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Bridging Technology and Art in Hair Restoration Surgery

Abstract Book
2013 ANNUAL SCIENTIFIC MEE TING COMMIT TEE Robert H. True, MD, MPH Chair Paul J. McAndrews, MD Advanced/Board Review Course Chair Bertram M. Ng, MBBS Advanced/Board Review Course Co-Chair Jonathan L. Ballon, MD Basics Course Chair Samuel M. Lam, MD Basics Course Co-Chair James A. Harris, MD Workshops & Lunch Symposia Chair Jerry Wong, MD Live Patient Viewing Chair Bessam K. Farjo, MBChB Newcomers Chair Francisco Jimenez, MD Immediate Past-Chair Antonio S. Ruston, MD Jerzy R. Kolasinski, MD, PhD Diana Carmona Baez Surgical Assistants Chair

How to read this book


Abstracts 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 Presentation Author Block The bold name is the presenting author. Biography of Presenting Author

002 Presidents Address


Carlos J. Puig, DO, ABHRS, FAACS Physicians Hair Restoration Center, Houston, TX, USA Dr Puig has been actively involved in the practice of hair restoration surgery since 1973. Founding Member of both the AACS and ISHRS, over the years Puig has presented papers, workshops and surgical demonstrations on many topics. Dr. Puig is a Fellow of the American Academy of Cosmetic Surgery, and Diplomate, and Past President of the American Board of Hair Restoration Surgery. Dr. Puig has served as chair of the ISHRS Fellowship Training Committee, Core Curriculum Committee, and currently is the President of the ISHRS. He 2011 joined the staff at the Baylor College of Medicine, in Houston to help start their hair restoration surgery program. C.J. Puig: None. TAKE HOME MESSAGE: The ISHRS is a vibrant active professional organization working hard to sever its membership. ABSTRACT: Dr Puig reviews the year at ISHRS, summarizing the completed and in process projects under taken by the Board of Governors.

Disclosure of Conflict of Interest Block Take Home Message 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 presenters abstract. Disclosures of conflict of interest are included in the introductory pages as well as next to each presenters abstract throughout this book.

Disclaimer

Registrants 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 no medical 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. 2013 International Society of Hair Restoration Surgery

ABSTRACTS
21st Annual Scientific Meeting of the International Society of Hair Restoration Surgery

October 23-26, 2013 Hyatt Regency San Francisco San Francisco, California, USA

Continuing Medical Education Mission Statement


CME Purpose
The purpose of the International Society of Hair Restoration Surgerys (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 ISHRSs 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 Physicians 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. The learning objectives are listed on the adjacent page as well as by each General Session listing within this Abstract Book.

Learning Objectives

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 34.25 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 34.25 AAD Recognized 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
Welcome to the 21st Annual Scientific Meeting o Describe program goals. State of the Art Hair Restoration Surgery o Review the state of the art in hair restoration surgery for both donor strip harvesting and follicular unit extraction. Research Studies o Describe various research projects on the subject of hair and how they may impact therapies or treatments for hair loss. Beyond FUT & FUE o Discuss a novel surgical approach for donor harvesting. Operation Restore Panel o Discuss the surgical approaches to several repair cases, including several that were supported by the ISHRSs Operation Restore pro bono program. Cicatricial Alopecia and Non-Androgenetic Alopecia o Discuss the diagnosis and treatment of non-androgenetic alopecia. o Discuss the role of hair transplants in non-androgenetic alopecia. Post Finasteride Syndrome Session o Review the latest studies on the efficacy and safety of finasteride 1 mg in androgenetic alopecia. o Discuss possible adverse events relating to the use of finasteride, including claims of persistent sexual dysfunction, and concerns relating to prostate cancer. Coffee with the Experts o Discuss various hair restoration surgery topics in-depth in small groups. Recipient Sites and Cosmesis o Compare and contrast different surgeons approaches to the cosmetic aspects of the hair transplant procedure, including designing hairlines, in order to improve ones own skills. o Discuss the surgical approaches to hair transplantation in special situations: advancing the female hairline and HT in eyebrows.

FRIDAY
Anatomy and Basic Science o Discuss new concepts of scalp and eyelash anatomy and the effect of aging on male scalp hair. Norwood Lecture o Review the latest developments in hair follicle cloning, regeneration, and other prospective developments and discuss their relevance to clinical practice. Advancing the FUE Technique o Describe the various techniques and instruments that can be used for FUE including their advantages and disadvantages. o Evaluate donor area safety in FUE procedures. o Discuss techniques to reduce follicle transection rates in FUE procedures.

FRIDAY (continued)
Enhancing Donor Management in Strip Harvesting o Describe the various techniques that can be used to improve donor area healing in FUT including their advantages and disadvantages. Poster Overview Session & Poster Inquiry Session o Review key points relating to a variety of studies and surgical pearls regarding hair restoration surgery. Hairline Design Panel o Compare and contrast different surgeons approaches to designing hairlines and temporal points.

SATURDAY
Breakfast with the Experts o Discuss various hair restoration surgery topics in-depth in small groups. Difficult Cases I o Discuss challenging and atypical cases and treatment options. o Recognize surgical limitations in marginal candidates and develop appropriate treatment plans for these patients. Advances in Hair Biology o Demonstrate understanding of basic biology of molecular influences on follicular behavior. o Describe effect of ATP on follicle viability. o Review the results of platelet growth factors and porcine urinary bladder matrix in wound healing and hair growth. Diagnostic Aids and Treatment Outcome Assessments with a Focus on FPHL o Compare and contrast methods for measuring results of medical and surgical hair restoration. o Review clinical evidence for the effect of low level laser light therapy. o Discuss proper hormonal evaluation in female pattern hair loss (FPHL). Advanced Surgical Videos I: FUT Donor Management; Improving Cosmesis o Compare methods to improve donor closure in FUT. o Describe approaches to reduce post operative cosmetic problems. o Discuss FUE as an approach to repairing poor results. Difficult Cases II: Repair o Discuss challenging and atypical cases and treatment options. o Recognize surgical limitations in marginal candidates and develop appropriate treatment plans for these patients. Advanced Surgical Videos II: Innovations in the Use of Implanters; Improving Efficiency in FUE o Compare and contrast different surgeons approaches to and devices for graft implantation. o Describe the various techniques that make the FUE process more efficient. 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 ISHRSs 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 those in control of content have with commercial interests related to the content of the activity Commercial support (funding or in-kind resources) of the activity Anecdotal content

The ISHRS gratefully acknowledges the following commercial supporters of the 21st Annual Scientific Meeting for their generosity.

Silver

Bosley Restoration Robotics, Inc. A to Z Surgical Cole Instruments Ellis Instruments, Inc. HSC Development Micro-Vid Q-Optics Robbins Instruments

Bronze

In-Kind

Summary of Disclosures of Financial Relationships


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 disclosed relevant financial relationships. All identified conflicts of interest have been resolved through a peer-review process. (Listed in alpha order by last name.)
Part of Meeting General Session Publishing Title Efficacy and Safety of Low Dose Enalapril in Minimizing Linear Donor Scars from Hair Restorarion Surgery - A Randomized Double Blind Placebo Control Study Disclosure Block P. Asawaworarit: Research Grant (principal investigator, collaborator or consultant); ISHRS. D. Pathomvanich: Research Grant (principal investigator, collaborator or consultant); ISHRS. J.T. Navalta: Research Grant (principal investigator, collaborator or consultant); ISHRS. O. Pathomvanich: Research Grant (principal investigator, collaborator or consultant); ISHRS. R. Sittiwangkul: Research Grant (principal investigator, collaborator or consultant); ISHRS. M.R. Avram: Consultant with Restoration Robotics. A. Barrera: Royalties (small percentage on sales of books), textbook due to come out in Oct., "Hair Transplantation- The art of follicular micrografting and minigrafting" C. Chuong: Research Grant (principal investigator, collaborator or consultant); Reported work are supported by NIH. Ownership Interest (royalty, patent, or other intellectual property); Paten of our work was filed to University of Southern CA. Consultant/Advisory Board; I am consutant for Kao company for a unrelated subject. B. Cohen: Ownership Interest (royalty, patent, or other intellectual property); Owns patents and receives royalties. J.P. Cole: Ownership Interest (owner, stock, stock options); Cole Instruments. W.D. Ehringer: Ownership Interest (royalty, patent, or other intellectual property); I am an inventor on a temperature controlled surgical dissection board. G.K. Naughton: Ownership Interest (owner, stock, stock options); Dr. Naughton is a shareholder of Histogen, Inc. M. Hubka: Employment; Histogen. M.P. Zimber: Employment; Histogen. D. Ehrlich: Employment; Histogen. J.M. Mansbridge: Employment; Histogen. J. Peralta-Arambulo: None. T.M. Reyes-Cacas: None. J.F. Greco: Employment; Director Clinical Research for OroGen BioSciences. J.A. Harris: Employment; HSC Development. Research Grant (principal investigator, collaborator or consultant); Restoration Robotics. Ownership Interest (owner, stock, stock options); HSC Development, Restoratoin Robotics. J.A. Harris: Ownership Interest (royalty, patent, or other intellectual property); patent owner and receive income from a relationship with HSC Development.

Expert Table Leader Workshop/Course Faculty General Session

Coffee with the Experts, Table Leader on the Topic of "Clinical Experience with ARTAS" Workshop 202: Corrective Surgery and Strategies Extra-Follicular Environmental Modulation of Hair Regeneration

Expert Table Leader FUE Course: Non-CME Workshop/Course Faculty Poster

Breakfast with the Experts, Table Leader on the Topic of "How to Perform CrossSectional Trichometry" FUE Hands-on Course: Utilizing the Programmable Cole Isolation Device (PCID) for FUE Lunch Symposium 213: New Interventions that Can Improve Outcomes of HT Surgery Embryonic-like Cell-Secreted Proteins Induce Hair Growth in a Phase I/II trial in Male Pattern Baldness

Workshop/Course Faculty General Session

Advanced/Board Review Course

Lunch Symposium 213: New Interventions that Can Improve Outcomes of HT Surgery Utilizing the HairCheck Device to Assess the Preservation of Hair Mass after Hair Restoration Utilizing Strip, Dull Punch FUE and Robotic FUE Graft Harvest Techniques FUE

Part of Meeting General Session FUE Course: Non-CME Expert Table Leader Workshop/Course Faculty Basics Course General Session

Publishing Title State of the Art: Hair Restoration via Extraction Harvesting FUE Hands-On Course: Utilizing SAFE System for FUE Breakfast with the Experts, Table Leader on the Topic of "Proper Use of Minoxidil" Lunch Symposium 213: New Interventions that Can Improve Outcomes of HT Surgery Donor and Recipient Anesthesia, and Station 2: Strip Harvesting Importance of Depth Control when Transplanting Hairs and the Best Way How to Use OKT (Optimally Kept Transplanter) Implanter Lunch Symposium 212: Question the Expert New Stick-and-Place Shiao MicroImplanter Breakfast with the Experts, Table Leader on the Topic of "Implanters" Top 10 Characteristics

Disclosure Block J.A. Harris: Ownership Interest (royalty, patent, or other intellectual property); patent owner and receive income from HSC Development. J.A. Harris: Ownership Interest (owner, stock, stock options); president of the company that manufactures the SAFE System. R.T. Leonard: Speakers Bureau/Honoraria (speakers bureau, symposia, and expert witness); Speakers Bureau; Consultant. A.J. Mathew: Employment; BioLife Solutions, Inc.. P. Mohebi: Ownership Interest (royalty, patent, or other intellectual property); Laxometer. K. Oc: Ownership Interest (royalty, patent, or other intellectual property); OKT (Optimally Kept Transplanter). P.T. Rose: Ownership Interest (owner, stock, stock options); restoration robotic stock. T. Shiao: Ownership Interest (royalty, patent, or other intellectual property); patent pending. I. Shiao: Ownership Interest (royalty, patent, or other intellectual property); patent pending. T. Shiao: Ownership Interest (royalty, patent, or other intellectual property); Shiao microimplanters. A. Tykocinski: Ownership Interest (royalty, patent, or other intellectual property); I have developed the instrument INTRUDER, used for blunt dissection and will be mentioned in the talk. C.C. Velasco: Consultant/Advisory Board; Advisory Board. K. Washenik: Employment; Bosley/Aderans, Allergan Advisor, Clinical Investigator. Ownership Interest (owner, stock, stock options); Bosley/Aderans. Ownership Interest (royalty, patent, or other intellectual property); Bosley/Aderans. Consultant/Advisory Board; Allergan, Johnson and Johnson Healthcare. K. Washenik: Employment; Bosley/Aderans, Allergan Advisor, Clinical Investigator. Ownership Interest (owner, stock, stock options); Bosley/Aderans. Ownership Interest (royalty, patent, or other intellectual property); Bosley/Aderans. Consultant/Advisory Board; Allergan, Johnson and Johnson Healthcare. K. Washenik: Employment; Bosley/Aderans, Allergan Advisor, Clinical Investigator. Ownership Interest (owner, stock, stock options); Bosley/Aderans. Ownership Interest (royalty, patent, or other intellectual property); Bosley/Aderans. Consultant/Advisory Board; Johnson and Johnson Healthcare, Allergan. S.M. Wasserbauer: Research Grant (principal investigator, collaborator or consultant); ISHRS Grant Award recipient. Other Research Support (receipt of drugs, supplies, equipment, or other in-kind support); HairCheck cartriges obtained at discounted. C.K. Wesley: Ownership Interest (owner, stock, stock options); CEO of Pilofocus. Ownership Interest (royalty, patent, or other intellectual property); Intellectual Property.

Workshop/Course Faculty General Session

Expert Table Leader General Session

Poster Expert Table Leader

Acute Telogen Efluvium in Women: A retrospective Review of 503 Cases Breakfast with the Experts, Table Leader on the Topic of "Advances in Hair Biology"

Moderator

Moderator Introduction, Advances in Hair Biology

Panelist

Panelist for Post Finasteride Syndrome Session

General Session

The Effect of Cold Laser Therapy on Hair Mass as Measured by Cross Sectional Diameter Too Good to be True? A Scarless Hair Follicle Harvesting Method Enhancing Transplanted Graft Viability

General Session

Planners and managers who have disclosed relevant financial relationships:


Name Robert S. Haber, MD Position CME Committee Reported Areas of Conflict Ownership interests (owner, stock, stock options), President, Stockholder, LaserCap, Inc.; Ownership Interest (royalty, patent, or other intellectual property) Ellis Instruments, Inc., Haber Spreader royalty. Ownership interests (owner, stock, stock options), HSC Development, Restoration Robotics; Consultant/Advisory Board, Restoration Robotics.

James A. Harris, MD

CME Committee, Webinars Chair, 2013 ASM-Workshops & Lunch Symposia Chair

In addition, the ISHRS reports the following relationships with commercial interests associated with this activity:
Name of Commercial Interest Bosley Restoration Robotics, Inc. A to Z Surgical Cole Instruments Ellis Instruments HSC Development Micro-Vid Q-Optics Robbins Instruments Type of Financial Relationship Provided unrestricted educational grant Provided unrestricted educational grant Provided in-kind support Provided in-kind support Provided in-kind support Provided in-kind support Provided in-kind support Provided in-kind support Provided in-kind support

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

Planners and managers who have disclosed no relevant financial relationships:


Name of Planner or Manager Victoria Ceh, MPA Melanie Stancampiano Paul C. Cotterill, MD Marco Barusco, MD Francisco Jimenez, MD Sharon A. Keene, MD Matt L. Leavitt, DO Carlos J. Puig, DO Ken Washenik, MD, PhD Bradley R. Wolf, MD Robert H. True, MD, MPH Paul J. McAndrews, MD Bertram M. Ng, MBBS Jonathan L. Ballon, MD Samuel Lam, MD Jerry Wong, MD Bessam K. Farjo, MBChB Antonio S. Ruston, MD Jerzy Kolasinski, MD, PhD Diana Carmona Baez Position Executive Director, CME Director (planner and manager) Program Manager (planner and manager) CME Committee Chair CME Committee CME Committee, 2013 ASM Cmt CME Committee CME Committee, LSW Committee Chair CME Committee CME Committee CME Committee CME Committee, 2013 ASM Chair CME Committee, Advanced/Board Review Course Chair CME Committee, Advanced/Board Review Course Co-Chair CME Committee, Basics Course Chair CME Committee, Basics Course Co-Chair CME Committee, Live Patient Viewing Chair CME Committee, Newcomers Chair CME Committee, 2013 ASM Cmt CME Committee, 2013 ASM Cmt CME Committee, Surg Asst Chair No relevant financial relationships to disclose. No COI to report. No COI to report. No COI to report. No COI to report. No COI to report. No COI to report. No COI to report. No COI to report. No COI to report. No COI to report. No COI to report. No COI to report. No COI to report. No COI to report. No COI to report. No COI to report. No COI to report. No COI to report. No COI to report. 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 offlabel or other non-FDA approved, investigational use of a medical device or pharmaceutical product:
Part of Meeting General Session Publishing Title Bioenhancements of Hair Transplantation First Name Jerry Author Last Name Cooley Off-label Disclosure HypoThermosol (BioLife), ATP/Cellenergy (BioLife/Energy Delivery Solutions) HypoThermosol (BioLife), ATP/Cellenergy (BioLife/Energy Delivery Solutions) Reduced Glutathione tested for cellular culture at 5% (SIGMA ALDRICH) VAFED newly invented FUE devise, ,patent under process ETG Mark I by CTC, Canada Rogaine Foam; Johnson and Johnson The Laxometer Rogaine 5% (Johnson&Johnson) Finasteride piloscope (IMDS)

Workshop/Course Faculty

Lunch Symposium 213: New Interventions that Can Improve Outcomes of HT Surgery

Jerry

Cooley

Poster

Use of Glutathione as Part of Holding Solution and its Effect in Oxidative Stress During Hair Transplantation Vacuum Assisted Follicle Extraction Devise (VAFED), an Innovative Devise for FUE With Negligible Follicle Transaction and Easy to Learn Methodology The Effect of Electromagnetic Field Based Multimodality Treatment on Patient Undergoing Hair Transplantation Breakfast with the Experts, Table Leader on the Topic of "Proper Use of Minoxidil" Donor and Recipient Anesthesia, and Station 2: Strip Harvesting Coffee with the Experts, Table Leader on the Topic of "Ten Tips for a Great Consultation" Acute Telogen Efluvium in Women: A retrospective Review of 503 Cases Too Good to be True? A Scarless Hair Follicle Harvesting Method Enhancing Transplanted Graft Viability

Mrcio

Crisstomo

General Session

Anil

Garg

Poster Expert Table Leader Basics Course Expert Table Leader Poster General Session Oral

Hyo Robert Parsa Nicole Carlos Carlos

Kang Leonard Mohebi Rogers Velasco Wesley

Listed below are those who answered that they DO NOT have a relevant financial relationship to disclose:
Publishing Title Comparison of the Results of Hair Restoration Surgery in Cicatricial Alopecias Induced by Inflammatory Diseases with Cicatricial Alopecias Induced by Traumatic Events Anatomy and Arrangment of Human Eyelashes Useful and Practical in Eyelash Transplantation Introduce a New Clinical Pattern of Lichen Planopilaris, it is a Pitfall if Implanted Because the Disease May Flare Up, and Result in Disaster Comparison of the Results of Hair Restoration Surgery in Cicatricial Alopecias Induced by Inflammatory Diseases with Cicatricial Alopecias Induced by Traumatic Events Anatomy and Arrangment of Human Eyelashes Useful and Practical in Eyelash Transplantation Electrolysis Assisted Follicular Unit Extraction ( An Innovation in Hair Harvesting ) Minimizing the Postoperative Pain in Patients Undergoing Strip Surgery Extended Hair Transplant: Old Techniques with a New Combination Hair Removal Laser for Creating Fine Hairs Correction of Improper Female Hairline Restoration Procedures Composit Graft for Incomplete Donor Site Closure Due to High Tension Advantages and Disadvantages of FUE Using ARTAS SYSTEM for Japanese Miniaturization in the Donor Hair Density Count- A Comparative Study Among Different Types of Densitometer Study of Temple Pattern and Fronto-Temporal Point in Asian Men without Male Pattern Baldness Basics Course in FU Hair Restoration Surgery - Chair (Introduction 8:30AM-8:35AM) Real Data of FUE Transection Rate in Asians FUE Hands-on Course: Utilizing the Programmable Cole Isolation Device (PCID) for FUE Video Presentation - The "No-Shave FUE Technique": A Method to Improve Patient Satisfaction with FUE Procedures Medical Treatments: OTC's Graft Survival and Storage Solutions and Station 3: Graft Preparation and Placing Coffee with the Experts, Table Leader on the Topic of "Tips on Conducting a Hair Transplant Research Study" Lunch Symposium 214: Hair Transplant Marketing Strategies Panelist for Difficult Cases I Lunch Symposium 214: Hair Transplant Marketing Strategies FUE vs. FUT: Comparison Study in 2 Patients of FU Growth History of Hair Restoration Surgery and Station 1: Hairline/Crown; Design of Overall Hair Transplantation Coffee with the Experts, Table Leader on the Topic of "Tips on Conducting a Hair Transplant Research Study" Live Patient Viewing Case Lunch Symposium 211: Hair Transplant Complications and Their Avoidance (Lunch Symposium Director) Anesthesia Panelist for Difficult Cases II Panelist for Post Finasteride Syndrome Session Lunch Symposium 212: Question the Expert Unfavorable Results with FUE Technique. Have We Come Full Circle? Live Patient Viewing Case Disclosure Block A. Abbasi: None. S. Abbasi: None. R. Rabbani: None.` S.-. Abbasi: None. A. abbasi: None. G. Abbasi: None. K. Kamyab hesari: None. F. Molaeei: None. R. Rabbani: None. A. Abbasi: None. S. Abbasi: None. S.-. Abbasi: None. A. abbasi: None. S. Gholami: None. S. Sadraei Mousavi: None. M. Adabi: None. H. Kord: None. Y. Hosseini: None. A. toor: None. H. mohmand: None. M. Ahmad: None. M. Ahmad: None. H. Mohmand: None. K. Seo: None. J. Jung: None. H. Park: None. J. Kim: None. J. Ahn: None. J. Ahn: None. J. Ahn: None. K. Kasai: None. I. Haruyama: None. Y. Aikawa: None. K. Saito: None. C. Bisanga: None. T. Meyer-Gonzalez: None. A. Alcaide-Martin: None. P. Asawaworarit: None. D. Pathomvanich: None. R. Sittiwangkul: None. O. Pathomvanich: None. P. Asawaworarit: None. D. Pathomvanich: None. A.K. Vaggu: None. S. Caroli: None. J.L. Ballon: None. J. Bang: None. J. Bang: None. M.N. Barusco: None. M. Barusco: None. M. Barusco: None. M. Barusco: None. M. Batt: None. A.J. Bauman: None. A.J. Bauman: None. M.L. Beehner: None. M.L. Beehner: None. M.L. Beehner: None. M.L. Beehner: None. M.L. Beehner: None. M.M. Behnke: None. R.M. Bernstein: None. R.M. Bernstein: None. R.M. Bernstein: None. T. Bhatti: None. T. Bhatti: None.

Publishing Title Miniaturization in the Donor FUE Hands-On Course: Utilizing SAFE System for FUE Prophylactic Antibiotic Use in Hair Transplantation Surgery--Indications and Recommendations ISHRS & ABHRS Morbidity and Mortality (M&M) Conference Oral/Intramuscular/Intravenous Sedation and Station 4: Introduction to FUE Breakfast with the Experts, Table Leader on the Topic of "Peri-Operative Risk Management" Surgical Assistants Graft Preparation & Placement Workshop (Implanting Station) Ergonomics Alternative Holding Mediums Scalp Biofilm, Hair Loss and Associated Chronic Diseases Basics Course in Hair Restoration Surgery, Station 2: Strip Harvesting Assisting with Donor Harvesting Welcome and Introductions Study of Temple Pattern and Fronto-Temporal Point in Asian Men without Male Pattern Baldness FUE Hands-on Course: Utilizing the Programmable Cole Isolation Device (PCID) for FUE Identical twin to twin FUE hair transplant using ARTAS. Coffee with the Experts, Table Leader on the Topic of "Clinical Experience with ARTAS" Role of Body Hair Transplantation in Vitiligo Graft Harvesting in FUE Giga Session (>3500 FU grafts) CST Evaluation of Donor and Recipient Areas Before and After FUT and FUE Hair Follicle Regeneration in Minimal Depth Follicular Unit Extraction sites treated with Acell Commentary on State of the Art HRS, "Hair Restoration via Extraction Harvesting" Moderator Introduction, Advanced Surgical Videos II Workshop 204: Body Hair FUE Lunch Symposium 213: New Interventions that Can Improve Outcomes of HT Surgery Bioenhancements of Hair Transplantation Lunch Symposium 213: New Interventions that Can Improve Outcomes of HT Surgery Panelist for Difficult Cases I Coffee with the Experts, Table Leader on the Topic of "Managing Female Hair Loss" Combining Follicular Unit Extractionand Strip Surgery in Secondary Procedures to Achieve More Follicular Units -The Management of Donor Area and Previous Scar Use of Glutathione as Part of Holding Solution and its Effect in Oxidative Stress During Hair Transplantation Combining Follicular Unit Extractionand Strip Surgery in Secondary Procedures to Achieve More Follicular Units -The Management of Donor Area and Previous Scar Use of Glutathione as Part of Holding Solution and its Effect in Oxidative Stress During Hair Transplantation Instrument Cleaning Scalp Advance Technologies Panel Discussions: Donor Removal Techniques (strip) FUE Hands-On Course: Utilizing SAFE System for FUE From Man to Woman: Frontal Line Transformation by FUE Technique Lunch Symposium 214: Hair Transplant Marketing Strategies Coffee with the Experts, Table Leader on the Topic of "Assessing FUE Transection" When is Traction Alopecia in Black Women Transplantable ? Non-Androgenetic Alopecia and Station 2: Strip Harvesting Moderator Introduction, Cicatricial Alopecia and Non-Androgenetic Alopecia

Disclosure Block C. Bisanga: None. T. Meyer-Gonzalez: None. A. Alcaide-Martin: None. M. Bishara: None. S.A. Boden: None. S.A. Boden: None. S. Boden: None. S. Boden: None. L.E. Burdine: None. L.E. Burdine: None. B.J. Burgess: None. J.E. Frank: None. R. Burk: None. T.P. Carman: None. T.P. Carman: None. D. Carmona Baez: None. P. Asawaworarit: None. D. Pathomvanich: None. A.K. Vaggu: None. S. Caroli: None. B. Chang,Hung-Chia: None. G.M. Charles: None. G.M. Charles: None. D. Chouhan: None. D. Chouhan: None. J.P. Cole: None. J.P. Cole: None. J.P. Cole: None. J.P. Cole: None. J.P. Cole: None. J.P. Cole: None. J. Cooley: None. J. Cooley: None. J. Cooley: None. P.C. Cotterill: None. M. Crisstomo: None. M. Crisostomo: None. D. Tomaz: None. M. Crisstomo: None. M. Crisstomo: None. M. Crisstomo: None. M. Crisostomo: None. D. Tomaz: None. M. Crisstomo: None. M. Crisstomo: None. S.N. Salanitri: None. F.H. Lopes: None. G. Lopes: None. C.F. da Silva: None. M.S. Dauer: None. M.S. Dauer: None. C. de Hoyos Alonso: None. J.M. Devroye: None. J.M. Devroye: None. J.C. Donovan: None. J.C. Donovan: None. J.C. Donovan: None.

Publishing Title How to Shorten Outside Body Time in FUE Megasessions Humanism in Hair Transplant Marketing How to Shorten Outside Body Time in FUE Megasessions Humanism in Hair Transplant Marketing Panelist for Hairline Design Panel Workshop 205: Ethnic Considerations in Hair Restoration (Workshop Director) FUE Hands-On Course: Utilizing SAFE System for FUE Our Covering Method for Shaved FUE Donor Area Minoxidil, Finasteride and LLLT and Station 5: Recipient Sites Synthetic Fibers Implantation: To Ban or Not To Ban Moderator Introduction and Post Finasteride Syndrome Session Panel Coffee with the Experts, Table Leader on the Topic of "Finasteride" FUE Hands-on Course: Manual, Non-Powered FUE Techniques and Instrumentation Moderator Introduction, Norwood Lecture Workshop 202: Corrective Surgery and Strategies Lunch Symposium 214: Hair Transplant Marketing Strategies (Lunch Symposium Director) Hair Anatomy and Biology Highlights from the 7th World Congress for Hair Research FUE Hands-on Course: Manual, Non-Powered FUE Techniques and Instrumentation Scalp Biofilm, Hair Loss and Associated Chronic Diseases Is Low Level Laser Therapy Effective in Treating Androgenetic Alopecia? A Review of 5 Years Experience in Treating Hundreds of Patients With Male and Female Pattern Hair Loss Workshop 201: Non Androgenetic Alopecias by Medical and Surgical Super Specialists Coffee with the Experts, Table Leader on the Topic of "Treating the Young Patient" Vacuum Assisted Follicle Extraction Devise (VAFED), an Innovative Devise for FUE With Negligible Follicle Transaction and Easy to Learn Methodology Electrolysis Assisted Follicular Unit Extraction ( An Innovation in Hair Harvesting ) Workshop 204: Body Hair FUE (Workshop Director) Surgical Assistants Graft Preparation & Placement Workshop (Slivering Station) Follicle Injury and Graft Survival Coffee with the Experts, Table Leader on the Topic of "Surgical Assistants Table: Postoperative Care" Surgical Assistants Graft Preparation & Placement Workshop (Slivering Station) Cleaning Etiquette Details That Make a Difference in Eyebrow Transplantation Details That Make a Difference in Eyebrow Transplantation Technical Aspects for Optimizing the Results of Donor Area Scars A New Ergonomic Microscope for Hair Transplantation Photography: The Importance of Good "Before" and "After" Photos and Station 5: Recipient Sites Moderator Introduction, State of the Art Hair Restoration Surgery: Part I: Hair Restoration via Donor Strip Harvesting Moderator Introduction, State of the Art Hair Restoration Surgery: Part II: Hair Restoration via Extraction Harvesting Poster Overview ISHRS & ABHRS Morbidity and Mortality (M&M) Conference Repair of Aplasia Cutis Congenita in a 13 Year Old Female Program Overview

Disclosure Block A. Dua: None. K. Dua: None. K. Dua: None. A. Dua: None. A. Dua: None. K. Dua: None. K. Dua: None. A. Dua: None. K. Dua: None. K. Dua: None. K. Dua: None. K. Ebisawa: None. Y. Kamei: None. M. Onda: None. H. Iawa: None. K. Inoue: None. V.W. Elliott: None. S. EL-Maghraby: None. E.S. Epstein: None. E.S. Epstein: None. K. Erdogan: None. B. Farjo: None. B. Farjo: None. B. Farjo: None. N.P. Farjo: None. N.P. Farjo: None. B.X. Feriduni: None. J.E. Frank: None. R. Burk: None. S.A. Friedman: None. J. Fu: None. V. Gambino: None. A.K. Garg: None. S. Gholami: None. S. Sadraei Mousavi: None. M. Adabi: None. H. Kord: None. Y. Hosseini: None. A. Ginzburg: None. L. Gorham: None. L. Gorham: None. B.M. Graham: None. B.M. Graham: None. B. Graham: None. C.G. Guimaraes: None. C.A. Guimaraes: None. C.G. Guimaraes: None. C.A. Guimaraes: None. C.G. Guimaraes: None. R.S. Haber: None. R.S. Haber: None. R.S. Haber: None. R.S. Haber: None. R.S. Haber: None. J.A. Harris: None. J.A. Harris: None. D. Perez-Meza MD: None. J.A. Harris MD FACS: None. A.S. Ruston MD: None. J. Kolasinski MD PhD: None.

Publishing Title Advantages and Disadvantages of FUE Using ARTAS SYSTEM for Japanese State of the Art: Hair Restoration via Donor Strip Post Finasteride Syndrome Update: Urologist's Perspective Coffee with the Experts, Table Leader on the Topic of "Finasteride" Electrolysis Assisted Follicular Unit Extraction ( An Innovation in Hair Harvesting ) Using Single Follicles Divided from Multi-hair Follicular Unit for Natural Result in Asians Breakfast with the Experts, Table Leader on the Topic of "Hyaluronidase in Hair Transplantation" Workshop 205: Ethnic Considerations in Hair Restoration Our Covering Method for Shaved FUE Donor Area Our Covering Method for Shaved FUE Donor Area Surgeon and Trichologist Collaboration - A State-of-the-Art Contemporary Hair Restoration Surgery Hair induction by transplantation of human follicular stem cells, dermal papilla cells or their combination with or without laser pretreatment in Nude Balb/c mice Hair Follicle Cloning, Regeneration and Other Prospective Developments for the Transplant Clinic - Where Are We Now? Moderator Introduction, Diagnostic Aids and Treatment Outcome Assessments with a Focus on FPHL Lunch Symposium 213: New Interventions that Can Improve Outcomes of HT Surgery (Lunch Symposium Director) Application of High-Density Follicular Unit Hair Transplantation in Treatment of Cicatricial Alopecia Dermoscopy is a Valuable Aid in Diagnosing Female Hair Loss and Guiding Treatment Breakfast with the Experts, Table Leader on the Topic of "KoreanSpeaking Table: Total Hairline Correction in Low Grade Hair Loss" Hair Removal Laser for Creating Fine Hairs Total Hairline Correction in Female Patients Differences in Preferences for Female Hairline Between Doctors and Patients Advance Technologies Panel Discussions: Tissue Expansion & Flaps Panelist for Difficult Cases II New Approaches to the Surgical Treatment of Secondary Cicatricial Alopecia Our Covering Method for Shaved FUE Donor Area Introduce a New Clinical Pattern of Lichen Planopilaris, it is a Pitfall if Implanted Because the Disease May Flare Up, and Result in Disaster Restoration of Hair-Inducing Capacity of Cultured Human Dermal Papilla Cells by Three Dimensional Spheroid Culture The Effect of Electromagnetic Field Based Multimodality Treatment on Patient Undergoing Hair Transplantation How I Do a Preevaluation Test in FUE and How I Calculate My Transection Rate The Advantages of Being Able to Do FUT and FUE in Making a Treatment Plan Basics Course in Hair Restoration Surgery, Station 3: Graft Preparation and Placing Breakfast with the Experts, Table Leader on the Topic of "Surgical Assistants Table: Maximizing Team Efficiency" Surgical Assistants Graft Preparation & Placement Workshop (Dissecting Station) Stress Management in a Surgical Setting Advantages and Disadvantages of FUE Using ARTAS SYSTEM for Japanese Moderator Introduction, Recipient Sites and Cosmesis

Disclosure Block K. Kasai: None. I. Haruyama: None. Y. Aikawa: None. K. Saito: None. V. Hasson: None. W.J. Hellstrom: None. W.J. Hellstrom: None. S. Gholami: None. S. Sadraei Mousavi: None. M. Adabi: None. H. Kord: None. Y. Hosseini: None. J. Hwang: None. S. Park: None. S. Hwang: None. S. Hwang: None. K. Ebisawa: None. Y. Kamei: None. M. Onda: None. H. Iawa: None. K. Inoue: None. K. Ebisawa: None. Y. Kamei: None. M. Onda: None. H. Iawa: None. K. Inoue: None. J. Kolasinski: None. K. Jach-Skrzypczak: None. F. Jaffary: None. C. Jahoda: None. F. Jimenez: None. F. Jimenez: None. Z. Jufang: None. A. Juliano: None. J.H. Jung: None. K. Seo: None. J. Jung: None. H. Park: None. J. Kim: None. J. Ahn: None. J.(. Jung: None. J. Kim: None. I. Park: None. J. Jung: None. S. Kabaker: None. S. Kabaker: None. D.G. Papaskiri: None. A.A. Makharashvili: None. A.E. Shestopalov: None. N.N. Kakiashvili: None. K. Ebisawa: None. Y. Kamei: None. M. Onda: None. H. Iawa: None. K. Inoue: None. G. Abbasi: None. K. Kamyab hesari: None. F. Molaeei: None. M. Kim: None. Y. Sung: None. B. Kang: None. J. Kim: None. H. Kang: None. S. Park: None. S. Yoon: None. E.A. Karadeniz: None. E.A. Karadeniz: None. E. Karamanovski: None. E. Karamanovski: None. E. Karamanovski: None. E. Karamanovski: None. K. Kasai: None. I. Haruyama: None. Y. Aikawa: None. K. Saito: None. S.A. Keene: None.

Publishing Title Hormonal Evaluation of Female Pattern Hair Loss Lunch Symposium 212: Question the Expert (Lunch Symposium Director) Non-Absorbable Buried Sutures in HT to Minimise Donor Scars How to Minimize Hair Angle Alteration in Wide Donor Wound How to Minimize Hair Angle Alteration in Wide Donor Wound Hair Removal Laser for Creating Fine Hairs The Phenotype of Hairline Evolution An Easy Method to Minimize Transection with Fine Blade Angle Adjustment in FUSS Restoration of Hair-Inducing Capacity of Cultured Human Dermal Papilla Cells by Three Dimensional Spheroid Culture Controlling FUE Transection Rate with Difficult Scalp Character Differences in Preferences for Female Hairline Between Doctors and Patients Restoration of Hair-Inducing Capacity of Cultured Human Dermal Papilla Cells by Three Dimensional Spheroid Culture The Clinical Utility of the Hair Check Device Moderator Introduction and Hairline Design Panel Panelist for Difficult Cases II Workshop 203: Hairline Design & Recipient Area Planning Induction Anesthesia in Hair Transplantation Body Hair Transplant (BHT) - a Good Supplement to Traditional Hair Transplantation Surgeon and Trichologist Collaboration - A State-of-the-Art Contemporary Hair Restoration Surgery Optimization of Hair Transplantation Using FUE Method Workshop 202: Corrective Surgery and Strategies (Workshop Director) Hair Transplant for Burn Scars Program Overview Body Hair Transplant (BHT) - a Good Supplement to Traditional Hair Transplantation Optimization of Hair Transplantation Using FUE Method Electrolysis Assisted Follicular Unit Extraction ( An Innovation in Hair Harvesting ) An Alternate Technique from Shaving the Recipient Area Basics Course in Hair Restoration Surgery, Station 3: Graft Preparation and Placing Keys to Obtaining Aesthetic Results in Eyebrow Transplants: A Review of over 500 Procedures Workshop 205: Ethnic Considerations in Hair Restoration Lunch Symposium 212: Question the Expert Lunch Symposium 214: Hair Transplant Marketing Strategies Basics Course in FU Hair Restoration Surgery - Co-Chair Surgical Assistants Graft Preparation & Placement Workshop (Implanting Station) Placing Challenges and Solutions Coffee with the Experts, Table Leader on the Topic of "How to Hire and Train Assistants for Your Practice" Micropigmentation: Camouflaging Scalp Alopecia and Scars in Asians Commentary on State of the Art HRS, "Hair Restoration via Donor Strip Harvesting" Hair Plastic Surgery Not Only Restoration How I Correct Too low Hairline Using FUE Instrument Cleaning Scalp Instrument Cleaning Scalp FUE Hands-on Course: Manual, Non-Powered FUE Techniques and Instrumentation (Course Director) Top 10 Characteristics

Disclosure Block S.A. Keene: None. S.A. Keene: None. M. Khanna: None. D. Kim: None. H. Kim: None. D. Kim: None. H. Kim: None. K. Seo: None. J. Jung: None. H. Park: None. J. Kim: None. J. Ahn: None. W.R. Rassman: None. J.P. Pak: None. J. Kim: None. J. Kim: None. M. Kim: None. Y. Sung: None. B. Kang: None. J. Kim: None. J. Kim: None. J. Kim: None. I. Park: None. J. Jung: None. M. Kim: None. Y. Sung: None. B. Kang: None. J. Kim: None. R.G. Knudsen: None. R. Knudsen: None. R. Knudsen: None. R.G. Knudsen: None. S. Zari: None. T. Kohn: None. J. Kolasinski: None. M. Kolenda: None. J. Kolasinski: None. K. Jach-Skrzypczak: None. M. Kolenda: None. J. Kolasinski: None. J. Kolasinski: None. J. Kolasinski: None. D. Perez-Meza MD: None. J.A. Harris MD FACS: None. A.S. Ruston MD: None. J. Kolasinski MD PhD: None. J. Kolasinski: None. M. Kolenda: None. M. Kolenda: None. J. Kolasinski: None. S. Gholami: None. S. Sadraei Mousavi: None. M. Adabi: None. H. Kord: None. Y. Hosseini: None. S. Kotai: None. J. Martinick: None. S. Kotai: None. J.S. Epstein: None. G. Kuka: None. M. Kulahci: None. M. Kulahci: None. O. LaBeck: None. S.M. Lam: None. T. Lardner: None. T. Lardner: None. T. Lardner: None. S. Lee: None. J. Park: None. B.L. Limmer: None. Y.I. Lin: None. Y.I. Lin: None. S.N. Salanitri: None. F.H. Lopes: None. G. Lopes: None. C.F. da Silva: None. S.N. Salanitri: None. F.H. Lopes: None. G. Lopes: None. C.F. da Silva: None. J.F. Lorenzo: None. J.F. Lorenzo: None.

Publishing Title Breakfast with the Experts, Table Leader on the Topic of "SpanishSpeaking Table: FUE" Workshop 204: Body Hair FUE New Approaches to the Surgical Treatment of Secondary Cicatricial Alopecia Coffee with the Experts, Table Leader on the Topic of "Reconstructive Hair Restoration" Lunch Symposium 211: Hair Transplant Complications and Their Avoidance Cosmesis in Hair Restoration Surgery? Does It Matter? An Alternate Technique from Shaving the Recipient Area Coffee with the Experts, Table Leader on the Topic of "How to Hire and Train Assistants for Your Practice" Lunch Symposium 212: Question the Expert Team Building Advance Technologies Panel Discussions: Trichophytic Closures Moderator Introduction, Research Studies Coffee with the Experts, Table Leader on the Topic of "Stem Cells for Hair Loss" Lunch Symposium 213: New Interventions that Can Improve Outcomes of HT Surgery Advanced/Board Review Course - Chair Lunch Symposium 211: Hair Transplant Complications and Their Avoidance Advance Technologies Panel Discussions: Recipient Sites Surgical Assistants Graft Preparation & Placement Workshop (Dissecting Station) Miniaturization in the Donor Workshop 201: Non Androgenetic Alopecias by Medical and Surgical Super Specialists Partial Trichophytic Closure - A Calculated Approach in Performing Double Edged Trichophytic Closure for Improving the Appearance of Scalp Scar. Minimizing the Postoperative Pain in Patients Undergoing Strip Surgery Extended Hair Transplant: Old Techniques with a New Combination Introduce a New Clinical Pattern of Lichen Planopilaris, it is a Pitfall if Implanted Because the Disease May Flare Up, and Result in Disaster Surgical Assistants Graft Preparation & Placement Workshop (Slivering Station) Graft Selection During Placement Workshop 205: Ethnic Considerations in Hair Restoration The Roles of Injected Steroid in Donor Strip Wound Healing Female Hairline Extension Technique Advanced/Board Review Course - Co-Chair Lunch Symposium 214: Hair Transplant Marketing Strategies Lunch Symposium 213: New Interventions that Can Improve Outcomes of HT Surgery Peri-surgical Drug Management and Safety Tools for Monitoring Patients on Medical Therapy Lunch Symposium 211: Hair Transplant Complications and Their Avoidance The Use of a Long Acting Anesthetic to Diminish Post Operative Pain in Hair Transplant Patients Our Covering Method for Shaved FUE Donor Area The Phenotype of Hairline Evolution Coffee with the Experts, Table Leader on the Topic of "Micro-Tattooing" Effects of Low-Level Laser Therapy (LLLT) on Cell Proliferation and Insulin-Like Growth Factor-1 (IGF-1) Secretion of Dermal Papilla Cells from Balding Hair Follicles

Disclosure Block J.F. Lorenzo: None. B.G. Mahadevia: None. D.G. Papaskiri: None. A.A. Makharashvili: None. A.E. Shestopalov: None. N.N. Kakiashvili: None. E. Mangubat: None. E. Mangubat: None. J.H. Martinick: None. S. Kotai: None. J. Martinick: None. J.H. Martinick: None. J.H. Martinick: None. H. Marzola: None. M. Marzola: None. M. Marzola: None. M. Marzola: None. M. Marzola: None. P.J. McAndrews: None. P.J. McAndrews: None. R. Mejia: None. W. Mendoza: None. C. Bisanga: None. T. Meyer-Gonzalez: None. A. Alcaide-Martin: None. P. Mirmirani: None. P. Mohebi: None. A. toor: None. H. mohmand: None. M. Ahmad: None. M. Ahmad: None. H. Mohmand: None. G. Abbasi: None. K. Kamyab hesari: None. F. Molaeei: None. K. Morgan: None. K. Morgan: None. P. Mwamba: None. B.M. Ng: None. B.M. Ng: None. B.M. Ng: None. B.M. Ng: None. R. Niedbalski: None. R.P. Niedbalski: None. B.P. Nusbaum: None. B.P. Nusbaum: None. P.T. Rose: None. B. Nusbaum: None. K. Ebisawa: None. Y. Kamei: None. M. Onda: None. H. Iawa: None. K. Inoue: None. W.R. Rassman: None. J.P. Pak: None. J. Kim: None. J.P. Pak: None. R. Panchaprateep: None.

Publishing Title New Approaches to the Surgical Treatment of Secondary Cicatricial Alopecia Hair Removal Laser for Creating Fine Hairs Differences in Preferences for Female Hairline Between Doctors and Patients Clinical Importance of Parietal Whorl in Male Pattern Baldness Novel Implanter Technique that Enables More than 1600 Grafts in 1 Hour with Dense Packing Micropigmentation: Camouflaging Scalp Alopecia and Scars in Asians The Effect of Electromagnetic Field Based Multimodality Treatment on Patient Undergoing Hair Transplantation Using Single Follicles Divided from Multi-hair Follicular Unit for Natural Result in Asians Surgical Assistants Graft Preparation & Placement Workshop (Slivering Station) Cutting Challenges and Solutions Hair Density Count- A Comparative Study Among Different Types of Densitometer Study of Temple Pattern and Fronto-Temporal Point in Asian Men without Male Pattern Baldness Complication and Solution for Severe Folliculitis after Eyebrow Transplantation Moderator Introduction, Anatomy and Basic Science Lunch Symposium 212: Question the Expert Workshop 205: Ethnic Considerations in Hair Restoration Hair Density Count- A Comparative Study Among Different Types of Densitometer Embryonic-like Cell-Secreted Proteins Induce Hair Growth in a Phase I/II trial in Male Pattern Baldness

Disclosure Block D.G. Papaskiri: None. A.A. Makharashvili: None. A.E. Shestopalov: None. N.N. Kakiashvili: None. K. Seo: None. J. Jung: None. H. Park: None. J. Kim: None. J. Ahn: None. J. Kim: None. I. Park: None. J. Jung: None. J. Park: None. J. Park: None. S. Lee: None. J. Park: None. H. Kang: None. S. Park: None. S. Yoon: None. J. Hwang: None. S. Park: None. M.W. Parsley: None. M.W. Parsley: None. P. Asawaworarit: None. D. Pathomvanich: None. R. Sittiwangkul: None. O. Pathomvanich: None. P. Asawaworarit: None. D. Pathomvanich: None. A.K. Vaggu: None. S. Caroli: None. D. Pathomvanich: None. D. Pathomvanich: None. D. Pathomvanich: None. D. Pathomvanich: None. P. Asawaworarit: None. D. Pathomvanich: None. R. Sittiwangkul: None. O. Pathomvanich: None. G.K. Naughton: Ownership Interest (owner, stock, stock options); Dr. Naughton is a shareholder of Histogen, Inc. M. Hubka: Employment; Histogen. M.P. Zimber: Employment; Histogen. D. Ehrlich: Employment; Histogen. J.M. Mansbridge: Employment; Histogen. J. Peralta-Arambulo: None. T.M. Reyes-Cacas: None. D. Perez-Meza: None. J. Vincent: None. D. Perez-Meza: None. D. Perez-Meza: None. D. Perez-Meza MD: None. J.A. Harris MD FACS: None. A.S. Ruston MD: None. J. Kolasinski MD PhD: None. M. Pitchon: None. D. Poswal: None. D. Poswal: None. D. Poswal: None. V. Price: None. V. Price: None. C.J. Puig: None. C.J. Puig: None. C.J. Puig: None. R. Rabbani: None. A. Abbasi: None. S. Abbasi: None. H.N. Radwanski: None.

Difficulties Facing Hair Restoration Surgeons Providing Hair Transplants to Hair System Users Hair Transplantation of the Scalp after Car Accident Lunch Symposium 213: New Interventions that Can Improve Outcomes of HT Surgery Program Overview Workshop 201 - Non Androgenetic Alopecias by Medical and Surgical Super Specialists (Workshop Co-Director) Less is More Approach - A Novel Hair Transplant Approach for Patients with Extensive Hairloss (NW 6/7) A Mathematical Way of Graft Estimates in a Patient Customized Manner Workshop 204: Body Hair FUE Cicatricial Alopecia: What You Should Know About the Many Different Types Workshop 201 - Non Androgenetic Alopecias by Medical and Surgical Super Specialists (Workshop Co-Director) President's Address Breakfast with the Experts, Table Leader on the Topic of "The Art & Pitfalls of Internet Consultation" Moderator Introduction, Advanced Surgical Videos I Comparison of the Results of Hair Restoration Surgery in Cicatricial Alopecias Induced by Inflammatory Diseases with Cicatricial Alopecias Induced by Traumatic Events Moderator Introduction, Enhancing Donor Management in Strip Harvesting

Publishing Title Understanding the Attitude and Behavior of Hair Loss Patients a Review of 2000 Cases The Scientific Basis for Diet Modification for Hair Loss Patients The Phenotype of Hairline Evolution Coffee with the Experts, Table Leader on the Topic of "Rare Complications of Hair Transplantation" Test Taking Strategies Pre and Post-op Management Lunch Symposium 213: New Interventions that Can Improve Outcomes of HT Surgery ISHRS & ABHRS Morbidity and Mortality (M&M) Conference (Workshop Director) Embryonic-like Cell-Secreted Proteins Induce Hair Growth in a Phase I/II trial in Male Pattern Baldness

Disclosure Block R.J. Rajput: None. R.J. Rajput: None. W.R. Rassman: None. J.P. Pak: None. J. Kim: None. W.R. Rassman: None. R.J. Reese: None. R.J. Reese: None. R.J. Reese: None. R.J. Reese: None. G.K. Naughton: Ownership Interest (owner, stock, stock options); Dr. Naughton is a shareholder of Histogen, Inc. M. Hubka: Employment; Histogen. M.P. Zimber: Employment; Histogen. D. Ehrlich: Employment; Histogen. J.M. Mansbridge: Employment; Histogen. J. Peralta-Arambulo: None. T.M. Reyes-Cacas: None. F. Reynoso: None. F. Reynoso: None. F. Rinaldi: None. S. Roberts: None. N.E. Rogers: None. P.T. Rose: None. B. Nusbaum: None. P.T. Rose: None. P.T. Rose: None. I. Roseborough: None. D.E. Rousso: None. A.W. Russell: None. A. Ruston: None. A. Ruston: None. A. Ruston: None. A.S. Ruston: None. A.S. Ruston: None. D. Perez-Meza MD: None. J.A. Harris MD FACS: None. A.S. Ruston MD: None. J. Kolasinski MD PhD: None. H. Ryu: None. S. Gholami: None. S. Sadraei Mousavi: None. M. Adabi: None. H. Kord: None. Y. Hosseini: None. K. Kasai: None. I. Haruyama: None. Y. Aikawa: None. K. Saito: None. S.N. Salanitri: None. F.H. Lopes: None. G. Lopes: None. C.F. da Silva: None. S. Salas: None. P. Salgado: None. K. Seo: None. J. Jung: None. H. Park: None. J. Kim: None. J. Ahn: None. J. Shafer: None. J. Shafer: None. J. Shafer: None.

Surgical Assistants Graft Preparation & Placement Workshop (Implanting Station) Graft Hydration and Proper Graft Handling Workshop/Course Lunch Symposium 213: New Interventions that Can Improve Outcomes of HT Surgery Surgical Assistants Graft Preparation & Placement Workshop (Continued Learning Station) Coffee with the Experts, Table Leader on the Topic of "Ten Tips for a Great Consultation" The Use of a Long Acting Anesthetic to Diminish Post Operative Pain in Hair Transplant Patients The Use of a Suction Apparatus to Improve Wound Healing of FUE Sites Workshop 201: Non-AGA Workshop 201: Non Androgenetic Alopecias by Medical and Surgical Super Specialists Panelist for Difficult Cases I Slivering Thin vs. Thick Making Less Look Like More Temporal Points - Their Importance and Impact on a Youthful Appearance and as a Prognosis for Baldness Scalp Reconstruction after Pitbull Attack Workshop 203: Hairline Design & Recipient Area Planning (Workshop Director) Lunch Symposium 214: Hair Transplant Marketing Strategies Program Overview Combination Techniques for Donor Strip Wound Closure Electrolysis Assisted Follicular Unit Extraction ( An Innovation in Hair Harvesting ) Advantages and Disadvantages of FUE Using ARTAS SYSTEM for Japanese Instrument Cleaning Scalp Surgical Assistants Graft Preparation & Placement Workshop (Dissecting Station) Placing Forceps: Straight vs. Angled Hair Removal Laser for Creating Fine Hairs Basics Course in Hair Restoration Surgery, Station 3: Graft Preparation and Placing Surgical Assistants Graft Preparation & Placement Workshop (Implanting Station) Good Lighting and Magnification

Publishing Title Low Anabolic Profile in Assessing a Patient's Overall Hair Loss Program and S.H.A.P.I.R.O. Chart Workshop 203: Hairline Design & Recipient Area Planning Advance Technologies Panel Discussions: Hairline Design New Approaches to the Surgical Treatment of Secondary Cicatricial Alopecia Hair Density Count- A Comparative Study Among Different Types of Densitometer Optimizing Graft Distribution and Density in Giga Session of Hair Transplant Overshooting the Safe Donar Zoni in Mega Session of FUE Technique Panelist for Hairline Design Panel Basics Course in Hair Restoration Surgery, Station 4: Introduction to FUE Panelist for Post Finasteride Syndrome Session Surgical Assistants Graft Preparation & Placement Workshop (Continued Learning Station) Strip vs. FUE: Overview of Pros & Cons and Station 1: Hairline/Crown; Design of Overall Hair Transplantation Restoration of Hair-Inducing Capacity of Cultured Human Dermal Papilla Cells by Three Dimensional Spheroid Culture Vertex Accentuation in Female Pattern Hair Loss in Asians A Pilot Study of the Efficacy of 5% Minoxidil Solution Combined with Oral Chelated Zinc Supplement in Treatment of Female Pattern Hair Loss Combining Follicular Unit Extractionand Strip Surgery in Secondary Procedures to Achieve More Follicular Units -The Management of Donor Area and Previous Scar Minimizing the Postoperative Pain in Patients Undergoing Strip Surgery My Performance in Large FUE Sessions Program Chair Welcome & Announcements Moderator Introduction, Beyond FUE and FUE ISHRS & ABHRS Morbidity and Mortality (M&M) Conference Breakfast with the Experts, Table Leader on the Topic of "Beard FUE" Workshop 204: Body Hair FUE Surgical Assistants Graft Preparation & Placement Workshop (Workshop Director) Hands-on Workshop Overview Workshop 203: Hairline Design & Recipient Area Planning Study of Temple Pattern and Fronto-Temporal Point in Asian Men without Male Pattern Baldness A Retrospective Study on the Quality of FUT Scars with a Related Patient Satisfaction Survey Are Postoperative Antibiotics Necessary in FUE Procedures? A DoubleBlind Prospective Study FUE Hands-on Course: Manual, Non-Powered FUE Techniques and Instrumentation Difficulties Facing Hair Restoration Surgeons Providing Hair Transplants to Hair System Users Moderator Introduction and Difficult Cases I Panel Moderator Introduction and Difficult Cases II Panel Workshop 202: Corrective Surgery and Strategies Lunch Symposium 214: Hair Transplant Marketing Strategies Speeding up the FUE Routine: How to Achieve 2000+ Grafts Per Day by Combining Motorized FUE with Implanter Pens - A Video Presentation FUE Hands-on Course: Utilizing the Programmable Cole Isolation Device (PCID) for FUE Arrow Shape Laxometer Widow's Peak Type 2 to Camouflage Scar FUE Hair Transplant Using NeoGraft and Implanter Pens Advance Technologies Panel Discussions: Graft Placement Techniques Coffee with the Experts, Table Leader on the Topic of "Getting Started with FUE" ISHRS & ABHRS Morbidity and Mortality (M&M) Conference Medical Treatments: Medical Therapies

Disclosure Block L. Shapiro: None. P.V. Shapiro: None. P.V. Shapiro: None. D.G. Papaskiri: None. A.A. Makharashvili: None. A.E. Shestopalov: None. N.N. Kakiashvili: None. P. Asawaworarit: None. D. Pathomvanich: None. R. Sittiwangkul: None. O. Pathomvanich: None. S. Soni: None. S. soni: None. M.M. Speranzini: None. R. Stoller: None. D. Stough: None. H. Stretch: None. E. Suddleson: None. M. Kim: None. Y. Sung: None. B. Kang: None. J. Kim: None. R. Thuangtong: None. R. Thuangtong: None. M. Crisstomo: None. M. Crisostomo: None. D. Tomaz: None. A. toor: None. H. mohmand: None. M. Ahmad: None. L.R. Trivellini: None. R.H. True: None. R.H. True: None. R.H. True: None. R.H. True: None. A. Tsilosani: None. A.Ullrich: None. A.Ullrich: None. R. Unger: None. P. Asawaworarit: None. D. Pathomvanich: None. A.K. Vaggu: None. S. Caroli: None. A. Vekris: None. A. Vekris: None. M.X. Vila Martnez: None. D. Perez-Meza: None. J. Vincent: None. J.E. Vogel: None. J.E. Vogel: None. J.E. Vogel: None. J.E. Vogel: None. C. von Albertini: None. C. von Albertini: None. V. Vong: None. V. Vong: None. M. Vories: None. M. Vories: None. M. Vories: None. M. Vories: None. M. Waldman: None.

Publishing Title Overview of BLS with AED Graft Counts of FUE and Traditional "Strip" Surgeries: A Surgical Technique Comparison Scalp Anatomy and Histology and Station 5: Recipient Sites Breakfast with the Experts, Table Leader on the Topic of "Eyebrow Restoration" Multi-Centre, International, Randomized Investigation as to the Efficacy of Adipose Derived Mesenchymal Stem Cells for Stimulating Hair Growth in Androgenic Hair Loss Patients Coffee with the Experts, Table Leader on the Topic of "Stem Cells for Hair Loss" Lunch Symposium 213: New Interventions that Can Improve Outcomes of HT Surgery Basics Course in Hair Restoration Surgery, Station 4: Introduction to FUE Moderator Introduction, Advancing the FUE Technique FUE Hands-on Course: Utilizing the Programmable Cole Isolation Device (PCID) for FUE FUE Hands-on Course: Utilizing the Programmable Cole Isolation Device (PCID) for FUE State of the Art: Recipient Sites and Graft Placement Overview of Live Patient Viewing Cases Breakfast with the Experts, Table Leader on the Topic of "ChineseSpeaking Table: Total Hairline Correction in Low Grade Hair Loss" Novel Application of Hyaluronidase on Scalp Laxity Antithrombotic Medications in Hair Transplantation: Safe Operation in Coronary Heart Disease and Atrial Fibrillation Breakfast with the Experts, Table Leader on the Topic of "Peri-Operative Risk Management" Workshop 205: Ethnic Considerations in Hair Restoration The Effect of Electromagnetic Field Based Multimodality Treatment on Patient Undergoing Hair Transplantation Post Brow Lift Fixation - Eyebrow Transplantation Post Brow Lift Fixation - Eyebrow Transplantation Induction Anesthesia in Hair Transplantation The Initial Consultation and Patient Selection and Station 1: Hairline/Crown; Design of Overall Hair Transplantation How Image Processing in FUE Harvesting Can Be Used in Calculating the Reduction of Skin Trauma by Injecting Normal Saline

Disclosure Block M. Waldman: None. S.M. Wasserbauer: None. S.M. Wasserbauer: None. S. Wasserbauer: None. R.J. Welter: None. R.J. Welter: None. R.J. Welter: None. K.L. Williams: None. K.L. Williams: None. K.L. Williams: None. B. Wolf: None. B.R. Wolf M.D.: None. J. Wong: None. W. Wu: None. W. Wu: None. K. Yagyu: None. K. Yagyu: None. W.D. Yates: None. H. Kang: None. S. Park: None. S. Yoon: None. J. Yu: None. A. Yu: None. J. Yu: None. A. Yu: None. S. Zari: None. T. Kohn: None. C.L. Ziering: None. 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.

D AY- B Y- D AY P R O G R A M

THURSDAY/OC TOBER 24, 2013


6:30AM-6:30PM 6:30AM-6:30PM 7:00AM-6:00PM 7:00AM-8:30AM 7:45AM-9:15AM 7:45AM-7:30PM 9:30AM-12:30PM Registration Poster Viewing Speaker Ready Room Newcomers Orientation Breakfast
(ticket required)

Part II: H air R estoration

via

E xtraction H arvesting

9:52AM-9:54AM 2 Moderator Introduction Robert S. Haber, MD 007 9:54AM-10:11AM 17 State of the Art: Hair Restoration via Extraction Harvesting James A. Harris, MD 008 10:11AM-10:16AM 5 Top 10 Characteristics Jos Lorenzo, MD 009 10:16AM-10:20AM 4 Commentary 010 John P. Cole, MD 10:20AM-10:30AM 10 Q&A 10:30AM-10:50AM 10:50AM-11:34AM Coffee Break

Continental Breakfast Exhibits Surgical Assistants Hands-on Cadaver Workshop: Graft Preparation and Placement (ticket required) GENERAL SESSION

9:00AM-6:00PM 9:00AM-9:13AM

W elcome to the 21st A nnual S cientific M eeting


LEARNING OBJECTIVE Describe program goals.

R esearch S tudies
LEARNING OBJECTIVE Describe various research projects on the subject of hair and how they may impact therapies or treatments for hair loss.

9:00AM-9:05AM 5 Program Chair Welcome & Announcements Robert H. True, MD, MPH 001 9:05AM-9:13AM 8 Presidents Address Carlos J. Puig, DO 002 9:13AM-10:30AM

10:50AM-10:52AM 2 Moderator Introduction 011 Mario Marzola, MBBS 10:52AM-10:59AM 7 FUE vs. FUT: Comparison Study in 2 Patients of FU Growth 012 Michael L. Beehner, MD 10:59AM-11:06AM 7 Utilizing the HairCheck Device to Assess the Preservation of Hair Mass after Hair Restoration Utilizing Strip, Dull Punch FUE and Robotic FUE Graft Harvest Techniques James A. Harris, MD 013 11:07AM-11:14AM 7 Graft Counts of FUE and Traditional "Strip" Surgeries: A Surgical Technique Comparison 014 Sara M. Wasserbauer, MD 11:14AM-11:24AM 10 CST Evaluation of Donor and Recipient Areas Before and After FUT and FUE John P. Cole, MD 015 11:24AM-11:34AM 10 Q&A

S tate of the A rt H air R estoration S urgery


LEARNING OBJECTIVE Review the state of the art in hair restoration surgery for both donor strip harvesting and follicular unit extraction.

Part I : H air R estoration

via

D onor S trip H arvesting

9:13AM-9:15AM 2 Moderator Introduction Robert S. Haber, MD 003 9:15AM-9:32AM 17 State of the Art: Hair Restoration via Donor Strip Method 004 Victor Hasson, MD 9:32AM-9:37AM 5 Top 10 Characteristics Arthur Tykocinski, MD 005 9:37AM-9:41AM 4 Commentary Bobby L. Limmer, MD 006 9:41AM-9:51AM 10 Q&A

THURS

D AY- B Y- D AY P R O G R A M

11:35AM-12:07PM

B eyond FUT

and

FUE

2:00PM-3:10PM

LEARNING OBJECTIVE Discuss a novel surgical approach for donor harvesting.

C icatricial A lopecia and N on -A ndrogenetic A lopecia


LEARNING OBJECTIVES Discuss the diagnosis and treatment of nonandrogenetic alopecia. Discuss the role of hair transplants in nonandrogenetic alopecia.

11:35AM-11:37AM 2 Moderator Introduction 016 Robert H. True, MD, MPH 11:37AM-11:57AM 20 Too Good to be True? A Scarless Hair Follicle Harvesting Method Enhancing Transplanted Graft Viability 017 Carlos K. Wesley, MD 11:57AM-12:07PM 10 Q&A 12:08PM-12:30PM

2:00PM-2:09PM 9 Moderator Introduction 024 Jeffrey C. Donovan, MD, PhD 2:09PM-2:39PM 30 C icatricial A lopecia : W hat You S hould

K now A bout

the

M any D ifferent Types

O peration R estore Panel


LEARNING OBJECTIVE Discuss the surgical approaches to several repair cases, including several that were supported by the ISHRSs Operation Restore pro bono program.

025

Featured Guest Speaker: Vera H. Price, MD, FRCP(C)


Department of Dermatology University of California at San Francisco

12:08PM-12:12PM 4 Program Overview 018 David Perez-Meza, MD

Chair, ISHRS Operation Restore Pro Bono Program

2:39PM-2:46PM 7 Comparison of the Results of Hair Restoration Surgery in Cicatricial Alopecias Induced by Inflammatory Diseases with Cicatricial Alopecias Induced by Traumatic Events 026 Ramin Rabbani, MD 2:47PM-2:54PM 7 Introduce a New Clinical Pattern of Lichen Planopilaris, It Is a Pitfall If Implanted Because the Disease May Flare Up, and Result in Disaster Gholami Abbasi, MD 027 2:54PM-3:00PM 6 When is Traction Alopecia in Black Women Transplantable? 028 Jeffrey C. Donnovan, MD, PhD 3:00PM-3:10PM 10 Q&A 3:12PM-4:00PM
030 031, 032

12:12PM-12:15PM 3 Repair of Aplasia Cutis Congenita in a 13 Year Old Female 019 James A. Harris, MD 12:15PM-12:18PM 3 Scalp Reconstruction After Pitbull Attack 020 Antonio S. Ruston, MD 12:18PM-12:21PM 3 Hair Transplant for Burn Scars 021 Jerzy R. Kolasinski, MD, PhD 12:21PM-12:24PM 3 Identical Twin-to-Twin FUE Hair Transplant using ARTAS 022 Glenn M. Charles, DO 12:24PM-12:27PM 3 Hair Transplantation of the Scalp After Car Accident 023 David Perez-Meza, MD 12:27PM-12:30PM 3 Q&A 12:30PM-2:00PM 12:30PM-2:00PM 12:30PM-2:00PM Lunch on your own or Informal Networking Lunch (ticket required) Global Council of Hair Restoration Societies Meeting (invitation only)

P ost F inasteride S yndrome S ession


Panel: Robert M. Bernstein, MD, Edwin S. Epstein, MD, Wayne J. G. Hellstrom, MD, Dow B. Stough, MD, Ken Washenik, MD, PhD
LEARNING OBJECTIVES Review the latest studies on the efficacy and safety of finasteride 1 mg in androgenetic alopecia. Discuss possible adverse events relating to the use of finasteride, including claims of persistent sexual dysfunction, and concerns relating to prostate cancer.

3:12PM-3:22PM 10 Moderator Introduction 029 Edwin S. Epstein, MD 3:22PM-3:47PM 25 Post Finasteride Syndrome Update: Urologists Perspective Featured Guest Speaker Wayne J.G. Hellstrom, MD, FACS 033
Professor; Chief, Section of Andrology, Department of Urology, Tulane University School of Medicine

3:47PM-4:00PM 13 Q&A

THURS

D AY- B Y- D AY P R O G R A M

4:00PM-4:10PM 4:00PM-5:10PM 4:10PM-5:10PM

Break Visit Exhibits/Coffee

5:10PM-6:00PM

R ecipient S ites

and

C osmesis

C offee

with the E xperts Open to all attendees on a first-come, first-served basis. This is an informal session for small groups to discuss a specific topic as noted on the list. The round tables in the General Session room will be labeled with a topic and table leaders name. You may sit at any table you like and rotate to as many tables as you wish. NEW THIS YEAR! At the half-way point, an announcement will be made so attendees can switch to another table if they choose. The table leader will repeat any mini-presentations or opening remarks about the topic. Coffee pots will be set out on tables. Coffee also available in Exhibit Hall.

LEARNING OBJECTIVES Compare and contrast different surgeons approaches to the cosmetic aspects of the hair transplant procedure, including designing hairlines, in order to improve ones own skills. Discuss the surgical approaches to hair transplantation in special situations: advancing the female hairline and HT in eyebrows.

5:10PM-5:12PM 2 Moderator Introduction 054 Sharon A. Keene, MD 5:12PM-5:22PM 10 Making Less Look Like More 055 Antonio S. Ruston, MD 5:22PM-5:32PM 10 State of the Art Recipient Sites and Graft Placement Bradley R. Wolf, MD 056 5:32PM-5:42PM 10 Cosmesis in Hair Restoration Surgery? Does It Matter? Jennifer H. Martinick, MBBS 057 5:42PM-5:49PM 7 Female Hairline Extension Technique 058 Bertram M. Ng, MBBS 5:49PM-6:00PM 11 Q&A 5:15PM-6:00PM 6:00PM-7:30PM Surgical Assistants Committee Meeting
(invitation only)

LEARNING OBJECTIVE Discuss various hair restoration surgery topics indepth in small groups.

034 035 036 037 038 039 040 041 042 043 044, 045 046 047

1. Stem Cells for Hair Loss Mario Marzola, MBBS & Ryan J. Welter, MD, PhD 2. Rare Complications of Hair Transplantation William R. Rassman, MD 3. Reconstructive Hair Restoration E. Antonio Mangubat, MD 4. Ten Tips for a Great Consultation Nicole E. Rogers, MD 5. Finasteride Edwin S. Epstein, MD & Wayne J.G. Hellstrom, MD 6. Treating the Young Patient Vincenzo Gambino, MD 7. Managing Female Hair Loss Paul C. Cotterill, MD 8. Getting Started with FUE Michael W. Vories, MD 9. Clinical Experience with ARTAS Glenn M. Charles, DO & Marc R. Avram, MD 10. Assessing FUE Transection Jean Devroye, MD 11. Micro-Tattooing Jae Pak, MD 12. Tips on Conducting a Hair Transplant Research Study Michael L. Beehner, MD & Marco N. Barusco, MD 14. How to Hire & Train Assistants for Your Practice Jennifer H. Martinick, MBBS & Tina M. Lardner 15. Surgical Assistant Table: Postoperative Care Brooke M. Graham

Welcome Reception (in Exhibit Hall)

048 049 051, 052 053

THURS

001 Program Chair Welcome & Announcements


Robert H. True, MD, MPH. True & Dorin Medical Group, P.C., New York, NY, USA. MDCM McGill University Faculty of Medicine Post Grad 1-3 Mayo Clinic and U of Illinois Diplomate American Board of Hair Restoration Surgery Past President ABHRS Chair 2013 ISHRS Annual Scientific Meeting. Author of over 40 hair restoration papers and publications Practitioner of FUE for 11 years New York, New York drtrue@hairlossdoctors.com R.H. True: None.

002 President's Address


Carlos J. Puig, DO ABHRS FAACS. Physicians Hair Restoration Center, Houston, TX, USA. Dr Puig has been actively involved in the practice of hair restoration surgery since 1973. Founding Member of both the AACS and ISHRS, over the years Puig has presented papers, workshops and surgical demonstrations on many topics. Dr. Puig is a Fellow of the American Academy of Cosmetic Surgery, and Diplomate, and Past President of the American Board of Hair Restoration Surgery. Dr. Puig has served as chair of the ISHRS Fellowship Training Committee, Core Curriculum Committee, and currently is the President of the ISHRS. He 2011 joined the staff at the Baylor College of Medicine, in Houston to help start their hair restoration surgery program. C.J. Puig: None. TAKE HOME MESSAGE: The ISHRS is a vibrant active professional organization working hard to sever its membership. ABSTRACT: Dr Puig reviews the year at ISHRS, summarizing the completed and in process projects under taken by the Board of Governors.

003 Moderator Introduction, State of the Art Hair Restoration Surgery: Part I: Hair Restoration via Donor Strip Harvesting
Robert S. Haber, MD. Dermatology, 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 140 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: None.

