Highlights of the 2010 Annual ISHRS Hair Restoration Meeting in Boston, Massachusetts

Recently, the Publishers of the Hair Transplant Network  attended the 2010 18th annual ISHRS scientific meeting held in Boston from October 20 th through the 24th.

Each year hair restoration physician from around the world gather for several days to attend lectures, meetings, workshops and discussions focused on hair loss treatments. It’s practically impossible to cover all of the important topics discussed at the meeting. Thus, this report will feature the highlights that may be of most interest to hair loss sufferers and those wanting to restore their hair. A few of these topics have been discussed and debated by patients for years online using our hair loss forum, while other topics provide information on innovative techniques and treatments that may potentially revolutionize the hair restoration profession in the future. However, despite some exciting anecdotal evidence provided in various presentations, it’s important to remain cautiously optimistic while much needed research continues and investigation is underway. Some of these topics include the benefits, limitations, and refinements in follicular unit extraction (FUE), its tools and techniques; treating and minimizing the risks of scar stretching via follicular unit hair transplantation (FUT); Platelet Rich Plasma (PRP)  as a storage solution for grafts; Bioengineering of the hair follicle (hair multiplication) including exciting preliminary findings using the highly talked about formula ACell; the advantages and disadvantages of dense packing; studies on the causes and treatments for female hair loss and more.

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

Background on the ISHRS, Meetings and the New President

The primary mission of the ISHRS (International Society of Hair Restoration Surgery) is to educate hair restoration physicians ranging 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 the Hair Transplant Network led or were a part of almost every discussion panel.

At the meeting, highly esteemed Coalition member Dr. Jerry Cooley of Charlotte, NC became the acting President of the ISHRS for the coming year.

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

The “Golden” and “Platinum” 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.

Congratulations to recommended physician Dr. Damkerng Pathomvanich of Thailand, Asia who received the Golden Follicle and Coalition member Dr. Bill Reed who was awarded the Platinum Follicle.

To learn more about these prestigious awards and to congratulate these highly esteemed physicians, visit the discussion forum topic “2010 ISHRS Physician Awards: The Golden and Platinum Follicles“.

See the formal Press Release.

Congratulations as well to Dr. Dow Stough for winning the coveted Manfred Lucas Award for his many contributions to the advancement of physician and staff education, including his long time role in founding and nurturing the International Society of Hair Restoration Surgery (ISHRS).

The critical role played by hair restoration technicians in preparing and placing grafts, was also recognized with a “Distinguished Assistant Award”, which this year was awarded to Emina Karamanovski. She is the hair transplant coordinator at the Lam Institute for Hair Restoration in Dalllas and has trained physicians and their staffs through out the US and Canada. She has also lectured widely on maintaining quality control and co authored the second volume of the book Hair Transplant 360 with Samuel M. Lam M.D., F.A.C.S. This second volume is written specifically for training medical assistants and includes numerous educational videos on DVD.

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

The Advantages, Limitations and Refinements in FUE, its tools and Techniques

Given the increased number of inquiries about FUE on our forum over the last year, no wonder FUE has become a hot topic of discussion and debate amongst hundreds of hair transplant surgeons. Many leading surgeons consider follicular unit extraction (FUE) a viable alternative to follicular unit hair transplantation (FUT). Others feel that FUE may eventually replace FUT and yet others reject its use entirely and feel that its lack of consistency in results is enough to prevent them from incorporating this technique into their practice. However, due to the increased patient interest and refinements in various tools and techniques, several surgeons initially turned off by FUE are starting to recognize its place in the hair restoration profession.

Below, we feature several innovative tools surgeons are using to perform FUE procedures. But just because someone is handed a hammer, doesn’t mean that everyone knows how to use it properly and efficiently. The vast majority of leading surgeons agree that the experience and skill of the surgeon performing the procedure is always paramount over any tool they use. Inexperienced hands with any tool are extremely dangerous to patients and the outcome of the procedure. It’s also doubtful that any tool listed below or otherwise will become universally accepted amongst hair restoration physicians. However, these tools do provide options for surgeons performing FUE. Just as there’s always more than one way to skin a cat, there’s always more than one tool available for experienced surgeons to choose from to perform an optimal FUE procedure.

