethoprim--sulfamethoxazole DS BID, or sulfamethoxazole DS BID, or

ciprofloxacin 750 mg BID, or doxycycline 100 mg BID, with rifampinciprofloxacin 750 mg BID, or doxycycline 100 mg BID, with rifampin

•• If staph carrier: mupirocin ointment intranasal QD for 1 week, then q monthIf staph carrier: mupirocin ointment intranasal QD for 1 week, then q month

•• For dissecting cellulitis: isotretinoin (small doses), infliximab**For dissecting cellulitis: isotretinoin (small doses), infliximab**

*Powell et al. Br J Dermatol 140:328*Powell et al. Br J Dermatol 140:328--33, 199933, 1999

**Grant et al. JAAD 62: 205**Grant et al. JAAD 62: 205--17, 201017, 2010

Therapy for predominantly neutrophilic/plasmacytic group: Therapy for predominantly neutrophilic/plasmacytic group:

AntimicrobialsAntimicrobials

Gene expression profiling of lichen planopilaris biopsies (affected & Gene expression profiling of lichen planopilaris biopsies (affected &

unaffected scalp) & controlsunaffected scalp) & controls

Findings:Findings:

•• Loss of PPARLoss of PPAR--γγ in hair follicles and sebaceous glandsin hair follicles and sebaceous glands

•• Abnormal lipid metabolism and cholesterol biosynthesisAbnormal lipid metabolism and cholesterol biosynthesis

•• Buildup of proBuildup of pro--inflammatory (toxic) lipidsinflammatory (toxic) lipids

•• Inflammatory responseInflammatory response

•• Hair follicle and sebaceous gland dystrophyHair follicle and sebaceous gland dystrophy

•• LipidLipid--mediated programmed cell deathmediated programmed cell death

•• ScarringScarring


•• Targeted deletion of PPARTargeted deletion of PPAR--γγ in hair follicle in hair follicle stem cells of the hair follicle bulgestem cells of the hair follicle bulge

•• Progressive, pruritic alopecia after 4 weeks Progressive, pruritic alopecia after 4 weeks with complete alopecia after 4 monthswith complete alopecia after 4 months

Knockout mouse modelKnockout mouse model

Hair Follicle Stem CellHair Follicle Stem Cell--Specific PPARSpecific PPARγγ Deletion Causes Scarring Alopecia.Deletion Causes Scarring Alopecia.

Karnik P, Tekeste Z, McCormick TS, Gilliam AC, Price VH, Cooper KD, Karnik P, Tekeste Z, McCormick TS, Gilliam AC, Price VH, Cooper KD, Mirmirani P. JID 129; 1243Mirmirani P. JID 129; 1243--57, 200957, 2009

PPARPPARγγ story: new upstream treatment strategystory: new upstream treatment strategy

PPARPPARγ γ agonists: agonists: pioglitazone, rosiglitazonepioglitazone, rosiglitazone

•• Diminish inflammatory cytokines: TNFDiminish inflammatory cytokines: TNFαααααααα

•• Used widely to treat type 2 diabetes mellitusUsed widely to treat type 2 diabetes mellitus

•• Can be used safely in nonCan be used safely in non--diabeticsdiabetics

•• SideSide--effects include weight gain, peripheral edemaeffects include weight gain, peripheral edema

•• Used in atopic dermatitisUsed in atopic dermatitis

•• Successful use in LPP*Successful use in LPP*

*Mirmirani P, Karnik P. Arch Dermatol 145; 1363*Mirmirani P, Karnik P. Arch Dermatol 145; 1363--66, 200966, 2009

SummarySummary

PPARPPARγγ deficiencydeficiency demonstrated in LPP, FFA demonstrated in LPP, FFA

In CCCA, PPARIn CCCA, PPARγγ is not decreased, although a cois not decreased, although a co--activatoractivator

of PPARof PPARγγ is decreasedis decreased

For predominantly neutrophilic alopecias, further For predominantly neutrophilic alopecias, further molecular study in progressmolecular study in progress


Need to identify triggers:Need to identify triggers:

environmental?environmental?

genetic?genetic?

microbial?microbial?

dietary?dietary?

other?other?

Loss of PPARLoss of PPAR--γγ function may be central to function may be central to

pathogenesis of cicatricial alopeciaspathogenesis of cicatricial alopecias

Case ReportCase Report

•• 47 year old male with sudden onset scalp irritation, patchy 47 year old male with sudden onset scalp irritation, patchy

hair losshair loss

Mirmirani P, Karnik P. Arch Dermatol 145; 1363Mirmirani P, Karnik P. Arch Dermatol 145; 1363--66, 200966, 2009

HistologyHistology

•• PeriPeri--follicular inflammation of lymphocytes at the level of follicular inflammation of lymphocytes at the level of

the sebaceous glands confirming LPPthe sebaceous glands confirming LPP

Treatment FailureTreatment Failure

•• Oral prednisone, plaquenil, oral antibiotics Oral prednisone, plaquenil, oral antibiotics

(doxycycline), cellcept, intralesional (doxycycline), cellcept, intralesional

injections, high potency topical steroid injections, high potency topical steroid

solution and shampoo, topical tacrolimus, solution and shampoo, topical tacrolimus,

and antiseborrhea shampoo(nizoral). The and antiseborrhea shampoo(nizoral). The

patient declined a trial of oral cyclosporine patient declined a trial of oral cyclosporine

due to concerns of side effects.due to concerns of side effects.

After oral pioglitazone 15mg dailyAfter oral pioglitazone 15mg daily

Before pioglitazoneBefore pioglitazone

After pioglitazoneAfter pioglitazone

C. A. R. F.C. A. R. F.

CICATRICIAL ALOPECIA RESEARCH FOUNDATIONCICATRICIAL ALOPECIA RESEARCH FOUNDATION

NewsletterNewsletter

Online Patient VideoOnline Patient Video

Biannual Patient/Doctor ConferencesBiannual Patient/Doctor Conferences

SAVE THE DATE: BOSTON, AUGUST 10 SAVE THE DATE: BOSTON, AUGUST 10 –– 12, 201212, 2012

Website: Website: www.carfintl.orgwww.carfintl.org

Do any of the treatments really help?Do any of the treatments really help?

•• First ever evidenceFirst ever evidence--based (objective) evaluation of based (objective) evaluation of

2 treatments for lichen planopilaris (LPP)2 treatments for lichen planopilaris (LPP)

•• Hydroxychloroquine (40)Hydroxychloroquine (40)

•• Mycophenolate mofetil (16)Mycophenolate mofetil (16)

ResultsResults

•• Hydroxychloroquine showed significant Hydroxychloroquine showed significant

improvement (p<0.001) in LPPAI after 6 & 12 improvement (p<0.001) in LPPAI after 6 & 12

months (69%, 83%)*months (69%, 83%)*

•• Mycophenolate mofetil also showed signficant Mycophenolate mofetil also showed signficant

improvement (p<0.005) after 6 months (83%)**improvement (p<0.005) after 6 months (83%)**

*Chaing et al. (March 2010 JAAD)*Chaing et al. (March 2010 JAAD)

**Cho et al. (March 2010 JAAD)**Cho et al. (March 2010 JAAD)

126

Clinical and histopathological analysis of Frontal Fibrosing Alopecia Francisco Jimenez, MD1, Eduardo Escario2, Enrique Poblet2 1Private Practice, Las Palmas Gran Canaria, Spain, 2Hospital Universitario de Albacete, Albacete, Spain.

Francisco Jimenez, MD is a dermatologist and hair transplant surgeon working in private practice in Las Palmas, Canary Islands, Spain. Dr. Jimenez is the author of more than 70 scientific articles and various chapters in textbooks, and has been coeditor of the Hair Transplant Forum Journal (2008-2010).

F. Jimenez: None. E. Escario: None. E. Poblet: None.

ABSTRACT: Introduction: Frontal fibrosing alopecia (FFA) is a progressive scarring alopecia first described by Kossard in 1994. The origin of FFA remains a mystery, although the presence of lymphocitic infiltration around hair follicles suggest a chronic inflammatory process triggered by an unknown factor. While there is no clear cut histological difference between FFA and lichen planopilaris, we have observed subtle difference that may suggest the diagnosis of FFA. For example, a very characteristic finding in FFA is the presence of eosinophilic necrosis of cells of the outer root sheath (1). This could indicate that apoptosis is increased in FFA lesions. Apoptosis represents a defined form of a tightly controlled, programmed cell death. Apoptosis plays a role in the catagen phase of the normal hair cycle. Apoptosis is also involved in a number of chronic inflammatory and malignant skin disases. Caspases are key effector molecules of apoptotic cell death. Caspase 3 is a critical effector caspase, expressed in most cells and activated in response to most apoptosis triggers. Similarly, lamin A is a ubiquitously expressed nuclear protein, which is cleaved in a caspase-dependent manner during apoptosis. It has been recently reported the usefulness of antibodies anti-cleaved (activated) caspase 3 and anti-cleaved lamin A is a very sensitive method for the detection of apotosis in formalin-fixed tissue using immunohistochemistry (2). Objective: To analyze the clinical and histopathological findings in patients with FFA. To evaluate the presence of apoptosis in scalp biopsies of patients with FFA using a very sensitive immunohistochemal staining method, based on the use of antibodies anti cleaved caspase 3 and lamin A. Material and Methods: Fifteen patients with clinical and histological diagnosis of FFA were included in the study. All cases had biopsy samples fixed in formalin and embedded in paraffin. The detection of apoptotic cells in tissue sections was performed using a monoclonal anti-human cleaved caspase 3 antibody (Clone 5A1, Cell Signaling Technology) and a polyclonal anti-cleaved lamin A antibody (Cell Signaling Technology). The sections were stained using the standard avidin-streptavidin method, and diaminobenzidine was used as chromogen. We performed a biopsy in a hair transplant test site in one patient with FFA. Results: In all the biopsies of patients with FFA, we found a low or very low expression of lamin A and caspase 3 positive cells in the folicular epithelium. Discussion: We did not confirm increased apoptosis in FFA lesions. The presence of necrotic keratynocites of the external root sheath could be due to a premature, unusually located keratiinzation of the cells triggered by still unknown factors. Normal follicles transplanted to the scarring area of FFA can reproduce the histological anomalies of FFA.

References: 1. Poblet E, Jimenez F, Pascual A, Piqué E. Frontal fibrosing alopecia versus lichen planopilaris: a clinicopathological study. Int J Dermatol 2006;45:375-80. 2. Jakob S, Corazza N, Diamantis E, Kappeler A, Brunner T. Detection of apoptosis in vivo using antibodies agains caspase-induced neo-epitopes. Methods 2008; 44: 255-61.

127

Association of Hair Transplantation and Lichen Planopilaris Nilofer P. Farjo, MBChB1, Bessam K. Farjo, MBChB1, Matthew J. Harries, MBBS2, Ralf Paus, MD, PhD2 1Farjo Medical Centre, Manchester, United Kingdom, 2Dermatological Sciences, The University of Manchester, Manchester, United Kingdom.

Nilofer Farjo has been exclusively performing hair restoration since 1993 in Manchester, UK. She is a member of the ISHRS, Member of the Fellowship Training Committee, Co-editor of the Forum International and diplomat of the American Board of Hair Restoration Surgery. Nilofer is the immediate past President and founder member of the British Association of Hair Restoration Surgeons, Fellow of the Institute of Trichologists, past President of The Trichological Society and member the European Hair Research Society. She currently works with three universities and one public company on basic hair sciences projects.

N.P. Farjo: None. B.K. Farjo: None. M.J. Harries: None. R. Paus: None.

ABSTRACT: Hair transplantation and face-lift surgery are common procedures that have well-documented complications in the peri- and immediate postoperative periods, but there is little information regarding development of dermatological conditions in the longer term. Lichen planopilaris (LPP) is an uncommon inflammatory hair disorder of unknown aetiology that results in permanent alopecia and replacement of hair follicles with scar-like fibrous tissue. Frontal fibrosing alopecia (FFA) is thought to be a variant of LPP involving the frontal hairline, with histological findings indistinguishable from those of LPP. Here we report eight patients who developed LPP / FFA following cosmetic scalp surgery; four male patients and two female patient developed LPP following hair transplantation, and two female patients developed FFA following cosmetic face-lift surgery. The age of the eight patients ranged from 34 to 63 years. In the six cases of LPP, hair transplantation was performed between a few months and six years prior to diagnosis. In the two cases of FFA, the face lift procedure was performed three months and six months prior to diagnosis. In all cases there was no previous history of LPP or FFA. All patients showed the classical clinical morphological features of LPP, with subsequent histological assessment supporting the clinical diagnosis in all cases. There is currently a lack of evidence to link the procedures of hair transplantation and cosmetic face-lift surgery to LPP and FFA respectively. This is the first case series to describe this connection and to postulate as to the possible pathological processes underlying this clinical observation. Explanations include Koebner’s phenomenon induced by surgical trauma, an autoimmune processes targeting an (as yet, unknown) hair follicle antigen liberated during surgery or perhaps a post-surgery pro-inflammatory mileu inducing hair follicle immune privilege collapse and follicular damage. Other possibilities are misdiagnosis of the original hair loss or just coincidence.

The Association of Hair Transplantation and Lichen

Planopilaris

Nilofer Farjo, MBChB

Manchester UK

Background

• Post-op complications:

– Immediate complications are well documented following surgeries such as HT

and face lifts

– Long term dermatological conditions less described

• LPP

• FFA

Lichen planopilaris: LPP

• uncommon inflammatory hair disorder of

unknown aetiology that results in permanent alopecia and replacement of

hair follicles with scar-like fibrous tissue

• Frontal fibrosing alopecia (FFA) thought to

be a variant of LPP involving the frontal

hairline, with histological findings indistinguishable from those of LPP.

Report of 8 patients

• Post Hair Tx

– 4 male

LPP

– 2 female

• Post face lift

– 2 female FFA

Clinical Features

• Age range: 34-63

• Time scale to derm condition:

– LPP: several months to 6 yrs

– FFA: 3mth, 6 mth

No prev hx

Classical clinical signs

Histology confirmed

Histology

Clinical case: 62 year old male with hair loss

following hair transplants. Hair loss to crown and templesClinical case: 54 year old with FFA following

facelift procedure

Discussion• Lack of evidence to link surgery and LPP/FFA

• 1st case series

• Possible etiology:

– Koebner

– an autoimmune processes targeting an (as yet, unknown) hair follicle antigen liberated during surgery

– post-surgery pro-inflammatory mileu inducing hair follicle immune privilege collapse and follicular damage

– misdiagnosis of the original hair loss

– coincidence

References1. Kossard S, Shiell RC. Frontal fibrosing alopecia developing after hair transplantation

for androgenetic alopecia. Int J Dermatol 2005; 44: 321-3. 2. Salanitri S, Goncalves JG, Helene A, Lopes F. Surgical Complications in Hair

Transplantation: A Series of 533 Procedures. Aesthetic Surgery Journal 2009; 29: 72-27.

3. Weiss G, Shemer A, Trau H. The Koebner phenomenon: review of the literature. Journal of the European Academy of Dermatology an Venereology 2002; 16: 241-248.

4. Anam K, Amare M, Naik S, Szabo KA, Davis TA. Lupus 2009; 18; 318-331.5. Shelly WB, Arthur RB. Biochemical and physiological clues to the nature of psoriasis.

Arch Dermatol 1958; 78: 14-29.6. Somani N, Bergfeld W. Cicatricial alopecia:classification and histopathology.

Dermatologic Therapy 2008; 21: 221-237.7. Kang H, Alzolibani A, Otberg N, Shapiro J. Lichen planopilaris. Dermatologic Therapy

2008; 21: 249-256.

8. Harries M, Sinclair R, MacDonald-Hull S, Whiting D, Griffiths C, Paus R. Management of primary cicatricial alopecias: options for treatment. British Journal of Dermatology 2008; 159: 1-22.

9. Weedon D. (1998) Skin Pathology, Churchill Livingstone.10. Mckee P, Calonje E & Granter S (2005) Pathology of the Skin, Elsevier Limited

128

Evidence Based Practice in Hair Restoration Mysore N. Venkataram, MD Venkat Charmalaya, Bangalore, India.

Introduction Dr. Venkataram Mysore, MD, DNB, DipRCPath (Lond) Dr. Venkataram, a unique combination of dermatologist-Hair transplant surgeon. Dr. Venkataram is the author of 90 publications and 7 books including a book on dermatopathology (for postgraduates) and dermatology (for undergraduates). He is currently the Vice President of the Association of Cutaneus Surgeons (India), Convenor of taskforce on dermatosurgery and Coordinator for special interest group on dermatopathology, of the Indian Association of Dermatologists, Venereologists and Leprologists( IADVL), and Chairman of the Ethical Committee of Association of Hair Restorations Surgeons of India . He is also the editor in chief of Journal of cutaneus and aesthetic surgeons. He presently is the director. Venkat Charmalaya-centre for advanced dermatology, in Bangalore.

M.N. Venkataram: None.

ABSTRACT: Evidence based practice involves adoption of evidence based medicine which is defined as the conscientious, explicit and judicious use of current best evidence about the care of individual patients. Such a practice involves examining available evidence for a given fact and then formulating guidelines for use based on such evidence. Evidence is classified as level A (double blind controlled trials), level B (multiple noncontrolled of large size), level C (isolated case reports/small studies), and level D (no published evidence or opinion of experts). The taskforce of dermatosurgery of Indian association of dermatologists, venereologists, leprologists, headed by the author framed standard guidelines of care for hair transplantation in 2007 which was published in the official journal IJDVL. In the light of that publication the author examines the available evidence for several practices in hair restoration surgery as it is practiced today. The following aspects which are considered crucial for an optimal outcome in hair restoration are examined for the evidence available:

1. Donor strip width 2. Type of suturing 3. Steromicroscopic dissection 4. Method of graft site creation 5. Method of graft placement 6. Density debate 7. Use of postoperative steroids 8. Use of other postoperative medications 9. Laser comb use 10. Efficacy of FUE

The author finds that level A evidence is not available for any of the commonly accepted practices in the above areas. Level B evidence is available for donor strip width, steromicroscopic dissection, density issue, FUE technique and efficacy of different methods of insertion. However, there is only level C evidence for several other practices such as use of postoperative steroids, other medications, laser comb, etc. The author will elaborate on current available evidence and discuss the details.

Evidence based practice in Hair restoration

surgery- a critical look

� EBM is defined as the conscientious, explicit and judicious use of current best evidence about the care of individual patients”.

� EBP is defined as integrating one’s clinical expertise with the best external evidence

from systematic research.

� “conscientious” - signifies an active process which requires learning, practice and reflection;

� “explicit” describes it as a transparent processused to practice EBM;

� “current” reflecting being up to date� “best” which signifies that one should seek

the most reliable evidence source to inform practice

� Asking an answerable structured question generated from a patient encounter.

� Searching for valid external evidence.

� Critically appraising the evidence for relevance and validity based on heirarchy of strength in descending order

� Applying the results of that appraisal of evidence back to the patient

� Recording the information for the future

� Suzanne Fletcher and Dave Sackett years ago described "levels of evidence"

� Level 1: High quality meta-analyses, systematic reviews of RCTs, or RCTs

� 2.Well conducted case-control or cohort studies.� 3: Non-analytic studies e.g., case reports, case

series � 4: Expert opinion

� Indian association of dermatologists,

venereologists, leprologists constituted taskforce on dermatosurgery to draft standard guidelines on

different dermatosurgical procedures which

included guidelines on hair transplantation� The author of this paper was the convenor of the

taskforce

� An effort was made to outline standard guideline of care

� Venkataram Mysore GUEST EDITORIAL: Guest editor's remarks Indian Journal of Dermatology, Venereology, and Leprology, Year 2009, Volume 75, Issue 8 [p. 65-66]

� Hair transplantation: Standard guidelines of care NarendraPatwardhan, Venkataram Mysore Indian Journal of Dermatology, Venereology, and Leprology, Year 2008, Volume 74, Issue 7 [p. 46-53] Venkataram Mysore, KC Nischal

� Guidelines for administration of local anesthesia for dermatosurgery and cosmetic dermatology procedures Indian Journal of Dermatology, Venereology, and Leprology, Year 2009, Volume 75, Issue 8 [p. 68-75]

� Level of Evidence� Level A- Strong research-based evidence.

Multiple relevant, high-quality scientific studies with homogeneous results.

� Level B- Moderate research-based evidence. At least one relevant, high-quality study or multiple adequate studies.

� Level C- Limited research-based evidence/case reports. At least one adequate scientific study.

� Level D- No research-based evidence. Expert panel evaluation of other information

� Unfortunately, in the hair transplant field,

there are very few rigorous,blinded studies with sufficient numbers of patients to provide

enough power to give good statistical

evidence.

� Look at critical areas of hair restoration

surgery –commonly accepted facts/adopted practices and evidence available for such

practices

� Evaluate the levels of evidence of such data� Discuss important studies in the field and

their quality of evidence

� Make recommendations based on important findings of this critical review

� The author performed an extensive search on

different journals/search engines.� Specific types of articles , such as controlled

study, controlled clinical trial , clinical study,

comparitive study, RCT, multicentricstudy,metaanalysis, were sought.

� The articles were studied and classified as per level of evidence

� Key words: Hair AND transplantation in article

title yielded 301 results� When Limits were applied( controlled study,

controlled clinical trial , clinical study, comparitive

study, RCT, multicentric study,metaanalysis), search yielded only 10 results

� Of these only 3 results were published after 2002

� None of evidence level B or above

� key words: “Hair transplantation” in all fields

Total 9066 results � Key words: “Hair transplantation” in article

title yielded 62 results

� Keywords “ Surgical hair restoration” in article title yielded 3 results

� Forum is not indexed

� Mostly individual opinions/expert panel opinions( level D )

� Some small studies which are poorly

constructed/individual case reports( level C)

� Contemporary Hair Transplantation� MARC AVRAM, AND NICOLE ROGERS, M� Dermatologic Surgery� Volume 35, Issue 11, November 2009, Pages:

1705–1719,

� This excellent review has total 39 references� However of these, Only four references are with

reference to surgical techniques� All others are on drugs, anatomy, lasers

� Hair Transplantation: Management of Donor AreaDermatologic Surgery

� Volume 28, Issue 2, February 2002, Pages: 136–142, Gerard E. Seery

� This is a useful study recording experience in 1000 patients

� Has used 12 references� No study quoted in references, most references are

from text books

� These search results support the statement

that published data of good quality evidence are far and few for hair restoration surgery

� No article of level A evidence except for

drug trials

� Effects of Finasteride (1 mg) on Hair

TransplantDermatol Surg. 2005 Oct;31(10):1268-76

� MATT LEAVITT, DO,✽ LT COL (RET) DAVID PEREZ-MEZA, MD,† NAVEEN A. RAO, MD,‡ MARCO BARUSCO, MD,†KEITH D.

KAUFMAN, MD,§ AND CRAIG ZIERING, DOII

� In this randomized, double-blind, placebo-controlled study, 79 men with androgeneticalopecia (20–45 years of age) were assigned to treatment with finasteride 1 mg (n = 40) or placebo (n = 39) once daily from 4 weeks before until 48 weeks after hair transplant.

� Efficacy was evaluated by review of global� photographs by an expert dermatologist

and by macrophotography for scalp hair counts.

RESULTS. Treatment with finasteride resulted insignificant improvements from baseline, compared withplacebo, in scalp hair based on global photographicassessment (p < .01) and hair counts (p < .01) at week 48.Visible increases in superior/frontal scalp hair post-transplant were recorded for 94% and 67% of patients inthe finasteride and placebo groups, respectively.Finasteride treatment was generally well tolerated.

CONCLUSION. For men with androgenetic alopecia, therapywith finasteride 1 mg daily from 4 weeks before until 48weeks after hair transplant improves scalp hairsurrounding the hair transplant and increases hair density.

� Specific areas in HT and their evidence , are

discussed in the next few slides

�� Single strip dissection , with strip centered around occipital Single strip dissection , with strip centered around occipital protuberance, is recommendedprotuberance, is recommended..

�� Though Though multibladedmultibladed knife yields multiple strips and hence makes knife yields multiple strips and hence makes dissection easier, it also results in dissection easier, it also results in higher transection higher transection of hairs of hairs and and hence is to be avoided. hence is to be avoided.

�� A A single strip is excised by elliptical excision. Width of the strip single strip is excised by elliptical excision. Width of the strip should preferably be about 1 should preferably be about 1 cm, cm, though wider strips have been though wider strips have been advocated by different authorities. advocated by different authorities.

�� Width Width and the length also depends on the number of grafts and the length also depends on the number of grafts needed and can be calculated by determining the density of needed and can be calculated by determining the density of follicular units by follicular units by densitometer.densitometer.

�� Suturing of strip is performed with sutures( either continuous or Suturing of strip is performed with sutures( either continuous or intermittent) or with staples , as each of these has its own intermittent) or with staples , as each of these has its own advocates. Absorbable sutures/advocates. Absorbable sutures/nonabsorbablenonabsorbable sutures can be sutures can be used.used.

� 77 results on forum� Unger WP:Suturing of donor sites. In Unger WP,editor; Hair

transplantation,New York,1979,Marcel Dekker,p 64� Seery GE. Hair transplantation: management of donor

area.Dermatol Surg. 2002 ;28(2):136-42.� 46.Brandy DA. Intricacies of the single-scar technique for donor

harvesting in hair transplantation surg.Dermatol Surg. 2004 ;30(6):837-44;

� Bernstein RM,Rassman WR.A New Suture for Hair Transplantation:Poliglecaprone 25 Dermatol Surg 2001; 27(1): 5-11.

� Brandy, D.A. New instrumentation for hair restoration surgery. Dermatol Surg, 1998 24(6): 629 Ð 631

� Bernstein RM . Measurements in Hair Restoration. Hair Transplant Forum International; 1998:8;1;27

� Chang SC. Estimation of number of grafts and donor area. Hair transplant Forum International 2001:11;4;101-3

� November/December 2009 Volumne 19,

Number 6 page 20� Intraoperative measurement of donor

closure tension: maximizing donor width

and minimizing donor scarring� Melvin L. Mayer

� Our method measures tension or weight exerted in newtons or grams on a 3.5-

inch towel clamp used to bring the wound edges together (Figure 1). Only two instruments are required: a tensionometer (scale) and a 3.5-inch towel clamp

(Figure 2).Over 150 patients were studied. Age, sex, race, and number of previous surgeries were recorded. In addition, the width of incision in the center and 6cm

lateral to the midline on the right side were recorded and donor scars were measured at 4, 8, and 12 months post-operatively.

� Results� When 500gm (5 newtons) of tension was exceeded, one begins to accelerate

accelerate rapidly up the tension curve. There is a steeper upward slope for tight scalps (<20% scalp elasticity) and a more gradual upward incline for loose scalps

(>30 % scalp elasticity) (Figure 3). Donor scar widths were usually 1-2mm with intraoperative closure tensions of 500gm or less, but frequently 2-5mm if the

tension was greater than 500gm. Scars tended to be wider when the intraoperative closure tension exceeded 500gm (5 newtons).

� It is appropriate to consider taking an additional 2-3mm strip from the lower incisional edge if the intraoperative closure tension is 200-300gm or less. Typically, it is possible to take a wider strip centrally than over the mastoid. Then, above the ear you can go a bit wider again.

� More extensive data evaluation will be published in a peer-reviewed journal, but from a practical surgical perspective, we have presented the most important clinical information.

� Morphometric Analysis of the Human Scalp

Hair Follicle:Practical Implications for the Hair Transplant Surgeon and Hair Regeneration

Studies

� FRANCISCO JIMENEZ, MD, ANDER IZETA, PHD,y AND ENRIQUE POBLET, Dermatol

Surg 2011;37:58–64

� METHODS AND MATERIAL Hair follicles from the occipital scalp were obtained from 29 individuals.

� Measurements were performed on digital pictures using a software imaging system. Antibodyanticytokeratin (CK), 15 was used as a bulge stem cell marker.

� RESULTS The mean length of a scalp hair follicle is 4.16mm. The infundibulum measures 0.76mm, the isthmus 0.89 mm, and the inferior portion 2.5mm. The insertion of the arrector pili muscle is located

� 1.65mm deep. CK15 immunoreactivity starts at a depth of 1mm and extends down to 1.8 mm.

� CONCLUSION The ideal depth for the trichophytic procedure is to cut the wound edge at a depth of less than 1mm to avoid the bulge zone. The data provided can serve as an objective anatomical reference in

� hair regeneration studies using horizontally transected follicles.

� Forum July/August 2005 Volume 15, Number 4� Trichophytic Closure of the Donor Area� Mario Marzola� 26 consecutive patients had one side closed trichophytically (i.e.,

with the top edge removed) and the other side closed non-trichophytically (i.e., with the top edge left intact) (see Table 1). My practice is ideally suited to this type of trial as all donor strips are removed in two pieces, one early in the morning and one a few hours later. After 13 cases, the study sides were switched.

� The results after seven months proved to me that while trichophytic closure is not a panacea, and we still have aspects to learn, it is by and large significantly better than the non-trichophytic traditional closure in producing a much more camouflaged and, therefore, less visible scar

� Dermatol Surg. 2001 Jan;27(1):5-11.

� A new suture for hair transplantation: poliglecaprone 25.

� Bernstein RM, Rassman WR, Rashid N.

� Poliglecaprone 25 is a synthetic, absorbable monofilament suture of low tissue reactivity. It was compared to closure with metal staples in a bilateral controlled study. One side of the donor area was closed with poliglecaprone 25 sutures using a running cutaneous stitch and the other side was closed with stainless steel staples. Patients were evaluated with regard to healing, postoperative discomfort, resultant surgical scar, and closure material preference.

� RESULTS: � Of the 22 patients studied, the following postoperative complaints were noted on the staples

side: tenderness (12), itching (4), swelling (2), and scabbing (1). This compared to only one complaint of itching and one complaint of swelling on the poliglecaprone 25 side. Two patients had postoperative complaints of visibility of staples showing through their hair. Objective measurements revealed a wider scar overall on the staples side in six patients and wider scar on the suture side in two patients. The average scar width on the staples side measured 1.78 mm compared to 1.42 mm on the suture side. Fourteen of the 22 patients preferred poliglecaprone 25 for future procedures, 1 preferred metal staples, and 7 had no preference. Most patients stated that postoperative discomfort from the staples and the inconvenience and occasional pain associated with their removal was responsible for their decision.

