Highlights of the 2008 ISHRS Annual Hair Transplant Meeting in Montreal Canada

Recently, the Publishers of the Hair Transplant Network  attended the 2008 16th annual ISHRS scientific meeting held in Montreal from September 3rd to the 7th.   See the formal Press Release.

Though many topics were discussed, this report will highlight topics that may be of most interest to hair loss sufferers. Many of these topics have been discussed and debated by patients for years on our hair loss forum. Topics include optimal hairline design and density, minimizing the appearance of the donor scar, using all follicular units (FUs) verses some multi follicular units (MFUs), FUE Megasessions, and complications with perpendicular (coronal/lateral) incisions and dense packing difficulties. There was a brief presentation on advances in hair biology discussing the latest research on cellular and molecular controls of follicular development and growth. However, because the Publishers of this community were not able to attend this presentation, this report won’t contain any new information on this topic.

The attention to detail at these meetings is certainly very impressive and hair transplant surgeons who regularly attend deserve to be commended for their dedication to continuing education.

Background on the ISHRS and Meetings

The primary mission of the ISHRS (International Society of Hair Restoration Surgery) is to educate hair restoration physicians from the beginner to the master. It is by far the most prominent hair restoration professional organization in the world and the host of the five day annual scientific meeting. Their website (www.ISHRS.org) provides useful information about hair restoration and profiles and contact information for its 700 worldwide physician members.

Many of the physicians well recognized by patients online for achieving excellent results have also become well known and respected by their colleagues as leaders and teachers in the industry. Many leading physicians recommended by this community led or were a part of almost every discussion panel.
This year, Coalition member Dr. Arthur Tykocinski  of Brazil did the hard work of chairing the meeting with help from his co-chairs. Last year’s ISHRS meeting was chaired by Coalition member Dr. Sharon Keene  of Tucson, Arizona.

At the meeting, recommended surgeon Dr. Bill Parsley  of Louisville, KY replaced Coalition member Dr. Bessam Farjo as the acting President for the coming year.

Physician Recognition and Awards: The “Platinum” and “Golden” Follicle

The “Platinum” and “Gold” follicle awards are the highest honors given to leading surgeons in hair restoration by the ISHRS at each meeting. These awards recognize outstanding achievement in basic scientific or clinically-related research in hair pathophysiology or anatomy as it relates to hair restoration.

This year, two outstanding physicians have been recognized by their peers and given the highest honor of the “Platinum” and “Golden” follicle awards. A special congratulations to Coalition member Dr. Jerry Cooley of Charlotte, NC who received the Platinum follicle award and Coalition member Dr. Paul Rose  of Tampa, FL who was given the Golden Follicle Award.

These two surgeons have been recognized for years by their patients online for consistently producing excellent results. No wonder their peers have recognized them as leaders and teachers in the hair restoration field.

Both hair transplant surgeons were respectfully given a standing ovation by their colleagues. Based on the outstanding reviews online by their patients, had they been there, the applause would have shaken the foundation.

See the formal Press Release.

Presentations at the ISHRS meeting of particular interest to Hair Loss Sufferers

Hairline Design and Optimal Density

Natural hairline reconstruction is probably one of the most important factors considered by prospective patients and one of the greatest challenges hair transplant surgeons face on a daily basis. Combining numbers of grafts with artistic design, a surgeon must recreate an age appropriate, natural looking hairline with suitable density to achieve an optimal cosmetic improvement.

Hairline Design

In a hairline demonstration panel discussion led by Dr. Knudsen of Australia, a few top surgeons in the field including Dr. Ron Shapiro, Dr. Arthur Tykocinski, Dr. William Parsley, and Dr. Walter Unger presented their approach to hairline design on the same few patients for compare, contrast, and discussion. Though each hairline design was aesthetically pleasing to the eye, each hairline was uniquely and creatively crafted based on scientific principles of measurement and individual experience and artistry.

Patients needing hairline reconstruction should discuss a surgeon’s approach with those they are considering and look through hair transplant photos that demonstrate their artistry.

Hairline Density

High density hair transplants are often hyped online giving hair loss forum members the impression that surgeons who produce the greatest densities (in FU/cm2) are the best in the industry. But are higher densities always superior? What about in particular for the hairline?

In a presentation and discussion led by Coalition member Dr. Sharon Keene  on maximum verses cosmetic densities, a few leading hair restoration physicians presented varying densities.

Surgeons representing the 35-45 FU/cm2 side of the debate include Coalition member Dr. Robert Bernstein, recommended physician Dr. William Parsley, and Dr. Walter Unger. On the 50-70 FU/cm2 side of the debate, Coalition member Dr. Thomas Nakatsui  and recommended physician Dr. Melike Kulahci  were represented.