The SAFE System – Powered Scribe by Dr. Jim Harris

Dr. James Harris presented the “Powered SAFE Scribe”, a new and revolutionary surgical FUE tool at this year’s 2010 ISHRS meeting. Research and testing have proven that this new powered instrument is even more effective than its manual, non-powered predecessor. The Powered SAFE Scribe is safe and effective in the hands of a skilled hair restoration physician and can reduce the time it takes to perform the procedure by half. Extraction rates of 500-700 per hour have been reported using the new powered version of the Scribe as opposed to approximately 200-300 with the manual one.

Benefits include a reduction in pain, minimal scarring, more patients can become candidates based on donor characteristics, minimal transection and decreased time. Additionally, because this tool uses “blunt dissection” as opposed to a sharp punch, angle and direction of the punch is less critical to avoid transection of the hair follicle.

The cost of Dr. Harris’ Powered SAFE scribe is approximately $3200.

Dr. Jean Devroye’s Proprietary Motorized FUE Tool

In an attempt to improve the quality of results patients can achieve with FUE, Coalition member Dr. Jean Devroye designed and has been using a unique powered instrument for FUE hair replacement procedures. This device was designed to improve the speed of the follicular unit extraction procedure while maintaining the same effectiveness as when performed manually by a skilled surgeon.

This new powered FUE device works by spinning alternatively with a low angular motion.   This allows for fast and effective penetration of the scalp and extraction of the follicle while keeping the risks of damage to the follicles virtually nonexistent.   Its  speed is controlled by a foot treadle allowing for better hand control of the device.

While Dr. Devroye believes his FUE tool prototype helps to increase the speed of the hair restoration procedure, he admits it doesn’t reduce the already very low transection rates he achieves while performing follicular unit extraction with a manual tool. Dr. Devroye’s powered FUE instrument has allowed him to increase the number of follicular unit grafts he can transplant daily via FUE from approximately 1200 to 1500 per day.

Above all else, Dr. Devroye feels the skill and experience of the physician and the size of the punch are crucial in achieving optimal results. By his observation, Dr. Devroye determined that smaller punches can easily increase the transection rate of hair follicles during the extraction process. For this reason, Dr. Devroye prefers using slightly larger 1 mm punches instead of incredibly tiny punches as small as 0.7 mm. In his experience, scars obtained with a 1 mm punch are hardly noticeable, even with a short hair cut.

The cost of Dr. Devroye’s FUE tool is approximately $3000.

Dr. Robert True Motorized FUE

Coalition member Dr. Robert True has over 7 years experience with FUE and feels that he gets the best results with a rotary hand engine FUE tool with a sharp punch system and variable speed control. This unit can be purchased for approximately $1500 and the punches can be replaced as needed for less than $50 a piece. Dr. True believes that the skill and experience of the surgeon is critical to achieving optimal results in addition to working with only those patients who make good candidates for FUE. Dr. True can extract between 400 to 600 follicular units (FUs) per hour from the scalp with approximately 2 to 5% transection, 300 to 400 FUs per hour from the beard with 2 to 4% transection and 150 to 350 FUs per hour from the torso with approximately 8.7% transection. Each follicular unit is then inspected under microscopes, a practice not typically performed by most FUE clinics. Dr. True feels this is essential in maximizing optimal hair growth yield.

The NeoGraft Machine

No other FUE tool has stirred up as much controversy amongst patients and physicians as the much hyped NeoGraft machine. To learn more about how the NeoGraft works, including several concerns about the functionality and promotion of this device, visit “Can the NeoGraft Machine Revolutionize FUE?”