� CONCLUSION: � Poliglecaprone 25 is a strong synthetic, absorbable, monofilament suture

with low tissue reactivity that can be used in hair transplantation to close the donor wound with a single, running cutaneous stitch. This suture can provide a donor closure that ensures hemostasis, has little risk of infection, and is comfortable for the patient

� The elliptical strip is first dissected in to small slivers of 1 or 2 follicular unit width( 1-2 mms) under a stereomicroscope . This is a crucial step and needs microscopic dissection to avoid transection of hairs. The slivers are then dissected in to units of one, two or three or four hair units .

� It has been generally recognized that stereomicroscopic dissection is needed proper identification and dissection to minimize transaction. However several surgeons from Asia for have been performing excellent dissection for Asian hair, with out microscopic dissection.

� Whether the grafts should be skinny( thin) or chubby( thick with a little amount of dermis around them) is a matter of debate. Skinny grafts need smaller recipient sites, and can be packed densely, but very fine dissection, has the risk of damaging arrectores muscle , sebaceous glands and telogen hairs, which may be important in hair growth. Skinny grafts also need more careful handling to avoid damage.

� Grafts are very susceptible for drying and hence they should be kept in cold saline.

� Dissection of hairs is a skilled job, needing proper training for the dissectors .Proper lighting and seating arrangements for the dissecting team is important to ensure proper visualization and to avoid fatigue

� Seager D: Binocular stereoscopic dissecting microscopes: should we use them? Hair Transplant Forum International1996 6:(4):2-5,

� Bernstein RM, Rassman WR: Dissecting microscope vs. magnifying loops with transillumination in the preparation of follicular unit grafts: A bilateral controlled study. Dermatol Surg 1998 24: 875-880,.

� Cooley J, Vogel J. Loss of the dermal papilla during graft dissection and placement: Another cause of x-factor? Hair Transplant Forum Int 1997; 7:20-21.

� Kurata S, Ezaki T, ItamiÊS, Terashi H TakayusuÊH. Viability of Isolated Single hair Follicles Preserved at 4¡C Dermatol Surg 1999;25(01); 26-29

�

� Raposio E, Cella A, Panarese P, Mantero S, Rolf E. Nordstrom A et al Effects of Cooling Micrografts in hair transplantation Surgery .Dermatol Surg. 2001;27( 01), 98-98

�

� Saeger D . chubby vs. skinny Dermatol Surg 1997;23: 757Ð61� Beehner M. A comparison of hair growth between follicular-unit grafts trimmed

ÒskinnyÓ vs. Òchubby.Ó Dermatol surg 1999;09:16.� Cooley J, Vogel J. Loss of the dermal papilla during graft dissection and placement:

Another cause of x-factor? Hair Transplant Forum Int 1997; 7:20-21.

� There are several methods for insertion;� a) ' stick and place method ' which involves making a

recipient site, followed immediately by insertion of hairs in to the recipient sites by an assistant

� b)creating all the required recipient sites at one time, and then placing the grafts one by one

� c) use of implanters such as Choi or KNU implanters� Each of the methods has its advocates and any of these

can be used by the surgeon as per his expertise. Different instruments such as NoKor needles( size 16 for three hair units, size 18 for two hair units), 18/19 size needles ( for 1-2 hair units), and blades of different sizes are used , each with its own advocates. Punches are not generally preferred for creating recipient sites.

� Brandy, D.A., Meshkin, M., "Utilization of No-Kor Vented Needles for Slit-Micrografts." J Dermatol Surg Onc 1994. 20:336 - 339,

� Arnold J: Mini-blades and a Mini-blade Handle for Hair Transplantation. Am J Cosm Surg 1997; 14(2): 195-200.

� Yung Chul Choi and Jung Chul Kim : Single hair transplantation using the Choi hair transplanter. J. Dermatol. Surg. Oncol., 1992. 18:945-948

�� Brandy DA. A Technique for HairBrandy DA. A Technique for Hair--Grafting in Between Existing Grafting in Between Existing Follicles in Patients with Early Pattern Baldness. Follicles in Patients with Early Pattern Baldness. DermatolDermatolSurg;2002: 26 : 08;801Surg;2002: 26 : 08;801--805805Unger W. Different grafts for Unger W. Different grafts for different purposes. different purposes. DermatolDermatol surgsurg 1997;14:177, 83.1997;14:177, 83.

�

� Dermatol Surg. 1999 Sep;25(9):705-7.

� Effects of cooling micrografts in hair transplantation surgery.

� Raposio E, Cella A, Panarese P, Mantero S,

Nordström RE, Santi P.

� total of 240 anagen hair follicles were obtained from 10 healthy male patients. Follicles were thus randomly assigned to one of the following groups: group A (control; n = 120 follicles), or group B (experimental; n = 120 follicles). Follicles from group A were preserved for 5 hours at room temperature (26 degrees C), and follicles from group B were preserved for 5 hours at 1 degrees C. Immediately after that 5-hour period, follicles from both groups were then cultured for 10 days. The length of each follicle was measured immediately following the 5-hour test period and at the end of the 10-day culture period.

� RESULTS: � No statistically significant differences were found between the survival and

growth rates of follicles from the control (survival rate = 87%, mean 10-day growth rate = 2.68 mm) and experimental (survival rate = 88%, mean 10-day growth rate = 2.54 mm) groups.

� CONCLUSION: � Although, at present, it is generally assumed that lowering the metabolism of

grafts by reducing their temperature may be of some utility for enhancing their survival rate, our data indicate of that there are no effects when performing hair transplantation surgery

� September/October 2007 Volume 17, Number

5 page 173� The Growth Factors, Part I: Clinical and

Histological Evaluation of the Wound

Healing and Revascularization of the Hair Graft After Hair Transplant Surgery

� David Perez-Meza, MD, Matt Leavitt, DO, Mel Mayer, MD

� March/April 2011, Volumne 21, Number 2,

page 37� 96-hour study of FU graft "out-of-body"

survival comparing saline to

Hypothermosol/ATP solution� Michael Beehner

� One case report?

� Polarized Light-Emitting Diode Magnification

for Optimal Recipient Site Creation during Hair Transplant Dermatologic Surgery

� Volume 31, Issue 9, September 2005, Pages:

1124–1127, Marc R. Avram

� March/April 2011, Volumne 21, Number 2,

page 38� How to manage intra-operative slippery

grafts

� Shobit Caroli, MBBS, DDVL, DamkerngPathomvanich, MD, FACS, Oravan

Pathomvanich, MD, Kulakarn Amonpattana

� There is much debate on the desired density

in hair transplantation. While it is generally agreed that minimum density required for

good cosmetic results is about 35-40/sq cm,

several teams have claimed higher density, up to 55 and even 70 / sq cm

�� LimmerLimmer B. The density issue in hair transplantation. B. The density issue in hair transplantation. 1997;23:747, 50.1997;23:747, 50.

�� Unger WP. Density issue in hair transplantation. Unger WP. Density issue in hair transplantation. DermatolDermatol SurgSurg : 1998;297Ð297: 1998;297Ð297

� MarrittÊE. The Death of the Density Debate DermatolSurg 1999; 25; 08;654-660

�� Brandy DA The Art of Mixing Follicular Units and Brandy DA The Art of Mixing Follicular Units and Follicular Grouping in hair Restoration Follicular Grouping in hair Restoration DermatolDermatol SurgSurg; ; 2002: 28, 04, 3202002: 28, 04, 320--328328

� Haddab AM, Kohn T, Sidloi M Effect of Graft Size, Angle, and Intergraft Distance on Dense Packing in hair Transplants. Dermatol Surg. 2004;30( 06); 846-856

�

Mayer M, Keene S, Perez-Meza D. Graft Density Production Curve with Dense Packing. International Society of Hair Restoration Surgery annual meeting, Sydney, Australia, August 24–28, 2005.

Nakatsui T. Survival of Densely Packed Follicular Units Using the Lateral Slit Technique. Annual Meeting of the InternationalSociety of Hair restoration Surgery, San Diego, October 19,2006.

Beehner M. Studying the Effect of FU Planting Density on HairSurvival. Hair Transplant Forum International, January–February2006; 247–248.

Norwood OT. Limmerization. Hair Transplant Forum Int 1996;6:12.

Unger W. In: Unger W, Shapiro R, editors. Unger’s and Seager’s Comparative Study on the growth of follicular units and 2 mm grafts in the same patient in Hair transplantation. New York:

Marcel Dekker Inc; 2004. p. 274–279.

� Survival of Densely Packed Follicular Unit

Grafts Using the Lateral Slit TechniqueTHOMAS NAKATSUI, MD, FRCPC, JERRY

WONG, MD,y AND DON GROOT, MD,

FRCPC, FACP� Dermatol Surg 2008;34:1016–1025

Survival of Densely Packed Follicular Unit Grafts Using the Lateral Slit Technique. THOMAS NAKATSUI, MD, FRCPC, JERRY WONG, MD, AND DON G

Examination of the most densely packed area (72 grafts/cm2) at 8 months posttransplant revealed that the number of implanted grafts showing growth was 98.6% whereas the least densely transplanted area (23 grafts/cm2) revealed a growth rate of 95.6%.

CONCLUSION This is the first study that demonstrates high growth rates in densely packed follicular units using the lateral slit technique, even at densities of 72 grafts/cm2.

� New Methodology and Instrumentation for

Follicular� Unit Extraction: Lower Follicle Transection

Rates and

� Expanded Patient Candidacy� JAMES A. HARRIS,Dermatologic surgery

2006:32;1

� Novel Technique of Follicular Unit Extraction Hair� Transplantation with a Powered Punching Device� MASAMITSU ONDA, MD, PhD,y HIROHARU H. IGAWA, MD,

PhD,y KOICHI INOUE, MD, PhD,RYUZABURO TANINO, MD, PhD � dermatologic surgery 2008:34;12� The P-FUE method had a shorter harvesting time (6.0 minutes for

100 grafts; 14.2 minutes for manual FUE) and lower graft transection rate (5.4% vs 17.3% with manual FUE). For 40 P-FUE cases,mean harvesting time for 100 grafts was 8.971.3 minutes. In 10 validated cases, the transection rate was 5.5%. Although there were limitations on patient selection with manual FUE, there were no restrictions on patient candidacy with the P-FUE method

� Dermatol Surg. 2002 Sep;28(9):795-8;

discussion 798-9.� Does the recipient site influence the hair

growth characteristics in hair

transplantation?� Hwang S, Kim JC, Ryu HS, Cha YC, Lee SJ, Na

GY, Kim DW.

� Low Level Lasers-are they beneficial?

� Only few studies of Level C are available

� a study on low level laser therapy (LLLT) was conducted which indicated that there was a 55% increase of growth (hair count) in the temporal area as well as 64% in the vertex of the female subjects who were treated with LLLT for hair loss.

� The study also indicated a 74% increase in the hair counts of the male subjects in the temporal area and 120% in the vertex region

� Further studies need to be conducted to confirm the initial results Further studies need to be conducted to confirm the initial results

� Leavitt M, Charles G, Heyman E, Michaels D (2009). "HairMax LaserComb laser phototherapy device in the treatment of male androgenetic alopecia: A randomized, double-blind, sham device-controlled, multicentre trial".

� Clinical Drug Investigation 2009; 29 (5): 283–92.

� Medicine is an art and science

� It can be an art based on science.� However, in hair restoration surgery, art and

science go together.

� The examination of the published data shows

that more high qualities are needed in the field of hair restoration surgery.

� Such studies are lacking even in important

areas such as donor strip width, transection rates, comparison of different techniques for

graft insertion

� We need more published Data of high quality� This will help to establish standard guidelines of

care

� It is recognised that in a technique such as Hair transplantation, where art and science go together closely, it is some what difficult to establish RCTs

� However, we can take a leaf out of the studies in other fields such as typical example is BTX A, vitiligo surgery, tumescent liposuction, fillers

� ISHRS has conducted periodic surveys on different surgical practices

� Can we have an online periodic registry on all aspects of hair restoration which is open to only members and which will allow periodic assessment and analysis?

� Such a registry has been established by Assn of Cutaneus surgeons(India) of which the author is the president

� Records surgical practices in special forms

� Each procedure has a form which members have to complete monthly

� All side effects are entered

� Analysis done monthly � Presently two studies are being conducted:

� A) Vitiligo stability study

� B) Study on procedures performed on patients receiving isotretinoin

� Similar registry by ISHRS would be very

useful to document practices in hair restoration by surgeons all over the world

� Accumulation of such data , with subsequent

analysis and study could lead to forlmulateion guidelines of care

� Thank you

� Welcome to India

129

Moderator Introduction, What's the Diagnosis Ivan S. Cohen, MD Yale University School of Medicine, Fairield, CT, USA.

Ivan S. Cohen MD is an Associate Clinical Professor of Dermatology at the Yale University School of Medicine. He has been performing hair transplantation and treating hair loss for over thirty years. He is in private practice in Fairfield , CT.

I.S. Cohen: None.

130

What's the Diagnosis?: Case 1 Ivan S. Cohen, MD Center for Hair Transplantation, Fairield, CT, USA.

Ivan S. Cohen MD is an Associate Clinical Professor of Dermatology at the Yale University School of Medicine. He has been performing hair transplantation and treating hair loss for over thirty years. He is in private practice in Fairfield , CT.

I. Cohen: None.

131

What’s the Diagnosis?: Case 2 Bessam Farjo, MBChB, Nilofer Farjo, MBChB Farjo Medical Centre, Manchester, United Kingdom.

Bessam Farjo, MBChB, graduated in 1988 from the Royal College of Surgeons in Ireland. After general surgery training, in 1993, he trained in hair surgery in Canada and co-founded the Farjo Medical Centre in Manchester and London exclusively practicing hair restoration surgery. Past President of ISHRS (07-08), Past President and co-founder of the British Association of Hair Restoration Surgeons, Diplomate and Board Director of the American Board of Hair Restoration Surgery, Fellow, Board Governor & Medical Director of the Institute of Trichologists, Fellow of the International College of Surgeons.

B. Farjo: None. N. Farjo: None.

132

What's the Diagnosis?: Case 3 Vera Price, MD 1701 Divisadero Street, Rm 335A, San Francisco, CA, USA.

Vera H. Price, MD, FRCP(C) Professor, Department of Dermatology, University of California, San Francisco After moving to California, Dr. Price spent three years doing basic research on human hair with the wool chemists at the USDA in Berkeley. This led to her expertise and subspecialty in hair and hair biology. Dr. Price has described several new hair disorders, and recently co-authored a book, Cicatricial Alopecia: An Approach to Diagnosis and Management. Her research interests include studies in cicatricial alopecia, alopecia areata, hormonal regulation of hair follicle, quantitative methods of estimating hair growth, structural hair shaft anomalies, and Afro-American hair.

V. Price: None.

133

What’s the Diagnosis?: Case 4 Bernard P. Nusbaum, MD Hair Transplant Institute of Miami, Coral Gables, FL, USA.

Bernard Nusbaum, MD is an ISHRS Past President, American Board of Hair Restoration Surgery Board of Governors, International Society of Hair Restoration Surgery and he was the Co-Editor Hair Transplant Forum International

B.P. Nusbaum: None.

134

What's the Diagnosis?: Case 5 Dow Stough, MD 7777 Forest Lane, The Stough Clinic, Dallas, TX, USA.

Dr. Dow B. Stough maintains private practice in Hot Springs, Arkansas, and Dallas, Texas. He is a board certified dermatologist and has practiced in Hot Springs since 1988. He is a Certified Clinical Trials Investigator for his pharmaceutical research company and a Clinical Assistant Professor of Dermatology at the University of Arkansas for Medical Sciences. In addition, Dr. Stough completed a cosmetic surgery fellowship sponsored by the American Academy of Cosmetic Surgery. He is a co-founder of The International Society of Hair Restoration Surgery, and has authored two textbooks on hair transplantation.

D. Stough: None.

135

ISHRS Best Practices Project Paul C. Cotterill, MD 21 Bedford Road, Toronto, ON, Canada.

Dr. Cotterill is a past president of the ISHRS and is the current chair of the CME Committee which oversees the ISHRS Best Practices Project

P.C. Cotterill: None.

ABSTRACT: This year the ISHRS and the CME Committee are continuing to develop Program Learning Objectives by addressing the educational "gap" between perceived Best Practices and Current Practices common to the profession. The CME Committee is again seeking your cooperation in completing a survey designed to identify what the current practices are for hair restoration surgery. The ARS will be employed for this survey. Your participation in this important research will help to contribute to the development of a strong medical education program and profession. Thank you in advance for your help with this very important project.

136

Moderator Introduction, Hairline Design Panel Russell G. Knudsen, MBBS Sydney, Australia.

Dr Knudsen is Past President of the ISHRS, past Co-Editor of the Hair Transplant Forum International and current President of the Australasian College of Cosmetic Surgery. He is in full-time practice in hair transplantation in both Australia and New Zealand.

R.G. Knudsen: None.

137

Panelist for Interactive Hairline Design Panel Robert M. Bernstein, MD Bernstein Medical, New York, NY, USA.

Robert M. Bernstein, MD is Clinical Professor of Dermatology at Columbia University. His private practice in Manhattan is devoted solely to hair restoration. Dr. Bernstein is the recipient of the 2001 Platinum Follicle Award for his pioneering work in Follicular Unit Transplantation. Other contributions include studies in examining graft sorting for increasing transplant density, graft anchoring, local anesthetic use, suture materials and Follicular Unit Extraction. His paired articles, The Art of Repair in Surgical Hair Restoration - Part I: Basic repair strategies and Part II: The Tactics of Repair, have served as a useful reference for those performing corrective work.

R.M. Bernstein: None.

138

Panelist for Interactive Hairline Design Panel Jean Devroye, MD 180 av de la chasse #152, Brussels, Belgium.

Jean Devroye is a "Doctor in Medicine and Surgery"(MD). He completed his studies at the University of Liège, in Belgium. In 1999, he decided to move to the United States and dedicated his time to Hair Transplant Surgery. He only performs hair transplants. Dr Devroye works in Belgium, Brussels. • 2009 : Amsterdam Chairman LPV (live patient viewing) ISHRS Congress. • 2008 : Rome, Live Surgery Demonstration FUE ISHRS and ISHR Congresses. • 2008 : Montreal 2nd Award for the best poster ISHRS Congress. • 2005 : Sydney Australia ISHRS Meeting Award for the best Poster, 3rd.

J. Devroye: None.

139

Panelist for Interactive Hairline Design Panel Mario Marzola, MBBS 83 Kensington Road, Norwood, Australia.

Over 30 years of Hair Restoration, seeing all the changes in that time. One thing that has remained constant however is the need to produce a well balanced hairline for our patients. Some aspects are easily reproduced such as the height of the hairline, while other aspects such as broad or narrow, receding or rounded temples can be more of a judgement on the part of the practitioner. Beauty, balance and harmony are aspects which can be studied and learned. Most often however it is simply an awakening of the innate artistic talents of the observer that is requiered.

M. Marzola: None.

140

Panelist for Interactive Hairline Design Panel Damkerng Pathomvanich, MD Phaholyotin Road, DHT Clinic, Bangkok, Thailand.

Dr. Damkerng Pathomvanich MD runs a Hair Restoration Surgery Clinic in Bangkok, Thailand since 1990. He is devoted in advancing the science in HRS, and has introduced the “Open Technique”. This new approach in minimizing injury to hair follicle during Donor harvesting has been presented and well received in journals and international conferences. He is Fellow of the American College of Sugeon; Fellowship in cosmetic & hair restoration surgery; American Board of Hair Restoration Surgery Certified. He is the only accredited Director of the ISHRS Fellowship Training Program in the Asian region (ISHRS).

D. Pathomvanich: None.

141

Moderator Introduction, Difficult Cases E. Antonio Mangubat, MD SCSHR, Seattle, WA, USA.

Dr. Mangubat is a graduated of the University of Washington School of Medicine, studied general surgery at the University of Kentucky and received his cosmetic surgery training from Dr. Richard Webster. Dr. Mangubat performs many different cosmetic surgery procedures but hair-related surgeries remain one of his favorite operations. His long history of service to the ISHRS includes serving as president from 2004-2005. He works tirelessly to promote the positive influence HRS plays in our patients’ lives. He is currently president of the Hair Foundation that will provide unbiased education raising awareness of hair health worldwide.

E. Mangubat: None.

142

Panelist for Difficult Cases Session Jon W. Gaffney, MD Suite 510, Hair Club, West Hollywood, CA, USA.

Dr. Jon Gaffney is a board-certified plastic surgeon who has performed over 14,000 hair transplant procedures. Dr. Gaffney is fully dedicated to performing hair transplants using his artistic eye and skills to help his patients achieve the new look they have always dreamed of. Dr. Gaffney has been a frequent lecturer on cosmetic procedures, training other physicians on the latest and most effective techniques. Dr. Gaffney has lectured at UCLA on hair restoration.

J.W. Gaffney: None.

143

Panelist for Difficult Cases Session Sheldon Kabaker, MD 3324 Webster Street, Oakland, CA, USA.

Dr. Kabaker is one of the founding members of the Board of Governors of the ISHRS and its 5th president. He was instrumental in introducing pedicle flap surgery, tissue expansion and surgical hairline lowering to the US hair transplant community . His present areas of interest and expertise are in hairline lowering, follicular unit hair transplantation and reconstructive scalp surgery with scalp expansion.

S. Kabaker: None.

144

Panelist for Difficult Cases Session Mario Marzola, MBBS 83 Kensington Road, Norwood, Australia.

In more than 30 years of Hair Restoration many difficult cases have presented. From mental issues such as OCD or BDD to tight closures, bad scarring and dissapointing growth. Difficult repair cases present their own challenges. At all times the patient needs to be well informed about the possible outcomes and be referred on if the problem lies outside the prctitioner's field of expertise.

M. Marzola: None.

145

Moderator Introduction, New Surgical Instruments and Techniques Sanjiv A. Vasa, MD Vasa Hair Academy, Ahmedabad, Gujarat State, India.

He has been Active member of ISHRS for last 15 years, Founder president of Association of Hair Restoration Surgeons of India, Director of Vasa Hair Academy. He has devoted last 16 years exclusively to hair restoration and performed procedures in more than four figures. His major research interests has been to find out pitfalls of current hair restoration practice and resolve them by innovating specially designed instruments, equipments and techniques. He has the ownership of many patents, design registry, trademarks. He has also innovated unique training system on simulators for hair restoration.

S.A. Vasa: None.

146

New Generation of the Laxometer Parsa Mohebi, MD US Hair Restoration, Los Angeles, CA, USA.

Parsa Mohebi, MD, is a hair transplant surgeon and the medical director of US Hair Restoration (USHR). Dr. Mohebi is a Diplomate of the American Board of Hair Restoration Surgery. He did his surgical residency at the University of New Mexico and York Hospital. Dr. Parsa Mohebi pursued an interest in surgical research at Johns Hopkins School of Medicine, Department of Surgical Sciences. At Johns Hopkins, he performed several studies on wound healing and hair growth, using growth factors and gene therapy methods. Dr. Mohebi completed a fellowship in surgical hair restoration at New Hair Institute (NHI).

P. Mohebi: Ownership Interest (royalty, patent, or other intellectual property); Yet to be determined..

ABSTRACT: The first generation of the Laxometer (Laxometer-I) was previously introduced along with its applications for scalp laxity assessment before hair transplant surgeries. Using Laxometer-I, we proved that scalp exercises can really improve the mobility of a patient’s scalp through serial scalp laxity measurement. We also introduced “sequential strip removal” utilizing the Laxometer in order to increase the safety of hair transplant procedures that involve a large number of grafts. Over the last few years and through further experience with the Laxometer, we became more aware of its pros and cons. Although the Laxometer-I has been a great step forward in understanding the mechanical forces involved in wound closure, it has had its limitations. The biggest challenge we had with the first generation of Laxometer was the impact of an individual’s skin characteristics (such as thickness and rigidity of skin) on the Laxometer readings. Laxometer-I measures the vertical mobility of an individual's scalp using two approximating jaws. The effect of tissue mass that was being squeezed between the two jaws of the Laxometer-I was an important variable that we could not disregard.

That variation could be secondary to the individual’s amount of subcutaneous fat, thickness and stiffness of skin. This diversity prevented the Laxometer readings from being always accurate. At times, this inconsistency left us with more laxity in the scalp than was expected by the Laxometer. That could lead the operator to be too conservative with the width of strip in order to avoid the risk of wound complications. This limitation of the Laxometer-I inspired us to develop another prototype to resolve the problem. The Second Generation of Laxometer (Laxometer-II) was made with only one pad to measure the vertical mobility of an individual’s scalp. The new prototype (Laxometer-II) does not require measuring the scalp laxity through approximating pads therefore we could eliminate the impact of individual skin characteristics. We designed a single pad Laxometer that can measure the vertical mobility of the scalp by shifting the skin up and down. We are currently reviewing the measured values of the Laxometer-II in comparison with the actual closing forces. We utilize a force meter on the edges of the wound in order to gauge the actual closing tension. Initial results have been promising and indicate that the Laxometer-II could be used as a valuable tool in pre-operative evaluation. Discussion: With today’s increasing demand for transplanting more hair in fewer surgical sessions, precise gauging of scalp mobility is an essential factor in pre-operative preparation. The Laxometer-II offers a more precise technique for measuring scalp laxity while it eliminates the limitations of previous methods of scalp laxity measurement.

147

Hair Bundle Cross-Section Trichometry Measurements in 250 Consecutive Cases of Hair Loss Alan J. Bauman, MD Bauman Medical Group, Boca Raton, FL, USA.

Alan J. Bauman, MD received his MD degree from New York Medical College and served as a resident in Surgery at Beth Israel Medical Center and Mt. Sinai Medical Center in New York before specializing in Hair Restoration. He is the Medical Director of Bauman Medical Group located in Boca Raton, Florida since 1997. Dr. Bauman is a Diplomate of the American Board of Hair Restoration Surgery.

A.J. Bauman: None.

ABSTRACT: Introduction: The quantitative evaluation and tracking of changes in hair growth can be a challenging task. Current methods are fraught with inaccuracies and inefficiencies. Diagnosis based on global photographic patterns of hair coverage provide little information on the progression of early hair loss or a patient’s subtle response to treatment over time. Even with a standardized and dedicated in-office photography studio, global photography can be inconsistent due to changes in hair length and styling (e.g. cut, color, curl). Video magnification (30x-200x) and hair count densitometry of the scalp provide some additional information and raw data but also have their limitations, including having to trim hair to obtain accurate measurements. Additionally, research confirms that a decrease of up to 50% hair density can occur without significant changes in coverage. Therefore, in general, these tools often fail to be

sensitive enough to quantitatively track changes in hair caliber and length which can dramatically alter coverage of the scalp and total overall hair volume. Prior research suggests that combined cross-sectional measurement of hair bundles may be a useful method for evaluating the severity of a patient’s hair loss and tracking his/her response to treatment. Being able to simultaneously measure both density and diameter and expressing them as a single numeric value, i.e “Hair Mass Index” or “HMI” in a matter of minutes offers distinct advantages over tedious hair counts and traditional clinical photography. In addition, previously unobtainable data regarding hair breakage, “Hair Breakage Index,” was measured and tracked in a select patient group. Hair bundle cross-section trichometry may add a new diagnostic dimension to the medical management of the hair loss patient in a clinic environment and in clinical research, but at what cost to in terms of resources, learning curve, personnel and time? Our practical ‘real-world’ experience in screening over 250 consecutive hair loss patients using hair bundle measurement will be presented. A detailed explanation of the resources required, implementation pearls and ‘how to’ information, patient feedback, interesting and unexpected data as well as physician commentary will also be reviewed. Purpose: Improving a physician’s diagnostic ability when faced with the evaluation and tracking of hair loss may have a significant effect on the patient’s understanding of his/her current condition and early subtle response to treatment, improving both patient compliance and outcomes. Our goal was to determine through implementation the pros and cons of hair bundle cross-section trichometry in the medical management of our hair loss patients. Materials and Methods: From November 2009 until present day, patients who presented for medical management of their hair loss condition and who had over 4cm of hair length were evaluated using hair bundle cross section trichometry. Measurements were typically performed in three areas of the scalp (Occipital, Vertex, Frontal) and repeated every 90 days when possible. When appropriate, Hair Mass and Hair Breakage data was obtained and recorded during initial consultations and follow-up visits. Results: At the time of this writing, over 250 individual patients have been tracked, with over 800 separate HairMass measurements recorded with the HairCheckTM (Divi International) in addition to our standard medical hair loss consultation which includes medical history, hair loss history, hair and scalp physical exam, laboratory tests/biopsies when appropriate, video microscopy and global photos. Their regimen of FDA-approved and non FDA-approved hair growth treatments were recorded including scalp condition, patient’s subjective impression of hair loss status prior to the measurement as well as a physician-recorded subjective treatment-compliance assessment. At the conclusion of each visit, the patient was presented with a ‘take-home’ graphical report of their HairMass data and verbal explanation of the data along with their printed diagnosis-summary and treatment plan. When possible, follow-up measurements were scheduled at 90-day intervals. Data: Occipital HMI Averages: 75-100 Midscalp > Occiput = normal or diffuse loss Midscalp < Occiput = pattern loss Very Low Occipital HMI = ultra-fine hair Resources: Cost of device Cost of disposable cartridges In-service training/practice Two Technicians

5-10 minutes for 2-3 measurements/patient Data recording / Printing Explanation to Patient Case Presentations of interest: Female: Midscalp > Occiput; history of hair extensions Female: Frontal, improvement with pure LLLT Male: donor area assessment before and after FUE Male: Vertex, improvement on Finasteride Female: Hair Breakage Index changes with chemical processing Female: HMI changes with consistent hair extension use Conclusions: The implementation of any new diagnostic tool requires an investment in time, effort, personnel and other resources. Each physician must make his own judgement whether these investments are “worth the return” of the benefits received in terms of patient care. In our opinion, hair bundle cross-section measurement has provided us with easily understandable clinical information within minutes that was previously not attainable. For example, during this initial trial period we were able to detect and quantify non-visible thinning in male patients with early balding and quickly differentiate diffuseness from pattern balding in females with hair loss. We have been able to track patients with thinning, telogen effluvium, and we were able to critically evaluate our patients' response to minoxidil, finasteride, dutasteride, low level laser therapy and nutritional modification in a shorter timeframe than ever possible before. We also discovered that when patients related to their hair loss in quantitative terms and could see hair growth changes in shorter intervals than previously obtainable. Communication and education were significantly improved and this resulted in enhanced compliance and treatment outcomes.