004 State of the Art: Hair Restoration via Donor Strip


Victor Hasson, MD. Vancouver, BC, Canada. V. Hasson: None. TAKE HOME MESSAGE: None provided. ABSTRACT: Definition Pre-operative Assessment -Patient Expectations - Hairloss pattern - present and future - Assessment of donor area - Density - Laxity Hairline Design/Placement Operative Technique 1. Donor area Donor anesthesia and tumescence

Strip excision - Determination of permanent donor - Position of strip excision - Size of donor strip -Undermining Wound closure using single layer staple closure Microscopic Dissection Large team necessary for large sessions 2 stage procedure Maintenace of stable follicular environment and storage Minimal trauma. Minimal Waste. 2. Recipient area - Anesthesia - Nerve blocks - Ring block Planning Megasessions and density/Coverage Limits and safety issues Tumescence of recipient scalp Recipient Sites Ideal recipient site and rationale for use Outcomes

Dr. Victor Hasson

Strip Excision
Tumescence & Hydrostatic Dissection Strip Position & Conguration Mutiple Section Harvest Closure & Scar Interface

HASSON & WONG


Aesthetic Hair Surgery

State-of-the-Art Hair Restoration

Microscopic Dissection
Ergonomics 2-Step Dissection

Megasessions & Density


Dense Packing Large Sessions

Graft Storage Recipient Area


Anaesthetic Tumescence

Recipient Sites
Natural Graft Orientation Lateral Slit Custom Blade Blade Angle, Control & Penetration Graft Compression

Planning
Medications Progressive Loss

Pre-Op Assessment
Patient Expectations Density & Laxity Hairline Design

005 Top 10 Characteristics


Arthur Tykocinski, MD. Tykocinski Medical Goup, Sao Paulo, Brazil. Dr. Tykocinski is a dermatologist from Brazil and one of the pioneers of the Follicular Unit Transplantation, since 1996, learning from Dr. Ron Shapiro. In 2003 he moved along with Dr. Jerry Wong to the Coronal FUT and again, in 2007 he reached the 5.000 FUs Giga session. He wrote several papers, book chapters and talks on hair restoration on donor area (dealing with fluid pressure, double layer closure, the intruder, managing donor area for large sessions) and his well known fast and accurate Stick & Place technique. Has also been in leading positions on the ISHRS Annual Meetings: Workshop Chair (2005), Advanced Review Course co-chair (2007) and Program Chair (2008). He is actually member of the Board of Governors. A. Tykocinski: Ownership Interest (royalty, patent, or other intellectual property); I have developed the instrument INTRUDER, used for blunt dissection and will be mentioned in the talk. TAKE HOME MESSAGE: The strip harvesting technique does not compete with FUE. Both have their merits and indications. No one replace the other. Being able to perform both techniques with quality is the desired goal. The patient will have the benefits. ABSTRACT: 1- Scalp massage to increase scalp laxity and maximize donor area removal (average 3.300 UFs per session). 15 twice a day for 2 months before the HT 2- Use preferably two methods of measurement to access scalp laxity. I use a personal laxity chart and the Wong method. Having to methods is good to avoid extremes. Evaluate at least 7 areas, and if there is a peak in just one area, better to equalize it to a average one. 3- Remove the strip as higher as possible, within the safe zone. The laxity is higher and less prone to stretch the scar. 4- If you are not secure, in hard skins, lower laxities or multiple sessions, remove one side and suture it. Then, reevaluate the other side. It is not rare to reduce 1-2 mm of the width after that. 5- Fluid pressure: the fluid you inject to protect the vessels and to erect the hairs can also make it harder to close, specially if injected under the galea. Infiltrate only the necessary amount and very superficially, basically intradermal. 6- Remove the strip using a blunt technique, like the Sandovals technique in combination with a dissecting device like Habers spreader, Roses spreader or the Tykocinskis intruder. For scars or extra hard tissues use the Damkers dissection technique. 7- Always as possible, remove the previous scar. If you can find it. 8- Always as possible, use the trichophytic closure. Despite some papers show the best outcome using the inferior border, I cannot use it in all cases due to increase in tension. In my experience using the Marzolas superior border technique will not increase tension and can be used in all cases. Also is much faster and easier to perform. 9- Nowadays suture on two planes is the standard for strip harvesting. The superficial suture does not support tension or isquemia. Is preferable to leave a 1-2 mm gap than closing under tension, that can end up in necrosis or other complications. 10- I use a third suture: the holding suture (prolane 2-0). The idea of that suture is to aline and stabilize the borders during the first two critical days. I perform it with big interrupted suture each 2-3 cm, before the superficial suture. It increases the patient comfort on the post op and the scar quality.

006 Commentary
Bobby L. Limmer, MD. San Antonio, TX, USA. Dr. Limmer has practiced Follicular Unit Transplantation since 1988. He has been the author of multiple articles and many international presentations on the art and science of hair restoration surgery as related to the follicular unit method. B.L. Limmer: None. TAKE HOME MESSAGE: Follicular Unit Transplantation remains the time proven standard methodology most used in the field today. ABSTRACT: Follicular Unit Transplantation as a methodology has stood the test of time since first performed in 1988. The 3 major components of elliptical donor harvest (strip harvest), stereoscopically controlled graft dissection, and implantation into very small incisional recipient sites remain unchanged since the initial description. Modifications of these steps have included trichophytic closures of the donor site, coronal orientation of incisions for implantation of multihaired grafts, and higher density of implantation in the recipient zone. All these modifications have combined to produce natural results that in most cases complete a satisfactory cosmetic density in a single session to any area of alopecia. Alternative methods of donor harvest remain the major arena of discussion in this proven method of hair restoration. The ultimate decision maker, the test of time, will tell us if such alternate methods of donor harvest constitute significant steps forward in methodology.

007 Moderator Introduction, State of the Art Hair Restoration Surgery: Part II: Hair Restoration via Extraction Harvesting
Robert S. Haber, MD. Dermatology, 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 140 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: None.

008 State of the Art: Hair Restoration via Extraction Harvesting


James A. Harris, MD. Otolaryngology/ Head and Neck Surgery, University of Colorado, Greenwood Village, CO, USA. James A. Harris, MD, FACS, received his medical degree with honors from the University of Colorado, Denver, Colorado. He is a Diplomate of the ABHRS, Fellow of the American College of Surgeons and member of the International Society of Hair Restoration Surgery. He is a Clinical Instructor of Hair Transplantation at the University of Colorado in Denver, Colorado. Dr. Harris has developed a surgical methodology and instrumentation for performing follicular unit extraction (FUE) that ensures graft safety and integrity called the Harris SAFE System and was a principle investigator in the development of the ARTAS System robot for FUE. J.A. Harris: Ownership Interest (royalty, patent, or other intellectual property); patent owner and receive income from HSC Development. TAKE HOME MESSAGE: Follicular unit extraction is a valuable tool for the hair restoration surgeon but there is a body of knowledge regarding the procedure yet to be amassed. ABSTRACT: Summary: The presentation will contain a retrospective of how we came to the current state of the art and a survey of the current practices. The core of the presentation will focus on the tasks that need to be performed in order to bring the body of knowledge regarding graft extraction including patient evaluation, donor area evaluation and limits as well as harvesting limits to a point where our knowledge base about the procedure matches our technical ability to remove grafts.

009 Top 10 Characteristics


Jos F. Lorenzo, MD. Hair restoration, Clinica MEDILOR, Madrid, Spain. Jos Lorenzo MD, received his medical degree from the Universidad Complutense de Madrid in 1991. He completed his specialization in General Surgery and Thoracic Surgery where he worked until he came to the field of hair restoration surgery in 2003. After seeing the first FUE procedures, he proposed to devote all his efforts in the development of the technique. Dr. Lorenzo uses the manual FUE Technique followed by implanter assisted graft insertion. He is a regular lecturer and demonstrator of his skills at workshops and conferences around the word. J.F. Lorenzo: None. TAKE HOME MESSAGE: Despite our current experience, the learning curve in FUE still not finished. ABSTRACT: Dear colleagues, Since Dr. Woods made the first reference in 1995 or Dr. Rasman and Dr. Bernstein published the first article in August 2002, FUE, as a definition of a technique, has enjoyed more than 10 years of evolution. It is a technique that has overcome many difficulties thanks to a better knowledge of the anatomy, the improvement of tools and the spirit of a few surgeons who have consolidated FUE as a truly valid technique for successfully carrying out any hair restoration procedures. In this brief reading, I will try to present the most important points which the surgeon needs to acquire and consider so that he can master the individual extraction of follicular units. We will discuss tools, surgical strategy, statistics, quality control, transection, speed of extraction, time out of body, and even insertion techniques. I hope that this quick list of the most important features common to state-of-the-art FUE, in 2013, from my personal point of view, will create more debates, and in the coming years FUE will continue evolving at the rate at which it currently is.

010 Commentary
John P. Cole, MD. International Hair Transplant Institute, Alpharetta, GA, USA. Private Practice Alpharetta, GA J.P. Cole: None.

TAKE HOME MESSAGE: State of the art FUE should be performed by a properly licensed individual with a focus on donor area management and acceptable results. ABSTRACT: The state of the art in FUE today consists of a mechanical or manual method of harvesting grafts such that there is minimal transection, maximal yield, and an aesthetically acceptable result. The healing should meet specific standards. The management of the donor area should be sound and rational. Transection rates should include completely transected grafts as well as partially transected grafts. The procedure should be performed by an appropriately licensed individual.

011 Moderator Introduction, Research Studies


Mario Marzola, MD. Norwood, Australia. Dr Marzola has been involved hair restoration for 35 years, seeing all the evolving techniques. For three years now he has been studying the latest evolution being cell based therapies. Platelet rich plasma (PRP) and stem cells for many conditions, and now for hair loss. Always interested in CME as a way of keeping up with the best treatments for our patients' benefit. Graduate of Adelaide University, moved from Family Practice to Hair Surgery and General Cosmetic Surgery. Past President ISHRS Diplomate ABHRS Fellow Faculty of Medicine Austrlasian College of Cosmetic of Cosmetic Surgery M. Marzola: None.

012 FUE vs. FUT: Comparison Study in 2 Patients of FU Growth


Michael L. Beehner, MD. Saratoga Hair Transplant Center, Saratoga Springs, NY, USA. Michael Beehner, M.D. has practiced hair transplant surgery fulltime 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 written several textbook chapters. M.L. Beehner: None. TAKE HOME MESSAGE: With FUE hair transplantation becoming more and more popular, it is imperative that we establish that the quality of the results in terms of hair follicle survival is similar to that of traditional microscopically dissected grafts. This study is a first step. It also represents what a typical physician who mixes FUE into his/her practice in 5-10% of cases could expect using good techniques, but not performing this full-time. ABSTRACT: Introduction: The follicular unit extraction procedure for donor harvesting has been around for several years and is starting to become widely used, and yet there has been a paucity of any studies comparing the growth of these grafts to those traditionally harvested with strips and microscopic dissection. This study is a first step in trying to build a body of research into this important clinical area. The results of the hair counts will be tabulated just prior to the October 2013 meeting and are not included in this abstract. Furthermore, because this study was performed on only two patients, the results must still be considered "anecdotal." However, the author feels strongly that these studies must be done, and that a large number of them will eventually have enough weight in numbers to give us a final evaluation as to this important result, namely, whether the end result of transplanting FUE grafts is similar to that of placing FUT grafts dissected from a strip of donor hair. Objective: The aim of this study is to determine if follicular unit extraction (FUE) does indeed produce the same growth and survival rates as with strip removal and graft dissection under the microscope. Materials / Methods: This study was conducted in the exact same manner on two patients. The study boxes were located in the frontal region of the scalp just behind the frontal hairline zone. 3-hair FU's: 35 FUE grafts and 35 FUT grafts were placed in 1.1mm lateral slit incisions, oriented sagitally, made with a custom-cut slit blade with 45 degree angulation. at the tip. The grafts were placed within two study boxes, each measuring 1.2cm x 1.2cm. 2-hair FU's: 40 FUE grafts and 40 FUT grafts were placed in 1.0mm lateral slit incisions, oriented sagitally, made with same type blade as above, with each study box measuring 1.2cm x 1.2cm.1-hair FU's: 35 FUE grafts and 35 FUT grafts were placed in 1cm x 1cm boxes. Incisions made with 0.9mm slits made with similar blades as described above. Each study box had a 1.2mm wide "moat" of bald skin around it and a light brown tatoo dot was placed in each of the four corners of all study boxes for easier later identification.Tumescent solution used in recipient area was normal saline with a 1:180,000 epinephrine concentration. FUE grafts were harvested using both the 0.9mm and the 1.0mm diameter dull punches of the SAFE-II system.Time "out-of-body" for grafts: For patient#1, FUE study grafts were placed 4-5 hrs after harvesting, and FUT study grafts were placed 5.5-7 hours after harvesting.For patient#2, FUE study grafts were placed 5 hours after harvesting, and FUT grafts were placed 7-8 hours after harvesting. Hair Counts: First count was conducted at 6 months for patient #1, and a second count, which will be reported in this talk will be done at 13

months. Patient #2 was operated on 4 months later and will have a 9 month count done prior to the reporting of this paper. Photos of all grafts placed in the study are recorded in photos and sample video will be shown of our FUE harvesting technique and the placing of the grafts. The grafts were stored in chilled plasmalyte solution from the time they were either harvested by FUE or dissected under the microscopes, and kept at 4 degree centigrade on top of a Cole Cooler. The same technician, our most experienced placer with 18 years experience, placed all of the study grafts for both patients. Counting method: The hairs growing in each study box were counted using the technique that I published in great detail in the Unger-Shapiro text, Hair Transplantation, 5th edition, 2011, on pages 338-340. The author conducted the count. Discussion/Results: The results will not be available until shortly before the October meeting and will be presented then. My chief concern in simply assuming that FUE FU grafts are the equal of microscopically dissected FU's, is that these two groups of grafts appear distinctly different. The FUT grafts have a thin, protective layer of fat and connective tissue around them, including around the bulb and dermal papilla, whereas the FUE grafts have a large percentage of them in which this protective tissue is absent and the bulbs are "naked", making placement more traumatic and difficult, and exposing the graft more easily to dessication injury. I also would like to make point that I am sure that the handful of doctors in the world that perform FUE every day as their only way of harvesting grafts most likely perform the task better than I and my team do. After all of these years, there are virtually no studies by these fulltime FUE physicians regarding graft survival. I am a good example of the average practitioner who wants to have FUE in his armamentarium of methods to accomplish hair replacement surgery, and in fact I have performed approximately 120 cases of FUE in the past 5 years. I feel I am quite adept at FUE harvest and have a high percentage of "positive plucks" in which I get an acceptable graft over 90% of the time. Therefore I think it is important to see whether the average doctor, who performs FUE surgery a few times a month, obtains satisfactory growth with this technique. If not, then the logical assumption would be that only doctors who commit to exclusively using this technique should be performing it. Conclusion: I cannot comment on this until the final results are available. The reasons for the importance of this study are discussed above.

013 Utilizing the HairCheck Device to Assess the Preservation of Hair Mass after Hair Restoration Utilizing Strip, Dull Punch FUE and Robotic FUE Graft Harvest Techniques
James A. Harris, MD. The Hair Sciences Center of Colorado, Greenwood Village, CO, USA. James A. Harris, MD, FACS, received his medical degree with honors from the University of Colorado, Denver, Colorado. He is a Diplomate of the ABHRS, Fellow of the American College of Surgeons and member of the International Society of Hair Restoration Surgery. He is a Clinical Instructor of Hair Transplantation at the University of Colorado in Denver, Colorado. Dr. Harris has developed a surgical methodology and instrumentation for performing follicular unit extraction (FUE) that ensures graft safety and integrity called the Harris SAFE System and was a principle investigator in the development of the ARTAS System robot for FUE. J.A. Harris: Employment; HSC Development. Research Grant (principal investigator, collaborator or consultant); Restoration Robotics. Ownership Interest (owner, stock, stock options); HSC Development, Restoratoin Robotics. TAKE HOME MESSAGE: The data presented will allow the participant to evaluate the potential of the hair mass measurement to be used as a metric for hair survival after transplant. There will also be preliminary data to begin evaluating harvest methods for the ability to preserve hair mass. ABSTRACT: Introduction: The traditional method for assessing the survival rates of a transplant methodology is to perform hair counts. In

addition to being tedious, this method does not account for the possibility that the transplanted hair, in addition to any preexisting hair in the transplanted area, may suffer a diminution of hair shaft diameter causing a result that is less than what would have been expected given the survival rate based on hair counts. Another factor which could impact the final result is permanent damage and loss of pre-existing hair in the recipient area. With the advent of the HairCheck device we have a tool that will allow the investigator to assess the hair mass in the recipient area, the hair mass of the grafts being implanted and the final hair mass of the grafts and pre-existing hair to derive an overall hair mass survival rate. Objective: This study is designed to develop the feasibility of this hair mass measurement technique is assessing transplant and native hair survival and to provide preliminary data in the comparison of strip, blunt punch powered FUE and robotic FUE harvest techniques. Materials and Methods: Two patients were recruited to undergo each of three harvest techniques: strip, blunt punch powered FUE and robotic FUE. In each patient three recipient regions in the crown measuring two by two centimeters were tattooed for subsequent evaluation. The HairCheck device was used to measure the hair mass of any pre-existing hair in the tattooed regions and the values were recorded. The following graft harvest protocol was utilized in both study patients: Utilizing the strip harvest method and leaving the donor hair long, a portion of the strip was that contained approximately 40-60 grafts was separated and the hair mass measured and recorded. The individual follicular units were then separated from the strip using the standard microscopic dissection technique. Next, individual follicular units were identified, the associated hair was cut and a powered blunt punch FUE device was then utilized to harvest the graft. If there was a graft produced, as opposed to a cap or complete graft transection, the hair was placed on a piece of single sided tape. This was repeated approximately 60 to 80 times and then when complete the hair mass of the collected hair was measured and recorded. Finally, a similar procedure was accomplished with a robotic FUE device. The graft counts were then recorded and the appropriate number of parallel recipient sites using a 1 mm chisel profile blade were made in each of the tattooed boxes and the grafts were subsequently placed using jewelers forceps. Theoretically the hair mass after the grafts have grown should be the sum of the pre-existing hair plus the mass of the transplanted hair. The plan is to check the hair mass in each of the tattooed boxes in order to assess the preservation of hair mass of the grafts and the pre-existing hair with each of the harvest techniques. The measurements will be taken at 8 and 12 months post op. Discussion and Results: Pending. Conclusions: The study will help in establishing the validity of using the hair mass measurement of the HairCheck device for assessing graft survival. This study will also provide some preliminary data regarding the preservation of hair mass after utilizing three methods of graft harvesting.

The Use of Cross Sectional Trichometry (CST) to Assess the Preservation of Graft Hair Mass After Strip, FUE, and ARTAS Graft Harvest: Investigation of the Concept
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

Background:
Hair counts for survival analysis are

James A. Harris, MD, FACS

inaccurate Hair counts dont account for loss of hair shaft diameter. Is there another option for measuring survival?

Background (cont.):
Strip and FUE grafts have different amounts

Study Objectives
Assess the feasibility of using CST to

of peri-follicular fat and differing levels of manipulation during graft production. Does these differences impact hair mass survival? Can it be measured?

gauge the preservation hair mass after transplant Compare the preservation of hair mass after strip, FUE and ARTAS System graft harvest

Methodology
Two male patients: strip, dull punch FUE and

Methodology (cont.)
Graft CST obtained (average of 3 measurements)

robotic FUE graft harvest performed Three 4 cm2 test areas on the crown/vertex scalp, mostly devoid of hair, tattooed for identification CST of existing hair was measured with the HairCheck device Three measurements taken, the average used as the CST value

Strip - hair bundled and measured while in the strip FUE - hair of target unit trimmed, placed on tape and when the proper number of grafts harvested the CST was obtained Recipient sites were made with a 1mm chisel profile blade in a parallel orientation Strip and FUE approximately 60 sites
- Robotic FUE approximately 40 sites

Manual forceps implantation

Methodology (cont.)
CST measurement of test area taken at 8 months Computation of CST preservation for each study area:
Pre TX CST CST Grafts Final CST % CST Preservation

Patient 1
Strip FUE ARTAS

(Final CST) (CST of grafted hair) + (CST of pre-existing hair)

Patient 2
Strip
Pre TX CST CST Grafts Final CST % CST Preservation

FUE

ARTAS

Combined CST Preservation


Strip % CST Preserved FUE ARTAS

Conclusions:
TBD

Thank you

014 Graft Counts of FUE and Traditional "Strip" Surgeries: A Surgical Technique Comparison
Sara M. Wasserbauer, MD. Sara Wasserbauer MD, Walnut Creek, CA, USA. Dr. Sara Wasserbauer, is a Diplomate of the American Board of Hair Restoration Surgery, based in the California Bay Area. 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. She has been the principal investigator for Restoration Robotics for the ARTAS, featured on The Doctors TV show, and writes an occassional column for the Forum. She likes tough cases, niche procedures, good data, and a scotch now and then... S.M. Wasserbauer: None. TAKE HOME MESSAGE: Different populations of grafts can be obtained when utilizing either the FUE or the Strip methods. A single investigator found that FUE obtains more three-haired FUs while the Strip technique graft totals include more doubles. Graft and total hair counts are similar for both techniques. There is also a wider variation among different cases using the strip technique. From this one may conclude that since strip grafts are obtained more "organically" by taking a representative sample from what is actually occurring in the scalp of the individual patient, FUE graft totals are likely skewed by physician preference during the harvest. This has implications for both growth and patient outcomes. ABSTRACT: Much speculation has swirled regarding the relative merits of the FUE technique versus the traditional "strip" technique. In particular, the FUE technique allows the surgeon to "cherry pick" which grafts he will pluck, whereas the traditional technique takes more of a representative sample. In order to assess the material differences in the graft populations harvested during each of these types of surgery, we performed a direct comparison of fifteen (15) FUE and fifteen (15) "strip" surgeries to evaluate graft counts. We found significant differences between the two techniques as well as some surprising similarities (at least in the hands of this investigator). Of note, there was a significant increase in the number of three-haired follicular units obtained using the FUE technique, a significant increase in the number of two-haired follicular units using the "strip" technique, and no significant difference in the number of single-haired follicular units between the two techniques in terms of percentages of the whole surgical yield. Strip surgery held a slight advantage over FUE in absolute numbers of grafts and absolute numbers of hairs obtained, and there was a wider range between and among individual cases for how many 1s, 2s, and 3-haired FUs a patient had. Still, even between the two techniques, double-haired FUs were by far the most common and the spread demonstrated a bell-shaped curve. This study was limited by lack of inter-investigator comparison, and by the use of a single device (SAFE scribe powered FUE device). Statistically speaking, more cases would provide a more powerful result and more compelling arguments. However, even if this only represents one surgeons experience, it is reasonable to assume that other surgeons would find significant variation in their graft harvests if they perform both techniques. Purely from a self-knowledge standpoint, this analysis, while limited, would be a useful exercise so that an individual practitioner might be better able to predict outcomes and to tailor which technique might be better suited to an individual patients needs. FUE surgeries, raw data

Date: 12/13/11 12/15/11 12/22/11 1/10/12 2/27/12 3/16/12 3/23/12 4/20/12 5/1/12 5/16/12 6/29/1 7/24/12 7/30/12 8/1/12 8/2/12

Singles: Doubles: Triples: Final Graft #: Total Hairs: 429 228 411 351 556 298 637 495 325 455 512 525 257 415 497 771 1052 1094 1051 999 1243 996 1142 787 1051 983 1106 873 942 970 288 749 703 439 257 869 339 251 382 336 509 336 447 314 473 1488 2029 2208 1841 1812 2410 1972 1888 1494 1842 2004 1967 1577 1671 1939 2835 4579 4338 3770 3325 5391 3646 3532 3045 3565 4005 3745 3344 3241 3856 Total Hairs 3748 5391 2835

Singles Doubles Triples Total Grafts AVERAGE 426 HIGH LOW 637 228 1004 1243 771 446 869 251 1876 2410 1488

%Total FUs Singles Doubles Triples 12/13/11 12/15/11 12/22/11 1/10/12 29% 11% 19% 19% 52% 52% 50% 57% 19% 37% 32% 24%

2/27/12 3/16/12 3/23/12 4/20/12 5/1/12 5/16/12 6/29/12 7/24/12 7/30/12 8/1/12 8/2/12

31% 12% 32% 26% 22% 25% 26% 27% 16% 25% 26%

55% 52% 51% 60% 53% 57% 49% 56% 55% 56% 50%

14% 36% 17% 13% 26% 18% 25% 17% 28% 19% 24%

Singles Doubles Triples Average High Low Range 23% 32% 11% 21% 54% 60% 49% 11% 23% 37% 13% 24%

Strip surgeries, raw data Date: 6/14/12 6/15/12 6/19/12 6/26/12 6/27/12 7/2/12 7/3/12 Singles: Doubles: Triples: Final Graft #: Total Hairs: 114 506 489 746 572 535 167 1145 1262 1699 1285 998 2002 1404 39 63 68 254 15 263 105 1298 1831 2256 2285 1585 2800 1676 2521 3219 4091 4078 2613 5328 3290

7/10/12 7/11/12 7/12/12 7/18/12 7/23/12 7/25/12 7/27/12 8/1/12

171 622 339 353 248 420 300 394

869 2131 1576 1704 701 1835 1415 944

100 465 203 259 85 196 482 430

1140 3218 2118 2285 1034 2424 2197 1768

2209 6279 4100 4538 1905 4678 4576 3572 Total Hairs 3800 6279 2209

Singles Doubles Triples Total Grafts AVERAGE 398 HIGH LOW 746 114 1398 2002 701 202 482 15 1994 2800 1034

%Total FUs Singles Doubles Triples 6/14/12 6/15/12 6/19/12 6/26/12 6/27/12 7/2/12 7/3/12 7/10/12 7/11/12 7/12/12 7/18/12 7/23/12 9% 28% 22% 33% 36% 19% 10% 15% 19% 16% 15% 24% 88% 69% 75% 56% 63% 72% 84% 76% 66% 74% 75% 68% 3% 3% 3% 11% 1% 9% 6% 9% 14% 10% 11% 8%

7/25/12 7/27/12 8/1/12

17% 14% 22%

76% 64% 53%

8% 22% 24%

Singles Doubles Triples Average High Low Range 20% 36% 9% 27% 71% 88% 53% 35% 10% 24% 1% 23%

Singles Doubles Triples Total Grafts Total Hairs AVG FUE 426 AVG Strip 398 1004 1398 446 202 1876 1994 3748 3800

Disclosures
Graft Counts of FUE and "Strip" Surgeries: A Surgical Technique Comparison
Lets analyze the grafts none

Methods
Much speculation has swirled regarding the relative merits of the FUE technique versus the traditional "strip" technique. In particular, the FUE technique allows the surgeon to "cherry pick" which grafts (s)he will pluck, whereas the traditional technique takes more of a representative sample.

Methods
In order to assess the material differences in the graft populations harvested during each of these types of surgery, we performed a direct comparison of fifteen (15) FUE and fifteen (15) "strip" surgeries to evaluate graft counts. We found significant differences between the two techniques as well as some surprising similarities.

Limitations
All surgeries were conducted by a single investigator (me). I am not perfect, nor am I a statistician.

Results
Significant increase in the number of 3haired follicular units obtained using the FUE technique. Significant increase in the number of 2haired follicular units using the "strip" technique No significant difference in the number of single-haired follicular units between the two techniques in terms of percentages of the whole surgical yield.

Results
Date: Singles:

Raw Data:FUE
Doubles: Triples: 429 228 411 351 556 298 637 495 325 455 512 525 257 415 497 771 1052 1094 1051 999 1243 996 1142 787 1051 983 1106 873 942 970 288 749 703 439 257 869 339 251 382 336 509 336 447 314 473

Final Graft #: 1488 2029 2208 1841 1812 2410 1972 1888 1494 1842 2004 1967 1577 1671 1939

Total Hairs: 2835 4579 4338 3770 3325 5391 3646 3532 3045 3565 4005 3745 3344 3241 3856

Strip surgery held a slight advantage over FUE in absolute numbers of grafts and absolute numbers of hairs obtained. There was a wider range between and among individual cases for how many 1s, 2s, and 3-haired FUs a patient had. Still, even between the two techniques, double-haired FUs were by far the most common and the spread demonstrated a bellshaped curve.

12/13/11 12/15/11 12/22/11 1/10/12 2/27/12 3/16/12 3/23/12 4/20/12 5/1/12 5/16/12 6/29/12 7/24/12 7/30/12 8/1/12 8/2/12

Singles AVERAGE HIGH LOW 426 637 228

Doubles 1004 1243 771

Triples 446 869 251

Total Grafts 1876 2410 1488

Total Hairs 3748 5391 2835

Raw Data: Strip


Date: 6/14/12 6/15/12 6/19/12 6/26/12 6/27/12 7/2/12 7/3/12 7/10/12 7/11/12 7/12/12 7/18/12 7/23/12 7/25/12 7/27/12 Singles: 114 506 489 746 572 535 167 171 622 339 353 248 420 300 394 Singles AVERAGE HIGH LOW 398 746 114 Doubles 1398 2002 701 Doubles: 1145 1262 1699 1285 998 2002 1404 869 2131 1576 1704 701 1835 1415 944 Triples 202 482 15 Triples: 39 63 68 254 15 263 105 100 465 203 259 85 196 482 430 Total Grafts 1994 Final Graft #: Total Hairs:

Results: FUE % total FUs


%Total FUs 12/13/11 2521 3219 4091 4078 2613 5328 3290 2209 6279 4100 4538 1905 4678 4576 3572 Total Hairs 3800 6279 2209 12/15/11 12/22/11 1/10/12 2/27/12 3/16/12 3/23/12 Singles 29% 11% 19% 19% 31% 12% 32% 26% 22% 25% 26% 27% 16% 25% 26% Singles Average High Low Range AVG 23% 32% 11% 21% Doubles 54% 60% 49% 11% Doubles 52% 52% 50% 57% 55% 52% 51% 60% 53% 57% 49% 56% 55% 56% 50% Triples 23% 37% 13% 24% Triples 19% 37% 32% 24% 14% 36% 17% 13% 26% 18% 25% 17% 28% 19% 24%

1298 1831 2256 2285 1585 2800 1676 1140 3218 2118 2285 1034 2424 2197 1768

FUE

4/20/12 5/1/12 5/16/12 6/29/12 7/24/12 7/30/12 8/1/12 8/2/12

8/1/12

2800
1034

Results: Strip % total FUs


%Total FUs 6/14/12 6/15/12 6/19/12 6/26/12 6/27/12 7/2/12 7/3/12 Singles 9% 28% 22% 33% 36% 19% 10% 15% 19% 16% 15% 24% 17% 14% 22% Singles Average High Low Range AVG 20% 36% 9% 27% Doubles 71% 88% 53% 35% Doubles 88% 69% 75% 56% 63% 72% 84% 76% 66% 74% 75% 68% 76% 64% 53% Triples 10% 24% 1% 23% Triples 3% 3% 3% 11% 1% 9% 6% 9% 14% 10% 11% 8% 8% 22% 24% 20% 10% 0% 50% 40% 30% 70% 60%

FUE

Results
100% 90% 80% 70% 60% 50% Average High Low 30% 20% 10% 0% 40%

Traditional strip

Traditional Strip

7/10/12 7/11/12 7/12/12 7/18/12 7/23/12 7/25/12 7/27/12

Average High Low

8/1/12

Singles

Doubles

Triples

Singles

Doubles

Triples

Results
FUE
7000 6000 5000 4000 6000 5000 4000 AVERAGE HIGH LOW 2000 1000

Summary Results
Singles Doubles Triples AVG FUE AVG Strip 426 398 1004 1398 446 202

Traditional strip

Total Total Grafts Hairs 1876 3748 1994 3800

3000

AVERAGE HIGH

3000

2000 1000

LOW

0 Singles Doubles Triples Total Grafts Total Hairs

0 Singles Doubles Triples Total Grafts Total Hairs

Average FUE and Strip surgeries had about the same total hairs obtained (Strip was very slightly more) FUE surgeries had significantly more 3haired FU grafts than in a Strip surgery Strip surgeries held the advantage in sheer numbers of grafts and in numbers of 2haired Fus obtained

Summary Results
4000 3500 3000 2500 2000 1500 1000 500 0 Singles Doubles Triples Total Grafts Total Hairs AVG FUE AVG Strip

Final Analysis and Limitations


This study was limited by
lack of inter-investigator comparison, and by the use of a single device (SAFE scribe powered FUE device) My technique and my judgment may be flawed since I seem to pick more multi-haired FUS per case than naturally occur in a Strip case!*

Graphically representing these results it becomes clear that the average Strip case will have more 2-haired FUs and the Average FUE case will have more 3-haired Fus while the Average Strip case edges out FUE in both numbers of hairs (nearly the same) and total grafts by small margins

Final Analysis and Limitations


Statistically speaking, more cases would provide a more powerful result and more compelling arguments. However, even if this only represents one surgeons experience, it is reasonable to assume that other surgeons would find significant variation in their graft harvests if they perform both techniques. Purely from a self-knowledge standpoint, this analysis, while limited, would be a useful exercise so that an individual practitioner might be better able to predict outcomes and to tailor which technique might be better suited to an individual patients needs.

015 CST Evaluation of Donor and Recipient Areas Before and After FUT and FUE
John P. Cole, MD. International Hair Transplant Institute, Alpharetta, GA, USA. Private practice physician. J.P. Cole: None. TAKE HOME MESSAGE: Strips are best suited for procedures involving minimal hair loss, while FUE is best suited for cases where hair loss is substantial. ABSTRACT: In 1998 the author introduced the term hair mass and defined it as the volume of hair transferred to the balding area. The volume or mass of hair transferred could be calculated from the mean hair volume with the hair 10 cm in length multiplied by the total number of hairs transferred in. In a series of examples, the author showed that hair diameter was more important in predicting coverage than graft size, total number of grafts, or donor hair density. Hair mass was introduced as a means to predict coverage based on mean hair diameter, the surface area of loss, and the total number of hairs transferred. Unfortunately, this prediction required measurement of the mean hair diameter and a calculation of the total number of hairs transferred. This places a tremendous burden on the staff and physician to make multiple evaluations and summations of data. Furthermore, Caucasian hair is typically elliptical in shape. As such, hair diameter along one minor axis is always less than the diameter along the major axis. This disparity may require a large number of individual evaluations to arrive at an acceptable average. Jim Arnold asked the author if there was a way to more easily calculated the mean hair diameter than to look at individual hairs. The author stated that one could bundle hair like spaghetti noodles or pencils and measure either the diameter or the circumference of the entire bundle, but without knowing the exact number of hairs, one could not estimate the mean hair diameter. Subsequent to this presentation Arnold arbitrarily chose a 4 cm2 area to bundle hair and determine the circumference. He introduced the term Hair Mass Index (HMI).2 Arnold described a method to determine the HMI. Arnold bundled 4 cm2 of hair, spun it into a single mass, and then measured the circumference of that mass of hair using a string. He calculated the radius using the formula Circumference = . He then divided this by 4 to obtain the radius of on square centimeter. If one then uses the formula surface area of a circle ( ), one has the surface area of 1 cm2 of a bundle of hair. One may not estimate the mean diameter of the hair unless one knows how many hairs are in the bundle, which one can only inaccurately estimate. The first measurement of HMI relied on string to measure the circumference and to calculate the surface area. Neidel further described the hair mass index in writing and defined the first HMI values:3 0.18 to 0.32 mm2 cosmetic effect of fine hair 0.32 to 0.5 mm2 cosmetic effect of normal hair 0.5-0.72 mm2 cosmetic effect of thick hair One problem with the HMI was that there was no standard tension on the string so the calculations were subject to variability. All one needs to do is multiply the hair length by this HMI to calculate the estimated hair volume of one cm2 of hair. The concept allows us to more objectively predict coverage and suitability for hair restoration surgery. In 2008 Cohen introduced the cross section trichometer, which measures (mm2 hair per cm2 scalp) X 100. The device relies on a 1 X 4 mm plastic hook, a optimal and standard compression load, and an accurate digital interpretation of the compressed surface area of the bundle of hair divided by 4. The stated ranges for 4 cm2 of hair were 3.0 (fine hair 60 micrometers) to 4.0 (coarse hair 80 micrometers). Of course these estimates are based on the highly inaccurate assumption of Cohen that 4 cm2 contains 800 hairs. The device divides the 4 cm2 to obtain the trichometer index and displays this in a digital readout. Dividing the range of 3.0 to 4.0 by 4 and multiplying by 100 translates to a normal range of 75 mm2/cm2 to 100 mm2/cm2. Cohen suggested the device might be useful to evaluate

response to treatment (surgical and medical), progression of hair loss, quantify the donor hair available for transplantation, detection of early balding, and quantify mass in a particular area of thinning or shedding. In 2011 Bauman presented similar data to confirm that the occipital average was 75 to 100 mm2/cm2 in 250 patient evaluations.4 Including this data he presented no additional information regarding his experience using the trichometric index than Cohen presented in his 2008 paper. The first thing one notes is that the cross section surface area seems to depend on the method of evaluation. For example cross section surface area ranges as defined by Neidel are significantly different than the cross sectional surface area defined by Cohen and Bauman using hair check What is lacking with the cross section trichometer is real life experience to document its applicability, precision, reliability, and potential to predict clinical outcomes from hair restoration surgery. In an effort to determine this information, the author performed Hair Check in multiple locations along with mean hair diameter, follicular density, quantification of total follicular density available, and bald surface area measurements. In doing this, the author was able to show that it is possible to predict coverage based on a single pre-operative assessment. The author wanted to insure that two units produce similar results. Two units did produce similar results. Does the Cross Sectional Trichometric Index (CSTI) with Hair Check provide clues to potential response and coverage from hair transplantation? The CSTI indeed does provide excellent prognostication to the potential coverage in a defined area of hair loss. At what percentage of hair loss in comparison to the donor area does hair loss become evident. It becomes evident around 50% in the crown, but far more hair loss is required to give the illusion of hair loss in the front and top region of the scalp. Methods: The Cross Sectional Trichometric Index (CSTI) was done in four locations in over 100 patients using the Hair Check device. The CSTI was done in the frontal zone, top of the scalp, crown, and donor area. Hair density and follicular density were measured at the mid-point along a line between the mid-occiput at the inion and a point 3 cm above the tragus with the head in the Franklin plane. A photograph was taken of the donor area. We measured 20 hairs to determine the mean hair shaft diameter using a Mitutyo Digital micrometer at 40X magnification. CSTI was done with a separate unit in the donor area to determine if both devices had similar readings. The surface area of hair loss was measured using digital photography and Hairmes software. We defined the recipient area into three zones. The frontal zone was measured between 4-11 cm above the glabella, the top was measured between12-16 cm above the glabella, and the crown was measured 17-27cm above the glabella. The donor area was measured 31-35 cm from the glabella. All measurements were done using the glasses and cm scale provided with Cohens Hair Check Kit. We measured the CSTI at all four points on the scalp. We compared global photography of the recipient area to the CSTI. We determined if hair loss was apparent. We then compared the optical effect of coverage to the CSTI. We compared the CSTI in the donor area to the CSTI in the recipient area. We calculated the percentage of loss by subtracting the measurement in the recipient area from the CSTI in the donor area and multiplying by 100. We measured the density in the donor area using photography to estimate the number hairs and the number of follicular units in the donor area. Placing saran wrap on the scalp and then tracing the surface area of hair loss with in indelible Sharpie marker allowed us to approximate the surface area of hair loss. After tracing the area of loss on the saran wrap, we photographed the surface area at a 90 degree angle on a flat surface with a metric ruler next to the tracing. The metric ruler then allowed us to calibrate the Hairmes software and estimate the surface area of loss of the irregular shaped area. We noted the range of loss for the front, top, and crown in a series of patients. We then compared the surface area of loss to the other objective findings to analyze our capacity to create the illusion of coverage.

Results: Evaluation of CSTI showed that the range was much greater in the donor area than previously reported by either Cohen or Bauman. Comparison of two different hair check units revealed that the CSTI results of both units were similar. Dividing the 4 square cm into 1 sq cm boxes whose values were combined resulted in close, but different values than a 4 sq cm box. Comparison of donor area density and hair shaft diameters to the CSTI showed that the CSTI value gave clues to the hair density and hair diameter. However it is a CSTI value does not identify whether it is the hair density or the hair diameter that leads to a high or low CSTI value. In other words a high diameter and a high density might lead to a high CSTI, but an average density and a high diameter might also produce a high CSTI. We are still evaluating how the CSTI, hair density, and hair diameter may influence the physicians capacity to predict coverage in a given surface area that is defined by Hairmes. We are also still evaluating the CSTI to determine if one might determine the mean hair shaft diameter by estimating the hair count. Evaluation of the CSTI value of the recipient area in three different zones on the scalp showed that a loss greater than 50% from the donor area CSTI value can still result in good coverage in both the frontal area and the top area of the scalp. A smaller loss in the crown area as defined by comparison of the CSTI values in both the crown and donor area will give evidence of hair loss. In other words hair loss in the crown area appears to become evident with a much smaller degree of CSTI decline as compared to the donor area CSTI. Replacing only The surface area of hair loss for the frontal area depends on where the hair line is located and how broad the hairline is drawn. The variation in the study are reported for the front, top, and crown. The mean donor area CSTI for my patients was 68.9, which is considerable lower than the data reported by both Bauman an Cohen. We compared the CSTI to the hair density, follicular density, and hair diameter to evaluate correlations between these values and the surface area of hair loss as noted by Hairmes. The following chart compares the mean cross sectional trichometry for three categories of patients including those who had no prior surgery, those who had one or more strip procedures, and those who had one or more FUE procedures. The total number of cases evaluated to date is 253. Status CST1 CST2 Mean Diameter Follicular Density Hair Density N 76.48 67.05 69.82 190.75 165.72 175.98 95 111 47

No Surgery 72.94 72.94 72.44 Prior Strip 52.35 52.05 69.48 FUE 65.9 69.67 71.31

016 Moderator Introduction, Beyond FUE and FUE


Robert H. True, MD, MPH. True & Dorin Medical Group, P.C., New York, NY, USA. MDCM McGill University Faculty of Medicine Post Grad 1-3 Mayo Clinic and U of Illinois Diplomate American Board of Hair Restoration Surgery

Past President ABHRS Chair 2013 ISHRS Annual Scientific Meeting. Author of over 40 hair restoration papers and publications Practitioner of FUE for 11 years New York, New York drtrue@hairlossdoctors.com R.H. True: None.

017 Too Good to be True? A Scarless Hair Follicle Harvesting Method Enhancing Transplanted Graft Viability
Carlos K. Wesley, MD. Private Practice, New York, NY, USA. Carlos K. Wesley, M.D. graduated cum laude from Princeton University with a thesis focused on hematopoetic stem cells. He received his medical degree from Yale Medical School with a thesis investigation of endothelial progenitor cells. His residency training in emergency medicine at Yale was followed by fellowship training with Drs. Unger. He was then honored to be the first ISHRS fellow invited to join their world-renowned practice. In addition to his surgical practice, Dr. Wesley is the founder and CEO of PiloFocus, Inc. a surgical device company developing a unique stem cell-focused surgical technique that renders donor scarring imperceptible. C.K. Wesley: Ownership Interest (owner, stock, stock options); CEO of Pilofocus. Ownership Interest (royalty, patent, or other intellectual property); Intellectual Property. TAKE HOME MESSAGE: A novel approach to harvesting donor hair follicles has demonstrated the ability to 1) select the follicular units (FU) without any trauma to the overlying skin surface and 2) yield FU with enhanced viability when compared to those harvested via traditional follicular unit extraction (FUE). This technique, therefore, may allow for sucessful hair transplant mega sessions with only a fine, 1cm-long donor scar. ABSTRACT: Introduction: Long-standing have been the two primary objectives of surgical hair restoration: 1) to transplant hair follicle grafts that demonstrate healthy growth and 2) to eliminate the stigma of donor area scarring. Patient demands for the latter have encouraged physicians who perform follicular unit extraction (FUE) to minimize punch sizes when harvesting hair follicles from the donor area. Although this trend may ultimately diminish noticeable punctate scarring pattern throughout the donor area, it may also compromise the yield of transplanted hair. A singlestep powered FUE dissection using a 1-mm punch may result in a transection rate ranging from 2% to 8.5%, while a 0.75-mm punch may lead to a more detrimental 3% to 10% transection rate.1 In addition to the increased transection rates, the survival of transplanted hair follicles is directly influenced by the amount of protective subcutaneous tissue around the stem cell-containing portion (the bulge and the bulb) of the follicular unit (FU). Beehner demonstrated that leaving a generous amount of protective tissue around chubby FU

resulted in a higher hair yield and a greater number of hairs at six months than closely trimmed skinny FU (103% versus 133%).2 Seager attributed the 113% survival rate of the chubby group at six months (compared with only 89% survival of skinny FU) to the dormant follicles not visible in the first counting.3 These limitations of the denuded grafts produced by traditional FUE are further magnified by Greco et als crush study demonstrating that the smaller the FU, the more significant the damage caused by traumatic handling (reflected by decreased posttransplantation survival).4 How then can we obtain chubby FU without producing either a linear scar (as seen with the traditional strip harvest) or the cosmetically unacceptable punctate scars that are generated if using motorized FUE punches with a large inner diameter? Jimenez et al may have provided the key insight in their 2011 publication in which hair follicle bulge stem cell marker, antibody anticytokeratin (CK), was found to extend downward from approximately 1mm beneath the skin surface.5 In other words, the stem cell-rich portions of the FU exist throughout the entire follicle, save the superficial-most 1 mm. Therefore, if intact chubby hair follicles can be effectively harvested from a beneath-the-skin-surface approach to also include the surrounding protective tissue and released (i.e. clipped) from their native environment within 1-mm from the overlying skin surface, they may 1) remain fully viable after subsequent transplantation 2) without any external evidence of trauma to the overlying skin surface (i.e. scarless). Further inching us towards our aforementioned primary objectives would be if this scarless method could resolve the detrimental out of body influence on graft survival first illustrated by Limmer and necessitated by large hair transplantation sessions using conventional harvest methods that require trimming of the unwanted epidermis from each FU in order to prepare them for subsequent transplantation.6,7 Technique: This surgical video demonstrates piloscopy, a novel method of hair follicle harvesting, that: 1) extracts intact hair follicles with no evidence of scarring in the donor area while, 2) producing chubby FU with an enhanced viability after transplantation when compared to those produced using traditional FUE. Creating a working cavity within the subgaleal plane of the scalp using an initial blunt dissection allows for the entry of an endoscopic hair follicle harvesting tool (piloscope) via a 1cm incision anywhere along the safe donor area of the scalp.8 The piloscope targets the overlying follicular units of interest when coupled with external visualization provided by high frequency ultrasound (50 MHz). Once aligned, the piloscope cores around the desired follicle, clips within 1mm of the skin surface, and immediately transports (via a saline flush) the ready-to-be-placed chubby FU outside of the scalp. The most current piloscope iteration allows for each harvest to occur rapidly and efficiently with the single push of a trigger. Discussion: Initiated in 2008, piloscopy reflects the principles of inclusion and protection of only the stem-cell-rich portions of the transplanted FU. A double-blind, 16-month, six-patient* clinical trial demonstrated that hair follicles that were harvested from a beneath-the-skin-surface approach produced no external evidence of trauma at the harvest site and generated survival rates generally equal to or greater than grafts harvested via traditional FUE method (using a 1.0 mm inner diameter punch). Donor harvest photography and transplanted graft survival data presented herein represent those from our proof of concept clinical trial. The surgical video will also display the actual piloscopic surgical technique being performed on fresh-frozen cadaveric scalp using the most recent iteration of the piloscopic device that has been generated since receipt of the requisite capital to develop a fully-functional piloscope for commercial use (though, not the same basic instrument used in the proof of concept clinical trial). Donor Harvest: Comparative photographs were taken during the donor harvest to carefully document the presence and absence of hair follicles before and after they were harvested using a beneath-the-skin-surface approach and separated from their native environment approximately 1mm from the overlying skin surface (Fig 1). In each instance, the beneath-the-skin-surface harvesting approach of these 10 - 25 follicles (indicated by yellow arrows) resulted in full maintenance of the integrity of the overlying skin surface and is sharply juxtaposed with the 10 - 25 follicles excised by traditional 1.0mm FUE punch. Transplanted Graft Survival: Each patient was tattooed using IntenzeTM tattoo ink (dark tone) applied via a 20G needle at two separate points in his scalp. The areas surrounding the tattoos possessed approximately equal pre-

existing hair densities. Extending from each tattoo, a 0.5cm radius of surrounding pre-existing hair was clipped and an equal number of recipient sites (between 10 and 25) were made around each tattoo with a 20G needle inserted to the depth of the needles bevel. Using a Folliscope, the investigator carefully documented the placement of each recipient site as well as the location of the pre-existing hair. Unknown to either the patient or the investigator, the surgical staff placed an equal amount of either FUE or piloscopy grafts into the sites and noted around which tattoo (left or right) the different types of micrografts (FUE or piloscopy) had been placed. Patients returned to the office for follow-up images between 3 and 16 months post-operatively. Using known distances from anatomical landmarks (e.g. lateral epicanthus, tragus, etc.), the investigator relocated the tattoos and archived follow-up images in the same manner using the Folliscope. Pixelmator Version 2.0.4 Chameleon (20504) software superimposed before and after images taken each month. By aligning the tattoo of each image in the series and normalizing the transparency of each image the investigator ascertained the growth or absence of transplanted hair follicles. Both the patients and the investigator remained blinded to the identity of the grafts until after the final counts had been made. Table 1 depicts the growth of piloscopic grafts versus those that were harvested via traditional FUE. Patient 5, the lone subject in whom FUE grafts demonstrated superior viability, had 100% growth of FUE grafts. During the 16-month interval of this hair survival study, the development of the piloscope surgical instrument continued to progress with the dual objectives of creating a more efficient and user-friendly surgical device. Viewers will be shown footage of the piloscope performing on a fresh-frozen cadaveric specimen. Ultimately, the piloscopic approach for harvesting hair follicles may benefit an expansive population of patients. Women can undergo FUE without having to shave their donor areas. African-American patients will have the curl of their hair straightened by the downward pull of the piloscope prior to extraction, rendering follicular harvesting more predictable and effective in this patient population. Finally, young patients with uncertain safe donor areas will benefit from the elimination of the stigma of surgical scarring throughout the donor area. In summary , patients undergoing piloscopy may ultimately realize the two long-standing objectives of surgical hair restoration. *the sixth subject in the trial is located in Brazil and is having his hair count analysis performed during the week of March 4th, 2013. Articles Cited: 1) Harris, JH. Conventional FUE. In Unger WP, Shapiro R, Unger RH, Unger M, eds. Hair Transplantation. New York:Informa,2011:292-3. 2) Beehner M. A comparison of hair growth between follicular-unit grafts trimmed skinny vs. chubby. Hair Transplant Forum Int 1999;9:16. 3) Seager DJ. Micrograft size and subsequent survival. Dermatol Surg 1997; 23:757-61. 4) Greco JF, Kramer RD, Reynolds GD. A crush study review of micrograft survival. Dermatol Surg 1997;23:752-5. 5) Jimenez F, Izeta A, Poblet E. Morphometric analysis of the human scalp hair follicle: Practical implications for the hair transplant surgeon and hair regeneration studies. Dermatol Surg 2011;37:58-64. 6) Limmer BL. Micrograft survival. In: Stough DB, Haber RS, eds. Hair Replacement. St. Louis:Mosby,1996:147-9. 7) Sandoval-Camarena A, Sandoval H. Classic microscope dissection of follicular units. In Unger WP, Shapiro R, Unger RH, Unger M, eds. Hair Transplantation. New York:Informa,2011:318. 8) Unger WP. Delineating the safe donor area for hair transplanting. The Amer Jour of Cosmetic Surgery 1994, 11:239-43

The Origin
T oo Good T o Be T rue?
A Scarless Hair Follicle Harvesting Method Enhancing Transplanted Graft Viability

Carlos K. Wesley, M.D.


710 Park Avenue New York, NY 10021

The Objective

The Strip Harvest

T ypical Postoperative Donor Scar Before 12 Months 2179 FU

Unger, W P. The Donor Area" Hair Transplantation, 5th Ed., Ungers and Shapiro: 82-83. 2011

Donor Wound Closure

Donor: After T wo Sessions

Trichophytic Closure

Complications in the Donor Area

Trichoplytic

Standard Closure

Follicular Unit Extraction (FUE)

FUE Variations

Variations on Follicular Unit

Extraction (FUE)
SAFE Scribe NeoGraft Automated ARTAS System Increasingly limited physician

involvement

FUE Shortcomings

African-American Hair

Follicle Transection Rates 10 15% Increase with smaller punch Skeletonized Grafts As compared to FUT Punctate Scarring Increase with >1mm punch

Pathomvanich D. Donor Harvesting; A New Approach to Minimize Transection of Hair Follicles Dermatol Surg 2000; 26:345-8.

FUE Shortcomings

Graft T rimming: Hair Survival

Follicle T ransection Rates 10-15% Increase with smaller punch Skeletonized G rafts As compared to FUT Punctate Scarring Increase with >1mm punch

Pathomvanich D. Donor Harvesting; A New Approach to Minimize Transection of Hair Follicles Dermatol Surg 2000; 26:345-8.

Graft T rimming: Hair Survival

Graft T rimming: Hair Survival

Follicular Units Obtained by Various Harvesting Methods


Strip Harvest

FUE Shortcomings

Stem Cell Protection from:


Dessication T raumatic Handling
Follicle T ransection Rates 10-15% Increase with smaller punch Skeletonized Grafts As compared to FUT Punctate Scarring Increase with >1mm punch

Dormant follicle inclusion


FUE

Survival rates approximately:


97-98% strip 90% scalp FUE 63-80% Beard FUE 25-86% Chest FUE

Umar S. Hair Transplantation in Patients With Inadequate Head Donor Supply Using Nonhead Hair Ann Plast Surg 2011;67: 332-335. Harris JA. Follicular Unit Extraction Facial Plast Surg. 2008;24:404-413.

Pathomvanich D. Donor Harvesting; A New Approach to Minimize Transection of Hair Follicles Dermatol Surg 2000; 26:345-8.

FUE Analysis
Pros
No permanent linear scar Comfortable Healing Process Decreased Healing Time Fewer limits on post-op activity Viable alternative if no scalp laxity Useful if limited number of grafts needed (e.g. eyebrow) Good if poor healer Ideal to repair donor scar that cannot be excised Enables harvest of finer hair from nape, etc.

FUE Analysis
Cons Pros
No permanent linear scar Comfortable Healing Process Decreased Healing Time Fewer limits on post-op activity Viable alternative if no scalp laxity Useful if limited number of grafts needed (e.g. eyebrow) Good if poor healer Ideal to repair donor scar that cannot be excised Enables harvest of finer hair from nape, etc. Grafts still need to be dissected to trim epidermis Likely to bury grafts (folliculitis) Limited candidates (FOX test) 30% Time consuming Costs more, labor intensive, etc.

Cons
Lower yield due to more follicle transection (20%)

Lower yield due to more follicle transection (20%) Small punctate scars Limited candidates (FOX test) 30% Time consuming Costs more, labor intensive, etc. Have to shave head Likely to bury grafts (folliculitis) Scarring and distortion of donor makes FUE sessions more difficult Grafts still need to be dissected to trim epidermis For efficiency, the largest FUs are targeted, but these may not be ideal for hairline Grafts are more fragile due to lack of protective dermis

Grafts are more fragile due to lack of protective dermis

FUE Analysis
Pros
No permanent linear scar Comfortable Healing Process Decreased Healing Time Fewer limits on post-op activity Viable alternative if no scalp laxity Useful if limited number of grafts needed (e.g. eyebrow) Good if poor healer Ideal to repair donor scar that cannot be excised Enables harvest of finer hair from nape, etc. Grafts still need to be dissected to trim epidermis Likely to bury grafts (folliculitis) Costs more, labor intensive, etc. Limited candidates (FOX test) 30%

Piloscopy
Cons

Lower yield due to more follicle transection (20%)

Grafts are more fragile due to lack of protective dermis

Piloscopy

Adoption of New Technology

In order for new technology to b e adopted into practice and replace the status quo, it must b e :

Better Faster Easier

Piloscopy

Piloscopy

Piloscopy

Adoption of New Technology

In order for new technology to b e adopted into practice and replace the status quo, it must b e :
Internal

Better Faster Easier

External

Piloscopy

Piloscopy

Piloscopy

Piloscopy

Piloscopy

Graft T rimming: Hair Survival

129%

Graft T rimming: Hair Survival

Piloscopy

204%

Piloscopy

Adoption of New Technology

In order for new technology to b e adopted into practice and replace the status quo, it must b e :

Better Faster Easier

Regeneration!

Piloscopy

Adoption of New Technology

In order for new technology to b e adopted into practice and replace the status quo, it must b e :

Better Faster Easier

Piloscopy
From MCRA Regulatory Advisory T eam: The (piloscope) is a Class I, Exempt device regulated under 21 CFR 878.4820, surgical instrument motors and accessories/attachments.

018 Operation Restore Panel, Program Overview


David Perez-Meza MD1, James A. Harris MD FACS2, Antonio S. Ruston MD3, Jerzy Kolasinski MD PhD4. 1 Permanent Hair Solutions, Mexico City, Mexico, Mexico, 2The Hair Sciences Center of Colorado, Denver, CO, USA, 3Hair Restoration Center, Sao Paulo, Brazil, 4Hair Clinic Poznan, Swarzeds, Poland. David Perez-Meza MD, Chairman of the ISHRS Pro Bono Program D. Perez-Meza MD: None. J.A. Harris MD FACS: None. A.S. Ruston MD: None. J. Kolasinski MD PhD: None. TAKE HOME MESSAGE: ISHRS Pro Bono Hair Restoration Foundation Hair loss can have far reaching effects on a person's sense of self image and self-esteem. The ISHRS Pro Bono Foundation is proud to support OPERATION RESTORE. ABSTRACT: ISHRS Pro Bono Hair Restoration Foundation Hair loss can have far reaching effects on a person's sense of self image and self-esteem. When the loss of hair occurs because of disease or trauma the factors associated with such a hair loss process may produce particularly profound effect. Recognizing that many of these people in the process of physical and emotional recovery may lack the resources for corrective hair restoration surgery, the ISHRS Pro Bono Foundation is proud to support OPERATION RESTORE. This program matches prospective hair loss patients with volunteer ISHRS physicians to obtain hair restoration services to help restore the physical and emotional wellness of the individual. The foundation provides financial, travel, lodging, and medical assistance to eligible patients. Since its inception in 2004 the OR program has helped more 45 patients with more than $460,000 USD in "free surgery". This year we will present five interesting Operation Restore cases: A) Scalp reconstruction after pitbull attack. B) Repair of aplasia cutis congenita in a 13 years old female. C) Hair transplant for burn scars. D) Hair Transplantation of the scalp after car accident. E) Identical twin to twin FUE hair transplant using the ARTAS system.

21ST ISHRS MEETING SAN FRANCISCO, CA

DISCLOSURE

NO COI
OPERATION RESTORE SESSION
David Perez-Meza, MD Diplomate ABHRS Chairman Operation Restore Program

Operation Restore
Overview- Dr. David Perez-Meza OR Repair Cases: ISHRS and BOG

Thank you
Annual Giving Fund ISHRS Members- Donations Our partners- Hotels and Resorts Hair Foundation- Promoting the OR and donation of $1,500 . OR Physicians- 90 of 1,000 ISHRS Members

OR Committee
Dr. David Perez-Meza- Chairman Dr. Paul Cotterill Dr. Alex Ginzburg Dr. Francisco Jimenez Dr. James Harris Dr. Jerzy Kolasinski Dr. Kenichiro Imagawa Dr. Marcelo Pitchon Dr. Paul Rose Dr. Franklin Weinstein

Operation Restore
Created in the year 2004. It is the ISHRSs Pro Bono Program designed to match prospective hair restoration patients with an OR physician. The patient lacks the financial resources to obtain HRS on their own.

Operation Restore Mission


To facilitate hair restoration surgery for hair loss patients after trauma, burns, accidents, cancer, scarring alopecias, radiation and who lack the financial resources to obtain the corrective surgery and restore their hair.

Operation Restore
ISHRS- Provides hotel, meals, transportation (air flights or gas) for the patient. OR Physician- the physician is expected to waive or cover the cost of all medical fees, supplies, etc. associated with all aspects of the procedure, including pre-op and post-op. The applications are voted twice a year or anytime if deemed necessary.

Operation Restore
It has provided more than $475,000 worth of FREE Hair Restoration Surgery. 45+ applications have been approved so far. 66 surgeries have been performed ( some patients 24 surgeries)- HTS, tissue extension and tissue expansion.

Operation Restore
We invite all ISHRS members to join the program.

We always accept donations to help change the lives of many hair loss patients WORLDWIDE

THANK YOU

OPERATION RESTORE CASES

CASE 1
Male patient 43 years old, healthy, no medication Trauma in the scalp- accident 17 years old Scarring and alopecic area in the crown area, 7 cm Several consults with another surgeons for tissue expansion, SS in Mexico for free surgery I evaluated the patient and both agree for HTS He applied for OR and case was approved

Surgical plan
Some scarring areas: thin vs thick FUT- 860 grafts different densities

Patient very happy with the results, Grateful to the ISHRS OR- Pro Bono Program We changed his life

019 Repair of Aplasia Cutis Congenita in a 13 Year Old Female


James A. Harris, MD. Otolaryngology/ Head and Neck Surgery, The Hair Sciences Center of Colorado, Greenwood Village, CO, USA. James A. Harris, MD, FACS, received his medical degree with honors from the University of Colorado, Denver, Colorado. He is a Diplomate of the ABHRS, Fellow of the American College of Surgeons and member of the International Society of Hair Restoration Surgery. He is a Clinical Instructor of Hair Transplantation at the University of Colorado in Denver, Colorado. Dr. Harris has developed a surgical methodology and instrumentation for performing follicular unit extraction (FUE) that ensures graft safety and integrity called the Harris SAFE System and was a principle investigator in the development of the ARTAS System robot for FUE. J.A. Harris: None. TAKE HOME MESSAGE: Interested physicians should participate in OR. ABSTRACT: A case presentation for an Operation Restore patient who had aplasia cutis congenita.

020 Scalp Reconstruction after Pitbull Attack


Antonio Ruston, MD Director, Clinica Ruston, Sao Paulo / SP, Brazil. Dr Antonio Ruston is a plastic surgeon from Sao Paulo, Brazil. He has been working with HRS for the last 17 years and has been a member ISHRS since 1998. A. Ruston: None. TAKE HOME MESSAGE: This presentation will show how to use tissue expanders to repair the scalp after a pitbull attack. ABSTRACT: This presentation will show how to use tissue expanders to repair the scalp after a pitbull attack.

021 Hair Transplant for Burn Scars


Jerzy Kolasinski, MD, PhD. Klinika Kolasinski - Hair Clinic Poznan, Swarzedz, Poland. JerzyKolasiski (M.D., Ph.D.) is a specialist in surgery currently undergoing specialty training in plastic surgery. He is a member of the Polish Society of Plastic, Reconstructive and Aesthetic Surgeons, the American Academy of Cosmetic Surgery, and the founder, owner and director of the Kolasinski Clinic- Hair Clinic Pozna. Dr.Kolasiski is an active member of the International Society of Hair Restoration Surgery and the American Society of Hair Restoration Surgery. Over the years 2000-2002 he was a Vice-President of the European Society of Hair Restoration Surgery. In the years 2000-2004 he was the President of the Polish Society of Hair restoration Surgery. Between 2005 and 2011 he was a Board Member of the International Society of Hair Restoration Surgery. Dr. Kolasiski has written and made over 140 articles and presentations on hair restoration surgery and esthetic surgery. He provided many courses in the American Academy of Cosmetic Surgery and in the International Society of Hair Restoration Surgery. Dr. Kolasiski also organizes conferences and professional trainings on esthetic surgery and Anti-Aging medicine both in Poland and abroad. J. Kolasinski: None. TAKE HOME MESSAGE: Hair Transplant for Burn Scars ABSTRACT: Surgeon: Jerzy Kolasinski MD, PhD Location: Klinika Kolasinski, 62020 Swarzedz, ul.Staszica 20A, Poland Patient: Kamil Nowaczek Date of Birth: 02/16/1995 Address: ul.Konopnickiej 45/1, 64-915 Jastrowie, Poland Health History and Hair Loss History: Child was treated with chemotherapy because of chest tumor - NonHodkin lymphoma T-cell, IIIrd degree. He was treated with 9 cycles of chemotherapy from 03/09/2002 to 08/21/2003. Than chemotherapy was stopped because of an infection with Microsporum canis which caused severe scalp scarring and hair loss. From 07/07/2008 to 05/05/2009 Patient was treated with Interferon because of a Hepatitis C virus infection.Location of Hair Loss: Many irregular patches of scarring alopecia Treatment: Three session of FUT were performed: On 03/29/2010 - 600 FUT On 09/24/2010 - 620 FUTOn 07/18/2013 - 150 FUT. The surgeries were performed in local anesthesia. Strip technique were used in all sessions. Result: A satisfactory result of treatment was achieved. There were no complications.

Surgeon:

JerzyKolasinski MD,PhD

Location: KlinikaKolasinski,62020 Swarzedz,ul.Staszica 20A,Poland Patient: KamilNowaczek Date ofBirth: 02/16/1995 JerzyKolasinski MD,PhD
POLAND

HealthHistory
Childwastreatedwithchemotherapybecauseof chesttumor NonHodkin lymphomaTcell,IIIrd degree. Hewastreatedwith9cyclesofchemotherapy from03/09/2002to08/21/2003. Than chemotherapywasstoppedbecauseofan infectionwithMicrosporum canis whichcaused severescalpscarringandhairloss. From07/07/2008to05/05/2009Patientwas treatedwithInterferonbecauseofaHepatitisC virusinfection.

Location ofHairLoss
Manyirregularpatchesofscarringalopecia

Treatment
ThreesessionofFUTwereperformed: On03/29/2010 600FUT On09/24/2010 620FUT On07/18/2013 150FUT

Results
Asatisfactoryresultoftreatmentwasachieved Therewerenocomplications

Thesurgerieswereperformedinlocal anesthesia Striptechniquewereusedinallsessions.

022 Identical Twin-to-Twin FUE Hair Transplant using ARTAS


Glenn M. Charles, DO. Charles Medical Group, Boca Raton, FL, USA. Glenn M. Charles D.O. Diplomate American Board of Hair Restoration Surgery. Founder and Medical Director of Charles Medical Group. Exclusively practicing hair restoration since 1997. Currently performing microfollicuar unit grafting and FUE procedures. Elected as President of American Board of Hair Restoration Surgery, January, 2011. Member ISHRS since 1998. Appointed member of Core Competencies Committee and Website Committee, 2008. G.M. Charles: None. TAKE HOME MESSAGE: Most hair restoration physicians will have some difficult or challenging cases at some point in their careers. If proper due diligence is done and the patients expectations are kept realistic the surgical results can often make a positive chance in the patients lives. In this case the patient and family fully understood the uncertainties of the outcome because the fact that an identical twin to twin FUE procedure using the ARTAS robotic assisted devise had not been done before. A conservative surgical plan was created and executed. The results of the procedure have been better than expected. The patient and family admits that he has shown an improvement in his self-esteem and selfconfidence. Being able to help people to feel better about themselves is one of the main reasons I chose this field of medicine. ABSTRACT: Case Presentation: Identical twins Alex and Austin are 19 years old and freshman at University of Nebraska. In January, 2005 at the age of 12 Alex was diagnosed with Medulloblastoma of the brain and spinal cord. His treatment consisted of immediate surgical removal of the tumor and a combination of chemotherapy and over 30 radiation treatments to his scalp and upper cervical spine over a period of 9 months at Childrens Hospital in Omaha, Nebraska. Initially Alex had virtually complete hair loss and only recovered partial density in some areas including the donor region. I received an email from the twins parents Chuck and Ann in January, 2012 that explained in detail what his family has been going through. He wanted to know if there was anything I could do to help his son Alex who he felt looked much older than his chronological age and had self- confidence and self- esteem issues because of this. He sent many photographs of both boys. Having identical twin boys myself I immediately felt compelled to help this family. Alexs brother Austin told his father that he would be willing to help his brother out in any way he could. I told Chuck I would do some research and contact several colleagues to find out more about the possibility of performing a twin to twin hair transplant procedure on his sons. I instructed the boys to go in for blood work to check overall health and genetic testing to confirm that they are truly identical. It turns out that there have been a few previous cases of grafting hair follicles from one identical twin to another on a very small scale without the use of immunosuppressive medications using the traditional FUT/strip technique. For the next several months I had many discussions with the family and told them that I thought it might be worth an attempt to transplant hair follicles from Austin to Alex, but there would be no guarantee of successful growth of the grafts. They responded, are family understands that this is entering uncharted territory but still want to move forward with this plan. Following discussions with both boys I learned that Austin had been doing research on-line and preferred FUE if possible so there would be no linear scar because he wanted to have option available to keep hair very short. We agreed to try a smaller FUE procedure because of the uncertainty of the outcome. Due of the financial limitations of Alex and his family I offered to perform the procedure at no expense and had the family submit an application to Operation Restore to see if they qualified for any additional financial assistance. All of the travel expenses where covered by Operation Restore. In June of 2012 I performed a 962 graft FUE procedure using the ARTAS robotic assisted technique. All of the grafts were placed in a frontal forelock location and there were no surgical difficulties or post-operative complications. It appears that that a good percentage of the grafted follicles have grown and Alex is very happy. Alex has been in remission for over six years and has an annual checkup and MRI as a follow up

protocol. I will show before and after photos of both twins and some short video segments of the pre-op interviews and surgical procedure. Alex and Austin will undergo a second procedure in May,2013.

023 Hair Transplantation of the Scalp after Car Accident


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 since 1997. He had received 10 ISHRS Research Grant Awards. In 2007, he received the ISHRS Platinum Follicle Award. Dr. Perez-Meza is the current Chairman of the Operation Restore- Pro Bono Program and OR Physician. D. Perez-Meza: None. TAKE HOME MESSAGE: The Operation restore patient represent a challenge for the hair restoration surgeon. We need to restore patient's hair loss, scarring area and self esteem. ABSTRACT: Operation Restore surgery case. I will present and discuss about hair transplantation of the scalp after trauma. The Operation Restore cases represent a real challenge for the hair restoration surgeon and will be discussed in my presentation.

024 Moderator Introduction, Cicatricial Alopecia and Non-Androgenetic Alopecia


Jeff C. Donovan, MD PhD FRCPC FAAD. Dermatology, University of Toronto, Toronto, ON, Canada. Jeff Donovan, MD PhD is a dermatologist and hair transplant physician. In addition to his private practice in hair restoration, Dr. Donovan is an Assistant Professor of Dermatology at the University of Toronto and conducts clinical research in hair loss. J.C. Donovan: None.

025 Cicatricial Alopecia: What You Should Know About the Many Different Types
Vera Price, MD. San Francisco, CA, USA. Vera Price, Professor, directs the Hair Disorders Clinic and Hair Research Center at UCSF. She received her medical degree at University of Toronto, Canada, and trained in Dermatology at NYU. She spent three years studying human hair with the wool chemists at the USDA Western Regional Research Laboratory in Berkeley, California. She founded the Cicatricial Alopecia Research Foundation (CARF) for the purpose of raising funds for research and educating patients. Dr. Price recently published a book with Dr. Paradi Mirmirani, Cicatricial Alopecia: An Approach to Diagnosis and Management. Private funds were raised to purchase DVD copies of the book and were donated to dermatology residents in the U.S. and Canada. V. Price: None. TAKE HOME MESSAGE: The clinical hallmark of primary cicatricial alopecia is the absence of follicular markings. This finding dictates that a scalp biopsy is needed. The goal of treatment is to alleviate symptoms and signs, and slow progression. Hair regrowth is not possible at this time, and activity may recur after months or years. ABSTRACT: The scarring or cicatricial alopecias comprise a group of inflammatory disorders characterized by permanent destruction of the pilosebaceous unit. In primary cicatricial alopecia, the hair follicle is the primary target of destruction. In secondary scarring alopecia, follicular destruction is incidental to a non-follicular process such as infection, tumor, traction, or burn. Primary cicatricial alopecia includes several entities with distinct clinical features. Clinically, the hallmark of scarring alopecia is the loss of follicular orifices and this finding dictates a scalp biopsy. Dermatopathology is essential for management, and shows a peri-infundibular or peri-isthmic infiltrate, and markedly reduced or absent sebaceous glands. If sebaceous glands are not reduced or absent, the diagnosis of a primary scarring alopecia is doubtful. Although the clinical variants are distinct, histopathology cannot distinguish

these clinical variants and can only separate them into 2 groups - the predominantly lymphocytic group and the predominantly neutrophilic/plasmacytic group. Generally, the primary cicatricial alopecias affect adults, are rare in children, occur worldwide, and there is seldom a family history with the exception of central centrifugal alopecia. 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) 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 treatment. It is essential to explain that the goal of treatment is to alleviate the symptoms and 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, a consideration for the surgeon contemplating hair restoration. New research suggests that in some primary cicatricial alopecias, the perifollicular inflammation may be secondary to lipid-metabolic changes in the sebaceous gland. Specifically, in some patients with lichen planopilaris, there is a loss of function of the peroxisome proliferator activated receptor gamma (PPAR-gamma) in the sebaceous gland. This leads to the abnormal processing and buildup of lipids, which triggers inflammation and eventuates in scarring and destruction of the follicle. For this reason, a PPAR-gamma agonist is listed as a new, off-label treatment option for lichen planopilaris.

ISHRS October 24, 2013

Cicatricial alopecia: What You Should Know About the Many Different Types
Vera H. Price MD, FRCPC University of California, San Francisco

Consultant for Allergan, Follica

Cicatricial (scarring) alopecia

Primary cicatricial alopecia

Cicatricial alopecias comprise a group of inflammatory disorders characterized by permanent destruction of the pilosebaceous unit. In primary cicatricial alopecia, the hair follicle is the primary target of destruction. In secondary cicatricial alopecia, follicular destruction is incidental to a non-follicular process such as infection, tumor, traction, or burn.

- Includes several entities with distinct clinical features - Clinical hallmark: loss of follicular markings - Pull test: loosely anchored anagen (growing) hairs

Dermatopathology

Why is cicatricial alopecia permanent?