Dr. Bob Bernstein also provides an excellent review of this tool on his website at “NeoGraft Hair Transplant Machine for Follicular Unit Extraction“.

In his review, Dr. Bernstein points out that the suction function of the Neograft machine introduces two risks not present with other FUE techniques:

• The suction has a tendency to strip the surrounding tissue from the lower portion of the grafts during their removal, exposing them to drying injury.
• The vacuum creates a continuous flow of dry air around the harvested grafts

Physicians at the meeting also expressed their concern that the NeoGraft machine was being marketed aggressively to physicians with no training or experience with hair transplant surgery.

However, despite the controversy the NeoGraft does have some useful features that have been reported advantageous by surgeons using this device such as Dr. Leonard who presented information on it at the ISHRS conference. Reported advantages include extractions quicker and easier to perform than manual tools and less manipulation of the follicles (uses suction rather than forceps). Disadvantages of this semi-automated NeoGraft device include the high cost of the machine ($80,000), potential desiccation (dehydration) of the follicles from the pneumatic pressure, and the potential damage to the follicles during the suction process.

Dr. Leonard feels confident that the NeoGraft machine extracts healthy follicles with minimal transection but admits that FUE as a whole is only for a small group of qualified candidates.

Summary

The above presentations focused primarily on extracting follicles from the donor area. However, placing these fragile follicular units into tiny recipient incisions is just as critical to ensure optimal growth.

FUE is still relatively new and most leading surgeons agree that while FUE has a place in hair restoration, despite its increasing popularity, not everyone is an optimal candidate. Thus, it’s recommended that patients explore and discuss the benefits and limitations of both FUT and FUE with several leading hair restoration physicians they’re considering for surgery.

Minimizing and Treating Stretched Donor Scars from Follicular Unit Hair Transplant Surgery (FUT)

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 forum, but also amongst leading physicians at the ISHRS scientific meeting this year.

The number one cause of a stretched donor scar is closure under high tension and/or poor surgical planning and suturing. And while the majority of leading physicians produce minimal scarring in the majority of patients closing the wound under minimal tension with the newest trichophytic closure technique, stretched scarring can also occur for unknown reasons due to a patient’s physiology, although this is reported as rare. So what can be done to reduce the appearance of a scar once it’s already stretched?

Patients with wide donor scars can sometimes undergo another strip procedure to attempt to reduce scarring. The old scar is harvested with a new strip and the new wound is closed under minimal tension using today’s state of the art techniques including the “gold standard” trichophytic closure. Double layer sutures are often used in order to reduce tension on the wound and minimize the air pockets underneath the scar. While at least some improvement is typical, optimal scarring isn’t always possible depending on the severity of the first scar.

Dr. James Harris presented the value of filling the scar with FUE grafts to minimize the appearance of the scar. He believes this method is valuable for patients who are fearful of another strip harvest, lacks scalp elasticity or already had previous scar revisions via harvesting another strip with no or minimal success. Dr. Harris feels that a density of 20 to 25 FU/cm2 placed into the scar is sufficient to camouflage the scar.

Coalition member Dr. James Vogel discussed the use of an expander for extreme cases in which the old scar is removed and an expander is inserted for a short time in order to expand viable and healthy tissue. Once removed, extra healthy skin is available while scarred tissue is significantly reduced.

While keloid and hypertrophic scars (tissue abnormalities that can develop during the healing process) are very rare with today’s refined donor harvesting and closing techniques, Coalition member Dr. Sharon Keene presented evidence to suggest that Ace Inhibitors such as enalapril may effectively improve their appearance. Additionally, the likelihood of any reoccurrence was reported as minimal.

Surgeons agree that the best remedy for stretched scarring is to prevent them from occurring. Thus, by carefully screening candidates and closing donors under minimal tension using a trichophytic closure is considered today’s “Gold Standard”.