148

Longitudinal or Horizontal Slivering Instead of Ordinary Method Kongkiat Laorwong, MD Absolute Hair Clinic, 96/39 The Royal Place, Chalermprakiat Rama IX Rd. Kathu, Phuket, Thailand.

He was a student of Dr. Pathomvanich. He is a ABHRS certified, has his private clinic in Phuket, Thailand.

K. Laorwong: None.

ABSTRACT: Introduction: The ordinary method of the donor strip slivering: the strip is placed and fixed on a tongue depressor or cutting board and grasped by its epidermis with the left hand by jeweler’s forceps and holding it steady applying gentle tension. The cutter’s right hand hold the razorblade gradually dissects across the width of strip. The strip is slivered under naked eyes, loupes or stereomicroscope. The strip is prevented from desiccation by wrap with moist gauze or PVC foil.

Method: In our method, a specialized cutting board designates two chambers; first the silicone block for fixation of donor strip and the other empty chamber. Both chambers are filled with cool saline to ensure that there is no desiccation. The 3-5 cm sectioned strip is stabilized on the silicon using 2-3 23G needles. The distal end of the strip is secured with skin hook and steady lateral tension is applied by non-dominant hand. A 15 bladed scalpel is superficially scored between the FU using the straight area of blade to avoid transection and easy to follow then a sliver is cut with curved and pointed area (Fig.1). The thickness of slivers can be made either one or two FU depends on the hair density. The slivering is performed under 3-4x loupes with external LED light, the reason that we do not perform this under a microscope is because the minimal depth of field. The microscope is unable to focus the entire length of the strip with frequent adjustment. Discussion: Why we make a sliver along the length of strip instead of across the width in classic method. It's generally understood that the natural orientation of follicular unit is right angle or perpendicular to the direction of hair growth. This concept leads to the coronal incisions in recipient area. In our observations, the FUs are aligned in row in horizontal line along the length of strip (Fig.2). More advantage, when a sliver is placed on a translucent plastic board for cutting under 10x magnification stereomicroscope (Fig.3), it’s clearl and easy to see the hair shaft compared to the ordinary vertical sliver (Fig.4A,4B). This makes the follicular unit graft cutting easier; reduces transection and is less time consuming.

Fig. 1 A sliver is cut with no.15 blade along the length of strip by fixing it on the silicone board and applying lateral tension with the skin hook. The strip is immersed in cool saline to prevent desiccation.

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Fig. 2 The natural orientation and alignment of follicular unit are along the length of strip.

Fig. 3 The hair shafts underneath epidermis are clearly seen under microscope.

Fig. 4A A sliver cut along the length of strip (above) compared to a sliver across the width of strip (bottom)

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Fig. 4B In a different view in same thickness, more translucent in above sliver is noticed


Longitudinal or Horizontal Slivering instead of Ordinary

Method

Kongkiat Laorwong, M.D., ABHRS

Absolute Hair Clinic, Phuket,Thailand

Introduction

• The ordinary method of the donor strip

slivering:

• The strip is slivered

under naked eyes, loupes or stereomicroscope.

• the strip is placed and fixed on a tongue

depressor or cutting board and grasped by its epidermis with the

left hand by jeweler’s forceps and holding it steady applying gentle tension.

• The cutter’s right hand hold the

razorblade gradually dissects across the width of strip.

• The strip is prevent from desiccation by

wrap with moist gauze or PVC foil.

• Its general understood that the natural

orientation of follicular unit is right angle or perpendicular to the direction of hair

growth this concept leads to the coronal

incisions in recipient area.

• Our observations, the FUs are aligned in

row in horizontal line along the length of

strip

Method

• Our method, specialized cutting board designates the two chambers; first the silicone block for fixation of donor strip and the other empty chamber.

• Both chambers are filled with cool saline to ensure that there is no desiccation.

• Autocavable

Method

• Strip is divided into 3-4 cms to fit in the chamber

Method

• The 3-5 cm sectioned strip is stabilized on the silicon using 2-3 23G needles.

• The distal end of the strip is secured with skin hook and steady lateral tension is applied by non-dominant hand.

Method

• A 15 bladed scalpel is superficial scored

between the FU using the straight area of blade to avoid transection and easy to

follow then a sliver is cut with curved and

pointed area. (VDO will be presented)

• The thickness of slivers can be made

either one or two FU depends on the hair density.

Sectioned Strip and Slivers Why not microscope?

• The slivering is performed under 3-4x

loupes with external LED light, the reason that we do not do under microscope

because the minimal depth of field.

• This is unable to focus the entire length of the strip with frequent adjustment.

• More advantage, when a sliver is placed on a translucent plastic board for cutting under 10x magnification stereomicroscope, it’s clearly and easily seen the hair shaft compare to the ordinary vertical sliver .

• This makes the follicular unit graft cutting is easier; reduce transection and less time consuming.

Horizontal vs Vertical sliver

Horizontal Sliver

Vertical Sliver

Cutting on Translucent Plastic Board Conclusion

• No desiccation

• Minimize transection

• Increase yield of grafts

• Less time consuming

• Easier dissection under microscope

149

Robotic Assisted Harvest of Follicular Units Sara M. Wasserbauer, MD #200, 1299 Newell Hill Place, Walnu Creek, CA, USA.

Dr. Sara Wasserbauer, is a Diplomate of the American Board of Hair Restoration Surgery, based in Walnut Creek, CA. She has dedicated her professional career to the medical restoration of hair for both male pattern and female pattern hair loss. Located in Walnut Creek, CA, she believes that when performed properly, by a skilled and artistic surgeon, modern follicular unit hair transplants can have dramatic results for the patient, not only restoring their hair, but giving them back their lives and dignity.

S.M. Wasserbauer: None.

ABSTRACT: Robotic-assisted Harvest of Follicular Units Sara Wasserbauer, MD Walnut Creek, CA Introduction: Follicular unit extraction (FUE) requires a high degree of technical skill to perform effectively. The technique is labor intensive and time consuming which further hinders broad clinical adoption. The potential advantages of the FUE technique are faster surgical recovery, less post-operative discomfort and avoidance of a linear scar. Robots have successfully been deployed in complex operations such as prostate surgery and interventional cardiology. We hypothesize that the repetitive, tedious and precise characteristics of the tasks employed in FUE technique lend themselves to robotic automation. Previous clinical studies presented at the ISHRS Conferences (2007, 2008, 2009) demonstrated the feasibility and safety of a prototype robotic harvesting technique. Ongoing work has been undertaken to improve the efficacy and efficiency of the system. Objective: The aim of this study is to demonstrate that the robotic system harvests hair follicles producing low transection rates. Materials and Methods: The device is an interactive image-guided robotic system (“System”) consisting of six main components: a robotic arm, a needle punch mechanism, dermal punches, video imaging system, and a user interface. The harvesting technique implements the FUE approach. Imaging algorithms and software enable the automated identification and automated harvesting of follicular units directly from the patients scalp. Clinical trials were conducted under Independent Review Board (IRB) scientific and ethical approval. Transection rate data was gathered prospectively. Results/discussion: Eight male patients were treated from January 2011 to March 2011. Mean age of patients was 45. Follicle transection rates were 8.0%. Harvest speeds ranged between 300-500 harvests per hour. No complications occurred. Conclusion: Robotic-assisted follicular unit harvests achieves low follicle transection rates.

Robotic Assisted FUE

Transection Rates,

Efficacy, and

Efficiency

Disclosures

• I now own stock in Restoration Robotics.

Robotic FUE Overview

• FUE is labor intensive, requiring a high level of

technical skill for both efficacy and efficiency

• Transection rates are a measure of the level of

technical skill and a possible indicator of

growth/survival for grafts harvested with FUE

• The objective of this study was to determine if

robotic-assisted FUE could produce grafts with

low transection rates

Methods

• Clinical trials were conducted under Independent

Review Board (IRB) scientific and ethical approval.

Transection rate data was gathered prospectively.

• The robotic system (aka ARTAS) consists of:

– Robotic Arm

– Needle Punch Mechanism

– Dermal Punches

– Video Imaging System

– User Interface

Recommended operating

room setup

Cart

Chair

Robot Arm

Physician seated at console, technician at patients bedside Grid Selection

LED Guide Lights In Force Drag Mode System aligned To scalp using fiducial markers

Follicle Selection and Tracking

Teal Halo: FU that has

been transected

Green Halo: FU

currently selected for

dissection

Purple Halo: Preview of

the next FU chosen for

dissection

Pink Line: Firing path of

the needle and punch

Green dot: Identified FU

Dual camera views and “No Harvest Zone”

Instant visual feedback of previous harvest

FU exit angle, pressure (force) on

scalp from punch (N)

Live Harvest View

Results

• Eight male patients were treated from

January-March 2011

– Mean Age: 45

– Average Transection Rate: 8%

– Harvest Speed Range: 300-500 per hour

– No Complications

Results: Data

Procedure date Case ID

Transection Rate Harvests

Harvest Time (hr)

Peak Harvest Speed (harvests/hr)

Average harvest speed (harvests/hr)

Adverse Events

1/19/11 WC-013 7.5% 912 2.9 749 552 No

1/31/11 WC-014-JR 10.4% 1000 2.5 1011 815 No

2/1/11 WC-15-SV 6.1% 1021 2.3 1054 795 No

2/7/11 WC-016-C 6.5% 1306 3.0 986 747 No

2/8/11 WC-017 10.9% 1122 3.4 1532 763 No

3/8/11 WC-018-JG 5.3% 1296 3.3 874 662 No

3/29/11 WC-019-RB 8.7% 1005 2.5 907 685 No

3/30/11 WC-020-CS 9.1% 1400 3.7 1009 751 No

averagesrange

6.1-10.9 1132.75 2.9 1015.25 721.25

Results: Data

Procedure

Date

Patient ID DOB AGE Ethnicity Norwood

Scale

19-Jan-11 WC-013-JT 3-Jul-56 55 white IIIv

31-Jan-11 WC-014-JR 11-Jan-66 45 white VI

1-Feb-11 WC-015-SV 15-Aug-63 48 asian IIIv

7-Feb-11 WC-016-CF 2-Dec-52 59 white Va

8-Feb-11 WC-017-AT 4-Sep-55 56 asian VI

8-Mar-11 WC-018-JG 27-May-59 52 hispanic VI

29-Mar-11 WC-019-RB 19-Sep-62 49 white V

30-Mar-11 WC-020-JS 11-May-59 52 hispanic VI

Results: Photos

• Patient 2: 1428 FU’s harvested

Donor Pre-Op Donor immediately post op

Patient 2: 7 days post op Patient 1 donor area , 549 FU’s harvested

Before AFTER 6 months

*Patient had 2 existing childhood scars before procedure

* * * *

Conclusion

• Robotic-assisted follicular unit harvests

achieves low follicle transection rates.

150

Moderator Introduction, Donor Management and Closure Techniques Damkerng Pathomvanich, MD DHT Clinic, Bangkok, Thailand.

Dr. Damkerng Pathomvanich MD runs a Hair Restoration Surgery Clinic in Bangkok, Thailand since 1990. He is devoted in advancing the science in HRS, and has introduced the “Open Technique”. This new approach in minimizing injury to hair follicle during Donor harvesting has been presented and well received in journals and international conferences. He is Fellow of the American College of Sugeon; Fellowship in cosmetic & hair restoration surgery; American Board of Hair Restoration Surgery Certified. He is the only accredited Director of the ISHRS Fellowship Training Program in the Asian region (ISHRS).

D. Pathomvanich: None.

SessionSession

Donor Management and Donor Management and Closure TechniquesClosure Techniques

D. Pathomvanich MD FACSDHT Clinic,Bangkok,Thailand

1919thth ISHRS Annual Scientific MeetingISHRS Annual Scientific MeetingAnchorage ,AlaskaAnchorage ,Alaska1414--1717thth June 2011June 2011

�� I have no conflict of interest to the I have no conflict of interest to the commercial supportorcommercial supportor

�� Patient anticipate minimal scar whatever Patient anticipate minimal scar whatever technique usedtechnique used

�� All surgeons keen to have their scar All surgeons keen to have their scar invisibleinvisible

�� There are many techniques for wound There are many techniques for wound closure, one layer or two layersclosure, one layer or two layers

�� Running subcuticular or skin onlyRunning subcuticular or skin only

�� Undermine or not underminingUndermine or not undermining

�� Trichophytic closure Trichophytic closure (superior vs inferior vs both)(superior vs inferior vs both)

Suture materials that are usingSuture materials that are using

�� StapleStaple

�� Absorbable stitchesAbsorbable stitches

�� Non absorbable stitchesNon absorbable stitches

�� BarbBarb

�� Nordstrom sutureNordstrom suture

Learning objectiveLearning objective

�� All of us will understand the current All of us will understand the current wound management and closure and wound management and closure and might be able to apply to use in our might be able to apply to use in our practicepractice

�� Avoid wound complicationsAvoid wound complications

151

How Deep Should We Actually Score While Donor Harvesting? Damkerng Pathomvanich, MD, Shobit Caroli, MBBS, Anand Vaggu Kumar, MBBS, MD, Oravan Pathomvanich, MD, Patcharee Thienthaworn, RN DHT CLINIC, Bangkok, Thailand.


D. Pathomvanich: None. S. Caroli: None. A.V. Kumar: None. O. Pathomvanich: None. P. Thienthaworn: None.

ABSTRACT: Introduction: Many new techniques have been proposed to minimize hair transection while donor harvesting. Most of them, especially the use of spreaders require deeper scoring. We realized that while dissection with the spreader, scoring should cut through the collagen-rich dermis to accommodate the spreader and to avoid laceration while separating the tissue. Scoring should always be made parallel to hair shaft instead of perpendicular to the surface of the skin to avoid transection but this increases the actual depth of incision. Another physician suggested in a study that the insertion of sebaceous duct is at 0.76 mm, the bulge area varies from 1 mm to 1.8 mm from epidermis and this needs to be saved during harvesting. So, if scored too deep, it increases the risk of stem cell bulge damage, transecting of follicles or severing larger vessels and nerves if cutting very deep. With this back ground, we plan to study the optimal depth of scoring by studying the depth of the collagen rich dermis. Objective: To establish the appropriate depth of scoring for donor harvesting. Material and methods: We randomly recruited 100 patients undergoing strip hair transplant surgery from November 2010 to February 2011. The distance from the epidermis to the lower dermis and also the distance from the epidermis to the hair bulb were recorded during the grafts dissection under 10X Stereozoom magnification. The racial descent with other important demographic data of the patient was also recorded. Results: The mean distance from epidermis to the lower collagen rich dermis was found to be 3.19 mm and the range is 2.5 - 4 mm. We use hemostat and skin hook to also spread the incision at different depth and found a minimum of 2.5 mm depth is required to separate the incision, deeper in Asians. We are in process of analyzing the data and the detailed data will be presented at the meeting. Discussion: Most hair transplant surgeons are reluctant to cut the donor site with the blade during harvesting to avoid transection and don't want to spend more time by cutting. Numerous tools or spreaders were introduced for the past 5 years to save time and reduce transection. How deep should we score the incision with safety to avoid damage to the stem that locate just 0.7 mm from the skin surface? Minimum depth less than 2 mm will not be able to separate the incision. Adequate depth of at least 2.5 mm (depend on the thickness of scalp) 2 mm in women will need be needed for the spreader to break the incision, at the expense of injury to stem cell that locate from 1mm-1.8 mm. Is there any impact of spreader on the hair follicle and surrounding soft tissue?

Hair bulge zone damage cannot be surely prevented while scoring deeper than 1mm with the use of spreader for donor dissection. We recommend the safety depth of scoring should be limited to less than 1mm to save the hair bulge zone.

1919thth ISHRS Annual Scientific MeetingISHRS Annual Scientific Meeting

Anchorage,Alaska. Sept 14Anchorage,Alaska. Sept 14--18,1118,11

How How deep deep should we actually should we actually

Score Score while donor harvesting?while donor harvesting?

Damkerng Pathomvanich M,D.,FACS

DHT Clinic, Bangkok, Thailand

�� I have no significant interest with commercial I have no significant interest with commercial

suporters. suporters.

BackgroundBackground

�� Blind donor harvesting result in unpredictable Blind donor harvesting result in unpredictable

follicular transectionfollicular transection

�� Majority of hair surgeons are still reluctant to Majority of hair surgeons are still reluctant to

spend more time by careful dissecting.spend more time by careful dissecting.

�� Many devices therefore have been introduced to Many devices therefore have been introduced to

separate incision in fear of follicular transection separate incision in fear of follicular transection

from harvestingfrom harvesting

Haber spreader

QuestionQuestion

��Do you need to score for strip Do you need to score for strip

harvesting?harvesting?

��If yes,how deep should we score?If yes,how deep should we score?

��If we score, should we score If we score, should we score

perpendicular or parallel to the hair perpendicular or parallel to the hair

shaft, any difference?shaft, any difference?

Picture of cut perp and obliquePicture of cut perp and oblique

1mm

A vertical section of a scalp hair follicle in anagen showing the A vertical section of a scalp hair follicle in anagen showing the different portions of the hair follicledifferent portions of the hair follicle

Skin surface

Insertion of sebaceous duct(0.76mm)

Insertion of arrector pili muscle(1.65mm)

Base of hair bulb

(4.16mm Average)

0.89mm

Courtesy of FRANCISCO JIMENEZ et al.

�� Paco Jeminez MD published bulge stem cell Paco Jeminez MD published bulge stem cell

region extends from 1 mm from skin surface to region extends from 1 mm from skin surface to

1.8 mm deep (Total length of bulge stem cells 1.8 mm deep (Total length of bulge stem cells --

0.8mm) almost equivalant to the length of 0.8mm) almost equivalant to the length of

isthmus.isthmus.

�� It’s the dangerous zone for the hair to grow if It’s the dangerous zone for the hair to grow if

damaged.damaged.

�� Blind harvesting with either single or multiBlind harvesting with either single or multi--

bladed knife need no scoring, numerous bladed knife need no scoring, numerous

transection expected even in good hand since transection expected even in good hand since

the hair direction changing along the curvature the hair direction changing along the curvature

of the scalpof the scalp

�� SpreaderSpreader

�� IntruderIntruder

�� Skin hookSkin hook

�� HemostatHemostat

�� All need scoring to insert the tool to separate or All need scoring to insert the tool to separate or

dissect the stripdissect the strip

�� Yagyu MD suggested to harvest in arc due to Yagyu MD suggested to harvest in arc due to

hair direction changing to prevent transectionhair direction changing to prevent transection

�� However in 10% of patients the hair direction However in 10% of patients the hair direction

are side way potential for increase follicular are side way potential for increase follicular

transectiontransection

OBJECTIVE:OBJECTIVE:

��To establish the To establish the

appropriate depth of appropriate depth of

scoring for donor scoring for donor

harvestingharvesting..

MATERIAL AND METHODS:MATERIAL AND METHODS:

��We randomly recruited We randomly recruited 93 93 patients undergoing patients undergoing

strip hair transplant surgery from November strip hair transplant surgery from November

2010 2010 to February to February 20112011. .

��The distance from the epidermis to the lower The distance from the epidermis to the lower

dermis and also the distance from the epidermis dermis and also the distance from the epidermis

to the hair bulb were recorded during the grafts to the hair bulb were recorded during the grafts

dissection under dissection under 1010X Stereomicroscope .X Stereomicroscope .

�� The racial descent with other important The racial descent with other important

demographic data was also recorded.demographic data was also recorded.

ResultsResults

��Total No of patientsTotal No of patients-- 9393

��CaucasiansCaucasians--4141

��AsiansAsians--5151

��AfroAfro--americansamericans--1 1

CaucasiansCaucasians

��All are males onlyAll are males only

��Min.AgeMin.Age--20 years, Max. Age20 years, Max. Age--68 years68 years

��Average AgeAverage Age--42.3 years42.3 years

��Average distance from epidermis to lower Average distance from epidermis to lower

dermisdermis-- 3.1mm3.1mm (Max 4 & Min 2)(Max 4 & Min 2)

��Average distance from Lower dermis to base of Average distance from Lower dermis to base of

hair bulb hair bulb --1.8mm1.8mm

��Average distance from epidermis to base of hair Average distance from epidermis to base of hair

bulbbulb--4.9 mm (Minimum 4 & Maximum 6)4.9 mm (Minimum 4 & Maximum 6)

AsiansAsians�� 47 47 males,males,4 4 femalesfemales

��Min.AgeMin.Age--26 26 years, Max. Ageyears, Max. Age--68 68 yearsyears

��Average AgeAverage Age-- 4141..27 27 yearsyears

��Average distance from epidermis to lower Average distance from epidermis to lower

dermis dermis 33..33mmmm (Max (Max 44& Min & Min 22..55))

��Average distance from lower dermis to hair bulbAverage distance from lower dermis to hair bulb--

11..77mmmm

��Average distance from epidermis to hair bulbAverage distance from epidermis to hair bulb--55..2 2

mm (Maximum mm (Maximum 6 6 & Minimum & Minimum 44..55))

AfroAfro--AmericansAmericans

��One transsexualOne transsexual

��AgeAge-- 31 31 yearsyears

��Distance from epidermis to lower dermis Distance from epidermis to lower dermis

junction junction 33mmmm

��Distance from lower dermis to hair bulbDistance from lower dermis to hair bulb--11..2 2 mmmm

��Average distance from epidermis to base of hair Average distance from epidermis to base of hair

bulbbulb--55mmmm


�� In able to use spreader or perforator the dept of In able to use spreader or perforator the dept of

scoring should be closed to the lowest dermis as scoring should be closed to the lowest dermis as

possible for easy separation of the incisionpossible for easy separation of the incision

�� Robert Haber MD present his new depth Robert Haber MD present his new depth

control device control device 2 2 mm deep for scoring that allow mm deep for scoring that allow

easy access for Haber Spreader at ISHRS easy access for Haber Spreader at ISHRS

Annual Meeting in Amsterdam, Annual Meeting in Amsterdam,

�� We have to be very careful not to damage the We have to be very careful not to damage the

stem cell that locates at stem cell that locates at 00..0707--22..5 5 mmmm

��So,what So,what is the appropriate is the appropriate

depth for scoring to depth for scoring to

preserve stem cell of all preserve stem cell of all

intact viable follicleintact viable follicle

�� If this is the case should we continue to use If this is the case should we continue to use

spreader at the initial scoring or use after spreader at the initial scoring or use after

carefully dissecting to the lower dermis and then carefully dissecting to the lower dermis and then

use the device to separate the incisionuse the device to separate the incision

�� How do we know we can cut at uniform depth How do we know we can cut at uniform depth

of of 00..07 07 mm without depth controll instrument?mm without depth controll instrument?

�� Do we need to be fearful of damaging the stem Do we need to be fearful of damaging the stem

cell by stay superficially?cell by stay superficially?

�� What would be the damage if we are scoring What would be the damage if we are scoring

blindly at blindly at 22--3 3 mm deep?mm deep?

ConclusionConclusion

�� I believe scoring should be as superficial as I believe scoring should be as superficial as

possible,less than possible,less than 1 1 mm in depthmm in depth

�� The blade must be angle parallel to the hair The blade must be angle parallel to the hair

folliclefollicle

�� Scoring deeper than Scoring deeper than 1 1 mm might damage stem mm might damage stem

cell that allow the follicle to growcell that allow the follicle to grow

�� More study is neededMore study is needed

Thank youThank you

152

Evaluation and Comparisone of Linear Scar Line in Donor Area After Lower and Upper With Lower Edge Trichophitic Closure Gholamali Abbasi, MD, Shieda Abbasi office, Tehran, Iran, Islamic Republic of.

Dermatologist, ABHRS Diplomate, Asian Society BOG, Winner of ISHRS Research Award, and poster in 2005 .

G. Abbasi: None. S. Abbasi: None.

ABSTRACT: In this study we compared and evaluated the final result of scar line in donor area in lower edge and upper, lower edge (double edge) trichophic closure. In this study 53 patients (34 men and 19 women) with mean age 35 Y/O, all did hair transplant for first time, the mean length was 25 cm and width was 1.2 cm, we divided the area into two parts, right and left site, in left site we did upper and lower trichophitic and in right site, just lower trichophitic closure. During suturing there was not any tension at all. The result, evaluated, in 6 and 9 months after surgery showed there was no considerable difference between the two methods.

153

VIDEO: V-Loc Knotless Dermal Wound Closure Suture Edwin S. Epstein, MD Suite 1, Bosley, Virginia Beach, VA, USA.

Edwin S. Epstein, MD, has been practicing hair restoration since 1990. He has served on the Board of Governors of the ISHRS since 2004, and was President from 2009-2010. Dr. Epstein earned his B.A. degree from Duke University and his MD from Georgetown University. He is a Diplomate of the ABHRS, and joined Bosley in 2006.

E.S. Epstein: None.

ABSTRACT: Introduction: 2-layer wound closure has been advocated to help minimize stretch back in donor wound closure. Epstein and Parsley have described using a running Vicryl suture(without knots) and Leavitt with Biosyn. The V-Loc™ by Covidien, is an absorbable glycomer that allows for a knotless wound closure, while the barbed system allows for a tighter closure.

Objective: To demonstrate the use of this wound closure system, and to assess its efficacy for reducing wound stretchback. Materials: The V-Loc™ absorbable wound closure device comes in multiple lengths, needles sizes, and two materials: glycomer ( Biosyn) and polyglyconate ( Monocryl). The exterior of the suture has multiple “barbs,” which allow for unidirectional closure, and a loop on the proximal end anchors the tissue without the need for knots. Discussion: A video describing the suture and surgical technique will be demonstrated. 20 randomly selected patients will be evaluated for width of donor scar, post operative discomfort, and overall wound healing. Conclusion: 2-layer closure using the V-Loc suture system allows for a continuous deep layer closure, that is 50% faster than the standard closure. The unique loop and barb system is knotless, and evenly distributes tension throughout the course of the wound closure. The efficacy of this system will be evaluated.

154

Importance of Hair Alignment in Disguising the Donor Scar Bessam Farjo, MBChB Farjo Medical Centre, Manchester, United Kingdom.

Bessam Farjo, MBChB graduated in 1988 from the Royal College of Surgeons in Ireland. After general surgery training, in 1993, he trained in hair surgery in Canada and co-founded the Farjo Medical Centre in Manchester and London exclusively practicing hair restoration surgery. Past President of ISHRS (07-08), Past President and co-founder of the British Association of Hair Restoration Surgeons, Diplomate and Board Director of the American Board of Hair Restoration Surgery, Fellow, Board Governor & Medical Director of the Institute of Trichologists, Fellow of the International College of Surgeons.

B. Farjo: None.

ABSTRACT: Introduction: Today's classic method of harvesting donor hair is through the excision of a strip of hair bearing scalp. This is then closed with either sutures or staples resulting in a linear scar. In recent years this has been further modified with the introduction of trichophytic closure. Premise: The hair at the donor area changes direction and angle to various degrees as you move down the scalp. Removing a donor strip can remove a transition zone of hair direction that is potentially significant in certain cases. When you couple this with hairs growing through scar in the case of trichophytic closure, it can potentially show as a sudden change in hair direction along the scar line and gives rise to a dark highlighting of the scar location (photo 1). The coarser the hairs, the more significant this can be.

Discussion: It is therefore worthwhile to observe this potential when aligning the wound edges during closure, and perhaps deciding against trichophytic closure in cases of very coarse hair. In many cases, in the donor area, as you move down the occipital scalp, the hairs change direction medially at the outer edges, but gradually change to an inferiorly pointing configuration near the centre of the occiput. There can be variations to this. Removal of a section of scalp can result in a sudden change of this hair direction rather than a transition zone. When closing, it becomes important to restore part of that gradual change in direction by reducing the directional angle of either the upper or lower edges of the wound or a little bit of both. At each end of the wound I move the upper edge medially and the lower edge laterally to line up the hairs closer in direction (photo 2). Conclusion: Strip harvesting of the donor is still the most efficient and reliable technique, and trichophytic closure has undoubtedly further improved the scars appearance. However, in the cases I highlighted above, the changes in hair direction can still betray the scar's disguise and paying attention to this detail can keep scars better camouflaged.

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155

FUE vs Strip FUT: A Side By Side Comparison Bradley R. Wolf, MD Wolf Medical Enterprises, Cincinnati, OH, USA.

Bradley R. Wolf MD has performed hair transplantation surgery for 20 years, including FUE for 8 years. He lives on a farm in Ohio with his wife and son.

B.R. Wolf: None.