Each set of photos including those representing lower and higher densities were artistic with attention to detail. So the question remains, are higher densities necessary if lower densities can achieve the same cosmetic appearance? Where higher densities may be needed is when a patient steps under harsh lighting. Hair characteristics surprisingly were not discussed, but plays a huge role in the number of FU/cm2 needed to achieve proper hairline naturalness and hair density.

Dr. Keene believes that studying natural hairline density in non-hair loss suffering patients is the only way to conclude appropriate density needed for the hairline. Dr. Keene  suggests based on her anecdotal findings that natural hairline density in non-hair loss sufferers is only between 40-50 FU/cm2 on the average as opposed to the conjectured 80. If her findings prove accurate, surgeons may very well re-evaluate the need to densely pack greater numbers in such a small area. Before Dr. Keene  feels comfortable drawing final conclusions however, she intends on increasing her sample size to at least 50 subjects.

Creating an Optimal and Invisible Scar

Minimizing the appearance of the donor scar is a high priority for most hair transplant patients and leading hair restoration physicians alike. That’s why creating an optimal donor scar is a hot topic not only on our hair loss forum, but also amongst leading physicians at the ISHRS scientific meeting this year.

The trichophytic closure technique has been labeled the “Gold Standard” by a number of leading physicians including Coalition member Dr. Robert Haber. This method involves trimming the edge of one side of the wound and overlapping the layers to complete the procedure. This allows non-harvested hair to grow through the wound, masking the appearance of the scar. But should the trichophytic closure technique be used during every hair transplant procedure?

Coalition members Dr. Robert Haber  and Dr. William Reed  admit that there are always exceptions, but advocate its use in all cases “possible” since it increases the probability of a minimal scar. Coalition member Dr. Bill Rassman and recommended physician Dr. Michael Beehner  argue that use of the trichophytic closure technique is best reserved for the “last” procedure in order to preserve scalp elasticity for subsequent procedures to come.

Surgeons agree that the trichophytic closure technique is best implemented with minimal tension to reduce the risk of scar stretching. In the event of a difficult wound closure, even those presented advocates of always using the trichophytic closure technique will use a standard closure to minimize tension on the wound.

It makes sense to preserve scalp elasticity for patients intending to have multiple procedures however, whether or not the patient will return for subsequent sessions is not guaranteed.

All Follicular Units verses Mixed Grafts

Since the advancement in hair restoration and the preference by many leading  physicians toward all follicular units (hairs as they occur naturally in the scalp), there has been some debate on whether or not it’s acceptable to mix multi unit grafts (called MUGs) with follicular units (FUs) and still create a natural looking hair transplant.

Multi unit grafts contain follicular units similar but distinct from minigrafts. However, when MUGs are carefully trimmed under microscopes into refined double follicular units (DFUs – two distinct follicular units very close together) or follicular families (follicular units in close proximity), MUGs are often much smaller and can be easily camouflaged. Old school minigrafts are typically bulkier even though they may or may not contain the same number of hairs as MUGs.

Arguments for using all follicular units include creating the most natural looking head of hair without appearing “pluggy” or “grafty” and the ability to densely pack grafts close together in a single session.

Advocates of the occasional use of MUGs mixed with follicular units argue that the transplanted MUGs cannot be spotted in qualified patients, looks completely natural, and create a greater illusion of hair density.   Coalition member Dr. Bill Rassman  admits that using MUGs should be reserved for male patients with blond fine hair and in female hair loss patients where scalp to hair contrast ratio is minimal. He also notes that MUGs should also be used in minimal quantity.   Some also feel that using some MUGs in patients with gray hair is acceptable. No surgeon on the panel advocated the use of all multi unit grafts to replace follicular units.

Perpendicular (Coronal/Lateral) verses Parallel (Sagital) Incisions

Perpendicular incisions (commonly referred to as the “lateral slit technique” or coronal incisions) have a number of cited advantages such as maximizing the shingling effect of the follicular units, increased dense packing, and optimizing angulation control of the hair from the scalp. However, as Coalition members Dr. Jerry Wong  and Dr. Thomas Nakatsui  pointed out in their presentation, there are a few complications to overcome with this technique.

While parallel (sagital) incisions slide easily in and out between existing hairs, perpendicular (coronal/lateral) incisions increase the risk to transect existing hair if a surgeon is not extremely careful and accurate. Additionally, perpendicular incisions also tend to disrupt the scalps vasculature more than parallel incisions. Thus parallel incisions transect less hairs and blood vessels, assuming the same size blade. Disrupting the scalps vasculature can lead to an increased risk of avascular necrosis (a disease resulting from temporary or permanent loss of the bloody supply to the bones).

Both Dr. Wong  and Dr. Nakatsui  noted that minimizing these risks include to avoid dense packing in areas of poor vasculature and to avoid making incisions too deep.