Platelet Rich Plasma as a Graft Storage Solution

Whether or not Platelet Rich Plasma (PRP) is effective in treating hair loss has been a hot topic on our forum. And while there was no discussion of this at this year’s annual meeting, Dr. Melike Kulahci, who is recommended on the Hair Transplant Network presented studies regarding the use of PRP as a storage solution for dissected follicular unit grafts while outside of the body. The aim of the study was to determine the effects of PRP on wound healing and transplanted hair growth yield. After conducting a study on 300 patients, it was determined that postoperative crust/scabs fell off more rapidly however, shock loss still occurred. More research is needed to determine whether or not growth yield is higher using PRP as a graft holding solution.

Preliminary Findings Cloning Hair Shafts with ACell MatriStem MicroMatrix

There’s nothing that promotes as much excitement in balding men and women as the concept of being able to clone thousands of precious hair follicles until all of the balding areas are fully covered and hair loss is no longer a problem. While the majority of research on hair multiplication (cloning) to date has been in cloning derma papilla cells in order to reproduce a healthy, growing follicle, Coalition member Dr. Jerry Cooley has reported some exciting (although preliminary) findings in potentially creating derma papilla from hair shafts using the ACell MatriStem MicroMatrix.

ACell Matrix MicroMatrix has been FDA approved for wound healing and has demonstrated benefits in healing injuries adjunct to surgery. Dr. Cooley has been using this product which is available both as a powder and a sheet for the last 18 months to study its effects on strip harvesting donor wound healing, FUE and punch harvest sites, dissected follicular unit grafts via FUT and last but not least, its use with the hair duplication (formerly known as “autocloning”) technique in which plucked hairs are used for grafting.

Dr. Cooley feels that the ACell Matrix MicroMatrix solution demonstrated overall improved scarring. Most exciting however is Dr. Cooley’s report on hair duplication (autocloning). Dr. Cooley reported that by dipping plucked hairs in the ACell Matrix MicroMatrix solution and transplanting them into tiny prepared recipient sites – approximately 30 to 50% of these hairs actually began to grow. Since the donor area still contained the follicle, it would reproduce new hair. Meanwhile, evidence suggests that some of these transplanted hair shafts may indeed be reproducing follicles and derma papilla in order to continue growing.

While the above preliminary findings are exciting, Dr. Cooley admits that the permanency of these “plucked” growing hairs are unknown and more research is needed before drawing any kind of real conclusions.

Causes and Treatments for Female Hair Loss

While male pattern baldness (androgenic alopecia) is pretty well understood by doctors as a condition by which the hormone DHT plays a major role in attacking healthy follicles genetically susceptible to it, whether or not DHT plays a role in female hair loss isn’t entirely understood. Thus, many hair restoration physicians are still asking, does androgenic alopecia truly exist in women or is it something entirely different?

Dr. Andrea Marliani of Italy believes that insufficient local follicular estrone activity rather than increased levels of DHT may be responsible for the majority of hair loss cases in women. If this is the case, true androgenic alopecia doesn’t exist in women and should be renamed to something more suitable such as Low Local Estrone Alopecia or Estrone Deficiency Alopecia. Moreover, the above would mean that any antiandrogen treatments such as finasteride (Propecia) (which is prescribed by doctors to some women beyond child bearing years and/or not interested in having children) would be entirely ineffective in treating women with hair loss.

To make matters more confusing, contradicting studies were presented at this year’s conference on the effectiveness of finasteride in the treatment of female related hair loss. Despite a smaller recent study suggesting that finasteride has no effect in women, Coalition member Dr. Sharon Keene reported findings demonstrating the positive effect of finasteride in some women with hair loss. This suggests that femaleresponders to finasteride have androgen mediated hair loss.

Additionally, a large percentage of women who suffer from Polycystic Ovarian Syndrome (PCOS) also experience hair loss. Women with PCOS experience high levels of androgens (male hormones like DHT) in the body and as a result, are more susceptible and likely to experience hair loss.