ABSTRACT: Introduction: Follicular Unit Transplants (FUT) microscopically dissected from a harvested strip is currently the gold standard in hair transplants. In recent years Follicular Unit Extraction (FUE) has become more popular due to less visible donor scarring with short donor hair. There remain questions concerning growth rates, transaction rates, difficulty placing, and numbers of hairs per graft obtained using the FUE method. Questions also exist concerning the relative amount of donor scarring from the two techniques. To compare these two harvesting techniques a case study was performed in which one half of a hairline and frontal scalp was transplanted using grafts dissected from a strip. The contra lateral side was transplanted using grafts harvested using FUE. Eight months after surgery the data, results, and photographs will be studied and a comparison between the two sides will be presented. The donor areas will be also be compared and presented. Objective: After eight months of growth, the two sides will be compared to see which donor harvesting technique resulted in more effective coverage of the frontal scalp. The number of grafts, number of hairs per graft, and transection rates from the two techniques will be compared. Before and after photos will be compared; in particular after photos of the two sides will be compared. The growing hairs on both sides will be counted and compared to presurgery hair counts. The hair counts of the two sides will be compared after growth. The patient will be questioned as to which side he thinks provided the best coverage and feel. The donor area will be photographed to compare the scarring incurred by the two techniques. Materials and/or Methods: In January 2011, a 50 year old patient underwent two successive days of surgery. On day one, 970 grafts (2237 hairs) harvested by FUE were transplanted to the left half of the scalp. This included 179 one, 358 two, and 403 three to four hair grafts. Grafts were placed into incisions made by chisel point blades of 0.8, 1.0, and 1.1mm widths respectively. Approximately 952 hairs were present in the left half of the frontal scalp prior to grafting. A mechanical rotatory punch handle was used at 2500rpm. A 1.05mm diameter outside diameter punch was used. The average density of the donor area was 68FU/cm2. On day two 1006 grafts (2218 hairs) harvested by strip excision and microscopically dissected under 10X power were transplanted to the right half of the scalp. This included 200 one, 557 two, and 289 three to four hair grafts. Grafts were placed into incisions made by the same instruments of 0.8, 1.0, and 1.2mm widths respectively. Approximately 378 hairs were present in the right half prior to grafting. A strip 7-9mm wide X 15 cm long was harvested from the right half of the occipital scalp. The average density of the donor area was 64FU/cm2. The same assistant placed all the grafts on both sides. (See attached photos) Discussion/Results: In September 2011 prior to the ISHRS conference, photographs will be taken and used to compare the coverage obtained from the two techniques. The data will be analyzed to compare the growth of the hairs and effective coverage on the two sides of the scalp. The number of grafts, number of hairs per graft, and transection rates of the two techniques, FUE and FUT will be analyzed. The donor areas will be compared to show the scarring incurred from the two techniques.

Conclusion: This is one case study. The results shown and analyzed will fairly compare two donor harvesting techniques, FUE and FUT from strip excision. Data will not be analyzed and photos will not be taken until September 2011 and are not available at this time.

156

Moderator Introduction, Unique Issues in Ethnic Transplantation Nicole Rogers, MD Old Metairie Dermatology, Metairie, LA, USA.

Dr. Nicole Rogers is a board-certified dermatologist who completed an ISHRS fellowship with Dr. Marc Avram in 2007-8. Together they have published extensively, including several review articles and a textbook on Hair Transplantation. She is currently in private practice in the New Orleans metropolitan area where she specializes in the surgical and medical treatment of hair loss for both men and women. She also volunteers her time in the Tulane Dermatology Clinic, instructing residents and medical students about various scarring alopecias such as lichen planopilaris, frontal fibrosing alopecia, and traction and chemical alopecias.

N. Rogers: None.

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157

Comparative Study of Follicular Unit Extraction Between Different Ethnic Groups With 0.9mm and 1.0mm Punches Anastasios Vekris, MD1, Viral Desai, MD2, Konstantinos Giotis1 1DHI International Medical Group, Athens, Greece, 2DHI India, Mumbay, India.

Dr Anastasios Vekris is a specialist plastic surgeon registered with the Specialist Registry of the GMC (General Medical Council) in the UK, the ISHRS, HESPRAS, IPRAS and several other medical societies. He has a vast experience in burns and hand surgery. He is a well trained reconstructive microsurgeon and a master hair restoration surgeon for many years. He has performed several hundreds of hair restoration procedures. Dr Vekris currently holds the position of the Medical Director of the DHI Medical Group. He has presented more than 80 papers on various aspects of plastic surgery and hair restoration in more than 120 international congresses. He has several published articles in international medical journals in the fields of microsurgery and burns.

A. Vekris: None. V. Desai: None. K. Giotis: None.

ABSTRACT: Introduction: There have been many reports in the recent years on the use of smaller caliber punches (less than 1.0mm) in follicular unit extraction with the objective of producing fine, intact hair follicles and, at the same time, leaving the donor area as much as possible intact, without marks or scars. On the other hand, there are also several reports indicating that smaller caliber punches may lead to more transected hair follicles and thus affecting the end result of a hair restoration procedure as well as the condition of the donor area. Objective: The aim of this study is to compare the effect of the use of different caliber punches, 0.9mm and 1.0mm, on the same patient, in terms of transection and postoperative condition of the donor area, both short and long term. Also, to compare the results of groups of patients coming from different ethnicities, Europeans and Indians, and trying to establish if there are or not any differences between these groups. Finally, in the long term, the hair growth of the hair follicles extracted with different caliber punch will be compared to establish if there are any differences in the survival of the hair follicles. Materials & Methods: Two groups of patients, randomly selected, will be used, one group of Europeans and one of Indians. Each group will consist of 20 patients. On each patient there will be two spaces in the central part of their donor area, of equal size, selected, marked and photographed. Then, the same doctor will cut a specific number of hair follicles in each space, with a different caliber punch (0.9 or 1.0 mm). The caliber of the punch will not be announced to the doctor and will be known only by the supervisor. After the hair follicles are cut, in equal numbers, in both spaces, the doctor will extract the hair follicles from each space separately. The assistant will count the number of intact hair follicles extracted from each space and also the hair per hair follicle ratio of the specific area. Following extraction, the hair follicles from each space will be transplanted to their new selected position in the recipient area with the use of implanter devices. The transplanted areas will be photographed, as well as the donor area. There will be specific follow up periods in 1,7 and 30 days and every two months after, until 12 months of postoperative follow up are completed. Photos of both the recipient and the donor area will be taken in each follow up in order to demonstrate the hair growth in the recipient area and the condition of the donor area. Discussion/Results: The final results of this study will be announced at the upcoming ISHRS meeting. The primary results so far provide strong indications that there is a significant increase in the transection rate and a significant decrease in the ratio of hairs per hair follicle in the group of Indian patients, with the use of the 0.9 mm punch in comparison to the 1.0 mm punch where the transection rate is quite low and the ratio of hairs per hair follicle higher. On the contrary, in the European group of patients, the transection rate with both calibers is almost the same and the ratio of hairs per hair follicle varies, but there is no solid evidence that it is affected significantly by using the 0.9 mm punch. The results

are still inconclusive and there are still no comparable results concerning the hair growth which will be evident in the following months. It appears that there may be differences between different ethnic groups based probably on the fact that hair follicles of Asian people tend to be thicker than those of the Caucasians. If this is verified by our results, it would mean that there are different indications for the use of different caliber punches in different ethnic populations. While it seems that the quantity and the quality of the extracted hair follicles is not significantly affected in Europeans by the use of smaller caliber punches, this is not the case with the Indian group. If this is verified by our final results it would mean that there must be a different balance between the need for less invasive and traumatic extraction with smaller caliber punches and the need to produce fine, intact hair follicles, suitable for a successful transplantation with minimal transection, depending on the quality, thickness and depth of the hair follicles of each patient that are largely affected by the ethnic origin of the individual. Conclusion: With the final results of our study still pending, it seems that the need to improve the healing and the appearance of the donor area after a hair restoration procedure using follicular unit extraction, by using smaller caliber punches has to coexist and consider seriously the specific needs of each individual. People of different ethnic groups might have different properties (caliber, depth etc) of their hair follicles that might require handling with different caliber punches and sometimes, smaller caliber punches might not be suitable for certain patients as they might increase the transection rate and reduce the quality of the hair follicles.

Dr Anastasios Vekris MDDr Anastasios Vekris MD, Konstantinos Giotis,, Konstantinos Giotis,

Dr Viral Desai MD Dr Viral Desai MD

DHI Medical GroupDHI Medical Group

1919thth ISHRS ANNUAL MEETINGISHRS ANNUAL MEETINGAnchorage, September 14Anchorage, September 14--18 201118 2011

Since the introduction of Follicular Unit Extraction in Since the introduction of Follicular Unit Extraction in 2003, we have witnessed significant progress in the 2003, we have witnessed significant progress in the

speed of extraction& the quality of the extracted hair speed of extraction& the quality of the extracted hair folliclesfollicles

In the recent years, FUE techniques have gained wide In the recent years, FUE techniques have gained wide acceptance around the world & they have become very acceptance around the world & they have become very popular between hair restoration specialists as well as popular between hair restoration specialists as well as

patients suffering from hair losspatients suffering from hair lossIn general, there is a rapidly spreading worldwide In general, there is a rapidly spreading worldwide trend towards minimally invasive hair restoration trend towards minimally invasive hair restoration

procedures that will provide the best possible results procedures that will provide the best possible results with the least possible discomfort & the minimum with the least possible discomfort & the minimum

possible damage of the donor areapossible damage of the donor area

One of the key points in Follicular Unit One of the key points in Follicular Unit Extraction is the caliber of the cylindrical Extraction is the caliber of the cylindrical

punch used to extract the hair folliclepunch used to extract the hair follicleThe punch must have the proper caliber in The punch must have the proper caliber in

order to:order to:•• Provide the best possible extraction, avoiding total Provide the best possible extraction, avoiding total or partial or partial transectiontransection of the hair follicleof the hair follicle•• Avoid, if possible, the numerous little empty spots in Avoid, if possible, the numerous little empty spots in the donor area that create the “moththe donor area that create the “moth--like” effectlike” effect

The “MothThe “Moth--like” effect after FUElike” effect after FUE

High partial or total High partial or total transectiontransection may affect may affect final hair growthfinal hair growth

Smaller punch Vs bigger punchSmaller punch Vs bigger punch Higher yield of extraction Higher yield of extraction Vs faster healing & less Vs faster healing & less

marksmarks

Struggle for balanceStruggle for balance

• Which is the optimal choice of punch to combine Which is the optimal choice of punch to combine high quality extraction & less visible marks in the high quality extraction & less visible marks in the donor area?donor area?

•• Is there a punch suitable for all patients?Is there a punch suitable for all patients?

•• Do people from different ethnic backgrounds Do people from different ethnic backgrounds have the same response to the same instruments have the same response to the same instruments using the same technique?using the same technique?

• To compare the use of different caliber punches To compare the use of different caliber punches in the same population in the same population

•• To compare patients’ groups of different, distinct To compare patients’ groups of different, distinct ethnic origin in terms of quality & actual yield of ethnic origin in terms of quality & actual yield of extraction using the same technique & the same extraction using the same technique & the same caliber of punchescaliber of punches

• The 1.0 mm punch was selected as the most The 1.0 mm punch was selected as the most commonly used punch nowadayscommonly used punch nowadays

•• The 0.9 mm punch was selected on the hypothesis The 0.9 mm punch was selected on the hypothesis that it may combine the effectiveness of the 1.0 mm that it may combine the effectiveness of the 1.0 mm punch in extraction with significantly less trauma & punch in extraction with significantly less trauma & scarring of the donor area scarring of the donor area

S= S= ππr²r²

rr1=0.45 mm1=0.45 mm

rr2=0.5 mm2=0.5 mm

rr11

rr22

Although the diameter of the 0.9mm Although the diameter of the 0.9mm punch is only 10% smaller than the punch is only 10% smaller than the

1.0mm, the surface that is extracted is 1.0mm, the surface that is extracted is 20% smaller than the 1.0mm20% smaller than the 1.0mm

• Selection of distinct ethnic groups, representative of their Selection of distinct ethnic groups, representative of their area, from different continents & different backgroundsarea, from different continents & different backgrounds

•• Selection of distinct ethnic groups that the doctors Selection of distinct ethnic groups that the doctors participating in the study have sufficient experience withparticipating in the study have sufficient experience with

•• Selection of one Caucasian ethnic group, the GreeksSelection of one Caucasian ethnic group, the Greeks

•• Selection of one Asian ethnic group, the IndiansSelection of one Asian ethnic group, the Indians

AA distinctdistinct southernsoutherneuropeaneuropean ethnicethnic groupgroupwithwith significantsignificantinfluencesinfluences fromfrom thetheMediterraneanMediterranean area,area,AsiaAsia Minor,Minor, thethe BalkansBalkans&& CentralCentral EuropeEurope..AA vastvast varietyvariety ofof hairhairtypestypes && colors,colors, fromfromstraightstraight blondblond toto curlycurlyblackblack..HairHair folliclesfollicles ofofmediummedium lengthlength..

AA large,large, distinctdistinct AsianAsianpopulationpopulation residentresident toto thetheIndianIndian subcontinentsubcontinent withwith aavarietyvariety ofof originsorigins &&characteristics,characteristics, rangingranging fromfromthethe DravidianDravidian peoplepeople ofof thethesouthsouth toto thethe IndoIndo--AryanAryan ofof thethenorthnorth..Long,Long, thickthick darkdark coloredcolored hairhairwithwith thickerthicker && longerlonger hairhairfolliclesfollicles..UsuallyUsually straightstraight hairhair butbut wavywavyoror curlycurly hairhair cancan bebe foundfoundmostlymostly inin southsouth IndiaIndia

••Random selection of patients, separated in two groups, Greeks & Random selection of patients, separated in two groups, Greeks & IndiansIndians•• Random selection of age, grade of alopecia & condition of the Random selection of age, grade of alopecia & condition of the donor areadonor area•• Doctor selection between those that:Doctor selection between those that:1.1. Had experience of both patients’ groupsHad experience of both patients’ groups2.2. Experience in FUE procedures between 2Experience in FUE procedures between 2--7 years with more 7 years with more

than 300 hair restoration procedures eachthan 300 hair restoration procedures each•• Assignment of cases per doctor was randomAssignment of cases per doctor was random

• On each patient, two equal parts, side by side, in the middle of the donor area On each patient, two equal parts, side by side, in the middle of the donor area were selected, marked & photographedwere selected, marked & photographed••The same doctor would cut the same number of hair follicles in each marked The same doctor would cut the same number of hair follicles in each marked areaarea•• The caliber of the punch used would be 1.0mm or 0.9mm & it would be given The caliber of the punch used would be 1.0mm or 0.9mm & it would be given randomly to the doctor by the supervisorrandomly to the doctor by the supervisor•• The doctor would perform a test extraction before the comparative study, to The doctor would perform a test extraction before the comparative study, to establish the depth & direction of the hair folliclesestablish the depth & direction of the hair follicles•• After the cutting of the hair follicles, the doctor would extract the hair follicles & After the cutting of the hair follicles, the doctor would extract the hair follicles & the assistant would count the exact number of extracted hair follicles & those the assistant would count the exact number of extracted hair follicles & those that were totally transected & separate them according to the number of hairs per that were totally transected & separate them according to the number of hairs per hair follicle (singles, doubles, etc)hair follicle (singles, doubles, etc)•• The supervisor would estimate the average ratio of hair per hair follicleThe supervisor would estimate the average ratio of hair per hair follicle•• The hair follicles would then be transplanted to the recipient area with The hair follicles would then be transplanted to the recipient area with implanter devisesimplanter devises•• Photos were taken after the extraction & placement in both donor & recipient Photos were taken after the extraction & placement in both donor & recipient areaarea•• Follow up appointments to be scheduled to estimate the healing process & hair Follow up appointments to be scheduled to estimate the healing process & hair growth (1,7,30 days after & every 2 months up to 12 months after the session)growth (1,7,30 days after & every 2 months up to 12 months after the session)

Demographics

Group Greeks (n=18) Indians (n=16)

Age 34 37

Norwood scale

III-IV III-IV

0.9 punch 1.0 punch

Attempts Grafts Hairs

Total

transection

Ratio hair/hair

follicle Attempts Grafts Hairs

Total

transection

Ratio

hair/hair

follicle

50 43 85 14% 1,98 50 45 92 10% 2,04

36 33 60 8% 1,82 35 32 63 8% 1,97

55 46 107 16% 2,33 55 54 124 2% 2,3

300 249 705 17% 2,83 300 259 684 14% 2,64

100 95 213 5% 2,24 100 95 229 5% 2,41

120 108 248 10% 2,3 120 113 266 6% 2,35

110 95 215 14% 2,26 110 95 208 14% 2,19

50 45 97 10% 2,16 50 46 87 8% 1,89

160 147 292 8% 1,99 160 135 251 16% 1,86

60 55 118 8% 2,15 60 50 103 17% 2,06

60 52 118 13% 2,27 60 51 130 15% 2,55

80 68 171 15% 2,51 80 73 184 9% 2,52

250 179 439 28% 2,45 250 218 539 13% 2,47

150 134 345 11% 2,57 150 136 336 9% 2,47

100 85 247 15% 2,91 100 93 221 7% 2,38

50 49 108 2% 2,2 50 49 123 2% 2,51

220 199 415 10% 2,09 220 194 400 12% 2,06

100 88 169 12% 1,92 100 95 203 5% 2,14

Average 114 98 231 12% 2,28 114 102 236 10% 2,27

0.9 punch 1.0 punch

Attempts Grafts Hairs

Total

transecti

on

Ratio

hair/hair

follicle Attempts Grafts Hairs

Total

transecti

on

Ratio

hair/hair

follicle

65 40 59 42% 1,47 65 53 95 18% 1,8

50 40 60 20% 1,5 50 43 94 14% 2,19

50 28 50 44% 1,78 50 48 98 4% 2,04

50 40 57 20% 1,43 50 46 79 8% 1,71

50 37 74 25% 2,00 50 45 101 10% 2,24

50 32 54 35% 1,7 50 44 92 12% 2,11

50 34 60 32% 1,76 50 35 64 30% 1,85

50 40 74 20% 1,85 50 37 66 26% 1,78

50 30 50 40% 1,66 50 40 92 20% 2,3

50 36 73 28% 2,04 50 41 81 18% 1,98

50 30 53 40% 1,77 50 24 34 52% 1,42

50 29 67 42% 2,31 50 39 93 22% 2,38

50 40 83 20% 2,08 50 37 80 26% 2,16

50 31 49 38% 1,58 50 34 58 32% 1,71

52 48 113 8% 2,35 52 51 124 2% 2,43

50 37 84 26% 2,27 50 44 114 12% 2,59

Average 52 36 68 30% 1,85 52 42 87 19% 2,04

Greeks Indians0.9mm 1.0mm 0.9mm 1.0mm

Total transection

rate

12% 10% 30%30% 19%19%

Ratio hairs/hair

follicle

2.28 2.27 1.851.85 2.042.04

0% 10% 20% 30% 40%

0.9 mm punch

1.0 mm punch

Indians

Greeks

0 0.5 1 1.5 2 2.5

0.9 mm punch

1.0 mm punch

Indians

Greeks

•• The use of smaller caliber punch (0.9mmThe use of smaller caliber punch (0.9mm) does not ) does not seem to seem to significantlysignificantly affect the total affect the total transectiontransection rate (12% Vs 10%) or the ratio of rate (12% Vs 10%) or the ratio of hairs/hair follicle (2.28 Vs 2.27) hairs/hair follicle (2.28 Vs 2.27) in Greek patientsin Greek patients

••The use of smaller caliber punch (0.9mm) seems toThe use of smaller caliber punch (0.9mm) seems to significantly affectsignificantly affectboth the total both the total transectiontransection rate (30% Vs 19%) & the ratio of hair/hair rate (30% Vs 19%) & the ratio of hair/hair follicle (1.85 Vs 2.04) follicle (1.85 Vs 2.04) in Indian patientsin Indian patients

•• Despite the caliber of the punch used (0.9 or 1.0 mm), it seems that Despite the caliber of the punch used (0.9 or 1.0 mm), it seems that there is significantly there is significantly higher total higher total transectiontransection rate in Indians rate in Indians in in comparison to the Greeks (19% & 30% Vs 10% & 12%) comparison to the Greeks (19% & 30% Vs 10% & 12%) & lower ratio of & lower ratio of hairs/hair folliclehairs/hair follicle (2.04 & 1.85 Vs 2.27 & 2.28)(2.04 & 1.85 Vs 2.27 & 2.28)

•• While the use of smaller caliber punch in Greeks seems to have no While the use of smaller caliber punch in Greeks seems to have no negative effect to the quality & quantity of the extraction, it seems to negative effect to the quality & quantity of the extraction, it seems to largely affect in a negative way the quality & quantity of extraction in largely affect in a negative way the quality & quantity of extraction in Indian patients Indian patients

•• Further studies are required to establish the benefit in hair growth by Further studies are required to establish the benefit in hair growth by using bigger or smaller caliber punches & the quality of the healing of using bigger or smaller caliber punches & the quality of the healing of the donor areathe donor area

The significant difference in the The significant difference in the transectiontransection rate & the rate & the hairs/hair follicle ratio between the Indians & the Greeks hairs/hair follicle ratio between the Indians & the Greeks may be attributed to the different properties of the hair may be attributed to the different properties of the hair follicles in the two groups:follicles in the two groups:••Indians tend to have thicker hair follicles that may be Indians tend to have thicker hair follicles that may be easily transected if a smaller punch is usedeasily transected if a smaller punch is used••The hair follicles in Indians are longer and deeper in The hair follicles in Indians are longer and deeper in comparison to the Caucasians. This may lead to comparison to the Caucasians. This may lead to difficulties during the extraction that may lead to difficulties during the extraction that may lead to increased increased transectiontransection, partial or total, partial or totalThere must be a balance between the need to extract good There must be a balance between the need to extract good quality hair follicles and the need to respect the donor quality hair follicles and the need to respect the donor area area

••Always start with a test extraction. It will guide you to Always start with a test extraction. It will guide you to choose the proper instrument choose the proper instrument

••It is quite safe to use smaller caliber punches (0.9mm) in It is quite safe to use smaller caliber punches (0.9mm) in Caucasians without compromising the quality or the Caucasians without compromising the quality or the quantity of extractionquantity of extraction

•• In Indians, keep all your guns on the table but you’ll most In Indians, keep all your guns on the table but you’ll most probably need the big onesprobably need the big ones

••Always respect each individual. There is no “magic” tool Always respect each individual. There is no “magic” tool that can meet the needs of all patientsthat can meet the needs of all patients

••Marketing small caliber extraction may be trendy & a good Marketing small caliber extraction may be trendy & a good advertisement for your practice but always remember: advertisement for your practice but always remember: 0.5mm punches will provide excellent results in the donor 0.5mm punches will provide excellent results in the donor area without any visible marks but, most probably, there area without any visible marks but, most probably, there will be no visible hair growing in the recipient area as well will be no visible hair growing in the recipient area as well

THANK YOUTHANK YOU

158

FUE Donor Harvesting All Over the World, Our Experiences Considering Ethnical Varieties Frank G. Neidel, MD, Karin Leonhardt, MD Hairdoc Germany, Duesseldorf, Germany.

Frank G. Neidel, MD, approved surgeon, works in the field of hair transplantation since 1991. He performed since then about 6,000 hair transplant procedures. He has experience with all common procedures, such as micro-holes, micro-slits, laser-assisted hair transplant, strip harvesting, FUE. In his office “Hairdoc” in Dusseldorf, Germany, he does exclusively hair transplantation and reduction of scalp (Frechet Extender). He trained other in this field interested - collegues from Germany and Europe - he gives support to different clinics in Europe to secure quality in hair transplantation. Frank Neidel is president of the German Society Hair Restoration Surgery, secretary of European Society Hair Restoration Surgery and member of the ISHRS.

F.G. Neidel: None. K. Leonhardt: None.

ABSTRACT: Introduction: We have been performing strip harvesting for more than 20 years now on a daily basis in our clinics and in addition have started FUE harvesting on a regular basis two years ago. When starting something different it is very important to critically examine the procedure and the result. Premise: We have a precise protocol of harvesting to get data about our quality of work considering different aspects. Not every FUE is easy, there are good days and bad days. Why? Substantiating data: We first thought that we needed to find the perfect instrument to make the procedure easier. We started out with a Titanium hand punch. We got better and faster with this technique but still had some patients where we had difficulties. Sometimes follicles got damaged due to a “three dimensional fault”, sometimes the harvesting was more difficult in the temporal areas, sometimes there were differences between left and right and between surgeon assisting staff. We tried a rotating motor punch which we were already accustomed to from the time of using micro-holes as recipient sites. We found out that some patients had better results with the hand punch and some had better results with the rotating motor punch. The motor punch was faster than the hand punch. We then tried an oscillating motor punch, which combines advantages of both techniques. We also added a blunt punch to our tools and will show the advantages and disadvantages of all the tools. Discussion: So why not one tool for all patients? Take a look at our patients and try to find out for yourselves why certain techniques might work better than others. We will continue our strive to find the best individual treatment for all of our patients even if sometimes we have to make compromises.

159

The Demographics of Male Pattern Baldness in India Tejinder Bhatti, MD Darling Buds Hair Transplants, Chandigarh, India.

www.hairtransplant-india.org Joint Editor, Indian Journal of Plastic Surgery 2008-2011www.ijps.org Governing Council Member, Association of Plastic Surgeons of India 2008-2010 www.apsi.org.in Governing Council Member, Indian Asso of Aesthetic Plastic Surgeons 2009-2011 ww.iaaps.net Founder Secretary, Association of Hair Restoration Surgeons, India 2009-2014 www.ahrsindia.com Global Council Member, International Society of Hair Restoration Surgeons (USA) www.ishrs.org Governor for Chandigarh region, Association of Restorative & Cosmetic Surgery Co-ordinator, National Training Programme, Association of Hair Restoration Surgeons Founder Member: Association of Hair Restoration Surgeons, India www.ahrsindia.com India hair Forum www.besthairtransplants.ning.com

T. Bhatti: None.

ABSTRACT: Summary: Male pattern baldness is an ever-growing affliction today and affects men from the age group of 16-65. The last decade has seen an increase in the number of patients suffering from male pattern baldness (MPB) in the Indian scenario. Many studies have been carried out in the western populations regarding MPB. However, this is the only pilot study of its kind in India. 50,000 male patients were randomly selected through e-mail contact groups and mailers sent. Of the 50,000 mailers sent, 36,788 responses were obtained and were collated and studied. The study brings out the results of this landmark study in the subcontinent. Introduction: MPB is an ever increasing and distressing affliction in male populations the world over today. In a study carried out in the USA, 56.6% males surveyed had Type I-VII MPB. The present study carried out in India through e-mail mailers covered a diverse socioeconomic group from all corners of the country. The age ranged from 21-61 years (mean 46 years) and all respondents were healthy males engaged in heterogenous professions. Conclusions: The striking results of the study are brought out as under - 1. 63.2% Indian males in the age group 21-61 years suffered from MPB. This is more than the US figure of 56.6%. 2. The severity of MPB was - Type I- 32.7%; Type II- 18.1%; Type III- 22.0%; Type IV- 16.2%; Type V- 8.6%; Type VII- 2.4% 3. The age distribution of respondents was- 21-31 years: 46%; 32-41 years: 35%; 42-51 years: 10%; 52- 61 years: 9% 4. 65% of the respondents had received various medicines for MPB. The medicines were mostly from the ayurvedic, allopathic and homeopathic systems of medicines. 22% had received creams and pastes from untrained physicians. Only 1.03% patients were happy with medications since in the rest hair fall continued despite the exorbitant medicine costs involved. 5. 235 respondents had got hair transplantation done. Of these, 66% were very satisfied with the result; 21 % were not satisfied with the density; whereas 13% were dissatisfied with the results. Of the dissatisfied group, 88% had received outdated punch grafting at clinics which had not updated their techniques. 6. 89.35% had a smooth recovery after the procedure, whereas 10.65% had complications. Of the latter group, 65% had reversal of complications like infection within 7-10 days whereas 35% had bad scars due to strip/FUE techniques. 7. The study compares results of a USA study from 2009 wherein 56% of the US study group (total 35,000) had one form of MPB or the other.

8. The study concluded that MPB was significantly more prevalent in Indian population as compared to the US study group. 9. Complications and poor results could be avoided by getting hair transplantation done at reputed centres where the procedure is done routinely. 10. The study repudiates the claim that patients are dissatisfied with hair transplants.

160

Refinements of Asian Female Hairline Surgerys Sung-Jae Yi, MD Mojelim Hair Transplantation Centre, Seoul, Korea, Republic of.

Sung-Jae Yi MD has practiced hair restoration surgery as supervising surgeon at Mojelim Hair Trasnplantation Centre. He graduated Kyungpook National University, received internship and residency in the department of Plastic & Reconstructive Surgery at Daegu Catholic University Medical Center. He is the member of hair transplantation research group in the Korean Society of Plastic & Reconstructive Surgeons.

S. Yi: None.

ABSTRACT: Introduction: Since 2008 I have been using both FUE(Follicular Unit Extraction method) and strip method for aesthetic female hairline correction hair transplantations. In order to achieve the optimal and best results in aesthetic female hairline correction one has to continually strive to gain perfection in all aspects. These aspects include hairline designs, highly dense packing (using slit knifes and Choi needle), optimal implantation direction, angle and depth of hair, postoperative implantation level check, postoperative use of EGF (Epidermal growth factor) for promotion the implantation site wound healing. I report and present several refined rationales and method in this study. Objective: Present refined methods for Asian female hailine correction hair transplantation and modified rationales for female hairline design which is based on face length ratio, width of both temporal area, degree of the frototemporal recession, spherical shape of frotal bony structure and thickness of temporal muscles (which emphasize angle of frototemporal recession which make masculine hairline) I have refined the method for hairline design which associate with the degree of frontotemporal recession (in front view, called ‘M-shape hairline’), spherical surface of the scalp with all bone structures and their irregularities. Methods and discussion: For implantation method, I have used slit knifes and 20G needle for 2-hair follicle, 21G needle only for 1-hair follicle making slit site. Insertion of follicle was done by only using Choi needle. Using only Choi needle, not micro-forcep, for insertion make less mechanical injury to hair follicle, especially Asian female (who has thicker outer rooth sheath of the hair follicle compared with which of Caucasians)

Direction of implantation of the follicle is the key point for the more aesthetically preferable hairline. Direction of implantion of the follicle is only lateral direction ( not gradually change from caudal direction at posterior recipient site to lateral direction at frontal recipient site). In other words the direction of implantion of the follicle follows the terminal direction of adjacent hair not initial direction of root area of hair shaft. I critically checked the depth of every single follicle after implantation for secure optimal transplantation and avoided complications like folliculitis, pit fall or cobble stone deformity of scalp around hairs. I used EGF (epidermal growth factor) for promoting healing of insertion wound. Conclusions: Refined methods for Asian female hailine correction hair transplantation and modified rationales for female hairline design make it possible to take the hairline even closer to what is seen in nature. Preoperative view

Postoperative view (9months)

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POSTER PRESENTATIONS Posters Room: Tikahtnu Ballroom C, 3rd floor of the Dena’ina Civic and Convention Center Set-up: Wednesday/September 14, 2011 1:00pm-7:00pm.