- Essential for management - Inflammatory infiltrate around upper 1/3rd of follicle - Infiltrate predominantly lymphocytic or neutrophilic/plamacytic - Sebaceous glands and stem cells destroyed - Dermpath cannot separate clinical subtypes

Primary cicatricial alopecia

Working classification of primary cicatricial alopecia*


Lymphocytic
Lichen planopilaris Frontal fibrosing alopecia Central centrifugal cicatricial alopecia Pseudopelade (Brocq) **Chronic cutaneous lupus erythematosus **Keratosis follicularis spinulosa decalvans

General features Who is affected? Where in the world? - Adults, otherwise healthy - Worldwide - Chronic - Periods of activity and inactivity, may re-activate

Neutrophilic Mixed End-stage

Folliculitis decalvans Tufted folliculitis **Dissecting cellulitis **Folliculitis keloidalis

* Olsen et al. JAAD. 48: 103-10, 2003 (modified) ** Not a primary cicatricial alopecia

Lichen planopilaris

Lymphocytic cicatricial alopecia

Symptoms frequent Peri-follicular scaling and erythema at active borders Loss of follicular markings

Frontal fibrosing alopecia

Band-like alopecia Frontal and temporal scalp Loss of brows

Central centrifugal cicatricial alopecia

African-American women Symptoms vary Starts at vertex scalp

Pseudopelade (Brocq)

footprints in the snow No symptoms or signs

Neutrophilic cicatricial alopecia

Folliculitis decalvans

Suppurative Crusting Pustules

Tufted folliculitis

Focal areas of tufting Minimal hair loss Tufted follicles are a feature of many cicatricial alopecias

Dissecting cellulitis

Mixed cicatricial alopecia

Boggy, pus-filled sinus tracts

Folliculitis keloidalis

Non-specific or end stage cicatricial alopecia

Non-specific (End stage)

Primary cicatricial alopecia

- Histologic findings do not distinguish the various clinical forms - Can only separate predominantly lymphocytic and neutrophilic/plasmacytic groups - Nevertheless, the inflammatory infiltrate provides a practical guide for selecting treatment

Primary cicatricial alopecia

Therapy of primary cicatricial alopecia

Essential to explain goals of treatment: - Alleviate symptoms & signs - Retard or slow progression - Regrowth is not possible - May re-activate months or years later important consideration if contemplating hair restoration

For predominantly lymphocytic group: immunomodulating agents For predominantly neutrophilic/plamacytic group: antimicrobials For mixed group: antimicrobials, anti-inflammatories, isotretinoin

New clues to pathogenesis

New research: perifollicular inflammation may be due to lipid-metabolic changes in the sebaceous gland Loss of function of transcription factor PPAR found in LPP, FFA, CCCA For this reason, PPAR agonist (pioglitazone) is new off-label treatment option

026 Comparison of the Results of Hair Restoration Surgery in Cicatricial Alopecias Induced by Inflammatory Diseases with Cicatricial Alopecias Induced by Traumatic Events
Ramin Rabbani, Resident, Ali Abbasi, MD, Sheida Abbasi. Abbasi hair clinic, tehran, Iran, Islamic Republic of. Resident of Dermatology R. Rabbani: None. A. Abbasi: None. S. Abbasi: None. TAKE HOME MESSAGE: Differences between the natures of cicatricial alopecias induced by inflammatory diseases and cicatricial alopecias induced by traumatic events, and their impacts on the results of hair restoration surgery ABSTRACT: Background: Permanent loss of hair follicles in cicatricial alopecia may be induced by various etiologies such as inflammatory diseases and traumatic events which are different in nature. Objective: To evaluate the outcomes of 7 year follow up of hair restoration surgery in cicatricial alopecias induce by inflammatory diseases or trauma. Methods: Thirty five patients with cicatricial alopecia, 17 induced by inflammatory diseases and 18 by trauma were studied. Same surgery method with 30 skinny micrografts per cm2 was performed for all. At least 2 year quiescence was confirmed by biopsy in all inflammatory cases prior to surgery. Results: In 7 year follow up among those with inflammatory diseases, relative success was achieved in 2 cases, and the results were disappointing in 15 cases while 7 of them experienced disease flare up. The results in all 18 cases with traumatic events were desirable. Conclusions: Hair restoration surgery results in cicatricial alopecias induced by inflammatory diseases are disappointing while the results in cicatricial alopecias induced by trauma are favorable.

10/7/2013

Cicatricial alopecias:

1. Primary (LPP,DLE,folliculitis decalvans,acnekeloidalis,


pseudopelade ofBrocq ) AliAbbasi,MD Ramin Rabbani,MD Sheida Abbasi,Medicalstudent Dr.Abbasis HairTransplantClinic

2. Secondary (Traumas,Developmental defects,Infections,


DrugsandNeoplasm)

Cicatricial alopecias: 1. Unstable (LPP,DLE,PPB)


Unstablecicatricial alopeciaisintermittentwithpossiblesubsequenthairlossin eitherneworoldareas.

ThereforeCAshavevariousetiologieswhich aredifferentinnatures.

1. Stable (Traumassuchasburns,cosmeticsurgeriesand
Fixedpermanentscarring.

radiationinducedalopecia)

Toevaluatetheoutcomesof7yearfollowup ofhairrestorationsurgeryinCAsinducedby inflammatorydiseases(Unstable) withCAs inducedbytraumaticevents(Stable).

20012008 Dr.AbbasisHairClinic,Tehran,Iran 35patients: 14females 21males Averageage:35

10/7/2013

TRAUMA

INFLAMMATORYDISEASES

Diagnosesweredocumentedinallbyhistory, clinicalexamination andbiopsy. Biopsy:Two4mmpunchbiopsyspecimensfrom lesion


1)forverticalsection 2)fortransversesection

Biopsyfromanysuspectedactivelesion,Extending infat.

Inflammationinpathologyreport shouldbetreatedtopreventprogressionofthedisease(Flareup phenomenon)

Inthisstudyinallwithinflammatorydiseases,therewasatleast2 yearsofquiescence ofthedisease,andnoinflammatory infiltrationexistedinhistopathologicalassaypriortohair restorationsurgery.

Onesession forallwithsametechnique. Donorarea:Occipitalregion.(Singlebladeexcision) Recipientsite:smallincisionswith45degree obliqueangle werecreatedbycustommadeblades withdiameterof1mm. Skinnyfollicularunitmicrografts withdensityof30 slit/cm2 wereimplanted.

Shorttermfollowup:1months.(infection necrosis) Longtermfollowup:7years.

Inamonthfollowupaftersurgerynoneof thepatientsdevelopedcomplicationssuchas ischemia,necrosisandinfection.

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InCAsinducedbytrauma successful results inall18 Caseswereachieved.

BEFORE

AFTER

Butininflammatorydiseases: onlyarelativesuccess wasachievedin2

andtheoutcomesweredisappointing in15(88%)

andthediseaserecurrence occurredin7(41%)

BEFORE

AFTER

BEFORE

AFTER

BEFORE

AFTER

BEFORE

AFTER

DISEASEFLAREUPANDPROGRESSIONOFTHE UNDERLYINGDISEASE

10/7/2013

BEFORE

AFTER
DISEASEFLAREUPANDPROGRESSIONOFTHE UNDERLYINGDISEASE

BEFORE

AFTER

Relativesuccess

BEFORE

AFTER

DISEASEFLAREUPANDPROGRESSIONOFTHE UNDERLYINGDISEASE

Outcomedependsontheunderlying etiology. Trauma Favorable Inflammatorydiseases disappointing.

Relapsingandprogression inCAsinducedby inflammatorydiseases,isarulebecauseof thenatureofdiseaseandsurgery canleadto diseaseflareup. ConverselyitdoesnotoccurinstableCAs suchasthoseinducedby ytrauma.

Inliterature itisrecommendedtoconfirm diseasequiescenceforatleast1year priorto surgery. Although,2year quiescenceinallofour patientswithinflammatorydiseaseswas ,theresultsweredisappointing. pp g considered,

10/7/2013

Thereforeitsa matterofdebate thathow long afterdiseasequiescencein inflammatorydiseases,hairrestoration surgerycouldbeperformed. Longerperiod?

Hairrestorationsurgeryisan effective treatmentforCAsinducedbytrauma,but noteffective andcanevenpromotethe relapseoftheunderlyingdiseaseinCAs inducedbyinflammatorydiseases.

Howeverifsurgeryisgoingtobeperformed onthesepatients,itisimportanttoexplainto thembeforetheprocedureandwarn them aboutpossibilityofprimarydisease recurrence andadecreasedhairsurvivalrate.

027 Introduce a New Clinical Pattern of Lichen Planopilaris, it is a Pitfall if Implanted Because the Disease May Flare Up, and Result in Disaster
Gholamali Abbasi, MD1, Kambiz Kamyab Hesari, MD, Pathologist2, Fazaneh Molaeei, MD,Dermatologist1. 1 office, Tehran, Iran, Islamic Republic of, 2Razi dermatology Hospital,Tehran University Medical science, Tehran, Iran, Islamic Republic of. Ali Abbasi MD, DO, BOD Member, ABHRS, ABHRS Diplomate, Faculty Member of ISHRS and Orlando Live Workshop, BOG Member, Asian Society of Hair Restoration, Research Award Winner, ISHRS 2005 Poster Award Winner, ISHRS 2005 Winner, Dedication and Recognition of Education, ISHRS 2012 G. Abbasi: None. K. Kamyab Hesari: None. F. Molaeei: None. TAKE HOME MESSAGE: If you can diagnose this new pattern of LPP you will never do hair-transplants for these patients and can prevent a disaster. ABSTRACT: We would like introduce a new clinical pattern of Lichen planopilaris ,it is mimic to Androgenetic alopecia or Femal pattern hair loss, it is a pitfall if implanted because the disease may flare up, and resulted in disaster scaring alopecia. Introduction: in this prospective study, among 650 cases complained Hair loss with primary FPHL or AGA diagnosis and asked us for H.T in our clinic,from Jun.2011 till Jan.2013, in 58 cases (52 female and 6 male) had addition sign to AGA, a diffuse even hair loss with a prominent terminal hair and very small punctuate needle shape scaring (those are hardly visible in a perfunctory glance) and with less number Miniaturized follicles than usual AGA and other clinical signs like,perifollicular erythema, follicular keratosis, and loss of follicular orifices those were limited to in a patterned AGA area , in view of the clinical appearance, these cases mimic to AGA and Chronic telogen alopecia ,All these suspected cases were done biopsy, with Differential diagnosis like female patern hair loss, alopecia areata, chronic telogen effluvium,LPP and chronic lupus erythematosus,all histopathology , were reported : low hair follicle density, anisotrichosis, mild perifoliicular fibrosis specially around vellus hair follicles in horizontal sections and mild fibrosis with lichenoid lymphocytic infiltration around infundibular area of vellus or miniaturized in vertical sections in early phase of alopecia.In late lesion, atrophic follicles are replaced by fibrous bands resemble end stage of Lichenplanopilaris or frontal fibrosing alopecia.We would like to re- introduce this new clinicopathologic image as new pattern of LPP under this term:Fibrosing Alopecia in a Pattern Distribution(FAPD) (2 )that in view of clinical appearance is very different from classical LPP and Frontal Fibrosis Alopecia( FFA) Conclusion: We severely emphasize, before any H.Tof AGA or FPHL, in clinical exam if you couldnt find miniaturized hair, and almost the hair are terminal hairs, look for more sign like prifolicular erythema and follicular keratosis and we insist to take biopsy for rule out the FAPD Ref:1-(Donovan J. (Dermatol Surg. 2012 Dec; 38(12):1998-2004),, Br J Dermatol. 2012 Mar; 166(3):666-370. doi: 10.1111/j.1365-2133.2011.10692.x. Epub 2012 Jan 9Chiang YZ, Tosti A,),Dermatol Surg. 2012 Dec;38(12):2005. doi: 10.1111/j.1524-4725.2012.02578.x.Dermatol Surg. 2012 Dec; 38(12):2005. doi: 10.1111/j.15244725.2012.02578.x.. (An Bras Dermatol. 2011 Mar-Apr; 86(2):359-62.) 2-{Arch dermatol;2000;136.205-211}

Lichenplanopliaris mimicsAndrogenetic alopecia


AliAbbasi,M.D 1 kambizKamyabhesari,M.D2 FazanehMolaeei,M.D,3. 1Boardcertificatedindermatology AmericanHairRestorationSurgeryBoardCertified BoardDirectorofAmericanHairRestorationSurgery BoardgovernorofAsiansociety FacultymemberofISHRS&Orlandoworkshop Researchawardwinner Tehran,Iran 2 Tehran,Iran,IslamicRepublicof,2Razidermatologyhospital,Tehranuniversitymedical science,Tehran,Iran, 3Boardcertificatedindermatology

Noconflictofinterest

LichenPlanus (LP) Idiopathicinflammatorydiseaseof:


Skin Mucousmembranes Hair Nails Seenmostcommonlymiddleaged

ClinicalfeaturesofLP
ActinicLP AnnularLP AtrophicLP BullousLP HypertrophicLP Inverse Pigmentosus Lichenplanopilaris

ClinicalfeatureofLichenplanopilaris
Scarringalopeciatype GrahamLittlePiccardi Lasseur Syndrome FrontalFibrosing Alopecia Weintroduceanewclinicalfeature,mimicking Androgenetic alopeciaorFemalePatternHairLoss (wehavenotfoundanyreportinliterature)

IntroducingaNewClinicalPatternofLichen Planopilaris,mimicsAGA,
Itisclinicallysimilarto Androgenetic Alopeciaor FemalePatternHairLoss itisaPitfall,ifmisdiagnosed,andifImplanted: theDiseaseMaybeirritated,FlareUp,and ResultedinDisasterofscarringalopecia

ItseemsallreportsofLLPafterH.Twere alreadyLLPmimicsAGAandwerenot diagnosedinadvance


Lichen planopilaris after hair transplantation:reportof17cases. DonovanJ. Dermatol Surg.2012 Dec;38(12):19982004.

Introduction:
Inthis retrospectivestudy, among650casescomplainedhairloss withprimaryAGAorFPHLdiagnosis askedusforH.T, inourclinic,(Abbasi Hairclinic) fromJun.2011tillJan.2013, in58cases(52femaleand6male,mainage32.5y/o) wefoundanewclinicalfeaturesweredifferentfromAGA,but mimicsAGA BiopsydemonstrateditwasLPPnotAGA

Commentary: Lichen planopilaris after hair transplantation. Jimnez F. Dermatol Surg.2012 Dec;38(12):2005. doi:10.1111/j.15244725.2012.02578.x.

Lichen planopilaris following hair transplantation andfaceliftsurgery. ChiangYZ,Tosti A,Chaudhry IH,Lyne L,Farjo B,Farjo N,Cadore deFarias D,GriffithsCE,Paus R,HarriesMJ. BrJDermatol.2012 Mar;166(3):666370. doi:10.1111/j.13652133.2011.10692.x. Epub 2012 Jan9 Hair loss dueto lichen planopilaris after hair transplantation:areportoftwocasesandaliteraturereview. Crisstomo MR,Crisstomo MC,Crisstomo MG,Gondim VJ,Crisstomo MR,Benevides AN. AnBrasDermatol.2011 MarApr;86(2):35962. Review.

Clinicalfeatureof LichenPlanopilaris,mimicsAGA:

2limitedtointheareaofAGA

1Clinically,resemblestoAGAorFPHL

3Theterminalhairsarepredominant

4Miniaturizedhairsarefewerthanusually seeninAGA

5 Aroundthevellus hairsKeratotic plaquesare usuallysurroundedbyanarrowerythema andterminalhairsoftenareintact

6verysmallpunctuateorpinpointshapescarringdiffused amongtheterminalhairs(thosearehardlyvisibleina perfunctoryglance)

Histopathology Theminiaturizedfolliclesappeartobe preferentiallytargeted

inearlyphase
inhorizontalsection
Speciallyaroundvellushairfollicles: 1Lichenoidlymphocyticinfiltration 2Perifoliicularfibrosis

inearlyphase
(inverticalsections)
aroundinfundibular areaofminiaturizedfollicles
mildfibrosiswithlichenoidlymphocytic

HistologyComparingLPPmimicsAGA
LPPmimicsAGA

AGA

Thevellusfolliclesaretargetedwith significantinflammation

AGAwithminiaturize hairfollicles nosignificant inflammation

CourtesyofDermatologyBolognia

HistologyComparingLPPmimicsAGA
LPPmimicsAGA LPP

Differentialdiagnosis
AGA LPP ChronicTelogen Effluvium AlopeciaAreata

Vellushairsareinvolved

Terminalhairsareinvolved

LPPmimickingAGA

ClinicalcomparingLPPmimicsAGA withAGA
AGA Thehallmarkisfollicular miniaturization

ClinicalcomparingLPPmimicswithAGA
LPPmimicsAGA AGA

Thehallmarkisterminalhair

verysmallpunctuatescarring amongtheterminalhairs

noscarring

ClinicalcomparingLPPmimicswithLPP
LPPmimicsAGA
verysmallpunctuatescaring

Result:Lichenplanopliaris mimics androgenetic alopecia


Diffusehairloss, limitedtointheareaofAGA Terminalhairsarepredominant Theminiaturizedhairsarefewerthan AGA verysmallpunctuateshapescarsareseen (thosearehardlyvisibleinaperfunctoryglance)

LPP
Plaquetypingscar

Perifollicularerythema,follicularkeratosis,andlossoffollicular orifices Mostpatientsarewomen BiopsydemonstratedLPP

WeintroduceanewclinicalpatternofLLP,aclinicalfeature isverydifferentfromallpatternofLPPandclinicallysimilar toAGA Overall,infaceofanyAGAifyouarenotabletofindeasily vellusorminiaturizedhairlikeinAGA,andnearlyallhairare interminalshape,considerthisnewpatternofLLP Ifyouhesitateaboutthispattern,don'tforgettobiopsy Misdiagnosisofthispattern,anddoinganyhairtransplant, thediseasemaybeflareup,intheimplantedarea Treatmentismedicalnotsurgical

Conclusion

Thankyouforattention

028 When is Traction Alopecia in Black Women Transplantable ?


Jeff C. Donovan, MD PhD FRCPC FAAD. University of Toronto, Toronto, ON, Canada. Jeff Donovan, MD PhD is a dermatologist and hair transplant physician. He is also an Assistant Professor of Dermatology at the University of Toronto and conducts clinical research in hair loss. J.C. Donovan: None. TAKE HOME MESSAGE: Black women with traction should be carefully evaluated for possible co-existent CCCA before rendering them good candidates for surgery. ABSTRACT: Introduction: Traction alopecia (TA) is common in black women. Although TA is generally easy to diagnose, several considerations should be given when evaluating the candidacy of women with TA for hair transplant surgery. Hairstyling practices that contribute to TA need to be stopped in order to ensure optimal growth of newly transplanted hairs. Prolonged TA may be associated with histopathologial evidence of scarring which may in turn affect target density or graft survival. In addition, a proportion of black women with TA have central centrifugal cicatricial alopecia (CCCA). Black women with TA and coexistent CCCA may have inflammatory changes in the frontal hairline which affect graft survival. Objective: To review the incidence of CCCA in black women with traction alopecia presenting for hair transplant consultations over the years 2010-2012 and to present patients with TA referred to the author for evaluation of poor growth of grafts. Materials and Methods: A retrospective review of the clinical records of 43 women with TA seeking advice on hair restoration was performed. In addition, case files of 8 patients with TA referred for evaluation after failing to achieve expected density were also reviewed. Discussion: 43 black women with TA were evaluated. Biopsies were performed in 38 of the 43 women. 27/38 (71%) of women had coexistent CCCA, confirmed by biopsy. In 24 women, biopsies of both the central scalp and frontal scalp were obtained.13 of these 24 women (54 %) had perifollicular inflammatory changes and perofollciular fibrosis in hairs in the frontal hairline which was consistent with a lymphocytic scarring alopecia. 7 of 8 women (88%) with TA (age range 27-46) referred to the authors clinic after failing to achieve expected density were diagnosed with a lymphocytic scarring alopecia in the frontal hairline and mid scalp. 4 women had mild pruritus in the mid scalp prior to their transplant and 4 gave histories of ongoing hair loss in year prior their hair transplant. Iron deficiency was present in 3 women. Conclusion: Black women with TA should be carefully evaluated for possible co-existent CCCA before rendering them good candidates for surgery. Patients with scalp pruritus and ongoing hair loss may indicate a subset of patients requiring additional clinical or histopathological evaluation.

029 Moderator Introduction and Post Finasteride Syndrome Session Panel


Edwin S. Epstein, MD. Bosley, Virginia Beach, VA, USA. Edwin S. Epstein, M.D., has been practicing hair restoration since 1990. He served on the Board of Governors of the ISHRS from 2004-2009, and as President from 2009-2010. Dr. Epstein earned his B.A. degree from Duke University and his M.D. from Georgetown University. He is a Diplomate of the ABHRS, American Board of Urology, and a Fellow of the American College of Surgeons. He joined Bosley in 2006. E.S. Epstein: None.

LernerObjectives PostFinasterideSyndrome Session


PanelMembers: Robert Bernstein, MD Edwin Epstein, MD Dow Stough, MD Ken Washenik, MD PhD Wayne Hellstrom, MD

Updateandreviewofefficacyandsafetyof finasteride1mginandrogeneticalopecia Discusspossibleadverseeventsrelatedtothe useoffinasteride


Reportsofpersistentsexualandothersideeffects afterdiscontinuation Prostatecancer concernsandcontroversies relatedtofinasteride

Disclosures
NorelevantfinancialrelationshipsorCOI

FinasterideTimeLines
1992:Finasteride5mgFDAapprovalforBPH 1997:Finasteride1mgFDAapprovalforAGA 2003:PCPTTrial 2009:MHRA(UK):recommendsbreastcancerwarning
inproductinformation reducedriskofprostatecancerorchemopreventionby5ARIs includepersistentsexualsideeffectsafterdiscontinuation

Dec2010:FDAdeniesproductlabelchangesclaiming April2012:FDAannouncesproductlabelchangesto

ISHRSResponse
April2011:TaskForceonFinasterideAdverseEvents Controversies
DrsBernstein,Epstein,Stough,Washenik April2011:UpdatepostedonISHRSwebsite Sept2012revisionpostedonISHRSwebsite

MultiDisciplinaryColloquium?
Dec2011:Letterssentto8specialtysocietiesto participateinamultidisciplinarycolloquium Aug2012:meetingwithpresidentsofSMSNA,ISSM Oct2012:DrStephenFreedland presentsatISHRS AnnualMeeting:Finasteride:Sotellmedoctor,arethereanyside
effects

PostFinasterideSyndromeFoundation
PrincipalInvestigator: Mohit Khera, M.D. Institution: BaylorCollege ofMedicine; St.LukesEpiscopalHospitalandThe MethodistHospital.

Title: Geneticand EpigeneticStudiesonPost FinasterideSyndrome Patients


Objective:Tostudywhythepatient population of postfinasteride syndrome(PFS)patients develops sexualdysfunction. Methods:To(i)evaluate sexualandpsychological function, (ii) assesshormonelevels, (iii)measure penile hemodynamicandsensoryparameters,(iv) studyandrogen receptor geneticsandgene expression, and(v)anddetermine geneexpression patterns andprofiles.

Title:APreliminary,Hypothesis GeneratingInvestigationofthe PostFinasterideSyndrome: DescriptionofthePhenotype, andElucidationoftheHormonal, GeneticandEpigenetic Mechanisms


Principal Investigator: Shalender Bhasin, M.D.,
DirectoroftheResearchProgramin MensHealth:AgingandMetabolism atBrighamWomensHosp.

Mar2013:SMSNApositionstatementonwebsite

030 Panelist for Post Finasteride Syndrome Session


Robert M. Bernstein, MD. Columbia University, New York, NY, USA. Robert M. Bernstein MD, MBA, FAAD, ABHRS is a Clinical Professor of Dermatology, Columbia University in New York. Dr. Bernstein has been a member of the International Society of Hair Restoration Surgery Task Force on Finasteride Adverse Events since 2011. He is co-author of Finasteride in the treatment of female androgenetic alopecia: An interesting case and review of the literature. Cutis 2012; 90:73-76. R.M. Bernstein: None.

031 Panelist for Post Finasteride Syndrome Session


Dow Stough, MD. 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 completed a cosmetic surgery fellowship sponsored by the American Academy of Dermatology. He is a member of the St. Joseph's Institutional Review Board and is a Certified Clinical Trials Investigator for clinical research. Dr. Stough is a co-founder and past president of the International Society of Hair Restoration Surgery. He is a renowned hair transplant surgeon and has authored/co-authored several textbooks on the field of hair restoration. D. Stough: None.

032 Panelist for Post Finasteride Syndrome Session


Ken Washenik, MD, PhD. Bosley, Beverly Hills, CA, USA. Ken Washenik, M.D., 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. K. Washenik: Employment; Bosley/Aderans, Allergan Advisor, Clinical Investigator. Ownership Interest (owner, stock, stock options); Bosley/Aderans. Ownership Interest (royalty, patent, or other intellectual property); Bosley/Aderans. Consultant/Advisory Board; Johnson and Johnson Healthcare, Allergan.

033 Post Finasteride Syndrome Update: Urologist's Perspective


Wayne J.G. Hellstrom, MD, FACS. Department of Urology, Tulane University, New Orleans, LA, USA. Dr. Wayne J.G. Hellstrom is professor of urology and chief of andrology (male infertility and sexual dysfunction) at Tulane University School of Medicine in New Orleans, where he has been a faculty member since 1988. His practice is specialized in the diagnosis and treatment of male sexual dysfunction including Peyronie's disease, surgical and vascular reconstruction, prosthetic surgery, male infertility (both surgical and medical therapies), male hypogonadism, premature ejaculation, BPH, and urethral stricture disease. W.J. Hellstrom: None. TAKE HOME MESSAGE: 5ARIs are commonly prescribed for BPH and AGA. Through inhibition of 5AR, finasteride and dutasteride result in decreases in several downstream hormones including DHT, 5-DHP, 5-DHDOC, 3-diol, 3,5-THP, 3,5THDOC. The latter three have been identified as functional neurosteroids. Several randomized, placebo controlled, long-term, multicenter trials have evaluated the efficacy and safety of 5ARIs. A pooled analysis of over 62,827 patients demonstrated slightly increased rates of decreased libido, ED, EjD, and gynecomastia among 5ARI users over placebo (1.5%, 1.6%, 3.4%, 1.3%, respectively). Post-marketing surveillance of AEs associated with 5ARI use has questioned whether published results are underreported, with the possibility of some symptoms persisting beyond drug discontinuation. This has resulted in recent modifications to regulatory labeling, although no causal link has been thus far established. Additional RCTs using validated questionnaires are required to more fully assess the true prevalence and potential long-term persistence of AEs resulting from 5ARI use. ABSTRACT: Introduction: 5-reductase inhibitors (5ARI) include finasteride and dutasteride and are commonly prescribed in the treatment of benign prostatic hyperplasia (BPH) and androgenic alopecia (AGA). 5ARIs are associated with several known adverse effects (AE), with varying reported prevalence rates. Aim: To review and summarize findings from published literature detailing AEs associated with 5ARI use. A secondary aim was to review potential mechanisms of action, which may account for these observed and reported AEs. Methods: A pubmed search was conducted on articles published from 1992-2012, which reported AEs with 5ARIs. Priority was given to randomized, placebo-controlled trials. Studies investigating potential mechanisms of action for 5ARIs were included for review. Main Outcome Measures: AE data reported from available trials was summarized and reviewed.

Results: 5ARIs have been associated with several AEs including sexual dysfunction, infertility, mood disorders, gynecomastia, and have debatable associations with high-grade prostate cancer, breast cancer, and cardiovascular morbidity / risk factors. A pooled summary of all randomized, placebo-controlled trials evaluating 5ARIs (n=62,827) revealed slightly increased rates over placebo for decreased libido (1.5%), erectile dysfunction (1.6%), ejaculatory dysfunction (3.4%), and gynecomastia (1.3%). The limited data available on the impact of 5ARIs on mood disorders demonstrate statistically significant (although clinically minimal) differences in rates of depression and/or anxiety. Similarly, there are limited reports of reversible, diminished fertility among susceptible individuals. Post-marketing surveillance reports have questioned the actual prevalence of AEs associated with 5ARI use and suggest the possibility of persistent symptoms after drug discontinuation. Well-designed studies evaluating these reports are needed. Conclusions: 5ARIs are associated with slightly increased rates of decreased libido, ED, EjD, gynecomasia, depression and/or anxiety. Further studies directed at identifying prevalence rates and persistence of symptoms beyond drug discontinuation are required to assess causality.

034 Coffee with the Experts, Table Leader on the Topic of "Stem Cells for Hair Loss"
Mario Marzola, MD. Norwood, Australia. Dr Marzola has been involved hair restoration for 35 years, seeing all the evolving techniques. For three years now he has been studying the latest evolution being cell based therapies. Platelet rich plasma (PRP) and stem cells for many conditions, and now for hair loss. Always interested in CME as a way of keeping up with the best treatments for our patients' benefit. Graduate of Adelaide University, moved from Family Practice to Hair Surgery and General Cosmetic Surgery. Past President ISHRS; Diplomate ABHRS; Fellow Faculty of Medicine Austrlasian College of Cosmetic of Cosmetic Surgery M. Marzola: None.

035 Coffee with the Experts, Table Leader on the Topic of "Stem Cells for Hair Loss"
Ryan J. Welter, MD, PhD. Brown University School of Medicine, NEhair, North Attleboro, MA, USA. Dr. Welter obtained his doctorate in Biochemistry and Molecular Biology from Oklahoma State University and his MD from the University of Oklahoma. He completed his residency at Brown University of Medicine where he remains a clinical associate professor. Research continues to be very important to Dr. Welter, and he continues to be active in clinical trials. In 2005, Dr Welter founded the New England Center for Hair Restoration and NEhair.com having built a state of the art operating suite designed exclusively for accommodating hair transplant surgery and stem cell research. Dr. Welter continues work as a pioneer in the field of hair transplant surgery, working to develop new techniques using stem cells to achieve unparalleled results in hair restoration density. R.J. Welter: None.

036 Coffee with the Experts, Table Leader on the Topic of "Rare Complications of Hair Transplantation"
William R. Rassman, MD. NHI, Los Angeles, CA, USA. In 1991, Dr. Rassman founded the New Hair Institute (NHI), and quickly became a world leader in hair transplant technology. His many innovations in techniques and equipment have been presented at medical meetings around the world, and he published these advances in prestigious medical journals as he pioneered these advances. Dr. Rassman pioneered the Megasession in 1992-4 (he was the first to perform 2000 grafts, 3000 grafts and 4000 grafts in single sessions when most doctors were performing under 100 unnatural appearing large plugs), dense packing of grafts (1994), the Fast Track method of hair transplantation whereby a patient's restoration can be completed in just one or two sessions 1993, The Follicular Unit Transplant (1995) and The Follicular Unit Extraction technology (2002). All of these advances were published in peer-reviewed articles in prestigious medical journals. W.R. Rassman: None.

037 Coffee with the Experts, Table Leader on the Topic of "Reconstructive Hair Restoration"
E. Antonio Mangubat, MD. La Belle Vie Cosmetic Surgery Centers, Tukwila, WA, USA. Dr. Mangubat is a graduate 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 past president of the Hair Foundation that will provide unbiased education raising awareness of hair health worldwide. E. Mangubat: None.

038 Coffee with the Experts, Table Leader on the Topic of "Ten Tips for a Great Consultation"
Nicole E. Rogers, MD. Hair Restoration of the South, Metairie, LA, USA. Dr. Nicole Rogers is an accomplished hair transplant surgeon and board-certified dermatologist. She is in private practice in New Orleans, Louisiana, and serves as Assistant Clinical Professor at Tulane School of Medicine. She completed a fellowship in hair transplantation under the direction of Dr. Marc Avram. Dr. Rogers has been featured on Sirius XM Radio, WebMD, and on numerous local news stations. She has also been quoted in the Wall Street Journal, Better Homes & Gardens, and Real Simple magazine. N.E. Rogers: None.

039 Coffee with the Experts, Table Leader on the Topic of "Finasteride"
Edwin S. Epstein, MD. Bosley, Virginia Beach, VA, USA. Edwin S. Epstein, M.D., has been practicing hair restoration since 1990. He served on the Board of Governors of the ISHRS from 2004-2009, and as President from 2009-2010. Dr. Epstein earned his B.A. degree from Duke University and his M.D. from Georgetown University. He is a Diplomate of the ABHRS, American Board of Urology, and a Fellow of the American College of Surgeons. He joined Bosley in 2006. E.S. Epstein: None.

040 Coffee with the Experts, Table Leader on the Topic of "Finasteride"
Wayne J.G. Hellstrom, MD. Department of Urology, Tulane University, New Orleans, LA, USA.

Dr. Wayne J.G. Hellstrom is professor of urology and chief of andrology (male infertility and sexual dysfunction) at Tulane University School of Medicine in New Orleans, where he has been a faculty member since 1988. His practice is specialized in the diagnosis and treatment of male sexual dysfunction including Peyronie's disease, surgical and vascular reconstruction, prosthetic surgery, male infertility (both surgical and medical therapies), male hypogonadism, premature ejaculation, BPH, and urethral stricture disease. W.J. Hellstrom: None.

041 Coffee with the Experts, Table Leader on the Topic of "Treating the Young Patient"
Vincenzo Gambino, MD. Istituto Medico Quadronno, Milano, Italy. Dr. Gambino is Vice President Board of Governors ISHRS. He serves as Director of Hair Restoration Surgery at San Raffaele University Hospital in Milan. Currently he serves a 3 year term as President of the Italian Society of Tricology (S.I.Tri). A past president, he serves on the Executive Board of The Italian Society of Hair Restoration (ISHR) and is Professor of Hair Restoration Surgery at the University of Florence. He has authored the hair restoration chapters in numerous dermatology text books. V. Gambino: None.

042 Coffee with the Experts, Table Leader on the Topic of "Managing Female Hair Loss"
Paul C. Cotterill, MD. The Cotterill Clinic, Toronto, ON, Canada. Dr Cotterill is a past President of the ISHRS and the current Chair of the ISHRS Continuing Medical Education Committee. He has specialized in hair restoration for over 25 years and has lectured and written extensively on the surgical treatment of hair loss pertaining to females. P.C. Cotterill: None.

043 Coffee with the Experts, Table Leader on the Topic of "Getting Started with FUE"
Michael Vories, MD. Carolina Hair Surgery, Mount Pleasant, SC, USA. Michael Vories, MD practices exclusively Follicular Unit Extraction (FUE) hair restoration surgery in South Carolina. He is a member of the Board of Directors of the American Board of Hair Restoration Surgery and is the Chairman of the ABHRS Oral Examination. He has administered the Oral Examination for the ABHRS for the past 5 years both in Houston and the International Exams in Capri, Italy, Bangkok, Thailand, and Seoul, South Korea. He is the current Chairman of the Admissions Committee of the ISHRS. He has been practicing hair restoration surgery for the past 10 years. M. Vories: None.

044 Coffee with the Experts, Table Leader on the Topic of "Clinical Experience with ARTAS"
Glenn M. Charles, DO. Boca Raton, FL, USA. Glenn M. Charles D.O. Diplomate American Board of Hair Restoration Surgery. Founder and Medical Director of Charles Medical Group. Exclusively practicing hair restoration since 1997. Currently performing microfollicuar unit grafting and FUE procedures. Elected as President of American Board of Hair Restoration Surgery, January, 2011. Member ISHRS since 1998. Appointed member of Core Competencies Committee and Website Committee, 2008. G.M. Charles: None.

045 Coffee with the Experts, Table Leader on the Topic of "Clinical Experience with ARTAS"
Marc R. Avram, MD. New York, NY, USA.

Clinical professor of dermatology Weill Cornell Medical School New York, New York . Private practice 905 Fifth Avenue NY, NY M.R. Avram: Consultant with Restoration Robotics.

046 Coffee with the Experts, Table Leader on the Topic of "Assessing FUE Transection"
Jean Devroye, MD. Brussels, Belgium. Dr Jean Devroye, Doctor of Medicine, Surgery and Obstetrics, specializing in hair restoration for more than 15 years in Brussels Belgium Dr Jean Devroye performs both FUT/FUE techniques and has even developed his own motor for extracting follicular grafts. He takes a very active interest in the latest innovations in his field, attending meetings and workshops all over the world in order to share his experience and knowledge. He is an active member of the ISHRS: He is part of the FUE Research Committee. In 2005, Dr Devroye organized the ESHRS Annual Meeting in his clinic in Brussels and he intends to organize an European Live FUE and FUT Surgery Workshop in 2014 in his brand new clinic in Brussels. J.M. Devroye: None.

047 Coffee with the Experts, Table Leader on the Topic of "Micro-Tattooing"
Jae P. Pak, MD. Los Angeles, CO, USA. Dr. Jae Pak graduated from the University of California Irvine with a Bachelor of Science degree in Aerospace and Mechanical Engineering. His interest in medicine crossed paths with Dr. William Rassmans interest in

engineering in 1997. Since then, the two have been pioneering hair transplant methods, automation, and instrumentation from the initial FUE techniques and tools to Hair Implanting Pen devices which are routinely used at NHI. He has collaborated on U.S. Patents with Dr. Rassman and has been intimately involved with innovative hair transplant surgical techniques incorporating new technology. Dr. Paks training in hair transplant surgery stems from the apprenticeship with Dr. Rassman since 1997 perfecting the art of hair transplantation. Dr. Pak brings his engineering and artistic skills to the clinical practice at New Hair Institute in Los Angeles, California. Dr. Pak continues to develop new surgical techniques and invent surgical instrumentation to further advance the field of hair transplant surgery. J.P. Pak: None.

048 Coffee with the Experts, Table Leader on the Topic of "Tips on Conducting a Hair Transplant Research Study"
Michael L. Beehner, MD. Saratoga Hair Transplant Center, Saratoga Springs, NY, USA. Michael Beehner, M.D. has practiced hair transplant surgery fulltime 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 written several textbook chapters. M.L. Beehner: None.

049 Coffee with the Experts, Table Leader on the Topic of "Tips on Conducting a Hair Transplant Research Study"
Marco N. Barusco, MD. Tempus Hair Restoration, PA, Port Orange, FL, USA.

1- Founder & Medical Director - Tempus Hair Restoration Port Orange, Florida, USA 2- Diplomate of the ABHRS 3- Chairman - American Society of Hair Restoration Surgery (a Chapter of the American Academy of Cosmetic Surgery) 4- Chief Editor for Hair Restoration - American Journal of Cosmetic Surgery M. Barusco: None.

050 Withdrawn 051 Coffee with the Experts, Table Leader on the Topic of "How to Hire and Train Assistants for Your Practice"
Jennifer H. Martinick, MBBS. Salvado Medical, Nedlands, Australia. Dr Martinick is Immediate Past President of the ISHRS, past Program Chair of the ISHRS, past Editor of Cyberspace Chat and has chaired and served on numerous committees. In 2003 she received the Platinum Follicle award, the societys highest award for outstanding achievement in scientific research as it relates to hair restoration She has gained international recognition for her studies on transected hairs and developing the natural looking hairline placement known as the snail tracked hairline. Dr Martinick has developed the Trainer Placer Board for staff training and was the Chair of the Task Force for Training Surgical Assistants, developing a set of videos and PowerPoints for members to train their staff. She is renowned for her restorative work and is deeply committed to its mission of promoting the highest ethical standards in professional hair restoration. J.H. Martinick: None.

052 Coffee with the Experts, Table Leader on the Topic of "How to Hire and Train Assistants for Your Practice"
Tina Lardner Hair Sciences Center of Colorado, Greenwood Village, CO, USA. Tina Lardner is the Surgery Coordinator for Dr. James Harris in Denver, Colorado. She has been involved in hair restoration for 17 years. She has been on the SA Executive Committee since 2007 and was part of the ISHRS Task Force to develop training material for assistants. She has served as faculty for the St. Louis Cadaver Workshop since 2009. She was awarded the 2012 Distinguished Surgical Assistant Award. Currently, she is the section editor and author for the upcoming book Hair Transplant 720. T. Lardner: None.

053 Coffee with the Experts, Table Leader on the Topic of "Surgical Assistants Table: Postoperative Care"
Brooke M. Graham, MA. Anson & Higgins Plastic Surgery, Henderson, NV, USA. My name is Brooke Graham and Im currently a Clinical Coordinator/Lead Hair Tech/M.A. at Anson & Higgins Plastic Surgery, located in Las Vegas, NV. We have three physicians at our office, Dr. Anson M.D. F.A.C.S., Dr. Terry Higgins M.D., and Dr. Alison Tam D.O. (ISHRS) Not only does Dr. Tam do hair transplants, but all aspects of cosmetic dermatology. Ive been working with Dr. Tam for nearly four years. I graduated in 2002 from Tide Water Tech located in Norfolk, VA. After graduating I immediately moved to Las Vegas, NV and started my career as a hair transplant tech. I find great satisfaction in helping patients to feel more confident about their appearance. In my off time I enjoy watching movies and spending time with family. B.M. Graham: None.

054 Moderator Introduction, Recipient Sites and Cosmesis


Sharon A. Keene, MD. Tucson, AZ, USA. Sharon Keene, M.D. is a board certified general surgeon in the solo practice of medical and surgical hair restoration in Tucson, AZ. She has been a pioneer in the use and advancements of follicular unit megasessions, developing instruments to protect grafts and improve ergonomics of surgery. She has performed research on the effect of genetics on response to finasteride therapy in women, and published a series of articles reviewing the probable influence of epigenetic variables which can influence and accelerate hair loss in AGA. S.A. Keene: None.

055 Making Less Look Like More


Antonio Ruston, MD. Clinica Ruston, Sao Paulo / SP, Brazil. Dr. Ruston is a plastic surgeon from Sao Paulo, Brazil. He has been working with HRS for the last 17 years and has been a member ISHRS since 1998. A. Ruston: None. TAKE HOME MESSAGE: In using the available follicular units in the correct manner, a greater aesthetic impact can be achieved and that not only the number of grafts determines the quality of our results, but primarily the manner in which they are used and distributed. ABSTRACT: Introduction: We know that in most cases we do not have sufficient donor area to cover the recipient area with the desired density, especially in these FUE times. Objective: The author will show that in using the available follicular units in the correct manner, a greater aesthetic impact can be achieved and that not only the number of grafts determines the quality of our results, but primarily the manner in which they are used and distributed. Materials and/or Methods After 17 years of experience, the author will show how to optimize the results for each session. To do so, he will show all of the factors that influence a greater "illusion of density". The author separated them in three groups: - major factors: correct distribution of the grafts, angles, patterns, correct use of the follicular units with 1, 2 and 3 hairs, coronal vs. sagittal, and temporal recession (when and how). - minor factors: when to prioritize temporal peaks rather than lowering the hairline, blind and cascade effects and hair style. - new horizons: stem cell and SMP (scalp micro pigmentation) The author will

show not only his cases, but will also use graphic animation, illustrations and celebrity photos to show how to make less look like more. He will also show the inverse, since often we use more than necessary in certain areas in detriment to other areas. In other words, our efforts can be undermined by more being made to look like less. Discussion/Results: We know that homogeneously distributing follicular units over the bald area often times generates a poor result with low density and in treating one area at a time, a denser result is obtained, however the final look is not totally aesthetic until the patient undergoes a second or third surgical session, often "forcing him" to do so sooner than the right moment or than he can afford. In FUE cases this optimization is more important because we usually have fewer grafts for each session compared to conventional FUT cases. The correct distribution of the follicular units has the intention of making the patient the "least bald possible" with totally natural results each session, therefore a new surgical session is optional, and not "required." Conclusion: After many years, the author has reached the conclusion that the correct distribution of follicular units, combined with a state of the art hairline is more important than the total number of follicular units transplanted.

056 State of the Art: Recipient Sites and Graft Placement


Bradley R. Wolf MD. Wolf Medical Enterprises, Cincinnati, OH, USA. Bradley R. Wolf M.D. has been treating hair loss patients since 1990. He has presented over 35 lectures at meetings and workshops throughout the world, was director of all workshops at the 2002 ISHRS meeting, director of the Hands-on FUE workshop ISHRS 2012 meeting, and served as faculty at eight other ISHRS workshops. He is the author of the Anesthesia chapter in the 5th Edition of Hair Transplantation. In 1997 he was awarded a Research Grant by the ISHRS. A past member of the ISHRS Ethics and Website committees, he is a current member of the CME committee. He was awarded first place for poster presentation at the 1999 ISHRS meeting in San Francisco and second place in 2012 at the Bahamas. He is ABHRS Board Certified and was a member of the Board of Directors of the ABHRS from 2000-2005. B.R. Wolf M.D.: None. TAKE HOME MESSAGE: The hair transplant process combines a variety of repetitive skills. Mastering these skills allows the operators to craft growing hair that mimics lost hair while minimizing alterations in the surface and histological anatomy of the scalp. Creating perfectly sized and angled recipient sites and precise, differential (graded) graft placement are critical, rate limiting steps in the hair transplant process. The minute details of these skills must be analysed, recognized, and learned to be able to offer patients the most natural results with greatest yield when transplanting hair. Understanding and implementing the nuances of incision making and graft placement takes experience and more importantly the desire to create the best results possible.

ABSTRACT: Introduction: The hair transplant process combines a variety of repetitive skills. Mastering these skills allows the operators to craft growing hair that mimics lost hair while minimizing alterations in the surface and histological anatomy of the scalp. Creating perfectly sized and angled recipient sites and precise, differential (graded) graft placement are critical, rate limiting steps in the hair transplant process. These steps will be discussed in detail. Premise: Perfectly sized and angled incisions into which graded grafts can be precisely placed are critical and often overlooked when evaluating the outcome of the modern hair transplant process. Substantiating Data: Photos and videos of all components of recipient site creation and differential graft placing will be shown. Before and after patient photos will be shown. Discussion: The hair transplant process consists of graft harvesting, strip dissection, recipient site creation, and graft placement. Recent advances in strip harvesting (single bladed scalpel, superficial incisions, blunt dissection) have reduced follicular destruction prior to graft placement. Motorized FUE devices have decreased graft damage and transection rate. Magnification has reduced graft damage during strip dissection while advanced microscopy has rendered graft dissection easily taught and learned. While follicles can be destroyed and/or damaged prior to placement, the follicular attrition rate prior to graft placement has been reduced to 5% or less in experienced hands. Placers receive grafts in relatively good condition. Even if grafts are of variable size or quality, skilled, differential placing can make up for mediocre or poor dissection as long as the actual follicles from dermal papilla to the supra bulge area are intact prior to placement. To make transplants natural and undetectable it is important to place grafts so that when healed the scalp surface is unaltered. Limiting the depth of incisions is necessary and important. Most grafts are 4mm in length with slight variation. Incisions made too deep cause unnecessary damage, pain, and bleeding. Grafts placed too deeply in incisions made too deep can cause the scalp surface to become pitted after healing, a noticeable scalp surface alteration. Grafts placed too deeply can also cause inclusion cysts in addition to pitting. Grafts placed in incisions made to shallow can cause the dermal papilla to be compressed and damaged, compromising growth. If grafts are placed too shallow and their epidermis is left over one millimeter above the skin, an elevation or bump can be seen at each graft. The epidermis should remain approximately millimeter above the scalp surface after graft placement. This epidermis will slough 7-10 days postop leaving the scalp surface smooth. Leaving the grafts slightly elevated, acts as an important marker to indicate that the graft is not placed too deeply avoiding ugly pitting. Generally follicle length is consistent in each patient so once the depth is set, it remains constant for all grafts. Each time a blade is changed, the depth must be reset. One, two, and three to four hair grafts increase in volume. For perfect fit, the width of incisions for these respective grafts sizes should vary, matching the volume of each graft size. Generally incision size increases by 0.1 to 0.2 millimeters for each larger graft size or 0.70.9mm wide incision for one hair grafts, 0.9 to 1.1mm for two hair grafts, and 1.1-1.3mm for three to four hair grafts. One size and depth incision does not fit all. A few trial incisions for each graft size should be made and grafts inserted to test graft size, depth, and spacing. Incisions placed to close can lead to popping during placement which can cause damage due to repetitive placing trauma decreasing yield. Incisions made too narrow can lead to follicle damage during placing and compression of multihair grafts during growth, visible as over dense areas. Incisions made too wide can cause grafts to spontaneously fall out, movement of the graft within the incision, and misangled growth. Relaxation of elastic fibers due to their being incised during site creation is precisely equal to and compensates for the volumetric increase caused by adding tissue during graft placement when incision width and depth is perfect. When grafts too large are placed into incisions made too small, a volumetric expansion of the scalp tissue can occur causing ridging and negative effects to the scalp surface. These abnormalities can be visible, detracting from the natural results of hair transplantation. Hair exit angles vary greatly in different areas of the scalp. The exit angle of even adjacent hairs can vary. The angle of the incision ideally mimics existing hair to create a natural flow and to avoid damage to existing hairs when present. Damage to existing hair can lead to permanent shock loss. In the absence of existing hairs, incision direction is based on experience or reference. Precise placement of grafts is one of the most important, if not the most important, skills to be mastered. Differential, or graded, placement refers to first, grading, or closely examining each graft and each hair in the graft, prior to placement, based on the structural integrity of the hair and the chance it will regrow. For example, all two hair grafts are not equal, one of the two hairs may be miniaturized or of questionable structural integrity/quality. After grading, the best

grafts or ones most likely to have all hairs grow, should be placed in areas of greatest cosmetic priority. Grafts of lesser quality are cosmetically hidden by being placed in areas of lesser cosmetic importance either at the time of grading or set aside and placed at the end of the case. One hair grafts are graded for diameter as well as potential to regrow. The highest graded thin to moderate diameter hairs are placed in the front row of the hairline while the thickest single hairs are place in the second and/or third row depending on hair/skin colormatch. Hair shafts exit the top of grafts at an angle, they are rarely perpendicular to the graft epidermis. Therefore there is always an acute and obtuse angle associated with this hair shaft exit which is important in determining hair direction and flow after placement. During graft placement into incisions there are two options, placing the acute angle forward or backwards. The acute angle should always be placed forward or in the direction the hair is intended to grow based on the angle of the incision. In the hairline and frontal aspect the acute angle should be anterior while in the crown it is oriented posterior. There are variations laterally. Grafts should be grasped with the acute angle forward and placed as such. If the acute angle is posterior the graft should be rotated during insertion or spun after insertion. When placed properly the epidermis of the graft will be in the same orientation as the curvature of the scalp helping to leave the scalp surface unaltered after healing. Anesthesia and hemostasis are of the utmost importance. Anesthesia and the vasoconstrictive effect of epinephrine wear off simultaneously. When patients begin to feel pain, they begin to bleed. Bleeding acts as a hydraulic pump, pushing grafts out of incisions after placing which can lead to repetitive placing trauma, decreasing yield. Care must be taken to avoid trapping existing hairs under grafts during placement either by clearing the area of the incision prior to placement or removing trapped hairs after placement. The former is preferable. If hairs remain under grafts in the incisions, grafts can be popped out postoperatively during combing causing bleeding and decreased yield. Understanding and implementing the nuances of incision making and graft placement takes experience and more importantly the desire to create the best results possible.

057 Cosmesis in Hair Restoration Surgery? Does It Matter?


Jennifer H. Martinick, MBBS. Salvado Medical, Nedlands, Australia. Dr Martinick is the immediate Past President of the ISHRS, a past Program Chair of the ISHRS, past editor of Cyberspace Chat and currently serves as Secretary 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 societys 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. J.H. Martinick: None. TAKE HOME MESSAGE: Minor steps, major improvement. ABSTRACT: Cosmesis refers to the surgical correction of a defect or cosmetic improvement made by a surgeon following incisions. It is generally limited to the additional minor steps that a surgeon takes to improve the aesthetic appearance of an operation. A major problem with hair transplantation is that it appears to be a remarkably easy form of surgery to perform. 'A bad hair transplant is due to inexperience, poor technique, or failure to properly plan on the part of the surgeon. The Internet is full of complaints regarding incompetent and unskilled surgeons; this is directly due to surgeons who do not attend meetings or workshops and have little idea about the artistry as well as the surgery component required to carry out a state-of-the-art hair transplantation.The author assumes that all grafts have been harvested by FUT or FUE. The author also assumes that the clinic practices quality control in graft preparation, and the grafts have been kept in suitable holding solutions, and that the patient is suitable for hair transplantation. The paper will concentrate on all the aspects of cosmesis using photos of poor results as well as demonstrating how to avoid poor outcomes in the future.

058 Female Hairline Extension Technique


Bertram M. Ng, MBBS. Dr Bertram Hair Transplant, Kowloon, Hong Kong. Dr Bertram Ng has his Hair Transplant practice in Hong Kong. He is an ISHRS Certified Fellow after completing the one year training program with Dr Pathomvanich. He is also an ABHRS Diplomate and examiner. In 2013 Dr Ng is appointed Director of the board. His main interest is in Hairline Restoration. In 2008 he invented a hand-held laser device in hairline placement.

B.M. Ng: None. TAKE HOME MESSAGE: The concept of an extension is very important in female hairline design. The new hairline should follow the flow of existing hairs rather than an island of hairs. ABSTRACT: Introduction: 95% of hair loss in man is from Androgenetic Alopecia. Receding hairline is a typical presentation. Hair transplant helps to restore this once existed hairline. The term hair restoration surgery is therefore appropriate. In female a receding hairline is atypical of AGA. In fact the occurrence raises the suspicion of an underlying pathological condition such as Frontal Fibrosing, Alopecia Areata, or Hirsutism. There are 3 major groups of female patients requesting hairline restore: 1. Congenital high forehead or fronto-temporal thinning; 2.Undergone cosmetic surgery 3.Transgender Since they never have that hairline before, the term restore may not be appropriate. We use the term female hairline extension to refer to: 1.Lowering the hairline to a never existed level; 2.Rounding up the apexes for a more feminine look; 3.Changing the shape of the hairline. The concept of an extension is very important in female hairline design. The new hairline should follow the flow of existing hairs rather than an island of hairs. The Hairline Extension Technique The key consideration is matching the transplanted hair to existing hair, especially at the temporal point. - Hairline Design 1. 2. 3. 4. 5. 6. 7. Draw 3 points as shown (Fig. 1); Look at the existing hair and draw a line to extend it 1-2cm (Fig. 2); Check for the natural parting. Extend the lines into smooth curves crossing the fronto-temporal triangle to blend into the temporal point, paying attention to the hair direction (Fig. 3). Existing cowlicks are also extended; Fine tune the curve to create the desired pattern (Heart shape, Inverted-U..etc) or a widow peak. The natural flow of the hair actually pre-determine the pattern and whether a widow peak is natural; Finally check for symmetry.

- Incision and implantation 1. 2. 3. 4. 5. - Result Before (Fig. 5) and after (Fig. 6) pictures show the result of 2,349 grafts (4,361 hairs) after 12 months. More pictures will be shown during the presentation Discussion - Potential for Female Hairline Extension Coronal incision is recommended for the front rows of 1-hair grafts to better control the hair insertion angle (Fig. 4); Incision is made in a special way (shown in video); Allow for more 1 hair at the fronto-temporal areas; Sagital incisions are used for the rest especially in areas with existing hairs; The curvature of the grafts should be adjusted during implantation

It was widely accepted that only 15% of female with hair loss is candidate for hair transplant. The concerns are shock loss, poor donor hair quality, underlying inflammatory causes, and progression of female pattern hair loss with age. This however addresses more to add-on-density. Many ladies seeking hairline restore do not have severe FPHL. The quality of donor hair is usually good. The small to-be-transplanted area does not require mega- or Giga-session. Surgeon with an intermediate level of skill can easily manage the 2000 plus grafts required. Female hairline extension is rewarding as the visual improvement is permanent. Also there is less worry for donor scar and future hair loss. Most females wear long hair and are more ready to accept a hairpiece. Shock loss is less often when working on a no hair area. - Problem with existing techniques The main technical problem is achieving the desired naturalness. The surgeon usually draws an arbitrary hairline to the patients liking (Fig. 7). Incisions can be sagital or coronal. Problems can arise from: 1. 1. 2. 3. 4. Hairlines being too rigid when incisions in the front row are made across the forehead one next to each other. 2.Mounds and humps are artificially created to mimic the natural pattern; 3.Transplanted hair not matching the existing hair in angle and direction, especially when there is a cowlick; 4.The new hairline pattern not matching the natural hair flow; 5.The created parting is always at the center, not matching the existing one.

- Female Hairline Extension vs. hairline advancement 1.Speed - the latest hairline advancement can change the appearance within a couple of weeks instead of months; 2.Naturalness - Unless combined with follicular unit transplant, hairline advancement cannot achieve the naturalness of hairline extension.

2013/9/3

Conflict of Interest
I have nothing to declare

Female Hairline Extension Technique


Dr Bertram Ng (Hong Kong)

Introduction
95% of hair loss in man is from Androgenetic Alopecia. Receding hairline is a typical presentation. Hair transplant helps to restore this once existed hairline. The term hair restoration surgery is therefore appropriate In female a receding hairline is atypical of AGA In fact the occurrence raises the suspicion of an underlying pathological condition such as Frontal Fibrosing, Alopecia Areata, or Hirsutism

Definition
Since they never have that hairline before, the term restore is not appropriate We use the term female hairline extension to refer to: - Lowering the hairline to a never existed level; - Rounding up the apexes for a more feminine look; - Changing the shape of the hairline.

Candidates
3 major groups of female patients requesting hairline restore Congenital high forehead or fronto-temporal thinning Undergone cosmetic surgery Transgender

Key Concepts
Concept of an extension is very important in female hairline design New hairline should follow the flow of existing hairs, rather than an island of hairs The key consideration is matching the transplanted hair to existing hair, especially at the temporal point

2013/9/3

Step 1 : Hairline Design


Draw 3 points as shown

Step 1 : Hairline Design


Existing cowlicks are also extended Fine tune the curve to create the desired pattern (Heart shape, InvertedU..etc) or a widow peak. The natural flow of the hair actually predetermine the pattern and whether a widow peak is natural Finally check for symmetry

Look at the existing hair and draw a line to extend it 1-2cm Check for the natural parting Extend the lines into smooth curves crossing the fronto-temporal triangle to blend into the temporal point, paying attention to the hair direction

Step 2 : Incision and implantation


Coronal incision is recommended for the front rows of 1-hair grafts to better control the hair insertion angle Incision is made in a special way Allow for more 1 hair at the fronto-temporal areas Sagittal incisions are used for the rest especially in areas with existing hairs Curvature of the grafts should be adjusted during implantation

Result
Before and after pictures will be shown during the presentation

Video Here

Potential for Female Hairline Extension


It was widely accepted that only 15% of female with hair loss is candidate for hair transplant The concerns are shock loss, poor donor hair quality, underlying inflammatory causes, and progression of female pattern hair loss with age This however addresses more to add-on-density

Discussion

2013/9/3

Potential for Female Hairline Extension


Many ladies seeking hairline restore do not have severe FPHL Quality of donor hair is usually good The small to-be-transplanted area does not require mega- or Giga-session Surgeon with an intermediate level of skill can easily manage the 2000 plus grafts required

Potential for Female Hairline Extension


Female hairline extension is rewarding as the visual improvement is permanent Also there is less worry for donor scar and future hair loss Most females wear long hair and are more ready to accept a hairpiece Shock loss is less often when working on a no hair area

Problems with Existing Technique


The main technical problem is achieving the desired naturalness The surgeon usually draws an arbitrary hairline to the patients liking Incisions can be sagittal or coronal Grafts are inserted to fill up the marked area

Problems with Existing Technique


Problems can arise from: Hairlines being too rigid when incisions in the front row are made across the forehead one next to each other Mounds and humps are artificially created to mimic the natural pattern Transplanted hair not matching the existing hair in angle and direction, especially when there is a cowlick The new hairline pattern not matching the natural hair flow The created parting is always at the center, not matching the existing one

Female Hairline Extension vs. Hairline Advancement


Speed the latest hairline advancement can change the appearance within a couple of weeks instead of months Naturalness Unless combined with follicular unit transplant, hairline advancement cannot achieve the naturalness of hairline extension.

Unisex Hairline Design


More men are actually seeking a softer hairline with a rounded apex The hairline extension approach can also be applied

FRIDAY/OC TOBER 25, 2013


6:00AM-6:00PM 6:30AM-6:00PM 6:30AM-6:00PM 7:00AM-8:30AM 8:15AM-9:15AM 8:15AM-5:30PM 9:00AM-5:35PM 9:00AM-9:52AM Speaker Ready Room Registration Poster Viewing Workshops 201, 202, 203, 204, 205
(ticket required)

D AY- B Y- D AY P R O G R A M

10:45AM-11:45AM

N orwood L ecture
LEARNING OBJECTIVE Review the latest developments in hair follicle cloning, regeneration, and other prospective developments and discuss their relevance to clinical practice.

Continental Breakfast Exhibits GENERAL SESSION

10:45AM-10:48AM 3 Moderator Introduction 065 Bessam K. Farjo, MBChB 10:48AM-11:18AM 30 NORWOOD LECTURE Hair Follicle Cloning, Regeneration, and Other Prospective Developments for the Transplant Clinic Where Are We Now? Featured Guest Speaker Colin Jahoda, MD, PhD 066
Professor, School of Biological and Biomedical Sciences, Durham University, U.K.

A natomy

and

B asic S cience

LEARNING OBJECTIVE Discuss new concepts of scalp and eyelash anatomy and the effect of aging on male scalp hair.

9:00AM-9:02AM 2 Moderator Introduction Damkerng Pathomvanich, MD 059 9:02AM-9:09AM 7 Study of Temple Pattern and FrontoTemporal Point in Asian Men without Male Pattern Baldness Prapote Asawaworarit, MD 060 9:09AM-9:16AM 7 Miniaturization in the Donor Christian Bisanga, MD 061 9:17AM-9:25AM 8 Anatomy and Arrangement of Human Eyelashes Useful and Practical in Eyelash Transplantation Sheida Abbasi 062 9:25AM-9:32AM 7 Temporal Points Their Importance and Impact on a Youthful Appearance and as a Prognosis for Baldness Antonio S. Ruston, MD 063 9:33AM-9:42AM 9 The Phenotype of Hairline Evolution William R. Rassman, MD 064 9:42AM-9:52AM 10 Q&A 9:55AM-10:40AM 10:30AM-10:45AM

11:18AM-11:23AM 5 Q&A 11:23AM-11:30AM 7 Multi-Centre, International, Randomized Investigation as to the Efficacy of Adipose Derived Mesenchymal Stem Cells for Stimulating Hair Growth in Androgenic Hair Loss Patient Ryan J. Welter MD, PhD 067 11:30AM-11:40AM 10 Highlights from the 7th World Congress for Hair Research 068 Nilofer P. Farjo, MBChB 11:40AM-11:45AM 5 Q&A 11:45AM-12:00PM 12:00PM-2:00PM Break for hotel to set the room for lunch symposium, attendees can visit the exhibits Lunch Symposia 211, 212, 213, 214
(ticket required) 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. Handouts for lunch symposia are available as electronic PDFs only. They were e-mailed to all registrants prior to the meeting. The handout PDFs are also on the desktops of the Internet Caf computers.

G eneral M embership B usiness M eeting & S ervice Awards


Coffee Available

FRI

D AY- B Y- D AY P R O G R A M

2:15PM-3:18PM

A dvancing

the

FUE Technique

3:20PM-4:05PM

LEARNING OBJECTIVES Describe the various techniques and instruments that can be used for FUE including their advantages and disadvantages. Evaluate donor area safety in FUE procedures. Discuss techniques to reduce follicle transection rates in FUE procedures.

E nhancing D onor M anagement H arvesting

in

S trip

LEARNING OBJECTIVE Describe the various techniques that can be used to improve donor area healing in FUT including their advantages and disadvantages.

2:15PM-2:17PM 2 Moderator Introduction 069 Ken L. Williams, DO 2:17PM-2:24PM 7 How Image Processing in FUE Harvesting Can Be Used in Calculating the Reduction of Skin Trauma by Injecting Normal Saline Georgios Zontos, MD, PhD, MSc, BSc 070 2:24PM-2:31PM 7 Controlling FUE Transection Rate with Difficult Scalp Character Juyong Kim, MD 071 2:32PM-2:39PM 7 Overshooting the Safe Donor Zone in Mega Session of FUE Technique Suneet Soni, MD 072 2:39PM-2:46PM 7 The Use of a Suction Apparatus to Improve Wound Healing of FUE Sites Paul T. Rose, MD, JD 073 2:46PM-2:53PM 7 Unfavorable Results with FUE Technique. Have We Come Full Circle? Tejinder Bhatti, MCh 074 2:54PM-3:01PM 7 Vacuum Assisted Follicle Extraction Device (VAFED), an Innovative Device for FUE with Negligible Follicle Transection and Easy to Learn Methodology Anil K. Garg, MS, MCh 075 3:01PM-3:08PM 7 Electrolysis Assisted Follicular Unit Extraction (An Innovation in Hair Harvesting) 076 Shahin Gholami, MD 3:08PM-3:18PM 10 Q&A

3:20PM-3:22PM 2 Moderator Introduction 077 Henrique N. Radwanski, MD 3:22PM-3:28PM 6 The Roles of Injected Steroid in Donor Strip Wound Healing 078 Bertram M. Ng, MBBS 3:28PM-3:35PM 7 Efficacy and Safety of Low Dose Enalapril in Minimizing Linear Donor Scars from Hair Restoration Surgery Prapote Asawaworarit, MD 079 3:36PM-3:42PM 6 Partial Trichophytic Closure - A Calculated Approach in Performing Double Edged Trichophytic Closure for Improving the Appearance of Scalp Scar Parsa Mohebi, MD 080 3:42PM-3:48PM 6 Novel Application of Hyaluronidase on Scalp Laxity 081 Wen-Yi Wu, MD 3:48PM-3:55PM 7 The Use of a Long Acting Anesthetic to Diminish Post Operative Pain in Hair Transplant Patients Paul T. Rose, MD, JD 082 3:55PM-4:05PM 10 Q&A 4:05PM-4:20PM

P oster O verview S ession


LEARNING OBJECTIVE Review key points relating to a variety of studies and surgical pearls regarding hair restoration surgery.

4:05PM-4:20PM 15 Poster Overview 083 Robert S. Haber, MD 4:20PM-4:50PM 4:50PM-5:35PM Poster Inquiry Session during Coffee Break

H airline D esign Panel


LEARNING OBJECTIVE Compare and contrast different surgeons approaches to designing hairlines and temporal points.

4:50PM-5:35PM 45 Moderator Introduction and Hairline Panel 084 Russell G. Knudsen, MBBS Surgeon Designers: Kapil Dua, MD, 085 Russell G. Knudsen, MBBS & Mauro Speranzini, MD 086 6:00PM-8:00PM 8:00PM-9:30PM ISHRS & ABHRS M&M Conference
(ticket required)

Presidents Annual Giving Fund Reception


(ticket required)

FRI

059 Moderator Introduction, Anatomy and Basic Science


Damkerng Pathomvanich, MD, FACS. DHT Clinic, Bangkok, Thailand. Dr. Pathomvanich is the Director of the DHT clinic in Bangkok, Thailand and has been one of the Directors of the ISHRS Fellowship Training Program in hair restoration surgery for 8 years. He is a Diplomate of the American Board of Hair Restoration Surgery, American Board of Surgery and Fellow American College of Surgeon and has been performing hair restoration surgery for the past 22 years. He has published many articles in Hair Forum International, Dermatologic Surgery Journal and text books. He received the Golden Follicle Award in 2010 during the ISHRS Annual Scientific Meeting in Boston, USA and the Asian Follicle Award in 2012 during the 2nd Annual Meeting of the Asian. D. Pathomvanich: None.

060 Study of Temple Pattern and Fronto-Temporal Point in Asian Men without Male Pattern Baldness
Prapote Asawaworarit, Damkerng Pathomvanich, MD,FACS, Anand Kumar Vaggu, MD, Shobit Caroli, MBBS. DHTclinic, Bangkok, Thailand. Doctor of Medicine Faculty of Medicine, Prince of Songkla University, Thailand Internship Thammasat University Hospital, Thailand Master of Science in Dermatology Faculty of Medicine, Srinakharinwirot University, Thailand Fellowship in Hair Restoration Surgery approved by ISHRS DHT Clinic, Bangkok, Thailand P. Asawaworarit: None. D. Pathomvanich: None. A.K. Vaggu: None. S. Caroli: None. TAKE HOME MESSAGE: In this study, a method of creating normal fronto-temporal point is described and the normal shape of the temple is found to be isosceles triangle. Both temporal and fronto-temporal points are angulated in shape in majority of individuals and most commonly observed angle at temporal and fronto-temporal point is 90 and 80 respectively. ABSTRACT:

Introduction For temple hair restoration, temporal scalp designing is important, which further needs describing normal temple pattern and normal fronto-temporal point. Previous studies on classification of recession of temporal peaks which was not described in Hamilton and Norwood classification, do not described the normal temple pattern. Currently young patients are approaching for restoration of alopecic fronto-temporal triangles. The most important decision in these patients is location of normal fronto-temporal point to design the natural hairline. So we have done a pilot study on 100 Asian men who have no androgenetic alopecia. We made an attempt to study the normal temple pattern in men - including shape of temple and temporal point, angles, direction of hair and normal fronto-temporal point location. Objective To study the temple pattern in 100 Asian men without male pattern baldness and a method to create a frontotemporal point. Material and Methods 100 Asian men who were randomly enrolled. The age range was 20yrs and above and do not have male pattern baldness. In each person, the distance between fronto-temporal point to temporal point(A), temporal point to side burn point (B), and front-temporal point to side burn point (C) were measured(Figure 1). Angles at all these points were also recorded. The distance from a point on lateral orbital rim opposite to lateral canthus to temporal point (E) and from the same point to sideburn point (F) was obtained. Direction of hair was recorded. Shape and angles of the frontotemporal point and temporal point were also noted. While recording all these points, we noticed the extension of line between mandibular angle point and side burn point meet at fronto-temporal point on lateral fringe. So this finding was also examined additionally in all the men Results Out of 100 men, 53 are between 20-29 years age group, 24 are 30-39, 11 are 40-49, 8 are 50-59 and 4 are 60-69 yrs age group. Temple shape is noted as Isosceles triangle (Table 1) (Fig 1) in 75% of men where the length A is equal to the length B and 25% showed non-isosceles triangle. Similarly internal angle at fronto-temporal point and sideburn point is same in 75% of men. Most common angle noticed at temporal point is 90 (48%).. On observation, in all age groups, pointed (angulated,80%) shape of the temporal point is more common than round (convex,20%) shape. At frontotemporal point, the most common angle observed is 80 in 44%, followed by 70 in 21% and 90 in 17% (table 3). Pointed (Angulated) shape is seen in 88% whereas convex (round) shape is seen in 12% In 78% of men, superior extension of the line joining the mandibular angle to the sideburn point ended at fronto-temporal point on lateral fringe. The length of E and F are equal in 75%.The length E of right side and length E of left side are equal in all the patients. Table 1) Temple pattern in different age groups. Age group Number of people No of men showing Isosceles triangle No of men not showing Isosceles triangle. 20-29 30-39 40-49 50-59 60-69 Total 53 24 11 8 4 100 40 18 8 6 3 75 13 6 3 2 1 25

Table2). Temple point angle in different age groups. Temple point angle 20-29 30-39 40-49 50-59 60-69 Total No of Men

70 80 90 100 110 120

1 12 27 11 0 2

0 4 12 6 2 1

0 1 4 6 0 0

0 0 3 4 0 1

0 0 2 2 0 0

1 17 48 29 2 3

Discussion In our study, in majority of men, temple shape is noted as isosceles triangle. That means the distance from temporal point to fronto-temporal point and temporal point to sideburn point is equal. We noticed superior temple line i.e the line from fronto-temporal point to temporal point, is neither convex nor concave but it is a straight-line with irregularity like frontal hairline. Both temporal and frontotemporal points are angulated in shape in majority of males (80% & 88% respectively). And most commonly observed angle at temporal and frontotemporal points is 90 and 80 respectively. According to our observations in the study, in 93% of men, the line joining the mandibular angle to side burn point is meeting at fronto-temporal point on lateral fringe, on extending superiorly. So creating a frontal hairline lower than this point at fronto-temporal region, gives an unnatural appearance. This point also guides us in creating superior temporal hair line by joining this point to temporal point. . Conclusion In this study, a method of creating normal fronto-temporal point is described and the normal shape of the temple is found to be isosceles triangle. Both temporal and fronto-temporal points are angulated in shape in majority of individuals and most commonly observed angle at temporal and fronto-temporal point is 90 and 80 respectively.

STUDY OF TEMPLE PATTERN AND FRONTO-TEMPORAL POINT IN ASIAN MEN WITHOUT MALE PATTERN BALDNESS
Ihavenoconflictofinteresttodeclare
Anand Kumar Vaggu, MD Shobit Caroli, MBBS Damkerng Pathomvanich, MD, FACS Prapote Asawaworarit, MD
path_d@hotmail.com DHT Clinic, Bangkok, Thailand

Background

Background

Hair restoration surgeons did not reconstruct temporal area for the fear of unnatural results in the past, till the advent of follicular unit grafting ,temporal transplanting has become popular

For temple transplantation, it is paramount that surgeon needs to know how to design Normal temple pattern and fronto-temporal point need to be addressed

Background

Objectives

To my knowledge, there has been no study regarding temple pattern in none-androgenic alopecia

To study the temple pattern in Asian men without male pattern baldness To identify the shape and angle of temple point and fronto-temporal angle

Study Design
We randomly studied temple pattern in 100 Asian males They were 20yrs and above and do not have male pattern baldness

Materials and Methods


Measured the distance between

Fronto-temporal point to temporal point(A) Temporal point to side burn point (B) Front-temporal point to side burn point (C)

All the angles at these points were recorded

Materials and Methods


Measured the distance between

Materials and Methods

The point on lateral orbital rim opposite to lateral canthus and temporal point (E) The point on lateral orbital rim opposite to lateral canthus and sideburn point (F)

Materials and Methods


Recorded Hair direction Shape and angles of the frontotemporal and temporal point The extension of line between mandibular angle point and side burn point meet at frontotemporal point on lateral fringe

Materials and Methods

Materials and Methods

Results

Temple pattern in different age groups

Temple point angle in different age groups


Temple point angle 70 80 90 100 110 120 20-29 30-39 40-49 50-59 60-69 Total No. of men 1 17 48 29 2 3

Age group

Number of people

No of men showing Isosceles triangle

20-29 30-39 40-49 50-59 60-69 Total

53 24 11 8 4 100
.