The above data suggests therefore, that at least some level of androgenic alopecia exists in women. Whether or not it’s as common in women as it was originally thought requires more research. It should be noted that each female should undergo a full medical examination in order to determine the specific cause of her hair loss. Determining the cause in each case is crucial in treating it.

Advantages and Disadvantages of Dense Packing

Whether or not to dense pack grafts and how closely they should be transplanted next to one another has been a hot topic amongst patient and physicians alike for years. Large densely packed hair transplant mega and giga sessions are desirable to patients since it often minimizes the number of subsequent procedures needed. But how many grafts/hairs can be transplanted safely in a square centimeter before growth yield is affected? Who is and who isn’t a candidate for dense packing?

Coalition members Dr. Arthur Tykocinski of Brazil and Dr. Jerry Wong of Vancouver feel that dense packing up to 40 to 50 FU/cm2 when appropriate for the patient can produce optimal yield. However, these larger numbers are typically only achieved with single haired FUs. Not as many double, triple or quadruple haired follicular units are needed per square centimeter in order to provide the same appearance of density. Other physicians feel that a slightly more conservative approach to preserve the scalp’s blood supply is a better option.

While a difference of opinion and philosophy will most likely always exist surrounding dense packing, how much and when to do it, the majority of leading hair restoration surgeons do agree that just because you can, doesn’t mean you always should. Due to the limited donor hair supply, dense packing too many grafts in a small area isn’t a good idea for patients with large balding areas to cover. It’s an issue of supply verses demand. Planting too many follicular units in a small area will leave less available donor for other areas of the scalp. Thus, it’s critical to make the best use of the available donor hair supply and only add more hair to areas of great concern to the patient.

Final Acknowledgements

Though being an ISHRS member and attending the meetings doesn’t guarantee a surgeon is performing state of the art hair transplants with 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. Scott Alexander
Dr. Bernardino Arocha
Dr. Alfonso Barrera
Dr. Michael Beehner
Dr. Robert M. Bernstein
Dr. Tim Carman
Dr. Glenn Charles
Dr. Ivan Cohen
Dr. Jerry Cooley
Dr. Robert Dorin
Dr. Jean Devroye
Dr. Bessam Farjo
Dr. Nilofer Farjo
Dr. Bijan Feriduni
Dr. Shelly Friedman
Dr. Steve Gabel
Dr. John Gillespie
Dr. Edmond Griffin
Dr. Robert Haber
Dr. Victor Hasson
Dr. Jim Harris
Dr. Sheldon S. Kabaker
Dr. Sharon Keene
Dr. Richard S. Keller
Dr. Raymond Konior
Dr. Melike Külahçi
Dr. William Lindsey
Dr. Pathuri Madhu
Dr. Ricardo Mejia
Dr. Mike Meshkin
Dr. Parsa Mohebi
Dr. Humayun Mohmand
Dr. Thomas Nakatsui
Dr. Bernard Nusbaum
Dr. Vladimir Panine
Dr. William Parsley
Dr. Damkerng Pathomvanich
Dr. Vito Quatela
Dr. H. Rahal
Dr. Bill Rassman
Dr. Bill Reed
Dr. Tom Rosanelli
Dr. Paul Rose
Dr. Marla Rosenberg
Dr. Paul Shapiro
Dr. Ron Shapiro
Dr. Cam Simmons
Dr. Ken Siporin
Dr. Martin Tessler
Dr. Robert True
Dr. Arthur Tykocinski
Dr. James E. Vogel
Dr. Jerry Wong

If you are a physician recommended by this community and attended the annual 2010 ISHRS meeting and don’t see your name on the above list, please  contact us we’ll be happy to add your name.

Bill Seemiller
Managing Publisher of  the Hair Transplant Network, the Hair Loss Learning Center, the Hair Loss Q&A Blog, and the Hair Restoration Forum and Social Community

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