Display Times: Thursday/September 15, 2011 6:00am-5:00pm Friday/September 16, 2011 6:30am-5:45pm (Poster Inquiry Session 3:30pm-4:00pm) Saturday/September 17, 2011 6:30am-1:30pm

Dismantle: Saturday/September 17, 2011 1:30pm-4:30pm The Poster Inquiry Session will be held during the afternoon coffee break of Friday/September 16. During this session poster presenters should stand by their posters so they may answer questions from attendees. The Scientific Research, Grants, and Awards Committee will review and rate the posters. Certificates of recognition will be awarded to the highest scoring posters on Saturday morning at the start of the General Session. Posters should be disassembled between 1:30pm-4:30pm on Saturday/September 17th. Posters remaining at the conclusion of the Annual Meeting will be discarded. P01 Determining the Efficacy of Supraorbital/Supratrochlear Nerve Blocks in Hair Transplant Surgery Muhammad Ahmad, MD P02 Donor Strip Slivering, Submerses in Normal Saline to Avoid Grafts Desiccation Kulakarn Amonpattana, MD P03 The Forelock Transplant Pattern Still Has a Place Michael L. Beehner, MD P04 Hair Transplantation in Frontal Fibrosing Alopecia: 2 Prospective Cases Shobit Caroli, MBBS, DDVL P05 Optimize the Efficiency of Recipient Area Estimation: A Comparative Study Shobit Caroli, MBBS, DDVL P06 A Prospective Study on the Role of Commercially Available Growth Factors in Hair Growth Shobit Caroli, MBBS, DDVL P07 To Transplant or Not to Transplant: Lessons from 10 Cases Jeff C. Donovan, MD PhD FRCPC FAAD P08 Effects of Caffeine on Human Hair Follicles and the Dermal Papilla Cells in Vitro Weixin Fan, MD, PhD P09 Selected Thymic Peptides Directly and Differentially Modulate Human Hair Growth, Stem Cell Activity Nilofer P. Farjo, MBChB P10 Intradermotherapy in Scarring Alopecias: Could it be an Alternative Treatment to Delay Their Progress

Waiting New Developments? Silvana Franzini, MD

P11 Is Soy Isoflavones an Alternative Treatment in Perimenopausal Females to Improve Hair Quality and Stop Hair Loss?

Silvana Franzini, MD P12 The Use of Silicone at the End of Graft Placing to Prevent Bleeding, Contamination and Improve Early Scab

Removing in Hair Restoration Surgery Silvana Franzini, MD P13 How to Try to Reduce the Possibility of Over Cutting and Subsequently Piggy Backing or Popping Shahin Gholami, MD P14 Prescribing Finasteride at Distance in a Safe Way, Including the Simplified BCS Scoring Mats G. Ingers, MD P15 The Gene Expression Patterns of Transplanted Human Hairs in Nude Mice Moonkyu Kim, MD, PhD P16 Analysis of EGFR Expression in Human Hair Follicles in Frontoparietal and Occipital Scalp Jerzy Kolasinski, MD, PhD P17 Comparison Study of FUE Techniques: Sharp vs Dull Punch Larry Leonard P18 New Anesthesia Mixture for FUE Larry Leonard P19 Protection from Free Radical Formation on the Scalp Frank Liebel, BS P20 The Hair Clock, Or (To Put It Another Way) Why is Hair Growth Cyclical? Andrea Marliani, MD P21 3D-Like Tattooing of Eyebrow Masahisa Nagai, MD P22 How to Manage an Intra-Operative Surprise When We Encounter Slippery Grafts Damkerng Pathomvanich, MD, FACS P23 Preview Long Hair Transplantation, The P Constant, the Patient Maximum Efficiency Equations and

Therasession Marcelo Pitchon, MD P24 Scoping Scalp Disorders: Updates in Dermatoscopy Nicole E. Rogers, MD P25 Surgical Complications in Hair Transplantation: A Series of 533 Procedures Sandro N. Salanitri, PhD P26 Ergo-scope, the New Microscope for Hair Transplant Patrick A. Tafoya P27 Are Analgesics and Sedatives Safe? Hair Transplantation in G6PD Deficiency Anand K. Vaggu, MD P28 Oral Tranexamic Acid as a Pre-operative Medication Before Hair Transplant Surgery Pradyumna P. Vaidya, MD P29 Beginner Small Team’s Dream Comes True - Mega and Giga Session by Multiple Mini Sessions on Consecutive

3 to 4 Days Sanjiv A. Vasa, MD, FRCS, FRCS

P30 Comparative Study Between Direct Hair Implantation and Classic FUE. How Can a Minimally Invasive Procedure Affect the Survival of Hair Follicles?

Anastasios Vekris, MD P31 FUE Transection Rates Sara M. Wassebauer, MD P32 A Proposal for Standard FUE Nomenclature Sara M. Wassebauer, MD P33 Management of Patients with Coronary Artery Disease and Updated Guidelines for Antithrombotic Therapy in

Hair Restoration Surgery Kuniyoshi Yagyu, MD P34 Additional Intra-epidermal Suture to Trichophytic Closure of Both Wound Edges to Minimize Scarring and

Camouflage Donor Scars Effectively Kazuhito Yamamoto, MD P35 Ziering Zones for Hair Restoration Craig L. Ziering, DO P36 Mathematical Approach of Lateral and Sagittal Incisions Georgios Zontos, MD P37 Hair Restoration For Congenital Etiology Baldness In Occipital Region Of The Head Of 15 Years Old Male

Patient Using FUE Georgios Zontos, MD

P01

Determining the Efficacy of Supraorbital/Supratrochlear Nerve Blocks in Hair Transplant Surgery Muhammad Ahmad, MD Islamabad Private Hospital, Islamabad, Pakistan.

Dr. Muhammad Ahmad is a Plastic and Hair Restorative Surgeon, currently working at the Hair Transplant Institute, Islamabad, Pakistan. He has written more than forty national and international publications.

M. Ahmad: None.

ABSTRACT: Objectives: To know the severity of pain while performing Supra-orbital/Supra-trochlear nerve blocks in hair transplant surgery. Materials and Methods: The study was conducted in a private setup on 50 patients. A 3ml syringe containing 1% Xylocaine with 1:100,000 epinephrine was used for the supraorbital/supratrochlear nerve blocks on either side. The supraorbital notch was palpated with the index finger of the left hand. The needle was inserted approximately 20mm above the notch. The tip of the left index finger was used to palpate the needle. About ½ ml was injected. The needle was slightly withdrawn and the solution was injected on lateral side (1.0 ml). The needle was redirected medially injecting 1.5 ml of the solution almost 10mm lateral to the supraorbital notch, thereby avoiding the second prick for the supratrochlear nerve block. The same procedure was repeated on the other side as well. All the injections were administered by the single surgeon (first author). At the end of the procedure, the patients were asked to rate the extent of the pain according to the Wong-Baker Faces Pain Scale (0 - 5). Results: Fifty male patients undergoing hair transplant surgery were included in the study. The patients having hair transplantation only on the vertex or crown were excluded. The age of the patients ranged from 23 to 52 years. Majority of the patients (56%) had score ‘2’ followed by ‘3’ (24%) and ‘1’ (16%). Only one patient had score ‘4’ and ‘0’ whereas none had score ‘5’. The mean age of the patients having score ‘2’ was 37.3 years followed by 40.3 years (for score ‘3’) and 33.1 years (for score ‘1’). Similarly patients of young age group (<30 years) had an average score of ‘1.8’, flowed by ‘2.03’ in middle age group (31 - 45 years) and ‘2.4’ in older age group (>45 years). 10% of the patients were alcoholics and 58% were smokers. Alcoholics had an average score of ‘2.6’. The smokers had an average score of ‘2.6’ as compared to the score of ‘1.6’ in non-smokers. 18% of the patients were diabetic. The mean age of diabetic patients was 41.1 years as compared to non-diabetic patients having mean age of 36.4 years. The diabetics had an average pain score of ‘3.0’ as compared to score of ‘1.9’ in non-diabetic patients. Conclusion: Supraorbital/supratrochlear nerve blocks are effective in hair transplant surgery, although associated with some degree of pain and discomfort.

P02

Donor Strip Slivering, Submerses in Normal Saline to Avoid Grafts Desiccation Kulakarn Amonpattana, MD1, Damkerng Pathomvanich, MD2. 1DHT Clinic, Bangkok, Thailand, 2DHT clinic, Bangkok, Thailand.

Dr.Kulakarn Amonpattana is a board certified plastic and reconstructive surgeon. She received her training from the top medical school in Thailand. After years of working in the cosmetic field, she turned her focus on hair restoration surgery, in which she added her own artistic ability. She is now working at DHT clinic with Dr. Pathomvanich, a leading hair restoration surgeon in Thailand.

K. Amonpattana: None. D. Pathomvanich: None.

ABSTRACT: Introduction: Donor strip harvesting is by far the most common practice in hair transplantation for the past decade. Once the strip is removed, it is sent to the assistant for slivering into small and thin slivers. Grafts cutting are then easy to carry on under a microscope or high power loupe. The process of slivering is a difficult task and a delicate work to perform and master. Most surgeons or assistants sliver a small piece of donor strip under a microscope, some use tongue blade, silicone block, rough plastic sheet etc. All techniques are performed in the dry environment. However, some surgeons wrap the strip with wet saline or add the saline at some time to prevent desiccation during slivering but the entire strip can not be assured that it is thoroughly moist. Dryness or grafts dehydration is critical for grafts survival. Dry environment when slivers may cause desiccation of grafts result in poor growth especially if the strip is left outside too long. Submersion of the donor strip in normal saline or other stock solution prevents dryness of the grafts during dissection. We believe it improves survival of the graft in conjunction with other precautions such as, minimize transection and less crushing injury during insertion.Once the donor strip is removed, it is placed in the Petri-dish contains cold chilled saline at 4 C and is ready for sliver. Since 1993, we have developed the platform which starts with from fixing the strip with a needle gauge on a piece of soft wooden board. A few years later, it was changed to silicone block for easy sterilization. In 2004 we have a new design platform made with stainless steel, size 9 x 9 inch and one inch high with the chamber located at the center of the plate size 3x3 inches and 3/4 inch deep. Low partition is made inside the chamber to house the silicone block. There are few different designs with small and narrow roof attached to the two posts and

fixes in the side of the chamber or at the rim of the chamber. Our preference is the posts located inside the chamber. Numerous holes were made at the top bar for placing the needle to fix the strip to the silicone block. The chamber contains cold saline or stock solution as needed. The whole unit can be totally made into an autoclave.There are two methods to sliver the donor strip: Transverse dissecting (vertical to the strip orientation on scalp). This is the most common practice among hair transplant surgeons. Longitudinal dissecting (horizontal to the strip orientation on scalp). We prefer the longitudinal dissecting since it’s faster. Why? It usually takes time to initially start dissecting. Once the dissection starts the process can be rapid compared with the transverse dissection with short distance and more repetitive maneuvers needed. If the strip is too long, it can be further cut into a shorter segment that is also submerged in NSS. An average strip length we prefer is 5 cm long. The strip is laid on top of the silicone block in the chamber and submerged in cool chilled saline. We use two to three 23 G long needles to fix the strip with the silicone block at both ends. The longer strip might need one more needle at the center for stabilization. The assistant either uses a fine skin hook or hook forceps to grasp the epidermis at the end and start to dissect either one or two rows (1-2 mm thick) with No. 15 or 10 blade from the top down to dermal papilla. Constant traction and abduction while cutting minimizes transection under direct visualization. We encourage all the assistants to use high power loupes at least 3x. Since it is submersed in NSS, there is no need to worry about desiccation of the grafts. At times the entire strip might be moving upward from the pull but this can be easily fixed by passing the needle to the small tube between the strip and the top of the post. Strip dissecting submerse in normal saline prevents the strip from desiccation. Whether this process can increase the growth rate is not known. Comparison between dissection under dry and wet environment will need further study. Discussion Desiccation of the grafts cause poor grafts survival or dying . we propose the strip dissection submerse in NSS and hope it may improve the grafts survival. This is only one part of the process in hair restoration surgery that is also need attention.The disadvantages are: Glare from the water surface and sometime from the sliver wave. This can be corrected when the assistant is familiar with the technique. If there is blood staining the strip and it is not adequately clean, it might cause the solution to become clouded and be difficulty to visualize during dissection. The water chamber is small, so the cool saline might not be as cold as needed, therefore needing to be changed more often if one believes chilled saline is essential to increase grafts survival. We have used an ice box to surround the chamber but it causes the mist and cold platform that make it more difficult for the dissector to place the hand on during dissecting. Advantages overcomes the disadvantages since the process of slivering is submersed in normal saline at all times. Even the beginner can take his or her time to dissect the strip to minimize transection.

P03

The Forelock Transplant Pattern Still Has a Place Michael L. Beehner, MD Saratoga Hair Transplant Center, Saratoga Springs, NY, USA.

Michael Beehner, MD has practiced hair transplant surgery full-time since 1989 in Saratoga Springs, NY. He is a diplomate of the American Board of Hair Restoration Surgery and formerly the American Board of Family Practice. He served as president of the ABHRS in 2005, was co-editor of the Forum (2002-2005), received the Platinum

Follicle Award in 1999 and the Manfred Lucas Lifetime Achievement Award in 2007, along with four research grants from the ISHRS. He has written over 50 clinical articles on hair transplantation and has written several textbook chapters.

M.L. Beehner: None.

ABSTRACT: Introduction: In men with an extreme degree of alopecia (ie: Norwood VII or advanced Norwood VI), and in young men whose future degree of alopecia is unknown, it is necessary to have a strategy that allows you to offer them hair restoration surgery that frames their face, but does not lock them into the possibility of later appearing freakish or unnatural when they become older. The frontal forelock pattern, or, more accurately, the frontal-midscalp forelock concept, allows us to do this Description of Technique and Designs: The great majority of patients who are good candidates for this approach fall into one of two categories: the "very young" and the "very bald." This pattern can also be used for a patient who had old "pluggy" grafts scattered over a large area in whom you want to reharvest and consolidate the existing hair into a forelock in the front-center area of the scalp. After trying many different design patterns over the years, I have settled on using one of the two following patterns: a) Oval Forelock or b) "Shield" Forelock. The oval forelock pattern can vary greatly in size, from a small isolated frontal forelock, to a much larger frontal-midscalp oval forelock extending from the mid-frontal hairline all the way back to the vertex transition point. Then, the gaps on each side are filled in artistically with small FU's, trying to create a "mirror image" in which the lateral hump on each side somewhat mirrors the thinning edge of the oval forelock body across from it. The other design is what I call the "shield" design. It features a slightly flared front hairline, which then curves back to the vertex transition point in a convex manner (as viewed from the back). Then the two posterior parietal triangle areas, which are posterior-lateral to this forelock body, are filled in less densely with FU's. Again, a mirror-image is once again created between the lateral hump and the forelock body, which are usually much closer to each other with this design. The vertex in both the oval and "shield" patterns is pretty much left out, and only later transplanted in a sparse manner if donor supplies allow for it. It is important that the surgeon create a "gradient of density" between the outer aspects of the forelock body and the inner areas. I find this easiest to do by using DFU and TFU grafts of 4-6 hairs in the central area, which are then placed either in small 1.9-2.0mm sagittal slit sites or in 1.3mm round hole sites. The outer border of both design patterns for a width of around 1.5-1.8cm is filled in with FU grafts with moderate density, using 1-hair grafts at the outside and progressing from 2-hair to 3-hair FU's at the inside border. Then the side and rear "scatter zones", described earlier, are filled in less densely, to create the mirror-image illusion. Besides using grafts of different sizes with different numbers of hairs in them, a gradient of density can be created by varying the relative planting density between two zones. When evaluating young patients, I will lean toward a forelock pattern if they have "whisker hair," indistinct fringes with miniaturization extending far laterally on 30x examination with the Micro-Vid scope, a strong family history of Norwood VII level baldness, or are in their early 20's. With regard to the middle aged and older patients who have a large area of alopecia wider than 13 or 14cm, I will almost always go to this type of pattern. The more severe the disparity between available donor hair and a large recipient area, the more likely I am to use the more conservative oval pattern. A moderate amount of donor hair is necessary to accomplish the shield pattern. Conclusion: Because many men naturally pass through a stage of hair loss in which a somewhat oval frontal-midscalp forelock pattern is present along with vertex thinning, fronto-temporal recessions, and a slight separation of the top hair from the side fringes, this type of transplant pattern can pass un-noticed by people around us and will always appear

normal. It also can be easily amended over the years, should the fringes fall further away from the forelock, simply by sprinkling in a few more FU's into the "scatter zones" to each side. This is a valuable pattern for each surgeon to have in his or her armamentarium for transplanting the male with a projected or actual large area of alopecia.

P04

Hair Transplantation in Frontal Fibrosing Alopecia: 2 Prospective Cases Shobit Caroli, MBBS, Damkerng Pathomvanich, MD, Anand Vaggu Kumar, MBBS, MD, Kulakarn Amonpattana, MD DHT Clinic, Bangkok, Thailand.

Dr. Shobit Caroli received his Bachelor’s in Medicine and Surgery from University College of Medical Sciences, University of Delhi, India. He did post-graduation in dermatology from Maulana Azad Medical College followed by Board certification in dermatology from University of Delhi, India. He is presently attending ISHRS accredited fellowship training under Dr. Damkerng Pathomvanich at DHT Clinic, Bangkok.

S. Caroli: None. D. Pathomvanich: None. A.V. Kumar: None. K. Amonpattana: None.

ABSTRACT: Introduction: Frontal fibrosing alopecia is a benign, cosmetically disfiguring form of cicatricial alopecia currently considered as a variant of Lichen planopilaris. It was first described by Kossard in 1994. The characteristic presentation is recession of fronto-temporal hairline with loss of eyebrow, eyelash and pubic hairs. Hair transplantation in such cases has been always a matter of debate. Here, we are want to discuss our experience of hair transplantation in two biopsy proven stable cases. Objective: To assess the growth and outcome of transplanted hair in histopathologically stable cases of frontal fibrosing alopecia. Material and method: Two postmenopausal females presented with complaints of hair loss at the clinic. The clinical and histopathological presentation suggested signs of inactive frontal fibroising alopecia. After detail discussion about the clinical course of the disease and explaining the possibility of poor prognosis, both the patients consented for hair restoration surgery. The patients were followed up to assess hair growth. Case 1 A 63 year Caucasian had marked recession of frontal and both temporal hairline with thinning of eyebrows. She reported no progression for past 2.5 years. The skin biopsy from centre and the periphery of the lesion showed no signs of activity and from the area of hair loss showed perivascular and periadenexal lymphocytic infiltrate with destruction of hair infundibulum and fibrosis. The temporal region was restored with 990 follicular unit grafts, 590 on left side and 400 grafts on right side. 334 follicular unit grafts were transplanted at eyebrows. Another 1611 follicular unit grafts were transplanted in frontal hairline making a total of 2935 follicular unit grafts over an area of 69 cm2. Case 2 A 69 year Asian presented with extensive loss of hair over the frontal, both temporal and parietal regions with complete loss of eyebrows and eyelashes. The hair loss had progressed over the last 18 years but stable for past 2 years. The skin biopsy from the centre and the periphery of lesion showed signs of cicatricial alopecia with chronic inflammatory cell infiltrate. Hair restoration was performed at frontal and temporal area measuring 65 cm2 with 2508 follicular unit grafts. Results: Case 1: Immediate postoperative period was uneventful. At 1 year follow up, hair growth along the hairline and eyebrow was good but after 1½ year, there was a visible loss of the transplanted hair along the temporal hairline and also, thinning at the medial end of both eyebrows. The patient was advised to take oral dutasteride 1 mg and topical pimicrolimus 0.1% ont. The patient was asked to follow up at next 6 months.

Case 2: The recipient site at 6 weeks of postoperative period showed good recipient site healing with minimal donor scar. The follow up call at 6 months patient stated that hair were growing well but lack of density due to very large area of baldness. Conclusion: Frontal fibrosing alopecia patient planning hair restoration surgery should be well emphasized for the recurrent nature of disease and subsequent loss of grafts at any time.Dutasteride and topical pimocrolimus 0.1% ointment should also be given that might prevent the relapse of the disease.

P05

Optimize the Efficiency of Recipient Area Estimation: A Comparative Study Shobit Caroli, MBBS, Damkerng Pathomvanich, MD, Kulakarn Amonpattana, MD, Anand Vaggu Kumar, MBBS, MD DHT Clinic, Bangkok, Thailand.

Dr. Shobit Caroli received his Bachelor’s of Medicine and Surgery from University College of Medical Sciences, University of Delhi, India. He did post-graduation in dermatology from Maulana Azad Medical College followed by Board certification in dermatology from University of Delhi, India. He is presently attending ISHRS accredited fellowship training under Dr. Damkerng Pathomvanich at DHT Clinic, Bangkok.

S. Caroli: None. D. Pathomvanich: None. K. Amonpattana: None. A.V. Kumar: None.

ABSTRACT: Background: Accurate recipient area estimation has always been a matter of concern. Even a small difference of 5 cm2 while planning dense packing can make a big difference in budget of grafts both for the patient and the hair surgeon. Objective: To establish an efficient methodology to estimate the recipient area of scalp to the maximum possible accuracy in comparison to the currently available methods. Material and Methods: A randomized prospective comparative study was performed among 71 patients to measure recipient site area. The area measurement was done by Refined Chang’s method (our proposed methodology), Chang’s method, and Farjo’s method. All the results were recorded and compared. Results: The comparison made in area estimation with our proposed method shows an average of 9.23% less measurement than the standard Chang’s method and an average of 5.12% less measurement than Farjo’s method. The area tracings recorded from the Refined Chang’s method can be precisely superimposed with the markings made on the scalp unlike other methods. Conclusion: The Refined Chang’s method for recipient area estimation appears more reliable and efficient than the current available methods.

P06

A Prospective Study on the Role of Commercially Available Growth Factors in Hair Growth Shobit Caroli, MBBS, Damkerng Pathomvanich, MD, Kulakarn Amonpattana, MD DHT Clinic, Bangkok, Thailand.

Dr. Shobit Caroli received his Bachelor’s of Medicine and Surgery from University College of Medical Sciences, University of Delhi, India. He did post-graduation in dermatology from Maulana Azad Medical College followed by Board certification in dermatology from University of Delhi, India. He is presently attending ISHRS accredited fellowship training under Dr. Damkerng Pathomvanich at DHT Clinic, Bangkok.

S. Caroli: Other Research Support (receipt of drugs, supplies, equipment, or other in-kind support); Recipent of cocktail solutions and dermaroller for the research in healthy volunteer patients. D. Pathomvanich: Other Research Support (receipt of drugs, supplies, equipment, or other in-kind support); Recipent of cocktail solutions and dermaroller for the research in healthy volunteer patients. K. Amonpattana: Other Research Support (receipt of drugs, supplies, equipment, or other in-kind support); Recipent of cocktail solutions and dermaroller for the research in healthy volunteer patients..

ABSTRACT: Introduction: Invivo growth factors play an important role in hair cycle, development and maturation. Researchers have used as a topical application, intradermal injections and stock holding solutions to promote hair growth. Platelet rich plasma usage has been well advocated for these purposes. With this background, we plan to observe the beneficial effects of commercially available cocktail solution for promoting the hair growth. Objective: To establish an efficacy of commercially available hair growth factor solution in the hair growth and the reduction of hair loss. Material and Methods: A prospective study was performed among 21 healthy volunteers with the history of hair loss and baldness. The patients were treated with commercially available hair growth promoting cocktail solution topically over the areas of hair loss. Dermaroller was applied over these areas to enhance the transdermal drug penetration of the solution. The treatment sessions were given once a week for a total of 10 sessions. The patient's self and investigator’s assessment, were recorded every week; photographs were recorded every two week and the hair count with Rassman’s densitometer and trichoscan was done at the study baseline and 10th week of the study. All the results were recorded and analyzed. Results: The investigator’s assessment shows no change in clinical pictures in 85 of 88 treatment sittings, but minimal improvement was noted in patient’s self assessment among 21 of 88 treatment sittings. At the final assessment, none of the 13 patients who completed the study show any observable change in clinical examination and on any objective assessment like photographs, but on patient’s self assessment, 8 patients reported minimal improvement on self assessment. Minimal side effects like stinging, slight pain, and itching was reported in very few sessions and none of the patients observed any severe or serious adverse effects. Conclusion: The topical application of commercially available hair growth cocktail solution was not found to be effective for the treatment of hair loss or to promote any hair growth.

P07

To Transplant or Not to Transplant: Lessons from 10 Cases Jeff C. Donovan, MD University of Toronto, Toronto, ON, Canada.

Dr. Donovan received his MD degree from the University of Ottawa; his post-graduate clinical training in Dermatology and PhD studies in cell biology and were conducted at the University of Toronto. In 2007-2008, Dr. Donovan pursued a post doctoral research fellowship in hair immunology at the Mount Sinai School of Medicine. During the Fall of 2009, he trained in the Hair Diseases Program at the University of California San Francisco under Dr. Vera Price before returning to Canada in 2010 to complete training in hair transplantation under Dr. Walter Unger. Dr. Donovan is currently an Assistant Professor of Dermatology at the University of Toronto.

J.C. Donovan: None.

ABSTRACT: Hair transplantation is contraindicated in alopecia areata or chronic telogen effluvium as well as in active stages of scarring alopecias. Although these entities are often easily distinguished based on patient history and clinical examination, some atypical cases of alopecia areata, telogen effluvium and lupus erythematosus mimic androgenetic alopecia and some cases of seemingly inactive scarring alopecias are, in fact, still active. Furthermore, rare cases of clinically presumed male pattern balding or female pattern hair loss are, in fact, variants of lichen planopilaris. The hair transplant physician needs to recognize features of the patient’s history or physical examination that raise suspicion for unusual presentations of the above diseases. It is only with this heightened suspicion that the physician will be prompted to consider a scalp biopsy before declaring a patient suitable for hair transplantation. The author runs a medical hair loss practice and a hair restoration practice at the University of Toronto. Ten patients seen in consultation within the past year for consideration of hair transplantation were ultimately deemed not to be candidates. These patients are used to illustrate key principles that hair restoration physicians need to be familiar with in order to prevent transplanting individuals who are not candidates for hair transplant surgery.

P08

Effects of Caffeine on Human Hair Follicles and the Dermal Papilla Cells in Vitro Weixin Fan, MD, PhD, Lei Chen, Resident, Ning-ning GUAN, Resident First Affiliated Hosptial of Nanjing Medical University, Nanjing, China.

I am a dermatologist, MD, PhD, the Editor in Chief of Journal of Clinical Dermatology. We have put a lot of efforts on hair growth in vitro and hair implantation for 15 years.

W. Fan: None. L. Chen: None. N. Guan: None.

ABSTRACT: Objective: To investigate the effects of caffeine on the growth of human hair follicles and the dermal papilla cells (DPCs) in vitro. Methods: Different concentrations of caffeine were incubated with human hair follicles and the DPCs. The morphological changes in the hair bulbs and growth speed of the hair follicles were observed and recorded daily. MTT assay was used to detect cell proliferation, flow cytometry to detect apoptosis, and RT-PCR was applied to analysis mRNA of VEGF, FGF, ER, AR and SRD5A. Results: Compared with the controls, 0.005% caffeine significantly stimulated the growth of hair follicles, and 0.0005% caffeine can both stimulate the proliferation and inhibit the apoptosis of human DPCs in vitro, also the expression of positive factors associated with the growth of hair was elevated and the negative factors was inhibited. Conclusion: Low concentrations of caffeine can promote the growth of human hair, while high concentrations inhibit hair growth.

P09

Selected Thymic Peptides Directly and Differentially Modulate Human Hair Growth, Stem Cell Activity

Nilofer P. Farjo, MBChB1, Bessam K. Farjo, MBChB1, Ralf Paus, MD,PhD2, Natalia T. Meier3, David Pattwell, PhD2 1Farjo Medical Centre, Manchester, United Kingdom, 2Epithelial Sciences, School of Translational Medicine, University of Manchester, Manchester, United Kingdom, 3Dept. of Dermatology, University of Lübeck, Lübeck, Germany.

Nilofer Farjo has been exclusively performing hair restoration since 1993 in Manchester, UK. She is a member of the ISHRS, coeditor of the Forum International and diplomat of the American Board of Hair Restoration Surgery. Nilofer is the immediate past President and founder member of the British Association of Hair Restoration Surgeons, Fellow of the Institute of Trichologists, past President of The Trichological Society and member the European Hair Research Society. She currently works with three universities and one public company on basic hair sciences projects.

N.P. Farjo: None. B.K. Farjo: None. R. Paus: None. N.T. Meier: None. D. Pattwell: None.

ABSTRACT: Background: Thymic protein extracts have been extensively characterized biochemically, and animal studies suggest that defined thymic peptides (thymosin α1, thymosin β4 and thymulin) modulate rodent hair follicle biology. Objectives: To explore whether prothymosin α (PTMA), thymosin β4 (TB4) and/or thymulin (TYL) alter key parameters of human hair growth and cycling. Methods: Microdissected human scalp hair follicles in anagen and human scalp skin samples were cultivated in serum-free medium under organ culture conditions. PTMA (100, 1000 ng/ml), TB4 (100, 1000 ng/ml) or thymulin (10, 100 pg/ml) were added to the media to then evaluate the influence of these substances on standard hair growth parameters. Expression and peptide distribution of PTMA and TB4 in human hair follicles were also assessed by RT-PCR and immunohistochemistry. Anagen hair follicles were transfected with a GFP (green fluorescent protein) expression construct driven by a fragment of the human Cytokeratin 15 promoter and cultured with 100 and 1000 ng/ml TB4. Results: TB4 and PTMA transcripts and proteins were found in human HF epithelium, where TYL immunoreactivity was also detected. TYL slightly stimulated hair shaft formation in human HF organ culture, whereas PTMA inhibited it. TYL and PMTA prolonged the duration of anagen. There was also an increased number of Ki67+ cells (marker of cell proliferation) and less TUNEL+ (apoptotic) cells in the hair matrix of HFs treated with 10 pg/ml TYL compared to control HFs. TB4 had no consistent effect on hair shaft production in vitro, however, it did increase cytokeratin 15 (k15) promoter activity in the stem cell region of the hair follicle (bulge) as well K15 immunoreactvity in the ORS within organ-cultured human skin. Conclusions: Here, we provide the first evidence that PTMA and TB4 are expressed by the human HF epithelium and that selected TPs directly and differentially modulate growth and/or cycling of normal human scalp HFs. While TYL prolongs anagen duration and stimulates hair shaft production, PMTA only prolongs anagen. TB4 does not stimulate human hair growth, but promotes K15 expression in human HF epithelial stem cells in situ. Taken together, this suggests that TPs do regulate human HF biology, and may thus be exploited therapeutically.