40 18 8 6 3 75

No of men not showing Isosceles triangle 13 6 3 2 1 25

1 12 27 11 0 2

0 4 12 6 2 1
.

0 1 4 6 0 0

0 0 3 4 0 1

0 0 2 2 0 0

Fronto-temporal angle in different age groups


Frontotemporal angle 70 80 90 100 110 120 20-29 30-39 40-49 50-59 60-69 Total No. of men 12 21 44 17 29 2

Shapes of Temple and Fronto-temporal in different age groups

Age group

5 11 26 9 9 1

5 2 10 5 1 1
.

1 6 2 2 0 0

1 1 4 1 2 0

0 1 0 1 2 0

Temple Pointed Round (Angulated) (convex) 42 19 9 7 3 80


.

Fronto-temporal Angulated Round 50 18 9 8 3 88 3 6 2 0 1 12

20-29 30-39 40-49 50-59 60-69 Total

11 5 2 1 1 20

Shapes of Temple and Frontotemporal

Direction of hair along the superior temporal hair line

% of Men 73 14 8 5

Temple shape Angulated Round Round Angulated


.

Frontotemporal shape Angulated Angulated Round Round

Right side Posterio-inferiorly Posterio-inferiorly Anterio-inferiorly

Left side Posterio-inferiorly Anterio-inferiorly Anterior-inferiorly

No. of men 55 43 2

Direction of hair along the inferior temporal hair line

Defining of frontotemporal point by extension of line from mandibular angle to sideburn point in different age groups

Right side Posterio-inferiorly Posterio-inferiorly Anterio-inferiorly

Left side Posterio-inferiorly Anterio-inferiorly Anterior-inferiorly

No. of men 55 43 2 Defining Not defining

20-29 40 13

30-39 18 6

40-49 8 3

50-59 7 1

60-69 3 1

Total 78 22

Discussion

Discussion

Both temple and frontotemporal points are angulated in shape Temple point is 90 Frontotemporal point is 90

93% of men, the line joining the mandibular angle to side burn point is meeting at frontotemporal point on lateral fringe, on extending superiorly The hair line appears to be higher than the fronto-temporal point This point also guides us in creating superior temporal hair line by joining this point to temporal point
.

Discussion

Conclusion

Majority of the people (55%), hair direction along the superior temporal line is directed posterio-inferiorly on both sides 43% are anterio-inferior on left side and posterior-inferior on the right

Most commonly observed temporal and frontotemporal angle is 90 Most people have angulated temporal and frontotemporal points

Thank you
path_d@hotmail.com DHT Clinic, Bangkok, Thailand

061 Miniaturization in the Donor


Christian Bisanga, MD1, Teresa Meyer-Gonzalez, MD2, Antonio Alcaide-Martin, MD2. 1 BHRClinic, Brussels, Belgium, 2Meyerhairtransplant Clinic, Malaga, Spain. Dr. Bisanga is actively involved in studies and research within the hair transplant industry. He has developed his own methods of extracting grafts and protocol while performing Follicular Unit Extraction (FUE) methods. In June 2005, Dr. Bisanga presented a lecture for the European Society of Hair Restoration Surgery in Brussels on the Follicular Unit Extraction (FUE) and Follicular Unit Transplantation (FUT) methods. Actually his work is focused in the study of the donor and characteristics of the hair follicle. C. Bisanga: None. T. Meyer-Gonzalez: None. A. Alcaide-Martin: None. TAKE HOME MESSAGE: When miniaturization affects a persons donor area, it will effectively reduce the available donor hair supply and decrease the chances that a patient will be a candidate for hair transplantation. Evaluation of the donor is very useful in planning the surgery since it gives the doctor a great deal of information regarding the available donor supply and the quality of a persons follicular unit grafts. ABSTRACT: Introduction: Miniaturization is a process whereby hair follicles that were once producing healthy hairs begin to produce thinner, shorter, more brittle hairs with weaker shafts. These hairs become less dense and lead to the appearance of hair loss. Evaluating a patient with clear-cut androgenetic alopecia for hair transplantation generally consists of the physician determining which Norwood Classification a person fits into, designing a hair line, examining the donor area and then deciding upon an appropiate number of grafts. The issue of the patients measured hair density is rarely called into question. However, miniaturization in the donor is rarely studied by many physicians in patients with androgenetic alopecia. Objective: The purpose of this study is to evaluate the clinical and histological characteristics of those patients with androgenetic alopecia and miniaturization in the donor area, compared to patients with androgenetic alopecia and no miniaturization evident in the donor. Material and Methods: An observational study of 15 patients who were diagnosed with androgenetic alopecia and miniaturization in the donor underwent a complete medical history and a skin biopsy to study the characteristics of the follicles and determine if there were any epidemiological or histological difference between patients with miniaturization in the donor and patients with no miniaturization apparent. Conclusion: When miniaturization affects a persons donor area, it will effectively reduce the available donor hair supply and decrease the chances that a patient will be a candidate for hair transplantation. Evaluation of the donor is very useful in planning the surgery since it gives the doctor a great deal of information regarding the available donor supply and the quality of a persons follicular unit grafts.

062 Anatomy and Arrangement of Human Eyelashes Useful and Practical in Eyelash Transplantation
Sheida -. Abbasi, medical studen1, Ali abbasi2. 1 islamic azad university of tehran, Tehran, Iran, Islamic Republic of, 2Abbasi Hair clinic, Tehran, Iran, Islamic Republic of. Medical Student and a Co-Researcher in Abbasi Hair Clinic S.-. Abbasi: None. A. abbasi: None. TAKE HOME MESSAGE: Knowing well about anatomy or arrangement of eyelashes is necessary, so without this knowledge, any eyelash transplant will result in disaster. If hair transplant of scalp is art, eyelash-transplant is masterpiece of art,and any undesirable result of H.T on scalp is restorable ,but undesirable result of eyelash transplant is disaster. Hope this lecture will be useful and practical for all audiences likely to do eyelash transplants. ABSTRACT: If hair transplant(H.T) of scalp is art,Eyelash-transplant is masterpiece of art, any undesirable result of H.T on scalp, is restorable, but Undesirable result of Eyelash transplant is disaster, so in order to avoiding Disaster, considering natural arrangement and anatomy of eyelashes is essential. The eyelash is structurally very close to the curly human scalp hair but some biological processes related to eyelash follicle cycle and pigmentation is markedly different, as well as the thinness of the eyelid epidermis, the absence of a hypodermis and the shortness of eyelash follicles cycle could be associated with these specific features. The duration of the eyelash follicle Anagen phase is strikingly shorter and growth rate is lower than the scalp hair follicle, all eyelashes are characterized by a tendency to bend from the bulb to the tip of the shaft. The eyelashes grow in rows of 4-5 in the upper and 2-3 in the lower lid. The mean number of eyelashes is 300-400 in the upper and 100-150 in the lower lid, while their length varies from 8 to 12 mm in the upper and from 6 to 8 mm in the lower lid. Material and method: In this study twenty Asian female and male Volunteers, aged between 26 and 56 years old were enrolled. In order to evaluate the eyelashes character, we took photos from front, upper and lower left and right view to review the characters of Eyelash (length, color, curl and arrangement) by using a high-resolution camera. Discussion: The earlier development of the eyelashes occurs at about the 9th weeks of gestation in region of upper lids. Role of the eyelashes: Blink reflex of eyelashes helps to prevent the eyes from trauma and foreign body particles also Eyelashes play an important role in beauty of face and eyes. The upper lids lashes grow upwards and they have a curved Shape. They are darker, longer and denser than lower eyelashes. On account of this kind of arrangement the upper and lower eyelashes dont interlace while the eyelids are closed. They grow in rows of 4-5 in the upper and 2-3 in the lower lid (1). Their mean number of eyelashes is 300-400 in the upper and 100-150 in the lower lid, while their length varies from 8 to 12 mm in the upper and from 6 to 8 mm in the lower lid (2, 3) .Eyelashes follicles compare with scalp hair follicle are free of arrectorpili muscle (1).There are a number of glands known as Zeis and Moll glands. (1, 2) Zeis glands are unilobar sebaceous glands, located on the margin of the eyelid. They produce an oily substance released through the excretory duct of the sebaceous lobule into the middle portion of the eyelash follicle. Moll glands are modified apocrine sweat glands that are found on the margin of the eyelid. They are next to the base of eyelashes, and anterior to Meibomian glands within the distal eyelid margin. Meibomian glands are sebaceous glands that secrete lipids and form a tear film. There are roughly 50 glands in the upper eyelids and 25 glands in the lower eyelids (1). The eyelash is characterized by a regular curved shape, eyelash cross-sections revealed a structure very close to the scalp hair, from the outside to the inside: 1) the cuticle, 2) the cortex (including melanin pigments, and 3) the

medulla (2,3). The length of eyelash is much shorter than scalp hair, due to a shorter hair cycle. The duration of the eyelash follicle Anagen phase was strikingly shorter and growth rate is lower than scalp hair follicle; as a result, eyelash length rarely exceeds 10 mm. The duration of Anagen and Telogen phases is 1-4 and 4-9 months, respectively (3, 4). At any given time, 59-85% of eyelash follicles are in Telogen phase (4). Duration and lasted around 90 5 days in all Length and cycle: Eyelash follicle morphology compared with scalp hair is much shorter and eyelid sections revealed a thinner epidermis and no hypodermis. Eyelash follicles rooted about 2 mm deep into the dermis. (1) All eyelashes were characterized by a tendency to bend from the bulb to the tip of the shaft. Pigmentation is generally admitted that eyelashes do not turn grey (or only at a very late stage) with ageing (2). Our results demonstrate an asymmetry of eyelash bulb proliferation resulting in a curved fiber, as previously observed in wavy and curly scalp hair, whose cuticular and cortical differentiation programs also showed asymmetry (1). The asymmetric proliferation of the bulb seems to be sufficient to induce a curved fiber and or could be forced by the keratin structure. The distribution of hair keratin K38 (a marker of hair curliness) was initially expressed on the concave side of the eyelash bulb (12). Conclusion: eyelash characteristics are identical. The eyelash is structurally very close to curly human scalp hair but some biological processes related to eyelash follicle cycle and pigmentation are markedly different, as well as the thinness of the eyelid epidermis, the absence of a hypodermis, and the shortness of eyelash follicles (2mm) this study is a good guideline for finding the more identical hair in view of eyelash character for eyelash transplant.

Liotet S, Riera M, Nguyen H. The lashes. Physiology, structure, pathology. Arch Ophtalmol (Paris) 1977; 37:697-708. 3 Na JI, Kwon OS, Kim BJ et al. Ethnic characteristics of eyelashes: a comparative analysis in Asian and Caucasian females. Br J Dermatol 2006; 155:1170-6. 4 Elder MJ. Anatomy and physiology of eyelash follicles: relevance to lash ablation procedures. OphthalPlastReconstrSurg1997; 13:21-5. 5 Johnstone MA, Albert DM. Prostaglandin-induced hair growth.Surv Ophthalmol2002; 47 (Suppl.):S185-202. 6 Bessis D, Luong MS, Blanc P et al. Straight hair associated with interferon-alfa plus ribavirin in hepatitis C infection. Br J Dermatol 2002; 148:392-3.

Abstract
American Hair Restoration Surgery Board Certified Board Director of American Hair Restoration Surgery Board governor of Asian society Faculty member of ISHRS & Orlando workshop Research award winner Sheida Abbasi, Medical Student
AbbasiHairClinic . Tehran, Iran Tel: +98 21 88886700 , 88879222 Fax: +98 21 88630117 Info@abbasihairclinic.Com

Ali Abbasi M.D

Inthisstudywereenrolled,TwentyAsianfemaleand

malevolunteersagedbetween26 56yearsoldand reviewedthecharactersofEyelash(cyclelength,color, curlandarrangement)


byusingahighresolutioncameraandother

references
Wefoundouttheeyelashnatureisstructurallyuniqueand

wec0uldnotfindahairaslikeaseyelashnature,inthe body

Introduction
Roleoftheeyelashes: TheEyelashesByBlinkReflexHelpToPreventTheEye

Developmentoftheeyelash
Theearlierdevelopmentoftheeyelashoccursat

From: Trauma ForeignBodyParticle(DustAndGrit)


EyelashesDoContributeToFaceAndEyeBeauty.

about9weeksofgestationinupperlid,then lowerlid. lengthvariesfrom8to12mmintheupperand from6to8mminthelowerlid

Eyelashesfolliclescomparewithscalphair folliclesare:
.EyelashisFreeofarrectorpilimuscle
ThereareanumberofglandsknownasZeisandMollglands. Zeisglandsareunilobarsebaceousglands, locatedonthemarginofthe eyelidandTheyproduceanoilysubstancereleasedthroughtheduct intothemiddleportionoftheeyelashfollicle. MollglandsaremodifiedapocrinesweatglandsMeibomianglandsare sebaceousglandsthatsecretelipidsandformatearfilm. Thereareroughly50glands intheuppereyelidsand25glandsinthe lowereyelids

Eyelashcrosssectionisveryclosetothe scalphair,
fromtheoutsidetotheinside:
1thecuticle, 2thecortex(includingmelaninpigments, 3themedulla.

Thelengthofeyelashcycleismuchshorter thanscalphair,
Thedurationofanagenandtelogenphasesis14

Eyelashincomparedwithscalphairis:
Muchshorterlength, Eyelashfolliclesrootedabout2mmdeepintothe

and49months,respectively. 5985%ofeyelashfolliclesareintelogenphase, Theaveragedailyeyelashgrowthrateis0.12 0.05mm Durationandlastedaround90 5daysinall assessedlashcycles/scalp,shairis3years

dermis.
Sectionsrevealedathinnerepidermisandno

hypodermis.

TheEyelashesAreThick,AndCurved Hairs

Eyelashcurl: Alleyelasheswerecharacterized byatendency tobendfromthe bulbtothetipoftheshaft likeasFrenchneedle

CauseofCurvedhair

Eyelashesdonotturngrey
eyelashesdonotturngreyoronlyataverylate

Keratin38(K38)weredescribedasamarkerofhair curliness, TheasymmetricdistributionofkeratinK38inthe bulb,resultinginacurvedfiber

stagewithageing.
Melanocytesareveryhighdensity,inthebasallayerof

theeyelidepidermis,theORSandthematrixof eyelashfollicle

TheUpperLidsLashesGrowUpwards andHaveaCurveShape

Arrangementandmorphology

UpperEyelashesAreThicker,Darker,Longer AndDenser ThanLowerEyelashes

TheLowerEyelashesAreThinner,Lighter,Sparser ThanUpperLid

Lower Lid

300400EyelashesInUpperLid

100150EyelashesOnLowerLid

Comparing EyelashesArrangementInInnerAnd OuterPartOfLids


Outer Inner

The upper lids lashes arranged In3Or4RowsAtTheTarsalMargin

Dense and thick

Sparse and thin

Outer

Inern 1 2 3 Sparse and thin


Upper Tars

Dense and thick

Viewsofuppereyelashes
3
FrontView LowerView Upperview

The Lower lids lashes arranged In 3 Rows At The Tarsal Margin

UpperEyelidfrom FrontView 1020EyelashesarrangedInaGroupandmakeTriangleOr PyramidShape

InFrontView TriangleOrPyramidShape

UpperEyelid,fromLowerView LooklikeWheel

UpperEyelid,fromupperView LooklikeBarbedWire

25

GrowDownwardsandlooklike

LowerLidsLashesinfrontview:

Waterfalllike

Lower Tars

Lower Tars

Compare,FUGofscalpwithedgeof lid

Eyelashisuniquenatureintermsof:
Thickness, curliness Color, Growth, Anagenphase Although,somesitearerelativelysimilartoeyelashesnature: TheInferiorNape Sideburn, Eyebrow LowerLeg Backoffingers

forthesereasonstheIndicationForEyelashesTransplantshouldbelimited For: (Noncosmetic)

conclusion, eyelashcharacteristicsareidentical.
Theeyelashisstructurallycurlyhair pigmentationdiffermarkedly Thethinnessoftheeyelidepidermis, theabsenceofahypodermis,inthelid Thedurationoftheeyelashfollicleanagenphase

Burn Traumatic Congenital(Atrichia) AlopeciaAreata(longdurationestablishedby

pathologyreport)

isstrikinglyshorterandgrowthratelowerthan thatofthescalphairfollicle;

wecannotfindahairaslikeaseyelashnaturein

bodyforcosmeticreason

Thank You for Your Attention

33

063 Temporal Points - Their Importance and Impact on a Youthful Appearance and as a Prognosis for Baldness
Antonio Ruston, MD. Clinica Ruston, Sao Paulo / SP, Brazil. Dr. Ruston is a plastic surgeon from Sao Paulo, Brazil. He has been working with HRS for the last 17 years and has been a member ISHRS since 1998. A. Ruston: None. TAKE HOME MESSAGE: Temporal points have a huge impact on a youthful appearance and as a prognosis for baldness and only 200 to 300 follicular units in each side of the temporal points make an enormous difference in appearance. ABSTRACT: Introduction Little has been said about the importance of temporal peaks and their impact not only on aesthetics but on their "youthfulness". Often we choose to lower the front hairline a little more, when in fact, if we use these follicular units to increase density or bring forward the temporal regions a bit we would have a greater aesthetic impact on our results. But how can we know when to prioritize temporal regions rather than lowering the hairline? This is what the author intends to show. Materials and Methods The author will show cases in which he prioritized the temporal regions rather than lower the hairline further and vice-versa, cases where he lowered the hairline and did not transplant in the temporal region. He will compare the cases. After analyzing many cases, the author came to the conclusion that only 200 to 300 one-hair folicular units transplanted on either side in the temporal regions make a great difference in terms of aesthetic impact and that these 400-600 units will lower the hairline very little. The author will also show his own case to illustrate the subject. The other aspect observed was the thinning or receding of the temporal points serve as a prognosis for more extensive balding cases, in other words, patients with a tendency for more extensive hair loss generally present thinning earlier in this region. The opposite holds true as well, patients who maintain density in their temporal points do not advance to more extensive balding (norwood VI or VII). Discussion and results There are several considerations to be made before transplanting in the temporal region. Among them are: Whether there is an indication: Cases that present significant reduction in density in the temporal regions, or cases in which there has been receding (along the line of the sideburns or further back). The extent to which the transplant in the temporal points will impact on the final result and the youthfulness. To determine this one must have a refined aesthetic sense to take into consideration the shape of the face and proportions. Design: the temporal points are a bridge between the hairline and the sideburns; correct design is very important. Texture of the hairs in the donor region vs. the temporal points in cases with patients who have thick or curly hair, one must be careful to avoid a "rustic" look. Incision angle: the existing angle must be followed, usually it is a sharp and angled backward. Probable progress of hairloss and balancing the donor area vs. the recipient area when balding has stablized to see whether we have sufficient folicular units to be used in the temporal points.

Whether the hairline is truly natural, as transplanting temporal points is pointless if the hairline is not totally natural.

Conclusion Often only 200 to 300 folicular units in the temporal points make an enormous difference in appearance. These same units would have far less impact in the hairline.

064 The Phenotype of Hairline Evolution


William R. Rassman, MD1, Jae Paul Pak, MD1, Jino Kim, MD2. 1 NHI, Los Angeles, CA, USA, 2NHI, Seoul, Korea, Republic of. In 1991, Dr. Rassman founded the New Hair Institute (NHI), and quickly became a world leader in hair transplant technology. His many innovations in techniques and equipment have been presented at medical meetings around the world, and he published these advances in prestigious medical journals as he pioneered these advances. Dr. Rassman pioneered the Megasession in 1992-4 (he was the first to perform 2000 grafts, 3000 grafts and 4000 grafts in single sessions when most doctors were performing under 100 unnatural appearing large plugs), dense packing of grafts (1994), the Fast Track method of hair transplantation whereby a patient's restoration can be completed in just one or two sessions 1993, The Follicular Unit Transplant (1995) and The Follicular Unit Extraction technology (2002). All of these advances were published in peer-reviewed articles in prestigious medical journals. W.R. Rassman: None. J.P. Pak: None. J. Kim: None. TAKE HOME MESSAGE: Learn how a hairline develops from childhood to adulthood with particular emphasis on the comparison between the development of the male and female hairline. ABSTRACT: The phenotype of hairline evolution exploits observational science with the focus of how the hairline evolves from childhood to adulthood in men and women. It also includes a snapshot of 1051 children from school yearbooks, ages 5-10 and 15-18 whose hairlines were not hidden by styling. It adds a missing link to the insights by Norwood and

Hamilton in their respective seminal articles on balding in men and women; however, this article's main focus in not about balding, but rather about the visual changes in the hairlines that we see as humans age. What we see in hairline changes may result from environmental events (e.g. traction alopecia), age and hormones as they influence the genetics that code the various parts of the anatomical hairline. These genetics are evident in the phenotype of the hairlines evolution at each point in time. The available medical information on hairline evolution unfortunately approaches hairline change as if it reflects a disease process or a genetic abnormality. We believe that this article will provide physicians with a better understanding (1) on how to educate the patient to better understand the changes seen in the hairlines of their patients, (2) whether the changes are typical or not, (3) in providing the physician with a more precise understanding of the genetic influences of the phenotype of hairline evolution from childhood and on to adulthood, and (4) for the hair restoration surgeon, to give him/her a foundation to design a hairline appropriate to meet each individuals needs, specific to their age and sex.

Phenotype of Normal Hairline Maturation


William R. Rassman, MD Jae P. Pak, MD, Jino Kim, MD
ISHRS Presentation October 2013 Original Article Published in: Facial Plastic Surgery Clinics of North America, August 2013

Disclaimer: The conclusions drawn by the authors in this presentation are based upon clinical observations from:

1. A review of 1051 children from various school yearbooks, eliminating those children whose hairlines could not be clearly seen. 2. Reviews of thousands of swim team hairlines in photo albums found on the internet 3. Review of male and female Olympic competitors in various athletic events when hairlines could be seen 4. Years of clinical observations from the New Hair Institute hair restoration medical practice observing men and women What is needed is more data correlating a variety of clinical observations by clinicians who are interested in establishing better understanding of genetic correlations and trends in hairline evolution.

Boys Boys Boys Boys Girls Girls Girls Girls

5 6-10 15-17 18 5 6-10 15-17 18

38 170 374 51 28 56 281 53 360

0 6 36 (10%) 14 (27% 8 (28%) 11 (20%) 31 (11%) 11 (20%) 292 (81%)

0 0 14 16 0 0 19 25

Defined distinct end-stage balding patterns in mature men and women Defined patterns that may reflect thinning and/or balding Suggested that thinning patterns may be progressive and lead to balding Hairlines were not addressed

Women * ~40

* Nusbaum BP, Fuentefria S.

Three Basic Defined Hairline Patterns


1.

There is remarkable similarity across ethnic lines in pre-teen boys and girls Hairlines have a distinct concave shape in most pre-teen boys and girls Hairlines may change as children mature into adulthood The observed phenotype of the maturing hairline likely reflects different genetics of the apoptotic process The hairline patterns of male and female children diverge in teens and early adulthood

2.

1. Juvenile: Concave shape. Lower edge hugs the highest crease of the furrowed brow in the mid-line 2. Intermediate: Halfway between juvenile and mature hairline (generally flat) 3. Mature: Convex shape. Located ~2cm above the highest crease of the furrowed brow in the mid-line

3.

4.

5.

Defined Hairlines
Area A

Hair Transplant Surgeons


1. Must understand what is an age/sex appropriate hairline pattern

A3 A2 A1

B3 B2 B1 C3 C2 C1 C2

2. Must understand hair direction in masculine and feminine hairline patterns 3. Build future appropriate hairlines for the balding and non-balding patient 4. Define patient expectations for hairline reconstruction

Genetically Coded Structures.


1. Widows peak (up to 2 cm high) 2. Temple peaks (remnant of temple mounds) 3. Zone D (1 cm zone of hair above the juvenile HL) 4. Zone E (~1 cm zone of hair below mature male HL) 5. Forelock (central mass of hair extending from the HL that does not follow the Norwood balding patterns) Hair
Frontalis

Maturing Hairline Zones May Disappear.

Zone E Zone D

Frontalis 1. Concave shape 2. Position of hair lines are A1, B1 and C1 3. Full temple mounds 4. No widows peak or temple peak 5. Note hair direction at leading edge Hair in these zones may remain, even with advanced balding patterns and may not follow the Norwood or Hamilton thinning areas In many female thinning patterns, Zones D&E are not impacted by frontal balding

Genetically Coded Structures.


Area A B C

To A3 (mature male HL) To A2 (intermediate)

A3 A2 A1

B3 B2 B1 C3 C2

C1

Hairlines mature by area from A1 (child)

B2-B3

Hair is thinning at point B2-B3 (see photo) Thinning in this area is common in women

Mature Hairline

Small widows peak


Extends to point A2

Large widows peak


Extends to point A1

Forelock Sizes Vary

Thank You
1. Runs in family lines and are often isolated 2. May extend close to fringe area and up to mid-head 3. If forelock lasts past 35 y/o, even in the face of an advanced balding pattern, they may last into old age
Please join us in studying childrens and womens hairlines

065 Moderator Introduction, Norwood Lecture


Bessam Farjo, MB BCh. Farjo Hair Institute, Manchester, United Kingdom. Qualified in medicine in 1988 from the Royal College of Surgeons in Ireland. After general surgery training, in 1993, trained in hair restoration surgery in Canada and co-founded the Farjo Medical Centre in Manchester and London exclusively practicing hair restoration surgery and medicine. He is a Past President of International Society of Hair Restoration Surgery (ISHRS) (07-08), and appointed ISHRS International Ambassador in 2012. Past President and co-founder of the British Association of Hair Restoration Surgery, Diplomate and Past Board Director of the American Board of Hair Restoration Surgery, Fellow of the International College of Surgeons and Fellow, Board Governor & Medical Director of the Institute of Trichologists. Over the last 12 years, he has been involved with on-going research collaborations with Universities of Manchester, London, Bradford and Durham as well as Unilever plc. Dr Farjo was the Principal Clinical Investigator with Intercytex plc (2003-2009) for the worlds 1st human clinical trial in hair cell multiplication/cloning. In October 2012, the ISHRS jointly awarded him, with Dr Nilofer Farjo, the prestigious Platinum Follicle Award for Outstanding achievement in basic scientific or clinicallyrelated research in hair pathophysiology or anatomy as it relates to hair restoration. B. Farjo: None.

066 Hair Follicle Cloning, Regeneration and Other Prospective Developments for the Transplant Clinic - Where Are We Now?
Colin Jahoda, PhD. Durham University, Durham, United Kingdom. Dr Jahoda is a developmental/cell biologist with over 30 years of research expertise in the field of skin and hair follicle biology. He studied for his PhD at Dundee University in Scotland and spent time studying feather development as a NATO Research Fellow in the laboratory of Professor Philippe Sengel in Grenoble, France. He returned to Dundee and became a Royal Society University Research Fellow, and subsequently after a brief period there as a lecturer took up a post at Durham University where he is now a Professor. In relation to skin appendages, his focus has been on the molecular basis of adult hair follicle growth, as well as adult stem cell biology and wound healing. His research has impacted on, a number of overlapping fields including developmental biology, stem cell biology, dermatology and tissue engineering of skin for therapeutic purposes., He has published nearly 100 research articles, as well as numerous review articles and book chapters. C. Jahoda: None.

TAKE HOME MESSAGE: We now have a much better understanding of the underlying biological basis that limit "hair follicle cloning" using cultured follicle dermal papilla cells. Consequently we are developing solutions, part of which involves creating three dimensional structures that resemble the dermal papilla and that, when grafted, can induce new human hair follicles. ABSTRACT: The promise of being able to newly create multiple hair follicles using microsurgical and cell biological techniques has been around for decades, ever since the pioneering work of Roy Oliver. It was he who first demonstrated both the capacity of follicles to regenerate in situ after experimental amputation of their bases, and the inductive powers of the isolated dermal papilla. Subsequently hair follicle neogenesis has been repeatedly demonstrated in rodents using cultured hair follicle dermal cells, and new follicles were induced in humans from intact follicle dermis nearly 15 years ago. Nevertheless so called hair follicle cloning has, to large extent, been unsuccessful in humans. We have investigated the reasons underpinning these discrepancies between animal and human work, and attempted both to resolve the biological reasons behind them, and work towards a more successful outcome in humans. One feature of hair follicle dermal cells that sets them apart from intrafollicular skin fibroblasts is their stem cell-like behaviour, which means that, among other things, they can be directed in culture to become fat or bone type. Another explanation as to why injected follicle dermal cells fail to perform their normal function after injection into skin, is that that lose some of their hair specific identity and assume the role of wound healing fibroblasts. Related to this is the observation that, unlike rodent vibrissa follicle cells in culture, human hair follicle dermal papilla (DP) cells do not spontaneously aggregate. Our collaborator Claire Higgins in Angela Christianos laboratory performed global transcriptome profiling of intact dermal papillae, which are capable of neogenesis, and compared this to cultured DP cells at different time points. She discovered dramatic early changes in DP cells after growth in culture. We previously demonstrated that growing DP cells in hanging drop cultures results in the formation of spheroids, which are morphologically akin to intact DP. Transcriptome analysis of these spheroids showed a significant restoration of the intact DP signature by this three dimensional culture method. To evaluate if recapitulation of the DP signature equated to a restored inductive potential, we developed a human-to-human hair follicle neogenesis assay that could be used to reliably assess the inductive capacity of human DP cells against human skin. When we micro-implanted dermal spheroids into recombined foreskins placed onto the back of SCID mice, we observed human hair follicle neogenesis in the foreskins after 6 weeks. Hair follicles grew down into the dermis and produced hair fibers, showing for the first time that intact human DP can induce a de novo human HF. Therefore the partial restoration of the transcriptional profile in human DP cells, achieved simply by growing the cells in a 3D spherical microenvironment, is sufficient in some instances to restore the inductive capacity of DP cell cultures and elicit complete human HF neogenesis. Together with the regeneration potential of human follicles these findings lay the foundation to new approaches to both hair follicle regeneration and improved skin equivalents for skin replacement in plastic surgery.

Hair Follicle Cloning, Regeneration and Other Prospective Developments for the Transplant Clinic - Where Are We Now?

Follicle neogenesis from cultured dermal papilla cells

Colin Jahoda School of Biological and Biomedical Sciences University of Durham

Insert into split skin (footpad)

Whisker type fibres

Development. 1992 Jun;115(2):587-93.

Experimental-Epithelial Mesenchymal Interactions

Human Hair follicle induction - Reynolds et al. (1999) Nature 402(6757):33-4.

Lillie and Wang Feathers


DERMAL PAPILLA

Jack Cohen - Hair

DERMAL SHEATH

Roy Oliver - Hair

The lower hair follicle regenerates after experimental amputation

DS precursors replace DP. No Scarring

HF cell isolation and culture from human scalp


DS

DF

DP

Follicle multiplication/hair cloning


Biopsy Reimplantation

STEM CELL ACTIVITIES FROM FOLLICLE DERMAL CELLS


ADIPOCYTE OIL RED O DP/DS CELLS BLOOD

Culture Expansion

MUSCLE

BONE CALCIFED DEPOSITS


Lako M,.J Cell Sci. 2002,;115::3967-74.

Using cultured human follicle dermal cells for follicle regeneration

Androngenetic Alopecia -follicle mesenchymal cells and follicle size?


What is the cellular basis for loss of papilla cell numbers and follicle miniaturisation? How and when does this happen?

Aaron Gardner

Jahoda CA.Exp Dermatol. 1998,7(5):235-48.

Why, by and large, have these approaches not been successful?


Why is this? What can we do about it?

Adhesion loss/migration hypothesis - loss of cells


Catagen

Telogen

Jahoda CA.Exp Dermatol. 1998,7(5):235-48.

During the follicle cycle there can be exchange of cells not only between the dermal sheath and the dermal papilla, but between the follicle dermis and the interfollicular dermis

Aggregative properties of follicle dermal cells are different


Rat whisker

Tobin D.J. et al.(2003) J. Invest Dermatol,120, 895-904

Human scalp

Why are cell injection methods not

Hair Follicle Dermal Cells in 3D Skin Equivalent Models

more successful?

Aaron Gardner

Concepts
1) DP and DS relationships are not steady state cell movement/cell adhesion important in this compartment. 2) Dichotomy of activities between follicle mesenchyme and interfollicular skin.

Hair follicle dermal cell expansion and loss of function.


Using cell expansion techniques - 1.2 x 108 cells/L during the production phase. Routinely cryo-preserve 200 vials from a production master or working cell bank. However cells lose function over time - but when?

Rat whisker dermal papilla cells specifically lose inductive properties after 3-4 passages in culture, how quickly do human cells lose their in vivo characteristics?

Human follicle induction model

SHORT PERIOD

LONG PERIOD

INTACT

CULTURE

Human follicle neogenesis


We observed human hair follicle neogenesis in the skins after 6 weeks. Hair follicles grew down into the dermis and produced hair fibers, showing for the first time that intact human dermal papilla can induce a de novo human HF. Therefore the partial restoration of the transcriptional profile in human papilla cells, achieved by growing the cells in a 3 dimensional spherical microenvironment, is sufficient in some instances to restore the inductive capacity of dermal papilla cell cultures and elicit complete human HF neogenesis.

CHANGES IN HAIR FOLLICLE GENE EXPRESSION IN CULTURE

Dermal Papilla Spheres

Hair follicle neogenesis problems/difficulties


Reproducibility, understanding the reasons why cells sometimes induce and other times do not - individual variation? Nature of the epidermal signals? Technical challenges - delivery methods, correct orientation, cycling follicles etc.. Nevertheless, there is confidence in future developments.

Other potential developments


The capacity of human follicle dermal cells to induce follicles raises genuine possibilities for creating tissue engineered skin grafts, and skin equivalents that have the potential to develop hair follicles and other skin appendages. The basic regenerative properties of the upper follicle means that this phenomenon could be combined with intact papilla follicle induction to at least double follicle numbers.

Thanks and Acknowledgments


DURHAM Amanda Reynolds Gavin Richardson DUNDEE Roy Oliver

NEW YORK USA Angela Christiano Claire Higgins Robert Bernstein

TUFTS, USA Jonathan Garlick Nilofer and Bessam Farjo

067 Multi-Centre, International, Randomized Investigation as to the Efficacy of Adipose Derived Mesenchymal Stem Cells for Stimulating Hair Growth in Androgenic Hair Loss Patients
Ryan J. Welter, MD PhD. New England Center for Hair Restoration, North Attleboro, MA, USA. Dr. Welter obtained his doctorate in Biochemistry and Molecular Biology from Oklahoma State University and his MD from the University of Oklahoma. He completed his residency at Brown University of Medicine where he remains a clinical associate professor. Research continues to be very important to Dr. Welter, and he continues to be active in clinical trials through his research company. In 2005, Dr Welter founded the New England Center for Hair Restoration and NEhair.com having built a state of the art operating suite designed exclusively for accommodating hair transplant surgery and stem cell research. Dr. Welter continues work as a pioneer in the field of hair transplant surgery, working to develop new techniques using stem cells to achieve unparalleled results in hair restoration density. R.J. Welter: None. TAKE HOME MESSAGE: Adipose derived mesenchymal stem cells may be an appropriate therapeutic option for androgenic hair loss patients. ABSTRACT: Regeneration of the body through the use of autologous stem cells is fast becoming a reality. Recently, bone marrow derived mesenchymal stem cells have been shown to enhance ventricular remodeling in patients with ischemic cardiomyopathy (Jama, Dec. 2012) when allogenic cells are deployed via transendocardial injection. However, bone marrow stem cells are difficult to obtain and require culture. In contrast, adipose-derived mesenchymal stem cells (ADMSC) are easy to obtain and do not require culture to obtain large quantities. Further ADMSC have been shown in preliminary investigations to have positive effects in wound healing, collagen synthesis, joint healing, and skin rejuvenation. In addition, both locally injected ADMSC and IV deployed ADMSC have been shown be efficacious in various settings. This study investigates the use of ADMSC in stimulating hair growth in male and female patients with androgenic hair loss. Recruited non surgical patients are randomized to either IV only deployment or local deployment with split scalp controls. Recruited surgical patients are randomized to to either IV only deployment with surgery or surgery with grafts incubated with ADMSC. To date no adverse reaction as been reported. Study is ongoing and still recruiting patients. Preliminary results are discussed.

Multi-Centre, International, Randomized Investigation as to the Efficacy of Adipose Derived Mesenchymal Stem Cells for Stimulating Hair Growth in Androgenic Hair Loss Patients
Ryan Welter M.D. Ph.D. Clinical Associate Professor, Brown University School of Medicine

Adult Mesenchymal Stem Cells

Adult Mesenchymal Stem Cells

DISCLOSURES: Speaker has no relevant financial relationships or conflicts of interest to declare.

Bonfeild, et. al., Case Western Reserve University

Adult Mesenchymal Stem Cells


Found all over the body Bone marrow produces continual flow of mesenchymal stem cells Fat stores abundant source of mesenchymal stem cells Multi-potent No moral or ethical issue

(Suga, et.al.PRS, 122(1)103-114,2008; Eto, et.al.,PRS, 124(4)1087-1097,2009)

Fat tissue

1 gm fat = 1 million Adipocytes, 1 million Adipose Stem Cells (ASC), 1 million vascular endothelial cells, 1 million other Pre-Adipocytes or ASC can multiply and change into additional fat cells when challenged by increased caloric intake If weight remains stable, ASC remain dormant until fat cells die or are injured Generally believed that fat cells survive for 7 10 years ASC when separated from fat are mesenchymal stem cells

Adult Mesenchymal Stem Cells


Differentiation vs. Secretion Although MSCs can differentiate into various phenotypes of mature cells, their intrinsic capacity to secrete cytokines and growth factors at sites of tissue injury and inflammation contribute significantly to their therapeutic capacity. We assume that the production of these trophic mediators is defined by their in vivo location, niche, and severity of injury (Abdallah et al., 2007; Caplan et al., 2006).

Adult Mesenchymal Stem Cells

Adult Mesenchymal Stem Cells

Adult Mesenchymal Stem Cells


New Horizons New equipment and enzymes Adipose (fat) derived stem cells are easy to harvest Safe under local anesthesia Autologous Abundant numbers of cells Procedure takes 3 hours total

IRB Approved Research Protocol for Investigating ADMSC Stimulation of Hair Growth

Objective: To determine if Adult Adipose Mesenchymal Stem Cell Rich Stromal Vascular Fraction SVF is effective in treating hair loss

Materials and Methods


Equipment and Materials:
1. Manual liposuction cannula 3.0 mm 2. Liposuction, centrifuge and celltibator kit 3. Medikan bench top centrifuge 416 D 4. Medikan Celltibator MSM-100 5. Roche Collagenase USP 6. 100 ml. of Bio-life Hypothermosol

SVF Harvesting
Liposuction

Dermlite II Pro densitometer


1. Countess Automated Cell counter model C10281 by Life Technologies 2. Cell counter chamber slides C10310 3. Trypan blue stain 0.4% 4. BRAND Transferpette S Single-

Channel Pipettors Model F-10 by VWR 5. 14 megapixels Digital camera 6. Camera adapter for densitometer

Solution 7. 1 ml of New England Labs ATP solution 10 mM

Patient Selection and Randomization


NON-SURGICAL

SVF Harvesting
Spin Fat

FRONTAL ONLY

VERTEX ONLY

SVF Harvesting
Sterile Prep Tray

SVF Harvesting
Add Collagenase and Incubate

SVF Harvesting
Wash off Collagenase

Case Study

27 year old male Steady hair loss in androgenic pattern since age 18 Strong family history of androgenic hair loss Previous use of Rogaine and Propecia but without improvement Previous strip transplant in July 2006 and June 2010

Adult Mesenchymal Stem Cell (Stromal Rich Factor Isolate)

Case Study

30 cc adipose tissue extracted Yield of 2.9 million stem cells Randomized to vertex injection site

Adult Mesenchymal Stem Cell (Stromal Rich Factor Isolate)

Thank you

Stem/progenitor cells

068 Highlights from the 7th World Congress for Hair Research
Nilofer P. Farjo, MBChB, LRCPSI, BAO, ABHRS, FIT. Farjo Hair Institute, 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 Forum International and diplomat of the American Board of Hair Restoration Surgery. Nilofer is a past President and founder member of the British Association of Hair Restoration Surgery, Fellow of the Institute of Trichologists, past President of The Trichological Society and treasurer of the European Hair Research Society. She currently works with four universities and one public company on basic hair sciences projects. N.P. Farjo: None. TAKE HOME MESSAGE: There is a wide diversity in the type of research dedicated to studying hair follicle behaviour. The rapidly developing fields of genetic testing and stem cell function, in particular, may lead to new diagnostic and therapeutic modalities. ABSTRACT: Edinburgh, Scotland was the venue of the 7th World Congress on Hair Research which brought together researchers from a range of disciplines to present some of their leading scientific advances. The 597 attendees included clinicians, scientists, patient representatives and industry personnel. Pre-Congress Clinical Course: Included in this years meeting was a pre-congress clinical course which had presentations on topics such as genetics and epigenetics: the new tools involved in research, the role of chromatin folding on gene expression, microRNA in hair follicle function, and the potential to reprogram hair follicle cells to a pluripotent state. The latest in hair modelling and culturing systems were discussed as well as a session on the hair fibre with a focus on curly hair. The clinical session reviewed latest diagnosis and treatments for alopecia areata and androgenetic alopecia. Main Congress: The main area of focus at the meeting was on scientific studies relating to hair biology but there were also plenary sessions that were more clinically orientated. I will review some of the highlights from sessions on the following: Alopecia Areata, tissue engineering and regeneration, stem cells and epigenetics, clinical cases, Androgenetic Alopecia, factors affecting hair growth, genetic hair disorders and hair fibre science, cicatricial alopecia, hair follicle development, control of the hair cycle and pigmentation. Keynote lectures were given by Elaine Fuchs and Ulrike Blume-Peytavi. Fuchs research using murine models studies regulatory mechanisms of HF stem cells. She showed that the synchronicity of murine hair cycles can help in our understanding of stem cell regulation in health and disease. Blume-Peytavi discussed how research along with well-controlled clinical trials can help us produce new therapies for hair diseases.

Who Attends?
Review of World Congress for Hair Research Nilofer Farjo, MBChB Manchester UK
No Conflicts of Interest This year 597 attendees from 47 countries:
clinicians investigators surgeons patient representatives and industry personnel

Opportunity for young investigators to present their work in conjunction with the world's leading pioneers

What is the World Congress?


Combined meeting of regional Hair Research Societies: Australasia Hair and Wool RS European HRS Hair RS of India Japanese SHR Korean HRS North American HRS

Why is it Important for Hair Transplant Surgeons? Why should we be interested?

What is the Aim?


Is it for the Sights?
20 years of common international pursuit towards a better understanding of hair health and disease

Day 1: Clinical Course Days 2-3: Basic Science & Research

Overview of 4 speakers
Or Perhaps the Drink? Control of the hair cycle Genetics PGD2 Cicatricial alopecia

Or MAYBE because your mates will be there?

Translational medicine:
How can hair biology research help to produce clinical treatments AND how can our understanding of stem cell behaviour lead to prevention/treatment of hair loss? Colin Jahoda has already shown us some examples of how this cooperation might work

Fuchs reviewed her fundamental work in studying the regulatory mechanisms of the hair follicle stem cells, and especially the crosstalk between these cells and their microenvironment. She showed how the hair follicle which is a selfregenerating organ is a perfect model to study stem cells. In particular mouse models are ideal because the hair cycles are synchronous so it is easier to study how quiescent stem cells become active to regenerate tissue and then become quiescent again. There is evidence that shows that some tumours result from these mechanisms becoming deregulated

MicroRNA in hair follicle function Natalia Botchkareva


MicroRNAs: are small non-coding RNAs Research shows that microRNA modulation of gene expression is important in HF development Looking at the role of a particular microRNA that is expressed during skin morphogenesis her studies showed that it has an essential role in skin and HF development as a key regulator of the Wnt/beta-catenin pathway

Conclusion
AIM: common international pursuit towards a better understanding of hair health and disease These few examples show a small selection of the diversity of hair research that is going on I encourage you to attend the Hair Research meetings and even if you dont understand the science you can at least visit the sights, have a few drinks and meet up with some friends!

Cotsarellis
Showed that bald scalp has higher activity of prostaglandin D2 synthase and hence prostaglandin D2 (PGD2) vs nonbald scalp He then showed that PGD2 inhibits hair growth both in culture and when applied topically in mice Translational for AGA Treatment: develop PGD2 inhibitor

8th World Congress Jeju Island Korea, May 14-17, 2014 www.hair2014.org

Cicatricial alopecia: Is the environment important?


Pratima Karnik discussed her work showing that in PCA there is up regulation of genes that produce a specific transcription factor: aryl hydrocarbon receptor (AhR) This transcription factor regulates a number of diverse physiological processes including enzymes that metabolize environmental toxins (dioxins and polycyclic aromatic hydrocarbons) She developed a mouse model, which overexpresses the Ahr in the skin. These mice developed clinical and histopathological phenotypes, which resemble scarring alopecia So this suggests that there is a possible connection between the environment and the development of PCA

069 Moderator Introduction, Advancing the FUE Technique


Ken L. Williams, MD. Irvine Institute of Medicine and Cosmetic Surgery, Irvine, CA, USA. Dr. Williams is a hair restoration surgeon primarily practicing FUE surgery on his male and female patients. His hair restoration practice incorporates both medical and surgical care based on the concept of best practices and solid hair science. Dr. Williams is excited to share his FUE techniques with his colleagues and participates in many hair workshops with the ISHRS. K.L. Williams: None.

070 How Image Processing in FUE Harvesting Can Be Used in Calculating the Reduction of Skin Trauma by Injecting Normal Saline
Georgios Zontos, MD PhD MSc BSc. University of Patras, Patra, Greece. Dr Georgios Zontos short biography. University of Patras, Greece, School of Medicine, Labo-ratory of Medical Physics. Dr Georgios Zontos has studied Medicine and Physics at the University of Patras in Greece and holds an M.Sc degree in Medical Physics. He is researcher at the Medical School of the University of Patras and member of ISHRS. e has been working in the field of Hair Restoration for 10 years and he has performed numerous of FUE operations. He is the Medical Director of Haarkliniken Hair Restoration Clinic in Copenhagen and Medical Consultant of Hair Restoration SA Clinic in Johannesburg South Africa. His research is focused on mathematical modeling in the field of Hair Transplantation, scar repair using FUE, and non shaven FUE hair transplantation technique. G. Zontos: None. TAKE HOME MESSAGE: How image processing in FUE harvesting can be used in calculating the reduction of skin trauma by injecting normal saline. ABSTRACT: Objective, Materials And Methods Although FUE is considered as a minimally invasive method the trauma on the skin is sometimes very noticeable especially if the patient has very sort hair. Many reasons influence the trauma on the donor area like the size of the punch, the number of the follicular units, the transection rate, the previous operations and the outgrowth angle of the hair follicles. Due to the latter it has been proven(1) that although the punch cross section is circular the shape of the wound is elliptic, which is calculated by the formula 1

Where S1 is the punch surface, S2 is the surface of the wound and z is the outgrowth angle of the hair follicles. The possible consequences of this injury could be the extensive fibrosis, the multiple visible scars, the delay heaving process and the post operative pain. However, to manage this problem it has been proposed normal saline to be injected intradermally into the donor area. In this way the hair follicles become more vertical and the value of sinz increases making the value S2 much smaller. The objective of this study is: 1)To determine the exact percentage of mass of the skin which is removed by the punch in FUE harvesting. 2)How the injection of normal saline minimizes the injury of the donor area and accelerates the healing process. 3)How image processing is a invaluable tool in validating the aforementioned aims. To that purpose a theoretical approach to the problem based on the Figure 1 in conjunction with physical principles can be expressed by the following formulas: (2) which represents the percentage of mass which was removed by the punch. Where ro, ro and rx, rx are the small and large semi-axis of the elliptic wound, which is caused by the punch, immediately after the extraction of the follicular unit and at the end of the procedure respectively. When formula (3) represents the relation between the mass m which is removed by the punch at a certain angle z without injecting normal saline, and the mass mx which is removed by the same size punch when angle z is at 90o after injecting normal saline. where ro is the radius of the punch and rx is the radius of the shrunken hole, when normal saline has drained away. By studying formula 3 we can find that m is inversely proportional to sin2z. This implies a dramatic increase in the trauma if normal saline is not used. All the calculations of the study were based on the principle that injection of normal saline expands the volume of the skin, while decreasing the density of the mass which is contained in the same area. This implies that once normal saline has drained away the stretching of the skin ceases so that the dimensions of the wound, which has been produced by the punch, are reduced. To validate this assumption digital images of the wound were taken by a USB high resolution camera, in two steps. At the beginning of the extraction where the skin was expanded and at the end of the procedure, when the skin was relaxed. Using image processing the digital images (Figure 2) were analyzed, I order for the parameters of formula (2) to be measured automatically. In pictures (Figure 3, 4) the marked rectangle represents the expansion of the skin before and after the injection of normal saline. Discussion - Results The results are shown in pictures (Figure 5), where it can be seen that although a punch size 1,00 mm was placed perpendicular to the skin surface the shape of the wound was surprisingly elliptic rather than circular. It is important to notice that one of the axis of the ellipsis was much larger than the diameter of the punch. The reasonable explanation of this fact is that the punch is cylindrical so the walls have a certain thickness. On the other hand due to the friction which is produced by the rotation of the punch, on the skin, a small deviation from the 90o angle can be achieved. On further observation of the pictures (Figure 6, 7) it is noticeable that the surface of the wound caused by the punch was decreased by 29,05%. This number represents the mass of the skin which was rescued by the intradermal injection of normal saline. In this way the degree of scarring is remarkably reduced causing less fibrosis and minimizing the appearance of multiple scars on the donor area. Conclusion The injection of normal saline plays an extremely important role in improving the quality of the extraction and minimizing the skin injury either by making the follicular units more vertical or by expanding the skin and reducing the amount of skin mass which is removed by the punch. Thus the dimensions of the wound decrease after the removal of normal saline, making the holes smaller and accelerating the healing process. Additionally the wound contracts controlling any blood loss, and minimizing the extent of scar tissue on the donor area.

BACKGROUND
HOW IMAGE PROCESSING IN FUE HARVESTING CAN BE USED IN CALCULATING THE REDUCTION OF SKIN TRAUMA BY INJECTING NORMAL SALINE
Georgios Zontos1 MD, PhD , Georgios Nikiforid is2 PhD
1Medical Director of Harklinikken, Denmark- University of Patras, School of Medicine 2Professor of Medical Physics, Head of Department of Medical Physics University of Patras, School of Medicine DISCLOSURES:

Although the punch cross section is circular, the shape of the wound is elliptic, which is calculated by the formula S2 = S1/ sinz 1

Same punch size: the surface of wound depends on the value of outgrowth angle

The Speaker has no relevant financial relationships or conflicts of interest to declare.

Georgios Zontos MD, PhD

Objective
1) To compare the exact percentage of skin mass which is removed by placing the same size punch in both cases: at a certain angle z without injecting normal saline (Acute o Extraction- AE) and at 90 after injecting normal saline (Vertical Extraction - VE). 2) How the injection of normal saline minimizes the injury to the donor area and therefore accelerates the healing process. 3) How image processing is a invaluable tool in validating the aforementioned aims.
Georgios Zontos MD, PhD

A theoreticalapproach to the problem


All the calculation of this study are based on the principle that injection of normal saline increases the volume of the skin, while decreasing the density of the mass which is contained in the same area.

S P x % S0

_2

P : the percentage of skin mass which is removed in Vertical Extraction (VE) S0: initial surface of wound in Vertical Extraction (VE) Sx : final surface of wound , when normal saline has drained away in VE

S m 1 x m sin 2 z S
x

Acute extraction causes tissue damage inversely proportional to sin2z

m: mass removed in Acute Extraction (AE) mx: mass removed in Vertical Extraction (VE) S: final surface of wound in Acute Extraction (AE)

In VE, z= 900 then sin 900 = 1 so formula 3 becomes equal to formula 2.

Method
1. Pictures of wounds were taken with high resolution USB camera immediately after the extraction and 4 hours later in both Vertical Extraction (VE) and Acute Extraction (AE) . 2. The surfaces were measured accurately by using an advance image processing system and the results of all 13 cases were interpreted statistically.
Georgios Zontos MD, PhD

The marked rectangles demonstrate thestretchingof theskin before and aftertheinjection of normal saline
Before 8.49 mm2

After the digital images are analyzed the surface of the skin is recorded automatically. The percentage of the increase in the surface due to the stretching of the skin is (10.92-8.49) / 8.49 % =28.62%

After 10.92 mm2

Georgios Zontos MD, PhD

Advanced image processing system


Immediately after extraction: 0.97 mm2

Further comments

Vertical Extraction:
Although a punch size 1.00 mm was placed perpendicularly to the skin surface the shape of the wound was surprisingly elliptic rather than circular.

By using normal saline and placing the punch perpendicularly to the surface of the skin, the elliptic shape of the wound decreases by 39.18% and this number represents the rescued mass.

4 hours after extraction: 0.59 mm2

Although a punch size 1.00 mm with surface 0.785 mm2 was placed perpendicularly to the skin surface, it is important to note that the surface of the wound was recorded to be equal to 0.97 mm2 . The reasonable explanation of this fact is that the walls of the punch have a certain thickness. By using a digital micrometer the outer diameter of the punch was found to be 1.111 mm, and the surface 0.968 mm2
8

Georgios Zontos MD, PhD

Advanced image processing system


Acute Extraction:
Without normal saline and placing the punch at a certain angle z, the elliptic shape wound decreases by a mere 5.93% caused by edema.

Immediately after extraction: 1.18 mm2

STATISTICAL ANALYSIS FOR BOTH(Acute Extraction AE & Vertical ExtractionVE) TECHNIQUES IN 13 CASES
Mean SAE1 (mm2) SAE2 (mm2) (SAE1 SAE2)/SAE1 SVE1 (mm2) Values 1.39 1.25 10.21% 1.09 0.25 Std.Dev.
1.39 1.4 1.2
Surface of the wound (mm2)

SVE2 (mm2) (SVE1 SVE2)/SVE1 0.67 38.56% 0.14

1.25 1.09

For SAE2 & SVE2 independent samples t-test, we found that Sig. (2-tailed) p= 0.000 < 0.05.
Because of this, there is a statistically significant difference between the means, with 95% Confidence Interval of the Difference

1 0.8 0.6 0.4 0.2 0 0.67

The mean surface of the wound, in AE, reduces by 10.21%, while the mean value of the wound in VE reduces by 38.56 % within the same time frame.

4 hours after extraction: 1.11 mm2

Georgios Zontos MD, PhD

Right after extraction

4 hours after extraction

Georgios Zontos MD, PhD

10

STATISTICAL ANALYSIS FOR BOTH(Acute Extraction AE & Vertical ExtractionVE) TECHNIQUES IN 13 CASES
Mean Values Std.Dev. M % AE 356.17% 119.81% Wound % AE 87.01% 24.73%
400.00% 350.00% 356.17%

CONCLUSION
The injection of normal saline plays an extremely important role minimizing the tissue damage, by making the follicular units more vertical, while stretching the skin, thereby reducing the amount of skin mass which is removed by the punch. Image processing confirmed that the dimensions of the wound decrease after normal saline has drained away, leaving smaller holes and accelerating the healing process. Hence, the wound contracts controlling any possible blood loss, minimizing the extent of scar tissue on the donor area.
Georgios Zontos MD, PhD

Based on formulas:

S2

in conjunction with advanced image processing, it was found that the mass removed in AE was 356.17% larger than the mass removed in VE. The wound surface in AE was 87.01% larger than the wound surface in VE.

S1 __1, sin z

m 1 S x mx sin 2 z S

300.00%

250.00% 200.00% 150.00% 100.00% 50.00% 0.00% M % AE Wound % AE 87.01%

Georgios Zontos MD, PhD

11

12

Real cases

In Acute Extraction 2512 follicular units

Georgios Zontos MD, PhD

In Vertical Extraction 2487 follicular units

13

071 Controlling FUE Transection Rate with Difficult Scalp Character


Juyong Kim, MD. Mojelim Plastic Surgery Clinic, Seoul, Korea, Republic of. Mojelim Plastic Surgery Clinic, Seoul National Universtiy, Bundang Hosp., Hair Center, Researcher J. Kim: None. TAKE HOME MESSAGE: Difficult scalp character require extra efforts and techniques to harvest good quality hair grafts for FUE procedures. ABSTRACT: Background When FUE originally started by Dr. Rassman of NHI, 2.8 mm of punch depth would be suggested to be deep enough to harvest for fibrotic donor tissue with FUE procedure. Years back, as we first tried to harvest hair grafts with FUE, punch depth of 2 to 3 mm was not really enough. We had to experience either capping of epidermis or cutting of hair shafts as we attempted to extract. It was because that the hair follicles were buried so deep or tethering fibrotic septa was strong that wouldnt come out. So that we had to punch at least 4mm deep, sometimes even 5mm deep. Between punching depth from 2mm to 4.0mm, it made a huge difference with transection rates. The transaction rate raised up to double. For one patient, the transection rate was near 50% at some point when we were novices. Purpose For some patients, punching depth of 2.8 mm was not enough to extract efficiently if the patients were old with fibrotic tissue or tethering fibrotic septa layer was rigid. Then we had to increase the punching depth to extract more fluently to avoid stripping of perifollicular tissue of the grafts. People would know better how to handle patients with deeply buried hair follicles or fibrotic donor tissue. Methods We tried various ways to find out increasing the efficiency with FUE transection rates. We tried slower or faster motor speed, a bigger or smaller punch tips, manual FUE tips or dental motorized device, blunt or sharper punching tips, and so on. Nothing really worked much better than the others. It would depend on a case by case. However, one worked out extraordinary, and that was an firm and steady grip of FUE hand piece. Some other tried and increased efficiency ways would be suggested. Results The following list was a short list of focusing points.1. Working distance2. Working field 3. Insertion angle4. Insertion site 5. Tumescent solution6. Sharpness of punching tip7. Grip of hand piece Conclusion Some patients have rigid scalp tissue with strong septal junction or fibrotic donor tissue. Then the punching depth should be deeper to harvest proper hair grafts with enough perifollicular tissue. We suggested some tips to increase efficiency for FUE procedure with such problematic donor characters. Firm and steady FUE hand grip is the most important factor to control the transection rates along some other methods. Then good quality hair grafts would be granted.

Short grip Pinky bridge

Mojelim PS Clinic Kim, Ju Yong, MD

Light & smaller hand-piece Progressive punching

Longer average depth of hair follicles for Asian (5mm) Vs for Caucasian (3mm) makes it hard to harvest

Pinky bridging Virtual progressive punching

Acute angled hair bearing makes it hard to harvest

Deeper hair follicle position makes it harder to harvest good grafts for capping, hair shafts being cut, and skeletonization - straightly deep punching Acute angled hair makes it hard to center - virtual progressive punching

1. 2. 3. 4. 5.

Punch 1.0 mm Extraction Curved forceps Trimming digital microscope Insertion slits, Folli-pen 5X loupe

1 marking the donor area

2 shaving the donor area

Easy extraction : no capping Less hair shaft cutting

3-4 harvesting with hand piece

5 immediate post-op

Less shock Less time

trimming epidermis

prepared grafts

Higher transection rates Higher possibilities of less perifollicular tissue

using folli-pen

insertion

Easy capping Rigid micro septal junction Long hair follicle position

Too acute angled hair bearing

No epidermis planing, but actual punching Actual controlling of angle

Punch distance : short Punch size : 1.0mm Punch depth : 3.0mm min Punch handle size & weight : small & light Punch speed : fast enough Punch sharpness : sharp enough Punch angle & direction : center, straight & progressive

Long time to get used to Ambiguous to teach others

GRIP : pinky bridging Tumescent Centering Inserting Angle : virtual progressive punch Punch depth : start with 60%

Skin tension Bleeding control Hair alignment Flow with the skin movement..

Least number of joints Straight horizontal movements Pinky bridging

Slower speed with better precision Slower with much less


heat

Slow can detect hair shaft cutting More time to adjust Punching power : gravity & rotational F.

Set up tip length by 60% of average follicle depth Do not measure the graft length
1. 2.

Smaller Lighter

Safety check Shallow check for centering Deep check for angle Not always deeper is better, SO, If epidermis gets elevation, then stop

Better control with less fatigue

Start with short handgrip : firm & stable Punch tip must be short

Dull punch can be useful : sharpening during operation DULL, but sharp enough to punch w/o strength Vasoconstriction Sensation of hair shaft

Capping Skeletonization Shaft cut-off

- Causes 1. Not enough punch depth 2. Rigid soft tissue anchoring

Capping, skeletonization - increase punch depth Partial transection - more acute angle Total transection - control centering Hair shaft cut-off - both punch depth and insertion angle

Handgrip of a hand-piece : easy and stable Punching power : gravity & rotational F. Patient position : sitting is more scientific BUT less ergonomic Follow to the TEXTBOOK

Time-consuming work Learning curve.. SO, Take time and Be patient * THINK & ADJUST

072 Overshooting the Safe Donar Zoni in Mega Session of FUE Technique
Suneet Soni, MD. Medispa Laser and Cosmetic Surgery Center, Jaipur, Rajasthan, India. M.B.B.S.,M.S.,M.Ch.(plastic surgery) Director-MEDISPA Laser and Cosmetic Surgery Center, Jaipur, India.www.medispaindia.in S. Soni: None. TAKE HOME MESSAGE: while attempting giga session of FUE safe donor zone should not be voileted.so prior assisment and proper selection of case is must to get long lasting result.mega sessions of FUE should be restrictrd to lower grade of baldness, with high donor density and should not be considered in patients of higher grade of baldness with stgong family history of baldness. ABSTRACT: Introduction Long term results of mega sessions of hare transplant some time shows early fall of transplanted hair. In retrospective study it showed that in these type of patent the FUE was done violating the safe donor zone (the area in which hair is going to last almost forever). So we just tried to define the safe donor zone and formulate the indications of mega session FUE technique. ObjectiveTo formulate the indications of mega sessions of FUE . Materials and Methods We retrospectively studied patens of mega hair transplant exclusively done by FUE i.e. 2500 FU in one sitting. The patients who complained for loss of transplanted hair (fig )were specially studied for area of harvest of follicular units. Old photographs (eg fig no ) were used to access area of harvest and compared to patent (e.g. fig no) who still maintained the transplanted density. It was observer patent with donor harvest from area more than 5cm X 28 cm (safe zone as showed in fig) showed gradual loss of transplanted hair as there grade of baldness increases. Discussion While attempting mega sessions of FUE hair transplant it is important to be in limits of safe donor zone .As we observer that hair extracted from unsafe areas have higher tendency of loss of transplanted hair as the grade of baldness increases. Conclusion Procedure of Mega sessions of FUE hair transplant should be restricted to patents which have good donor density and in which good no of grafts can be harvested from safe zone. Mostly these patients have lower grade of baldness and no strong family history. Strip method should be utilized in patients of higher grade of baldness or with strong family history of baldness as most of the graft harvested in strip method lies in safe donor zone and have higher chances of long term stability. Although FUE can be combined with strip method to increase the no of graft harvest

in one sitting without violating the safe zone (e.g.fig ).

Over Shooting The Safe Donor Zone In FUE Mega Sessions


Dr Suneet Soni
MBBS,M.S., M.Ch. (Plastic surgery) Director MEDISPA Hair Transplant Center Jaipur, India
www.medispaindia.in

DISCLOSURES
Speaker has no relevant financial relationships or conflicts of interest to declare.

Aim of Hair Transplant


PERMANENT HAIR ZONE

Natural looking Permanent hair Without long term medication With minimum side effects

Unger`s Safe donor Area

Ungers Safe Zone

Permanent Hair ?

Permanent Hair ?

Permanent Hair ?

FU distribution by BERNSTIN

www.medispaindia.in

Calculation of the Safe Donar Area

4CM X 8CM X 80 FU/CM (2560) + 5CM X 10CM X 100FU/CM (5000) + 4CM X 8 CM X 80 FU/CM (2560) = 10120 (2000)

In FUE method we can safely extract 20 to 25% grafts in one sitting

That comes out to be 2000 to 2500 grafts Considering 5 to 10% transaction rate the actual yield will be 1900 to 2250

Ideal Extraction in FUE average 1800 to 2000 FU

Overzealous Extraction 3000 FU, Overshooting the Safe Donor Area

Overshooting Safe Zone

Giga Sessions of FUE


Higher chances of extracting grafts from unsafe donar area Leading to early Transplanted Hair loss in long term follow up

Before Transplant

After 3000 FUE transplant in 2010

Early transplanted hair Loss in2012

Strip Method
Occipital Width 1.3 to 1.8 cm

Strip Method
Temporal Width 1.0 to 1.3 cm

Yield of Grafts
Strip Method Extraction
1.3cm x 8cm x 80cm FU/cm(832) + 1.8cm x 10cm x100FU/cm (1800) + 1.3cm x 8 cm x 80 FU/cm (832) = 3464 (+-400) Considering 1 % transaction rate Still average extraction per session is 3000+FU

Before and After 3500 FUT Transplant (Strip Method)

same after 5 years

2100 FU by FUE

3500 FU strip method

www.medispaindia.in

www.medispaindia.in

3450 FU Strip method

4350 FU By Strip Method

www.medispaindia.in

www.medispaindia.in

CONCLUSION
One should avoid overshooting safe donor zone Strip Method preferred over FUE
>2000

Practical Utility

Lower grade of baldness

FU

Less no of grafts required In combination with strip to extract 1500 additional grafts to add on mega session

Grade III baldness & more Grade II & III baldness with strong family history of high grade baldness

Beard, Mustache, Eye lashes, Eyebrow transplant Body hair transplants Patient refuses for Strip method due to

073 The Use of a Suction Apparatus to Improve Wound Healing of FUE Sites
Paul T. Rose, MD, JD. Miami Hair Institute, Coral Gables, FL, USA. Dr Paul Rose is a board certified dermatologist. He has been performing hair restoration surgery for over 20 years. Dr Rose has served on the BOG of the ISHRS and also served as President of the ISHRS. He has often lectured at various ISHRS meetings and has made numerous contributions to the field of hair restoration. P.T. Rose: None. TAKE HOME MESSAGE: Using a suction device for wound healing may help to improve FUE/FIT wound site scars ABSTRACT: Introduction: A frequently cited advantage of follicular unit extraction as a means for harvesting grafts has been the fact that a linear scar is not created. While this is true, the use of FUE produces round wounds that heal as hypopigmented scars that appear as "dots". These scars are often greater in size than the actual punch diameter used for harvesting. In an attempt to improve the results of FUE harvesting and create smaller scars the author has employed a suction apparatus to decrease the size of the wounds post operatively. The results of this approach will be presented. Objective; The objective of this work is to determine if post operative suction can be used to decrease the size of FUE scars Materials and Methods After performing FUE on a patient the donor area was cleansed with saline. An area was marked out in the donor area and divided in half. The area was photographed. Suction was applied to the wounds in one half of that area , using a Schuco ( Model S 130 A) suction device. Suction tubing was connected to the device and the end of the tubing applied to the wound area selected. The pressure was measured to be approximately 600 - 760 mm Hg . The pressure was applied continuously for several minutes or until there appeared to be significant approximation of the wounds. The wound area was then dressed with polysporin ointment . The patient returned the next day and the wound areas assessed by measuring the size of the wounds on the treated half of the area as compared to the other. Discussion The wounds from FUE result in hypopigmented circular scars resembling dots. Oftentimes these scars are larger than the punch used. If the patient elects to shave his head these scars can be obvious and there is a pattern akin to a buckshot appearanceThe author hypothesizes that while most skin wounds contract, the FUE wounds may not do so because in situations where significant grafts are removed the contractile forces are dissipated in all directions. An analogy might be taking an elastic sheet and placing numerous holes in it. At some point the elasticity is lost. In wound healing centers suction assisted devices have been used for quite some time to aid in healing. Based on this observation the author decided to employ a suction device to try to decrease the resulting scars. Conclusions; The results of this study will be presented.

ConflictofInterest TheUseofSuctionAssisted WoundforFUEWounds


PaulT.Rose,MD CoralGables,Florida DrsRoseandNusbaumhaveobtaineda provisionalpatentondevicetoassistin woundclosureusingnegativepressure.

FUEwounds
FUEisgenerallyperformedwithpunchesthat rangefrom0.81.2mm Thewoundcreatedoftenleavesa hypopigmented scarthatislargerthanthe punchdiameter Insomeinstancesthescarcanbedoublethe sizeofthepunchutilized Thescarscreateabuckshotappearanceto thedonorarea

Strategytoreducewoundsize
Considertheuseofvacuumassistedwound closure Vacuumassistedwoundclosurehasbeen usedinwound healing;primarilydecubitus ulcersandwounds thataredifficulttoheal

Method
Shuco S130Asuctionmachine Approx700mmHg 3minutes 3x3cmsquares,onesidewithsuctionthe othernosuction Suctiontubingapplieddirectlytowoundarea

Results
Itwasdifficulttoobtainexactmeasurementsas thewoundsarequitesmallandchangesinskull contourmayhaveaccountedfordistortionof somemeasurements Whenweusedevaluatorstoassessedtheareas therewasauniformconsensusthatthesuction areasseemedtoproducewoundsthatwere shallower Measurementsofrandomlychosenwounds showedapproximatelya1020%decreasein wounddiameter.

Benefits
Removessomefluid/edema Apparentimprovedwoundclosure Woundsareshallowerandappearsmallerin size

Disadvantage
Timeinvolvedtoperformthesuctiontothe woundareas Uncertainastolongtermdecreaseinwound size

Futureapproach
Prolongeduseofintermittentsuctionmight providebetterresultsoveralongerperiodof timewithaninhomedevice. ConsideruseofPRPasadjunct

074 Unfavorable Results with FUE Technique. Have We Come Full Circle?
Tejinder Bhatti, MCh. Darling Buds Hair Transplant Center, Chandigarh, India. Director, Plaza Clinic, Chandigarh, India Founder Secretary, Association of Hair Restoration Surgeons of India Joint Editor, Indian Journal of Plastic Surgery T. Bhatti: None. TAKE HOME MESSAGE: All young doctors wanting to fully or partially switch over to FUE technique should realise that like any other technique, it has a long learning curve. Hasty implementation and trying to achieve larger graft counts in a single day can have adverse affects on results. ABSTRACT: FUE is a wonderful technique. However, during the present hype for the technique due to several advantages, a lot more doctors have taken the plunge. Far greater numbers of FUE surgery are being performed today than many would suspect or admit. Since this is the period of growth for the technique, like always, a larger number of complications are being witnessed. This reminds one of the early years of hair transplant. Have we come full circle? narrate some real life stories with tips to avoid such disasters.

075 Vacuum Assisted Follicle Extraction Devise (VAFED), an Innovative Devise for FUE with Negligible Follicle Transaction and Easy to Learn Methodology
Anil K Garg, MS, MCh. Rejuvenate Hair Transplant Centre, Indore, India Dr.Anil K.Garg has done medical post graduation in General surgery and super specialization in Plastic, Reconstructive surgery. He has done fellowship in microsurgery from CGMS Taiwan and EVMS,norfolk USA.He in this field since 1990.He is doing hair transplant by FUT and FUE regularly. A.K. Garg: None. TAKE HOME MESSAGE: This newly invented VAFED is a FUE devise using three step of FUE. It is easy to learn, cost effective and going to reduce follicle transaction remarkably. It has corrected almost all limitations of other existing devises of FUE. ABSTRACT: Introduction preference for FUE is increasing day by day. Now it seems hair transplant surgeon is supposed to do FUE regularly. Healthy graft extraction and minimum follicle transection is pre requisite for success of FUE. This depends upon quality and type of instrument and surgeons experience. More and more sophisticated follicle extraction devises are coming with increasing cost. I have invented a devise which is cost effective and does not need much skill and experience to get healthy graft with negligible graft transaction. Objective My main objective is to make FUE comfortable and compatible to every hair transplant surgeon with minimal follicle transection and expenditure. Existing FUE devices are either surgeon experience dependent or having high cost of instrumentation. In some devises extracted follicles are collected in dry chamber there by having chances of follicle dehydration. This innovative VAFED is cost effective and does not require much experience to reduce follicle transection and has many other advantages over existing various devises of FUE. In this follicles are directly collected in storage media (lactated ringer/normal saline/other). Material and Method Principle_three step FUE techniques is used in this method of FUE. First step can be done using manual FUE devise or motorised. The epidermis and upper dermis is scored with sharp dermal punch. Second Step and third step_these both steps are done simultaneously with new invented devise and that is vacuum assisted follicle extraction. VAFED_VACUUM ASSISTED FOLLICLE EXTRACTION_this devise has three part. A) Suction machine which generate minus one atmospheric pressure. B) Vacuum chamber having graft storage solution and filters. This is attached to suction machine with adapter and silicone tubing. C) Dull punches which is of larger (+0.1mm) diameter then used in first step. Method_Donor area is prepared in same manner as for any FUE devise. First sharp punch is mounted on manual/motorise and follicles are cut up to dermal level. Now VAFED is used. A dull punch of size larger than previously used sharp punch is mounted on VAFED. This is attached to suction machine and around 10 ml of graft storage solution is sucked in vacuum chamber of devise. Now previously partially dissected follicles are chosen and with gentle pressure devise is pushed deeper up to subcutaneous level following same angle of exist of hair. As follicles are separated from

all over and attached to its base with loose fatty tissue, they are sucked immediately by negative pressure in vacuum chamber having storage solution. Discussion VAFED has many advantages over existing FUE devise. 1. Tremendous reduction in follicle transaction. 2. Preservation of multi follicular unit grafts. 3. Preservation of peri follicular tissue and fat. 4. No chances of desiccation of graft after extraction . 5. No chances of buried graft. 6. Easy to learn. 7. Economical devise 8. This has practically corrected limitations of all existing FUE devices. As two separate punches one is sharp smaller and another larger dull blunt punch so chances of follicle transection is negligible. After cutting with sharp punch because of elastic property of skin, the cut circle size around follicle is increased and previously injected tumescence solution leaks through the cut, causing overall reduction in splaying of follicle unit (Tumescence causes splaying of follicle unit). As the blunt tipped punch is advanced into deep dermis and subcutaneous tissue, splayed follicles are gathered together, avoiding transaction. In effect, the dull punch technique allows a full realization of the extraction concept which is finally completed by suction extraction of already dissected FU graft. As we have separated follicles (with blunt punch) all around the graft so there is no avulsion while extraction. Use of larger size punch (without larger skin cut) preserves some amount of peri follicular tissue and fat so follicles are not skinny (very thin). Follicles are extracted directly in storage media so there is no dehydration of graft. Conclusion Success of FUE not only depends on reduction of follicle transection but a healthy graft with intact follicles and well preserved peri follicular tissue is also mandatory. Then we can achieve healthy timely hair growth. VAFED not only full fills all possible requirements to extract an ideal graft but a surgeon with average skill can extract graft with minimum finance.