Dense Packing Complications

High density hair transplant megasessions  are desirable to patients since it typically limits the number of subsequent surgeries needed. And though a handful of leading hair restoration physicians have taken on this challenge when appropriate for the patient, some complications have been cited in a panel discussion led by Dr. William Parsley. Dr. Ron Shapiro  and Dr. Michael Beehner  shared their experience and expertise on this subject.

One debated complication is graft survival at higher densities. Previous studies have been done on graft survival rates that indicate graft survival decreases when density increases. Whereas just about anyone can transplant higher densities, hair growth yield is debatable.

The introduction of smaller blades to make recipient incisions has convinced many leading surgeons that higher densities may produce adequate growth yield, but not in all cases. Dr. Beehner  believes that the staff’s experience and ability to trim and place grafts safely into recipient sites plays major role in graft survival at higher densities. Dr. Ron Shapiro  agrees but also believes that more scientific study is needed to determine graft survival rates at maximum densities.

Other potential complications of dense packing  include increased risk of necrosis, “shock loss” to existing hairs, abnormal distribution of hair in the event the patient loses more hair, and using an abundance of a finite donor source in a concentrated area.

Most surgeons will agree that cases exist where extreme dense packing is suitable. But in many patients, lower density hair transplants are appropriate.

FUE Megasessions vs. Strip Surgery

Most surgeons feel that small sessions of follicular unit extraction (FUE) can be a viable solution for qualified patient candidates. But just as strip surgery has evolved over the years into larger “megasessions”, some hair restoration physicians continue to push the envelope with follicular unit extractino by removing  and planting more follicles in a single session.

In a panel discussion on the controversy “Regular” strip vs. “Big” FUE sessions led by Dr. Kolasinski, a few vital issues were discussed.

Those who took the “Regular Strip” side of the debate which includes Coalition member Dr. Jerry Wong  and Dr. James Harris who is recommended cited a few disadvantages of FUE Megasessions.

Unlike with strip whereby a “session” is usually defined by what is accomplished on a single surgery day, an FUE “session” is defined by how many grafts can be removed and planted over several consecutive days. Therefore, a 3200 FUE “session” may sound impressive, but if accomplished over 4 days, the hair transplant clinic is only averaging 800 follicular units daily.

Using the FUE technique, additional forces are placed on the follicle and are removed blindly. Follicle transection therefore, is often higher than with strip, lessening the number of viable hairs for transplanting. Cysts can also form in the donor area and impact the surrounding hairs.

Those who took the “Big FUE Sessions” side of the debate cited a few disadvantages of strip.

Strip surgery will undoubtedly produce an irreversible linear scar even though it can often be well camouflaged. The danger however, of future scar exposure may occur if a hair loss sufferer loses enough hair to become a level 7 on the norwood scale of hair loss.

No consensus has been made  regarding the viability and maximum hair growth yield when doing FUE megasessions. Therefore, until more proof is provided by physicians regularly performing them to their peers, this controversy will most likely continue.

Final Acknowledgements

Though attending the ISHRS scientific meeting doesn’t guarantee a surgeon is producing excellent results, it appears that most physicians who regularly attend these conferences are dedicated to continually improving their technique and level of patient care.

A special thanks to all those physicians who attended the meeting and are working for the best interest of patients. Surgeons who are recommended by this community who attended the meeting include:

Dr. Bernardino Arocha
Dr. Michael Beehner
Dr. Robert M. Bernstein
Dr. Tim Carman
Dr. Glenn Charles
Dr. Jerry Cooley
Dr. Robert Dorin
Dr. Jeffrey Epstein
Dr. Herbert Feinberg
Dr. Christopher Gencheff
Dr. Edmond Griffin
Dr. Robert Haber
Dr. Jim Harris
Dr. Sheldon S. Kabaker
Dr. Sharon Keene
Dr. Richard S. Keller
Dr. Raymond Konior
Dr. Bradley Limmer
Dr. Ricardo Mejia
Dr. Bernard Nusbaum
Dr. William Parsley
Dr. Vito Quatela
Dr. Bill Rassman
Dr. Bill Reed
Dr. Paul Rose
Dr. Marla Rosenberg
Dr. Brandon Ross
Dr. Paul Shapiro
Dr. Ron Shapiro
Dr. Ken Siporin
Dr. Martin Tessler
Dr. Robert True
Dr. James E. Vogel
Dr. Arthur Tykocinski
Dr. Jean Devroye
Dr. Bessam Farjo
Dr. Nilofer Farjo
Dr. Bijan Feriduni
Dr. Melike Külahçi
Dr. John Gillespie
Dr. Thomas Nakatsui
Dr. H. Rahal
Dr. Jerry Wong

If you are a physician recommended by this community and attended the annual ISHRS meeting and don’t see your name on the above list, please  contact us we’ll be happy to add your name.

—

Bill
Associate Publisher

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