P10

Intradermotherapy in Scarring Alopecias: Could it be an Alternative Treatment to Delay Their Progress Waiting New Developments? Silvana Franzini, MD, Nicolas Lusicic, MD, Alejandra Susacasa, MD Hair Recovery Argentina, Buenos Aires, Argentina.

Silvana Franzini MD: Certified internal medicine, and certified cardiologist. Nicolas Lusicic MD: Certified general surgeon and certified plastic surgeon. Alejandra Susacasa MD: Certified general surgeon and certified cosmetic surgeon has been active member of ISHRS for the last 14 years. She has more than 16 years of experience in hair restoration surgery. Sixteen year ago Dr. Lusicic & Dr. Susacasa have founded a hair restoration center in Argentina with 16 offices including other Latin American countries. In 2006 they started with their innovative technique, intradermotherapy.


ABSTRACT: We know that the term "scarring alopecia" refers to a group of rare disorders that destroy the hair follicle, replace it with scar tissue, causing permanent hair loss. There are different presentations with or without symptoms. Generally hair loss could be gradual and be unnoticed for long periods. In other cases, hair loss is associated with severe itching, burning and pain and is rapidly progressive. The inflammation that destroys the follicle is below the skin surface and there is usually no "scar" seen on the scalp we only observed patchy areas without hair. It is an entity that is being constantly investigated not only its etiology. We look forward to finding new drugs to treat it . Today we cannot cure it, but we try to delay the progress as much as possible. Objective: To evaluate the usefulness of Intradermotherapy in the treatment of alopecias which have not improved with conventional treatments to delay progression of the disease. Methods: We enroll 10 patients, both sexes, with scarring alopecias of different etiologies, biopsy confirmed. Several years of different conventional treatments with different dermatologists. We treat them during a period of 6-12 months, evaluating their evolution during 24 months follow up. Results: 60% of patients had improved hair quality and delayed hair loss. In 30 % of patients the disease did not progress, that’s good, but they do not have improved hair quality. 10% got worse, in association with other severe systemic illness. Conclusion: Intradermotherapy could be an alternative treatment to those patients without progress with conventional treatments. A "hope light " to delay the progress of this pathology waiting new developments.

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Is Soy Isoflavones an Alternative Treatment in Perimenopausal Females to Improve Hair Quality and Stop Hair Loss? Silvana Franzini, MD, Nicolas Lusicic, MD, Alejandra Susacasa, MD Hair Recovery Argentina, Buenos Aires, Argentina.



ABSTRACT: While the focus was always on androgen action on the hair growth cycle, the role of estrogens and its relationship to hair loss and hair quality has been studied for years. It is also well known that soy and soy-derived isoflavones mimics the actions of estrogens, and it is used in postmenopausal women to improve symptoms for decades. Soy isoflavones also have a significant anti-inflammatory and antioxidant activity. Presently they are an alternative treatment for different diseases, including skin diseases. Estradiol is a female sex hormone of the estrogen group that binds to certain parts of cells called receptors alpha estrogenic (aER) and beta-estrogenic receptor (bER) to perform its functions. Isoflavones, having a structure similar to estradiol, bind these same receptors. Estrogen Receptor (ER)-beta expression in the hair follicle of frontotemporal skin shows marked sex differences. In females, the main ER-beta expression was found in dermal papilla fibroblasts, whereas in male subjects the expression was limited to matrix keratinocytes. In addition to these findings, the expression of ER-beta differs between hair follicles of the occipital area as compared to the vertex The effects of isoflavones on binding receptors produced a similar effect but lower than the estradiol. The aim of this study is to evaluate the effects of soy isoflavones mimicking estrogen and observe their action in the hair growth cycle, improving hair loss and the hair quality, in perimenopausal and postmenopausal women. Material and Methods: We performed a randomized study of 308 patients between 40 and 60 years old, which were divided into four groups:

a) Was treated with oral isoflavone b) Was treated with oral vitamins plus amino acids. c) Was treated with intradermotherapy including soy flavones .

d) Was treated with intradermotherapy with vitamins and amino acids. A complete hormonal test was performed at the beginning and at the end of the study, including testosterone, and dihidroepiandrostenediona.

Results: In both groups treated with isoflavones (A ,C) the results in terms of thickness and quality was better than the group of vitamins and amino acids (B,D). Laboratory test improved in the group of oral isoflavones (A) The group with the best results was the intradermotherapy isoflavones group (C) where improvement was observed faster than in the other group. Conclusion: The use of soy flavones, both oral and intradermotherapy, improves hair quality in perimenopausal and postmenopausal women. While no one can say that hair loss has stopped, it decreased significantly. We continue using this treatment gaining better results each day.

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The Use of Silicone at the End of Graft Placing to Prevent Bleeding, Contamination and Improve Early Scab Removing in Hair Restoration Surgery Silvana Franzini, MD, Nicolas Lusicic, MD, Aejandra Susacasa, MD Hair Recovery Argentina, Buenos Aires, Argentina.



ABSTRACT: In order to improve early postoperative hours of patients undergoing hair transplant surgery and trying to shorten their social reinsercion, we evaluate the advantage use a silicone spray, in order to achieve a bleed-repellent action for 4-6 hours, not allow the passage of irritants and keeping the recipient area free from external aggression. The silicone spray does not alter the normal physiology of the skin, works as an emollient and is soothing to the skin

restoring its natural health. Objective: Evaluate the effectiveness of silicone to reduce bleeding and contamination during the first hours following graft placing, and shorten time of scabs removing. Material and Methods: cohort, randomized, prospective, open. Number of patients: 80 80 Patients underwent hair restoration surgery in the frontal area

A) In 40 patients we use a silicone spray that forms a protective elastic film on the graft surface. B) 40 patients do not use anything.

Conclusion: There is a great advantage in using the silicone spray. There was 57% bleeding reduction in silicone spray group. For the patients that don't use silicone spray, the full scab is removed before those that do use the silicone spray. We recommend to use this protective silicone especially in those patients with important intraoperative bleeding to avoid graft removing in early postoperative hours.

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How to Try to Reduce the Possibility of Over Cutting and Subsequently Piggy Backing or Popping Shahin Gholami, MD Adabi Hair Graft Center, Babol, Iran, Islamic Republic of.

Shahin Gholami, MD graduated from Mazandaran Medical University and studied Dermatology at Yerevan State Medical University of Armenia in 2006. He has been working in the Hair Transplantation field under the supervision of an ISHRS member in Iran and also working on two other research studies about PRP that will be presented in the future.

S. Gholami: None.

ABSTRACT: Introduction : As you know the major arterioles of the scalp traverse through the subcutaneous space and the major blood supply is well beneath the depth of follicles. A multitude of capillaries from the subcutaneous arteries branch vertically to enter the dermis as very small vessels. This explains the absence of visible blood vessels observed during graft dissection even under microscopic magnification Moreover, most of the bulbs of hair follicles are located in the subcutaneous (somewhere between the deep dermis and mid subcutaneous) (figure 1) and when implanting follicles in the receiving area, the implant of the hair bulbs in the proper point in the scalp, can have a determinative role in the surgery prognosis because the deeper penetration of blades is referred to as “overcutting” that can cause: 1. Trauma to the underlying blood supply 2. Popping while implanting 3. Slipping the grafts below the scalp surface incurring accidental piggy backing (figure 2).

Objective: This study aims to estimate the most appropriate depth to place the hair follicles in a given person. Materials & Methods: To specify this method, we selected 30 patients as candidates for hair implant surgery (25 men and 5 women in various age groups which 5 of the men had reported various diseases in the receiving area) and after injection of enough anesthetic in the receiving area, and just a few minutes before implanting starts, (injecting any solution in the scalp causes the thicknesses to change and therefore this should be done after anesthesia and just before the implant) using a puncher 2 mm in diameter, we vertically took a biopsy in the depth of approximately 1 cm in three areas (frontal, mid scalp, and vertex) and studied the biopsies under microscopic high magnification to specify the approximate thickness of epidermis, dermis, and subcutaneous. If there is hair in the receiving area, taking a sample biopsy along with the hair, can be very helpful in specifying the depth of implant. Discussion: 1. The thickness of the skin layers (epidermis, dermis, and subcutaneous) in a given person in the three mentioned areas (frontal, mid scalp, and vertex) does not have a significant difference. Therefore, one biopsy from one patient from the receiving area, which is better to be along with the hair follicle, would be enough for specifying the appropriate thickness and depth. 2. The most appropriate point to implant hair bulbs in depth is different in people of various genders, ages, races, and the ones with a record of head skin diseases. Although this difference is limited to one millimeter or sometimes one tenth of a millimeter, but it is not suitable to consider a fixed depth of implant for all people or even for one person with various implant angles. 3. Calculating the thicknesses and specifying the appropriate vertical implant depth, we can use the following formula to specify the length of blade for implanting in various angles: Length of diagonal implant = appropriate vertical implant depth/sine of the implant angle For example, if the depth of point A, approximately 4 mm long, is considered as the proper depth, and we intend to reach this point at a 45 degree angle, taking sine 45 = √2/2 and using the above formula, 4/√2/2=5.5 we should adjust the blade length at 5.5 mm to reach point A at a 45 degree angle. (Figure 3). Conclusion: In hair implant process, we will have to consider millimeters and tenth of millimeters, and irrespective of the anesthesia method, or the cutting tools used, we can achieve better results by estimating the thicknesses, and specifying the appropriate depth in millimeters and tenth of millimeters units and subsequently adjusting the blade length without harming the blood vessels particularly in the surgeries where many grafts are to be implanted. This can be noteworthy for the fresh surgeons who have just started implanting to minimize over cutting or under cutting to attain better results.

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Prescribing Finasteride at Distance in a Safe Way, Including the Simplified BCS Scoring Mats G. Ingers, MD New Hair Clinic, Lund, Lund, Sweden.

Medical Director of New Hair Clinic in Sweden

M.G. Ingers: None.

ABSTRACT: Introduction: Since the beginning of 2010, we have used a questionnaire on our web site when prescribing finasteride. If the doctor does not get all information needed to decide whether a patient is suitable to take the drug or not, the formula makes it easy for him to contact the patient and do an interview. At the same time, patients can read all about finasteride through internal links on the page. When renewing a prescription, all questions about side effects have to be answered. Again, the doctor can contact the patient when something "odd" occurs. This way you can learn more about the character and true incidence of side effects, and even detect new ones. Through this routine, paperwork and time consumption have been greatly reduced. Prescriptions and the envelops to mail them are prepared by an assistant, and presented to the doctor along with the patients questionnaire. The service is chargeable: All patients wanting finasteride also have to pay an administrative fee. Although the principle reason to put many patients on finasteride may be to spare them their career as future transplant patients, you will probably recruit many patients for surgery from this group. By following literally thousands of men with hair issues, we will, in a systematic way, learn more about the natural course of “hair psychology” over the years. In the questionnaire we have added a question called “BCS score”. BCS is short for Balding Consequence Scale, originally presented in 8 steps at the ISHRS meeting in 2008. We now are using a simplified scale with 4 steps: 1 point: Losing hair is not a big issue, and not a daily concern. If I could choose I would preferred to have more hair, but I have accepted my situation. 2 points: In my own opinion my hair issues are somewhat out of proportion, and almost a daily “energy consumer”. I just can´t help thinking about it every time I see a mirror or meet people. 3 points: Like previous, but in addition I have found myself avoiding many activities that I used to do. This could mean giving up swimming in public or making excuses when friends ask me to join them for a party. 4 points: My social life is seriously crippled by my discomfort whenever I have to show in public without a cap. Young people may very well be unwilling showing their head even for close friends and family. In some rare cases, a reactive depression has established. Anyway, self esteem is taking a severe and constant blow and a patient with 4 points should be handled very seriously. Patients filling in the quest are also encouraged to use intermediates, like “1-2”, “2-3” or “3-4” if they find those points more accurate to their situation. Method: The questionnaire and its internal links can be loaded down from the following link: www.newhairclinic.se. To succeed sending the formula electronically, all fields have to be completed. If the BCS-score seem inadequate or 3 or higher we usually contact the applicant. If the patient is 21 or younger we discuss consensus from his parents. All statistics resulting from thousands of answers will be automatically recorded. Result: We found, with very few exceptions, that all patients are willing and capable of filling in the quest. Occasionally we help them doing so by phone interview. We will publish the statistics from 18 months/ app. 1500 formulas on our web site. This will include side-effect frequency, treatment satisfaction and BCS score in different age groups Conclusion: If you want to serve not only your hair transplant patients but also all those in need of just finasteride, I suggest you do it by a questionnaire similar to ours. This will also give you a deeper knowledge and understanding of the side effects of finasteride. The BCS in 8 steps turned out to be too complicated, but in 4 steps it is easily handled, both by patients and staff. Using a formula and collecting information is useful for multi center studies. Although prescription routines and rules may differ from state to state and from country to country, the questionnaires and statistics could be harmonized to compare the psychological aspect of loosing ones hair in different parts of the world.

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The Gene Expression Patterns of Transplanted Human Hairs in Nude Mice Moonkyu Kim, MD, PhD, Ji Won Oh, MD, Jung-Chul Kim, MD, PhD Kyungpook National University School of Medicine, Daegu, Korea, Republic of.

Education: Kyungpook National University School of Medicine, Daegu, Korea, March 1983 - February 1989, M.D. Kyungpook National University Graduate School, March 1989 - August 1991, M.S. Kyungpook National University Graduate School, March 1991 - February 1995, Ph.D. Professional Society: Member of European Hair Research Society, 2000 Member of International Society of Hair Restoration Surgery, 2002 Awards: Travel Award, 3rd Intercontinental Meeting of the Hair Research Society, Japan, 2001 Mile Stone’s Award, 8th Italian Society for Hair Restoration, Rome, Italy, 2003

M. Kim: None. J. Oh: None. J. Kim: None.

ABSTRACT: Introduction: The hair follicle is a complicated organ, which has cyclic changes from anagen, catagen to telogen. What controls the HF cycling is the main question for a group of physicians and hair biologists. After a hair transplant, hairs rapidly enter the dystrophic catagen phase and lots of hairs are shed. After 2-3 months, transplanted hairs enter the new hair cycle (new anagen). However, there is little explanation during these periods especially in human. It is significant for any hair transplant surgeons to draw a detailed picture of each stages of the hair cycle. Objective: The aim of this study is to know the cyclical changes after human hair transplant. To understand those, we transplanted human scalp hairs in immune-compromised nude mice and analyzed the histological changes with time and immunological study. Materials and Methods:

1) Histological analysis: to search the histological difference after hair transplantation, we carried out H&E stain as well as immunohistochemistry of several important genes related with apoptosis, regeneration at each stages.

2) Hair transplantation onto immune-compromised nude mice; Hair follicles are transplanted into backskin of 7-week old female nude mice using KNU transplantator.

3) Hair graft biopsy after hair transplantation: Each mouse is sacrificed at the time point we wish to check (from post-operation day 1 to day 395). We basically took biopsy of hair graft every week. After biopsy, we could stain several important genes at each stage according our formal study.

Results/Discussion: We could have clear pictures of the histological finding and immuno-histochemical results at each time point. In first week they enter the catagen, which is characterized as corrugated epithelium and onion shaped dermal papilla. We could conclude after hair transplant, the hair follicle goes into dystrophic catagen. After 3 weeks, the epithelium enters apoptosis and dermal papillae get rounder than the anagen VI ones. Five weeks later, some HFs are entering new anagen and we could find some important gene pattern. In 7 weeks, most of HFs are in the anagen III to VI. After 12 weeks every follicles are in anagen VI which is similar with in vivo HF

Conclusion: We could make the model of human hair cycle using hair transplanted nude mice in formal study. This method can identify the genes that are differentially regulated at different stages of the hair follicle. This model could be used to study physiology of human hair follicle cycle.

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Analysis of EGFR Expression in Human Hair Follicles in Frontoparietal and Occipital Scalp Jerzy Kolasinski, MD1, Malgorzata Mackiewicz-Wysocka1, Anna Przybyla2, Andrzej Mackiewicz2 1Klinika Kolasinski - Hair Clinic Poznan, Swarzedz, Poland, 2University of Medical Sciences, Poznan, Poland.

Dr. Jerzy Kolasinski, a member of the American Academy of Cosmetic Surgery, and American Society for Hair Restoration Surgery is the founder and director of Klinika Kolasinski Hair Clinic Poznan in Swarzedz, Poland. He is an author of 100 articles and presentations concerning hair restoration surgery.

J. Kolasinski: None. M. Mackiewicz-Wysocka: None. A. Przybyla: None. A. Mackiewicz: None.

ABSTRACT: Androgenetic alopecia is a common condition characterized by hair loss in frontoparietal scalp in men and over a crown area with maintained frontal hairline in women. Androgenetic alopecia is a continuous, progressive process. Disorders in hair follicle cycling lead to hair miniaturization which is a hallmark of androgenetic alopecia. Among many factors influencing the hair cycle, epidermal growth factor receptor (EGFR) activity seems to be one of very important factors. Cancer patients treated with Cetuximab - anti-EGFR monoclonal antibody, Panitumumab - anti-EGFR monoclonal antibody and tyrosine kinase inhibitors of EGFR (Erlotinib, Gefitinib) demonstrate hair loss. Interruption of this therapy restores hair growth. Accordingly expression of EGFR or loss of its function may be associated with androgenetic alopecia. The aim of the study was to analyze and compare the expression of EGFR within hair follicles obtained from frontoparietal and occipital areas. The study included 28 patients (23 men and 5 women) aged 26 - 58 years who underwent a hair transplantation surgery. During that procedure several hair samples from frontoparietal and occipital regions were taken. From collected samples RNA was isolated and subsequently analyzed for the expression of EGFR. The EGFR mRNA was studied using quantitive PCR method. The initial results are very promising. But there are many different factors controlling hair cycle and to obtain final results this study needs further investigation.

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Comparison Study of FUE Techniques: Sharp vs Dull Punch Larry Leonard Global Hair Institute, Covington, WA, USA.

Larry Leonard, President/CEO Global Hair Institute (GHI) A sugical assistant in hair restoration since 1995, Larry has developed and taught advanced concepts of micro-scopic slivering, dissecting, and placement techniques thoughout North America and Western Europe. He has given multiple presentations at the ISHRS Annual Scientific Meetings and has had the honor of being elected to serve on the Surgical Assistant's Board for the ISHRS. Since 2000, GHI has teamed up with numerous physicians and hair restoration facilities trying to develop a protocol approach to Follicular Unit Extraction (FUE).

L. Leonard: None.

ABSTRACT: Introduction: Over the past 10 years FUE has proven to be a challenging, labor intensive method of hair restoration. One of the major hurdles for offices attempting to harvest complete follicular units with any size biopsy punch is choosing the correct instrumentation. This is a multi-facility comparison of the two predominant methods of FUE, sharp punch only vs. dull punch only. Objective: Learn which method is most successful for FUE harvest. We will determine the rate of harvesting, rate of transection/graft, and rate of transection/hair for each of these methods. Method: .8mm punch is the standard punch we will use for both sharp and blunt methods. Grafts will be harvested by multiple persons in multiple facilities. Fifty FUE grafts will be harvested with each method, sharp punch only and dull punch only. The 100 attempted FUE grafts will be harvested and evaluated to determine:

1) Rate of harvest 2) Rate of transection/hair 3) Rate of transection/graft

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New Anesthesia Mixture for FUE Larry Leonard Global Hair Institute, Covington, WA, USA.

Larry Leonard, Global Hair Institute (GHI) President/CEO A surgical assistant in hair restoration since 1995, Larry has developed and taught advanced concepts of microscopic slivering, dissecting, and placement techniques throughout North America and Western Europe. He has given multiple presentations at the ISHRS Annual Scientific Meetings and has had the honor of being elected to serve on the Surgical Assistant's Board for the ISHRS. Since 2000, GHI has teamed up with numerous physicians and hair restoration facilities attempting to develop a protocol approach to Follicular Unit Extraction (FUE).

L. Leonard: None.

ABSTRACT: One of the benefits of the FUE method is the ability to access areas of the donor region that were "un-harvestable" with traditional strip harvesting. This increase in the donor region for FUE also increases the risks of vaso-vagal responses from the over-use of lidocaine, marcaine, and epinephrine. I was introduced to a plastic surgeon who chose to use Polocaine mixed in a 100cc bag of NaCl with 1cc epinephrine (1:1000) and 1cc sodium bicarbonate. The mixture is as follows:

1) Remove 10cc NaCl from 100cc bag sterile NaCl 2) Add 8cc Polocaine 2% 3) Add 1cc Epinephrine 1:1000 4) Add 1cc Sodium Bicarbonate

The use of Polocaine instead of Lidocaine and Marcaine has dramatically decreased the incident of vaso-vagal response in FUE patients.

P19

Protection from Free Radical Formation on the Scalp Frank Liebel, BS Johnson & Johnson Consumer Companies, Inc, Skillman, NJ, USA.

For over 20 years, Frank Liebel has been employed by Johnson & Johnson Group of Consumer Companies at the Skin Research Center in New Jersey. He is currently heading the Beauty Hair Care Platform for Johnson & Johnson

Consumer Companies and his current research focuses on skin biology of the scalp and hair follicle. During his time at Johnson & Johnson, he has numerous publications and patent filings on the areas of skin inflammation, pigmentation and aging. His roles have included the development of new preclinical test systems to predict efficacy on human skin and biological testing for scientific claims.

F. Liebel: None.

ABSTRACT: Hair is a protective barrier for the body against external aggressors such as solar radiation. People with bald scalps or thinning hair do not benefit from this protective barrier. It is known that solar exposure can induce oxidative stress to the skin; however not many studies have examined the potential for oxidative damage to the scalp. Free radicals produced by these stressors can lead to the generation of pro-inflammatory cytokines, MMP’s and the breakdown of collagen and elastin. They can also inhibit proliferation and induce apoptosis in hair follicles. In order to determine whether scalp skin is a potential target of oxidative stress, we developed a non-invasive method to assess the generation of free radicals from measuring the chemiluminescence signal in skin. Significant free-radical production was detected from the scalp after exposure to dose of visible light (400-700nm). Traditional sunscreens block only the UV (290-400um) wavelengths of solar light, leaving the longer wavelengths to stimulate and produce free radicals in the skin. A photostable UVA/UVB sunscreen combined with a triple combination of natural antioxidants including a Parthenolide-free Feverfew Extract, a natural extract known to be a potent antioxidant, was developed to reduce the production of free radicals from the scalp. Topical application of the triple antioxidant sunscreen significantly reduced the amount of generated free radicals on the scalp. These results demonstrate that the scalps of men and women with thinning to bald scalps are a potential target of oxidative damage. Excessive damage to the hair follicle could lead to decreased proliferation and be a contributing factor to hair loss. This study suggests the need for a sunscreen with potent antioxidants to protect the scalp from the free radical induced damage from solar exposure.

P20

The Hair Clock, Or (To Put It Another Way) Why is Hair Growth Cyclical? Andrea Marliani, MD S..ITri. - Italian Society of Trichology, Firenze, Italy. Andrea Marliani MD Firenze, Italy Dermatologist, Endocrinologist, - Born, July 15, 1947 in Florence - Gratuated with honors University of Firenze, Italy, 1974. - Specializes in Dermatology in 1977 and in Endocrinology in 1990 - Founding President and President Emeritus of S.I.Tri. (Italian Society of Trichology). - Scientific Director of the Italian Journal of Trichology - He currently teaches Trichology at the International School of Aesthetic Medicine of Rome and at University of Florence, master's degree in Scienze Tricologiche Mediche e Chirurgiche.

A. Marliani: None.

ABSTRACT: For medical hair specialists, and also for hair transplantation surgeons, it is very important to understand the physiology of hair because this can suggest simple therapies that may really improve the outcome of a transplant. Hair growth is cyclical so hair and body hair do not grow indefinitely. Therefore, the hair of a 50 year-old person will not reach 6 or 7 meters in length. Hair cuts are not part of natural processes. How long the anagen phase lasts is determined by the amount of energy available. If the anagen phase and protein synthesis are to be maintained, the follicle needs ATP energy. This energy is released by the metabolism of glucose by way of Glycolysis and by the Pentose Phosphate Shunt. It continues to be produced during the Krebs Cycle. ATP is produced during Glycolysis, while NADPH is produced in the Pentose Phosphate Shunt. The metabolism of glucose is activated (is turned both on and off) by the Adenil cyclase enzyme. When this enzyme is withheld, Glycolysis stops, as do the Pentose Phosphate Shunt and the Krebs Cycle. The interruption of glucose metabolism turns off the supply of energy and ends the anagen phase. The hair cycle is controlled by sex steroids. Not by the hormones circulating in the blood but by hormones that are produced within the follicle itself. Dihydrotestosterone inhibits the Adenil cyclase enzyme, while Estrone increases it. A follicle in the anagen phase makes a “physiological attempt” to reach the catagen stage and then the telogen stage. For the follicle to be able to move on to the catagen stage, 5 alpha reduction is required. The 5 alpha Reductase enzyme changes testerone into Dihydrotesterone. 5 alpha reduction uses the NADPH produced in the Pentose Phosphate Shunt. It is, therefore, dependent on NADPH. Glycolysis is stopped at the end of the anagen phase, as is the Pentose Phosphate Shunt, and NADPH is no longer produced. There is no 5 alpha reduction, and all metabolic activity is geared to aromatization. There is an abundant production of Estrone at the close of the anagen phase, and this activates the Adenil cyclase enzyme. Glycolysis begins again and the cycle is set once more in motion. Why is the anagen phase longer in women than in men? The reason is that, in males, the most natural metabolic process is for testosterone to be turned into Dihydrotestosterone. In women, the most natural development is one leading to the production of Estrone. The result is that the anagen phase lasts 3 years in males and 6 years in females. Men have short anagen phases and rapid hair cycles. In women, anagen is long and the cycle is slow. A shorter anagen phase results in a quicker cycle. This does not mean there will be involution of the follicle, nor miniaturization of the hair. A shorter anagen cycle is in no way synonymous of baldness. But that’s for another story... References: Adachi K., Kano M.: "Adenil cyclase in human hair follicles: its inhibition by dihydrotestosterone" Biochem Biophys Res Commun 1970; 41: 884. Adachi K., Takayasu S., Takashima I., Kano M., Kondo S.: "Human hair follicles: metabolism and control mechanism" J Soc Cosmet Chem 1970; 2: 911. Adachi K.: "The metabolism and control mechanism of human hair follicles" Curr Probl Dermatol 1873; 5: 37. Butcher E.O.: "The oxygen consuption of the skin during hair growth in the rat" J Amer Physiol 1943; 138: 408. Caballero M.J.: "Metabolism of 5 alpha-androstane - 3 beta , 17 beta-diol in bald and hairy areas of scalp" Horm Res 1994; 42/3: 100 - 105. Comaish S.: "Metabolic disorders and hair growth" Br J Dermatol 1971; 84: 83. De Villez R.L.: "The growth and loss of hair", Kalamazoo-Michigan, Upjohn Company, 1986. Farthing M.J., Mattei A.M., Edwards C.R.: "Relationschip between plasma testosterone and dihydrotestosterone concentrations and male facial hair growth" Br J Dermatol 1982; 107: 559. Hamilton J.: "Male hormone stimulation is a prerequisite and an incitant in common baldness" American J of Anatomy1942; 71 :451. Halprin K.M., Ohkawara A.: "Glucose and glicogen metabolismin the human epidermis" J Invest Derm 1966; 46: 43. Itami S., Sonoda T., Kurata S., Takayasu S.: "Mechanism of action of androgen in hair follicles" J Dermatol Sci 1994; 7/suppl: s98 - s103.

Jeanmougin M.: "Patologia dei capelli e del cuoio capelluto", edizione italiana, Milano, CE.D.RI.M. s.r.l., 1991: 9 - 12. Kossard S.: "Postmenopausal frontal fibrosing alopecia: Scarring alopecia in a pattern distribution" Arch Dermatol 1994; 130: 770 - 774. Lyndfield Y.L.: "Effect of pregnancy on the human hair cycle" J Invest Derm 1960; 35: 323. Marliani A.: "TRICOLOGIA" - diagnostica e terapia - Firenze, Tricoltalia: 2007. Ohnemus U., Uenalan M., Inzunza J.,Gustafsson J.A. and Paus R: "The hair follicle as an estrogen taget ad surce" Endocrine Reviews, 2006; 27 (6): 677 - 707. Parker F.: "Cute e ormoni" in Williams R.H. eds: "Trattato di Endocrinologia". III° edizione italiana, Piccin, Padova, 1979 , vol II°, cap 23, 1115-19. Randall V.A.: "Androgen and human hair growth" Clin Endocrinol 1994; 40: 439 - 57. Sansone-Bazzano G., Reisner R.M., Bazzano G.: "Conversion of testosterone 1-2 3H to androstenedione 3H in the isolated hair follicle of man" J Clin Metab 1972; 34: 512. Sawaya M.E.: "Biochemical mechanisms regulating human hair growth" Skin Pharmacol 1994; 7: 5-7. Schmidt J.B.: "Hormonal basis of male and female androgenetic alopecia: Clinical relevance" Skin Pharmacol 1994; 7: 61 - 66. Schweikert H.U., Milewich L., Wilson J.D.: "Aromatization of androstenedione by isolated human hairs" J Clin Endocrinol Metab 1975; 40: 413-17. Schweikert H.U., Wilson J.D.: "Regulation of human hair growth by steroid hormones: I. testosterone metabolism in isolated hairs" J Clin Endocrinol Metab 1974; 38; 811. Schweikert H.U., Wilson J.D.: "Regulation of human hair growth by steroid hormones: II. testosterone metabolism in isolated hairs" J Clin Endocrinol Metab1974; 39: 1012. Takayasu S., Adachi K.: "The conversion of testosterone to 17 beta-hydroxy 5 alfa-androstane 3-one (dihydrotestosterone) by human hair follicles" J Clin Endocr Metab1972; 34: 1098. Wilson J.D., Walker J.D.: "The conversion of testosterone to 5 alfa androstan 17 beta-ol-3-one (dihydrotestosterone) by skin slice of man" J Clin Invest1969; 48: 371.