VACUUM ASSISTED FOLLICLE EXTRACTION DEVICE (VAFED)


DR.Anil K.Garg MS.,MCh Plastic surgeon Dr.Seema Garg MBBS.,MSc INDIA www.anilgarg.com Email anil@anilgarg.com

FUE
GOAL OF FUE

ZERO FOLLICLETRANSECTION

IDEAL FUE DEVICE


TRANSECTIONZERO /Nearly ZERO FOLLICLE SAFETY Peri follicular tissue,

DEVICES
HAND MOTORISED SAFER ROBOTArtas

Graft desiccation, Safety of all Fos in multi FUs


LEARNING CURVE USERFRIENDL Y COST

COMPARISION
DEVICE TRANSECTION

TRANSECTION
FOLLICLE SAFETY SAFE SAFE DRY DRY COST ECONOMICAL Eco to Exp. EXPENSIVE V.EXPENSIVE

?
HAND MOTORISED SAFER ARTASROBOT 5 TO10% 5 TO10% 8 TO10% 10 TO12 %

LEARNING CURVE ++ ++ +++ +

SHARPPUNCH SMALLER

V/S V/S

DULLPUNCH LARGER

VAFED

1 to3%

SAFE / WET

ECONOMICAL

TRANSECTION
common site

SUPRA BULBAR TRANS BULBAR

Vacuum Assisted Follicle Extraction Device


PRINCIPLE Three step technique (modified Harris) First Step scoringDermis (Sebaceous gland ) Second Stepdissection up to subcutaneous Third StepExtraction

VAFED

VAFEDFirst Step
Using sharppunch mounted on hand /motorized handle, wecut up tosebaceous gland. we cando evenup to100 to200follicles continuously.

FOLLICLE EXTRACTION TEST control depth of sharp punch

VAFED STEP II & III


Blunt punch ofsize largerthan previously

used, mounted onVAFED gently push deeperthrough circular cut (created bysharp punch). thiswill separatefollicle from surrounding tissue without damaging follicle

VAFED

THIRD STEP

EXTRACTION Dissected graft is extracted using vacuum suction mechanism through a larger dull punch. WET STORAGE Extracted grafts are collecteddirectly in storage media

TRANSECTION
Sharp punch can transect while scoring level up to sebaceous gland

TRANSECTION

<3%

Three StepTechnique Larger blunt punch without making larger

hole is used for deepergraft dissection.

LEARNING CURVE
Follicle Safety in this three step technique

ADVANTAGE
Negligible FT Peri follicular tissue preservation Follicle preservationin multipleFus Noburied graft Graftextracted directly instorage media Simultaneous implantation Noloss of transected follicles

with the use of blunt largerpunch makes easy to learn.

076 Electrolysis Assisted Follicular Unit Extraction (An Innovation in Hair Harvesting)
Shahin Gholami, Seyedalireza Sadraei Mousavi, Morteza Adabi, Hadi Kord, Yadollah Hosseini. Babol Hair Transplantation Center, Babol, Iran, Islamic Republic of. Shahin Gholami, Dermatologist,completed dermatology in YSMU 2008, 5 years experience in hair restoration surgery. S. Gholami: None. S. Sadraei Mousavi: None. M. Adabi: None. H. Kord: None. Y. Hosseini: None. TAKE HOME MESSAGE: Electrolysis Assisted Follicular Unit Extraction. (An Innovation in Hair Harvesting) ABSTRACT: Introduction: Electrolysis is the removal of unwanted hair through the means of a probe or needle inserted into the hair follicle. There are three different methods available on the market, all of which are described below. The aim of all the methods is to damage the base of the growing hair in order to cut off the blood supply and nutrition to the hair, preventing any new growth from developing. The technique is selective and minimal damage should occur to surrounding tissues. Galvanic electrolysis The galvanic method works by using a Direct Current (DC) of electricity. When the needle is inserted, the electricity coming down the needle causes the salt and water in the skin around the probe to be chemically altered. Salt, water and electricity combine to produce a small amount of sodium hydroxide. If enough is produced, this solution can damage the cells that cause hair growth. Thermolysis/Diathermy/Short Wave Electrolysis The thermolysis method, also known as diathermy or short wave, works by using an Alternating Current (AC) of electricity. This electricity causes the water molecules in the skin around the needle to vibrate, which creates heat. If enough heat is produced, it can damage the cells that cause hair growth. Blend Electrolysis The Blend Method combines both the Short Wave and Galvanic procedures. Sodium hydroxide is created and is then heated by the electricity. This heat, plus the chemical solution, then destroys the hair tissue. Properly used, all the methods described above are capable of the same result. We would like to determine if a hair extracted with electrolysis method is appropriate for transplantation and if so, do we have a chance in donor area to regrowth ? Materials and Methods: we have used single follicle extraction from donor site by using short wave high friquency hair removal elctrolysis in FUE method. The Shortwave unit produces an impressive 0.01- 0.4991 dBwEIRP RF output, (at 5 watts).and produce maximum of 120 F degree in follicle unit.but we set the unit in which RF output with minimum injury to follicle unit that easily can be pulled out. after extracting follicles, units implanted into 0.7mm sticks in reciepiant area. This procedure was done on 5 cases ( 3 andogenetic alopecia , 2 cicatricial alopecia ) . For each case around 50 units were harvested from donor area with electrolysis and implanted in recipient area. Both donor and recipient areas were observed 3 days,14days,1month,3 months and 6 months after implanting.( befor and after pictures and histopathologic assessment will be shown in the congress ). Results : Case no 1 - 30 units harvested and implanted ( in donor area 14 units regrow , In recipient area 28 units grew). Case no 2 - 50 units harvested and implanted ( in donor area 21 units regrow, In recipient area 44 units grew). Case no 3 - 50 units harvested and implanted ( in donor area 21 units regrow, In recipient area 46 units grew). Case no 4 - 35 units harvested and implanted ( in donor area 16 units regrow, In recipient area 31 units grew). Case no 5 - 50 units harvested and implanted ( in donor area 23 units regrow,

In recipient area 45 units grew). In 5 cases 44% success in donor area regrowth, 90 % seccess in recipient area growth. Conclusion : As we know with Ordinary FUE no hair will grow in donor area but with this method we have hairs in donor area .we can call this INVIVO DUPLICATION ,A method if we work on it and improve it can be an appropriate replacement for manuual or motorized FUE because we harvest hairs and we again have hairs in donor area. Some problem exist that must be eliminated in the future : 1- It is not a device for harvesting ,new device must be invented for this purpose ,our team are working on it. 2- the ratio of success both in donor and recipient areas must increase. 3- this technique must be done on more cases. Finally we hope we would be able to introduce a new device and new technique to the world of hair transplantation.

077 Moderator Introduction, Enhancing Donor Management in Strip Harvesting


Henrique N. Radwanski, MD. Private Clinic, PILOS CENTER, RIO DE JANEIRO, Brazil. Dr. Radwanski is a plastic surgeon, member of the Brazilian Society of Plastic Surgery and the International Society of Aesthetic Plastic Surgery. He is associate professor (plastic surgery) at the Ivo Pitanguy Institute in Rio de Janeiro. H.N. Radwanski: None.

078 The Roles of Injected Steroid in Donor Strip Wound Healing


Bertram M. Ng, MBBS. Dr. Bertram Hair Transplant, Kowloon, Hong Kong.

Bertram Ng is a ISHRS Certified Fellow and a ABHRS Diplomate. After serving as an examiner for the last 2 years, he is recently appointed Director of the ABHRS. His main interest is in Hairline Restoration, especially in women. In 2008 he invented the hand-held laser for hairline placement. His motto is using the least number of grafts to achieve the best result, making good use of every single graft. His hair transplant center is located in Hong Kong. B.M. Ng: None. TAKE HOME MESSAGE: Immediate postoperative steroid injection reduces the severity of effluvium and scar formation. ABSTRACT: Introduction: There are 2 major complications following donor strip harvesting - postoperative effluvium and scar. Postoperative donor effluvium is anagen effluvium starting from 3 weeks onward (1). Though almost all hairs regrow within 4 months, the effluvium can be extensive and alarming. Despite many efforts trying to establish a cause (2), the effluvium remains unpredictable. The scar raises 4 concerns: color, width, consistency and tenderness. Despite the use of many techniques such as Trichophytic Closure, wide scars up to 4-5mm still occur especially in megasession. Keloid never ceases to be a concern in certain ethnic group. Application of silicone gel to the donor wound in the first 2 months is routinely recommended by the author, but its efficacy remains uncertain. Immediate postoperative steroid injection has been recommended by many experience surgeons. Abbasi mixed the Kenalog in the tumescence solution; Jerry Wong injects Kenalog along the wound once the wound is stapled. Yet there is no reported study to justify its routine use. Objective A study was commenced in July 2012 to examine the effect of steroid in the donor site regarding: 1.Postoperative donor effluvium 2.Scar formation Material & Method Patients were randomly assigned to the study. Just before discharge 2.5ml of 1% xylocaine + 1:100,000 adrenaline + 1.6mg/ml Kenalog was injected along the left inferior border of the donor wound; another 2.5ml without the Kenalog was injected along the right inferior border. One concern about the Abbasis and Wongs approaches is that the steroid containing solutions will be dissipated during incision and insertion when the patients head rests on the pillow. The amount retained will be unpredictable. We therefore opted to mix the Kenalog with the top-up local anesthesia. The patients are asked to return at 1 week, 1 month, 4 months and 8 months after the procedure. The donor wound is examined for effluvium; and the scar width, discoloration, tenderness, and consistency were noted. Results: So far on close inspection the side injected with Kenalog had less postoperative effluvium at 1 month. The scar at 8 month was also thinner and less indurated. As more patients will be returning for follow-up, the final result will be presented in this year ISHRS Annual Scientific Meeting. The study may be abandoned earlier if the advantages are too obvious. Discussion: Inadequate dosage of Kenalog used for the injection may not give the desired result. Excessive dosage on the other hand may cause postoperative infection and scar atrophy. Abbasi mixed 0.4mg/ml in his tumescence, whilst Mayer used 10mg/ml for patients of African decents. There is no universally accepted protocol regarding the dosage. Our dosage of 1.6mg/ml was arbitrary determined. Conclusion This study so far demonstrates that immediate postoperative steroid injection reduces the severity of effluvium and scar formation. The results support the routine use of steroid injection after donor harvesting.

Reference: 1.Ng & Pathomvanich. Post-surgical hair loss in the donor site after hair transplantation: anagen or telogen effluvium. Forum 19:2, Mar/Apr 2009 2.Panchaprateep, Pathomvanich. Does Epinephrine influence post-surgical effluvium? A pilot study. Forum 22:3, May/June 2012

2013/9/3

Conflict of Interest
I have nothing to declare

Roles of Injected Steroid in Donor Strip Wound Healing


Dr Bertram Ng (Hong Kong)

Introduction
There are 2 major complications following donor strip harvesting - postoperative effluvium - scar

Postoperative Donor Effluvium


Postoperative donor effluvium is anagen effluvium starting from 3 weeks onward Though almost all hairs re-grow within 4 months, the effluvium can be extensive and alarming Despite many efforts trying to establish a cause, the effluvium remains unpredictable

Donor Scar
The scar raises 4 concerns: - Color - Width - Consistency - Tenderness Despite the use of many techniques such as Trichophytic Closure, wide scars up to 4-5mm still occur especially in megasession Keloid never ceases to be a concern in certain ethnic group Application of silicone gel to the donor wound in the first 2 months is routinely recommended by the author, but its efficacy remains uncertain

Steroid Injection
Immediate postoperative steroid injection has been recommended by many experience surgeons Protocols involve: - Mixing the Kenalog in the tumescence solution - Injecting Kenalog along the wound once the wound is stapled There is no reported study to justify its routine use

2013/9/3

Objectives
A study was coducted between July 2012 to October 2013, examining the effect of steroid in the donor site regarding: Postoperative donor effluvium Scar formation Folliculitis or ingrown hair Other discomfort such as itchiness, tenderness

Material & Method


One concern about the mentioned approaches is that the steroid containing solutions will be dissipated during incision and insertion when the patients head rests on the pillow. The amount retained will therefore be unpredictable e therefore opted to mix the Kenalog with the top-up local anesthesia.

Material & Method


Patients were randomly assigned to the study The donor strip was symmetrical in width and shape No undermine Tumescence was used Minimal to moderate tension on wound closure Interrupted 3O Nylon followed by running 4O Vicryl Rapid

Material & Method


Our Steroid mixture was arbituary formulated: 1% xylocaine + 1:100,000 adrenaline + 1.6mg/ml Kenalog Just before discharge 2.5ml of the above was injected along the left inferior border of the donor wound Another 2.5ml without the Kenalog was injected along the right side

Video Here

Material & Method


The patient was asked to return at 1 week, 1 month, 4 months and 8 months after the procedure The donor wound was examined by 3 staff for the presence of - effluvium - scar width - discoloration - tenderness - induration

Results
In the majority of cases there was no differences In some cases the side injected with Kenalog had less postoperative effluvium at 1 month Only minority has better scar on the injected side at 8 month, thinner and less indurated There was no increase of complication

2013/9/3

Discussion
Inadequate dosage of Kenalog used for the injection may not give the desired result Excessive dosage on the other hand may cause postoperative infection and scar atrophy Some surgeon mixed 0.4mg/ml in the tumescence Others use up to 10mg/ml for patients of African decents There is no universally accepted protocol regarding the dosage Our dosage of 1.6mg/ml was arbitrary determined.

Conclusion
We have changed our recommendation since submitting the abstract This study demonstrates that immediate postoperative steroid injection reduced the severity of effluvium and width of scar only in a very small number of cases The majority showed no dramatic difference

Conclusion
Routine use of steroid injection after donor harvesting may not be necessary It should be reserved only for selected cases e.g. Keloid prone patients

079 Efficacy and Safety of Low Dose Enalapril in Minimizing Linear Donor Scars from Hair Restorarion Surgery - A Randomized Double Blind Placebo Control Study
Damkerng Pathomvanich, MD, FACS, Jocelyn Theresa Navalta, MD, DPDS, Prapote Asawaworarit, MD, Oravan Pathomvanich, MD, Rangsit Sittiwangkul, MD. DHT Clinic, Bangkok, Thailand. Doctor of Medicine Faculty of Medicine, Prince of Songkla University, Thailand Internship Thammasat University Hospital, Thailand Master of Science in Dermatology Faculty of Medicine, Srinakharinwirot University, Thailand Fellowship in Hair Restoration Surgery approved by ISHRS DHT Clinic, Bangkok, Thailand D. Pathomvanich: Research Grant (principal investigator, collaborator or consultant); ISHRS. J.T. Navalta: Research Grant (principal investigator, collaborator or consultant); ISHRS. P. Asawaworarit: Research Grant (principal investigator, collaborator or consultant); ISHRS. O. Pathomvanich: Research Grant (principal investigator, collaborator or consultant); ISHRS. R. Sittiwangkul: Research Grant (principal investigator, collaborator or consultant); ISHRS. TAKE HOME MESSAGE: ABSTRACT: Introduction Hypertrophic scars and keloids are abnormal responses to dermal injury caused by exuberant deposition of collagen developing over the three basic stages of wound healing (inflammation, proliferation, maturation or remodeling).1 Predisposition of individuals to these scars include racial (Black, Hispanic, Asian) and familial factors (autosomal dominance and recessive variants) have been identified.2,3,4 Current treatment for hypertrophic scars and keloids with supporting evidence include silicone sheets, pressure dressings, and corticosteroid injections. Other surgical modalities include cryotherapy and surgical removal may have risk of recurrence, while alternative postsurgical options including pulsed dye laser, radiation, imiquimod cream, intralesional verapamil, fluorouracil, bleomycin, and interferon alpha-2b have been found to be beneficial.5 Despite these various treatment modalities, scars and keloids most especially are far more difficult to manage and may even recur. In 2006, a fortuitous report of 2 cases of treatment of long-standing post-surgical keloid scars using low-dose ACEinhibitor (Enalapril) for 4-months and 6-months showed improvement in the first case and complete recovery in the second. There were no reported adverse effects from the intake of the medication in both cases.6 In 2009, another study compared Enalapril and Captopril in skin flap viability on rats and results showed Enalapril improved survival area in a dose dependent-manner while Losartan failed to improve survival area.7 Dr. Sharon Keene presented 2 cases of donor site improvement of keloids using ACE inhibitors for 3-4 months during the 18th ISHRS Annual Scientific Meeting in Boston, USA, which provided us a glimpse into a novel approach in treating keloids and hypertrophic scars in the field of hair transplant surgery8. ACE inhibitors have long been used to treat patients with cardiovascular disease. Several animal and human studies have concluded the effects of ACE inhibitors on left ventricular remodeling by decreasing left ventricular hypertrophy and infarct wall thickness.9-12 ACE inhibitors Perindopril and Enalapril were found to have antiinflammatory effects by decreasing lymphocytes with the reduction of interleukin-2, interferon-g and

TNFa.13Enalapril has also been found to improve histological healing biomarkers and have reduced inflammation in infarcts by decreasing excessive recruitment of monocytes.14 Minimizing scar formation at the donor site in hair transplant surgery is one of the main concerns of most hair transplant surgeons. Patients desire to have minimal if not less visible scars is becoming more apparent and is a common factor in their final decision to undergo hair transplantation. Although the use of trichophytic closure has considerably decreased donor scar visibility15-17 undergoing multiple hair transplantation surgeries where incisions are made along previous scars usually leave behind even larger scars. A new safe and effective treatment modality that can considerably improve cosmetic outcome of donor scars from hair transplantation can become a formidable response to the concerns and apprehension of patients to go under the knife. Hypothesis Alternative: Enalapril 10mg daily dose over the Control is an effective and safe treatment in minimizing donor linear scar formation from hair transplantation. Null: Enalapril 10mg daily dose over the Control is not an effective and safe treatment in minimizing donor linear scar formation from hair transplantation. Scope and Limitations of the Study The purpose of this study is to determine the efficacy and safety of using an ACE inhibitor (Enalapril) in a low dosage to minimize linear scar formation at the donor site of hair transplant patients. To our knowledge, this is the first randomized control clinical trial to investigate the effect of an ACE inhibitor (Enalapril) on wound healing in hair transplantation surgery. Limitations of this study are that the mechanism of action of the possible effects of Enalapril on wound healing, long-term effects (beyond the duration of the study) from prolonged use of the drug, and long-term adverse effects will not be investigated. The duration of the study will be limited to 6 months. Objectives a. To determine a significant difference in the size (width) of donor linear scars after strip FUT among patients assigned to the Treatment group (Enalapril 10mg) vs. the Control group (Placebo) comparing measurements taken on the 3rd and 6th months of treatment. b. To determine a significant change in clinical appearance of donor scars between the Treatment Group (Enalapril 10mg) vs. Control group (Placebo) between the 3rd and 6th month of treatment using the following parameters: Digital Photography (Nikon SLR camera) - Visual Rating to be assess by participant and 2 independent investigators c. To determine any adverse effects (AEs) during the 6-month study period with once a day intake of Enalapril 10mg by monitoring for the following at 3rd and 6th month follow-up: (1) hypotension (measure blood pressure) (2) allergic reactions (i.e. rashes) (3) syncope/fainting/dizziness (4) persistent dry cough (5) headache (6) other side effects Study Participants and Sampling Design Inclusion Generally healthy males 18 years old and above Will be able to follow-up at the clinic after 3 and 6 months or will be able to correspond and send study data through email Has had at least 1 previous session of strip hair

transplantation (FUT) resulting in a hypertrophic scar or keloid OR Has had a history of hypertrophic scarring or keloid formation on other areas of the body Non-smoker Non-alcoholic beverage drinker Exclusion Presence of concomitant uncontrolled systemic disease (i.e. hypertension, hypotension, diabetes, kidney and liver diseases, allergies to oral medications, etc) Presence of concomitant active inflammatory skin lesions during the time of enrolment into the study (i.e. seborrhea, folliculitis, psoriasis) History of atopy and susceptibility to allergic reactions (wheal formation, urticarial, swelling, angioedema) to any form of allergen Has been undergoing treatment for the donor scar in the last (1) month (i.e. intralesional injections, topical application, etc) Withdrawal from the Study Participants will be allowed to withdraw from the study for any reason, particularly due to the following: Noncompliance with the intake of medication or with the post-op instructions during the 6- month study period Experience any adverse event (AE) from the treatment drug that will hinder their participation in the study Unable to complete the 6-month duration of the study Consent to withdraw or voluntarily drop out from the study Materials and Methods Participants will be initially screened for eligibility into the study using the Inclusion/Exclusion criteria. All participants will be allocated to one of the two study groups using a computer-generated randomization scheme (Group 1 or Group 2). A clinic staff not participating in the study will list down the allocation of participants into Treatment group 1 or 2. All participants and investigators/assistants will be blinded to the study. After the participants sign a written Informed Consent form (Appendix 3), baseline digital photography (Nikon SLR camera) and measurements of the post-op incision using a standard metric ruler (cm) will be taken (right side 5cm from the edge, midline, and left side 5 cm from the edge) and recorded (photographed) by an investigator/assistant. Photographs will be taken under good lighting in the same room and at 3 angles of the scar (left side, midline and right side). Study participants will undergo strip FUT. For participants who have undergone more than one hair transplant strip method, the number of procedures and the current surgical management (whether to incise along the previous scar, to include the scar within the strip, or to avoid the scar altogether) will be recorded. In all participants, lower flap trichophytic closure will be performed. Donor site will be closed with retention stitches using simple interrupted sutures (Nylon 4-0) followed by simple running sutures (Rapide Vicryl 4-0). Antibiotic ointment (Mupirocin) will be applied immediately post-operatively (Day 0) underneath a sterile gauze dressing. Postoperative donor wound care will be advised and written post-operative instructions and medications (oral antibiotic and pain medication) given. On the 5th day post-surgery, study participants will come back to the clinic for removal of retention sutures. Each participant will be instructed to take Enalapril 5mg/tablet 2 tablets or to take 2 tablets of placebo once a day continuously for 6 months commencing on Day 5 post-surgery. All participants will be instructed to refrain from using any other form of scar treatment and will be advised to avoid excessive head movements (over bending) during the duration of the study. They will be informed to contact the clinic at any time during the study period should they experience any complication or adverse effects (i.e. dizziness, persistent coughing, headache, hypotension, angioedema, urticarial, muscle cramps). Adverse effects will be noted and will be managed accordingly. Study participants will be asked to visit the clinic on the 3rd and 6th month after surgery for follow-up photos and measurements. For participants who will be unable to come back for personal follow-up at the clinic, they will be instructed on the proper method of measurements and photography and will be asked to send these data via email correspondence. Based on the photos taken, the participant and 2 independent investigators will be instructed to rate the clinical appearance of the donor scar by comparing the 3rd and 6th month photos on the 6th month follow-up. On the 6th month, participants will be instructed to discontinue the allocated treatment regimen. Participants with persistent donor scarring after 6 months will be managed accordingly. Data will be collated and sent for statistical analysis.

Result and Discussion Pending References 1 Jackson IT, Bhageshpur R, DiNick V, Khan A, Bhaloo S. Investigation of recurrence rates among earlobe keloids utilizing various postoperative therapeutic modalities. Eur J Plast Surg. 2001;24(2):88-95. 2 Omo-Dare P. Genetic studies on keloid. J Natl Med Assoc. 1975;67(6):428-432. 3 Brissett AE, Sherris DA. Scar contractures, hypertrophic scars, and keloids. Facial Plast Surg. 2001;17(4):263-272. 4 Butler PD, Longaker MT, Yang GP. Current progress in keloid research and treatment.J Am Coll Surg. 2008;206(4):731-741. 5 Juckett G, Hartman-Adams H. Management of Keloids and Hypertrophic Scars.American Family Physician. 2009 Aug 1;80(3):253-260. 6 Ianello S, Milazzo P, Borndonaro F, Felfiore F. Low Dose Enalapril in the Treatment of Surgical Cutaneous Hypertrophic Scar and Keloid - Two Case Reporst and Literature Review.MedGenMed. 2006; 8(4): 60. 7 Pazoki-Troudi H, Ajami M, Habibey R, Haliiaboli E, Firooz A.The effect of enalapril on skin flap viability is independent of angiotensin II AT1 receptors. Ann Plast Surg. 2009 Jun;62(6):699-702. 8 Sharon A. Keene, 2010. Use of ACE Inhibitors in Donor Site Keloids. Boston, Massachusetts, USA, 20-24 Oct 2010, Boston: International Society of Hair Restoration Surgery. 9 Jugdutt BI. Effects of amlodipine versus enalapril on left ventricular remodelling after reperfused anterior myocardial canine infarction. Can J Cardiol. 1997 Oct;13(10):945-54. 10 Jugdutt BI, Musat-Marcu S. Opposite effects of amlodipine and enalapril on infarct collagen and remodelling during healing after reperfused myocardial infarction.Can J Cardiol. 2000 May;16(5):617-25. 11 Jugdutt BI, Menon V, Kumar D, Idikio H. Vascular remodeling during healing after myocardial infarction in the dog model: effects of reperfusion, amlodipine and enalapril. J Am CollCardiol.. 2002 May 1;39(9):1538-45. 12 ShigemashaTani et al. Effects of Enalapril and Losartan in Left Ventricular Remodeling after Acute Myocardial Infarction: A Possible Mechanism of Prevention of Cardiac Events by Angiotensin-converting Enzyme Inhibitors and Angiotensin Receptor Blockers in High-risk Myocardial Infarction. Inter Med 48: 877-882, 2009. 13 Robert Krysiak, Bogus3aw Okopien. Lymphocyte-suppressing action of angiotensin-converting enzyme inhibitors in coronary artery disease patients with normal blood pressure.Pharmacologic Reports 2011, 63, 1151-1161. 14 Leushner F et al. ACE inhibition prevents the release of monocytes from their splenic reservoir in mice with myocardial infarction. Circ Res. 2010 November 26; 107(11): 1364-1373. 15 Yamamoto K. Trichophytic closure of both wound edges after strip excision for hair transplantation. Hair Transplant Forum International. 2009 Nov-Dec;19:185,190-191. 16 Frechet, P. Donor harvesting with invisible scars.Hair Transplant Forum International. 2005;15(4):119-120. 17 Marzola, M. Trchophytic closure of the donor area.Hair Transplant Forum International. 2005: 15(4):113, 116. 18 Baker R, Urso-Baiarda F, Linge C, Grobbelaar A. Cutaneous Scarring: A Clinical Review. Dermatol Res Pract. 2009; 2009: 625376, Published online 2010 February 10. 19 Draaijers LJ, et al. The Patient and Observer Scar Assessment Scale: A Reliable and Feasible Tool for Scar Evaluation. Plastic and Reconstructive Surgery. 2004 June;11(7):1960-1965.

EFFICACY AND SAFETY OF LOW DOSE ENALAPRIL IN MINIMIZING LINEAR DONOR SCARS FROM HAIR TRANSPLANT SURGERY A RANDOMIZED DOUBLE BLIND PLACEBO CONTROL STUDY Researchgrantsupportedby InternationalSocietyofHairRestorationSurgery
Jocelyn Theresa P. Navalta, M.D, DPDS Damkerng Pathomvanich, M.D, FACS Prapote Asawaworarit, MD Oravan Pathomvanich, MD
DHT Clinic, Bangkok, Thailand path_d@hotmail.com

Background

Background

Hypertrophic scars and keloids are abnormal responses to dermal injury caused by exuberant deposition of collagen developing over the three basic stages of wound healing Despite various treatment modalities, scars and keloids most especially are far more difficult to manage and may even recur

ACE inhibitors have long been used to treat patients with cardiovascular disease Perindopril and Enalapril were found to have anti-inflammatory effects by decreasing lymphocytes with the reduction of interleukin-2, interferon-g and TNFa Enalapril has also been found to improve histological healing biomarkers and have reduced inflammation in infarcts by decreasing excessive recruitment of monocytes .

Background

Background
The purpose of this study is to determine the efficacy and safety of using an ACE inhibitor (Enalapril) in a low dosage to minimize linear scar formation at the donor site of hair transplant patients.

A new safe and effective treatment modality that can considerably improve cosmetic outcome of donor scars from hair transplantation can become a formidable response to the concerns and apprehension of patients to go under the knife

Background
To our knowledge, this is the first randomized control clinical trial to investigate the effect of an ACE inhibitor (Enalapril) on wound healing in hair transplantation surgery.

Objectives
To determine a significant difference in the size (width) and clinical appearence of donor linear scars after strip FUT among patients assigned to the Treatment group (Enalapril 10mg) vs. the Control group (Placebo) comparing measurements taken on the 3rd and 6th months of treatment.

Study Design
Inclusion

Study Design
Inclusion

Generally healthy males 18 years old or over Will be able to follow-up at the clinic after 3 and 6 months or will be able to correspond and send study data through email

Has had at least 1 previous session of strip hair transplantation (FUT) resulting in a hypertrophic scar or keloid OR Has had a history of hypertrophic scarring or keloid formation on other areas of the body Non-smoker Non-alcoholic beverage drinker
.

Study Design
Exclusion

Study Design
Exclusion

Presence of concomitant uncontrolled systemic disease (i.e. hypertension, hypotension, diabetes, kidney and liver diseases, allergies to oral medications, etc) Presence of concomitant active inflammatory skin lesions during the time of enrolment into the study (i.e. seborrhea, folliculitis, psoriasis)
.

History of atopy and susceptibility to allergic reactions (wheal formation, urticarial, swelling, angioedema) to any form of allergen Has been undergoing treatment for the donor scar in the last one month (i.e. intralesional injections, topical application, etc)

Study Design
Withdrawal from the Study

Materials and Methods

Non-compliance with the intake of medication or with the post-op instructions during the 6month study period Experience any adverse event (AE) from the treatment drug that will hinder their participation in the study Unable to complete the 6-month duration of the study . Consent to withdraw or voluntarily drop out from th t d

All participants will be allocated to one of the two study groups using a computer-generated randomization scheme (Group 1 or Group 2) A clinic staff not participating in the study will list down the allocation of participants into Treatment group 1 or 2 All participants and investigators/assistants will be blinded to the study
.

Materials and Methods

Materials and Methods

Each participant signs a written Informed Consent form Baseline digital photography (Nikon SLR camera) Photographs will be taken under good lighting in the same room and at 3 angles of the scar (left side, midline and right side).

Lower flap trichophytic closure will be performed to all participants Donor site will be closed with retention stitches using simple interrupted sutures (Nylon 3-0) followed by simple running sutures (Rapide Vicryl 4-0)

Materials and Methods

Materials and Methods

Antibiotic ointment (Mupirocin) will be applied immediately post-operatively (Day 0) underneath a sterile gauze dressing Post-operative donor wound care will be advised and written post-operative instructions and medications (oral antibiotic and pain medication) given

On the 5th day post-surgery, study participants will come back to the clinic for removal of retention sutures Each one will be instructed to take Enalapril 5mg/tablet 2 tablets or to take 2 tablets of placebo once a day continuously for 6 months commencing on Day 5 post-surgery

Materials and Methods

Measurements of the post-op incision using a standard metric ruler (cm) will be taken (right side 5cm from the edge, midline, and left side 5 cm from the edge) by an investigator/assistant.

Materials and Methods

Materials and Methods

All participants will be instructed to refrain from using any other form of scar treatments and will be advised to avoid excessive head movements (over bending) during the duration of the study They will be informed to contact the clinic at any time during the study period should they experience any complication or adverse Adverse effects will be noted and will be managed accordingly
.

Study participants will be asked to visit the clinic on the 3rd and 6th month after surgery for followup photos and measurements For participants who will be unable to come back for personal follow-up at the clinic, they will be instructed on the proper method of measurements and photography and will be asked to send these data via email correspondence
.

Materials and Methods

Materials and Methods

Based on the photos taken, the participant and 2 independent investigators will be instructed to rate the clinical appearance of the donor scar by comparing the 3rd and 6th month photos on the 6th month follow-up

On the 6th month, participants will be instructed to discontinue the allocated treatment regimen Participants with persistent donor scarring after 6 months will be managed accordingly Data will be collated and sent for statistical analysis

Results

Discussion

pending

pending

Thank you

080 Partial Trichophytic Closure - A Calculated Approach in Performing Double Edged Trichophytic Closure for Improving the Appearance of Scalp Scar
Parsa Mohebi, MD. US Hair Restoration, Los Angeles, CA, USA. Parsa Mohebi, MD, is the medical director of US Hair Restoration. He performed his surgical residency at University of New Mexico and York Hospital in Pennsylvania. He also served as a post doctorate research fellow at John Hopkins School of Medicine, Department of Surgical Sciences. He performed several studies on wound healing and hair growth, utilizing growth factors and gene therapy methods. Dr. Mohebi completed his fellowship in surgical hair restoration at the New Hair Institute. As a hair restoration surgeon Dr. Mohebi, has forwarded the industry by inventing the Laxometer for a more precise measurement of scalp laxity before hair restoration procedures. Dr. Mohebi is a Diplomate of the American Board of Hair Restoration Surgery. P. Mohebi: None. TAKE HOME MESSAGE: The partial trichophytic closure is a novel method for closing the donor wound that can improve the overall appearance of the donor scar significantly in many patients. ABSTRACT: Introduction: Trichophytic closure has been used for scalp surgeries for many years now. The main purpose of this technique has been to improve the appearance of donor scar by bringing hair into the scar. Introducing hair into the scalp scar helps minimize the contrast of the scar, which has no hair in comparison to the surrounding areas with 100% hair density. Premise: Trichophytic closure has been suggested to be performed in different forms: 1. upper edge 2. lower edge and 3. double edge. When we should perform each method and when it is indicated to do a combination of two has not been clearly discussed in the past. Substantiating data: The visibility of a donor scar has to do with two components: 1. High density of hair surrounding the donor scar 2. No hair inside the scar area Lack of hair in a scalp scar is due to two reasons: 1. Presence of scar tissue 2. Transection of the lower portion of hair follicles on the edge of the scar that leads to a slim strip of scalp with no hair; this phenomenon can add to the width of the hairless area, therefore making the visibility of the scar more prominent. The presence of hairless areas alongside the scar is mainly due to transection of distal ends of some of the hair follicles that are supposed to grow hair in those marginal areas. This area will add to the hairless area of the scar and make the scar appear wider. Partial trichophytic closure requires the surgeon to observe the donor wound edges and to calculate the width of the edge that needs to be removed in any area. This is different than the traditional trichophytic closure in which the surgeon removes a fixed width of the epithelial layer despite of presence or absence of follicular transection. In a partial trichophytic closure, the surgeon needs to closely observe the wound edges with magnifying loupes. We recommend doing a traditional upper trichophytic closure with a 1mm deepithelialized edge when there is no

transection at the edges. In the areas that we see follicular distal transection, we increase the size of deepithelialized area proportionately to eliminate the hairless sliver. We do not deepithelialize the entire lower edge. We only deepithelialize the areas that show distal end transection. This method guarantees the removal of the edge of skin that will become hairless otherwise. Partial trichophytic closure with the above method assures growing hair into the scar from the upper edge to minimize the contrast between the hairless scar and surrounding scalp. It also eliminates the occurrence of hairless areas alongside the scar on the opposite edge. Discussion: The partial trichophytic closure on one side may add to the time of strip removal. This added time has been around 10 minutes in average during my procedures. However, it can eliminate one important element that may increase the visibility of the scar. I have been performing this method on a majority of my patients in the last two years and I believe it has improved the overall quality of the donor scars in our patients significantly.

Parsa Mohebi, MD Los Angeles, CA

Disclosure: None

Donor scarvisibility

Whatdoes TPC do?


Scar tissue with no hair Hairless areas due to transection of hair at the edges

Brings hair into the scar Minimizes the contrast between scar with no hair and surrounding areas with 100% density of hair

Howit is usually done

Prosand Cons

Single edge:
Brings hair from one side into the scar area and

Single edge
Upper edge Lower edge

reduces the contrast


No coverage for the transected hair on the opposite

Double edge

side

Double edge
Bring more hair into the scar from both side Can eliminate the hairlessness at the edge due to

transection
May introduce too much hair into the scar at times

Partial Trichophytic Closure


Complete Trichophytic on one side that allows bringing hair into the scar from that side Deepithelialization of the scar edge from the opposite side minimizes the chance of presence of hairless area due to transection

Howit is done
Trichotomy on one side of the scar Measuring the surface area of the epithelium that needs to be removed based on the level of transection and hair angle Removing the precise area that will otherwise lead to hairless edge

Prosand Cons

Add to the time of procedure Reduces the visibility of the scar be eliminating the effect of transection of hair at the edges

081 Novel Application of Hyaluronidase on Scalp Laxity


Wen- Yi Wu, MD, ABHRS. Taiwan Hair Transplantation, Taipei, Taiwan. W. Wu: None. TAKE HOME MESSAGE: Hyaluronidase has a wound softening property. When dealing with a tight or difficult wound closure, hyaluronidase may be injected to the donor area to increase scalp laxity; enhancing a much easier closure. ABSTRACT: Hyaluronidase, any of a group of enzymes that catalyze the hydrolysis of certain complex carbohydrates such as hyaluronic acid and chondroitin sulfates. The enzymes have been found in insects, leeches, snake venom, mammalian tissues (testis being the richest mammalian source), and in bacteria. Hyaluronidase has a temporary and reversible depolymerizing action on the polysaccharide hyaluronic acid which is present in the intercellular matrix of connective tissue. The intercellular "cement" is thereby made more permeable, permitting the rapid dispersal and absorption of injected substances; the reduction of tissue tension; and the rapid dispersal of extravascular fluid in joint and tissue damage. One of the most important factors in determining whether a scar remains fine or not is the tension on the wound at closure. There is a chance that the scar will stretch on tight closure. If the closure is loose, the chance of stretching is reduced. Hyaluronic acid controls the amount of water in the skin. Theorectically, when Hyalronidase is injected to the skin, water is allowed to leave. This increases the laxity of the skin and enables the wound to be closed with less tension. This study is conducted to find out if Hyaluronidase does reduce the wound tension, thus enhancing an easier closure. And if Hyaluronidase has any effect on the scar outcome. Procedures: A total of 45 patients were recruited . The Hyaluronidase solution was created by mixing 300 I.U. Hyaluronidase ( Ovine ) powder with 10 ml saline solution. After the donor strip was removed, the closing wound tension was measured by Kanon Tension Gauge. The 10 ml Hyaluronidase solution was then injected into the upper and lower flaps at the bilateral Mastoid areas. Wound tension was then re-measured after 15 minutes of injection. Results: 1. No adverse reactions were noted after the injection. 2. The overall wound tension were 10-20% softer, making wound closure easier. 3. There was no worsening of the scars post-operatively. 4. There was either no improvement of the scars. Comments: Hyaluronidase has a wound softening effect on scalp laxity. When encountering tight donor scalp or wound with difficult closure, the conventional approach to approximate the wound include undermining, milking of the wound, delayed closure and leaving a gap for secondary wound healing. Hyauronidase may also be injected to the mastoid areas, which are usually the areas with the most tension for closure. Hyauronidase may be included in the physicians armamentarium for reducing wound tension.

Novel Application of Hyaluronidase on Scalp Laxity

WEN -YI WU M.D. Diplomate ABHRS

Taiwan Hair Transplant

2013 ISHRS

Off Label use of Hyaluronidase

No Conflict

Hyaluronidase
A soluble protein enzyme that acts at the site of local injection to break down and hydrolyze Hyaluronic acid; a glucosaminoglycan polysaccharide in skin, connective tissue and vitreous humor of the eye.

Hyaluronidase hydrolyzes Hyaluronic acid by splitting Hyaluronidase hydrolyzes acid by the glucosaminidic bond betweenHyaluronic C1 of the glucosamine moiety and C4 Glucuronic acid. splitting the of glucosaminidic bond between C1 of the glucosamine moiety and C4 of Glucuronic acid.

The Hyaluronic acid is present in the intercellular matrix of connective tissue. This intercellular CEMENT is thereby made more permeable, permitting the rapid dispersal and absorption of injected substances upon the action of Hyaluronidase.

Indications and Usage of Hyaluronidase as an adjuvant to increase the absorption and dispersion of other injected drugs for hypodermoclysis as an adjunct to subcutaneous urography for improving resorption of radioopaque agents

Off label use of Hyaluronidase


Our study is conducted to find out if use of Hyaluronidase to dissolve Hyaluronic acid dermal fillers are very effective, safe and acceptable Hyaluronidase does reduce the wound tension; thus enhancing an easier closure

Materials

Towel clamp

Tension Gauge KANON

Methods
45 patients were recruited in 2012 Hyaluronidase solutions created by mixing 300 I.U Hyaluronidase ( Ovine ) powder with 10 ml saline solution Intraoperative wound tension was measured ( Kanon Tension Gauge) after donor strip removal. 10 ml Hyaluronidase solution injected into the upper and lower flaps of the donor wound at the bilateral mastoid areas ( sites with highest tension ) Tension re-measured 15 minutes after injection

Results
Tension%tensiondecreased preinjectionpostinjection PT1 PT2 PT3 300g250g300250/300=16.6% 200g160g200160/200=20% 350g300g350300/350=14.2%

Results
tension changes No change 0-10% 10-20% 20-30% 30-40%
Total

number of patients 0 7 28 9 1
45

Results
No adverse reactions were noted after injection There is decrease in wound tension after Hyaluronidase injection; with majority in the range of 10-20 % There is no worsening of the scars post-operatively. There is either no improvement of the scar

Strategy in difficult closure


undermining milking of the wound delay closure leave a gap Hyaluronidase injection

082 The Use of a Long Acting Anesthetic to Diminish Post Operative Pain in Hair Transplant Patients
Paul T. Rose, MD, JD1, Bernie Nusbaum, MD2. 1 Miami Hair Institute, New Port Richey, FL, USA, 2miami hair institute, coral gables, FL, USA. Dr Paul T. Rose, MD, JD is board certified dermatologist. He has been performing hair restoration procedures for over twenty years. He has served as President of the International Society of Hair Restoration. Dr Bernard Nusbaum is a board certified dermatologist. He has been performing hair restoration procedures for over twenty five years. He has served on the BOG of the ISHRS and was an editor for the FORUM. Drs. Rose and Nusbaum have written numerous peer reviewed articles and chapters in various medical textbooks. They have help develop several techniques used in hair replacement surgery. P.T. Rose: None. B. Nusbaum: None. TAKE HOME MESSAGE: The use of a long acting marcaine in a liposomal delivery system can markedly reduce post operative discomfort. ABSTRACT: Introduction: Post operative pain is a common problem with hair transplant patients. The pain is usually confined to the donor area and traditionally can be managed well with the use of modest to moderate amounts of analgesic medication. Nevertheless in an effort to try to further eliminate post op pain the authors have begun to use a long acting marcaine which is encapsulated in liposomes. In this lecture we discuss the results of a study of 10 patients who elected to try this new anesthetic agent formulation. Objective:' The objective of this study was to determine if a liposomal encapsulated form of marcaine provided superior anesthesia compared to the use of lidocaine and non liposomal marcaine. Materials and Methods Ten patients who elected to use the liposomal marcaine underwent hair transplantation procedures. The liposomal marcaine was injected into the donor area after the donor area had been previously anethtized with lidocaine 1% with epinephrine 1:100,000 and the donor strip removed and closed. The liposomal marcaine is designed to release marcaine over a period of 48 hours or more. This slow release of marcaine should provide patients with an essentially painless post operative course. Approximately 20 cc of the liposomal mixture was used on each patient. Patients were seen the next day and given a survey to fill out to assess their level of pain if in fact there was any. Results The results of the study will be presented Discussion Post opertaive pain can occur with hair transplantation and many patients express marked concern about having any post operative pain. In some cases potential patients decline surgery for fear of post op pain. To try to ensure a comfortable and virtually painless procedure we have started using a new form of marcaine that is encapsulated in liposomes. Conclusion; The result of the study will be presented.


PaulT.Rose,MD CoralGables,Florida

None

Marcaine encapsulatedinmultivesicular liposomes BasedonaproductDepofoam, biodegradable,biocompatible Maylastupto72hours

Usedinhemorrhoidectomy and bunionectomy procedures Inthesofttissuestudyatotalof30ccwas used

PlasmaBupivacaineConcentration(ng/mL)

300 250 200 150 100 50 0 0 24 4 8 Initialpeakdueto3% extraliposomalbupivacaine Secondpeakdueto slowreleaseofbupivacaine fromDepoFoam EXPAREL266 mg

Peak P1: 02hours P2:2448hours

Duration 96hours

Maxdoseis266mg(20mlof1.3%undiluted) Wediluteto30or40mlandlimitto20ml Preservativefreesaline Canstoreupto4hoursatroomtempafter removalfromthevial(unclearastowhyfour hours?contamination)

72

9 6

Otherformulationsofbupivacaine shouldnotbeadministeredwithin96hoursfollowingadministrationof EXPAREL Systemicplasmalevelsofbupivacaine followingadministrationofEXPARELarenotcorrelatedwithlocal efficacy Therateofsystemicabsorptionofbupivacaine isdependentuponthetotaldoseofdrugadministered, theroute ofInternational administration, and theSociety vascularity ofthe administration site CA. Presented atthe2009 Anesthesia Research Annual Meeting; March 1417, 2009;San Diego,

Adverse EventsOccurring5%inEXPAREL Patients Following EXPARELAdministration inPivotal Phase 3Trials


Bunionectomy EXPAREL SystemOrgan Class Preferred Term Anytreatmentemergent AE Gastrointestinal disorders Nausea Vomiting Nervoussystemdisorders Somnolence
Dataonfile. Pacira Pharmaceuticals, Inc.

EXPARELiscontraindicated inobstetrical paracervical blockanesthesia EXPARELhasnotbeenstudied foruseinpatients youngerthan18 yearsofage Nonbupivacainebased localanesthetics, including lidocaine, maycause animmediate release ofbupivacaine fromEXPARELifadministered togetherlocally. Theadministration ofEXPAREL mayfollowtheadministration oflidocaine aftera delayof20minutes ormore. Other formulations ofbupivacaine shouldnotbeadministered within 96hoursfollowing administration ofEXPAREL Monitoring ofcardiovascular andneurological status, aswellasvitalsignsshouldbeperformed during andafterinjection ofEXPARELaswithotherlocalanesthetic products Becauseamidetype localanesthetics, suchasbupivacaine, aremetabolized bytheliver, EXPARELshouldbeusedcautiously inpatientswithhepaticdisease. Patients withsevere hepaticdisease, becauseoftheirinability tometabolize localanesthetics normally, areata greater riskofdevelopingtoxicplasmaconcentrations Inclinical trials, themostcommonadversereactions (incidence10%)followingEXPAREL administration werenausea, constipation,and vomiting

Hemorrhoidectomy EXPAREL 266mg (n=95) n(%) 2(2.1) 2(2.1) 2(2.1) 2(2.1) 0(0.0) 0(0.0) Placebo (n=94) n(%) 4(4.3) 4(4.3) 1(1.1) 4(4.3) 0(0.0) 0(0.0)

Placebo (n=96) n(%) 38(39.6) 37(38.5) 36(37.5) 17(17.7) 1(1.0) 1(1.0)

106mg (n=97) n(%) 42(43.3) 40(41.2) 39(40.2) 27(27.8) 5(5.2) 5(5.2)

EXPAP0091201205

Nodosingadjustmentformildtomoderatehepaticimpairment
MeanCmax andareaunderthecurvevalueswere1.5 and1.6fold higher,

respectively,inpatientswithmoderatehepaticimpairmentthaninhealthy controlvolunteers
EXPARELshouldbeusedcautiously inpatientswithseverehepatic disease;

CV,(noQTprolongation) neuro risksmust checkvitalsetc Monitordose

likeallamidetypelocalanesthetics,EXPARELismetabolized bytheliver

Noabnormalfindingsreflectingimproperwoundhealing1 Nodosingadjustmentrequiredinpatientswithrenalimpairment
Bupivacaineisknowntobesubstantially excreted bythekidney,andtherisk

oftoxicreactionstothisdrugmaybegreaterinpatientswithimpairedrenal function;careshouldbetakenindoseselectionofEXPAREL

Safeandeffectiveinelderlypatients*

*Inthewoundinfiltrationstudies(N=823),nooveralldifferencesinsafetyoreffectivenesswereobservedpatients65yearsofage (n=171)comparedtopatients<65yearsofage;however,greatersensitivityofsomeolderindividualscannotbe ruledout.


1. GolfM,etal.AdvTher.2011;28(9):776788.

Usealongdonorincision Injectapproxonecmaway Injectwith25gneedle Injectdeepandindermis Checkforinjectionintobloodvessel Injectatleast30minafterremovalofdonor tissue

Nointeractionwithepi Nointeractionwithantibiotics Nointeractionwithcorticosteroids

Canbeusedwithlidocaine butthe bupivicaine mustbeusedatleast20min afterinfiltrationoflidocaine

. . .. . Patientsreportlesspaincomparedto patientswhoreceiveonlylidocaine andnon liposomalmarcaine Verygoodforpatientswithprevious surgeries

Lessuseofnarcoticsbypatient Morepleasantexperience Fewerphonecalls

Maybedifficulttore anesthetizeifneedfor moreanesthetic(ex;needmoredonor) Onceyouusetotaldoseyouareverylimited astoaddingmoreanesthesiatothearea

083 Poster Overview


Robert S. Haber, MD. Dermatology, 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 140 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: None. TAKE HOME MESSAGE: Audience will focus on important conclusions contained in presented posters. ABSTRACT: This Poster Review session will briefly summarize key messages in selected poster presentations.

084 Moderator Introduction and Hairline Design Panel


Russell Knudsen, MD. Knudsen Clinic, Double Bay, Australia. Russell Knudsen practices full-time in hair restoration surgery in Australia and New Zealand. He has 30 year experience in the field and is a past-President of the ISHRS. R. Knudsen: None.

085 Panelist for Hairline Design Panel


Kapil Dua. MD. A K CLINICS, LUDHIANA, India. Dr. Kapil Dua, MS (ENT) has been practicing hair transplant since 2007. He has been one of the pioneers of FUE Hair transplant in INDIA. His special interest is in studying the analytical data of extraction for FUE, including Follicular transection rate with different type & depth of punches which has helped him to bring down the FTR to single digits. He is well versed with various techniques of FUE & routinely does Body hair transplants. He runs multiple clinics in Delhi, Ludhiana, Mumbai & has an exposure of dealing with patients of all ethnicities including Caucasians, Africans & East Asians. He has been regularly delivering lectures on various aspects of FUE. He is the founder member & currently Honorary Secretary of Association of Hair Restoration Surgeons of India. He is the Scientific Chairman for the 3rd Asian Society Meeting of Hair Restoration Surgeons. K. Dua: None.

086 Panelist for Hairline Design Panel


Mauro M. Speranzini, MD. So Paulo, Brazil. Graduated from FMUSP, So Paulo, Brazil, Residency in general surgery at Hospital das Clnicas, So Paulo, Brazil; Residency in plastic surgery at Hospital dos Defeitos da Face, So Paulo, Brazil; Master of Plastic Surgery at FMUSP, So Paulo, Brazil; Membro Titular of Brazilian Society of Plastic Surgery; Former Vice-President of Brazilian Association of Hair Restoration Surgery; ISHRS member since 2003; In hair restoration since 1992 M.M. Speranzini: None.

D AY- B Y- D AY P R O G R A M

SATURDAY/OC TOBER 26, 2013


6:45AM-8:30AM 7:00AM-4:30PM 7:00AM-3:45PM 7:00AM-8:00AM Continental Breakfast Registration Speaker Ready Room 7:00AM-12:40PM 7:30AM-2:00PM 8:15AM-5:00PM Poster Viewing Exhibits Viewing GENERAL SESSION

B reakfast

with the

E xperts

8:15AM-9:00AM
103 104 105

D ifficult C ases I
Panel: Alan J. Bauman, MD, Jerry E. Cooley, MD, Daniel E. Rousso, MD, and James E. Vogel, MD
LEARNING OBJECTIVES Discuss challenging and atypical cases and treatment options. Recognize surgical limitations in marginal candidates and develop appropriate treatment plans for these patients.

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 as noted on the list. The round tables in the General Session room will be labeled with a topic and table leaders name. Get your breakfast from the Exhibit Hall and then sit at the table of your choice to have breakfast with an expert.You may sit at any table you like and rotate to as many tables as you wish. NEW THIS YEAR! At the half-way point, an announcement will be made so attendees can switch to another table if they choose. The table leader will repeat any mini-presentations or opening remarks about the topic. LEARNING OBJECTIVE Discuss various hair restoration surgery topics indepth in small groups.

8:15AM-9:00AM 45 Moderator Introduction and Difficult Cases I Panel James E. Vogel, MD 102 9:00AM-9:03AM 9:03AM-10:20AM Poster Awards

087 088

1. Advances in Hair Biology Ken Washenik, MD, PhD 2. Beard FUE Robert H. True, MD, MPH 3. How to Perform Cross-Sectional Trichometry Bernard Cohen, MD 4. Proper Use of Minoxidil Robert T. Leonard, Jr., DO 5. Eyebrow Restoration Sara M. Wasserbauer, MD 6. Surgical Hairline Advancement Mario Marzola, MBBS 7. Peri-Operative Risk Management Scott A. Boden, MD & Kuniyoshi Yagyu, MD 8. The Art & Pitfalls of Internet Consultation Carlos J. Puig, DO 9. Hyaluronidase in Hair Transplantation Sungjoo Tommy Hwang, MD, PhD 10. Implanters Tseng-Kuo Shiao, MD 11. Chinese-Speaking Table: Pearls for Asian Hair Transplantation Wen-Yi Wu, MD 12. Korean-Speaking Table: Total Hairline Correction in Low Grade Hair Loss Jae Heon Jung, MD 13. Spanish-Speaking Table: FUE Jos Lorenzo, MD 14. Surgical Assistant Table: Maximizing Team Efficiency Emina Karamanovski

A dvances

in

H air B iology

089 090 091 092 093 094 095 096 097

LEARNING OBJECTIVES Demonstrate understanding of basic biology of molecular influences on follicular behavior. Describe effect of ATP on follicle viability. Review the results of platelet growth factors and porcine urinary bladder matrix in wound healing and hair growth.

9:03AM-9:10AM 7 Moderator Introduction 106 Ken Washenik, MD, PhD 9:10AM-9:40AM 30 ADVANCES IN HAIR BIOLOGY LECTURE Extra-follicular Environmental Modulation of Hair Regeneration Featured Guest Speaker Cheng-Ming Chuong, MD, PhD 107
Professor of Pathology, Chair of Graduate Committee, University of Southern California The Advances in Hair Biology Lectureship is generously supported by a grant from BOSLEY.

9:40AM-9:47AM 7 Q&A 9:47AM-9:57AM 10 Hair Follicle Regeneration in Minimal Depth Follicular Unit Extraction Sites Treated with ACell John P. Cole, MD 108 9:58AM-10:10AM 12 Bioenhancments of Hair Transplantation Jerry E. Cooley, MD 109 10:10AM-10:20AM 10 Q&A 10:20AM-10:45AM Coffee Break

098

099 100

101

SAT

D AY- B Y- D AY P R O G R A M

10:45AM-11:48AM

D iagnostic A ids and Treatment O utcome A ssessments with a F ocus FPHL

11:50AM-12:40PM
on

A dvanced S urgical Videos I


LEARNING OBJECTIVES Compare methods to improve donor closure in FUT. Describe approaches to reduce post operative cosmetic problems. Discuss FUE as an approach to repairing poor results.

LEARNING OBJECTIVES Compare and contrast methods for measuring results of medical and surgical hair restoration. Review clinical evidence for the effect of low level laser light therapy. Discuss proper hormonal evaluation in female pattern hair loss (FPHL).

11:50AM-11:52AM 2 Moderator Introduction 117 Carlos J. Puig, DO


FUT D onor M anagement

10:45AM-10:47AM 2 Moderator Introduction Francisco Jimenez, MD 110 10:47AM-10:54AM 7 The Clinical Utility of the Hair Check Device 111 Russell G. Knudsen, MBBS 10:54AM-11:01AM 7 Tools for Monitoring Patients on Medical Therapy 112 Bernard P. Nusbaum, MD 11:02AM-11:09AM 7 Dermoscopy is a Valuable Aid in Diagnosing Female Hair Loss and Guiding Treatment Alessandra Juliano, MD 113 11:09AM-11:17AM 8 The Effect of Cold Laser Therapy on Hair Mass as Measured by Cross Sectional Diameter Sara M. Wasserbauer, MD 114 11:18AM-11:28AM 10 Is Low Level Laser Therapy Effective in Treating Androgenetic Alopecia? A Review of 5 Years Experience in Treating Hundreds of Patients with Male and Female Pattern Hair Loss Shelly A. Friedman, DO 115 11:28AM-11:38AM 10 Hormonal Evaluation of Female Pattern Hair Loss Sharon A. Keene, MD 116 11:38AM-11:48AM 10 Q&A

11:52AM-11:57AM 5 How to Minimize Hair Angle Alteration in Wide Donor Wound 118 Dae-young Kim, MD 11:57AM-12:02PM 5 Arrow Shape Laxometer 119 Viroj Vong, MD 12:03PM-12:08PM 5 Composite Graft for Incomplete Donor Site Closure Due to High Tension 120 Ji-sup Ahn, MD, PhD
I mproving C osmesis

12:08PM-12:13PM 5 An Alternate Technique from Shaving the Recipient Area Sara J. Kotai, MBBS 121 12:14PM-12:19PM 5 The "No-Shave FUE Technique": A Method to Improve Patient Satisfaction with FUE Procedures Marco N. Barusco, MD 122 12:19PM-12:24PM 5 How I Do a Preevaluation Test in FUE and How I Calculate My Transection Rate Emre A. Karadeniz, MD 123 12:25PM-12:30PM 5 How I Correct Too Low Hairline Using FUE Yi-Jung I. Lin, MD 124 12:30PM-12:40PM 10 Q&A 12:40PM-2:00PM 12:45PM-1:45PM 12:40PM-2:00PM 2:00PM-7:00PM Lunch on Your Own FUE Research Committee Meeting
(invitation only)

Posters Dismantle Exhibits Dismantle

SAT

D AY- B Y- D AY P R O G R A M

2:00PM-2:45PM
126 127 128

D ifficult C ases II
Panel: Robert M. Bernstein, MD, Sheldon S. Kabaker, MD, Russell G. Knudsen, MBBS, and James E. Vogel, MD
LEARNING OBJECTIVES Discuss challenging and atypical cases and treatment options. Recognize surgical limitations in marginal candidates and develop appropriate treatment plans for these patients.

3:35PM-5:00PM

L ive Patient Viewing


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

3:35PM-3:40PM 5 Overview of LPV Cases Jerry Wong, MD 137 3:40PM-3:40PM 1 Adjourn Main Meeting in General Session Room Robert H. True, MD, MPH 3:40PM-5:00PM 80 Live Patient Viewing 5:00PM 4:30PM-5:30PM 7:00PM-12:00AM 12:00AM-2:00AM Meeting Adjourns CME Committee Meeting
(invitation only)

2:00PM-2:45PM 45 Moderator Introduction and Difficult Cases II Panel 125 James E. Vogel, MD 2:48PM-3:35PM

A dvanced S urgical Videos II


LEARNING OBJECTIVES Compare and contrast different surgeons approaches to and devices for graft implantation. Describe the various techniques that make the FUE process more efficient.

Gala Dinner/Dance & Awards Ceremony


(ticket required)

After Hours Jam Session

2:48PM-2:50PM 2 Moderator Introduction 129 John P. Cole, MD


I nnovations
in the

U se

of I mpl anters

2:50PM-2:55PM 5 New Stick-and-Place Shiao Micro-Implanter 130 Tseng-Kuo Shiao, MD 2:55PM-3:00PM 5 Novel Implanter Technique that Enables More than 1600 Grafts in 1 Hour with Dense Packing Jae Hyun Park, MD 131 3:00PM-3:05PM 5 Importance of Depth Control when Transplanting Hairs and the Best Way How to Use the New OKT (Optimally Kept Transplanter) Implanter 132 Kun Oc, MD
I mproving E fficiency
in

FUE

3:06PM-3:11PM 5 FUE Hair Transplant Using NeoGraft and Implanter Pens 133 Michael W. Vories, MD 3:11PM-3:16PM 5 How to Achieve 2000+ Grafts Per Day by Combining Motorized FUE with Implanter Pens 134 Conradin von Albertini, MD 3:17PM-3:22PM 5 My Performance in Large FUE Sessions Luis R. Trivellini, MD 135 3:22PM-3:27PM 5 Graft Harvesting in FUE Giga Session (>3500 FU grafts) Kavish Chouhan, MD 136 3:27PM-3:35PM 8 Q&A
SAT

087 Breakfast with the Experts, Table Leader on the Topic of "Advances in Hair Biology"
Ken Washenik, MD, PhD. Bosley, Beverly Hills, CA, USA. Ken Washenik, M.D., 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. K. Washenik: Employment; Bosley/Aderans, Allergan Advisor, Clinical Investigator. Ownership Interest (owner, stock, stock options); Bosley/Aderans. Ownership Interest (royalty, patent, or other intellectual property); Bosley/Aderans. Consultant/Advisory Board; Allergan, Johnson and Johnson Healthcare.

088 Breakfast with the Experts, Table Leader on the Topic of "Beard FUE"
Robert H. True, MD, MPH. True & Dorin Medical Group, P.C., New York, NY, USA. MDCM McGill University Faculty of Medicine Post Grad 1-3 Mayo Clinic and U of Illinois Diplomate American Board of Hair Restoration Surgery Past President ABHRS Chair 2013 ISHRS Annual Scientific Meeting. Author of over 40 hair restoration papers and publications Practitioner of FUE for 11 years New York, New York drtrue@hairlossdoctors.com R.H. True: None.

089 Breakfast with the Experts, Table Leader on the Topic of "How to Perform CrossSectional Trichometry"
Bernard Cohen, MD. Dept. of Dermatology & Cutaneous Surgery, University of Miami, Miami, FL, USA. Dr. Cohen is the inventor of Cross Section Trichometry. He is a Diplomate of the ABHRS, a Diplomate of the American Academy of Dermatology, and a Clinical Professor at the University of Miami School of Medicine, Department of Dermatolgy. Dr. Cohen is recipient of the ISHRS Platinum Follicle award 2010. B. Cohen: Ownership Interest (royalty, patent, or other intellectual property); Owns patents and receives royalties.

090 Breakfast with the Experts, Table Leader on the Topic of "Proper Use of Minoxidil"
Robert T. Leonard, DO. Leonard Hair Transplant Associates, Cranston, RI, USA. Founder and Chief Surgeon, Leonard Hair Transplant Associates; Past President, ISHRS. I have been practicing in the field of HRS for the last 27 years. I provide my patients with all options in restoring their hair including both strip and FUE harvesting surgery as well as making recommendation of sound medical and scientific products to slow the progression of male and fem,ale pattern hair loss including Rogaine Foam, Propecia, and Low Level Laser Therapy. R.T. Leonard: Speakers Bureau/Honoraria (speakers bureau, symposia, and expert witness); Speakers Bureau; Consultant.

091 Breakfast with the Experts, Table Leader on the Topic of "Eyebrow Restoration"
Sara M. Wasserbauer, MD. Sara Wasserbauer MD, Walnu Creek, CA, USA.

Dr. Sara Wasserbauer is a Diplomate of the American Board of Hair Restoration Surgery and an active member of the ISHRS, the AMA, and her local medical society. She practices hair restoration full-time at her office in the Bay Area, outside of San Francisco, in Walnut Creek, California. She completed her undergraduate studies with a B.A. in Classical Archeology at the prestigious Dartmouth College. She then went on to earn her medical degree from the renowned Medical College of Ohio and, after finishing her training in Internal Medicine, Dr. Wasserbauer discovered she had a natural aptitude for hair surgery and she completed her fellowship in hair transplantation in 2005. Dr. Wasserbauer is a contributor to the Hair Transplant Forum International, Dermatologic Surgery, and TheHairDoctors.org website. She takes a special interest in FUE and reconstructive techniques, as well as high quality hair restoration for both men and women with pattern hair loss. She has conducted primary research for the FDA approval of the ARTAS hair transplant (FUE) robotic system, received an ISHRS grant to study the effect of lasers on hair growth, and she also performs specialized hair restoration surgeries for eyelashes, eyebrows and body hair transplantation. She likes to make jokes about hair during her transplant surgeries and keeps a big fluffy dog named Bacchus in her office to inspire her patients to want more hair. S. Wasserbauer: None.

092 Breakfast with the Experts, Table Leader on the Topic of "Surgical Hairline Advancement"
Mario Marzola, MD. Restoration Clinics of Australia, Norwood, Australia. Dr Marzola has been involved hair restoration for 35 years, seeing all the evolving techniques. For three years now he has been studying the latest evolution being cell based therapies. Platelet rich plasma (PRP) and stem cells for many conditions, and now for hair loss. Always interested in CME as a way of keeping up with the best treatments for our patients' benefit. Graduate of Adelaide University, moved from Family Practice to Hair Surgery and General Cosmetic Surgery. Past President ISHRS Diplomate ABHRS Fellow Faculty of Medicine Austrlasian College of Cosmetic of Cosmetic Surgery M. Marzola: None.

093 Breakfast with the Experts, Table Leader on the Topic of "Peri-Operative Risk Management"
Scott A. Boden, MD. Hair Restoration Center of Connecticut, Wethersfield, CT, USA. Scott A. Boden, M.D., is a Diplomate and Secretary of the Board of Directors of the American Board of Hair Restoration Surgery. He is Medical Director of the Hair Restoration Center of Connecticut and provides medical and surgical treatment for men and women with hair loss. He has particular interest and expertise in Follicular Unit Extraction and the treatment of scarring and radiation-induced alopecia. Contact information: drboden@hairtransplantct.com; www.HairTransplantCT.com S. Boden: None.

094 Breakfast with the Experts, Table Leader on the Topic of "Peri-Operative Risk Management"
Kuniyoshi Yagyu, MD. NHT International Research Institute, Tokyo, Tokyo, Japan. Kuniyoshi Yagyu, M.D., has been exclusively practicing hair transplantation in Tokyo. He serves as Secretary of the International Society of Hair Restoration Surgery and board member of the Asian Association of Hair Restoration Surgeons (AAHRS). He is a Diplomate of the American Board of Hair Restoration Surgery, Past President of the Japan Society of Clinical Hair Restoration, and a Winner of the ISHRS Research Award in 2010. He has authored 46 research and clinical publications in books and journals. He had specialized in cardiac surgery for 22 years. He is a Diplomate in Surgery, Cardiology and Respiratory Medicine as well. K. Yagyu: None.

095 Breakfast with the Experts, Table Leader on the Topic of "The Art & Pitfalls of Internet Consultation"
Carlos J. Puig, DO ABHRS FAACS. Physicians Hair Restoration Center, Houston, TX, USA. Dr Puig has been actively involved in the practice of hair restoration surgery since 1973. Founding Member of both the AACS and ISHRS, over the years Puig has presented papers, workshops and surgical demonstrations on many topics. Dr. Puig is a Fellow of the American Academy of Cosmetic Surgery, and Diplomate, and Past President of the American Board of Hair Restoration Surgery. Dr. Puig has served as chair of the ISHRS Fellowship Training Committee, Core Curriculum Committee, and currently is the President of the ISHRS. He 2011 joined the staff at the Baylor College of Medicine, in Houston to help start their hair restoration surgery program. C.J. Puig: None.

096 Breakfast with the Experts, Table Leader on the Topic of "Hyaluronidase in Hair Transplantation"
Sungjoo (Tommy) Hwang, MD. Dr. Hwang's Hair Clinic, Seoul, Korea, Republic of. Sungjoo Tommy Hwang, MD Board of Governors of ISHRS Vice President of KSHRS Immediate Past President of AAHRS Director of Dr. Hwang's Hair Clinic, Seoul, Korea S. Hwang: None.

097 Breakfast with the Experts, Table Leader on the Topic of "Implanters"
Tseng-Kuo Shiao, MD. DR TK LLC, Overland Park, KS, USA. Dr. Tseng-Kuo Shiao is a graduate of the University of Kansas School of Medicine. He has been working with Dr. Isen Shiao on various medical devices for years, joined Dr. I-sen Shiao's practice in 2006, and has his own practice in the Kansas City metropolitan area. Dr. I-sen Shiao is the director of FuFa Hair Restoration Clinic in Taipei Taiwan. He first became a hair restoration surgeon in 1986. Since then, he had performed thousands of cases in Taipei, Taiwan. As a team, the senior and junior Dr. Shiao had worked on several innovations in hair restoration surgery such as the Shiao micro-implanters, depth control sleeves, laser level hair line design, and the use of advanced but inexpensive LED as cross-polarized surgical lights. T. Shiao: Ownership Interest (royalty, patent, or other intellectual property); Shiao microimplanters.

098 Breakfast with the Experts, Table Leader on the Topic of "Chinese-Speaking Table: Total Hairline Correction in Low Grade Hair Loss"
Wen Yi Wu, MD. Taipei, Taiwan. Wen-Yi Wu M.D. ABHRS,Taiwan Hair Transplant W. Wu: None.

099 Breakfast with the Experts, Table Leader on the Topic of "Korean-Speaking Table: Total Hairline Correction in Low Grade Hair Loss"
Jae Heon Jung, MD Plastic Surgery, KangNam Yonsei Plastic Clinic, Seoul, Korea, Republic of.

Direcctor of KangNam YonSei Plastic Surgery clinic Attending professor of Department of Plastic Surgery of YonSei University President of Korean Society of Hair Restoration Surgery Korean board of the plastic surgery since 1990 American board of hair restoration surgery since 2007 Honorable Mention Award from 2004 Vancouver ISHRS meeting J.H. Jung: None.

100 Breakfast with the Experts, Table Leader on the Topic of "Spanish-Speaking Table: FUE"
Jose F. Lorenzo, MD. Hair restoration, Clinica MEDILOR, Madrid, Spain. Jose Lorenzo MD, received his medical degree from the Universidad Complutense de Madrid in 1991. he completed his specialization in General Surgery and Thoracic Surgery where he worked until he came to the field of hair restoration surgery in 2003. After seeing the first FUE procedures, he proposed to devote all his efforts in the development of the technique. Dr. Lorenzo uses the manual FUE Technique followed by implanter assisted graft insertion. He is a regular lecturer and demonstrator of his skills at workshops and conferences around the word. J.F. Lorenzo: None.

101 Breakfast with the Experts, Table Leader on the Topic of "Surgical Assistants Table: Maximizing Team Efficiency"
Emina Karamanovski. Lam Institute for Hair Restoration, Plano, TX, USA.

Dr. Karamanovski obtained her medical degree from the University of Belgrade (Yugoslavia, 1989). In 1991, she immigrated to Canada where she began to work in hair restoration as a technician. In 1997 she joined Pierre Amelotte International (PAI) working with Dr. Vance Elliott (among other physicians), and for the following seven years, Dr. Karamanovski assisted in surgery and performed training, assessment and quality control of the PAI medical and ancillary staff across the United States and Canada. In 2004, she joined Dr. Samuel M. Lams team as a coordinator for the Lam Institute for Hair Restoration (Dallas, Texas). In 2011Emina joined Restoration Robotics as Director of Training and Professional Education, helping launch training program for the ARTAS system. In 2012 she returned to Dallas to join Dr. Lams practice. Emina is the recipient of the Distinguish Assistant Award for 2010 and has been the co-director of the Hair Restoration Cadaver Workshop in St. Louis for the last five years. The author of the Hair Transplantation 360 for Assistants and Emotions Simplified, Kararamovski demonstrate unique ability to understand stress in surgery. E. Karamanovski: None.

102 Moderator Introduction and Difficult Cases I Panel


James E. Vogel, MD Lutherville, MD, USA. 74-78 MD Degree- Mt Sinai School of Medicine, NY, NY 78-83 General Surgery Residency and Chief Resident UNC , Chapel Hill, NC 83-87 Plastic Surgery Residency, Johns Hopkins Hospital Baltimore, Md 96-97 President , ISHRS J.E. Vogel: None.

103 Panelist for Difficult Cases I

Alan J. Bauman, MD. Hair Restoration for Men & Women, Bauman Medical Group, Boca Raton, FL, USA. Dr. Alan J. Bauman is the Founder and Medical Director of Bauman Medical Group located in Boca Raton, Florida and established in 1997. A full-time Hair Restoration Physician, Dr. Bauman received his M.D. degree from New York Medical College and is Diplomate of the American Board of Hair Restoration Surgery. Over the past fifteen years, he has built an international practice, treated nearly 15,000 patients and has been extensively featured in the world's leading media in print, radio and television as a medical expert and successful early adopter of the most advanced technologies in the treatment of hair loss. Dr. Bauman also serves as a consultant for several national and international companies involved in the field of hair loss and hair science. Follow @DrAlanBauman on Twitter. A.J. Bauman: None.

104 Panelist for Difficult Cases I


Jerry Cooley, MD. Charlotte, NC, USA. Dr. Cooley is a past president of the ISHRS (2010-2011) and served as co-editor of the Hair Transplant Forum (2005-2008). J. Cooley: None.

105 Panelist for Difficult Cases I


Daniel E. Rousso, MD. Birmingham, AL, USA. Dr. Daniel E. Rousso, M.D. restricts his private practice to Facial Plastic Surgery and Hair Replacement Surgery. He

is a clinical assistant professor of Surgery at the University of Alabama in Birmingham. Dr. Rousso is a past president of the ISHRS and the American Academy of Facial Plastic and Reconstructive Surgery. D.E. Rousso: None.

106 Moderator Introduction, Advances in Hair Biology


Ken Washenik, MD, PhD. Bosley, Beverly Hills, CA, USA. Ken Washenik, M.D., 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. K. Washenik: Employment; Bosley/Aderans, Allergan Advisor, Clinical Investigator. Ownership Interest (owner, stock, stock options); Bosley/Aderans. Ownership Interest (royalty, patent, or other intellectual property); Bosley/Aderans. Consultant/Advisory Board; Allergan, Johnson and Johnson Healthcare.

107 Extra-Follicular Environmental Modulation of Hair Regeneration


Cheng Ming Chuong, MD, PhD. University of Southern California, Los Angeles, CA, USA. Dr. Cheng-Ming Chuong received his M.D. from Taiwan University in 1978. He then obtained his Ph.D. from The Rockefeller University in 1983. Later he moved to the University of Southern California in 1987 and work on the development and regeneration of feather, tooth, and hairs. He is currently a professor of pathology. Dr. Chuong directs the Laboratory of Tissue Development and Engineering (http://www-hsc.usc.edu/~cmchuong/ cmchuong@usc.edu) in the Department of Pathology, USC. The laboratory studies how stem cells are guided to

form special tissues and organs of specific size and shape. Using the ectoderm as a Rosetta stone, they learned how to mold stem cells into different ectodermal organs during development, evolution and stem cell engineering. C. Chuong: Research Grant (principal investigator, collaborator or consultant); Reported work are supported by NIH. Ownership Interest (royalty, patent, or other intellectual property); Paten of our work was filed to University of Southern CA. Consultant/Advisory Board; I am consultant for Kao company for a unrelated subject. TAKE HOME MESSAGE: Hair growth and regeneration is not affected by both intra-follicle micro-environment composed of stem cells and dermal papilla, but also extra-follicular macro-environment between hair follicles and dermis, adipose tissue, body hormone, and external environment. It is now possible to modulate hair growth and / or regeneration by stimulating or improving the macro-environment. ABSTRACT: Extra-follicular Environmental Modulation of Hair Regeneration Cheng Ming Chuong, M.D., Ph.D. Professor, University of Southern California; cmchuong@usc.edu http://www-hsc.usc.edu/~cmchuong Skin appendages such as hairs are unique in that they regenerate under physiological conditions, and can respond to physiological cues to morph into different shapes of appendages, even in the sam follicle (Chuong et al., 2012). Here we explore how extra-follicular environment can affect the regenerative ability of hair follicle stem cells. The hair follicle undergoes cyclic degeneration and regeneration cycle throughout life. The length of growing (anagen) and resting phase (telogen) can determine the hair length. Long resting phase mean shorter or no hair, i.e., alopecia. We have developed ways to visualize hair stem cell activation over entire skin in living mice. With this, we found cyclic BMP signaling from subcutaneous adipose layer regulates stem cell activation during hair regeneration (Plikus et al. 2008,). More molecular analyses showed wnt serves as activators and hair growth patterns are governed by simple rules based on a pair of activator/inhibitor signaling. Regeneration in a population of hair follicles spreads like chain reaction, forming diverse wave patterns (Plikus et al. 2011). Mathematical modeling reveals unexpected self-organizing and stochastic nature of this novel stem cell behavior, which emerge only at higher organ population level, allowing hair regeneration to become a very adaptable trait. These variations are seen among different animal species with different needs for hairs: robust spreading in rabbits, gradual wave spreading in mice, and random growth with loss of coupling among follicles in human skin. The hair wave can also vary under different physiological conditions of a same individual. We recently show hair matrix cell proliferation is under circadian rhythm control, In mouse, hairs grow faster in the morning than in the evening. Thus gamma radiation administered in the morning cause more severe hair loss in the mouse, while those administered in the evening cause minimal damage (Plikus et al., 2013). Environment such as puberty, pregnancy and aging can also modulate hair cycle and growth and alopecia (Chen and Chuong, 2012). We are have developing ways to modify macroenvironment for hair follicles, and hence can stimulate many more resting phase hair follicles to re-enter growing phase. Similar principles apply after injury (Chueh et al., 2013). We can modify environment to modulate the formation of new hair follicles after wounding. This can be applied to tissue engineering process for the rebuilding of a reconstituted skin with newly generated hairs that can undergo cycling and can heal (Lee et al., 2011). The concept that modulating stem cell niche can change skin appendage phenotypes also applies to feather regeneration and its fantastic pigment patterns (e.g., spots versus stripes). They can change in different age or sex by alteration of body hormone environment (Lin et al., 2013). Thus, our works demonstrate the dynamic interactions among genetic and physiological events that allow the robust regenerative and morphogenetic activity of skin appendage organs. The progress of these basic research is now ripe for us to apply these principles to modulate hair growth. Instead of implanting new stem cells, it may be easier to modulate the soil surrounding stem cells and make stem cells grow better. References:

Review: Chen CC, Chuong CM. 2012 Multi-layered environmental regulation on the homeostasis of stem cells: the saga of hair growth and alopecia. J Dermatol Sci. 66:3-11. PMID: 22391240. Chueh SC, Lin SJ, Chen CC, Lei M, Wang LM, Widelitz R, Hughes MW, Jiang TX, Chuong CM. Therapeutic strategy for hair regeneration: hair cycle activation, niche environment modulation, wound-induced follicle neogenesis, and stem cell engineering. Expert Opin Biol Ther. 2013 Mar;13(3):377-91. Chuong CM, Randall VA, Widelitz RB, Wu P, Jiang TX. 2012. Physiological regeneration of skin appendages. Physiology. 27:61-72. Research: Lee L, Jiang TX, Garner W, Chuong CM. 2011. A simplified procedure to reconstitute hair producing skin. Tissue Engineering 17:391-400. Lin SJ, Foley J, Jiang TX, Yeh CY, Wu P, Foley A, Yeh CM, Huang YC, Cheng HC, Chen CF, Reeder B, Jee SH, Widelitz RB, Chuong CM. 2013. Topology of feather melanocyte progenitor niche allows complex pigment patterns to emerge. Science. 340:1442-1445. Plikus et al. 2008, Cyclic dermal BMP signaling regulates stem cell activation during hair regeneration. Nature. 451:340-344. Plikus et al. 2011, Self organizing and stochastic behaviors during the regeneration of hair stem cell. Science 332:586-589. Plikus MV, C Vollmers, D de la Cruz, S Panda, and CM Chuong. 2013. Local circadian clock gates cell cycle progression during hair cycle. Proc. Natl.Acad. Sci. 110:2106-2115.

108 Hair Follicle Regeneration in Minimal Depth Follicular Unit Extraction sites treated with Acell
John P. Cole, MD. International Hair Transplant Institute, Alpharetta, GA, USA.

Private Practice Physician J.P. Cole: None. TAKE HOME MESSAGE: Minimal Depth extraction allows for follicle regeneration. ABSTRACT: Acell is an extracellular matrix used in regenerative medicine. Cooley has shown that Acell treated plucked hairs may generate into terminal hairs when transferred to the recipient area. Cooley has also shown that Acell helps scar tissue in strip procedures feel more like normal tissue. Cole has shown that Acell treated minimal depth extraction sites have a smaller Hypopigmented surface area and also have new angiogenesis that is not found in untreated FUE extraction sites. Cole also discovered that minimal depth FUE extraction sites may regenerate hair follicles. The author evaluated the follicle regeneration in a series of patients treated with Acell following minimal depth FUE. Methods: A series of patients underwent a minimal depth FUE procedure using a sharp punch set at a depth between 1.8 to 3.0 mm. Following incision with the sharp punch, the follicles were eased out from the adipose tissue so that the outer root sheath (ORS) was intact, but the follicles were devoid of adipose tissue. As a result, stem cells from the connective tissue sheath (CTS) and (ORS) were left in the donor area. The extraction sites were then treated with a mixture of viscous hyaluronic acid and fine particles of Acell. The donor area was initially left uncovered, but subsequently the donor area was treated with a silicone spray (Kelokote) to minimize oozing of the Acell from the extraction sites. More recently, a biodegradable gel invented by the author was developed to minimize oozing from the extraction sites, as well as, a biodegradable drug delivery system containing fine particles of Acell. Following treatment, patients returned for evaluation. Following FUE, extraction sites often heal with a Hypopigmented appearance. They also heal with a void where a follicular group should be located. The author used a specialized digital counting pen to document the total number of extraction sites on follow up examination. Each extraction site was marked with a dot of gentian violet and as each dot was placed, the device recorded each individual healed extraction site lacking hair follicles. The total number of extraction sites on follow up examination was compared to the total number of extraction sites at the time of surgery. The percentage of regrowth was calculated by the following formula: Results: The average regrowth rate following administration of Acell in a viscous hyaluronic acid solution at the time of this writing is 48%. Acell also reduces the size of hypopigmentation in extraction sites following and improves microcirculation of the extraction sites. Discussion: While it appears that Acell does promote follicular regeneration following minimal depth extraction, it is possible that the rate of regrowth is not as high as the author suggests. One reason is that Acell improves healing such that Hypopigmented sites may be missed in same cases. The other concern is that sometimes following the extraction of a three hair follicular group, only a single hair follicle to regrow in its place. Follicular transection may also result in an apparent reduction in Hypopigmented spotting and single hair regrowth, but the authors overall follicle transection rate is quite low.

109 Bioenhancements of Hair Transplantation


Jerry Cooley, MD. Carolina Dermatology Hair Center, Charlotte, NC, USA. Dr. Cooley is a past president of the ISHRS (2010-2011) and served as co-editor of the Hair Transplant Forum (2005-2008). J. Cooley: None. TAKE HOME MESSAGE: Hair restoration surgeons need to be knowledgeable about bioenhancement therapies even if they choose not offer them in their practice. ABSTRACT: Transplantation by strip or FUE generally produces good results in experienced hands. However, there is always room for improvement. Bioenhancements refers to therapies borrowed from the fields of wound healing, tissue preservation, and regenerative medicine. These include optimized holding solutions (e.g. HypoThermosol/BioLife Solutions), platelet rich plasma, porcine urinary bladder matrix (MatriStem/ACell), and liposomal ATP (Cellenergy/BioLife Solutions). Each therapy targets a specific biological pathway involved in hair restoration and transplantation. The author discusses use of each, possible benefits, costs, as well as the difficulty in establishing efficacy for these therapies.

110 Moderator Introduction, Diagnostic Aids and Treatment Outcome Assessments with a Focus on FPHL
Francisco Jimenez, MD. Private Practice, Las Palmas Gran Canaria, Spain. Dr. Jimenez is a dermatologist trained at the University of Navarra and Madrid and a hair transplant surgeon trained with Dr. Dow Stough in Hot Springs, AR. He has received training also in other fields suchs as dermatopathology and in Mohs micrographic surgery at the University of Miami and Duke University. Dr. Jimenez currently works in private practice in Gran Canaria, Canary Islands, Spain. He has been past Editor of the journal International Hair Transplant Forum, and Chairman of the 2012 ISHRS meeting in the Bahamas. F. Jimenez: None.

111 The Clinical Utility of the Hair Check Device


Russell G. Knudsen, MB, BS. Knudsen Clinic, Double Bay, Australia. Dr Russell Knudsen practises full-time in Hair Restoration Surgery and has 30 years experience in the field. He is a Past-President of the ISHRS. He has practices in multiple cities in Australia and in New Zealand. R.G. Knudsen: None. TAKE HOME MESSAGE: CST via the Hair Check Device is a simple, cost-effective and very valuable assessment tool for both the patient and the physician. ABSTRACT: The Hair Check device utilises bundled Cross Section Trichometry (CST) to assess hair volume in a measured area. This simple, non-invasive test creates values that are reproducible and not dependent upon the operator of the device. I have found it to be a valuable adjunct to the objective assessment of patients both at the time of their first consultation and to monitor therapeutic efficacy. Photographic evaluation is useful but sometimes misleading and the Hair Check provides a measurable data-point which is a significant advantage. Patients are often unsure as to the efficacy of various treatments and hair cross section trichometry assists them, and the physician, to objectively monitor the progress of their condition or treatment. The device has great utility in assessing efficacy of both current drug therapies and low laser light therapies (LLLT) and is of significant use in trials of any new therapy. In addition, surgical patients can have monitoring of their donor area as well as assessment of their recipient area pre- and post-operatively. I have been using the device to assess response to LLLT in women with both female pattern loss and diffuse loss. The CST data on 10 female patients, treated by LLLT, measured over a 6 month period will be presented.

112 Tools for Monitoring Patients on Medical Therapy


Bernard P. Nusbaum, MD. Hair Transplant Institute Miami, Coral Gables, FL, USA. Dr. Nusbaum has been treating hair loss patients for 30 years and is a diplomat of the American Board of Dermatologyand the American Board of Hair Restoration Surgery B.P. Nusbaum: None. TAKE HOME MESSAGE: Computer-assisted photography used in combination with hair mass measurements can improve physician assessment of patient's response to non-surgical therapies. ABSTRACT: The use of computer assisted photography utilizing the Fotofinder system in correlation with hair- mass measurements is described for following the progress of hair-loss patients treated with non- surgical therapies.Scenarios to be presented include the diagnoses of male and female pattern hair loss as well as chronic chronic telogen effluvium . Treatments asessed include:finasteride,spironolactone, minoxidil/retinoic acid/steroid lotions, laser comb, laser cap as well as a few cases of scalp mesotherapy utilizing different injectable mixtures. The Foto finder system allows follow-up photos to be posed overlying a "ghost" of the original pretreatment photograph in order to better standardize the reproducibility of patient distance and positioning. Fotographic asessments correlated well with hair mass measurements, the latter providing a numerical confirmatory parameter which is strongly valued from the patient perspective. In addition, hair mass measurements overcome difficulties encountered when patients present for follow-up photos with significant hair length differences as compared to their pretreatment visit. The nuances of interpreting hair mass measurements with regards to published data on reproducibility will be described. The use of these two modalities, in combination, has improved assessment of patient response to the various therapeutic modalities at our disposal.

TOOLSFORMONITORING FEMALEHAIRLOSSPATIENTS BernardP.Nusbaum,M.D. Miami,Florida

NOCONFLICTOFINTEREST

COMPLEMENTARYTOOLS
HistoryandScalpExamination Videomicroscopy HairPullTest 7consecutivedayhaircollection HairFeatheringTest

FOTOFINDERSYSTEM

GlobalPhotography HairCheck
ScalpBiopsy

DonorDensityDermoscopy

TRICHOSCAN

BASELINEPHOTOS

FOLLOWUPPHOTOGRAPHY

GHOSTFEATURE

COMPARISON

6months

6months

HairBundleCrossSection Measurements(HAIRCHECK)
Quick,inexpensive Noshavingrequired Measurescombination ofhaircaliberand density Goodreproducibilitydataandcorrelation withhairweight Accuracymaximizedby:singleoperator, usingmagnification toassemblebundle

HairBundleCrossSection Measurements(HAIRCHECK)

Findings
22randomlyselectedFPHLpatients followupat46 months Midlinepartphotographsgradedas:nochange, improvedorworse In18(82%)photographicassessmentconsistentwith HAIRCHECK In3patients:photosshowedimprovementand HAIRCHECKwasunchanged(onewasonlytwo monthsoftreatment) Inonepatient:midlinepartphotowasunchanged andHAIRCHECKwasincreased(templeslooked improved)

THANKYOU

113 Dermoscopy is a Valuable Aid in Diagnosing Female Hair Loss and Guiding Treatment
Alessandra Juliano, MD. Clinica do Cabelo, Brasilia, Brazil. Alessandra Juliano, MD practices hair restoration surgery and hair dermoscopy at the International Clinica do Cabelo in Brasilia, Brasil. A. Juliano: None. TAKE HOME MESSAGE: Hair dermoscopy is a valuable skill to diagnose hair loss in females and guide treatment decisions. ABSTRACT: Introduction: Diagnosis, management and treatment of hairloss is an integral part of a hair restoration practice. Female hair loss can have multiple origins and requires special attention to advice patients on proper diagnosis and treatment. Objective: To demonstrate a clinical protocol that can be used for properly diagnosing female hair loss and guiding treatment decisions. Materials and Methods: Dermoscopy is a non-invasive in vivo technique that can be utilized in assessing hairloss in patients, especially when the clinical presentation is nebulous. Sophisticated tools such as FotoFinder with Trichoscan digital hair analysis can help in quantifying hair loss dynamics (hair counts, hair density, vellus and terminal hair counts, anagen/telogen ratio) and be helpful in assessing hair disorders. Additionally, simple clinical tests such as the pull-test can give additional information valuable for diagnosis. An easily implementable clinical protocol will be presented that enables confident diagnosis of female hair loss. The differential diagnosis, dermoscopic photographic patterns and treatment options for hair disorders such as frontal fibrosing alopecia (FFA), lichen plano pilaris, traction alopecia, alopecia areata, cicatrial marginal alopecia, alopecia androgenetica, telogen effluvium, lupus, folliculitis decalvans and trichotillomania will be discussed in this presentation. Discussion/Results: Diagnosis of female hair loss can be challenging issue. Furthermore, obtaining the correct diagnosis is important in choosing who can benefit from a hair restoration procedure or medical treatment. The need for easily implementable clinical tools for diagnosis is valuable for hair restoration surgeons. Through dermoscopy the clinician can readily identify imaging patterns of hair loss that can point to the right diagnosis. Conclusion: Dermoscopy, along with clinical evaluation of patients, is a valuable tool in diagnosing female pattern hair loss and guiding treatment.

Why female hair loss is complex?


Multifactorial:androgenetic alopecia,chronictellogen effluvium,alopeciaareata icognito,deficitofiron,vitamins, hormonesdisorders,autoimune disorders,etc

Dermoscopy is a Valuable Aid in Diagnosing Female Hair Loss and Guiding Treatment
DermatologistaSBDDF/ISHRS Professoraresidnciamdica HRAN Departamentodecabelo Fellow Dr.Tosti MiamiUniversity FL Fellow Dr.Unger Mount SinaiHospital NYC

Theyaremoreworriedaboutbeingbald culturallynot accepted Theywillgotoahairspecialist YouneedtogiveherCONFIDENCE! WOMENNEEDANSWERS THEYAREMOREANXIOUSTHAN MEN!!!

AlessandraJuliano,MD

Why hair dermoscopy is important?


Importantnoninvasiveinstrumenttoguideyouforthe correctdiagnosisandchoosethebestcandidateforahair transplant Iusedermoscopy likeasradiologistusesanXrayor cardiologistusesanEKG. YOUWILLBEABLETOGIVETHEMANANSWER Willincreasethepatientpopulationcomingtoyourpractice

How can you do it?


Portabledevices ex:dermoscopy Dermlite DL3/handyscopy Highresolution
betterquality: Fotofinder 2070x

Immersionfluidsand contact/polarizedand nonpolarizedlightcan maketheimagebetter andhighquality

Protocol for hair evaluation


OBSERVATION CLINICALHISTORYOFHAIRLOSS,ETAL PULLTEST+ismorethan5hairs DERMOSCOPY

4 important steps of hair dermoscopy


1. Vascularization 2. Dots/orifices 3. Caliber 4. Others:casts, exclamationmarks, shapeofthehair shaft
WhatshouldIdoDr? 28yold???? Whatshoud Ido?
2

Anagen =golfclub

Telogen =Qtip

1. Vascularization
Reddots=psoriasis Twistloops Andcasts Reddotsand telangiectasias= sebohreico dermaitites Simpleloops

2. Yellow dots: 95% areata , 5% androgenetic

Canbegoodcandidate

Canbegoodcandidate implantation canbe littledifficult

Yellow dots
Alopeciaareata incognito and androgenetic alopecia

2. Black dots
Indicativeof:
Cadaverized hair Inflammation Canbepresentin:

notagoodcandidate

Alopeciaareata Cicatricial alopecia Inflammatoryhairdisease Lymphomas Syphillis

2.White dots
Sweatglands indarkskin

Absenceofhairorifices LPP

3. Caliber
Dr.Iamloosingmyhairwhatisgoingon??? >20%variabilityofcaliber

Goodcandidate NOTGOODCADIDATE

Androgenetic alopecia clinical treatmentfirst

3. Caliber
Iamloosingmyhairandmymommyisbald Chronictelogen efluvium

4. Others: casts LPP

Notagoodcandidate

Variability is<20%

Casts around the follicles LPP

4. Others: exclamation marks

NOTAGOODCANDIDATE

Alopeciaareata

4. others:
Frontalfibrosing alopecia

Case studies

PilliTorti cicatricial alopecia hairtransplant hair

43 yo 3 months of acute hair loss

Alopecia areata 2m laser, minoxidil & clobetasol

62 yo female, 2 years hair loss with pain & burn


Hairlossinfrontalparietal

Graham Little Piccardi Lasseur Syndrome 6 months treatment

NOTGOODCANDIDATE

BEFORE

AFTER

57yo male, 20 years hair loss, 10 years treatment with finasteride and minoxidil.

AA/alopecia areata incognito 6m treatmentlaser & clobetasol.

BEFORE

AFTER

Androgenetic alopecia & alopecia areata incognito

Conclusion
ADVANTAGES: Youcanguideforthe correctdiagnosis Lowcostandlowtime Femalepatientmore confident Canscreenmore patientsforyourclinic becauseyouareahair expert OBRIGADA aledermato@me.com DISADVANTAGES Stoptostudynewfield

BEFORE

AFTER HEISHAPPYTODAY

114 The Effect of Cold Laser Therapy on Hair Mass as Measured by Cross Sectional Diameter
Sara M. Wasserbauer, MD. Sara Wasserbauer MD, Walnut Creek, CA, USA. Dr. Sara Wasserbauer, is a Diplomate of the American Board of Hair Restoration Surgery, based in the California Bay Area. 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. She has been the principal investigator for Restoration Robotics for the ARTAS, featured on The Doctors TV show, and writes an occasional column for the Forum. She likes tough cases, niche procedures, good data, and a scotch now and then... S.M. Wasserbauer: Research Grant (principal investigator, collaborator or consultant); ISHRS Grant Award recipient. Other Research Support (receipt of drugs, supplies, equipment, or other in-kind support); HairCheck cartriges obtained at discounted. TAKE HOME MESSAGE: Preliminary data from this study elucidates intra- and inter-operator variability. Final data will help determine Laser Hair Therapy effects on hair mass. ABSTRACT: This is a mid-study report of the investigation being conducted at my office whose aim is to assess the effect of twice weekly Low Level Laser Therapy (LLLT) on hair mass using the Revage 670 laser (a laser device that has already been approved by the FDA for safe use on patients). The hypothesis is that one year of twice weekly 20 minute treatment will produce measurable improvements in the hair mass of patients with androgenetic alopecia. Hair mass measurement (using the HairCheck technology), unlike traditional phototrichograms which measure density alone, has the unique ability to measure changes in both hair density and hair diameter the two anatomic hallmarks of hair loss and growth. Cold lasers (LLLT) are routinely touted as effective treatments for hair loss and specifically claim to increase hair growth. There are few studies in the field of hair medicine to support these claims, and often the treatments are promoted by non-physicians, leading to further confusion. This study, while small, will provide objective data to either support or refute these claims, as well as provide an initial basis on which future studies may be initiated. Although studies counting hairs per square centimeter of scalp (before and after treatment) have been conducted as directed by the FDA, they do not take into consideration the wide range of hair diameters that characterize the miniaturization of hair shaft diameter seen in patients with androgenetic alopecia and are therefore relatively imprecise. Cross-sectional trichometry technology (via a Hair Check device, www.haircheck.com) simultaneously measures both the diameter and hairs per square centimeter thus measuring hair mass. This has been scientifically documented as equivalent to dry hair weight measurement the industry gold standard at a fraction of the cost. Additionally, because the technology is relatively new, scientific studies using a cross-section trichometer (HairCheck) device for measuring hair mass have not been performed on a large scale or in a long term study although admittedly, the popularity and rationale for using this technology is growing. This study would have the added benefit of testing both intra- and inter-operator reproducibility for this new hair measuring technology. Thus far, 29 patients have been enrolled including roughly ten in the control group. Three patients have dropped out two females due to pregnancy, and one male who was unable to meet the time commitment.

Pt # Sex Case Type Start Date 1 2 3 4 5 6 7 8 9 M Treatment 9/15/12 M Treatment 9/25/12 M Treatment 9/26/12 M Treatment 11/14/12 M Treatment 10/23/12 M Treatment 10/11/12 M Treatment 11/9/12 M Treatment 11/27/12 M Treatment 12/13/12 Treatment 9/25/12 Treatment 9/28/12 Treatment 10/2/12 Treatment 12/19/12 Treatment 10/11/12 Treatment 10/15/12 Treatment 10/11/12 Treatment 10/26/12 Treatment 12/5/12 Treatment 1/8/13 Control 12/5/12 12/5/12 10/31/12 10/31/12 10/31/12 11/8/12

10 F 11 F 12 F 13 F 14 F 15 F 16 F 17 F 18 F 19 F 20 F

21 M Control 22 F 23 F Control Control

24 M Control 25 F Control

26 F 27 F 28 F 29 F

Control Control Control Control

10/31/12 11/8/12 12/3/12 11/1/12

Preliminary data, while thin for this OASIS submission, promises to at least elucidate intra- and inter-operator variability. Up to three out of the total seven HairCheck readings have been completed on about half of the subjects (not including the controls). We look forward to presenting the rest of the data closer to the date of the conference. PATIENT DATA (raw) Name Tabs TB 1 2 51, 54, 36 59, 58, 37 3 53, 61, 46 51, 60, 43

8, 18, 28 47, 59, 43 62, 55, 48

AL

8, 18, 28 56, 57, 64 64, 55, 67

CS

8, 18, 28 68, 66, 68 69, 70, 68

82, 94, 77 79, 83, 81 44, 53, 70 39, 54, 52 38, 43, 41 32, 40, 36 15, 23, 31 13, 24, 29 70, 37, 35 48, 35, 34

75, 91, 65 78, 87, 78

SS

8, 18, 28 38, 62, 76 49, 70, 78

PR

8, 18, 28 37, 40, 42 31, 39, 36

SG

9, 15, 26 15, 18, 33 13, 20, 33

14, 26, 34 18, 33, 34

KJ

8, 18, 24 47, 26, 36 46, 28, 35

CL

8, 18, 28 38, 55, 55 36, 51, 43

VM

8, 18, 28 47, 63, 58

55, 50, 64

42, 52, 58

53, 57, 58 SE 8, 18, 28 25, 44, 54 28, 40, 46 ES 10, 16, 32 10, 10, 29 11, 12, 35 TL

46, 36, 58 36, 35, 46 36, 41, 46 25, 5, 35 14, 4, 31

46, 54, 61 32, 44, 58 34, 44, 64 8, 9, 31 7, 7, 31

8, 19, 28 117, 143, 130 122, 145, 129 113, 124, 124 123, 138, 123

AE

15, 20, 30 34, 29, 66 18, 6, 72

15, 5, 74 15, 4, 71

9, 5, 58 6, 4, 47

DC

8, 18, 28 23, 60, 60 28, 60, 52

PS

10, 26, 30 16, 3, 27 20, 6, 38

23, 5, 37 25, 8, 39 2, 36, 50 1, 32, 50 41, 40, 57 37, 30, 58 32, 43, 59 24, 49, 49 42, 37, 97 39, 35, 81 12, 30, 65 11, 20, 60

KT

18, 28, 32 4, 31, 46 2, 30, 42

JE

10, 18, 28 31, 34, 52 37, 34, 66

JDB

8, 24, 30 10, 82, 47 8, 31, 47

AC

8, 18, 28 51, 49, 91 44, 46, 82

BE

8, 16, 24 60, 76, 79 49, 69, 84

TZ

10, 24, 30 37, 72, 84

9, 31, 81

30, 47, 93

16, 25, 68

CONTROL DATA (raw) Name Tabs CC 1 2

8, 18, 28 72, 72, 70 56, 69, 71

LD

8, 18, 28 69, 81, 85 67, 85, 83

MK

10, 18, 28 15, 45, 43 17, 41, 45

EC

11, 17, 30 22, 14, 37 20, 12, 36

SW

8, 18, 28 71, 91, 78 80, 99, 83

69, 92, 83 74, 98, 89 97, 101, 85 86, 98, 82

ML

11, 22, 28 96, 109, 82 97, 106, 91

RB

8, 15, 28 121, 130, 103 81, 149, 124 101, 120, 135 96, 140, 125

MC

8, 18, 28 61, 81, 70 63, 78, 71

68, 72, 73 59, 97, 66 25, 30, 44 17, 28, 46 65, 74, 65 67, 83, 56

JH

8, 18, 28 22, 32, 43 21, 40, 44

CS

8, 15, 28 69, 67, 71 70, 75, 72

Disclosures
TheEffectofColdLaserTherapyon HairMassasMeasuredbyCross SectionalDiameter
Aworkinprogress IreceivedagrantfromtheISHRSforthisstudy HairCheck hasallowedmetopurchasethe roughly1800+cartridgesIneedforthisstudy atadiscountedrate

TheHypothesis:
Ishairmassisaffectedbylaserhair treatment?
Multipledevices(combs,helmets/hoods/caps) now available,somewithLEDs andotherswithlasersinthe 640730nmrange Weknowlaserscandecreaseinflammation, increaseATP, andimprovelocalcirculation Weallwanttoknow
ifthesewillworkforourpatients,and howmucheffecttheywillhave,and forwhichpatientstheywillworkbest!

TheStudyDesign:
Wedesignedastudytoenroll:
15men 15women 15controlpatients(bothmenandwomen) 1yearoftreatmentwith20minutelaserhair treatment2Xweekly(FREE) Revage 670(FDAapproveddevice) CrossSectionaldiametermeasurementwith HairCheck in3differentspotsatbaselineandevery2 monthsthereafter(7totaldatapoints)

TheStudyDesign:
Toprovideforinter andintraoperatorvariability, CrossSectionaldiameter(HairCheck) measurementisperformedbytwostaffatevery 2monthintervalvisit ThefirstmeasurementisALWAYSperformedby thesamededicatedstaffmember TheothermeasurementisALWAYSperformedby oneofsixothertrainedstaffmembers Globalphotographsaretakenatbaselineandat6 and12monthsaswell.

TheStudyDesign:
Inclusion/ExclusionCriteria:
Agerange:1865 Abletovisitofficetwiceaweekfor20minuteseachsessionforone fullyear Hairmustbeatleast1inchinlength CannotbetakingPropecia oranyotherhairgrowthsupplements CannotbeusingRogaine,wigs,hairpieces,orextensions Mustconsenttoglobalphotosandtheuseofphotos MustconsenttoaHairCheckat2monthintervals(totalof7times)by 2differentpeoplein3differentspots(i.e.6measurementsateach HairCheck) No otherscalpdiagnosis(i.e.noscarringalopecias),previoushair transplant,Acell/PRPtreatment,microneedling,oranyother treatmentinthelast 18months Patientscanmissupto2weekstotalinthefullyearoftreatment

ResultstoDate
Enrolled 11females 13males 10controlsubjects(2males,8females)

ResultstoDate
Continuingtoenrollduetohighdropoutrate MeasurementstakenatFRONT,TOP,andBACK

8monthresultsavailablefor12ofthesepatients
4 females 3males 4controlsubjects(1male,3females)

ResultstoDate:TREATMENT
Treatment Arm: FRONT Treatment Arm:TOP

ResultstoDate:TREATMENT

Womenhappen tobethe4ontop,menthe3onbottom Atthisinterval,littlechange frombaseline

Menstillthe3onthebottom,butnocleartrendsare revealed

ResultstoDate:TREATMENT
Treatment Arm:BACK Control Arm: FRONT

ResultstoDate:CONTROL

Nocleartrendsinthedonorarea

ResultstoDate:CONTROL
Control Arm:TOP Control Arm:BACK

ResultstoDate:CONTROL

PreliminaryConclusions
Nocleartrendsintreatmentgroup LowNdecreasespowerofthisstudy Complianceclearlycomplicatesassessmentof thistreatmentmodality Crosssectionaldiametermeasurementcanvary widelyinteroperator(weusetheaverageforthis analysis) Consistentcrosssectionaldiameter measurementsincontrolgroupindicatesfair validityanddatafidelity

PlanforFuture
Continuethestudy!Addadditionalsubjects astheybecomeavailable(Iestimateafive yeartimelineatthiscurrentrate!) Recruitadditionalpatientsupto60+toadd powertothestudy Changedevicetoacaporhelmettoimprove patienttrackingandcompliance? Makepatientspayadollarforthetreatment?

PlanforFuture
Thankyou!

115 Is Low Level Laser Therapy Effective in Treating Androgenetic Alopecia? A Review of 5 Years Experience in Treating Hundreds of Patients With Male and Female Pattern Hair Loss
Shelly A. Friedman, D.O., FAOCD. Scottsdale Institute For Cosmetic Dermatology, Scottsdale, AZ, USA. Dr. Friedman is the Founding President of The American Board of Hair Restoration Surgery and is Board Certified in Dermatology and Hair Restoration Surgery. He has been practicing hair restoration surgery in Scottsdale, Arizona for the past 26 years. Dr. Friedman is the author of the consumer hair loss book: TO BALD OR NOT TO BALD That Is The Question. Dr. Friedman is a frequent lecturer and faculty member of the ISHRS Annual Meetings and the Orlando Live Surgery Workshop. S.A. Friedman: None. TAKE HOME MESSAGE: Low Level Laser Therapy is an additional tool for the physician in treating Male & Female Pattern Hair Loss. ABSTRACT: Low Level Laser Therapy (LLLT) has been utilized in medical and nonmedical settings for many years, but a lack of scientific documentation has been instrumental in the medical communitys reluctance in accepting this valuable technology. All patients undergoing Low Level Laser Therapy were evaluated prior to treatment, and at 3 months, 6 months, 9 months and 12 months with the following: 1. Global photography 2. Video Microscopy 3. HairCheck The data obtained from hundreds of patients utilizing Low Level Laser Therapy for Pattern Hair Loss, demonstrated that Laser was not only successful in stopping hair loss, but in many patients reversed the miniaturization cycle and gave the appearance of regrowth from converting vellus hairs to terminal hairs. A review of 5 years experience with Low Level Laser Therapy demonstrated the efficacy of utilizing laser therapy in Male and Female Pattern Hair Loss. The documentation presented in this paper should be helpful in giving Low Level Laser Therapy the credibility it rightly deserves in treating patients with hair loss. This paper should also allay any doubts or fears in hair loss professionals who have not accepted this technology as being a legitimate treatment

for millions of people.

116 Hormonal Evaluation of Female Pattern Hair Loss


Sharon A. Keene, MD. Tucson, AZ, USA. Sharon Keene, M.D. is a board certified general surgeon in the solo practice of medical and surgical hair restoration in Tucson, AZ. She has been a pioneer in the use and advancements of follicular unit megasessions, developing instruments to protect grafts and improve ergonomics of surgery. She has performed research on the effect of genetics on response to finasteride therapy in women, and published a series of articles reviewing the probable influence of epigenetic variables which can influence and accelerate hair loss in AGA. S.A. Keene: None. TAKE HOME MESSAGE: Hair loss in women is complex, with no single hormonal entity predominating as a cause. Medical evaluation should include evaluation of hormones likely to cause disruptions in normal hair growth in order to achieve homeostasis and promote normal growth if possible. ABSTRACT: Hair growth and loss are influenced by complex interactions of hormones and growth factors, many of these are not fully elucidated. This presentation will review some of the known hormones which influence hair health, and may assist in the diagnosis and treatment of female pattern hair loss, as well as some of the ongoing research into hair loss therapies for women.

Sharon A. Keene, M.D. Tucson, AZ ISHRS Annual Scientific Meeting 2013

The human skin as a hormone target and an endocrine gland, Zouboulis, C, Hormones, 2004, 3(1):9-26

Endocrine- chemicals are secreted into the blood and carried by blood to distant target organ or tissue Autocrine cell signals itself via chemical it synthesizes and responds to. Can occur in cell cytoplasm or secreted chemical interacting with receptors on cell surface Intracrine Chemical is produced and acts within the same cell Paracrine chemical signals diffuse into area, interact between neighboring cells within a tissue or organ. Ex: release of cytokines for inflammatory response ; or neurotransmitters at synapse in CNS.
Endocrinology: An Integrated Approach.Nussey S, Whitehead S.Oxford: BIOS Scientific Publishers; 2001. The human skin as a hormone target and an endocrine gland, Zouboulis, C, Hormones, 2004, 3(1):9-26

Survey in 1985 n=36 hirsute females Serum & target tissue exam hormone & receptor levels
No correlation : serum

hormone / tissue receptor levels


Conclusion: Direct

cellular level involvement

Steroid hormone levels in serum and skin receptor concentrations in hirsutism,Schmidt, JB, et al Endocrinol Exp, 1985, Sep; 19 (3): 147-55

Intracrine Hormones/Peptides: Formed & act within target tissues


(Intracrinology and the Skin, Hormone Research, 2000, 54: 218-229)

Intracrine Synthesis of Androgens in Skin : De novo from cholesterol or conversion weaker androgens
(Cutaneous Androgen Metabolism, Zouboulis et al, Jl of Invest Derm, 2002, 119:992-1007)

Circulating /Intracellular DHT Mostly peripheral conversion T in men, Androstendione in women Blood levels tissue levels, vary organ to organ
(DHT is a peripheral Paracrine Hormone, Horton, R, Jnl of Andrology, 1992 Vol 13, 1: 23-27,)

3 Androstanediol Glucuronide & DHT :


Serum marker DHT metabolism and 5R in target tissues
(Serum levels of 3 Androstanediol Glucuronide in hirsute and non hirsute women, Euro Jnl of Endocrin, 1998, 138:421-4.; Androgen Excess, Sabatini, L, eMedicine Ob and Gyn, May, 2007)

Androgen Precursors

Gene mutations = reduction of 21 Hydroxylase


Androgen Excess most frequent

Autosom Recess dz ; 1% of NY pop

1:27 Ashkenazi Jews; 1:40 Hispanics, also incr Italians and Yugoslavs Underdx, mild/moderate hyper androgen Not assoc w ambiguous genitalia
Intracrine Metabolism Cutaneous Androgen Metab, Chen, Zoubulis, Jnl of Invest Derm 119, 992-1007, 2002

Sx: Precocious Puberty, tall stature as child, short as adult; cystic acne, frontal balding, irreg menstr.
Non classical 21 Hydroxylase Deficiency, New, M., Jnl of Clinical Endocrinology & Metab, 2006, Nov, 9(11):4205

Androgens: T, SHBG, DHEA-S, Androstenedione Prolactin FSH, LH 17 OH-progesterone Estrogen. Androstanediol Glucuronide

17-hydroxyprogesterone (17-OHP).

Dx 21-OHD CAH confirmed by elevated serum 17-OHP ACTH Stim test most accurate

TSH not accurate under many circumstances:

Physiologic stress, depression, inflammation, insulin resist

Serum levels tissue levels Euthyroid Sick Syndrome

Tests
TSH Unbound thyroid

T4 , T3 bound to Thyroxine Binding Globulin (TBG), 1% unbound, active T3 >> activity vs T4 >rT3 or reduced T4 uptake cause hypothyroidism

hormone
Free T4 Free T3 Reverse T3

How accurate is TSH testing? National academey of hypothyroidsm, Jan 2012, http://nahypothyroidism.org (118 ref)

Anti-TPO & anti- thyroglobulin

antibody (Hashimotos)

Serum thyroid hormone levels may not accurately reflect thyroid tissue levels & cardiac function in mild hypothyroidism, Yingheng, L., et al Am Jrnl of PhysiolHeart, May 2008, vol 294

US & Europe nutrition comm.: Vit D a hormone ; VDR (vitamin D Receptor) requires 1, 25 OH vit D for activation VDR regulatory role (anagen initiation) HVDRR (hereditary Vit D Resistant Rickets) 20 VDR mutation = hormone resistance, all have alopecia.
Steroid Biochem Mol Biol. 2007 March; 103(3-5): 34434ROLE OF THE VITAMIN D RECEPTOR IN HAIR FOLLICLE BIOLOGYMarie B. Demay, Paul N. MacDonald, Kristi Skorija, Diane R. Dowd, Luisella Cianferrotti, and Megan Cox. The Role of Vit D Receptor Mutations in the Development of Alopecia, Mol Cell Endocrinol 2012, Dec 5:347 (1-2):90-96

T4 up-reg prolif hair matrix keratinocytes T3, T4 down reg apoptosis T4 prolongs anagen in vitro, may inhibit TGF-beta 2 growth inhibitor HFs transcribe D2-D3 which convert T4 to T3 T3 , T4 modulate cytokeratins and stim intrafollicular melanin synthesis
J Clin Endocrinol Metab. 2008 Nov;93(11):4381-8. Thyroid hormones directly alter human hair follicle functions: anagen prolongation and stimulation of both hair matrix keratinocyte proliferation and hair pigmentation.van Beek N, Bod E, Kromminga A, Gspr E, Meyer K, Zmijewski MA, Slominski A, Wenzel BE, Paus R.

25, 0H Vit D is deficient @ < 20 ng/ml

RX: > 30 yrs in Women


RDA 600 IU d (upper

limits 4000 IU)


Replacement in

deficiency 1500-2000 IU (Upper limits 10,000 IU)

Evaluation, treatment and prevention of Vitamin D deficiency, Holick, M, et al An endocrine society clinical practice guideline, Jnl of Endocrin Metab, July 2011

Complex hormonal environment for hair growth, not yet fully elucidated Limits of serum testing for assessing tissue activity Overt serum steroid hormone abnormalities can direct medical diagnostics: free T, SHBG, DHEA-S, estradiol, androstenedione Non Classic 21-0h deficiency: 17 OH Progesterone (best if ACTH stim) Androstanediol Glucruronide reflects DHT metab Thyroid testing should include TSH, free T3 and T4, rT3
Bald Patients

Serum 25 (OH) Vitamin D best indicator for Vit D deficiency

Serum?
Gold Standard for accuracy, with known limitations

Saliva?
Salivary 17-OH Prog & androstenedione valued as non-

invasive tests monitoring hydrocortisone in CAH 20 21hydroxylase deficiency

Diagnostic value of salivary estradiol, progesterone,

testosterone, DHEA compromised 20 rapid fluctuations. Multiple samples required for accuracy.

Hair follicle? No data for comparisonpotential for greatest


accuracy
Salivary steroid assays: Research or routine? Wood, P, Ann Clin Biochem, 2009; May, 46: 183-196

117 Moderator Introduction, Advanced Surgical Videos I


Carlos J. Puig, DO ABHRS FAACS. Physicians Hair Restoration Center, Houston, TX, USA. Dr Puig has been actively involved in the practice of hair restoration surgery since 1973. Founding Member of both the AACS and ISHRS, over the years Puig has presented papers, workshops and surgical demonstrations on many topics. Dr. Puig is a Fellow of the American Academy of Cosmetic Surgery, and Diplomate, and Past President of the American Board of Hair Restoration Surgery. Dr. Puig has served as chair of the ISHRS Fellowship Training Committee, Core Curriculum Committee, and currently is the President of the ISHRS. He recently joined the staff at the Baylor College of Medicine, in Houston to help start their hair restoration surgery program. C.J. Puig: None.

118 How to Minimize Hair Angle Alteration in Wide Donor Wound


Dae-young Kim, MD, Hyung-suk Kim, MD. Apgujeong Yonsei Hair Transplant Clinic, Seoul, Korea, Republic of. Dr. Dae-young Kim is a board certified plastic surgeon and Diplomate of the ABHRS, and has been practicing hair restoration surgery since 2000 in Seoul. He presented 3 papers about "Pustule-Free Trichophytic Closure" at the ISHRS Annual Meetings in Montreal and Amsterdam. He's papers were printed in the FORUM of ISHRS 4 times and he contributed a trichophytic closure chapter to the 5th edition of the Unger's text book of Hair Transplantation. D. Kim: None. H. Kim: None. TAKE HOME MESSAGE: Differences in hair angle between upper and lower edges become larger in proportion to the width of the donor strip. The wide donor strip caused not only excessive closing tension, but also unnatural hair angle alteraion. The aim of this study is to find a method to minimize the hair angle alteration during wide donor wound closure. In comparison with our preliminary study, for a more natural appearance, two-layered sutures are placed 1.5 cm apart, rather than 2.5 cm. The two-layered suture technique used in this study reduces not only the closing tension in skin layers but also the hair angle alteration. These reductions were possible due to the dermal-subcutaneous suture technique which bites from the dermis to the subcutaneous fat tissue in two-layer sutures. ABSTRACT: The video file of this paper is available at: http://www.youtube.com/watch?v=BjL1YXXGlDA

Introduction A significant amount of researches has been conducted to produce an aesthetically acceptable donor scar. One shortcoming that has not been studied as extensively is the change of hair angulation caused by excessive closing tension. Some characteristics of hair should be considered during donor closure. The natural direction and angle of hair is determined in early infancy and does not change even after transplantation of a hair follicle; this characteristic is known as "drape." The hair angle at the donor site becomes more acute from the occipital protuberance to the nuchal area. In the donor wound, differences in hair angle between upper and lower edges grow larger in proportion to the width of the donor strip. The wide donor strip (usually 1.2-2.0cm) caused not only excessive closing tension, but also unnatural hair angle alteraion. Depending on the tension, some surgeons prefer to use deep sutures. These sutures were placed from 1.5 cm to 2.5 cm apart. The authors used deep sutures which were placed 2.5 cm apart during donor wound closure. In patients who had a mega-session and wear a short hairstyle, the clusters of tangled hair were seen in several places surrounding the donor scar, while the scar itself was nearly invisible since trichophytic closure had been used (Figure 1). We assumed that this noticeable and unnatural finding was caused by excessive hair angle alteration. Haber, who reported on an essentially unchanged hair angulation in an open wound, stated that the alteration of hair angle appears to occur during closure, and that further exploration of this phenomenon is needed. Therefore, we conducted a preliminary study of five patients who underwent secondary hair transplantation. In these patients, twolayered sutures with dermal bites were placed 2.5 cm apart. The hair angle created in-between the deep sutures showed greater change than the actual deep suture sites themselves (Figure 2). The aim of this paper is to find a method for minimizing hair angle alteration during wide donor wound closure in hair transplantation. Material and Methods This study included 50 patients who underwent hair transplantation surgery in our clinics from October 2010 to December 2011. Every patient underwent wide donor strip harvesting with a strip width of more than 1.5 cm; hair angles of occipital, parietal, and temporal areas were measured on the upper and lower edge levels prior to each operation. The measurement of an angle was performed with a protractor. The angle was checked as 90 degrees is the most vertical and 0 degree is the most horizontal in relation to skin surface. In donor closure, the trichophytic closure method was used in combination with a deep-buried dermal-subcutaneous suture technique using absorbable suture threads (Vicryl 4-0, Ethicon, Somerville, NJ). These sutures were placed 1.5 cm apart. A running suture technique using Nylon suture threads (Ethilon 4-0, Ethicon, Somerville, NJ) placed 2 mm apart was used for closure of skin layers. Out of 50 patients, four underwent revision surgery within one year after the first surgery. Previous donor scars were included in a second donor harvest. The removed donor strip was dissected into 12 serial blocks and photos were taken of the slivers from each block for the analysis of hair angle alteration. Results Out of 50 patients, 32 patients were male with a mean age of 41. The pattern of hair loss ranged from androgenic alopecia (AGA) Norwood III to VI. A total of 18 female patients with a mean age of 30 underwent hair transplant for hairline correction. Hair angulation on the upper edge of the donor site was 30 degrees on average, and, on the lower edge, it was 20 degrees (Table 1, Figure 3A). A total of 48 slivers were obtained from four patients who had undergone revision surgery. In the revision cases, there were 1 male and 3 females. The hair angle of most slivers was 60 degrees on average. Excessive change of angle was shown in 1-2 slivers for each patient. The hair angle of these slivers was 40 degrees in the previous upper edge area and 80 degrees in the previous lower edge area (Figure 4). Discussion In this study, measurement of hair angulation of the donor area was performed prior to the first surgery; results showed an average difference in hair angulation of 10 degrees between

upper edge and lower edge in wide strip harvesting. The intensity of closing tension exerted on the upper edge and lower edge was about the same, therefore, the upper edge moves to the inferior side and the lower edge moves to the superior side, approximating in the mid-level. Without tension, hair angulation can remain natural; however, as tension on the skin layer increases during donor closure, hair angulation in the upper edge and lower edge grows increasingly unnatural. This tugging process causes hair angle alteration, resulting in more acute hair angulation of the upper edge, and that of the lower edge grows wider. This type of hair angle alteration results in an unnatural transverse hairline, leading to an unacceptable aesthetic effect (Figure 3B). In comparison with our preliminary study, for a more natural appearance, two-layered sutures were placed 1.5 cm apart, rather than 2.5 cm. The two-layered suture technique used in this study reduced the closing tension in skin layers and hair angle alteration effectively. These reductions were possible due to the dermal-subcutaneous sutures(Figure 3C). However, there were two shortcomings of the two-layered suture technique which do not have a negative effect on the overall transplantation procedure. First, compared with the one-layered suture technique, surgeons require an additional 20 minutes of work; however, this does not prolong the total operation time since the work was done during the graft preparation period. Second, strangulation injuries to the hair follicles occurred yet were expected. At the one-year assessment, several small white spots where hair was partially absent along the donor scar were observed. However, they were so minimal as to be negligible. Conclusion In conclusion, the two-layered suture which involves a deep layer suture with dermal bites placed 1.5 cm apart demonstrated cosmetic advantages over other donor closure techniques by reducing the excessive hair angle alteration of the surrounding donor wound. Table

Table 1. Hair angle around the donor area. Figures

Figure 1. In this patient who had a mega-session about 4-years ago, the deep sutures were placed 2.5cm apart on the donor wound. (A) Clusters of tangled hair were noted in several places surrounding the donor scar. This type of

alteration results in an unnatural transverse hairline, leading to an unacceptable aesthetic effect (B) But, the donor scar itself was very thin and nearly invisible.

Figure 2. In the preliminary study, (A) two-layered sutures with dermal bite were placed 2.5 cm apart. After one year, serial blocks were obtained from the same patient. (B) The left block was obtained from the area where the deep suture was placed. (Blue arrow) (C) The right block was gained from in-between the deep sutures. (White arrow) The hair angle of the left block was more natural than that of the right. The hair angle created in-between the deep sutures showed greater alteration than the actual deep suture sites themselves.

Figure 3. Horizontal ellipse wider than 1.5 cm at the midline was harvested. (A) Difference in hair angle between upper (30) and lower (20) edges at the occipital protuberance. (B) Unnatural change of hair angulation occurred on the single-layered suture area. (C) Natural change of hair angulation occurred on the two-layered suture area with dermal bites placed 1.5 cm apart.

Figure 4. In this patient, a two-layered suture with dermal bite was employed for a wide donor wound. (A) Marked lines are indicates slivering sites. (B,C) 12 slivers were produced for the analysis of hair angle alteration. Slivers marked with an asterisk indicate excessive hair angle alteration surrounding the donor scar.

119 Arrow Shape Laxometer


Viroj Vong, MD. HHH Hair Transplant Center, Bangkok 10110, Thailand. Viroj Vong, MD ABHRS. Doing hair transplant in Bangkok,Thailand for 23 years. Strip harvesting, FUE, Body Hair transplant, Etc. V. Vong: None. TAKE HOME MESSAGE: Precise mathematic measurement of the doner tissue is very important for doner closure.

ABSTRACT: In Megasession,Gigasession precise estimation of the donor width is a must for any accuracy in doner wound closure. I make an arrow shape stainless steel template. Width vary from 10 mm-20 mm. Before I split out the donor tissue, I use this arrow head as my guide of the width. If I can move my arrow head along the width of the donor.Then it is safe to remove. If the movement of the head is less than the plan width then I have to narrow down the width of the donor. Very simple and effective home-made device.

120 Composit Graft for Incomplete Donor Site Closure Due to High Tension
Ji-sup Ahn, MD, PhD. Dr. Ahn Medical Hair Clinic, Seoul, Korea, Republic of. General Information: - Doctor degree of Medicine, Kyungpook National University school of Medicine - Clinical Assistant Fellowship at the Hair Transplantation Center, Kyungpook National University School of Medicine - Director of Dr. Ahn Medical Hair Clinic in Seoul, Korea Memberships & Affiliations: - Member of ISHRS - Member of AAHRS (Asia Association of Hair Restoration Surgeons) - Board Member of KSHRS (Korean Society of Hair Restoration Surgery) - Board Member of KADAT (Korean Association for Dermatology and Trichology) J. Ahn: None. TAKE HOME MESSAGE: Composit graft is useful for in case of incomplete donor closure with high tension. ABSTRACT: This is a summary of a surgical video about using composit graft from the harvested flap for incomplete donor site closure with high tension. It can minimize donor site pain, wide donor area alopecia, and reduce the time of open wound management. The composit graft length depends on the tension area length, the width being under 3mm, and keeping intact hair roots. If the patient wants to reduce scar visibility, FU can be transplanted around the scar area by FUE or have the scar tissue removed at a later time. This technique is useful for incomplete donor site closure with tension in the cases of wide donor harvesting, low scalp laxity, or low body fat percentage, etc.

121 An Alternate Technique from Shaving the Recipient Area


Sara Kotai, MBBS Hons, Jennifer Martinick, MBBS. Salvado Medical, Nedlands, Australia. Dr Sara Kotai qualified from the University of Western Australia with honours. She finished her internship in 2009. She has worked full time in hair transplantation from 2010 to 2012. In early 2010 she spent three months as a volunteer in an AIDS orphanage in Kenya where she was involved in obstetrics, teaching health care workers about hygiene, infection control, CPR and emergencies, as well as developing a safe sex program for teenagers at the local high school. S. Kotai: None. J. Martinick: None. TAKE HOME MESSAGE: Enlarging Patient choices without compromising outcomes. ABSTRACT: Abstract. Many men and all women for various reasons object to having the recipient area shaved. A 2 minute video will be shown explaining the alternative technique, as well as discussion regarding the ethnic and cultural reasons that patients may have for being reluctant to have their head shaved.

122 Video Presentation - The "No-Shave FUE Technique": A Method to Improve Patient Satisfaction with FUE Procedures
Marco N. Barusco, MD. Tempus Hair Restoration, PA, Port Orange, FL, USA. BIOGRAPHICAL INFORMATION MARCO N. BARUSCO, MD Dr. Barusco was born and raised in Brazil, where he trained in General and Cosmetic Surgery. Since 1998 Dr. Barusco has specialized in Hair Restoration Surgery, after relocating to the United States. He is one of the founders and the Medical Director for Tempus Hair Restoration, P.A. located in Port Orange, on the Atlantic Coast of Florida. Founder & Medical Director - Tempus Hair Restoration, PA Chairman - American Society of Hair Restoration Surgery (ASHRS) Diplomate - American Board of Hair Restoration Surgery (ABHRS) since 2001 Member of the Board of Directors of the ABHRS Chief Editor - Hair Restoration Section - American Journal of Cosmetic Surgery Expert Medical Advisor - REUTERS Insight Teaching Faculty - Expert2Expert Europe

M.N. Barusco: None. TAKE HOME MESSAGE: The "No-Shave FUE" technique improves patient satisfaction and allows females to experience FUE procedures. ABSTRACT: INTRODUCTION FUE procedures have been gaining popularity among hair restoration surgeons and patients as a method of hair restoration surgery that avoids the creating of a linear scar on the donor site of the scalp, thus allowing the patient to potentially wear a shorter hair style without seeing the scar. One of the major problems with FUE, from the patients perspective, is the practice of shaving the entire (or portions of) the donor area before harvesting, in order to allow better visualization of the follicular units and increase speed of harvesting (fig. 1). Although the donor hair tends to grow back in a matter of a few weeks, patients are normally required to refrain from normal professional and social activities until their donor hair has grown back. This technique, which is loosely derived from Dr. Jim Harris Microstripping technique, avoids the shaving of the donor hair, allowing the patients to completely hide the scars from the FUE harvesting, resuming regular activities sooner (fig. 2 and 3). Differently than the Microstripping, however, it does not require trimming of the microstrips, which causes the patient to have the appearance of a bad haircut in the days following the procedure. It also allows females to become candidates for FUE procedures, since most women will not agree to have their scalp shaved for this procedure. TECHNIQUE (VIDEO) Patient is prepared for the procedure in the normal fashion. We utilize the Mini AlphaGraft automated FUE device for harvesting. The donor zone to be harvested is identified and marked on the patients scalp, making sure we do not harvest from potentially dangerous zones (nape of the neck and high occipital area). After sedation and local anesthesia have been achieved, we start going through the patients donor hair, which has been kept at its normal length, identifying the best follicular units for harvesting, depending on our goals and the patients donor characteristics. Once a follicular unit has been chosen, the hairs in that follicular unit are carefully trimmed with scissors, and the follicular unit is harvested. Another follicular unit is then chosen in the vicinity of the last one, in a random fashion, as to avoid the appearance of shaved areas. Like many other FUE techniques (manual or automated), about 15% of the available FUEs are harvested from any given area in one session. After the procedure is complete, the patient is able to leave the office with no bandage, with their donor site covered with his or her own hair. DISCUSSION This technique has proven successful in our practice, and popular with the patients who have decided on the FUE method. Below, a list of advantages and disadvantages of this technique: Advantages: Quicker return to normal activities Harvested donor sites are immediately concealed I am able to select, one by one, the strongest and best follicular units to harvest, including hairs with the ideal curl and caliber, since they are being chosen one by one in their original length, before being trimmed and harvested Allows me to see, in real time, the overall effect of the harvesting in the donor area, which helps avoid over harvesting in a particular area, which can result in an uneven and thinned out appearance Ideal technique for patients with prior strip harvesting scars who now are choosing the FUE method, since the linear scars from the previous method will not be seen as they would if shaved

Allows female patients to have the FUE method, since most were are willing to shave their head Patient satisfaction in improved Disadvantages: Longer procedure time More demanding on the staff CONCLUSIONS The No-Shave FUE technique is a viable alternative to the traditional technique of shaving the entire donor area. It has proven to be popular in my practice and much preferred by patients. DESCRIPTION OF THE PICTURES Fig. 1- Traditional FUE harvesting, with the donor hair shaved prior to the procedure (+/- 500 follicular units have been harvested from this patient) Fig. 2 - No-Shave FUE technique, immediately following the procedure (+/- 500 follicular units harvested) Fig. 3 - Same patient as Fig. 2, with his hair dry, ready to leave the office on the day of the procedure. Notice how the FUE sites are completely concealed by the patients existing hair.

123 How I Do a Preevaluation Test in FUE and How I Calculate My Transection Rate
Emre A. Karadeniz, MD. Transmed, Istanbul, Turkey. Dr. Emre A. Karadeniz is a plastic surgeon currently practicing in Istanbul, Turkey. He has devoted most of his work and research to hair restoration surgery for the last 3 years. His experience in FUE has led to more than one million graft extractions in this period. On the other hand he strongly believes in the value of FUT and makes his treatment plans using both techniques. E.A. Karadeniz: None. TAKE HOME MESSAGE: FUT is the safest technique in most hair restoration cases. FUE on the other hand can be a good alternative in a lot of cases and the only option in some cases, including patients who have an inelastic skin, patients who have had multiple FUT operations and patients who refuse FUT. Although FUE is a tiring procedure for the surgeon and the learning curve is steep, it can be very rewarding if the necessary time and dedication is given. The surgeon must be experienced enough to know when FUE can be chosen without too much sacrifice. He must be truthfull to himself and the patient when making the treatment plan and should base his decisions on donor patient safety. ABSTRACT: Introduction FUE continues to be a hot topic in hair surgery, although not much information has been available on how an experienced surgeon makes a preevaluation test for safety and efficiency in FUE. Transection rates, is another topic

that hasn't been covered in detail. This is an abstract for a surgical video where the author would like to demonstrate how he analyzes these parameters in his cases. Technique The surgical video shown will be of FUE sessions of the author which starts with the preoperative evaluation of a patients donor area. While the shaving of the donor area is performed, the determination of the safe donor area is discussed. After local anesthesia, the surgeon makes a preevaluation test while extracting the first couple of grafts. He explains considerations such as what punch size and surgical depth he is going to choose, how difficult the session might be and what the transection rate is going to be for that session. During the extraction, the surgeon takes 3 to 5 graft samples (depending on the number of grafts to be taken) of 100 grafts for the calculation of transection rates. The assistants take notes of the number of grafts (G), the number of intact hair follicles (H), and the number of transected hair follicles (T) within each sample. At the end of the operation the surgeon calculates the transection rate (Tx) in each sample using the following equation : Tx = (T x 100) / (T + H). The average rate of these samples gives him the estimated transection rate of the operation. Discussion FUE is a relatively new technique which has a longer learning curve than FUT. At the same time the number of reports are limited in which the experts explain how they evaluate the donor area, what the safe zone for extraction is, how they make a preevaluation test in FUE and how they calculate their transection rates. There are technical nuances that if the surgeon can notice and make the necessary adjustments, he can extract grafts with low transection rates, giving him grafts at comparable quality with grafts he would get from a strip. The author shares his experiences and explains the technical subtleties he believes are critical for a successful extraction. A preevaluation test is routinely performed at the beginning of the operation. The extraction is performed after the surgeon optimizes his technique. According to the authors experience, for a large session of 2500 grafts or more, a transection rate above 20% is poor, 15-20% is acceptable only if a strip was not possible, 12-15% is average, 10-12% is good, 510% is excellent and under 5% is impossible. There are many factors that can effect transection rates and these are discussed. The author uses very simple instruments; an engine with a hand piece installed with a sharp FUE punch. He believes that with patience and dedication it can be possible to be an FUE expert without needing very high technology instruments or robots.

124 How I Correct Too low Hairline Using FUE


Yi-Jung I. Lin, MD. Victoria Biotech, Taipei, Taiwan. Dr.Yi Jung (Irene) Lin is an aggressive aesthetic hair restoration surgeon from Victoria Fa-Hair Clinic, Taipei, Republic of Taiwan (R.O.C.) that she started in 2009. She has worked in cosmetic trichology profession for more than 9 years. She has been the Director and Chief Physician of Cosmetic and Hair Loose Department of Country Hospital, Taipei, since 2005. Dr. Lin received her hair transplant training in Kyungpook National University Hospital Hair Center, South Korea from 2007. She is the elected Chairperson of both Taiwan Society of Hair Restoration Surgery and Taiwan Trichologists Federation. Dr. Yi Jung (Irene) Lin has attended ISHRS since 2008.

Y.I. Lin: None. TAKE HOME MESSAGE: FUE could be an alternative method to do micrcpunch. ABSTRACT: Introduction: Young male patients often ask for a very low hairline, since they consider low hair line will show more young, handsome, and charming. But a too low hair line can sometimes to be a disaster in the future, in particular the case with a positive alopecia family history. When it comes to a second hair transplantation, sometimes we had better to take out the FU of the too low position, and build a new hairline. Here, the author presents a case report of cicatrial alopecia after hair transplantation two years before but come to clear blank and very low hair line. How the author removes the too low hair line and creates a new hair line by using FUE and micropunches. Technique: Our procedure will be presented by video . Discussion: Sometimes it's hard to decide where is the most ideal place of the hair line should be. Communicating with the patient regarding to family history and patients face outline before the hair transplantation is very important. The author will present how she does to correct a too low hair-line, including different decision depending upon the age and family history of the patient. First, if the age of the patient over 35 years old, with or without family history , the author will inplant some fine one hair FU behind the very low hair line to make up the big gap between the low hair line and the hair loss behind. Second, if the patient is very young , even lower 30 years old, the author will consider to take off the FU of the very low hair line and construct a new hair line rather than supply more FU on the clear blank. Especially if the patient has a positive family history of hair loss. It's a more save way to preserve more FU for the alopecia change in the future.

125 Moderator Introduction and Difficult Cases II Panel


James Vogel, MD. Lutherville, MD, USA. 74-78 MD Degree- Mt Sinai School of Medicine, NY, NY 78-83 General Surgery Residency and Chief Resident, UNC , Chapel Hill, NC 83-87 Plastic Surgery Residency, Johns Hopkins Hospital, Baltimore, Md 96-97 President , ISHRS J.E. Vogel: None.

126 Panelist for Difficult Cases II


Robert M. Bernstein, MD. Columbia University, New York, NY, USA. Robert M. Bernstein MD, MBA, FAAD, ABHRS is a Clinical Professor of Dermatology, Columbia University in New York. Dr. Bernstein is a pioneer of Follicular Unit Transplantation and Follicular Unit Extraction and is an early adopter of the ARTAS System for Robotic-FUE. R.M. Bernstein: None.

127 Panelist for Difficult Cases II


Sheldon Kabaker, MD. Otolaryngology, University of California San Francisco, Oakland, CA, USA. Dr. Kabaker has written multiple chapters in textbooks and articles in medical journals on plastic surgery. He also lectures internationally to medical groups and has taught courses on hair replacement surgery since 1976. Dr. Kabaker has the longest ongoing experience in the U.S. with the Juri flap operation and introduced flap and scalp expansion surgery to many notable hair restoration surgeons. His practice presently emphasizes facial rejuvenation surgery, hairline lowering and forehead reduction for women and FUT. He is a past president of the ISHRS (1998-99). S. Kabaker: None.

128 Panelist for Difficult Cases II


Russell Knudsen, MD. Knudsen Clinic, Double Bay, Australia. Russell Knudsen practices full-time in hair restoration surgery in Australia and New Zealand. He has 30 years experience in the field and is a past-President of the ISHRS. R. Knudsen: None.

129 Moderator Introduction, Advanced Surgical Videos II


John P. Cole, MD. International Hair Transplant Institute, Alpharetta, GA, USA. Private Practice, Alpharetta, GA J.P. Cole: None.

130 New Stick-and-Place Shiao Micro-Implanter


Tseng-Kuo Shiao, MD1, I-sen Shiao, MD2. 1 DR TK LLC, Overland Park, KS, USA, 2FuFa Clinic, Taipei, Taiwan. Dr. Tseng-Kuo Shiao is a graduate of the University of Kansas School of Medicine. He has been working with Dr. I-sen Shiao on various medical devices for years, joined Dr. I-sen Shiao's practice in 2006, and has his own practice in the Kansas City metropolitan area. Dr. I-sen Shiao is the director of FuFa Hair Restoration Clinic in Taipei Taiwan. He first became a hair restoration surgeon in 1986. Since then, he had performed thousands of cases in Taipei, Taiwan. As a team, the senior and junior Dr. Shiao had worked on several innovations in hair restoration surgery such as the Shiao micro-implanters, depth control sleeves, laser level hair line design, and the use of advanced but inexpensive LED as cross-polarized surgical lights. T. Shiao: Ownership Interest (royalty, patent, or other intellectual property); patent pending. I. Shiao: Ownership Interest (royalty, patent, or other intellectual property); patent pending. TAKE HOME MESSAGE: The simple new stick-and-place version of our micro-implanter offers an inexpensive alternative from other stickand-place implanter. ABSTRACT: Because of the difficulty in placing, through the years, Drs. Choi, Kim, Rassman, Boudjema, Rose, Anaba, Vasa and many others including my father and I had developed various types of implanters. We first reported our Shiao micro-implanters in 2006. These disposable implanters are made of plastic and consist of two parts: a pushrod with a stopper at its tip that prevents the grafts from inserted too deep and a tube with a slit opening for easy graft loading. (See Picture 1)

Picture 1. Original plastic micro-implanter As the popularity of FUE rose, fragile FUE grafts lead to increased utilization of implanters and an expanding implanter market. Most of them are of the stick-and-place type. In our clinics, doctors create all recipient sites before assistants place the grafts. Our plastic micro-implanters work extremely well for the past 8 years. We also endured a period of time when 3 experienced assistants left in quick succession. New assistants were quickly trained, which proved the implanters advantage in terms of personnel turnover. When creating our new stick-and-place micro-implanter, we borrowed heavily from our original micro-implanter. (Picture 2 and 3). Differences include the utilization of a grooved needle instead of plastic tubing and metal instead of plastic pushrods. The new micro-implanter's simple design allows it to cost only a fraction of other stick-and-place implanters. We are currently working with manufacturers to create very thin walled (like that in an FUE punch) needles. We are also investigating a twin-needle micro-implanters. The results will be discussed at the conference.

Picture 2 and 3. Stick and Place micro-implanter Using the stick and place version of our micro-implanter is similiar to using our original plastic micro-implanters. After creating the site with the needle part of the micro-implanter, graft is pushed into the newly created site by the pushrod. While holding onto the bottom of the pushrod with the pushing finger, The needle is withdrawn and the graft is left in place by the micro-implanter (Picture 4)

Pictures 4 In vivo testing of the new micro-implanter Our preliminary findings indicate that it is feasible to make a stick-and-place micro-implanter based on the same principles of our original plastic micro-implanters. We will report the final product at the conference.

131 Novel Implanter Technique that Enables More than 1600 Grafts in 1 Hour with Dense Packing
Jae Hyun Park, MD. Dana Plastic Surgery Clinic, Seoul, Korea, Republic of. Plastic Surgeon, Private practice in Dana Plastic surgery clinic, Active member of Korean society of plastic and reconstructive surgery, Active member of Koren society of Aesthetic Plastic surgery J. Park: None. TAKE HOME MESSAGE: There is no royal road in Hair surgery. ABSTRACT: A. Introduction Implanter technique is a popular method in Korea. Implanter technique has the advantages of better angle and direction control and shorter operative time compared to the S & P. In case of the implanter techniques compared to slit technique, disadvantages are such as more popping-out, difficulties to make dense packing, more bleeding, etc. But I think that the biggest issue is, not being able to use the implanter properly. However, until now, In implanter transplantation method, basic instructions in using the implanters such as how to grip the implanter, posture, setting the proper position of the operator, team-work system, and detailed advanced techniques to reduce popping and make dense-pcking have not been rarely existed in the literature. This author implants 1600-2000 grafts per an hour without popping or bleeding with very satisfactory results. The author has received many questions form many other doctors regarding the way of the surgery how I use implanters in implanting hair without popping and bleeding. Therefore, I would like to introduce the way of implant operations based on the experience of the last 5000 cases, implanting quickly, accurately, denser, without bleeding or popping. B. Technique I usually place fast and accurately 1600 each graft transplantation per 1 hour by using implanter. The know-how is as follows: 1. 2(3)-1-1 system (2(3) loaders, 1 passer, 1 physician system) 2. A traumatic implanter handling technique 3. Rectilinear movement of implanter tip 4. 3 finger grip technique (basic instructions in position, grip, controlling and handling the implanter device) 5. Implanting order (posterior->anterior or anterior->posterior, left to right) 6. Gradual angle & direction change 7. Distribution 8. Sharp implanter tip 9. Place the bevel of implanter tip anteriorly

10. Segmental transplantation timing control (transplanted to adjust the timing differently by part, know-how) (according to epinephrine effect time) 11. Conversion to Stick & Place or Notouch technique, Both-hand Notouch technique in case of severe popping or bleeding 12. High magnifying loupe with LED assisted We will discuss the details of above know-hows in the meeting with video presentation. C. Discussion In hair trasplantation surgery, the importance of shortening the operation time cannot be overemphasized. The advantage of a fast surgical procedure are as follows: 1. Less bleeding 2. Better visual Op. field, less traumatic 3. Better microcirculation recovery, less scarring 4. Higher survival rate 5. Easier to make dense packing 6. More comfortable for Pt. 7. Less use of local anesthetic agent Graft insertion of the representative two ways are the S & P and Implanter method. The implanter technique is a method which gives the advantages of shorter operative time and better angle, direction control compared to the S & P, But many doctors do not want to use it because they think implanter produces more popping, more bleeding and difficult to make dense packing. But, I think that is a very big part of reason that doctors don't know how to use the implanter properly. This author would like to introduce the way of implant operations based on the experience of the last 5000 cases, implanting quickly, accurately, denser, without bleeding or popping.

Implanter Technique
Novel know-hows in implanter technique that enables more than 1600 grafts in 1 hour with dense packing; 5000 case experience
Jae Hyun Park M.D. ISHRS Meeting, San Fransisco, 2013 DaNa Plastic Surgery Clinic Seoul, Korea 1-2 loader + 1 physician, communication zone 2(3) loaders + 1 passer + 1 physician

Implanter; 1 step operation Simultaneous incision & insertion


Previous implanter technique system Parks Op. system : 2(3)-1-1 System

Factors influencing graft pop-out


1. Tissue factor hardness of skin (soft, mushy <-> hard) elasticity of skin (elastic <-> rigid) (elastic recoil) texture of skin (rubbery <-> smooth, tender) thickness of skin (thin <-> thick) 2. Mechanical factor (surgeon factor) implanter tip condition (sharpeness, diameter) method of insertion (slit, notouch, implanter) implanter handling skill skill level of Op. team 3. Local environment factor bleeding tendency scarring d/t previous op. location of implanting area pattern of preexisting hairs 4. Etc Pt's medical Hx (liver dis. CV disease, Soft tissue disease,,etc) PO med. d/t other disease (aspirin, heparin, wafarin) Op. time sex

12 know-hows for fast and accurate more than 1600 grafts placing per 1 hour using Implanter through personel >5000 case experiences 1. 2(3)-1-1 system (2(3) loaders, 1 passer, 1 physician system) 2. A traumatic implanter handling technique 3. Rectilinear movement of implanter tip 4. 3 finger grip technique 5. Implanting order 6. Gradual angle & direction change 7. Distribution 8. Sharp implanter tip 9. Place the bevel of implanter tip anteriorly 10. Segmental transplantation timing control (according to epinephrine effect time) 11. Conversion to Stick & Place, Notouch technique, or Both-hand Notouch technique in case of severe popping or bleeding 12. High magnifying loupe with LED assisted

1. 2(3)-1-1 system
No communication zone between physician and loaders A passer is situated next to the physician instead of communication zone and passes the loaded implanter to the surgeon. At this time, the surgeons eyes are fixed on operation field and surgeons hand move only within 5cm. This system reduces surgeons fatigue and enables fast and accurate graft placing. Accurate and fast movement and control allow to carry out operations without popping or bleeding. At that time, the "eye-hand coordination" is important. It is the concept that the accurate, fast and delicate operation can be possible by working with the hand and eye looking at the same position always.