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3D-Like Tattooing of Eyebrow Masahisa Nagai, MD Japan, Fukuoka City, Japan.

Born in 1965. Member of ISHRS Member of ISHR Member of ABHRS Expresident and board member of JSHR

M. Nagai: None.

ABSTRACT: Being able to recreate eyebrows through hair transplantation is good news for those who don’t have eyebrows. On the other hand, it can be quite a challenging task to create natural-looking eyebrows. Even if you overcome those challenges, you might face problems with low graft survival rate or lack of donated hair itself. In such cases, the only alternative solution was to provide people with guidance on applying makeup. But, the existing method of painting the outline of “eyebrows” especially seemed odd.

Now, the method I am introducing is this: I don’t make “eyebrows” as a design you should outline, rather I construct the eyebrows using a certain technique to re-create each and every hair and make it look as if real eyebrows are there.

P22

How to Manage an Intra-Operative Surprise When We Encounter Slippery Grafts Damkerng Pathomvanich, MD, Shobit Caroli, MBBS, Anand Vaggu Kumar, MBBS, MD, Kulakarn Amonpattana, MD, Oravan Pathomvanich, MD DHT CLINIC, Bangkok, Thailand.


D. Pathomvanich: None. S. Caroli: None. A.V. Kumar: None. K. Amonpattana: None. O. Pathomvanich: None.

ABSTRACT: Background: There were only a few reports in the medical journal regarding slippery graft and the topic is minimally discussed in the hair transplant surgery meeting. It is one of an important cause for grafts popping at recipient site. An intra-operative finding of slippery grafts does not only frustrate the inserter’s while holding and planting, it’s also increases the operative time and might be associated with yielding fewer grafts. Objective: To review the physical finding that may help in identifying the cases of slippery grafts thus avoid dense packing. To propose a modified jeweler’s graft holding forceps to assist the assistants' speed for planting. Material & Methods: All the newly registered cases with an intra-operative finding of slippery grafts in our clinic from January 2008 to November 2010 were reviewed. The findings among these patients were carefully recorded and assessed. Two designs of modified jeweler forceps were used in six of the prospective cases and their efficacy in comparison with the routine forceps were assessed. Results: The observation of very oily scalp while preoperative examination should alert the physician to suspect slippery grafts. Slippery feel while tissue handling and suturing, an oily coating over the surface of water while slivering or in graft holding cups with turbid mucus discharge in the graft holding cups can be a definitive findings of the slippery grafts. Using modified jeweler’s forceps or very fine pointed tip forceps will help to hold the grafts more securely with minimal crushing and graft handling. Popping up of the grafts was present in all cases.

Conclusion: We should plan not to densely pack in whom we suspected to have slippery grafts and also during the subsequent sessions among these patients. Thus will avoid the repeated handling of grafts, decrease frustration among assistants; reduce the trauma to the precious hair follicle which may lead to poor growth.

P23

Preview Long Hair Transplantation, The P Constant, the Patient Maximum Efficiency Equations and Therasession Marcelo Pitchon, MD Av. Contorno 5351 Sala 1004, Belo Horizonte, M.G., Brazil.

Dr. Marcelo Pitchon is a Plastic Surgeon exclusively dedicated to hair restoration surgery.

M. Pitchon: None.

ABSTRACT: Among many others, one important advantage of Preview Long Hair transplantation is the vision of the amount of actual hair transplanted immediately after surgery and hence, the vision of the best possible final result, the maximum volume that the patient can achieve some months later, only if 100% of the hair transplanted grows. The vision of the Preview hair, which is photographed after surgery, enables us to only macroscopically but quite satisfactorily compare the Preview result with the final definitive real result. The difference between the Preview result and the final late result is the hair that did not grow. Growth is directly related to technical quality, which is

the surgeon’s responsibility and to yet unknown or not completely understood patients’ personal factors. After seven years performing exclusively Preview Long Hair transplantation and comparing all the Preview temporary results with the final definitive results I could observe that each patient grows the transplanted hair with a different level of efficacy in the final definitive result. I could observe that the efficacy in growing hair varies a lot from patient to patient, even with the patients being submitted to surgery by the same surgeon. In my case I am also always the planter and my staff maintains the same level of technical quality and follicle preservation. That means that even with all the external factors kept identical there is still difference in growth, that is not related to any external agent or factor. We have seen patients growing from 30% to 100% of the Preview result, with the average definitive growth ranging from 70% to 100% of the original 100% Preview result. I called the percentage of transplanted hair that really grew the patient's “Personal Growth Index” - PGI, and presented it at the 18th ISHRS Meeting in Boston/2010. It is also very interesting the observation that patients who were submitted to more than one hair transplant session showed the same approximate constant index of final growth in all the hair transplant results, an index that will be confirmed as the same, every time that the same patient is submitted to a new hair transplant procedure with the same level of technical and preservation quality standards. That made me observe that there is a Preview Patient Personal Profile Pattern constant, which I call the “P Constant”. So as an example, if a certain patient submitted to an excellent technical quality hair transplant grew only 60% of the Preview result (evaluation currently done only with macroscopic evaluation), then his Personal Growth Index is 60% and his P Constant will be calculated using the following formula: P Constant = Personal Growth Index (%) / Total Preview Long Hair Result (= 100%) So, in the given example, P Constant = 60% / 100% = 0.6 And if his P Constant is 0.6 he will very probably grow the same 60% in every session he will do later on. The P Constant also provides us with two new elements: the “Patient Potential Donor Area” and the “Patient Real Donor Area”. As we know (demonstrated by Dr. Robert Bernstein), every patient has an average “donor area” of 6250 FU's. I will now call it the “Patient Potential Donor Area” instead of just “donor area”. Having this 6250 FU’s potential donor area does not mean that they will be transformed into 6250 live FU's in the recipient area. It will depend on the patient's PGI and the P Constant. So, although we know the Potential Donor Area of all patients before transplanting them, with the P Constant we will now discover each patient's Real Donor Area (only after the first hair transplant session, if done with the Preview Long Hair technique). The Real Donor Area of each patient is calculated as follows: Patient Real Donor Area = Patient Potential Donor Area (6250FU’s) X P Constant So, in the given example, Patient Real Donor Area = 6250 X 0.6 = 3750 FU’s How would we plan this patient’s hair transplant if we previously knew that his Real Donor Area is just 3750 FU’s? Would we cover all his front, top and vertex in one time not knowing if this would provide him the ideal density? The discovery of the Personal Growth Index PGI was only possible after the creation of the Preview Long Hair technique because with the traditional shaved non-Preview technique we can frequently make the mistake of considering that we achieved 100% growth in a specific patient, when the truth would be that the real growth was, for example, only 50% of the hair transplanted, that would be visible for comparison only if Preview Long Hair transplantation would have been performed. Discovering and understanding that growing the transplanted hair is not always as easy as we tended to think, generates relevant new changes in the hair transplantation universe, including information to patients before and after surgery, planning of the procedures, discovering the patient's personal real donor area and principally the definition of the ideal specific size of the first hair transplant session and the ideal specific size of the consecutive procedures. We should always consider the risk of patients having low Personal Growth Indexes and take this risk into consideration before planning the size of the first surgery. As we do not know yet why patients have different indexes (Personal Growth Indexes), which are constant, we still do not know what is

the PGI of a patient before surgery. We do not yet have a test for PGI evaluation because we still simply do not know what is or what are the agents that define the patient’s PGI. Although we are still working with evidences we should always consider that our patient may unluckily be a 30% PGI patient and his only chance of having a minimum improvement of his image with maximum optimization of his donor resource is if we start his hair transplantation project with a session that should never be what is currently called a megassession or gigasession. Before doing a megasession we should first access the patient’s PGI through what we currently call a small session and only after a sensible size first session and after finding what is the patient's PGI we could decide if we will do the next session big or small. If we find that a specific patient has a 90% PGI we will then, with consciousness and safety for the patient, perform a mega or gigasession in his second procedure. If the first session of a patient reveals us that he is a rare 30% PGI patient, then we will continue his hair transplantation project with “small” sessions always, at least until we finish the minimum essential aesthetic unit area of this specific patient (like a frontal forelock). If a patient will have his PGI defined as only 30% after a very big first session like a 4500 FU’s he will have lost so many hairs with what I call his “Δ Loss Index” [Δ Loss Index = Preview Long Hair Result (100%) - Final Definitive Result (PGI%)] that much probably he will not have the chance of completing satisfactorily even a small frontal forelock. The ideal first session should be no more or around 2500FU’s, a sensible number that may, at the same time improve the patient’s image, reveal his PGI and preserve enough donor area for future compensation for a possible very low PGI. In the opposite side, if confirmed a high PGI, the second procedure could be a very large one and use lots of donor area in a very safe giga or even the future “therasession”, the possible next step in session's sizes, which will then be performed with sufficient studied elements to legitimate and sustain it .

P24

Scoping Scalp Disorders: Updates in Dermatoscopy Nicole E. Rogers, MD Old Metairie Dermatology (Private Practice), Metairie, LA, USA.

Dr. Nicole Rogers is a board certified dermatologist and fellow of the American Academy of Dermatology. She is in private practice in the New Orleans area where she specializes in hair loss and hair restoration for both men and women. She completed an ISHRS fellowship in hair transplantation with Dr. Marc Avram in New York City. Together, they co-edited a textbook on hair transplantation and have authored numerous papers on medical and surgical treatments for hair loss. She is an assistant clinical professor of dermatology at Tulane and has taken a special interest in the subject of dermatoscopy.

N.E. Rogers: Other; I work as a spokesman for J&J for Rogaine, speaking with media outlets and at the AAD.

ABSTRACT: As hair transplant surgeons, we must often first identify and correct various forms of scalp disorders. This discussion will present dermatoscopic images from real patients demonstrating how useful this technique can be in diagnosing and treating scalp conditions. These conditions will include psoriasis, tinea capitis, contact dermatitis, seborrheic dermatitis, male and female pattern hair loss, and scarring alopecias. Relevant updates from the literature will be included.

P25

Surgical Complications in Hair Transplantation: A Series of 533 Procedures Sandro N. Salanitri, PhD, Americo Helene Jr., PhD, Antonio Ajg Jose Gonçalves, PhD, Flavia Helena Junqueira Lopes, MD Hospital Santa Casa de Sao Paulo, Sao Paulo, Brazil.

1.Arnold J. Hiccups following surgery of the scalp. Complications. In: Stough DB, Haber RS. Hair replacement. St.Louis: Mosby; 1996. p. 332-4. 2.Buchwach K, Konior RJ. Complications. In: Buchwach K, Konior RJ. Contemporary hair transplant surgery. New York: Thieme; 1997. p. 151-69. 3.Marzola M, Vogel JE. Complications. In: Haber RS, Stough DB. Hair transplantation. Philadelphia: Elsevier Saunders; 2006. p. 257-83. 4.Stough DB, Randall JK, Schauder CS. Complications in hair replacement surgery. Facial Plast Surg Clin North Am 1994; 2(2):219-29. 5.Swinerhart JM. Complications, repairs and special situations. In: Swinerhart JM. Hair restoration surgery. Stamford, CN; Appleton & Lange; 1996. p. 355-70. 6.Unger WP. Complications of hair transplantation. In: Unger WP. Hair transplantation. 3. ed. New York: Dekker; 1995. p. 363-74.

S.N. Salanitri: None. A. Helene Jr.: None. A.A. Jose Gonçalves: None. F. Helena Junqueira Lopes: None.

ABSTRACT: Background: Surgical complications in hair transplantation can sometimes constitute a serious matter, although literature on them is generally based on cases reports instead of larger series of patients. Complications in a set of 533 hair transplantations in 425 patients are the focus of this paper. This is the only paper with this casuistic and it is not a case report. Methods: Patients with androgenetic alopecia (407 males and 17 females), cicatricial alopecia (9 males and 8 females) and malformations (1 male and 3 females) with mean age of 36,9 plus or minus10,4 years submitted to hair transplantation (1995-2006) were postoperatively followed up at least for one year, and data on surgical complications was retrospectively analyzed. Results: Complications rate was (4.7%), including enlarged scar (1.2%), folliculitis (1.0%) and necrosis (0.8%) in donor area; keloid (0.4%), bleeding (0.2%), hiccups (0.2%), infection (0.2%) and pyogenic granuloma (0.2%). Frequencies of enlarged scar increased proportionally according to the number of surgical procedures. Conclusion: Hair transplantation complication rate in this series was 4.7%. A good relationship between patient and surgeon, a complete clinical and laboratorial assessment of the patient, accurate surgical technique, specific equipment, a trained team, and careful postoperative attention to the patient are crucial for successful hair transplantation and for decreasing complication rates. Keywords: 1. Hair transplantation: complications; 2. Alopecia. 3. Plastic Surgery.

P26

Ergo-scope, the New Microscope for Hair Transplant Patrick A. Tafoya Bosley, Maitland, FL, USA.

Patrick Tafoya Bosley Orlando, Florida Experience: All Hair Transplant Technique Assistance Experience: Scalp Reductions, Scalp Lifts, Scalp Flaps. Trainer of Hair Technicians, Physicians Published Articles/Illustrations Experience in Consultations Inventor of Hair Transplant Equipment - Ergo-Sect Arm Board (Ergonomic Equipment for dissection Binocular Microscope) Hair Surgery Experience: May, 1984-2011 (present) ISHRS Assistant’s Meeting: Presenter 1993, 1994, 1995, 1996, 1997, 2001, 2006 ASHRS Assistant’s Meeting: Presenter 1995, 1997 ISHRS Live Surgery Workshop: Presenter 2002, 2006 ISHRS Membership: 1993-1999, 2002-present

P.A. Tafoya: Ownership Interest (royalty, patent, or other intellectual property); inventor/royalty.

ABSTRACT: Introduction: This is a new binocular microscope specifically designed for hair transplant surgery (dissection of grafts). Ever since the introduction of microscopic dissection of grafts utilizing binocular microscopes by Dr. Limmer in the late 1980’s hair transplant assistants have adapted their dissection techniques to fit the microscope chosen from the general market. The available binocular microscopes in the market were designed to fit numerous applications and industries. The long term use of the general microscopes did not address ergonomic and specific problems observed from the dissection of follicular unit grafts. The Ergo-Scope binocular microscope is specifically designed to address these issues:

1. The ergonomic design improves body position to reduce the risk of repetitive motion injuries (RMI’s). Specifically the addition of the arm board provides support for the forearms which helps prevent shoulder and neck fatigue and injury. The tilting of the dissection surface (and arm board) also adjusts the viewing angle of the lens to a more neutral neck position. This also helps reduce the risk of neck and shoulder fatigue and injury.

2. All components of the Ergo-Scope (except the lens head) is made from high density polyethylene (HDPE) plastic. This material does not rust or deteriorate from long term exposure to normal saline application to tissue while dissecting.

3. Cutting surface and arm board is specifically designed to be one piece to prevent the trapping of contaminated fluids. This will help prevent potential cross contamination.

The Ergo-Scope binocular microscope also includes special features:

1. Automatic and controlled Normal Saline spray nozzle utilizing a medical pump. This can be timed automatically or controlled with a foot switch.

2. Enclosed video camera for training and quality control purposes. 3. Illumination and spot lighting for slivering and dissection of grafts.

Conclusion: The Ergo-Scope is specifically designed initially for the hair technician. It improves the comfort and productivity of all technicians through advanced ergonomic designing and application. Also included are special features which improve training and quality control. All hair restoration practices should always consider these factors and the Ergo-Scope is the only microscope which utilizes all of the above.

P27

Are Analgesics and Sedatives Safe? Hair Transplantation in G6PD Deficiency Anand K. Vaggu, MD, Shobit Caroli, MBBS, Kulakarn Amonpattana, MD, Oravan Pathomvanich, MD, Damkerng Pathomvanich, MD DHT Clinic, Bangkok, Thailand.

Anand Kumar Vaggu is a Dermatologist from Hyderabad, India. Presently he is participating in an ISHRS fellowship in hair restoration surgery at DHT Clinic,Bangkok, Thailand.

A.K. Vaggu: None. S. Caroli: None. K. Amonpattana: None. O. Pathomvanich: None. D. Pathomvanich: None.

ABSTRACT: Background: The most common red blood cell enzymatic defect is Glucose-6-phosphate dehydrogenase deficiency (G6PD). Hemolysis can be caused by oxidant agents during peroperative medications in patients with Glucose-6-phosphate dehydrogenase deficiency. Objective: To observe any intra and postoperative complications in G6PD deficiency patients undergoing hair transplantation due to analgesics or sedatives. Methods: A 26 year-old male with G6PD deficiency was scheduled for hair transplantation. The G6PD deficiency was diagnosed at birth via newborn screening . The patient had remained free of any haemolytic events and hospitalization. He had Norwood grade II male pattern baldness. The patient was given diazepam 20 mg and paracetamol1000mg preoperatively for sedation and analgesia. No medications were given intraoperatively. A total of 1901 follicular unit grafts, consisting of 672 single hair, 1112 double hair and 117grafts are 3-4 hair were transplanted over 41 cm2 recipient area. The patient’s pulse, blood pressure and oxygen saturation were monitored throughout the surgery. Total duration of surgery is 5 hours and 45 minutes. Results: Vital parameters were stable during intra and postoperative period. No respiratory or haemodynamic problems occurred. Patient was discharged with stable vital signs (blood pressure 110/72mm of Hg, pulse75/mt, peripheral oxygen saturation 99%) Discussion: Some drugs evoke production and accumulation of toxic peroxides, cause oxidation of hemoglobin and red blood cell membrane, and the use of these kinds of drugs results in excessive hemolysis in G6PD deficiency patients. In spite of against indication of the use, the patient is given acetaminophen for analgesia without any problems. In contrast, an in vitro study by Altikat et. al reported diazepam and midazolam had a inhibitoiry effect in G6PD enzyme activity, diazepam is continued but oral midazolam is avoided. However, there are a few reports in anaesthesiology literature where Emilio et al administered oral midazolam 5mg preoperatively without any problem. In this case intraoperative and postoperative course is uneventful such as stress, hemolytic problems, malignant hyperthermia, or methemoglobinemia. Post operatively, antibiotics like quinolones and sulfonamides which are oxidative agents are avoided and treated with cephalexin. Conclusion: In G6PD deficiency, paracetamol as a analgesic, diazepam or midazolam as a sedative can be given safely preoperatively without any problem.

P28

Oral Tranexamic Acid as a Pre-operative Medication Before Hair Transplant Surgery Pradyumna P. Vaidya, MD Skin & Laser Clinic, Pune, India.

Dr. Pradyumna Vaidya practices at the Skin & Laser Clinic in Pune, India.

D.P. Vaidya: None.

ABSTRACT: Background - Hair restoration surgery has become an exciting and challenging branch due to increased awareness about androgenetic alopecia and rewarding results. It is the most common aesthetic procedure done in male population. Hair transplantation is done under extensive infiltration of local anesthesia. There can be severe intraoperative oozing leading to difficulty in putting the grafts. This can increase the procedure time as well as patient discomfort. This along with the pain while infiltrating anesthetic constitutes major reasons of apprehension. Controlling hemorrhage will lead to reduced apprehension, reduction in duration of surgery, cleaner surgical field, better density of implantation and fewer complications. Methodology - To minimize hemorrhage we tried oral tranexamic acid as an oral dose given twice on the day prior to surgery, a dose before surgery and immediately after surgery if necessary. It exerts antifibrinolytic effect by competitively inhibiting the conversion of plasminogen to plasmin thus reducing intraoperative as well as the post operative bleeding. Results - The modality was tried in 30 patients. We observe that there is a better control of hemorrhage intraoperatively and improved post-surgical outcomes in the form of less post operative bleeding, increased acceptance of the grafts, better density & increase satisfaction of the patients.

P29

Beginner Small Team’s Dream Comes True - Mega and Giga Session by Multiple Mini Sessions on Consecutive 3 to 4 Days Sanjiv A. Vasa, MD Vasa Hair Academy, Ahmedabad, Gujarat State, India.

He has been an active member of ISHRS for the last 15 years, founder and president of the Association of Hair Restoration Surgeons of India, and director of Vasa Hair Academy. He has devoted the last 16 years exclusively to hair restoration and performed over 1,000 procedures. His major research interest has been to find out pitfalls of current hair restoration practices and resolve them by innovating specially designed instruments, equipment and techniques. He has the ownership of many patents, design registries and trademarks. He has also innovated a unique training system on simulators for hair restoration.


ABSTRACT: Introduction / background: Hair transplantion is becoming more popular due to low risk, high reward, and a gratifying day care procedure.

More and more new doctors from different specialties are joining the hair transplant family. Now it is possible to cover larger areas with high density in shorter time producing most natural results. A beginner with a small team thinks that this is possible only by established practitioners who have big infrastructure facilities and an army of supporting staff. The majority of centers perform only one day surgery leaving an impression that if you cannot plant desired number in one day you have to wait a few months before you can have second round. Objective: A beginner with a small team should be able to fulfill their dream of doing Giga (4000 +grafts) or Mega (2000+ grafts) session on one client by multiple Mini (1000+ grafts) or Minor (500+ grafts) sessions on three to four consecutive days. Material and method: A small team can easily harvest and plant up to 500 grafts in the morning. With fresh harvesting in the afternoon session another 500 grafts can be planted. The process can be repeated in the similar fashion to achieve the total of 4000 grafts over 4 consecutive days. Harvesting should be fresh every time limiting to the number you can plant. Do not bite more than what you can chew. Gradually with experience one can increase the speed and team members to perform higher number of grafts per day and reach the desired number of grafts in fewer days. Discussion / Results: Main factors which prevent the consecutive day’s surgery are bandage, dressing, edema, anesthesia, tumescent, harvesting and plantation techniques. How to conquer these factors will be discussed in detail during the talk. Small multiple sessions are less tiring for the clients. Another advantage is the grafts outside body time are much less. Two, three and four consecutive days procedures will be presented. One can conclude that higher density as well as total area coverage can be achieved with most natural looking results. Conclusion: Technically, it is possible to cover larger area with higher density by performing multiple small sessions up to 4 consecutive days. Image 1 - 2 Days Procedure Pre op Image 2 - 2 Days Procedure Day 1 Image 3 - 2 Days Procedure Day 2 Image 4 - 2 Days Procedure Post op Image 5 - 3 Days Procedure Pre op Image 6 - 3 Days Procedure Day 1 Front view Image 7 - 3 Days Procedure Day 1 Back view Image 8 - 3 Days Procedure Day 2 Image 9 - 3 Days Procedure Day 3 Image 10 - 3 Days Procedure Post op Image 11 - 4 Days Procedure Pre op Image 12 - 4 Days Procedure Day 1 Image 13 - 4 Days Procedure Day 2 Image 14 - 4 Days Procedure Day 3 Image 15 - 4 Days Procedure Day 4 Image 16 - 4 Days Procedure Post op

P30

Comparative Study Between Direct Hair Implantation and Classic FUE. How Can a Minimally Invasive Procedure Affect the Survival of Hair Follicles? Anastasios Vekris, MD, Konstantinos Giotis DHI Medical Group, Athens, Greece.

Dr Anastasios Vekris is a specialist plastic surgeon registered with the Specialist Registry of the GMC (General Medical Council) in the UK, the ISHRS, HESPRAS, IPRAS and several other medical societies. He has a vast experience in burns and hand surgery. He is a well trained reconstructive microsurgeon and a master hair restoration surgeon for many years. He has performed several hundreds of hair restoration procedures. Dr Vekris currently holds the position of the Medical Director of the DHI Medical Group. He has presented more than 80 papers on various aspects of plastic surgery and hair restoration in more than 120 international congresses. He has several published articles in international medical journals in the fields of microsurgery and burns.

A. Vekris: None. K. Giotis: None.

ABSTRACT: Introduction. The most common hair restoration techniques used today, FUT and FUE, although they approach the harvesting of the hair follicles from a different angle, they share some common characteristics. One of the main things they have in common is the need for preservation of the hair follicles from the time they are extracted, no matter how; from the donor area until the time they are successfully transplanted in the recipient area. There are numerous reports in the medical literature on the factors affecting the survival of hair follicles out of the body and the best means of preservation during this time or during their processing under the microscope. Dehydration, too high or too low temperatures, excessive handling during the processing of the hair follicles, length of time of exposure before transplantation, are some of the most common factors affecting hair follicle survival. Objective. The aim of this study is to check the effect of a new minimally invasive hair restoration technique, the direct hair implantation, to the survival and growth of the harvested hair follicles in comparison to a classic follicular unit extraction technique of hair restoration. Materials & Methods. A group of 10 patients participate in this study. They were chosen based on the grade of their alopecia (Norwood IV or higher), in order to have sufficient empty recipient areas to be able to compare the hair growth. Also, they had unharvested donor areas, in order to facilitate the extraction of hair follicles. Two equally sized areas in the middle part of the donor area were chosen and marked in each patient, one marked “direct”, the other marked “FUE”. The same doctor extracted the same number of hair follicles from each area with a 0.9 mm caliber punch. The hair follicles extracted from the “FUE” area were placed in a Petri dish with 0.9% NaCl solution at 4°C for 4 hours, while the hair follicles from the “direct” area were cut and left in the skin. During implantation, two equally sized areas were chosen and marked in the recipient area, one “direct” and one “FUE”. Then, the cut hair follicles from the “direct” area they were extracted and placed directly, one by one, in their recipient area, with the use of an implanter devise. No reception holes were created prior to the implantation. The hair follicles from the “FUE” site that were in the Petri dish were transplanted after 4 hours in their recipient area with the use of forceps. They were placed in premade recipient slits. The two recipient areas were photographed, the hair follicles were counted as well as the hair per hair follicle ratio. Follow up evaluation was done on the 1, 7 and 30 days and 2, 4, 6, 8, 10 and 12 months after the procedure. Photos were taken during each follow up and hair counts in both recipient areas with the assistance of a microcamera. Discussion/Rresults. The final results of our study will be presented at the upcoming ISHRS meeting. Although there are no conclusive results yet, as the follow up periods are still too short and not all the patients entered the study yet, there is one significant observation so far. There is evidence that the hair follicles from the “direct” area have not fallen during the period of the first weeks after the transplantation at the same rate as the hair follicles from the “FUE” area. This observation is in line with our previous experience with similar cases, where we did notice that most hair follicles remained and started growing from the first weeks after a direct hair implantation procedure. This way, we experienced early hair growth and a nearly end result in the first 3-4 months after the procedure. In contrast, we would normally expect gradual growth over a period of 8-12 months after a classic FUE procedure. The current study will be the first one trying to establish the early hair growth after a direct hair implantation and also to find out if there is any actual difference between direct hair implantation and classic FUE in terms of numbers of hairs grown after certain follow ups, up to 12 months after the procedure. At the moment we can only hypothesize on the possible explanations of early hair growth evident in direct hair implantation. Avoiding exposure of the hair follicles to the environment, avoiding dehydration, avoiding excessive handling and procession of the hair follicles by the assistants, might be some possible explanations. Also, the fact that the hair follicles in direct hair implantation remain out of the skin for, virtually, less than 30 seconds and then they are immediately transferred to a similar area with the same temperature as their origin, may contribute to the early hair growth. Another factor might be the significantly less trauma in the recipient area, as with the use of the implanter devises there is no need for premade reception holes which means less traumatized blood vessels, less bleeding and faster healing. The final results of the current study may shade some light to the possible advantages of the direct hair implantation technique.

Conclusion. One of the main issues that hair restoration surgeons face every day is how to increase the survival of the hair follicles and optimize the results of a hair restoration procedure. There are positive signs that a new, minimally invasive technique, the direct hair implantation, transferring hair follicles directly from the donor area to the recipient area in seconds, may be the solution to achieve the best possible hair growth at an early stage after a hair restoration procedure.

P31

FUE Transection Rates Sara M. Wassebauer, MD Sara Wasserbauer MD, Walnut Creek, CA, USA.

Dr. Sara Wasserbauer is a Diplomate of the American Board of Hair Restoration Surgery, with offices in San Francisco, Walnut Creek, Napa, and San Jose, CA. She takes a special interest in FUE and reconstructive techniques, as well as high quality hair restoration for both men and women. She also performs specialized hair restoration surgeries for eyelashes, eyebrows and body hair transplantation.

S.M. Wassebauer: None.

ABSTRACT: Follicular Unit Extraction (FUE) is a relatively new addition to many hair surgeons’ armamentarium of techniques. As promising as this method of graft retrieval is, questions remain regarding the effectiveness when compared with traditional strip surgery. The technique is also prone to variation due to physician skill levels (novice versus expert) and the wide selection of manual versus “powered” instrumentation. To that end, this study documents the harvest of approximately 20 grafts using the Harris SAFE Scribe powered FUE extraction tool on 107 of patients prior to traditional strip surgery. Objective: The objective of this study was to calculate the average transection rate and range for a typical FUE extraction. Methods: Approximately 20 grafts were extracted from the donor strip in 107 patients presenting for traditional “strip” surgery prior to tumescence or incision using the SAFE Scribe powered FUE tool with 1.0 mm punch tip. Grafts were then removed, examined under a microscope, and tallied. It should be noted that, initially, curly or wavy-haired individuals (including one looking to obtain high numbers of grafts) were included in the pool. After several tests demonstrating unacceptably high levels of transection, these patients were discouraged from pursuing any FUE and later patients with curly hair were not included in the data set. Likewise, variable results were obtained from patients with previous scarring in the area to be used for FUE. These data points are noted and the analysis was completed both with and without their contribution. Discussion/Results: Data from 107 patients was analyzed. Average transection rates were 6% with a standard deviation of 3.2% (2.8-9.2%). Average number of grafts harvested per patient was 26. When data from scar revision patients or those with curly/wavy hair are factored out, the average transection rate drops to 5% with an average graft harvest of 20

follicular units. Conclusion: Based on this limited study, powered FUE has the potential to obtain grafts with transection rates nearing that of the traditional “strip” method.