1. 2(3)-1-1 system
The passer takes out the implanter that completed transplant with the right hand from the surgeon's hand and passes the implanter held in the left hand in advance to the surgeons hand. While the surgeon transplants a graft, the passer prepares the next loaded implanter. A skillful passer can check if the graft is loaded accurately into the implanter tip in this short moment and push in a protruded hair follicle slightly or take out a wrongly loaded implanter and change it with the next loaded implanter.

2. 3 finger technique
Only three fingers of thumb, index & middle finger for the grip of implanter These three fingers are the most move free finger combinations. The insertion angle, direction can be controlled fast and accurately. More advantageous than using the 4th and 5th finger together in acute angle insertion, esp. in temple area, too.

3. Rectilinear movement of implanter tip


Very basic rule, but very important technique! Limit movement of finger joint, metacarpal joint, and wrist joint Only use the elbow and shoulder joint to make rectilinear movement of implanter Rationale of advantages and necessity of rectilinear movement 1. Avoid dimpling scar at skin penetration site 2. Faster wound healing, 3. Better microcirculation recovery, 4. Reduces push-out pressure to adjacent grafts 5. avoid popping, avoid scarring 6. Reduces bleeding & tissue trauma 7. better visual field 8. enables faster op. 9. higher survival rate

Implanting Order must be posterior to anterior, left to right (if the Doctor is right-handed). Push-out pressure that contributes to popping-out is much greater in anterior direction and previously placed grafts in posterior portion is less affected by push-out pressure due to offset of vector of pushout force It is better to secure visibility on Op. field since bleeding flows downward even if some bleeding occurs.

4. The authors general transplant order

5. Segmental transplantation timing control (transplanted to adjust the timing differently by part according to epinephrine effect time)

The duration of epinephrine should be considered for the duration. Vasoconstriction effect of Epi. usually persist for 30 minutes. But the time to start to show the effect of epinephrine and the effect disappearing times are different in the scalp by the parts. In addition, the severity of Tachyphylaxis to Epinephrine is different by parts.

5. Segmental transplantation timing control (transplanted to adjust the timing differently by part according to epinephrine effect time) For example, Epi. in the mid-frontal area, the effect arises slowly (about 5 minutes after injection) and disappear faster than other area. So it will be different by the overall transplant scope and quantity, so the transplant order should be set by dividing the parts which can be transplanted for about 30 minutes by the individual skill considering the Epi. effect time. After a nerve block and local anesthesia injection, start transplanting from the back of the M area on the right side (or the left side) for the first about 5-10 minutes -> Transplant the mid-frontal area after 5-10 minutes. -> Transplant anterior to the part of previous transplanting area again. -> Epi. injection in the additional parts after 30 minutes. -> Restart transplant.

6. Atraumatic implanter handling technique


Never do forceful implanter grip! Grip the implanter with only 3 fingers very gently and softly. If the skin is rigid or rubbery and if the resistance that penetrates the skin is great, an excessive force is added to the finger gripping the implanter without knowing. As a result, a deeper and wider slit hole is created. Also, if the implanter tip contacts the periosteum, often an implanter tip injury occurs. If resistance is great when the skin is penetrated, you should check if vellus hair is under it, and avoid giving more power to the finger tip excessively, and instead push it in gently as if you put slight force evenly to the overall big muscles of elbow and biceps while keep no movement of the wrist and finger joint soft and smooth and concentrate the force on one point of the implanter tip to avoid a trauma, bleeding or popping.
1+2+3=4

7. Gradual angle & direction change


Abrupt change of angle or direction can make more popping, injury to adjacent or previously placed grafts and more see through appearance

8. Distribution
It is important to control the graft distribution very delicately not for the hair to look overlapping in any directions 3-dimensionally viewed from the front, side and above. At the same transplant density, there are tighter visible effects, and the vector of push-out pressure occurring in hair follicle transplant is dispersed, which has an effect of reducing popping.

9. Sharp implanter tip


One of the most fundamental concepts Change the implanter tip immediately when you feel the tip being blunt or worn out Place the bevel of implanter tip anteriorly

10. Free conversion of transplant method


Basically, S&P, No-touch technique, Both-handed slit technique and implanter technique should be used properly for the situation. I think that various transplant methods can be applied to each part even in one person depending on individual scalp and hair characteristics. If the several rules described earlier were observed, popping is really very rare in transplant using an implanter. More than 50-60 graft/ can be transplanted sufficiently without popping or survival rate impairment. Nevertheless, this is a very rare case, but if there is popping or bleeding, the operation can be completed simply by converting to S&P, No-touch technique and both handed slit-technique.

10. Free conversion of transplant method

11. Place the bevel of implanter tip anteriorly


Inclining the bevel forward reduces damage on the tip.

12. Convenient operating room equipment and systems


High magnifying loupe with LED assisted: Use of LED assisted Loupe is necessary for clear visibility. Electronic op. bed: Make it easy to adjust the pitch without having to keep an eye on in the surgical site by positioning the pedal to adjust height under the feet. Nurse call electronic bell: Originally, it is from the bell for calling the waiter at the cafes and restaurants. It should be attached on the side of the foot pedal to adjust height of medical surgical bed, so it makes the surgeon calls the circulating assistant nurse during the operation without keeping an eye off the surgical site. It has an affordable price and a very convenient method.

Thank you very much.


Jae Hyun Park M.D.
Dana Plastic Surgery Clinic Seoul, Korea www.danaps.com jay8384@naver.com

132 Importance of Depth Control when Transplanting Hairs and the Best Way How to Use OKT (Optimally Kept Transplanter) Implanter
Kun Oc, MD. Oc Kun hairline hairtransplant center, Seoul, Korea, Republic of. Kun Oc MD worked in hair transplant centers Annexed to the Plastic Surgery Clinics which are one of the largest plastic surgery centers in Asia from 2005 till 2011. From 2011 he works in his own clinic named Oc Kun Hairline hair Transplant Center. He has been devoted only to hair transplant since 2005. He has his own donor harvesting technique, hairline design method and transplant know-how using implanter that can achieve better operation results. After all the trials and errors he invented OKT, the newly developed implanter which will change the history of hair transplantation using implanter. K. Oc: Ownership Interest (royalty, patent, or other intellectual property); OKT (Optimally Kept Transplanter). TAKE HOME MESSAGE: This abstract is almost enlightenment rather than a simple lecture for all doctors using implanters, but even experienced doctors dont seem to recognize this importance. Not just some but all the contents in this abstract are very crucial in hair transplantation using implanters and this lecture will be an inspiration to many doctors. The author is convinced with himself that OKT, the newly developed implanter, will change the history of hair transplantation using implanter. ABSTRACT: Introduction Last year the author presented 2 abstracts: One is Golden Rules to be Observed for Enhancing the Survival Rate in Hair Transplant Using a Choi-Hair Transplanter and the other is Newly Developed Hair Transplanter OKT (Optimally Kept Transplanter) that Improves the Hair Survival Rate. The papers are almost enlightenment rather than simple lecture for all doctors using implanters, but even experienced doctors dont seem to recognize their importance.The author is going to show you his surgical video the best way how to use implanter including OKT and how to improve the operation result with the depth control of implanted hairs. Objective What is most important but easily neglected in using a hair implanter is the adjustment of the depth of transplanted hair. The author is going to show the characteristic of hair implanter affecting the depth of transplanted hair, and operation know-how for producing the best effect in operation using OKT. Method OKT is a sensational tool making up the weaknesses of the existing Choi-implanter, but it is difficult to yield good results even with the best tools if they are not properly used. Here, the author explains his own know-how to get the best results with OKT. 1. The length of needle is adjusted according to the depth of hair root to be transplanted in each patient. As in photograph M1a, M1b and M1c, the best length is that at which the hair follicle to be planted is visible slightly at the beginning part of the bevel from the frontal view. Different from the length of the implanter needle, the depth of the core should be the same regardless of patients. The optimal depth is that at which when the button of the OKT is pressed its level is the same as the end of the OKT as in M2. When a hair is loaded on the OKT, the optimal depth is that at which the root of the hair is visible slightly in the bevel, and the hair follicle should not be visible from the side. See M1a and M1b.

2.

3.

4. 5.

6.

With regard to the direction of transplantation, it seems helpful not only for cosmetic purpose but also for the survival rate to align the direction of transplanted hairs with the direction of existing hairs as in M4. For the optimal position in which the OKT needle enters the scalp, as in M5a, make the bevel point at the ceiling to make a small laceration on the scalp using the tip of the OKT needle, and rotate the OKT half way around while thrusting the needle in the desired direction and angle. At the final position, the OKT needle bevel should point at the floor as in M5b. It is also important when to press the button on the end of the OKT. It should be pressed at the point of time when the OKT needle has been inserted completely into the scalp and then drawn out and the pressed scalp becomes even with the original surface of the scalp as in M6.

Results Its difficult to discuss the survival rate. But, for your reference, at the authors hospital where hair transplant is conducted using OKT, from October 10th 2011 to February 28th 2013, only 3.06 % which is 12 patients among 392 who received the first surgery using OKT requested another session for increasing hair density in our clinic. Discussion The explanation of the reason why one should follow the method forms 1~6 is omitted for space in this paper but authors surgical video will explain the reason. The author refers the reader to his discussion in Golden Rules to be Observed for Enhancing the Survival Rate in Hair Transplant Using a Choi-Hair Transplanter, presented at the Bahamas in 2012. What the author wants to account for here is why and how much important the adjustment of the length of the needle and the depth of the core is when using OKT or other implanters. The following are experiences the author has had when the length of the needle was longer than that of the actual hair follicle as in picture D1a. 1. 2. 3. Bleeding increased. Popping increased. (Doctors who operate in the slip method are perhaps unable to recognize this.) The hair survival rate decreased due to damages to the blood bed under the implanted hair. One can easily predict blood vessel damages and the following decrease in the hair survival rate just based on the fact that bleeding increases.

Even in cases of severe bleeding or popping during a surgery, the author was successful many times in getting them considerably reduced with the length of the implanter needle shortened only by 0.3 mm. In case the needle of OKT is shortly adjusted than the hair follicles as in D1b. The transplanted hair can be placed shallower than the reference depth and part of it may be exposed to the air or the hair follicle is crushed and makes the hair curly. What you may often experience and the only thing that you are able to observe with your naked eyes during a surgery is the depth of the core adjusted deeper than the end of the OKT as in D2b. In this case the transplanted hair is placed shallower than the reference depth of the scalp, and part of the root is exposed to the air. In a case where the core is adjusted protrusively as in D2a, the hair root is pressed and crushed, then a trauma can happen and the hair is highly likely to be curly but it cannot be found during a surgery,. The existing implanters other than OKT can adjust the length of the needle and the depth of the core, but cannot be fixed. Due to this, their length and depth keep changing during a surgery but cannot be observed in most cases. For this reason, you cannot notice that you are implanting hair in the wrong depth, and even when you recognize the issue, it is not a scientific method and only gives more damages to hair follicles to correct things after making them wrong. Education for nurses who will participate in surgery is as important as OKT because you can yield as bad results as when the needle or core of OKT is not adjusted, if hairs have not been properly loaded into OKT even though you have implanted hair correctly in the authors own method using OKT. Conclusion The author believes that the papers he has published for the recent two years have upgraded the standard of the

hair transplant surgery using implanters about 20 years after the advent of Choi Implanter. Having focused on the adjustment of the depth of implanted hair for the recent 4 years and used OKT for one year and a half, the author has confidence that his method of surgery is the greatest and best in the hair transplantation surgery using implanters. Now, I would like to leave the job of proving that for you.

133 FUE Hair Transplant Using NeoGraft and Implanter Pens


Michael Vories, MD. Carolina Hair Surgery, Mount Pleasant, SC, USA. Michael Vories, MD practices exclusively Follicular Unit Extraction (FUE) hair restoration surgery in South Carolina. He is a member of the Board of Directors of the American Board of Hair Restoration Surgery and is the Chairman of the ABHRS Oral Examination. He has administered the Oral Examination for the ABHRS for the past 5 years both in Houston and the International Exams in Capri, Italy, Bangkok, Thailand, and Seoul, South Korea. He is the current Chairman of the Admissions Committee of the ISHRS. He has been practicing hair restoration surgery for the past 10 years. M. Vories: None. TAKE HOME MESSAGE: FUE hair transplant surgery is a safe and consistently effective alternative for hair restoration patients. Using the NeoGraft machine for extractions and Hans Hair Implanter Pens for implantation, this 2600 graft procedure can be accomplished with one physician and one assistant in a one day setting. ABSTRACT: Introduction: Surgical Video of FUE hair transplant procedure. Technique: FUE hair transplant is performed with the NeoGraft machine for extractions and Hans Hair Implanter Pens for implantation. Discussion: FUE hair surgery has benefits for patients who desire a hair transplant, but wish to avoid the linear donor scar from FUT surgery. This procedure is a surgical procedure, and should only be performed by a licensed physician. The procedure is staff efficient, and this video details a 2600 graft procedure performed in one day with one physician and one surgical assistant.

134 Speeding up the FUE Routine: How to Achieve 2000+ Grafts Per Day by Combining Motorized FUE with Implanter Pens - A Video Presentation
Conradin von Albertini, MD. Riverside Center, Zurich, Switzerland. Dr. Conradin von Albertini runs a hair restoration clinic in Zurich, Switzerland. After residency in general and plastic surgery, he has spent the last eight years specializing in hair restoration. He performs FUT and FUE

procedures and has a special interest in novel surgical techniques and instruments. On an international level, he is a member of the ISHRS, the ESHRS and the AACS. C. von Albertini: None. TAKE HOME MESSAGE: We combine motorized graft harvesting (PCID) and graft placement with implanter pens. This enables us to routinely perform FUE procedures of 2000+ grafts per day in very reasonable time. ABSTRACT: Introduction: During FUE procedures, hair restoration surgeons need to overcome two major restrictions as compared to FUT. Firstly, they are more limited by the number of possible transplants per day. Secondly, they must minimize mechanical damage to the delicate grafts. However, with the right surgical techniques, it is possible to perform highquality, large-scale FUE surgeries. In this video presentation, we will show how to routinely achieve FUEs with 2000 or more grafts (FUs) per day by combining two proven hair restoration techniques: the motorized graft harvesting and the use of implanter pens for the graft placement. Technique: We have optimized a surgical protocol that combines harvesting the FUs with the PCID (Programmable Cole Isolation Device) and placement with implanter pens. We will present the techniques by observing a recent surgery. We will focus on a gentle step-by-step approach of graft harvesting using sharp, thin-walled punches followed by graft implanting with implanter pens. We will show the tumescence-free recipient site preparation. We will also present some recent results. Discussion: To our knowledge, very few hair restoration surgeons use this particular combination of PCID motorized harvesting and implanter pens. It facilitates large-scale FUE procedures while keeping a high standard of graft handling. It combines the following advantages of both techniques: Motorized harvesting with the PCID is a precise, gentle technique with a low transection rate (calculated according to True, 2011) and almost no FU burials. It is also a very fast procedure with extractions of 600-1000 FUE per hour. Therefore, FUE procedures with 2000 grafts or more per day are typical. By using implanter pens, it is possible to achieve an implantation rate of up to 500-800 grafts per hour while minimizing mechanical damage and popping. Moreover, it enables the physician to maintain tight control throughout the surgery. The major shortcomings of this combination are mostly related to the manpower: (1)It requires a highly skilled, well-functioning team to ensure swift graft extraction and handling. (2)The implanter pens demand a very high and intense physical workload for the physician throughout the surgery. (3)There is a steep learning curve, as every step of the procedure needs to be optimized to maximize both speed and quality. Combining these two techniques has enabled us to offer FUE as an alternative to FUT with a similar number of grafts and comparable results. As a result of this development, as well as due to changing demand, the share of FUE procedures in our clinic has risen from 10% to 90% over the last two years. References: True, Robert H. (2011): Proposal of Definition of FUE Transection, ISHRS Scientific Meeting, Anchorage

135 My Performance in Large FUE Sessions


Luis R. Trivellini, MD. Hair Again, Asuncion, Paraguay. L.R. Trivellini: None. TAKE HOME MESSAGE: Indicate FUE in advanced degrees of baldness ABSTRACT: This is a surgical video summary of follicular unit extraction (FUE) in which the systematic sampling of major surgery sessions was in advanced degrees baldness previous incisions performed in the coronal region with a punch of 0.70 mm, using the same apparatus with which we extractions. We started FUE, with two handpieces with a punch with little edge that allows me to leave the graft intact, almost loose in his bed. Simultaneously an assistant is taking grafts obtained and implanted directly into the incisions previously made When finished remove the drives to cover the crown, our assistant and implant more than 50 percent of them, we stop and we deliver the units to complete its work, from this point, we are dedicated to removing the units for the frontal region, when we completed the extraction, the crown is already implanted. Sat the patient and implant the frontal region, making stick and place. To address a large FUE session, you must have a well planned strategy and try to execute it with precision, avoiding unnecessary movement of the surgery team. When making incisions in the coronal region prior to the punch, we facilitate the insertion of the graft by our assistant and by that time we won, on the other hand to remove the compression (hypoxia) on graft survival and improve if we increase the Soon we delay to implement the units in the crown, we get a very high percentage of survival and thus can offer a solution to patients with large bald spots, especially because we optimize the extraction to be able to use almost all units taken as the transaction rate we place around 2%. Finally it is important to note that the fact of working with two handpieces simultaneously allows us to markedly increase our harvest.

136 Graft Harvesting in FUE Giga Session (>3500 FU grafts)


Kavish Chouhan, MD. DERMACLINIX-The complete skin and hair solution center, NEW DELHI, India. Dr. Kavish Chouhan is the Director of DERMACLINIX. He has done his MD in Dermatology from the prestigious All India Institute of Medical Sciences (AIIMS), DELHI. He has experience of successfully performing >1000 hair transplant procedures by FUE. He specializes in doing giga (>3500 FU) sessions of hair transplantation by FUE. He is amongst the pioneers of PRP treatment for hair fall in INDIA. He has published worlds first case of body hair transplantation in Vitiligo (JCAS,2013). He has several publication in international indexed journals like Lancet, British Journal of Dermatology (BJD), Clinical & experimental dermatology(CED) etc. He has been awarded Best young dermatologist in CUTICON 2010, DELHI & Best poster award in DERMACON, 2011. He also has

presented his work in World Congress of Dermatology at Seoul, KOREA in 2011. Dr. Kavish chouhan is a qualified member of ISHRS (International Society of Hair Restoration Surgery) since 2010. D. Chouhan: None. TAKE HOME MESSAGE: Key factors in performing Giga sessions with FUE are 1.Using Powered FUE 2.Using Sharp punches (we prefer 0.8mm punches) 3.Using good quality loupes and adequate lighting (LED) 4.Good tumescence should be achieved 5.Simultaneous drilling, extraction & implantation 6.Rotation of doctors and technicians to prevent fatigue ABSTRACT: Hair transplantation offers a permanent, living solution to lost scalp hair. Modern Hair transplantation involves harvesting permanent hair-bearing skin from the back and/or sides of the scalp (donor area) by cutting out a strip (FUT=FOLLICULAR UNIT TRANSPLANTATION/STRIP METHOD) or by directly removing individual follicular units using special equipments (FUE=FOLLICULAR UNIT EXTRACTION). As no cutting and suturing is required in FUE method the cosmetic results are excellent in the donor area with NO visible scarring. The Downtime is significantly less as compared to Strip (FUT) method. FUE method is considered to be a very time consuming method and most surgeons do not dare to do GIGA SESSION (>3500 FU) with FUE but in recent times with advancement in equipments and skill now it is possible to do Giga session with FUE. To achieve this we combine drilling and graft extraction so as to achieve a extraction rate of ~1000-1500 FU/hour. In some case graft implantation is also done simultaneously especially in vertex area. Graft extraction from scalp and body hairs can also be done simultaneously to save time in selected cases. We now on a regular basis perform giga sessions with FUE and have implanted even upto 6000 FU with FUE in a single day. I would like to share the problems which arises during such procedures (>3500 FU) and ways to deal with them. Key factors in performing Giga sessions with FUE are 1.Using Powered FUE 2.Using Sharp punches (we prefer 0.8mm punches) 3.Using good quality loupes and adequate lighting (LED) 4.Good tumescence should be achieved 5.Simultaneous drilling, extraction & implantation 6.Rotation of doctors and technicians to prevent fatigue

137 Overview of Live Patient Viewing Cases


Jerry Wong, MD. Vancouver, BC, Canada. Jerry Wong MD, is a graduate from University of Alberta medical school. He is currently doing full time hair transplant at Hasson and wong in Vancouver, Canada. He developed the lateral slit technique, and is a past golden follicle recipient. J. Wong: None. TAKE HOME MESSAGE: Overview of Live Patient Viewing Cases ABSTRACT: Overview of Live Patient Viewing Cases

POSTERS

S cientific P oster P resentations


P01
Correction of Improper Female Hairline Restoration Procedures - Ji-sup Ahn, MD, PhD Hair Density Count A Comparative Study Among Different Types of Densitometer - Prapote Asawaworarit, MD Real Data of FUE Transection Rate in Asians - Jisung Bang, MD Prophylactic Antibiotic Use in Hair Transplantation Surgery Indications and Recommendations - Scott A. Boden, MD Role of Body Hair Transplantation in Vitiligo - Kavish Chouhan, MBBS Use of Glutathione as Part of Holding Solution and its Effect in Oxidative Stress during Hair Transplantation - Mrcio Crisstomo, MD Combining Follicular Unit Extraction and Strip Surgery in Secondary Procedures to Achieve More Follicular Units The Management of Donor Area and Previous Scar - Mrcio Crisstomo, MD How to Shorten Outside Body Time in FUE Megasessions - Aman Dua, MD, MBBS Humanism in Hair Transplant Marketing - Kapil Dua, MD Our Covering Method for Shaved FUE Donor Area - Katsumi Ebisawa, MD, PhD Synthetic Fibers Implantation: To Ban or Not To Ban - Shady H. El-Maghraby, MBBCh Scalp Biofilm, Hair Loss and Associated Chronic Diseases - John E. Frank, MD Details That Make a Difference in Eyebrow Transplantation - Christine G. Guimaraes, MD Technical Aspects for Optimizing the Results of Donor Area Scars - Christine G. Guimaraes, MD

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A New Ergonomic Microscope for Hair Transplantation - Robert S. Haber, MD Hair induction by transplantation of human follicular stem cells, dermal papilla cells or their combination with or without laser pretreatment in Nude Balb/c mice - Fariba Jaffary, MD, PhD Total Hairline Correction in Female Patients - Jae Heon Jung, MD The Effect of Electromagnetic Field Based Multimodality Treatment on Patient Undergoing Hair Transplantation - Hyo Kang, MD The Advantages of being able to do FUT and FUE in Making a Treatment Plan - Emre A. Karadeniz, MD Advantages and Disadvantages of FUE Using ARTAS SYSTEM for Japanese - Keiichiro Kasai, MD Non-Absorbable Buried Sutures in HT to Minimise Donor Scars - Manoj Khanna, MD An Easy Method to Minimize Transection with Fine Blade Angle Adjustment in FUSS - Jino Kim, MD Differences in Preferences for Female Hairline between Doctors and Patients - Ju Yong Kim, MD Restoration of Hair-Inducing Capacity of Cultured Human Dermal Papilla Cells by Three Dimensional Spheroid Culture - Moonkyu Kim, MD, PhD Body Hair Transplant (BHT) A Good Supplement to Traditional Hair Transplantation - Jerzy Kolasinski, MD, PhD Surgeon and Trichologist Collaboration A State-of-the-Art Contemporary Hair Restoration Surgery - Jerzy Kolasinski, MD, PhD Optimization of Hair Transplantation Using FUE Method - Malgorzata Kolenda, MD Micropigmentation: Camouflaging Scalp Alopecia and Scars in Asians - Seung Yong Lee, MD

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Hair Plastic Surgery Not Only Restoration - Yi-Jung I. Lin, MD Extended Hair Transplant: Old Techniques with a New Combination - Humayun Mohmand, MD Embryonic-like Cell-Secreted Proteins Induce Hair Growth in a Phase I/II trial in Male Pattern Baldness - Gail K. Naughton, PhD Effects of Low-Level Laser Therapy (LLLT) on Cell Proliferation and InsulinLike Growth Factor-1 (IGF-1) Secretion of Dermal Papilla Cells from Balding Hair Follicles - Ratchathorn Panchaprateep, MD Clinical Importance of Parietal Whorl in Male Pattern Baldness - Jae Hyun Park, MD Using Single Follicles Divided from Multihair Follicular Unit for Natural Result in Asians - Soo-Ho Park, MD Complication and Solution for Severe Folliculitis after Eyebrow Transplantation - Damkerng Pathomvanich, MD Less is More Approach A Novel Hair Transplant Approach for Patients with Extensive Hairloss (NW 6/7) - Arvind Poswal, MBBS A Mathematical Way of Graft Estimates in a Patient Customized Manner - Arvind Poswal, MBBS Understanding the Attitude and Behavior of Hair Loss Patients a Review of 2000 Cases - Rajendrasingh J. Rajput, MCh The Scientific Basis for Diet Modification for Hair Loss Patients - Rajendrasingh J. Rajput, MCh Combination Techniques for Donor Strip Wound Closure - Hyo Sub Ryu, MD, PhD Instrument Cleaning Scalp - Sandro N. Salanitri, MD Hair Removal Laser for Creating Fine Hairs - Kyle Koo-Il Seo, PhD

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Low Anabolic Profile in Assessing a Patient's Overall Hair Loss Program and S.H.A.P.I.R.O. Chart - Lawrence Shapiro, DO New Approaches to the Surgical Treatment of Secondary Cicatricial Alopecia - Alexander E. Shestopalov, MD Optimizing Graft Distribution and Density in Giga Session of Hair Transplant - Suneet Soni, MBBS Vertex Accentuation in Female Pattern Hair Loss in Asians - Rattapon Thuangtong, MD

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A Pilot Study of the Efficacy of 5% Minoxidil Solution Combined with Oral Chelated Zinc Supplement in Treatment of Female Pattern Hair Loss - Rattapon Thuangtong, MD Minimizing the Postoperative Pain in Patients Undergoing Strip Surgery - Asad Toor, MD A Retrospective Study on the Quality of FUT Scars with a Related Patient Satisfaction Survey - Anastasios Vekris, MD Are Postoperative Antibiotics Necessary in FUE Procedures? A Double-Blind Prospective Study - Anastasios Vekris, MD Acute Telogen Efluvium in Women: A Retrospective Review of 503 Cases - Carlos C. Velasco, MD

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Widow's Peak Type 2 to Camouflage Scar - Viroj Vong, MD Antithrombotic Medications in Hair Transplantation: Safe Operation in Coronary Heart Disease and Atrial Fibrillation - Kuniyoshi Yagyu, MD Post Brow Lift Fixation Eyebrow Transplantation - Jack M. Yu, MD Induction Anesthesia in Hair Transplantation - Shadi Zari, MD Application of High-Density Follicular Unit Hair Transplantation in Treatment of Cicatricial Alopecia - Jufang Zhang, MD

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P01 Correction of Improper Female Hairline Restoration Procedures


Ji-sup Ahn, MD, PhD. Dr. Ahn Medical Hair Clinic, Seoul, Korea, Republic of.

General Information: - Doctor degree of Medicine, Kyungpook National University school of Medicine - Clinical Assistant Fellowship at the Hair Transplantatin Center, Kyungpook National University School of Medicine - Director of Dr. Ahn Medical Hair Clinic in Seoul, Korea Memberships & Affiliations: Member of ISHRS Member of AAHRS (Asia Association of Hair Restoration Surgeons) Board Member of KSHRS (Korean Society of Hair Restoration Surgery) Board Member of KADAT (Korean Association for Dermatology and Trichology) J. Ahn: None. TAKE HOME MESSAGE: 4Ds : The success of a woman's hairline restoration depends on artistic Design, Dense packing technique, Direction and angles, and Distribution of hair follicles. ABSTRACT: Several female patients have visited my clinic to correct their dissatisfactory initial hairline reconstruction procedures from other clinics. The various complaints are unnatural hairlines, difficulty in styling hair, and low survival rate of follicles and so on These can be avoided with following the 4Ds. The success of a woman's hairline restoration depends on artistic Design, Dense packing technique, Direction and angles, and Distribution of hair follicles. First, it is important to determine a design that fits the patients face type. The surgeon must find the golden scale in order to have a balanced hairline. If the incorrect ratio is used the hairline may be too low or too narrow. If the surgeon has proper implanting skill and experience he can minimize the scaring and will get a higher survival rate. If a surgeon does not have adequate experience or proper implanting skill the result can make fibrosis. This leads to tufted hair follicles growing out of a single pore and a low survival rate. The patient will also have an unnatural hairline. Fibrosis can be avoided if the surgeon has proper dense packing skill and a second procedure will not be necessary. The direction and angle is also an important factor. If the surgeon neglects to use the proper direction or angle it will result in an unnatural hairline and make it difficult to style the hair. The distribution of hair follicles must follow a pattern to develop a natural look. Some doctors choose to weaken the follicle by lasers or physically damaging the root to give the hair a villous appearance. However, this lowers the survival rate and there is a strong chance the hair will have an irregular curl, so I dont recommend this method. I believe using a thin single hair in the front area and behind that a single thick hair. After that in the back two hair follicular units should be used to create a natural look. I dont use three or more hair follicular unit in female hairline restoration.

The result of a womens hairline restoration should be a natural hairline that gives a more attractive appearance and a more feminine look.

Correction of Improper Female Hairline Restoration Procedures


Ji Sup Ahn, M.D., Ph.D.
Dr. Ahn Medical Hair Clinic, Seoul, Korea
Abstract
Several female patients have visited my clinic to correct their dissatisfactory initial hairline reconstruction procedures from other clinics. The various complaints are unnatural hairlines, difficulty in styling hair, and low survival rate of follicles and so on These can be avoided with following the 4Ds. The success of a women's hairline restoration depends on artistic Design, Dense packing technique, Direction and angles, and Distribution of hair follicles.

Case I Dense Packing


Less trauma will give the best results !
Tufted Hair Clumps :

Irregular Distance between grafts Weak Point

Asymmetric, Wide, and Unnatural looking hairline Severe fibrosis

Design
Irregularities

Golden Ratio ( 1 : 1.618) MFP lateral margin temporal point sideburns

1. Major irregularities : widows peak, 3 or more mounds 2. Minor irregularities : very important factor for natural hairline

Regular intervals between follicular units Sharp needle Depth control Needle diameter (under 1mm) above 1.2mm could result in interrupted blood supply 1) 1 hair FU Implanter S ( 0.8mm ) 2) 2 hair FU Implanter M ( 1.0mm ) Adequate Density : 30 ~ 50 FUs / cm2

Pitting, tufted hair clumps Poor growth

Wrong direction Severe fibrosis Pitting Tufted hair clumps Low density

Regular interval

Irregular interval

Case II
L M S
Unnatural Curling Hair Permanent Tattoo

Direction & Angle


Implanter should be easy to handle to control the direction and angle Patients head position Usually transplant by direction and angle of existing hair Direction : each hair FUs change little by little Hair FUs have unique direction & angle depending on scalp location Angle on Temporal Point : two-step insertion technique,

If necessary, can change implanted hair direction and angle

Only for Dense Packing Technique


S M L

Implanter Diameter

L-size Implanter : Inadequate >1.2mm : interrupted blood supply Dont use more than 3 hair FUs
:
Pythagorus Theory

Difficulty in Styling Hair

hair curvature & bevel-down technique

Case III

Mathematical Approach

1 mm
25 FU / cm2 + 25 FU / cm2 ------------------50 FU / cm2

1 mm

1 mm 2 mm (8)/2 1.4mm 0.4mm 8 2.8mm


Golden Ratio The Design is determined by the Height and Width In this Case, Only the Width was changed

2 mm

of the patients forehead.

Distribution
Transition zone : First 3~7 lines, 1 hair Fus, Make major & minor irregularities Define zone : Next to transition zone, about 1cm width, 1 & 2 hair FUs Dense zone : Posterior area of define zone, 2 & 3 hair FUs
Define Zone

X 2 hair FU -----------------= 100 hair / cm2

and the Density was increased.

X 3 hair FU -----------------= 150 hair / cm2

Take Home Message

Transition Zone

Dense Zone

Usually the Hair Diameter differs between Asian and Caucasian. 1 hair FU in the transition zone will give the appearance of natural looking hair.

4D

Design Direction and Angle Distribution Dense-packing technique

P02
Hair Density Count- A Comparative Study Among Different Types of Densitometer Prapote Asawaworarit, MD, Damkerng Pathomvanich, MD, FACS, Rangsit Sittiwangkul, MD, Oravan Pathomvanich, MD. DHT Clinic, Bangkok, Thailand. Doctor of Medicine Faculty of Medicine, Prince of Songkla University, Thailand Internship Thammasat University Hospital, Thailand Master of Science in Dermatology Faculty of Medicine, Srinakharinwirot University, Thailand Fellowship in Hair Restoration Surgery approved by ISHRS DHT Clinic, Bangkok, Thailand P. Asawaworarit: None. D. Pathomvanich: None. R. Sittiwangkul: None. O. Pathomvanich: None. TAKE HOME MESSAGE: Video microscope is a very useful and economical device and is recommended for densitometry in hair restoration surgery. ABSTRACT: Introduction To assess the donor hair, follicular unit count is an important process in both the strip and FUE technique. Not only can the number of grafts be estimated but the prognosis can also be made regarding the hair characteristic examined. A patient with more number of 3-or-4-hair grafts would have a better result than ones who have a lot of single unit hairs. Lack of precision in density measurements results in inappropriate number of grafts harvest. If the grafts are not enough, more time need to be spent for re-harvest. On the other hand, over-harvest is wasting the patients precious donor hair. Premise Densitometry can be performed with instruments such as densitometer, trichoscope, folliculoscope or dermoscope. There are several advantages each one can offer. In our practice, we have been using Rassman densitometer along with a dermoscope. We are also using a video microscope (Anyview Microscope: MV200UA) in the past year and its density count is almost comparable to densitometer. Substantiating data Rassman densitometer is very handy. Its focus can be adjusted to examine the hair. The number of counted grafts multiply by 10 is the calculated donor density. The limitation of the densitometer is when measuring patients with white hair which can hardly be seen. The calculated density would then be less than what actually is. This results in over harvesting. A dermoscope works similar to the densitometer. An area of one square centimeter is made where it attaches the scalp. The area is separated into 4 quarters equally and the hair grafts can be counted from one quarter. The number

of counted grafts times 4 will be the calculated donor density. A video microscope has to be connected to a laptop by a USB cable. It is a bit time-consuming when doing calibration each time but has a very high-accuracy measurement. Using 60-time magnification, an on-screen enlarged view aids thorough investigation of the hair and scalp. Scalp texture and hair characteristic, including white hairs, can clearly be seen on the monitor. The software helps counting number of follicle in sequence and can differentiate the objects into 2 groups. For example, normal hair follicles can easily be counted in sequence along with miniaturized hairs. Hair diameter can also be measured. Data files can be obtained in a hard disk. Discussion Densitometry is essential for donor evaluation. The densitometer and dermoscope are easy to use to quantify the density. However, there might be confusions in counting because they do not have a sequence counter. They are also more expensive than our selected video microscope. The video microscope takes some time for calibration but gives investigators a magnified view of the hair and scalp. White hair can easily be seen and data collection can also be done. Apart from densitometer, video microscope is a very useful and economical device and is recommended for densitometry in hair restoration surgery.

Hair density count: A comparative study among different types of densitometer


Prapote Asawaworarit, MD, Damkerng Pathomvanich MD FACS DHT Clinic, Bangkok, Thailand Premise and substantiating data:
Densitometry can be performed with instruments such as densitometer, trichoscope, folliculoscope or dermoscope. There are several advantages each one can offer. In our practice, we have been using Rassman densitometer along with a dermoscope. We also use a video microscope (Anyview Microscope: MV200UA) in the past year and its density count is almost comparable to densitometer. Rassman densitometer and dermoscope are very handy. The limitation of the densitometer is when measuring patients with white hair which can hardly be seen. The calculated density would then be less than what actually is. This results in over harvesting. A video microscope has to be connected to a labtop. It is a bit timeconsuming when doing calibration each time but has a very highaccuracy in measurement. Using 60-time magnification, scalp texture and hair characteristic, including white hairs, can easily be seen on the monitor. Scalp diseases can also be examined by the device. The software helps counting number of follicle in sequence and can separate into two groups. Hair diameter can also be measured. Data files can be obtained in a computer.

Introduction: To assess the donor hair, follicular unit count is an important process in both the strip and FUE technique. Not only can the number of grafts be estimated but the prognosis can also be made regarding the hair characteristic examined. A patient with more number of 3-or-4-hair grafts would have a better result than ones who have a lot of single unit hairs. Lack of precision in density measurements result in inappropriate number of grafts harvest. If the grafts are not enough, more time need to be spent for re-harvest. On the other hand, over-harvest is wasting the patients precious donor hair.

Dr. Prapote Asawaworarit DHT Clinic,Thailand

Discussion: Densitometry is essential in donor evaluation.

The densitometer and dermoscope are easy to use to quantify the density. However, there might be confusions in counting because they do not have a sequence counter. Moreover, Rassman densitometer is not available now. The video microscope takes some time for calibration but gives investigators a magnified view of the hair and scalp. White hair can easily be seen and data collection can also be done. Apart from densitometer, video microscope is a very useful and economical device and is recommended for densitometry in hair restoration surgery.

Figure 1. Density count with a video microscope

Figure 2. Using a video microscope

Figure 3. Examining a patient with grey hairs using a video microscope

P03
Jisung Bang, MD. Forhair Korea, Seoul, Korea, Republic of. Chief Doctor at Forhair Korea MD., ABHRS J. Bang: None. TAKE HOME MESSAGE: I want to give a realistic review on my FUE transection rate data. ABSTRACT: Introduction Despite much improvement made in the field of FUE, controversy still exists. This is especially true when it comes to survival rate and transection rate. Thus, I want to give a realistic review on my FUE transection rate data. Premise There are various definitions about transection. My definition of transection is; all kinds of mechanical injury of hair follicle, and therefore, minimal tear, crushing and incomplete amputation are included in my transection data. Coles FUE safe area is used for evaluating the donor area. Donor area is divided into 14 boxes - eight large upper boxes and six small lower boxes- and each box was evaluated. The grafts were inspected with 20x microscopic display system. 50 samples each from large boxes and 25 each from small boxes were randomly selected. Substantiating Data Average of transection rate from each box is calculated and a total average value of transection rate is obtained. Final average of transection is 5.61. Range of average value is between 2.34 and 12.69. Discussion There are no differences between manual punching and motorized punching in terms of transection. However, a slightly higher transection rate is seen in cases with scar tissue, rubbery skin, thick & tough skin and unstable posture of patient.

Real Data of FUE Transection Rate in Asians

Real data of FUE transection rate in Asians


Jisung Bang, M.D., ABHRS Seoul, Korea Contact: dr.jsbang@gmail.com

Introduction Despite much improvement made in the eld of FUE, controversy still exists. This is especially true when it comes to survival rate and transection rate. Thus, I want to give a realistic review on my FUE transection rate data. Premise There are various denitions about transection. My denition of transection is; all kinds of mechanical injury of hair follicle, and therefore, minimal tear, crushing and incomplete amputation are included in my transection data. Coles FUE safe area is used for evaluating the donor area. Donor area is divided into 14 boxes - eight large upper boxes and six small lower boxes- and each box was evaluated. The

grafts were inspected with 20x microscopic display system. 50 samples each from large boxes and 25 each from small boxes were randomly selected. Substantiating Data Average of transection rate from each box is calculated and a total average value of transection rate is obtained. Final average of transection is 6.04. Range of average value is between 1.37 and 18.02. Discussion There are differences between manual punching and motorized punching in terms of transection. A slightly higher transection rate is seen in cases with scar tissue, rubbery skin, thick & tough skin and unstable posture of patient.

TR (%) 18 15 13 11 9 7 5 3 1

P04 Prophylactic Antibiotic Use in Hair Transplantation Surgery--Indications and Recommendations


Scott A. Boden, MD. Hair Restoration Center of Connecticut, Wethersfield, CT, USA. Scott Boden, MD, is a Diplomate and Secretary of the Board of Directors of the American Board of Hair Restoration Surgery. Medical Director of the Hair Restoration Center of Connecticut, Dr. Boden has particular interests and expertise in Follicular Unit Extraction and the treatment of radiation induced alopecia. S.A. Boden: None. TAKE HOME MESSAGE: In hair transplantation procedures, antibiotics have a place for the treatment of infection, but present guidelines emphasize that the practice of routine prophylactic use of antibiotics should be abandoned. ABSTRACT: Goals of prophylactic antibiotics include preventing post-operative infection at the surgical site, preventing postoperative morbidity and mortality, and reducing the duration and cost of health care. If prophylactic antibiotics are to be used they must be active against the organisms most likely to cause a postoperative infection, be initiated within one hour before surgical incision, and discontinued within 24 hours of surgery completion. There is no documented benefit of antibiotics after wound closure in the reduction of surgical site infections. In low-risk surgical procedures, including clean dermatologic procedures, antibiotic-associated adverse effects exceed the benefits of prophylaxis. Negative aspects of antibiotic prophylaxis include non-fatal adverse reactions (e.g., rash, GI symptoms, C. difficile colitis, Stevens-Johnson syndrome), fatal anaphylactic reactions (~20 rxns/1 million patients treated with PCN), drug interactions, and adding to the drug resistance burden. Although oral agents such as cephalexin, amoxicillin, clindamycin, tmp/sulfamethoxazole and azithromycin have previously been recommended in reviews of antimicrobial prophylaxis in clean dermatological surgery, there is no current evidence that supports their routine use. American Heart Association guidelines note that exceptions may include individuals at highest risk for infectious endocarditis, including patients who are immunocompromised, have prosthetic heart valves, prior endocarditis, or cyanotic heart disease. Antimicrobial prophylaxis does not significantly decrease the risk of infection in clean plastic surgery procedures, and guidelines support no antimicrobial prophylaxis in patients undergoing clean facial or nasal procedures. In hair transplantation procedures, antibiotics have a place for the treatment of infection, but the practice of routine prophylactic use of antibiotics should be abandoned.

PROPHYLACTIC ANTIBIOTIC USE IN HAIR TRANSPLANTATION SURGERY Indications and Recommendations


Historically, many hair transplant surgeons have used prophylactic antibiotics routinely. Goals of prophylactic antibiotics include preventing post-operative infection at the surgical site, preventing postoperative morbidity and mortality, and reducing the duration and cost of health care. Guidelines for appropriate prophylactic use of antibiotics have evolved and antibiotics are recommended far less frequently than in the past. Although oral agents such as cephalexin, amoxicillin, clindamycin, tmp/sulfamethoxazole and azithromycin have previously been recommended in clean dermatological surgery, THERE IS NO CURRENT EVIDENCE THAT SUPPORTS THEIR ROUTINE USE. The most recent American Heart Association guidelines note that exceptions may include individuals at highest risk for infectious endocarditis or hematogenous joint infections, and include patients who are immunocompromised, have prosthetic heart valves, prior endocarditis, or cyanotic heart disease. If prophylactic antibiotics are to be used they must be active against the organisms most likely to cause a postoperative infection, be initiated within one hour before surgical incision, and discontinued within 24 hours of surgery completion. There is no documented benefit of antibiotics after wound closure in the reduction of surgical site infections. Prophylactic topical antibiotic creams and ointments (e.g., bacitracin or neosporin) have not been shown to prevent wound infections better than white petrolatum. In low-risk surgical procedures, including clean dermatologic procedures, antibiotic-associated adverse effects exceed the benefits of prophylaxis. Negative aspects of antibiotic prophylaxis include non-fatal adverse reactions (e.g., rash, GI symptoms, C. difficile colitis, Stevens-Johnson syndrome), fatal anaphylactic reactions (~20 rxns/1 million patients treated with PCN), drug interactions, and adding to the drug resistance burden. Antimicrobial prophylaxis does not significantly decrease the risk of infection in clean plastic surgery procedures, and guidelines support no antimicrobial prophylaxis in patients undergoing clean facial or nasal procedures. TAKE HOME POINTS: TAKE HOME POINTS: THERE IS NO DOCUMENTED BENEFIT FOR ROUTINE PROPHYLACTIC ANTIBIOTIC USE IN HAIR TRANSPLANTATION (Considered Class 1 {clean} cutaneous surgical wound). THERE IS NO DOCUMENTED BENEFIT OF ANTIBIOTICS AFTER WOUND CLOSURE IN THE REDUCTION OF SURGICAL SITE INFECTIONS. IF ANTIBIOTICS ARE TO BE CONSIDERED FOR PREVENTION OF INFECTIVE ENDOCARDITIS (IE) or HEMATOGENOUS JOINT INFECTION (HJI), USE IN HIGH RISK PATIENTS ONLY HIGH RISK FOR IE: Prosthetic heart valve; hx of IE; cardiac transplant with valvulopathy; unrepaired CHD; valve repair within past 6 months with synthetic material HIGH RISK FOR HJI: Surgery within 2 yrs of joint replacement; hx of prosthetic joint infection; immune compromised IF APPROPRIATE TO USE ANTIBIOTICS TREAT WITH ONE DOSE 30-60 MINUTES PRIOR TO PROCEDURE AND DO NOT EXCEED 24 HOURS OF TREATMENT CHOOSE ANTIBIOTIC APPROPRIATE FOR SKIN FLORA (typically cephalexin or dicloxacillin; clindamycin or azithromycin in PCN-allergic pateints)

In hair transplantation procedures, antibiotics have a place for the treatment of infection, but the practice of routine prophylactic use of antibiotics should be abandoned.
REFERENCES: Bratzler, et. al.Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. 2013; 70:195-283 . Classen DC, Evans RS, Pestotnik SL, et al. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med. 1992; 326(5):281-286. Edwards FH, Engelman RM, Houck P, et al. The Society Of Thoracic Surgeons practice guideline series: antibioic prophylaxis in cardiac surgery, part I: duration. Ann Thorac Surg. 2006;81(1):397-404. Fennessy BG, Harney M, OSullivan MJ, Timon C. Antimicrobial prophylaxis in otorhinolaryngology/head and neck surgery. Clin Otolaryngol. 2007 Jun;32(3):204-7. Halpern AC, Leyden JJ, Dzubow LM, McGinley KJ. The incidence of bacteremia in skin surgery of the head and neck. J Am Acad Dermatol 1988;19:112-6. Harbarth S, Samore MH, Lichtenberg D, et al. Prolonged antibiotic prophylaxis after cardiovascular surgery and its effect on surgical site infections and antimicrobial resistance. Circulation. 2000;101(25):2916-2921. Mohri Y, Tonouchi H, Kobayashi M, et al.; Mie Surgical Infection Research Group. Randomized clinical trial of single- versus multiple-dose antimicrobial prophylaxis in gastric cancer surgery. Br J Surg. 2007;94(6):683-688. Rossi AM, Mariwalla K. Prophylactic and empiric use of antibiotics in dermatologic surgery: a review of the literature and practical considerations. Dermatol Surg 2012;38:1898-1921. Salkind AR, Rao KC. Antibiotic Prophylaxis to prevent surgical site infections. Am Fam Physician. 2011;83(5):585-590 Slobogean GP, Kennedy SA, Davidson D, et al. Single- versus multiple-dose antibiotic prophylaxis in the surgical treatment of closed fractures: a meta-analysis. J Orthop Trauma. 2008;22(4):264-269. Smack DP, Harrington AC, Dunn C, Howard RS, et al. Infection and allergy incidence in ambulatory surgery patients using white petrolatum vs bacitracin ointment. A randomized controlled trial. JAMA 1996;276:972-7. Wilson W, Taubert KA, Gewitz M, Lockhart PB, et al. Prevention of infective endocarditis: guidleines from the American Heart Association. Circulation 2007;116:1736-54.

Scott A. Boden, M.D. 415 Silas Deane Highway, Suite 400, Wethersfield, CT USA 06109 860-563-1400 www.HairTransplantCT.com

P05 Role of Body Hair Transplantation in Vitiligo


Dr Kavish Chouhan, MD. DERMACLINIX-The complete skin and hair solution center, NEW DELHI, India. Dr.Kavish chouhan is the Director of DERMACLINIX. He has done his MD in Dermatology from the prestigious All India Institute of Medical Sciences (AIIMS), DELHI. He has experience of successfully performing >1000 hair transplant procedures by FUE. He specializes in doing giga (>3500 FU) sessions of hair transplantation by FUE. He is amongst the pioneers of PRP treatment for hair fall in INDIA. He has published worlds first case of body hair transplantation in Vitiligo (JCAS,2013). He has several publication in international indexed journals like Lancet, British Journal of Dermatology (BJD), Clinical & experimental dermatology(CED) etc. He has been awarded Best young dermatologist in CUTICON 2010, DELHI & Best poster award in DERMACON, 2011. He also has presented his work in World Congress of Dermatology at Seoul, KOREA in 2011. Dr. Kavish chouhan is a qualified member of ISHRS (International Society of Hair Restoration Surgery) since 2010. D. Chouhan: None. TAKE HOME MESSAGE: Body hair transplantation (BHT) by follicular unit extraction (FUE) appears to be an effective method for treating localized/segmental vitiligo, especially on hairy parts of the skin, including the eyelids and eyebrows and for small areas of vitiligo. As seen in our case even density of 6-8 FU/cm2 was sufficient to induce complete pigmentation. The best application of this method will be in vitiligo patches with leukotrichia. In cases of focal vitiligo with scarring/loss of hairs, this procedure could be considered as procedure of choice. ABSTRACT: Vitiligo (Leukoderma) is characterized by depigmented macules and carries huge social stigma in developing countries like INDIA. Various surgical procedures are practiced for treating stable vitiligo patches, e.g. punch graft, Thiersch's graft, blister-graft, full-thickness skin graft, autologous melanocyte transplants, micropigmentation and dermabrasion and all these techniques induce satisfactory repigmentation with some drawbacks. Scarring in vitiligo patch results in loss of hairs and thereby it is difficult to achieve good repigmentation in these cases. Body hair transplantation helps in repigmentation by perifollicular spread of melanocyte & stem cells from the implanted follicles. In addition, the aesthetic appearance also is restored by the new hairs. This method is effective in focal vitiligo, vitiligo in non-glabrous areas and in those patches with leukotrichia. FUT (follicular unit transplant) was introduced to repigment vitiligo patches in 1998. [1] This procedure is based on the concept of existence of undifferentiated stem cells in the hair follicle, which forms a good source of melanocytes for repigmentation. Staricco demonstrated that there were two types of pigment cells in the hair follicle, inactive and active melanocytes and the inactive melanocytes could migrate along with regenerated epidermis and would mature gradually. [2] Ortonne et al. proposed that repigmentation of vitiligo was derived from the melanocyte reservoir in the hair follicles. [3] Cui et al. demonstrated that during the repigmentation of vitiligo the number of inactive melanocytes in the outer sheath of hair follicles significantly increased and some active melanocytes appeared in the outer root sheaths, in the hair follicle orifices and around the perifollicular epidermis. [4] Regardless of the mode of treatment, repigmentation in vitiligo usually begins in the perifollicular area highlighting the importance of melanocytes and stem cells present in hair follicles. FUT for repigmentation for vitiligo has been reported earlier. [1], [5], [6] The diameter of pigment spread is 5-12 mm per hair grafted. [7]Pigmentation starts appearing at 4 th to 5 th week and continues upto 6 months or even longer. [7] Even in cases of unresponsive or treatment-resistant vitiligo, grafted hairs retained the pigmentation. [1]

Transformation of depigmented hairs into pigmented hairs has been reported following FUT as seen in our case also. [1] Noncultured extracted hair follicular outer root sheath (ORS) cell suspension transplantation has also been tried with 65.7% repigmentation [8] Body hair transplantation by follicular unit extraction(FUE) circumvents the need of tedious melanocyte suspension process. The advantages of hair transplantation in vitiligo: 1. 2. 3. 4. 5. 6. A single hair contains more melanocytes than normally pigmented glabrous, usually gluteal area skin. Hair follicle melanocytes also seem to be more resistant to the vitiligo process. [1] This method is advantageous for hair restoration in a non-glabrous area which is not possible with typical vitiligo surgery techniques. Does not produce post-operative hyperpigmentation in the grafted sites as does autologous suction blister grafts. Can be performed in the eyelash area or angle of the mouth where other surgical methods, such as epidermal grafting or minigrafting, are difficult. No need for dermabrasion of recipient area. Cobblestone hypertrophic scar does not appear because small bored needle is used for implantation. The advantages of body hair transplantation (by FUE) over FUT in vitiligo: S.No.Hair transplantation by strip method(FUT)Body hair transplantation(BHT) by follicular unit extraction (FUE) 1.Linear scarring in donor areaNo visible scarring 2.More invasiveLess invasive 3.Hairs require dissection prior to implantationReady to implant Follicular units 4.Scalp hair follicles are thicker than body hairsExcellent aesthetic outcome 5.Hairs requires frequent trimming to match length with other hairsDoes not require repeated trimming However, this method has some limitations; body hair transplantation (BHT) by follicular unit extraction (FUE) is a time-consuming and delicate procedure requiring lots of expertise. Body hair transplantation (BHT) by follicular unit extraction (FUE) appears to be an effective method for treating localized/segmental vitiligo, especially on hairy parts of the skin, including the eyelids and eyebrows and for small areas of vitiligo. As seen in our case even density of 6-8 FU/cm2 was sufficient to induce complete pigmentation. The best application of this method will be in vitiligo patches with leukotrichia. In cases of focal vitiligo with scarring/loss of hairs, this procedure could be considered as procedure of choice.

REFRENCES 1.Na GY, Seo SK, Choi SK. Single hair grafting for the treatment of vitiligo. J Am Acad Dermatol 1998;38:580-4. 2.Staricco RG. Mechanism of the migration of the melanocytes from the hair follicle into the epidermis following dermabrasion. J Invest Dermatol 1964;36:99-104. 3.Ortonne JP, Schmitt D, Thivolet J. PUVA-induced repigmentation of vitiligo: Scanning electron microscopy of hair follicles. J Invest Dermatol 1980;74:40-2. 4.Cui J, Shen L, Wang G. Role of hair follicles in the repigmentation of vitiligo. J Invest Dermatol 1991;97:410-6. 5.Malakar S, Dhar S, Malakar RS. Repigmentation of vitiligo patches by transplantation of hair follicles. Int J Dermatol 1999;38:237-8 6.Surgical treatment for vitiligo through hair follicle grafting: How to make it easy. Dermatol Surg

2001;27:685-6. 7.Malakar S, Na GY, Lahiri K. Transplantation of hair follicles for vitiligo. In: Gupta S, editor. Surgical management of Vitiligo. 1 st ed. New Delhi: Wiley India; 2007. p. 122-7. 8.Mohanty S, Kumar A, Dhawan J, Sreenivas V, Gupta S. Noncultured extracted hair follicle outer root sheath cell suspension for transplantation in vitiligo. Br J Dermatol. 2011 Jun;164(6):1241-6.

Role of Body Hair Transplantation in Vitiligo


DR.KAVISH CHOUHAN ,MD
Hair transplantation at vitiligo is based on the concept of existence of undifferentiated stem cells in the hair follicle, which forms a good source of melanocytes for repigmentation Body hair transplant was done for a 28-year-old male with stable vitiligo with scarring. Perifolllicularrepigmentation was noted at 4 weeks and complete repigmentation of vitiligo patch was achieved at 12 weeks

Advantages of HT in vitiligo
Hair restoration in areas of scarring (e.g. after phototoxicity) Restoration of hairs, reversal of leukorichia? No complications in donor area (with FUE) Does not require laboratory support Large areas can be covered Suitable even in patients with keloidal tendancy HT by follicular unit extraction(FUE) circumvents the need of tedious melanocyte suspension process

Body Hair Transplant(BHT by FUE) Vs FUT


S.No Hair transplantation by strip method(FUT) BHT by follicular unit extraction (FUE)

Perifollicular pigmentation

1 2 3

Linear scarring in donor area More invasive Hairs require dissection prior to implantation Scalp hair follicles are thicker than body hairs Hairs requires frequent trimming to match length with other hairs

No visible scarring Less invasive Ready to implant Follicular units Excellent aesthetic outcome Does not require repeated trimming

Partial reversal of leukotrichia

7 week
SUMMARY

14 week

Hair transplantation is an effective method for treating localized/segmental vitiligo, especially on hairy parts of the skin May be used in vitiligo patches with leukotrichia. In cases of focal vitiligo with scarring/loss of hairs, this procedure could be considered as procedure of choice.

P06 Use of Glutathione as Part of Holding Solution and its Effect in Oxidative Stress During Hair Transplantation
Mrcio Crisstomo, MD, MS. Marilia Crisstomo, MD. Clin - plastic surgery, dermatology, baldness treatment, Fortaleza, Brazil.

Dr. Mrcio Crisstomo is a Board Certified Brazilian Plastic Surgeon, post-graduated at the Prof. Ivo Pitanguy Institute - Rio de Janeiro. He has a Master Degree in surgery with research in oxidative stress during hair transplant, is a member of the FUE Research committee of the ISHRS and is Diplomate of the American Board of Hair Restoration Surgery. His practice is based in Fortaleza (State of Cear, Northeastern of Brazil) where he is dedicated exclusively to hair transplant surgery and medical treatments of alopecia. Dr. Crisstomo has a predilection for larger surgeries as mega and gigasessions and is especially interested in procedures combining Follicular Unit Extraction with Strip Surgery to improve the number of follicular units in one procedure with scientific publications and extensive presentations about this subject in congresses of Plastic Surgery and Hair Restoration Surgery. M. Crisstomo: None. M. Crisstomo: None. TAKE HOME MESSAGE: This study discuss about ischemia-reperfusion injury during hair transplant and the effect of an anti-oxidant (Glutathione) used as holding solution. The oxidative stress in follicular units was measured by Thiobarbituric Acid Reactive Substances (TBARS) in control, ischemia and post-grafting (reperfusion) groups, and the data was compared. ABSTRACT: Introduction During preparation and before implantation in the recipient site [19, 5, 12], FUs are subjected to an ischemia situation with cell damage which may or may not be reversible [5]. After the implant in the bald area, there is an elevation of the oxygen levels in the FUs started by the contact with a vascularized environment of the recipient area that unchains a series of changes derived from the action of oxygen reactive species (ORS) called reperfusion lesion [2, 4]. The organism defends itself against the deleterious action of the ORS through enzymatic systems and antioxidants which block the formation of ORS or inactivate them [4]. Oxidative stress, generated when ORS formation surpasses the antioxidant cellular capacity, caused by the cold ischemia and the reperfusion lesion, may be one of the causes of non integration of FUs after the implant. With the purpose of decreasing FUs cellular damage and improving the rate of integration, some authors have tried different preservation solutions [2, 8, 20]. Tripeptide glutathione (L-glutamyl-L-cysteinyl-glycine), the final metabolite of glutamine, is a known natural antioxidant [16]. It has a role in many biological processes, including protein synthesis, metabolism and cellular protection and is part of the Celsior and Belzer solutions, widely used in organ preservation during human transplants [11, 13, 15, 16]. Objective The aim of this study was to test the hypothesis that the use of glutathione (GSH) could have some protective effect over transplanted hair follicles, and to evaluate oxidative stress in FUs submitted to ischemia and grafting during hair transplant surgery in humans, and compare the effect of using different GSH concentrations in preservation solutions. This article is part of the Master Degree in Surgery Dissertation of the first author.

Materials and/or Methods A prospective study was conducted with eighteen male patients with an average age of 41 years old (varying from 26 to 60 years old) and who were operated on between April and July 2008. Patients with grade III to VI baldness, according to Norwoods classification [10], were included to be submitted to hair transplant (strip technique) under venous sedation and local anesthesia. Immediately after the extraction, five FUs were preserved in liquid nitrogen (N2) at a temperature of -190C in order to compose the pre-ischemia group (control). Right after that, 40 FUs were prepared, from which ten were preserved in Saline Solution 0.9% (SS 0.9%) and thirty in the GSH solutions at concentrations of 5mmol, 10mmol and 20mmol, each one containing 10 FUs. Reduced Glutathione tested for cellular culture at 5% (SIGMA ALDRICH) was used. After thirty minutes of preservation, 5 FUs were removed from each solution and preserved in liquid nitrogen, composing the ischemia group. The 5 remaining FUs of each solution were implanted in the recipient area and remained there for thirty minutes (grafting period), after which they were removed and preserved in liquid N2, composing the post-grafting group. Figure 1 contains a general overview of the different steps of the research [FIGURE 1]. The oxidative stress was evaluated through Thiobarbituric Acid Reactive Substances (TBARS) [18] level dosing, using a spectrophotometry (Beckman DU-640). TBARS are formed as a byproduct of lipid peroxidation which can be detected by the TBARS assay using thiobarbituric acid as a reagent. Because ORS have extremely short halflives, they are difficult to measure directly. Instead, what can be measured are several products of the damage produced by oxidative stress, such as TBARS [3, 18]. Discussion/Results The search for a preservation solution that reduces oxidative stress in FUs may be important to decrease the amount of non integrated grafts in hair transplant. The different concentrations of glutathione in the preservation solutions were not a factor capable of reducing oxidative stress in FUs, since there was no statistical significant alteration in the levels of TBARS amongst the studied groups [FIGURES 2]. Data analysis through an adjustment to a model of linear regression showed a tendency of reducing levels of TBARS with increasing concentrations of GSH in the preservation solution, but there was no statistical significance in this relationship in both ischemia and post-grafting groups [FIGURE 2]. Although the lesion that takes place during hair transplant is named by some authors as ischemia-reperfusion [2, 14], in this research the term post-grafting was used, because in the studied grafting time (30 minutes) revascularization does not occur, imbibition occurs instead [12]. However, since the oxygen levels in tissues surrounding the grafts are increased, it is believed that the local production of ORS would have a similar effect to the ischemia-reperfusion lesion [14]. Since the ischemia-reperfusion lesion is a biological phenomenon present in every transplant, it would be expected that a similar effect could be demonstrated in the samples studied. However, in the general evaluation of the oxidative stress, when the average values of the ischemia, post-grafting and control groups were compared, it was verified that the stress level found in the latter through the TBARS measurement (0.03046 0,017 mol MDA/g of tissue) was not statistically significant in relation to the ones found in the ischemia (0.03506 0.022 mol MDA/g of tissue) and post-grafting (0.03075 0.024 mol MDA/g of tissue) groups [FIGURE 4]. The time of 30 minutes chosen for both ischemia and grafting, may not have been sufficient for a greater

manifestation of the cellular lesion, interfering with the evaluation of the stress. Different and more prolonged times of ischemia and grafting may better expose the existent cellular lesion. The absence of a significant difference between the control, ischemia and post-grafting groups may imply that the measurements of TBARS by means of spectrophotometry would not be a suitable method to detect the oxidative stress in this kind of tissue as it was for other tissues [6, 9]. Probably more specific methods, such as DNA lesion detection at molecular level could elicit those alterations. The research model was conceived as an attempt to simulate the situation found during the surgery, where the whole FU is transplanted [1]. The FU is a structure that not only contains the hair and its follicle, but also the sebaceous gland, arrector pili muscle, perifoliculum and surrounding skin, subcutaneous and fatty tissue [7]. These structures are important for the viability and integration of the grafts; however, it is only the hair follicle which is going to generate the new hair [1]. This tissue diversity may have altered the sensitivity of the evaluation methods. The study of the oxidative stress in the follicle isolated could prevent this bias with a possible increase in the sensitivity of the oxidative stress detection methods. Additional studies are required to further clarify this issue. Conclusion Increasing GSH concentrations used in FUs preservation solutions do not reduce the oxidative effects of cold ischemia and reperfusion injury during hair transplant surgery measured by TBARS (spectophotometry). References 1. Bernstein RM, Rassman WR (1997) Follicular transplantation. Patient evaluation and surgical planning. Dermatol Surg 23:771-84 2. Cooley JE (2004) Ischemia-reperfusion injury and graft storage solutions. Hair Transplant International Forum 14:121-13 3. Crisstomo MR, et al. Oxidative stress in follicular units during hair transplantation surgery. Aesthetic Plast Surg. 2011; 35(1):19-23. 4. Fausto N, Kummar V, Abbas AK (2005) Adaptao, dano e morte celular. In: kummar V, Abbas AK, Fausto N (eds) Robbins & Cotran Patologia, Elsevier, Rio de Janeiro, pp 3-48. 5. Greco JF, Kramer RD, Reynolds GD (1997) A "crush study" review of micrograft survival. Dermatol Surg 23:752-5 6. Guimares SB, Arago AA, Santos JM, Kimura Ode S, Barbosa PH, Vasconcelos PR (2007) Oxidative stress induced by torsion of the spermatic cord in young rats. Acta Cir Bras 22:30-3 7. Headington jt (1984) Transverse microscopy anatomy of the human scalp. Arch. Dermatol 120:449 8. Krugluger W, Moser K, Hugeneck J, Laciak K, Moser C (2003) New storage buffers for micrografts enhance graft survival and clinical outcome in hair restoration surgery. Hair Transplant Forum International 13:324-343 9. De Lima Silva JJ, Guimares SB, Da Silveira ER, De Vasconcelos PR, Lima GG, Torres SM, De Vasconcelos RC (2008) Effects of Copaifera langsdorffii Desf. on Ischemia-Reperfusion of Randomized Skin Flaps in Rats. Aesthetic Plast Surg 4:104-9 10. Norwood OT (1975) Male pattern baldness: classification and incidence. South. Med. J 68:1359-65 11. Pedotti P, Cardillo M, Rigotti P, Gerunda G, Merenda R, Cillo U, Zanus G, Baccarani U, Berardinelli ML, Boschiero L, Caccamo L, Calconi G, Chiaramonte S, Canton, A, Carlis L, Carlo V, Donati D, Montanaro D, Pulvirenti A, Remuzzi G, Sandrini S, Valente U (2004) Comparative prospective study of two available solutions for kidney and liver preservation. Transplantation 77:1540-5 Erratum in: Transplantation 78:489 12. Perez-Meza D (2004) Wound healing and revascularization of the hair transplant graft: the role of growth factors. In: Unger WP, Shapiro R (eds) Hair Transplantation, Marcel-Dekker, New York, pp 287-294 13. Remadi JP, Baron O, Roussel JC, Habash O, Treilhaud M, Despins P, Duveau D, Michaud JL (2002) myocardial preservation using Celsior solution in cardiac transplantation: early results and 5-year follow-up of a multicenter prospective study of 70 cardiac transplantations. Ann Thorac Surg 73:1495-9

14. Rinaldi F, Soberlini E, Bezzola P (2007) Improving the revascularization of transplanted hair follicles trhough up-regulation of angiogenic growth factors. Hair Transplant International Forum 17:135-139 15. Roth E, Oehler R, Manhart N, Exner R, Wessner B, Strasser E, Spittler A (1999) Regulative potential of glutamine-relation to glutathione metabolism. Nutrition 18:217-221 16. Sies H (1999) Glutathione and its role in cellular functions. Free Redical Biology & Medicine 27:916-921 17. Sommer SP, Gohrbandt B, Fischer S, Hohlfeld JM, Warnecke G, Avsar M, Struber M (2005) Glutathione improves the function of porcine pulmonary grafts stored for twenty-four hours in low-potassium dextran solution. J Thorac Surg 130:864-869 18. Uchiyama M, Mihara M (1978) Determination of malondialdehyde precursos in tissues by thiobarbituric acid test. Anal Biochem 86:271-278 19. Uebel CO (1991) Micrografts and minigrafts: a new approach for baldness surgery. Ann Plast Surg 27:476-487 20. Uebel CO, Silva JB, Cantarelli D, Martins P (2006) The role of platelet plasma growth factors in male pattern baldness surgery. Plast Reconstr Surg 118:1458-1466

The Role of Glutathione in Follicular Units Oxidative Stress During a Hair Transplant surgery*
* This sudy is part of the authors Surgery Master Degree Research
Conflict of Interests: The authors have no conflicts of interests to declare.

Mrcio R. Crisstomo*, Marlia G. R. Crisstomo


Fortaleza / CE Brazil marcio@implantecapilar.med.br Although the lesion that takes place during hair transplant is named by some

INTRODUCTION
During preparation and before implantation in the recipient site, FUs are subjected to an ischemia situation with cell damage which may or may not be reversible. After the implant in the bald area, there is an elevation of the oxygen levels in the FUs started by the contact with a vascularized environment of the recipient area that unchains a series of changes derived from the action of oxygen reactive species (ORS) called reperfusion lesion. The organism defends itself against the deleterious action of the ORS through enzymatic systems and antioxidants which block the formation of ORS or inactivate them. Oxidative stress, generated when ORS formation surpasses the antioxidant cellular capacity, caused by the cold ischemia and the reperfusion lesion, may be one of the causes of non integration of FUs after the implant. With the purpose of decreasing FUs cellular damage and improving the rate of integration, some authors have tried different preservation solutions. Tripeptide glutathione (L-glutamyl-L-cysteinyl-glycine), the final metabolite of glutamine, is a known natural antioxidant. It has a role in many biological processes, including protein synthesis, metabolism and cellular protection and is part of solutions widely used in organ preservation during human organ transplants.

OBJECTIVE
The authors favor the hypothesis that the use of glutathione (GSH) could have some protective effect over transplanted hair follicles. Therefore the aim of this study was to evaluate oxidative stress in FUs submitted to ischemia and grafting during hair transplant surgery in humans, and compare the effect of using different GSH concentrations in preservation solutions. FIGURE 2: Schematic overview of the process used in harvesting and preserving the different groups samples.

authors as ischemia-reperfusion, in this research the term post-grafting was used, because in the studied grafting time (30 minutes) revascularization does not occur, imbibition occurs instead. However, since the oxygen levels in tissues surrounding the grafts are increased, it is believed that the local production of ORS would have a similar effect to the ischemia-reperfusion lesion. The time of 30 minutes chosen for both ischemia and grafting, may not have been sufficient for a greater manifestation of the cellular lesion, interfering with the evaluation of the stress. Different and more prolonged times of ischemia and grafting may better expose the existent cellular lesion. The absence of a significant difference between the control, ischemia and post-grafting groups may imply that the measurements of TBARS and tissue GSH by means of spectrophotometry would not be a suitable method to detect the oxidative stress in this kind of tissue as it was for other tissues in previous studies. Probably more specific methods, such as DNA lesion detection at molecular level could elicit those alterations.

MATERIAL AND METHODS RESULTS

A prospective study was conducted with eighteen male patients with an average age of 41 years old (varying from 26 to 60 years old) and who underwent hair transplant surgery. Patients with grade III to VI baldness, according to Norwoods classification, were included to be submitted to hair transplant (strip technique) under venous sedation and local anesthesia. Immediately after the extraction, five FUs were preserved in liquid nitrogen (N2) at a temperature of -190C in order to compose the pre-ischemia group (control). Right after that, 40 FUs were prepared, from which ten were preserved in Saline Solution 0.9% (SS 0.9%) and thirty in the GSH solutions at concentrations of 5mmol, 10mmol and 20mmol, each one containing 10 FUs. Reduced Glutathione tested for

Data analysis through an adjustment to a model of linear regression showed a tendency of reducing levels of TBARS with increasing concentrations of GSH in the preservation solution, but there was no statistical significance in this relationship in both ischemia and post-grafting groups [FIGURE 3].

CONCLUSION
Increasing GSH concentrations used in FUs preservation solutions do not reduce the oxidative effects of cold ischemia and reperfusion injury during hair transplant surgery. Author biography:
Dr. Mrcio Crisstomo is a Brazilian Plastic Surgeon

FIGURE 1: Chemical structure of Gluthatione

cellular culture at 5% (SIGMA ALDRICH) was used. After thirty minutes of preservation, 5 FUs were removed from each solution and preserved in liquid N2, composing the ischemia group. The 5 remaining FUs of each solution were FIGURE 3: TBARS level in the Ischemia and Post-grafting groups.

graduated in the Prof. Ivo Pitanguy Institute Brazil with master degree in surgery (research in oxidative stress during hair transplant). He is Diplomate of the American Board of Hair Restoration He is practicing hair transplantation for more than 12 years and is dedicated exclusively to Hair Transplant Surgery and medical treatments of alopecia. Dr. Crisstomo has a predilection for larger surgeries as mega and gigasessions and actually is especially interested in procedures combining follicular unit extraction with strip surgery.

REFERENCES
1.

implanted in the recipient

area (crown) and remained there for thirty minutes

DISCUSSION
The search for a preservation solution that reduces oxidative stress in FUs may be important to decrease the amount of non integrated grafts in hair transplant. The different concentrations of glutathione in the preservation solutions were not a factor capable of reducing oxidative stress in FUs, since there was no statistical significant alteration in the levels of TBARS amongst the studied groups.

2.

3.

4.

5.