Date: Pt

Name: Transection

Rate:

Final Graft

Count: 3/11/2010 SA 4% 20

3/22/2010 JS 8% 27 3/24/2010 AH 4% 23 3/25/2010 JC 3% 25 3/29/2010 EK 7% 23 3/31/2010 JK 7% 21 3/30/2010 AF 17% 421 *

4/7/2010 SH 6% 97 4/7/2010 CH 19% 42 *

4/14/2010 DG 23% 20 * 4/15/2010 YD 2% 21

4/23/2010 AD 3% 24 4/23/2010 KS 5% 20 4/28/2010 JC 3% 21 4/29/2010 CR 5% 20 5/6/2010 MM 7% 23 5/7/2010 JH 6% 24 5/12/2010 MP 8% 21 5/13/2010 MB 4% 21 5/14/2010 JJ 9% 19 5/19/2010 RL 3% 20 5/20/2010 KG 4% 20 5/21/2010 DB 6% 21 5/24/2010 SD 4% 23 5/25/2010 RR 5% 22 5/26/2010 CK 4% 20 5/27/2010 KB 3% 21 5/28/2010 CH 3% 21 6/1/2010 RL 7% 23 6/2/2010 JP 8% 22 6/3/2010 KJ 5% 20 6/3/2010 SP 4% 20 6/4/2010 AM 3% 20 6/7/2010 AM 8% 28 6/8/2010 PC 1% 25 6/9/2010 SK 5% 23

6/10/2010 SG 4% 22 6/11/2010 JO 6% 19 6/14/2010 SB 6% 21 7/21/2010 AL 7% 21 7/22/2010 YG 10% 20 7/27/2010 KJ 7% 22 7/28/2010 MD 5% 20 7/29/2010 WB 3% 20 7/30/2010 DD 3% 20 8/2/2010 SR 6% 20 8/3/2010 FS 5% 20 8/4/2010 JL 6% 20 8/16/2010 DM 5% 25 8/17/2010 EB 3% 21 8/18/2010 LE 6% 21 8/19/2010 SS 3% 20 8/20/2010 LM 5% 22 8/25/2010 AK 7% 21 8/26/2010 SW 9% 23 8/31/2010 RP 7% 22 9/2/2010 LK 2% 20 9/3/2010 RP 3% 21 9/7/2010 JO 5% 20 9/13/2010 RC 4% 20 9/17/2010 JW 6% 20 9/22/2010 MP 6% 20 9/23/2010 VB 4% 20 9/28/2010 JM 3% 20 9/29/2010 CB 9% 20 9/30/2010 AG 8% 20 10/7/2010 VM 4% 20 10/11/2010 EA 5% 20 10/12/2010 CS 5% 20 10/19/2010 MT 2% 20 10/25/2010 ET 3% 20 10/26/2010 BS 5% 20 10/28/2010 EE 5% 20 10/29/2010 RH 6% 20 11/4/2010 GT 5% 20 11/8/2010 CS 2% 20 11/11/2010 AP 5% 21 11/12/2010 JM 7% 21

11/16/2010 IS 8% 20 11/17/2010 JN 9% 20 11/18/2010 LS 7% 21 11/23/2010 LB 4% 20 11/29/2010 SM 8% 23 11/30/2010 IJ 6% 22 12/1/2010 LM 5% 20 12/3/2010 JW 3% 20 12/7/2010 EW 2% 20 12/9/2010 MB 6% 20 12/10/2010 JE 1% 20 12/16/2010 EJ 3% 21 12/17/2010 SB 7% 21 12/20/2010 SN 4% 25 12/21/2010 BK 6% 25 12/22/2010 LW 4% 25 12/23/2010 MS 4% 25 12/27/2010 JM 6% 20 12/28/2010 BF 7% 23 12/29/2010 MB 6% 20 12/30/2010 KK 2% 20 1/6/2011 RH 6% 20 1/7/2011 RR 4% 55 **

1/11/2011 JF 11% 21 ** 1/13/2011 PO 4% 22

1/14/2011 JH 5% 22 ** 1/17/2011 JS 8% 20

1/20/2011 RC 6% 20 1/21/2011 RS 7% 21

Average 6% 26.140187

Total without (* or **) 5.10% 20.71028

Standard deviation 3.20%

Median 5.00%

*Curly/Wavy hair **Scar Revision

P32

A Proposal for Standard FUE Nomenclature Sara M. Wassebauer, MD Sara Wasserbauer MD, Walnut Creek, CA, USA.

Dr. Sara Wasserbauer is a Diplomate of the American Board of Hair Restoration Surgery, with offices in San Francisco, Walnut Creek, Napa, and San Jose, CA. She takes a special interest in FUE and reconstructive techniques, as well as high quality hair restoration for both men and women. She also performs specialized hair restoration surgeries for eyelashes, eyebrows and body hair transplantation.

S.M. Wassebauer: None.

ABSTRACT: A Proposal for Standard FUE Nomenclature. Introduction: FUE is here to stay. Alongside traditional strip harvesting procedures, whether by hand or with the latest powered devices, all hair surgeons will need to at least know the technique as part of our professional arsenal. To that end, I was micro-minigraft-megasession inspired to propose a list of common terminology so that as more and more new surgeons adopt this technique, our knowledge and skills can be shared and expanded with that common language. FUE Glossary of Terms: Burial: A graft dissection that results in an intact graft below the epidermis that is unable to be harvested or implanted. Cap: Epidermis that slides off the hair shaft, typically during extraction, and often leaving the graft intact (but without the epidermal portion) in the hole to be possibly removed later. Does not contain any part of the hair shaft (as distinct from a “High Transection”). Compression: A follicular unit whose bulb and distal structures show evidence of damage from the initial dissection. I have also heard this referred to as “hooking,” but that may be misleading since this sort of damage does not always resemble a “hook.” Note that this does not refer to crushing of the graft from the aggressive use of forceps during harvest. Discards: Any patient tissue obtained during a harvest attempt that has no growth potential (e.g. very high transection graft, skeletonized follicular unit, or cap etc.). Skeletonized: A follicular unit that has neither the perifollicular sheath nor any adipose tissue surrounding the hair shaft. May or may not include a small circle of epidermis at the top. Stripped: A follicular unit that has the perifollicular sheath intact but little or no adipose tissue. May or may not include a small circle of epidermis at the top. Tethered: Any graft that proves difficult or impossible to harvest. Transection: Any follicular unit (graft) with one or more hairs severed below the level of the epidermis. Note that some transected hairs may still be considered implantable (i.e. typically those with 2/3 of the F/U intact). High transection: A follicular unit with one or more hairs transected above sebaceous lobules. Transection can occur either during the dissection or harvest phase of the procedure, but should be distinct from the phenomenon of “capping” which occurs only during extraction of the graft once it has been dissected. Low transection: A follicular unit with one or more hairs transected below sebaceous lobules but above bulb. Discussion: Further, I would propose that calculation of transection rates should be made as a fraction of the intact terminal or vellus hairs present, regardless of their implantability, and before any splitting of follicular units occurs (as might happen with the creation of single-haired follicular units for a hairline reconstruction, etc.). These term definitions are proposed as a starting point for discussion. It is my hope that this list will evolve into a more definitive form on which all hair surgeons can agree, so that our profession and our patients can benefit from clear and accurate communication regarding this new technique.

P33

Management of Patients with Coronary Artery Disease and Updated Guidelines for Antithrombotic Therapy in Hair Restoration Surgery Kuniyoshi Yagyu, MD Kioicho Clinic, Tokyo, Tokyo, Japan.

Kuniyoshi Yagyu, M.D., has been exclusively practicing hair transplantation in Tokyo. He serves on the Board of Governors of the International Society of Hair Restoration Surgery. He is a Diplomate of the American Board of Hair Restoration Surgery, Past President and Board Governor of the Japan Society of Clinical Hair Restoration, and a Winner of the ISHRS Research Award in 2010. He has authored 44 research and clinical publications in books and journals. He had specialized in the field of cardiac surgery for 22 years. He is a board certified Cardiac Surgeon, Cardiologist and Respiratory Physician as well.

K. Yagyu: None.

ABSTRACT: Introduction & Objective: Sometimes patients with coronary artery disease (CAD) visit our clinic for treatment of MPHL. Even if patients have no special past history, some of elderly patients may have latent ischemic heart disease. Latent CAD may cause angina pectoris, acute myocardial infarction (AMI) and arrhythmia even in patients without past history. In patients with valvular heart disease, careful management of antithrombotic therapy is necessary for safe operation. Recently, guidelines for perioperative management of antithrombotic therapy have been changed. The author will talk about updated guidelines for antithrombotic therapy and management of patients with cardiovascular disease in hair transplantation. Patients & Methods: The subjects of this study were patients with cardiovascular disease who visited our clinic for hair transplantation. All patients were accepted for surgery and underwent up to four sessions using 1,500 to 4,800 grafts in total. Ischemic heart disease in 21 patients included angina pectoris and myocardial infarction in 12 patients, percutaneous coronary intervention (PCI) and coronary artery stents treatment in 8, and coronary artery bypass graft with PCI in 1

patient. Other disorders included valvular heart disease before and after valve replacement operation. Results: Risk factors in these patients were coronary artery stents, mechanical heart valve and systemic arterial sclerosis including stenosis in the coronary artery and cerebral artery. Possible complications were stent thrombosis, acute myocardial infarction, acute ischemic stroke, and mechanical valve thrombosis. All patients went through safe operations. Monitors of ECG, SpO2, BP and HR were essential for safe operation. Anticoagulant and antiplatelet drugs were controlled in dosage but not discontinued during surgery. Other maintenance drugs were continued including beta blocker. Epinephrine in tumescence solution was used as usual or in lower dose. Discussion: In patients over 60 years old or in patients with history of cardiovascular disease, frequent check on ECG, SpO2, BP and HR is crucial. If the systolic blood pressure before surgery is 180 mmHg or higher, we should wait using sedative and vasodilator until systolic BP becomes 160 mmHg or lower. Anemia should be corrected before surgery to decrease the risk of cardiovascular ischemia and heart failure. Increased sympathetic nerve activity causes high blood pressure and mental and emotional stress, which may trigger arrhythmia, anginal pain and ischemic stroke. Analgesics and sedatives are useful to decrease pain and distress. Maintenance drugs including anti-hypertensive, anti-arrhythmia, vasodilator, sedatives and others should be continued in the maintenance doses. Maintenance doses of beta blocker should be continued. Control of antithrombotic therapy is crucial in patients with cardiovascular disease. Antithrombus therapy consists of combination of anticoagulant drug and antiplatelet drug. As for anticoagulant therapy, warfarin may be continued in the maintenance dose or it can be reduced to a half dose for three days before surgery. Warfarin should not be discontinued before operation. Optimal prothrombin time during surgery is about 1.5 in the international normalized ratio, which does not cause hemorrhagic tendency or thrombus formation. As for antiplatelet therapy, high dose aspirin, ticlopidine and clopidogrel can be discontinued for 5-7 days before surgery. Low dose aspirin does not cause hemorrhagic tendency and it can be continued during surgery. Other types of antiplatelet drugs including dipyridamole and cilostazol can be discontinued for 1-3 days or they can be continued in the maintenance dose without hemorrhagic tendency. We should always compare the risk of bleeding and the risk of thrombosis in cardiac patients. Mechanical valve thrombosis may cause severe heart failure. Stent thrombosis may cause acute myocardial infarction at a mortality rate of 20% in one year. In order to prevent coronary artery stent thrombosis, antiplatelet drug should be used at least for one month in patients with bare metal stent (BMS). In a patient with BMS, antiplatelet drug can be discontinued or reduced in dosage safely for one week before surgery, if more than one month has passed after PCI. Combination of two types of antiplatelet drugs should be continued for 12 months after PCI in patients with drug eluting stent (DES). Usually, both aspirin and clopidogrel are used for more than 6-12 months. Sometimes, one antiplatelet drug is continued after 6-12 months. If the patient is within six months after PCI with DES, antiplatelet drugs should not be discontinued. Hair transplantation should be postponed until more than six months or one year after DES treatment. If more than one year has passed after PCI with DES, clopidogrel can be discontinued for 5 days but low dose aspirin should be continued. If you want to discontinue both drugs before surgery, you may discontinue both for 3 days but not longer. Low dose aspirin does not cause hemorrhagic tendency, and it can be continued during hair transplantation. Risk of bleeding is low in hair transplantation. Antithrombotic therapy in hair transplantation is class I indication according to American Collage of Cardiology Foundation (ACCF)/American Heart Association (AHA) 2009 guidelines.

Risk of thrombosis is low in patients with old myocardial infarction, old cerebral infarction, permanent atrial fibrillation, and bio-prosthetic heart valve. Antiplatelet drugs can be continued or discontinued if you want. Risk of thrombosis is high in patients with unstable angina, acute phase of transient ischemic attack, mechanical heart valve, and coronary artery stent. In these cases, antiplatelet drugs should be continued during hair transplantation. Conclusion: All patients went through safe operation. Dosage of anticoagulant and antiplatelet drug was controlled according to updated guidelines for antithrombotic therapy.

P34

Additional Intra-epidermal Suture to Trichophytic Closure of Both Wound Edges to Minimize Scarring and Camouflage Donor Scars Effectively Kazuhito Yamamoto, MD Wellness Clinic, Osaka-Umeda, Sonezaki, Kita-ku, Osaka, Japan.

Dr. Kazuhito Yamamoto graduated from Kyoto Prefectural University of Medicine (KPUM) in Kyoto, Japan in 1991, entered the First Department of Surgery (currently called the Department of Surgery and Oncology of the Digestive System), and received his medical degree from KPUM in 1999. He is a Diplomate of the Japan Surgical Society, the Japanese Society of Gastroenterological Surgery and the Japanese Society of Gastroenterology. He has been exclusively practicing hair transplantation since 2004.

K. Yamamoto: None.

ABSTRACT: Introduction Many hair transplant surgeons have recognized the positive results of trichophytic closure after strip harvesting and have further developed the technique while adopting various methods in terms of the doctor’s preference. We have performed very effective double-sided trichophytic closure, which we reported at a previous meeting. Objective To introduce the author’s suturing method performed after the de-epithelialization technique of both wound edges. Materials and Methods After the donor excision is performed strictly parallel to the follicle under open technique, the scalp laxity examinations are carried out and the safety of closing the donor wound without any tension is confirmed. The procedures do not include additional undermining and a controlled removal of both wound edges follows the subcutaneous continuous or interrupted suture with 3/0 polydioxanone (deep-layer closure). Using surgical scissors, each thin strip of epithelium is cut 1 mm and 1.5-2.0 mm in width in upper and lower edges of de-epithelialization, respectively. Following these techniques, a running wavy suture is performed with 5/0 absorbable suture. This method involves not dermal but rather intra-epidermal suture. The initial buried suture is carried out in between the follicles of the one side of the wound end. As shown in Figure 1, in the intra-epidermal suture, the needle enters perpendicularly to the wound at the boundary between the skin surface and the wound plane and passes through to a depth of 1 mm

from the skin surface as the suture forms a big arc, and then leaves from its boundary. The suturing technique is repeated toward the other side of the wound end and the knot is buried at the wound end as well. The final aspect of the wound is wavy (Figure 2). Superficial stitches less than 1 mm in depth may be added partly with fine absorbable interrupted sutures when the sutural plane does not fit completely. Discussion When the ‘Intra-Epidermal Wavy Suture (IEWS)’, which is named after its characteristics, was added to trichophytic closure of both edges, very positive results were obtained in our previous study1. The perpendicular vector of the tensile strength to the wound is dispersed partly in the horizontal direction by the wavy suture and the tension of the superficial wound decreases. The wavy wound is also held without spreading by no removal of stitches for 2 to 3 weeks and is kept fixed as the collagen in the wound increases. This method does not use dermostitches except for both wound ends so as not to damage the bulge area and the bulb. There is neither permanent loss of hairs nor stitch marks due to the pressure of stitches. As a result, the final wavy line achieves narrower scars and camouflages them effectively. Conclusion The author has experienced even better results in terms of the appearance of the donor scars by using an additional superficial layer suture (IEWS) for double-sided trichophytic closure. Figure 1.

Figure 2.

P35

Ziering Zones for Hair Restoration Craig L. Ziering, DO Ziering Medical, Beverly Hills, CA, USA.

CEO and Medical Director of Ziering Medical. Practicing Hair Restoration for 20 years.

C.L. Ziering: None.

ABSTRACT: Abstract on a position: Introduction: I have developed a series of simple diagrams for determining a range of grafts to be transplanted in a given zone for both men and women. Premise: During the consultation it is often difficult for patients to comprehend a given number of grafts and the area that it will cover. These simple diagrams educate and empower the patient and help to shape their expectations while holding the surgeon (and if applicable the consultant) accountable for delivering on their proposed surgical plan. Substantiating data: The series of diagrams which are gender specific enable the patient to have a better understanding of what area (zones) will be covered with a certain number of grafts that they are contracting for. Meeting patient expectations is one of the most important aspects of hair restoration surgery. These diagrams are a simple way to shape those expectations and avoid disappointment for the patient and problems for the surgeon during the post operative evaluation. Discussion: As an example ,the Ziering zones of hair restoration for women are shown below as an attachment .The zones for men will be presented as well.

P36

Mathematical Approach of Lateral and Sagittal Incisions Georgios Zontos, MD 1)Haarklinikken APS CPH Denmark 2)GHR Global Hair Restoration Cyprus 3) Zontos Davies Hair Clinic South Africa, Athens, Greece.

Dr. Georgios Zontos MD, BSC, MSC. has studied medicine and physics at the University of Patras. Postgraduate studies were done in the field οf medical physics. Ηe has practiced in the field of Hair Restoration for 9 years and is the medical director of Hair Restoration Clinic - Haarkkliniken in Copenhagen, Scientific consultant of GHR Global Hair Restoration Company in Nicosia, and Scientific Consultant of Zontos-Davies Hair Restoration Company. His research interest is focused οn mathematical models of FUE hair transplantation issues, especially how the application of physical principles with the contribution of advanced mathematics will be able to improve very important issues like extraction, density, optimal distribution of hair follicles and mathematical approach of hair growth.

G. Zontos: None.

ABSTRACT: Introduction: We consider as lateral or coronal recipient sites the incisions are made parallel to the coronal plane of the head. On the other hand we consider as sagittal recipient sites the incisions are made perpendicular to the coronal plane of head. Many hair surgeons prefer to use sagittal recipient sites in order to avoid cutting across Langer's lines and to minimize transection of the blood vessels arising from the subdermal vascular plexus. Other hair surgeons believe that the use of coronal recipient sites have multiple advantages such as higher coverage, precise control of exit of FU, less injury of vascular plexus and less popping. Objective: In this study we are trying to present a precise and objective explanation of the advantages of coronal recipient sites and incisions. In order to achieve our main goal, which is the predominance of coronal incisions, we will try to approach the problem mathematically. It is the first time where mathematics has been used to give a reasonable explanation of the above issue in the hair transplantation field. Material and Methods: Using simple geometry as shown in figures 1 and 2 respectively, we represent the shape of sagittal and lateral incisions to the surface of the head. From the trigonometric theory in figures 1 and 2 we can assume that S=L/SINθ(3) for sagittal incisions and S=L for lateral incisions . where S is the size of incision, L is the size of blade, and θ is the angle of incision. Results:

1) Our mathematical calculations prove that the wound of the head for 1000 sagittal incisions is equal to the wound of the head for 2360 lateral incisions if the angle is between 20 and 30 degrees.

2) For the same angle of incisions (between 20 and 30 degrees) taking into consideration the formula 3 we can prove that by using lateral incisions we can achieve 62.07% increase of density and 30.5% decrease of wound of the skin at the same time vis-a-vis sagittal incisions.

3) Keeping the density the same in both lateral and sagittal incisions cases - around 30 follicular unit /cm2, the calculations prove that the wound of the skin is 41.42% more.

Conclusions: The mathematical approach of lateral and sagittal incisions prove that the use of lateral incisions: 1) Decreases the trauma of the skin on the recipient area.

2) Reduces injury to the subdermal vascular plexus. 3) The % of growth is higher. 4) Precise control of direction and orientation of hair follicles is achieved. 5) Allows higher density with less risk.

P37

Hair Restoration For Congenital Etiology Baldness In Occipital Region Of The Head Of 15 Years Old Male Patient Using FUE Georgios Zontos, MD Haarklinikken CPH Denmark, Athens, Greece.

Dr. Georgios Zontos MD, BSC, MSC. has studied medicine and physics at the University of Patras. Postgraduate studies were done in the field οΕ medical physics. Ηe has practiced in the field of Hair Restoration for 9 years and is the medical director of Hair Restoration Clinic - Haarkliniken in Copenhagen, Scientific consultant of GHR Global Hair Restoration Company in Nicosia, and Scientific Consultant of Zontos-Davies Hair Restoration Company. His research interest is focused οn mathematical models of FUE hair transplantation issues. Especially how the application of physical principles with the contribution of advanced mathematics will be able to improve very important issues like extraction, density, optimal distribution of hair follicles, and mathematical approach of hair growth.

G. Zontos: None.

ABSTRACT: Introduction A 15 year old male patient was suffering from congenital etiology baldness in occipital area (right) of the head. He visited our clinic and after the examination of his case, we decided to restore the problem using the FUE method. Objective. Using FUE method we would like to restore the problem of the patient. Materials and Methods The patient was a boy, 15 years old. The bald area was located in the lower right part of the occipital area of the head (fig. 1). The surface of the area was about 12 cm2. The skin was in good conditional. The hairs of the rest of the head were normal. Using partial shaving we removed from the normal donor area 290 hair follicles. Total number of hairs: 837 (fig. 2). The incision made using needle 21G for the end of the occipital line and blade 0.9mm lateral incisions for the rest of the recipient sites. For the placement we used implanters 0.9mm. Time of procedure: 2.5 hours. Concusions FUE was the best choice for this case studying the pictures before and after (fig. 3 and 4). The result is totally natural and the density is very high. The patient recovered very fast and using the FUE method we overcame the disadvantages of strip method or other more invasive methods like flaps or expanders.

AUTHOR INDEX

Faculty, moderators and panelists for the General Session and Posters are listed with corresponding Abstract Number. All contributing authors of abstracts are also listed. A bold Abstract Number indicates the presenting author. Abbasi, G. 152 Abbasi, S. 152 Ahmad, M. P01 Amonpattana, K. 015, 016, P02, P04, P05, P06, P22, P27 Ballon, J. L. 086 Barrera, A. 055 Barusco, M. N. 049, 120 Bauman, A. J. 029, 081, 147 Beehner, M. L. 094, P03 Bernstein, R. M. 092, 137 Bhatti, T. 159 Caroli, S. 015, 016, 151, P04, P05, P06, P22, P27 Chang, S. C. 053 Chen, L. P08 Cohen, I. S. 129, 130 Cole, J. P. 097, 115 Cooley, J. 002 Cotterill, P. C. 112, 135 Desai, V. 157 Devroye, J. 023, 138 DeYarman, J. B. 009 Donovan, J. C. 069, P07 Dua, A. 030 Dua, K. 030 Ehringer, W. D. 010, 043 Ergun, O. 101 Escario, E. 107, 126 Epstein, E.S. 088, 091, 153 Fan, W. P08 Farjo, B. K. 005, 064, 067, 127,131, 154, P09 Farjo, N. P. 005, 062, 064, 127, 131, P09 Franzini, S. 019, 048, 070, P10, P11, P12 Gaffney, J. W. 142 Gambino, V. 073, 074 Garde, C. 107 Gaviria, J. I. 059, 071, 103 Gholami, S. P13 Giotis, K. 157, P30 Greco, J. F. 008 Guan, N. N. P08 Haber, R. S. 011, 096 Harries, M. J. 127

Harris, J. A. 027, 100 Helena Junqueira Lopes, F. P25 Helene Jr., A. P25 Hitzig, G. S. 114 Hubka, M. 007 Huh, C. 072 Hwang, S. 013, 093, 108 Ingers, M. G. P14 Izeta, A. 107 Jimenez, F. 003, 054, 075, 107, 126 Jing, W. 102 Jose Gonçalves, A. Ajg. P25 Kabaker, S. 040, 143 Karadeniz, A. 101 Keene, S. A. 012, 032, 060 Khidhir, K. 064 Kim, D.-Y. 079, 098 Kim, J.-C. P15 Kim, M. P15 Knudsen, R. G. 020, 136 Kolasinski, J. 058, 076, P16 Kolenda, M. 076 Kulahci, M. 082, 101 Kumar, A. V.. 015, 016, 151, P04, P05, P22 Laorwong, K. -. 148 Lardner, T. 122 Leavitt, DO, M. 095 Leonard, L. P17, P18 Leonard, R. T. 028 Leonhardt, K. 158 Lorenzo, J. F. 026, 056 Lusicic, N. 019, 070, P10, P11, P12 Markou, M. 117 Marzola, M. 018, 041 Mayer, M. L. 001 Mackiewicz, A. P16 Mackiewicz-Wysocka, M. 076, P16 Mangubat, E. 110, 141 Mansbridge, J. 007 Markarian, A. 119 Marliani, A. P20 Marzola, M. 139, 144

Author Index (continued)

Meier, N. T. P09 Mohebi, P. 031, 146 Mohmand, D. H. 046 Nagai, M. P21 Neidel, F. G. 158 Nusbaum, B. P. 061, 063, 133 Oh, J. P15 Otberg, N. 124 Panchaprateep, R. 104 Parsley, M. W. 050, 116 Parsley, W. 014, 042 Pathomvanich, D. 015, 016, 068, 140, 150, 151 P02, P04, P05, P06, P22, P27 Pattwell, D. P09 Paus, R. 127, P09 Perez-Meza, D. 007, 021, 057, 095 Pitchon, M. 113 Poblet, E. 107, 126 Price, V. H. 125, 132 Przybyla, A. P16 Puig, C. J. 017, 047 Randall, V. 064 Rashid, M. N. 045 Rassman, W. R. 080 Reese, R. J. 118 Rogers, N. E. 106, 109, 156, P24 Ruston, A. 025 Sadick, N. S. 006, 065 Salanitri, S. N.. P25 Sawaya, M. E. 066

Shapiro, R. 044 Simmons, C. 078 Sosa-Cabrera, D. 075 Stough, D. 090, 134 Suddleson, E. 085 Susacasa, A. 070, P10, P11, P12 Tafoya, P. A.. P26 Thienthaworn, P. 151 Trius-Chassaigne, A. 071 True, R. H. 024 Tsilosani, A. 034 Tykocinski, A. 035 Umar, S. H. 099 Vaggu, A. K.. P27 Vaidya, D. P. P28 Vasa, S. A. 077,145, P29 Vekris, A. 157, P30 Venkataram, M. N. 128 Washenik, K. 004, 089, 123 Wassebauer, S. M. 149, P31, P32 Williams, K. L. 083 Wolf, B. R.. 022, 084, 111, 155 Wong, J. 033, 087 Woodward, D. 064 Yagyu, K. 052, 105, P33 Yamamoto, K. P34 Yi, S.-J. 160 Ziering, C. L. 007, 036, 121, P35 Zimber, M. 007 Zontos, G. P36, P37

TOPIC INDEX Anesthesia/Sedation: 053, P18, P28, P01, P27

Artistry and Aesthetics: P21, P03, 139

Avoiding poor graft growth: 124

Basic science update: 066, 104, P19, 004, 063, 103, 106, 126, P08, P15

Complications: 016, 017, 141, 013, 143, 142, P25, 105, P33

Consultation and Evaluation: P07, 051, 048, P35, 076, 147, P05

Density issues: 102, 032

Donor harvesting and donor closure: 154, 151, 081, 153, P34, 158, 034, 100, P31, 152, 078, 027, 150, 080, 021, 020

Endocrinology of hair loss: P11, P20, 070

Ethical issues: 022

Flaps, reductions, expansion: 110

Graft preparation, survival and growth: 024, 094, P22, 148, 079, 035, 006, 005, 043

Hair cloning, duplication, and growth factors: P06, P09, 008

Hair loss in women and ethnic variations: 112, 109, 059, 061, 060, 065, 156, 058

Hairline and Crown design: 138, 120, 136, 074, 054, 052, 137, 140

Instrumentation: 029, 028, P26, 030, 149

Marketing and internet issues: 036

Non-surgical or medical therapies: 007, 072, 090, 089, 091, 092, 125, 088, 132, 069, 064, 067, P24, P14, 071, 009, 019, 068, P10

Other: 015, P04, 159, 107, P13, 096, 145, 093, 128, 129, 046, 122, 077, P32, 097, 108, 073, P29, 001, 047, 123, 144, 010, 062, 018, 049, 002, 038, P16, 117, 135, 114, 042, 056, 083, 055, 050, 014, 033, 118, 085, 045, 130, 012, 116, 040, 039, 119, 057

Post-operative issues: P12, 127

Recipient site techniques: P36, 044, 095, 075

Surgical techniques: 131, P17, 041, 082, 134, P23, 121, 113, 115, 026, 087, 111, 084, 037, P37, P30, 003, 023, 133, 025, 155, 146, P02, 099, 098, 157, 011, 031, 101, 160, 086

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members can easily edit

their Physician Profile, too.

www.ISHRS.org

Hair Issues in Depth allow for commentary by

physicians and the public.

Multiple Languages

Linking is Easy and Effective Go to http://www.ishrs.org/ishrs-links.htm#link-to-us, select the link you want to place on your site, and then ask your webmaster to copy-and-paste the applicable link code to your web page. The link will take visitors to the home page of the ISHRS website.

Now with New Features

SAVE THE DATEOCTOBER 17-21, 2012

CALL FOR ABSTRACTS Opens in December 2011. Visit the ISHRS website for more details: www.ISHRS.org/AnnualMeeting.html

International Society of Hair Restoration Surgery • 303 West State Street, Geneva, IL 60134 USA • TEL 1.630.262.5399 or 1-800-444-2737 • FAX [email protected]; www.ISHRS.org

BLUE 100C 15M BLUE 50C YELLOW 25M 80Y

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ISHRS 19th ASM Abstract Book 2011 Alaska Final

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