Crisstomo, M.R., et al. Oxidative stress in follicular units during hair transplantation surgery. Aesthetic Plast Surg. 2011 Feb; 35(1):19-23. Cooley JE (2004) Ischemia-reperfusion injury and graft storage solutions. Hair Transplant International Forum 14:121-139 Krugluger W, Moser K, Hugeneck J, Laciak K, Moser C (2003) New storage buffers for micrografts enhance graft survival and clinical outcome in hair restoration surgery. Hair Transplant Forum International 13:324-343 Sies H (1999) Glutathione and its role in cellular functions. Free Redical Biology & Medicine 27:916-921 Perez-Meza D (2004) Wound healing and revascularization of the hair transplant graft: the role of growth factors. In: Unger WP, Shapiro R (eds) Hair Transplantation, Marcel-Dekker, New York, pp 287-294

(grafting period), after which they were removed and preserved in liquid N2, composing the post-grafting group. Figure 2 contains a general overview of the different steps of the research [FIGURE 2]. The oxidative stress was evaluated through Thiobarbituric Acid Reactive Substances (TBARS) level dosing, using a spectrophotometry (Beckman DU-640).

Diplomate of the American Board of hair Restoration Surgery

Titular Member of Brazilian Society of Plastic Surgery

Post-graduated at Prof. Ivo Pitanguy Institute RJ / Brazil (3 yr)

Brazilian Association of Hair Restoration Surgery

International Society of Hair Restoration Surgery Member of FUE Research Committee

European Society of Hair Restoration Surgery

Master Degree In Surgery by Federal University of Cear in Hair transplantation

P07 Combining Follicular Unit Extractionand Strip Surgery in Secondary Procedures to Achieve More Follicular Units -The Management of Donor Area and Previous Scar

Mrcio Crisstomo, MD, MS, Marilia Crisostomo, MD, Denize Tomaz, MD. Clin - plastic surgery, dermatology, baldness treatment, Fortaleza, Brazil.

Dr. Mrcio Crisstomo is a Board Certified Brazilian Plastic Surgeon, with post-graduate training at Prof. Ivo Pitanguy Institute - Rio de Janeiro. He holds a Masters Degree in surgery with research in oxidative stress during hair transplant. He is also a member of the FUE Research Committee of the International Society of Hair Restoration Surgery and is a Diplomate of the American Board of Hair Restoration Surgery. His practice is based in Fortaleza (State of Cear, Northeastern Brazil) where he works exclusively with hair transplant surgeries and the medical treatment of alopecia. Dr. Crisstomo favors larger surgeries such as mega and gigasessions and is especially interested in procedures combining Follicular Unit Extraction with Strip Surgery to improve the number of follicular units in a single procedure. Dr. Crisstomo has a significant record of scientific publications and extensive presentations about this subject in Plastic Surgery and Hair Restoration Surgery events. M. Crisstomo: None. M. Crisostomo: None. D. Tomaz: None. TAKE HOME MESSAGE: Secondary cases, especially in advanced degrees of baldness, are usually a challenge. Sometimes the patient still needs a large amount of hair and donor supply is limited by the previous surgery. This presentation will show a methodology to combine Follicular Unit Extraction and Strip Surgery to achieve more Follicular Units (FUs) in a single procedure and provide higher density in such cases. In order to achieve more hair in those cases, a study is shown comparing the difference in FU count when excising or leaving the previous surgerys scar. We will discuss: management of donor areas with the combined procedure in the intra and post operative period; number of grafts by Strip and FUE methods; a comparison with the primary surgery; management of the previous scar; late follow-up and results. ABSTRACT: Introduction Secondary cases, especially in advanced degrees of baldness, are usually a challenge. Sometimes the patient still needs a large amount of hair and donor supply is limited by the previous surgery. There are two main ways of harvesting hair, using the head as donor area: Strip Harvesting (FUT) and Follicular Unit Extraction (FUE). FUT is limited by scalp elasticity while FUE is limited by local density. Usually those methods are used separately but in advanced baldness some surgeons have recommended both harvesting methods combined in order to achieve more grafts. Another issue in secondary surgery is what to do with the previous scar: to excise or not, and how it affects the final count of FUs. Objective The aim of this presentation is to describe a methodology to combine FUE and Strip Surgery to achieve more Follicular Units (FUs) in a single procedure in secondary surgeries and how to manage the previous surgerys scar. Materials and Methods A prospective study was carried out with 12 male patients with an average age of 42 years old (ranging from 32 to 59), submitted to secondary hair transplant surgery. The previous surgery of all patients was done by strip technique. The author previously performed surgery on five of those patients and in such cases the secondary strip was compared with the primary. The other seven patients had their first procedure done elsewhere and the study

evaluated aspects pertaining to FUE and strip in the secondary procedure only. In the secondary procedure hair was harvested by excision of a strip of scalp just below (or above) the previous strip scar (Figure 1). After the implantation of all FUs by Strip more FUs were harvested with the FUE method using motorized sharp punches ranging from 0.8 to 1.0mm (Figure 2). The number of FUs achieved by Strip and FUE methods was determined and compared with a Student t test. To compare the number of FUs achieved excising the previous strip scar or not, part of the strip (an average of 2.2cm long) was excised including the previous scar. In the same patient, another strip of the same size was excised leaving the previous scar in the scalp (Figures 3 and 4). The number of FUs in each strip was counted with the aim to determine the percentage of reduction in FUs when excising the previous strip scar and both groups were compared with a Student t test. Discussion/Results Regarding the FU count in all 12 secondary surgeries, the average number of FUs achieved by Strip was 2,388 (ranging from 1,877 to 3,604). The average number of FUs achieved by FUE was 695 (ranging from 409 to 1,416). The average improvement with this methodology compared to FUT alone was 27.2% (ranging from 12.9% to 50.1%) with p value < 0.001 (Figure 5). In the Untouched Strip Technique, another method for combining FUE and FUT used in primary surgery, a strip of 1.0 to 1.5cm just below the strip suture is left without harvesting FUE to keep its anatomical features for a possible future strip procedure. In secondary patients, the author considers that this strip is equivalent to the first surgery and therefore harvests FUE in the entire Safe Donor Area (SDA), where the hair is not going to fall during patients lifetime without leaving the untouched area (Figure 2). It is very important to harvest FUE within the SDA only. The secondary strip surgery usually yields less hair than the first surgery, since elasticity is not the same. In this study, the author had previously performed surgery on five of those patients and in such cases a 12% reduction was observed when comparing the secondary strip to the primary strip (the average was respectively 2,292 and 2,605). In those patients, when performing FUE harvesting in the same surgery an average of 637 FUs were added, allowing a final number 27.8% higher than with strip harvesting alone (the average of total FUs in the combined secondary procedure was 2,929), thus allowing the secondary combined surgery to be a larger procedure than the first strip surgery by an average of 12.5% (Figure 6). In the study comparing the number of FUs when excising or not the previous scar, the length of the studied strip was 2.2mm (ranging from 1.0 to 3.0cm) and the width ranged from 1.0cm to1.2cm. The average number of FUs in the strip with scar was 119 (ranging from 65 to 194) and in the strip without a scar it was 166.8 (ranging from 87 to 302). The percentage of reduction was 27.4%, ranging from 15.9 to 37.3%. This difference was statistically significant with p value = 0.001 (Figure 7). For this reason, in secondary surgery of advanced degrees of baldness, the author prefers to leave the scar in the scalp, unless excising it is the patients option after being informed. The treatment of the scar (excision, refinement with grafts or tattooing) can be done in a future procedure. In secondary surgery the methodology of combining FUE with Strip Harvesting and leaving the previous scar in place provides a significantly higher number of FUs. With this improvement the surgeon can provide better coverage and density in the bald area. This can be very important when treating patients with advanced grades of Baldness as Norwood V, VA, VI and VII (Figure 8). Conclusions The secondary strip provides less FUs than the primary one. The use of FUE associated with a Strip surgery can significantly improve the number of FUs in a secondary procedure. Excising the previous scar in the Strip significantly reduced the number of FUs achieved. References 1. Uebel CO. Micrografts and minigrafts: a new approach for baldness surgery. Ann Plast Surg. 1991; 27:476-87. 2. Rassman, W.R., Bernstein, R.M., et al. Follicular unit extraction: minimally invasive surgery for hair transplantation. Dermatol Surg. 2002; 28(8):720-728. 3. True R. Combining FUE and Strip Harvesting in the same procedure. Oral presentation at the 17th Annual Scientific Meeting of International Society of Hair Restoration Surgery. Amesterdam, The Netherlands, 22-26, July,

2009. 4. Tsilosani A. Expanding graft numbers combining strip and FUE in the same session: effect on linear wound closure forces. Hair Transplant Forum Intl. 2010; 20(4):121-123. 5. Crisstomo MR, Crisstomo MGR, Tomaz DCC, Crisstomo MCC. Untouched Strip: a technique to increase the number of follicular units in hair transplants while preserving na untouched area for future surgery. Surg Cosmet Dermatol 2011;3(4):361-4. 6. Crisstomo M. Untouched Strip: FUE combined with strip surgery to improve the FU number harvested in one session, preserving na untouched area for a possible future transplant. Hair Transplant Forum Intl 2012;22(1):1214.

Combining Follicular Unit Extraction and Strip Surgery in Secondary Procedures to Achieve More Follicular Units - The Management of Donor Area and Previous Scar
INTRODUCTION AND OBJECTIVE
Secondary cases, especially in advanced degrees of baldness, are usually a challenge. Sometimes the patient still needs a large amount of hair and donor supply is limited by the previous surgery. Usually Follicular unit Extraction (FUE) and Strip Surgery (FUT) are used separately, but in advanced baldness some authors have recommended both harvesting methods combined in order to achieve more grafts. Another issue in secondary surgery is what to do with the previous scar: to excise or not, and how it affects the final count of FUs. The aim of this poster is to describe a methodology to combine FUE and Strip Surgery to achieve more Follicular Units (FUs) in secondary surgeries and how to manage the previous surgerys scar.
FIGURE 3: a. Strip including the previous scar; b. Strip without scar. FIGURE 4: Microscopic view of the slivering: a. with scar; b. without scar

Mrcio R. Crisstomo*, Marlia G. R. Crisstomo


Fortaleza / CE Brazil marcio@implantecapilar.med.br The authors have no conflicts of interests to declare.

A strip (average: 2.2cm length and 1.1cm in width) was excised including the previous scar. In the same patient, another strip of the same size was excised leaving the previous scar in the scalp (Figures 3 and 4). The number of FUs in each strip was counted with the aim to determine the percentage of reduction in FUs when excising the previous strip scar and both groups were compared with a Student t test.

FIGURE 5: Comparison between the primary (Strip) and the secondary procedure (Strip + FUE)

In the study comparing the number of FUs when excising or not the previous scar, the average number of FUs in the strip with scar was 119 (65 to 194) and in the strip without a scar it was 166.8 (87 to 302). The percentage of reduction was 27.4%, (15.9 to 37.3%). This difference was statistically significant with p value = 0.001 (Figure 6). For this reason, in secondary surgery of advanced degrees of baldness, the author prefers to leave the scar in the scalp, unless excising it is the patients option after being informed about the pros and cons. The treatment of the scar (excision, refinement with grafts or scalp micro pigmentation)
FIGURE 6: Average number of FUs obtained in the strip with scar and without scar, and the amplitude into each group.

2,01

MATERIAL AND METHODS


A prospective study was carried out with 12 male patients with an average age of 42 years old (32 to 59), submitted to secondary HT. The previous surgery of all patients was done by strip technique. In the secondary procedure hair was harvested by excision of a strip of scalp just below (or above) the previous strip scar (Figure 1). After the implantation of all FUs by Strip, more FUs were harvested with the FUE method using motorized sharp punches varying in size from 0.8 to 1.0mm (Figure 2). The number of FUs achieved by Strip and FUE methods was compared with the Student t test.

DISCUSSION AND RESULTS


Regarding the FU count in all 12 secondary surgeries, the average number of FUs achieved by Strip was 2,388 (ranging from 1,877 to 3,604). The average number of FUs achieved by FUE was 695 (ranging from 409 to 1,416). The average improvement with this methodology compared to FUT alone was 27.2% (ranging from 12.9% to 50.1%) with p value < 0.001. In the Untouched Strip Technique, another method for combining FUE and FUT used in primary surgery, a strip of 1.0 to 1.5cm just below the strip suture is left without harvesting FUE to keep its anatomical features for a possible future strip procedure. In secondary patients, the author harvests FUE in the entire Safe Donor Area (SDA), without leaving the untouched area (Figure 2). The secondary strip surgery usually yields less hair than the first surgery, since elasticity is not the same. In this study, the author had previously performed surgery on five of those patients and in such cases a 12% reduction was observed when comparing the secondary strip to the primary strip (the average was respectively 2,292 and 2,605). In those patients, with FUE an average of 637 FUs were added, with a final number 27.8% higher than with strip harvesting alone.

866
FIGURE 7: Male, 36 years old, NW VA. a: pre-op; b: 11 months PO 1st surgery (Strip = 2,812 FUs); c: intra-op - Strip = 2,015 FUs (decrease of 28.3%) + FUE = 866FUs (increase of 43%); d: i9 months PO 2nd Surgery (Total = 2,881FUs).

CONCLUSIONS
1. The secondary strip provides less FUs than the primary one; 2. The use of FUE associated with a Strip surgery can significantly improve the number of FUs in a secondary procedure; 3. Excising the previous scar in the Strip significantly reduced the number of FUs achieved.

Author biography:
Dr. Mrcio Crisstomo is a Brazilian Plastic Surgeon graduated at the Prof. Ivo Pitanguy Institute Brazil, with master degree in surgery (research in oxidative stress during hair transplant). He is Diplomate of the American Board of Hair Restoration Surgery and member of the ISHRS FUE Research Committee. He is practicing hair transplantation for more than 12 years, dedicated exclusively to Hair Transplant Surgery and medical treatments of alopecia. Dr. Crisstomo has a predilection for larger surgeries as mega and gigasessions and actually is especially interested in procedures combining follicular unit extraction with strip surgery.

can be done in a future procedure.

In secondary surgery the methodology of combining FUE with Strip Harvesting and leaving the previous scar in place provides a significantly higher number of FUs. With this improvement the surgeon can provide better coverage and density in the bald area. This can be very important when treating patients with advanced grades of Baldness as Norwood V, VA, VI and VII (Figure 7).

FIGURE 1: ombined procedure in secondary patients. Demarcation of the strip just blow the previous linear scar and the FUE area.

FIGURE 2: 1st PO. Donor area after the Strip removal and the FUE harvesting in all safe donor area.

The average of total FUs in the combined secondary procedure was 2,929, thereby allowing the secondary combined surgery to be a larger procedure than the first strip surgery by an average of 12.5% (Figure 5).

REFERENCES

1. True R. Combining FUE and Strip Harvesting in the same procedure. Oral presentation at the 17th Annual Scientific Meeting of International Society of Hair Restoration Surgery. Amesterdam, The Netherlands, 22-26, July, 2009. 2. Tsilosani A. Expanding graft numbers combining strip and FUE in the same session: effect on linear wound closure forces. Hair Transplant Forum Intl. 2010; 20(4):121-123. 3. Crisstomo MR, Crisstomo MGR, Tomaz DCC, Crisstomo MCC. Untouched Strip: a technique to increase the number of follicular units in hair transplants while preserving an untouched area for future surgery. Surg Cosmet Dermatol 2011;3(4):361-4. 4. Crisstomo M. Untouched Strip: FUE combined with strip surgery to improve the FU number harvested in one session, preserving an untouched area for a possible future transplant. Hair Transplant Forum Intl 2012;22(1):12-14. 5. Crisstomo M. Combination of Strip and FUE - The Untouched Strip Technique. Oral presentation at the 19th Orlando Live Surgery Workshop. 17 - 20, April 2013. Orlando FL, United States. 6. Crisstomo M. Combining Extraction and Transplantation: Untouched StripTechnique. In Barrera A and Uebel C. Hair Transplantation - the Art of Micrografting and Minigrafting. 2nd Edition, Quality Medical Publishing, St. Louis MO, EUA, 2013. Chapter 10, p. 237-261.

Diplomate of the American Board of hair Restoration Surgery

Titular Member of Brazilian Society of Plastic Surgery

Post-graduated at Prof. Ivo Pitanguy Institute RJ / Brazil (3 yr)

Brazilian Association of Hair Restoration Surgery

International Society of Hair Restoration Surgery Member of FUE Research Committee

European Society of Hair Restoration Surgery

Master Degree In Surgery by Federal University of Cear in Hair transplantation

P08 How to Shorten Outside Body Time in FUE Megasessions


Aman Dua, MD, Kapil Dua, MD. A K CLINICS, LUDHIANA, India.

Dr Aman Dua,is a consultant dermatologist and hair transplant surgeon at AK Clinics( hair transplant centre) in India. She has been actively pursuing hair transplant since 6 years primarily FUE .She is member ISHRS since 4 years and founder member Association of Hair Restoration Surgeons India. A. Dua: None. K. Dua: None. TAKE HOME MESSAGE: Shortening the outside body time can definitely improve the results of surgery in FUE megasessions. ABSTRACT: FUE Hair Transplant is a laborious and time consuming procedure that requires constant effort on part of team to minimize trauma to the grafts. The single most limiting factor in megasessions of FUE is the outside body time that should be taken care of while going on with long hours of surgery. It can surely adversely affect the outcome. The following aspects if taken care of can shorten this time: 1. 2. 3. 4. 5. 6. Planning of Surgery Speed of extraction Break up of extractions into smaller sessions All slits first and then extraction Direct Hair Implantation or simultaneous implantation Shorter Breaks

All these factors if taken into account can definitely reduce the overall outside body time and improve the general results of surgery 6. 1. Speed of extraction

P09 Humanism in Hair Transplant Marketing


Kapil Dua, MD, Aman Dua, MD. A K CLINICS, LUDHIANA, India.

Dr Kapil Dua is an ENT and Hair transplant surgeon at AK Clinics Pvt Ltd. India. He specializes in FUE procedure. He has experimented and successfully implemented newer methods in marketing to establish multiple clinics in India and abroad.He is member ISHRS , secretary AHRS India,National faculty in all AHRS conferences held till date , scientific chairman of joint meeting of 3rd Asian and 5th Indian meeting of Association of Hair Restoration Surgeons K. Dua: None. A. Dua: None. TAKE HOME MESSAGE: Hair transplant is a delicate surgery so it has to be communicated much beyond a before after exercise. It's about having your own communication , not about what everyone else is saying or doing. It's about being human and different in what you communicate. ABSTRACT: A typical syndrome when a patient visits any hair transplant clinic's website is accolades to the operating surgeon ,some big affiliations, pre-operative and post operative pictures and logos of associations where the surgeon is a member. There is practically no difference in all website contents and it becomes very difficult for the patient to differentiate. What seems to be missing is the patient himself. There is a need to develop a platform that says you rather than me. I will be covering the following points: # Whether accolades actually help # Pre- op vs post -op - who knows reality #. Videos that are animated not real # Social media - boon or bane #. Is it just about patient #. Communication orientation -it is you not me

P10
Our Covering Method for Shaved FUE Donor Area Katsumi Ebisawa, MD1, Shintaro Asai2, Yuzuru Kamei1.

1 Department of Plastic & Reconstructive Surgery, Nagoya University Graduate School of Medicine 2 Department of Plastic & Reconstructive Surgery, Social Insurance Chukyo Hospital
K. Ebisawa: None. TAKE HOME MESSAGE: A temporally hair piece is simple and very useful for covering the shaved FUE donor area, and for improving the patients quality of life after FUE harvesting.

ABSTRACT: In 2002, Rassman reported the FUE method, a procedure utilizing a small diameter biopsy punch that leaves unremarkable, diffused donor scars. Because of the non-linear nature of the scars, and less pain during the procedure compared to the conventional strip method, FUE is getting popular throughout the world, and it is anticipated that it will equal or surpass the conventional strip method as the procedure of choice. However, donor hairs have to be shaved to a length of 1-mm, which leaves a very visible donor site in patients requiring a large number of grafts. In cases requiring fewer grafts, the mini strip method a strip that can be covered naturally by the patients own hair, which can be staggered for multiple sites, or the micro strip method multiple thin rows of donor sites, are helpful. Unfortunately, these are timeconsuming procedures and there is a limitation for patients who require numerous grafts. Reports concerning this problem are unavailable at this time. In this presentation, we introduce our covering method for the shaved FUE donor area. Method: We first used a mannequin head as a pilot for this procedure. We created a 13-cm width x 7-cm height shaved patch in the occipital area to mimic the FUE donor site. The site could not be sufficiently covered with its original hair and was fitted with a temporary hairpiece, which has 95-m polyethylene artificial hairs attached to a mesh. We sutured the upper edge of the hairpiece with an unwoven thread as a guideline. The mannequins hairs were braided to the guideline every 1.5 cm along its length and were then fixed with an instant adhesive. We then applied this same procedure to a test subject. Results: The shaved area was completely covered with the partial hairpiece. The hairs were rigidly fixed to prevent loosening. The test subject wore the temporary hairpiece for about 1 month before removing it. As the hairs in the shaved area grew the skin of this site was no longer visible. He experienced no loosening of the hairpiece. There were no complications in using the hairpiece. Discussion: This is the first report concerning FUE donor coverage with a partial hairpiece, which is an effective, noninvasive procedure. It can be fitted to a variety of sizes of donor site, is available in four different colors, and can be used with styling tools such as curling irons to create a natural look. Indications for this method are patients who need a lot of grafts, have low donor hair density, or want to mask the donor area for their job and/or private life. Conclusion: This method is simple and very useful for covering the shaved FUE donor area, and for improving the patients quality of life after FUE harvesting. This donor site masking procedure can contribute to a gain in popularity of the FUE method. I will model the temporary hairpiece in this meeting.

Our covering method for shaved FUE donor area


Objectives !
Because of the non-linear nature of the scar, and less pain during the procedure compared to the conventional strip method, the FUE method is gaining popularity. However, donor hairs have to be shaved to a length of 1-mm, which leaves a very visible donor site in patients requiring numerous grafts. In this presentation, we introduce our covering method for the shaved FUE donor area. A B
Fig.1. A) Shaved area, B) Shaved area is not covered by original hairs

Method !

An occipital area of a mannequin head was shaved like the FUE donor, which could not be sufficiently covered with its original hai , and was fitted with a temporary hairpiece to cover it. This product has 95-m polyethylene artificial hairs attached to a mesh. We sutured the upper edge of the hairpiece with an unwoven thread as a guideline. Using a 0.9-mm crochet hook, hairs are braided with this guideline every 1.5cm along its length, then fixed with Ethyl-2-cyanoacrylate instant adhesive . A B
Fig.2. A) partial hair piece, B) 0.9-mm crochet hook.

Fig.3. Fixation Method. A) selecting hairs for fixation, B) pulling them underneath the guideline, and making a loop, C) inserting the hook into this loop above the guideline, and hooking the same hairs, D) pulling them to make a knot, E)tightening the knot, F) fixing the knot with an instant adhesive (arrow head).

Results!

The shaved area was completely covered with the partial hairpiece. The hairs were rigidly fixed to prevent loosening. The test subject wore the temporary hairpiece for about 1 month before removing it. As the hairs in the shaved area grew the skin of this site was no longer visible. He experienced no loosening of the hairpiece. There were no complications in using the hairpiece. A B

Discussion!

This is the first report concerning FUE donor coverage with a partial hairpiece, which is an effective, non-invasive procedure. It can be fitted to a variety of sizes of donor site, is available in four different colors, and can be used with styling tools such as curling irons to create a natural look. Indications for this method are patients who need a lot of grafts, have low donor hair density, or want to mask the donor area for their job and/or private life.

Conclusion!

This method is simple and very useful for covering the shaved FUE donor area, and for improving the patients quality of life after FUE harvesting. This donor site masking procedure can contribute to a gain in popularity of the FUE method. I will model the temporary hairpiece in this meeting.! !

! Contact Address:!

ebisawa@med.nagoya-u.ac.jp
Fig.4. A) underside view of hair piece after attachment, B) back view of the shaved area completely covered with the partial hairpiece.

P11
Shady EL-Maghraby, MD. Maghraby Skin & Hair Clinic, Cairo, Egypt.

Synthetic Fibers Implantation: To Ban or Not To Ban

Dr. Shady EL-Maghraby, MB BCh, Founder & Medical Director of Maghraby Skin & Hair Clinic, Cairo, Egypt. He is a dermatologist and hair transplant surgeon. Trained in Dermatology in Egypt, and he is currently finishing his Masters in Dermatology at Cairo Univeristy. S. EL-Maghraby: None. TAKE HOME MESSAGE: Synthetic fibers implantation is still done in many countries in spite of its numerous complications. In this presentation I will discuss the nature and the history of these fibers, and I will talk briefly about the complications of that procedure. I will also provide an overview of a case with squamous cell carcinoma of the scalp at the site of the implants that was reported in 2012. Whether to ban this procedure worldwide or not is open for discussion. Likewise, strict criteria for performing it need to be established or not. ABSTRACT: Introduction: Synthetic fibers or artificial hairs were first introduced in the early 1970s, as a new treatment of various types of hair fall. They were made of vinyl-halide polymers. Currently, only two companies manufacture a new generation of fibers made of polyamide material that they claim is inert and safe. This generation is CE approved in Europe and TGA-certified in Asia and Australia. These fibers are 0.08 mm in diameter, 15 cm in length and come in 13 colors, with straight or one of 3 wave types. They are implanted into the galea through an implanter device. A knot at one end ensures correct anchorage of the fibers. The procedure has to be performed as frequent as necessary due to spontaneous loss of the fibers. Premise: In 1983, these fibers were banned in the USA due to numerous reported side effects such as: Recurrent infections. Rejection and periodic loss of fibers needing frequent replacement. Frequent allergic reactions. Fears about possible carcinogenicity. Cicatricial alopecia. Granulomatous hypersensitivity. Cyst formation. Substantiating Data: One of the manufacturer companies posted on its website (http://www.biofibre.com) some published papers and presentations that support their claims. Research conducted in 2003 stated that the adverse events were limited to 1.02% of the cases. Another figure, 1.9%, was stated in research conducted in 2007 and the authors added that frontal scarring of the scalp caused by inflammation and generalized infection were resistant to topical and systemic steroids and

antibiotics. It should be noted however that 7.4% suffered from mild superficial inflammation and infection that were controlled by topical steroids and local/systemic antibiotics in the study. They also reported cases with occasional erythema, itching and excessive seborrhea. In some patients the skin surface showed small depressions and dilatations caused by unremoved sebum plugs, which were very rare to occur in scar tissue, as they claim. In Egypt, I see many cases with synthetic fibers implants, they are all complicated and seeking treatment of complications and asking for natural hair transplantation. They have been significantly depressed because the fibers caused more hair loss as a result of scarring thus leading to deformity and unnatural look of the scalp. The first case I present is for a 33 years old male patient, with a history of 6 sessions of synthetic fibers in the vertex implants, that were done over the last 3 years, where he suffered from chronic inflammation and infection that were treated with topical steroids and antibiotics. The fibers used were manufactured by the Italian company (Biofibre) The exact number of fibers is unknown. On examination the scalp showed excessive scarring (image 1). The fibers were removed by slow traction to extract the buried knots. The scalp then showed excessive scarring which was hypertrophic & atrophic, with deep pits that were filled with yellow waxy material which seemed to be sebaceous or keratinous in nature (image 2). The scalp was cleaned well by saline solution and alcohol and the sebaceous plugs were removed using a Comedo Extractor, followed by intralesional steroid injection. (image 3 & 4) Holes were made by 0.8 mm sharp punch, inside & between the pits, and deeper in the hypertrophic areas (image 5). Followed by implantation of 1800 grafts that were extracted by FUE (image 6) After 24 hours of the operation (image 7) Placement of the grafts was not easy due to increased bleeding, popping up of the grafts and rapid closure and tightening of the holes. Broad spectrum antibiotic and systemic steroid were prescribed. Photos of other cases having complications: Excessive sebum plugs at the sites of implantation (image 8) The same case 4 months after removal of the fibers, showing scarring and post-inflammatory hyperpigmentation (image 9) Multiple sebum plugs with frontal scarring (images 10 & 11) Frontal scarring with hypopigmentation and remnants of fibers (image 12) In 2012, a paper published by the International Society of Aesthetic & Plastic Surgery reported a case with squamous cell carcinoma of the scalp after several synthetic hair grafts. And the authors related the neoplasm to a recurrent local injury, repetitive irritation and micro-trauma similar to Marjolins ulcers occurred at a chronic scar with a latency of 20-30 years. Discussion: Forty years ago, the concept of artificial hair implant as a practical treatment of hair loss was acceptable. In view of the numerous complications associated with that procedure, it is no longer seen as the ideal solution. Whether to ban this procedure worldwide or not is open for discussion. Likewise, strict criteria for performing it

need to be established or not.



Synthetic Fibers Implantation To Ban or Not To Ban


Dr. Shady El-Maghraby, MBBCH

Founder & Medical Director of Maghraby Skin & Hair Clinic, Cairo, Egypt. He is a Dermatologist and Hair Transplant surgeon. Trained in Dermatology in Egypt, and he is currently finishing his Masters in Dermatology at Cairo University.

Dr. Shady El-Maghraby, MBBCH

Introduction
Synthetic fibers or artificial hairs were first introduced in the early 1970s, as a new treatment of various types of hair fall. They were made of vinylhalide polymers. They are implanted into the galea through an implanter device. A knot at one end ensures correct anchorage of the fibers. The procedure has to be performed as frequent as necessary due to spontaneous loss of the fibers.

Materials and Methods


1. On examination the scalp showed excessive scarring (image 1). 2. The fibers were removed by slow traction to extract the buried knots. 3. The scalp then showed excessive scarring which was hypertrophic & atrophic, with deep pits that were filled with yellow waxy material which seemed to be sebaceous or keratinous in nature (image 2). 4. The scalp was cleaned well by saline solution and alcohol and the sebaceous plugs were removed using a Comedo Extractor, followed by intralesional steroid injection. (image 3 & 4). 5. Holes were made by 0.8 mm sharp punch, inside & between the pits, and deeper in the hypertrophic areas (image 5). Followed by implantation of 1800 grafts that were extracted by FUE (image 6). 6. After 24 hours of the operation (image 7). Broad spectrum antibiotic and systemic steroid were prescribed.

Other Cases with Complications


Excessive sebum plugs at the sites of implantation (image 8) The same case 4 months after removal of the fibers, showing scarring and post-inflammatory hyperpigmentation (image 9) Multiple sebum plugs with frontal scarring (images 10 & 11) Frontal scarring with hypopigmentation and remnants of fibers (image 12)

Premise
In 1983, these fibers were banned in the USA due to numerous reported side effects such as: Recurrent infections. Rejection and periodic loss of fibers. Frequent allergic reactions. Fears about possible carcinogenicity. Cicatricial alopecia. Cyst formation.

Image 8

Image 9

Image 10

Image 11

Image 12

Image 1

Image 2

Image 3

Squamous Cell Carcinoma


In 2012, a case with squamous cell carcinoma of the scalp after several synthetic hair grafts was reported. And the authors related the neoplasm to a recurrent local injury, repetitive irritation and micro-trauma similar to Marjolins ulcers occurred at a chronic scar with a latency of 20-30 years.

Patients Background
33 years old male patient. History of 6 sessions of synthetic fibers in the vertex implants, that were done over the last 3 years. He suffered from chronic inflammation and infection that were treated with topical steroids and antibiotics. The fibers used were manufactured by the Italian company (Biofibre). The exact number of fibers is unknown.

Image 4

Image 5

Image 6

Objective
Removal of the fibers and doing natural hair transplant by FUE.

Discussion
Forty years ago, the concept of artificial hair implant as a practical treatment of hair loss was acceptable. In view of the numerous complications associated with that procedure, it is no longer seen as the ideal solution. Whether to ban this procedure worldwide or not is open for discussion. Likewise, strict criteria for performing it need to be established or not.

Image 7

P12 Scalp Biofilm, Hair Loss and Associated Chronic Diseases


John E. Frank, MD1, Robert Burk, MD2. 1 Anapelli Hair Clinic, New York, NY, USA, 2Albert Einstein College of Medicine, New York, NY, USA. Dr John E Frank is an Assistant Professor of Clinical Otolaryngology at Columbia University College of Physicians and Surgeons and the founder of Anapelli Hair Clinic in New York City. Dr Robert D. Burk, MD is a the Professor and Vice Chair for Translational Research in the Department of Pediatrics (Division of Genetics) and is a Professor of Microbiology & Immunology; Epidemiology & Population Health; and, Obstetrics, Gynecology & Women's Health at Albert Einstein College of Medicine Bronx, NY J.E. Frank: None. R. Burk: None. TAKE HOME MESSAGE: The audience should become more familiar with the Scalp Biodome and a possible relationship between Androgenic Alopecia and some common diseases. ABSTRACT: Androgenetic Alopecia (AA) has recently been linked to a number of gene polymorphisms- which in turn are associated with other common diseases (1,2). They have not normally formed a syndrome with AA. The conditions include prostate and coronary artery disease, metabolic syndrome and other disorders including hypertension, diabetes, obesity and dyslipidemia. It is also widely known that androgens and other inherited factors are implicated in AA (3). Additionally, it has recently become recognized that bacteria within the microbiome on different body surfaces and cavities can also influence hormonal levels and other biochemical functions (4,5). In fact, scalp dermal biofilms and microbial interactions may impact inflammation, wound healing and hair loss (6). A genetic component of biofilm susceptibility may also be related to chronic diseases. In this pilot study, we are evaluating the microbiome within the ecosystems of the scalp, including both those affected and unaffected by hair loss (7). We will be evaluating a possible link between the scalp microbiome community and AA. We are sampling the microbiome from areas of the scalp both sensitive and resistant to AA in 15 men with early onset AA and from 15 controls. In addition, we are obtaining questionnaire data in order to ascertain a family history of hair loss and other diseases. The objective is to test the notion that AA may be part of a syndrome associated with other diseases. We further speculate that the scalp microbiome will specifically interact with some as yet unknown host factors, effecting the natural history of hair loss. 1. 2. 3. 4. Li R, Brockschmidt FF, Kiefer AK, et al. Six novel susceptibility Loci for early-onset androgenetic alopecia and their unexpected association with common diseases. PLoS Genet 2012;8:e1002746. Nyholt DR, Gillespie NA, Heath AC, Martin NG. Genetic basis of male pattern baldness. The Journal of investigative dermatology 2003;121:1561-4. Hamilton JB. Patterned loss of hair in man; types and incidence. Annals of the New York Academy of Sciences 1951;53:708-28. Nakatsuji T, Chiang HI, Jiang SB, Nagarajan H, Zengler K, Gallo RL. The microbiome extends to subepidermal compartments of normal skin. Nature communications 2013;4:1431.

5. 6. 7.

Markle JG, Frank DN, Mortin-Toth S, et al. Sex Differences in the Gut Microbiome Drive HormoneDependent Regulation of Autoimmunity. Science 2013. Eloe-Fadrosh EA, Rasko DA. The human microbiome: from symbiosis to pathogenesis. Annual review of medicine 2013;64:145-63. Grice EA, Kong HH, Conlan S, et al. Topographical and temporal diversity of the human skin microbiome. Science 2009;324:1190-2.

P13 Details That Make a Difference in Eyebrow Transplantation


Christine G. Guimaraes, Dermatologist, Hair Restauration Surgeon, Carlos A. P. Guimaraes, Plastic Surgeon, Hair Restauration Surgeon. Clinica GrafGuimaraes, Curitiba/Parana, Brazil. Hair restauration surgeon since 2001, work with follicular units only, performing scalp and other body sites hair restauration, with a great interest for eyebrows. C.G. Guimaraes: None. C.A. Guimaraes: None. TAKE HOME MESSAGE: We can offer completely natural looking eyebrows transplantations, even in scar tissues, what brings a fantastic enhancement in patients self-esteem. ABSTRACT: The eyebrows are an essential part of facial harmony. Eyebrows deformed by excessive hair removal, scars or even absent or diminished by disease or congenital bring discomfort and low self-esteem. With advances in hair transplant techniques, the use of follicular units allows the correction of eyebrows in a completely natural way. Objective: Describe the standardization of technique in transplanting follicular units for eyebrows correction that allows even better results. Method: We performed 37 eyebrow transplantations from 2008 to December 2012 using follicular units of 2 follicles in the center and 1 in follicle in thecontour. In addition to performing the incisions following the direction and angle of the natural eyebrows, the hair curl was directed toward the skin. Results: Eyebrows transplanted as described have achieved a high degree of similarity to natural eyebrows.

Conclusion: The described technique allows performing eyebrows transplantations with completely natural results. Details and subtleties that make a difference in satisfaction and self-esteem of patients.

Details That Make a Difference in Eyebrow Transplantation


The eyebrows are part of the facial harmonization. Eyebrows deformed by excessive hair removal, scars or even diminished or absent due to illness or from birth bring great discomfort and low self-esteem. With the advances in hair transplant techniques, the use of follicular units allows the correction of eyebrows with completely natural aspect. Objective: To demonstrate the results obtained in eyebrows follicular units transplantation with the technique standardization that enables even better results. Method: We standardized the technique of transplanting eyebrows in our clinic since 2008. The design of the eyebrows to be followed is done in conjunction with the patient before surgery. Follicular units are removed in a range 3-5 cm long and about 1 cm width from the occipital region. The follicular units are prepared with the help of stereoscopic microscopes and kept in cold Ringer's lactate solution. The micro-incisions are made with an abocath 16 or 18, with the depth controlled by the catheter cut to the length of the follicles and following the direction and angle of the natural eyebrows. Two follicles follicular units are placed in the central region of the eyebrows and the one follicle follicular units in the contour. The curvature of the hair is inserted facing the skin. Results: In the period from 2008 to January 2013 were performed 37 eyebrows transplantations. Twenty-five women and twelve men. The immediate postoperative recovery is fast. Edema and ecchymosis were the most common complications, usually lasting 3-5 days. Small crusts occurred in 5 patients lasted up to 3 weeks. There were no other complications. The final result is obtained after 8 months of the surgery. Maintenance consists in eyebrows hair cutting, because it keeps growing the same way as the donor area. Discussion: The most common eyebrows correction technique still used today is the tattoo. Besides being unsightly from the beginning, draws attention to the defect, especially in the absence of hair, an important characteristic of the eyebrows. Surgical techniques for correction with the follicular unit transplantation surgery was able to achieve better aesthetic results. The implanted follicles following the direction and angle of the eyebrows natural curvature directed to the skin, with all the subtlety of distribution units and centrally 2 follicles follicular units of 1 follicle on the boundary finalize a refinement that reaches a high degree of naturalness. Conclusion: The described technique allows performing transplants eyebrows with completely natural results. Details and subtleties that make the difference in satisfaction and self-esteem of patients. References Barrera A. Hair Transplantation: the art of micrografting and minigrafting. St Louis: Quality Medical Publishing, Inc; 2002. Epstein JS. Eyebrow Transplantation. Hair Transplant Forum International. 2006 (16): 121. Gandelman M. Eyebrow Transplantation. Hair Transplant Forum International. 1994(4): 17. Haber RS, Stough DS. Hair Transplantation. Procedures in Cosmetic Dermatology. Elsevier Saunders; 2006. Uebel CO. Hair Restauration:micrografts and flaps. So Paulo: OESP; 2001.

Christine de Campos Graf Guimares Carlos Alberto Preto Guimares Clinica GrafGuimaraes

DISCLOSURES: Speaker has no relevant financial relationships or conflicts of interest to declare.

18 16 14 12 10 8 6 4

Causes of eyebrows alopeciaas

Christine Graf Guimares, MD Dermatologist and Hair Surgeon since 2001 Over 1000 hair tranplants performed

Carlos Alberto Preto Guimares, MD Plastic and Hair Transplant Surgery since 2000 Over 1000 hair tranplants performed

2 0 cicatrizes scars excessive hair removal diseases congenital

P14 Technical Aspects for Optimizing the Results of Donor Area Scars
Christine G. Guimaraes, MD. Clinica GrafGuimaraes, Curitiba/Parana, Brazil. Hair restauration surgeon since 2001, using follicular units transplantations only. C.G. Guimaraes: None. TAKE HOME MESSAGE: We believe that paying attention to basic surgical principles with technical rigor is the most important to achieve good quality scars, inconspicuous and leaving both surgeon and patient satisfied. Also, we dont want to have one or two great scars in 200, but a predictable healing. ABSTRACT: The follicular units hair transplant achieved a high degree of refinement and offers completely natural results. But we still face enlarged scars in the donor region, denouncing the procedure and bringing embarrassment to patients. Objective: Submit suture technique of hair transplant donor area, occipital, with better aesthetic result. Method: The transplants performed from August 2010 to December 2012 had the occipital donor site sutured with Vicryl 2-0 in Galea / hypodermis across deep wound to the approximation of borders and continuous suture of mononylon 4-0 of dermis / epidermis, removed after 10 days. These were compared by chart review to the results of scars from donor areas of surgeries performed between 2007 and July 2010. In all surgeries the donor area elasticity was tested and the largest allowed strips were removed, ranging from 1.5 to 2.2 width. The length was from one ear to the other using the U shape.Results: The donor area scars were described as having had good aesthetic result (scar up to 3mm wide) in 92.6% of cases (123 surgeries, 9 widened scars, in which there were performed 6 reoperations for scar corrections). Against 38% of enlarged scars using continuous sutures and superficial approach points scattered in the dermis-hypodermis, that were conducted between 2007 and July 2010. Of the 189 surgeries, there were 72 enlarged scars and from these, 11 needed reoperations for scar correction. Conclusions: To obtain better cosmetic results in donor area scar attention to the fundamentals of surgery are needed, return to classical principles.

Technical Aspects for Optimizing the Results of Donor Area Scars


Christine de Campos Graf Guimares Carlos Alberto Preto Guimares Clinica GrafGuimaraes Curitiba - Brazil
DISCLOSURES: Authors have no relevant financial relationships or conflicts of interest to declare

The follicular units hair transplant hit a high degree of refinement and offers completely natural results. But we still face enlarged scars in the donor region, denouncing the procedure and bringing embarrassment to patients. Objective: To present a suture technique for the occipital donor area, with better cosmetic results. Method: Hair transplants performed from August 2010 to December 2012 had the occipital donor site wound sutured with polyglactin 910 suture 2-0 in galea / hypodermis to approach the edges and continuous mononylon 4 0 suture at the dermis/epidermis level. The suture was removed after 10 days. These scars were compared by chart review with the scars of donor sites of surgeries performed between 2007 and July 2010. Between 2007 and July 2010 there were used superficial continuous suture, at the dermis/epidermis level, and scattered approach points in the dermis-hypodermis, not involving the galea. In all surgeries, from 2007 to December 2012, there were always observed good surgical standards seeking better surgical scars. Namely, closure without tension, asseptic and management pre, peri and post-operative to prevent infections, local hemostasis, adequate coaptation of the edges, post-operative instructions to restrict movements that could cause tension in the donor area. Results: We considered, according to the degree of patients' satisfaction, for comparison, scars up to 3 mm wide as having a good result and scar width above this as widened. Among the scars up to 3mm there were included scars of excellent results, which are inconspicuous, transfixed by hair. Among the largest, there were also those that ranged from 35mm and some rare of 2 cm. Scars wider and apparent underwent reoperations. In the study group (new technique) we found good healing (scar up to 3mm wide) in 92.6% of the cases. One hundred and twenty three (123) surgeries, 9 widened scars, in which there were performed 6 reoperation. The 13 patients operated during this period who did not return for review, by telephone, said they had good scar appearance in the donor area, being satisfied. These were considered to have a good scar result. In the group of the old technique: from the 189 surgeries performed between 2007 and July 2010 there were 38% (n = 72) enlarged scars. Eleven needed reoperation. Thirty-nine patients operated during this period did not return after surgery. By telephone all reported being satisfied with the scar in the donor area (scars were considered as having good result). Discussion: Often the result of the donor area scar is placed in the background by many hair transplant surgeons. But the constraint that an extended scar brings may be greater than the baldness could cause. The wound from the strip transplantation should heal by first intention. It is the duty of the surgeon to use all means to guide and control all that is possible within the healing process of the region. Seeking this purpose, from 2010 on we turned back to focus on the basic surgical principles: reduction of tension in the skin through galeal stitches, excellence in approaching the edges, minimal trauma, use of mononylon suture in the skin to decrease tissue reaction and finally the care in not releasing the edges from the galea to remove the strip, which causes shrinkage of the tissue of the Galea and hinders the approach of the edges with the galeal stitches. The use of tricofitic suture is difficult to implement and should be avoided by surgeons who routinely remove more than 1.5 cm width, since they add up to 1 to 2 mm to the wound and increase the suture tension, resulting in unsatisfactory outcomes. Furthermore, in the tricofitic suture the scarification of one side should not be performed with scissors, because it leaves a beveled edge that hardly allows a perfect approach and leads to a poor aesthetic quality of the scar. Conclusions: We believe that when we pay attention to basic surgical principles and technical rigor, scars have good quality, inconspicuous and leaving both surgeon and patient satisfied. Also, we do not want to have one or two great scars in 200, but a predictable healing that we believe we have. References: Barrera A. Hair Transplantation: the art of micrografting and minigrafting. St Louis: Quality Medical Publishing, Inc; 2002. Haber RS, Stough DS. Hair Transplantation. Procedures in Cosmetic Dermatology. Elsevier Saunders; 2006. Radwanski HN, Ruston A, Lemos RG. Transplante Capilar Arte e Tcnica. So Paulo:Gen Roca; 2011. Uebel CO. Hair Restauration:micrografts and flaps. So Paulo: OESP; 2001.

RESULTS
140 120 100 80 60 40 20 0 11 72

good scar
117

wided scar

reoperations
114

old technique

new technique

Christine Graf Guimares, MD Dermatologist and Hair Surgeon since 2001 Over 1000 hair tranplants performed

Carlos Alberto Preto Guimares, MD Plastic and Hair Transplant Surgery since 2000 Over 1000 hair tranplants performed

P15 A New Ergonomic Microscope for Hair Transplantation


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 140 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: None. TAKE HOME MESSAGE: We rely heavily on our staff for the crucial microscopic portion of the procedure, therefore it is incumbent upon us to provide the most comfortable and safe working environment. This ergonomic dissecting microscope elegantly achieves these goals. ABSTRACT: Introduction Assistants spend thousands of hours at the microscope meticulously slivering and dissecting grafts. Unfortunately, virtually all available dissecting microscopes are designed poorly, with eyepieces angled up, requiring the user to flex the neck, and with a short working distance, requiring the user to hunch the back (see Figure 1 below.)The Mantis scope permits a more ergonomic body position, but many find the optics difficult to use, as the image is reflected onto a screen instead of viewed directly through optical glass. This presentation will review in detail the ergonomics of microscope use, and the specifications of a new ergonomic microscope. Premise The most ergonomic microscope working position is with the back and neck held vertical, the eyes looking straight ahead, and the arms held with the elbows at a 90 angle. A search was undertaken to find a dissecting scope with traditional optics, but with design elements allowing an ideal ergonomic body position. Substantiating Data This search came to fruition with the discovery of the Unitron Stereo Microscope. Key features include an adjustable head allowing horizontal positioning of the eyepieces, expansion tubes elevating the head high enough to allow a straight back, and an objective lens allowing an extraordinarily large working distance without sacrificing magnification or image quality. Discussion Within minutes of switching to this new microscope, staff reported improvements in neck and back discomfort and fatigue. They were able to sit upright, look straight ahead, and keep their arms in a comfortable position (see Figure 2 below.) As we rely so heavily on our staff for the crucial microscopic portion of the procedure, it is incumbent

upon us to provide the most comfortable and safe working environment. This ergonomic dissecting microscope elegantly achieves these goals.

P16 Hair induction by transplantation of human follicular stem cells, dermal papilla cells or their combination with or without laser pretreatment in Nude Balb/c mice
Fariba Jaffary, MD, PhD. Skin Disease and Leishmaniasis Center, Isfahan, Iran, Islamic Republic of. F. Jaffary: None. TAKE HOME MESSAGE: POSTER ABSTRACT: POSTER _ Hair induction by transplantation of human follicular stem cells, dermal papilla cells or their combination with or without laser

Comparing the Trichogen ability of human dermal papilla cells with hair follicular stem cells : An In vivo study
By: Nilforoushzadeh MA.1,3, Aghdami N.2, Jaffary F.3,1, Rahimi E.1, Mohammadi P.2, Keshtmand G.1, Zarkoob H.3 1. Skin and Stem Cell Research Center(SSRC), Tehran University of Medical Sciences 2. Regenerative Biomedicine and Cell Therapy Group of Cell Science Research Center, Royan Institute for Stem Cell Biology and Technology, ACECR, Tehran, Iran 3. Skin disease leishmaniasis research center (SDLRC)

Introduction
Androgenic alopecia is the most common type of hair loss affecting both men and women. Although the disorder is typically viewed as medically benign condition, it could negatively impact the social and psychological well-being. Different treatment strategies have already been introduced for androgenic alopecia including both medical and surgical options. Topical minoxidil and oral finasteride are the only two FDA-approved drugs for androgenic alopecia. Both drugs require chronic use for efficacy and alopecia may rapidly recur on cessation of the treatment. Current surgical treatment involves harvesting small pieces of hair follicles from a donor site and grafting them to the bald or thinning areas. However, adequate donor supply is critical to a successful transplantation procedure. Over the last decade, new discoveries in stem cell research have revolutionized modern medicine, providing hope for new therapeutic options. Stem cells are undifferentiated slowly cycling cells with the ability of either self-regeneration or differentiation into more mature specialized population. This differentiation into the desired derivatives makes them a suitable candidate for restoring lost cells and damaged tissues. Hair follicles are the main source of multipotent stem cells in the skin. The division and differentiation of stem cells can potentially renew skin and restore hair follicles. However, their fate is controlled by both intrinsic factors and their surrounding microenvironment characteristics. Advances in the isolation technique and microarray analyses have revealed close signal interaction of stem cells with a population of mesenchymal cells in the skin, known as dermal papilla cells (DP). DP cells are specialized mesenchymal cells reside at the base of the hair follicle regulating development and growth of hair follicle. They also serve a reservoir of multi-potent stem cells. It was long believed that epithelial stem cells are able to renew hair only when combined with dermal papilla cells. This concept is changing as new observations identified induction of new dermal papilla cells in epidermis by activation of Wnt/-catenin. Nevertheless, the proliferation capability is not limited to hair follicle stem cells. There is evidence of capacity of other epithelia for hair follicle generation when juxtaposed with dermal cells. Interfollicular epidermis is the possible hair generator when combined with inductive dermal papilla in those cases without stem cell. As new insights into the hair follicle and its different cell populations are increasing, more attention has been devoted to their therapeutic application for alopecia. However, identification of each cell linage trichogen ability is essential for exact cell isolation and culture. It is also critical for achievement of smaller and more efficient hair generator units ready for hair transplantation. Although there are several in vitro reports of trichogen ability of the two cell populations, there is a few evidence concerning their trichogenicity in in-vivo studies. The present study was designed to assess the ability of follicular stem cells, DP cells and their combination in reconstitution of hair follicles in an animal model.

Methods
This interventional / experimental study was conducted in Skin and Stem Cell Research Center, Tehran University of Medical Sciences, Tehran, Iran. The study was carried out in two stages of cell preparation and cell injection. Stripe graft was obtained from hairy areas of scalp skin of a hair transplantation candidate after obtaining an informed written consent. A part of the donor strip with the diameter of 1.5*1.5 cm was transferred to Royan Institute in sterile conditions for cell culture and reproduction. Stem cells and dermal papilla cells were isolated and cultured in specific media as described elsewhere. Then, 20 male Balb/c athymic nude mice (4 weeks old) were divided into four groups (n=5). Mice in the first group were treated with a suspension of dermal papilla cells. In the second and the third groups a suspension of follicular stem cell or a combination of follicular stem and dermal papilla cells was injected. The last group received cell culture media only (placebo).Under sterile conditions, the mice were anesthetized by intraperitoneal injection of ketamine hydrochloride (100 mg/kg) and xylazine hydrochloride (10 mg/kg). Then the injection site was cleansed with 10% povidoneiodine solution and 70% ethanol. Each graft was transplanted through 10 subcutaneous incisions into the skin of the right and left dorsum using a 25-gauge needle. The grafts were covered with standard bandage dressing. No topical antibiotic was applied to the grafts. The animals were closely monitored throughout the study and weekly measurements were taken until the 7th weeks. Skin biopsies were taken at the 3rd week post- transplantation. The samples were fixed for 10 minutes in 10% formaldehyde solution at room temperature and 0.2-mthick sections were prepared for routine hematoxylin-eosin staining and light microscopy histological examination.

Results
Hair growth was observed in one mouse (20%) injected with stem cell and two mice (40%) injected with the combined suspension of stem cells and dermal papilla cells. There was no hair growth in the group treated with isolated dermal papilla cells or culture media. The difference between these four groups was not statistically significant (P=0.23). developed anagen follicles at the 3rd week in the mice injected with stem cells or combined dermal papilla and stem cells. No cystic change of sebaceous gland was observed. No obvious abnormalities or malignant transformation were detected in the morphology of epidermis, hair follicles and sebaceous glands.
Histologic examination of post-transplantation follicles shows fully

Hair growth in two mice treated with combined stem cell and dermal papilla cell suspension, 7 weeks after the injection

Although the hair growth was observed in a small number of the treated mice, the pathology reports of the stem cell- and mixed cell- injected mice revealed a progress to anagen phase which was not observed in dermal papilla cell treated group.

References
1. Mistriotis P, Andreadis ST. Hair follicle: a novel source of multipotent stem cells for tissue engineering and regenerative medicine. Tissue Eng Part B Rev. 2013 Aug;19(4):265-78. 2. . Al-Refu K. Stem cells and alopecia: a review of pathogenesis. Br J Dermatol. 2012 Sep;167(3):479-84. 3.. Jaks V, Kasper M, Toftgard R. The hair follicle-a stem cell zoo. Exp Cell Res. 2010 May 1;316(8):1422-8. 4.. Driskell RR, Clavel C, Rendl M, Watt FM. Hair follicle dermal papilla cells at a glance. J Cell Sci. 2011 Apr 15;124(Pt 8):1179-82. 5. Stenn KS, Paus R. Controls of hair follicle cycling. Physiol Rev. 2001 Jan;81(1):449-94. 6. Waters JM, Richardson GD, Jahoda CA. Hair follicle stem cells. Semin Cell Dev Biol. 2007 Apr;18(2):245-54. 7. Zhang Y, Andl T, Yang SH, Teta M, Liu F, Seykora JT, et al. Activation of beta-catenin signaling programs embryonic epidermis to hair follicle fate. Development. 2008 Jun;135(12):2161-72. 8. Stenn KS, Cotsarelis G. Bioengineering the hair follicle: fringe benefits of stem cell technology. Curr Opin Biotechnol. 2005 Oct;16(5):493-7. 9. Blanpain C, Lowry WE, Geoghegan A, Polak L, Fuchs E. Selfrenewal, multipotency, and the existence of two cell populations within an epithelial stem cell niche. Cell. 2004 Sep 3;118(5):635-48. 10. Lim TC, Leong MF, Lu H, Du C, Gao S, Wan AC, et al. Follicular dermal papilla structures by organization of epithelial and mesenchymal cells in interfacial polyelectrolyte complex fibers. Biomaterials. 2013 Sep;34(29):7064-72. 11. Levy V, Lindon C, Harfe BD, Morgan BA. Distinct stem cell populations regenerate the follicle and interfollicular epidermis. Dev Cell. 2005 Dec;9(6):855-61. .

Hair growth in one nude mouse 7 weeks after the injection of stem cells

Are isolated follicular stem cells and dermal papilla cells able to regenerate hair? Is combination of both cell linages critical for hair generation in invivo?

Only stem cells and combined stem cells with dermal papilla cells resulted in hair growth.

No hair growth with dermal papilla cell injection.

Acknowledgements
We would like to acknowledge ISHRS, SSRC, and SDLRC for their financial support of this project.

P17 Total Hairline Correction in Female Patients


JaeHeon (Jay) Jung, MD. KangNam YonSei Hair transplantation center, Seoul, Korea, Republic of. Graudated from Medical college of YonSei University at 1985 Korean board of Plastic surgery since 1990, American board of Hair Restoration Surgery since 2007 President of Korean Society of Hair Restoration Surgery Past chairman of Korean Association of Hair Plastic surgery Award on 2004 Vancour ISHRS meeting on the title of " Natural hairline correction in female patients with wide forehead " Co-author of Korean textbook of " Hair tramsplantation " J. Jung: None. TAKE HOME MESSAGE: In female patient with M shaped or rectangular hairline, total hairline correction which included not only mid-frontal area and fronto-temporal recession,but also temporal peak, infratemporal area and sideburn is better than simple correction of frontotemporal recess in reducing the facial area and maintaining the aesthetic facial balance. ABSTRACT: Introduction The shape of the hairline and the ratio of the forehead to the face are both important factors for a balanced and attractive face. Because males primarily have a hairline with a rectangular or M shape (a frontotemporal-recessed shape), females with such shapes often have a strong masculine image and appear older. In the past, forehead reduction was performed in a plastic surgery field so that the height of the forehead could be reduced, but the effect was negligible due to scarring along the hairline, the inability to correct the frontotemporal recess, and a backstretch phenomenon. However, follicular unit (FU) transplantation was used recently so that the forehead could be reduced naturally and effectively by changing the rectangular- or M-shape hairline to a round-shape hairline, thus reducing the forehead Premise In case of correcting only the frontotemporal recess or frontal area of hairline, you can see the wide rectangular shape of forehead on frontal view and promiminently broad side-face on three-quarter and lateral view. So author are going to introduce a harmonious, balanced correction, named as total hairline correction that corrects not only the frontal midpoint and fronto-temporal line, but also a temporal point, infra-temporal area, and/or sideburn. Substantiating Data Author studied 300 operation patients in last three years whose mean age was 29.3 years ( range 19-57 years ) and the average reduced length was followed : frontal mid-point : 0.63 cm ( 0 1.5 cm) frontotemporal apex : 3.38 cm ( 1-4.5cm) Rt side 3.18 cm ( 1-4.5cm) Lt side temporal point : 0.91 cm ( 0 3 cm) Rt side

0.88 cm( 0 - 3 cm) Lt side infratemporal apex : 0.92 cm ( 0-1.5cm) Rt side 0.93 ( 0 -2cm) Lt side Discussion I am going to explain my design technique of total hairline correction, dividing the hairline into five portions frontal area, fronto-temporal recess, temporal point, infra-temporal area and side burn and show a design process by video.

Total hairline correction in female patients Jae-Heon ( Jay ) Jung M.D. Objectives
Biography: Graduated from Medical college of YonSei Universit y at 1985 Korean board of Plastic surgery since 1990, American board of Hair Restoration Surgery since 2 007 President of Korean Society of Hair Restoration Sur gery Past chairman of Korean Association of Hair Plastic surgery Award on 2004 Vancouver ISHRS meeting on the tit le of Natural hairline correction in female patients with wide forehead Co-author of Korean textbook of Hair transplantati on KangNam YouSei Hair transplantation center, Seoul, Korea, Republic of. Introduction The shape of the hairline and the ratio of the fore head to the face are both important factors for a balanced and attractive face. Because males prima rily have a hairline with a rectangular or M shape ( a frontotemporal-recessed shape), females with su ch shapes often have a strong masculine image an d appear older. In the past, forehead reduction was performed in a plastic surgery field so that the height of the for ehead could be reduced, but the effect was neglig ible due to scarring along the hairline, the inability to correct the frontotemporal recess, and a backst retch phenomenon. However, follicular unit (FU) transplantation was us ed recently so that the forehead could be reduced naturally and effectively by changing the rectangul ar or M-shape hairline to a round-shape hairline, thus reducing the forehead.

In case of correcting only the frontotempor al recess or frontal area of hairline, you can see the wide rectangular shape of forehea d on frontal view and promiminent broad s ide-face on three-quarter and lateral view. So author are going to introduce a harmon ious, balanced correction, named as total h airline correction that corrects not only the frontal midpoint and fronto-temporal line, but also a temporal point, infra-temporal a rea, and/or sideburn.

Discussion I am going to explain my design technique of total hairline correction, dividing the hai rline into five portions frontal area, front o temporal recess, temporal point, infra temporal area and side burn.

Material and method Author studied 300 operation patients in la st three years whose mean age was 29.3 ye ars (range 19-57 years) and the average red uced length was followed: frontal mid- point : 0.63 ( 0 1.5 cm) frontotemporal apex : 3.38 ( 1-4.5cm) Rt 3.18( 1-4.5cm) Lt temporal point : 0.91 ( 0 3 cm) Rt 0.88 ( 0 - 3 cm) Lt infratemporal apex : 0.92 ( 0-1.5cm) Rt 0.93 ( 0 -2cm) Lt

Conclusion In female patient with M shaped or rectangul ar hairline, total hairline correction which incl uded not only mid-frontal area and fronto-te mporal recession, but also temporal peak, infr atemporal area and sideburn is better than si mple correction of frontotemporal recess in r educing the facial area and maintaining the a esthetic facial balance.

P18 The Effect of Electromagnetic Field Based Multimodality Treatment on Patient Undergoing Hair Transplantation

Hyo Kang, MD. So Jeong Park,MD. Sang Kwon Yoon, MD. Miracle Hair Implant, Gwangju, Korea, Republic of.

2002. Chonnam National University Medical School(CNUMS) Graduate, Korea 2005. CNUMS Master degree 2007. CNUMS Ph. degree 2002. Chonnam National University Hospital (CNUH)internship. 2003~2007 CNUH general surgery resident training 2007~2008 Military duty 2008 MultiNational Force, Zaytun, Iraq Surgical Captain 2009~2010 Military Surgical Captain, Korea. 2010 Fellowship of Colorectal surgery 2011 Hair transplantation training, Korean Clinic. 2012 Neograft Training, Centrailer Hospitalier, Paris, France 2012 ISHRS FUE Palooza attendance ISHRS, member AACS, member ASHRS, member KSHRS (Korea society of Hair restoration Surgery), member AAHRS (Asia Association of Hair restoration surgery), member H. Kang: None. S. Park: None. S. Yoon: None. TAKE HOME MESSAGE: EMF based multimodality approach for transplanted hair may help early growth of qualified transplanted hair. ABSTRACT: Background When the transplanted hair grow is the major concern for patients who underwent hair transplantation surgery. Many article reported that the grow time is variable and between three and four months. However, the range of growing time is as wide as between 2 month and 1 year. Several article about EMF(ElectroMagnetic Field) on hair referred the modulation of follicular cycle and the improvement of quality of hair shaft. So, this study is designed to evaluate the effect of electromagnetic field on early growth of transplanted hair. Material and Method Overall seventy patient were enrolled to study between January 2012 and January 2013. Fifteen patients were treated with multimodality therapy including electromagnetic field (ETG Mark I, produced by CTC, Inc., Canada) from 2 weeks before and after transplantation. EMF therapy was done weekly during 36 weeks after transplantation and microneedling with synthetic growth factors was done monthly. Four point for check of growth was set in a size 1 cm2 1 day after transplantation. Fourty five patients was cared with ususal post-transplantation protocol of my clinic. The effect of EMF was evaluated by photography, digital follioscope on same points at 8, 12, 16, 20, 24, and 36 weeks. Every patient were observed weekly and monthly. Mean follow-up period was 368 weeks. Results

The growth rate without shedding of transplanted hair was significantly higher in EMF based treatment group. And the growth rate after shedding of transplanted hair were also significantly higher in EMF group. In EMF group the growth of transplanted hair started at 9 2 weeks, while in other group it took loger time (13 2 weeks). Patients with EMF based post-transplantation therapy satisfied their visual improvement better in 20 weeks visual analogue scale. Conclusion Early hair growth and lower shedding rate was shown in cases with EMF based multimodality treatment after hair transplantation. Patients satisfied their transplanted hair earlier. EMF may affect positively on transplanted hair as modulating follicular cycle, although the mechanism of EMF on hair was not clearly known. For overcoming the limitation of single clinic and small data, further study will be needed. This study is not related with any financial disclosure and interest in any pattern.

The Effect of Electromagnetic Field Based Multimodality Treatment on Patient Undergoing Hair Transplantation
Hyo Kang, MD., So Jeong Park, MD. Hair Loss and Tranplantation Center, Miracle Clinic, Gwangju, South Korea.

Objective
Electromagmetic field(EMF) effects on soft tissue including hair follicles Especially effective in case of Telogen effluvium EMF may affect on transplanted hair follicular cycling positively Regrowth time after HT range between 2 months and 1 year. EMF based post-transplantion treatment may induce early re-growth of transplanted hair.

Method
From Jan. 2012 to Jan. 2013 EMF based multimodality Tx : 5aRI only = 15 : 55 EMF tx weekly during 36 weeks after transplantation Microneedling with synthetic growth factor monthly 7 angle photography, digital follioscope monthly

Results
100 90 80 70 60 50 40 30 20 10 0 EMF based multimodality Tx Conventional postop care. 10 9 8 7 6 5 4 3 2 1 0 3 month 6 month 9 month 12 month

Conclusions
45 40 35 30 25

P = 0.01

* P = 0.024

P = 0.059

P = 0.037 P = 0.006
EMF based postop care Conventional postop care

P = 0.67

P = 0.71

* P = 0.003
EMF based course Conventional course

20 15 10 5 0 3 month 6 month 9 month 12 month

Table 1. A comparison of the rate of shedding after hair transplantation.

Table 2. A Comparison of Analogue Scale for satisfaction of visuality after hair transplantation according to the interval.

Table 3. A Comparison of graft number start to grow between EMF based postoperative care group and conventional postoperative care group.

Pre

3m

6m

Pre

3m

6m

Pre

3m

6m

Figure 1A. A case of 25 years old, BASP F2 pattern male patient underwend 1987 graft transplantation with FUE and FUSS followed by EMF based mulitmodality treatment.

Figure 1B. A case of 28 years old, BASP M2F2 pattern male patient underwend 2375 grafts transplantation with FUE and FUSS followed by EMF based mulitmodality treatment.

Figure 1C. A case of 29 years old, BASP C2F2 pattern male patient underwend 2145 grafts transplantation with strip surgery followed by EMF based mulitmodality treatment.

In Asian people, the number of donor grafts are absolutely limited as compared with caucasian people. Aggressive behavior of androgenetic alopecia tends to increase recently in young male. st So, 1 session of hair transplantation and postoperative hair loss treatment is very important. EMF may lead less shedding and earlier growth of transplanted hairs. As postoperative treatment, EMF based multimodality treatment show synergic effect tp both involved hairs and transplanted hairs in earlier phase of post-transplantation course.

P19
Emre A. Karadeniz, MD. Transmed, Istanbul, Turkey.

The Advantages of Being Able to Do FUT and FUE in Making a Treatment Plan

Dr. Emre A. Karadeniz is a plastic surgeon currently practicing in Istanbul, Turkey. He has devoted most of his work and research on hair restoration surgery for the last 3 years. His experience in FUE has led to more than one million graft extractions in this period. On the other hand he strongly believes in the value of FUT and makes his treatment plans using both techniques. E.A. Karadeniz: None. TAKE HOME MESSAGE: FUT is the gold standard technique in most cases. FUE is a good alternative in many cases and is sometimes the only option. A combined technique is a good way of making a megasession without stretching the limits of either technique. In order to be able to make the optimum treatment plan, it is important to be able to offer both techniques. ABSTRACT: Introduction FUT has served as the main method of treatment in hair surgery for a long time and still is considered the gold standard method by most hair surgeons. FUE has been recently popularized and an ongoing debate on whether FUE is as valuable as FUT has started. Proponents of FUE have claimed that it has great potential, needing a smaller team, being able to extract grafts from areas that are beyond the scope of a strip and not having to leave a permanent linear scar. Opponents of FUE have been skeptical about high transection rates, physical trauma to the grafts, extraction from unsafe areas and moth-eaten appearances at donor areas that are even more problematic than a linear scar. Several authors, especially FUT surgeons, have attempted to address these issues but it has been doubtful if these authors have been able to do an objective evaluation, due to lack of experience with the other technique they have been criticizing. On the other hand, many young generation surgeons have gone off the rails with FUE, resulting with a high incidence of complications and suboptimal results, which in turn has encouraged FUT surgeons to emphasize the disadvantages of FUE, leading to a vicious circle where an objective assessment and appropriate utilization of techniques can hardly be made. Premise It is undebatable that FUT is the safest way of getting the best grafts in most cases. On the other hand, if the technique is mastered, FUE can be a good alternative in many patients and even be clearly advantageous or the only practical choice in some patients. Being able to offer both techniques gives the hair surgeon great capability of making an optimal treatment plan. The combined technique can also be useful when a megasession is needed. Substantiating Data The author presents cases of his own which he groups according to the formulation of a treatment plan: I) Patients he offers FUT and the patient agrees, II) Patients he offers FUT but the patient prefers FUE, III) Patients he gives the choice of both techniques and the patient chooses FUE, IV) Patients he offers FUE and the patient agrees and V) Patients he performs a combined technique. The two other groups of patients which are, patients he gives a choice of both techniques and the patient chooses FUT and patients he offers FUE but the patient chooses FUT are very rare in the authors practice. Three cases from each group are presented. The rationale behind the surgeons preference, the surgeons approach when the patient preferred the second best option and the outcome of the treatment is discussed. Generalizations for each group of patients are also made.

Discussion Many years of experience at hair surgery has brought us to a point; I) FUT is the safest technique for most cases, II) FUE can be a good alternative in many patients and the only option in some patients, when FUT isnt an option for various reasons such as inelasticity of the skin, patients with previous multiple FUT sessions and patients who refuse FUT. III) The combined technique can be the answer when a megasession is needed, without having to stretch either technique too much. Therefore, is it not time to leave the debates on which technique is better and utilize both techniques?

THE ADVANTAGES OF BEING ABLE TO DO FUT AND FUE IN MAKING A TREATMENT PLAN
Ali Emre Karadeniz, Melike Kulahci
Transmed Clinic, Istanbul, Turkey INTRODUCTION FUT has served as the main method of treatment in hair surgery for a long time and FUE has been recently popularized and an ongoing debate has started. Proponents of FUE have claimed that it has great potential, being able to extract grafts from areas that are beyond the scope of a strip and not having to leave a permanent linear scar. Opponents of FUE have been sceptical about high transection rates, physical trauma to the grafts, extraction from unsafe areas and motheaten appearences at donor areas that are even more problematic than a linear scar. Several authors, especially FUT surgeons, have attempted to address these issues but it has been doubtfull if these authors have been able to do an objective evaluation, due to lack of experience with the other technique they have been critisizing. On the other hand, many young generation surgeons and even unauthorised technicians have gone off the rails with FUE, resulting with a high incidence of complications and suboptimal results, which has lead us to an environment where an objective assesment and appropriate utilization of techniques can hardly be made. Mastering and being able to offer both techniques gives the hair surgeon great capability of making an optimal treatment plan, realizing the full potential of the donor capacity with multiple sessions and a higher number of grafts. The combined technique can also be usefull when a single method can not give a satisfactory number of grafts. PATIENTS AND METHODS The author presents three cases. The first patient (Figure 1) who is 41 years old, had his first operation in 2004, which was a 2974 graft FUT operation, the second operation in 2006, which was a 2255 graft FUT operation. When he came in 2011 (Figure 2) he had no skin laxity to permit a third FUT operation, so a 2710 graft FUE was performed (Figure 3). The distribution of the grafts in this operation was 300 singles, 700 doubles, 1150 3-haired and 560 4-haired FUs. The second patient who is 47 years old, had a Norwood type-6 patern hair loss (Figure 4). The width of the recipient area mesured approximately 20 cms. It was evident that to be able to cover a moderate area, it was necessary to obtain about 5000 grafts. For this purpose, a combined procedure of 4960 grafts was performed (Figure 5-6). The third patient who is 50 years old, had his first operation in 1999, which was a 1138 graft FUT, the second operation in 2007, which was a 1940 graft FUT. When the patient came in 2011 (Figure 7) the donor had little hight and it seemed that with either technique it would not be possible to get a satisfactory number of grafts, so a combined procedure was performed giving 3242 grafts (Figure 8). Figure 3 Figure 6 Figure 2 Figure 5

Figure 1

Figure 4

DISCUSSION FUT and FUE are like the fishing net and the fishing rod for the fisherman. It is not possible to make an optimal plan for every patient unless we can offer both techniques when needed. FUT should remain the main weapon and the technique of choice for the majority of first sessions. FUE should be considered after utilizing all FUT capacity or the combined technique can be the answer when a gigasession is needed, without having to stretch either technique too much. Is it not time to leave the debates on which technique is better and utilize both techniques? Figure 7 Figure 8
Education Istanbul University Istanbul Medical Faculty, Istanbul, 2000 Kocaeli University Department of Plastic, Reconstructive and Aesthetic Surgery, Istanbul, 2007 Experience Transmed Hair and Cosmetic Surgery Clinic, Istanbul, Plastic Surgeon, 2010 Today Memberships Member, International Society of Hair Restoration Surgery (ISHRS) 2011 Member, Turkish Society of Plastic, Reconstructive and Aesthetic Surgery (TPRECD), 2008

P20 Advantages and Disadvantages of FUE Using ARTAS SYSTEM for Japanese
Keiichiro Kasai, MD, Izumi Haruyama, MD, Yoshiyuki Aikawa, MD, Koichi Saito, MD. Shonan Hair Restoration Surgery Center, Tokyo, Japan. 1984 Graduated Shimane University 1997 Associated Professor of Neurosurgery in Toho University 2008 Chief Manager and Director of Shonan Hair Restoration Surgery Center K. Kasai: None. I. Haruyama: None. Y. Aikawa: None. K. Saito: None. TAKE HOME MESSAGE: This is the first presentation of the Artas System for Japanese patients. The quality of Japanese scalps and hairs are different from those of Caucasians. Then there need to be some strategies. ABSTRACT: Technique: We operated on 42 Japanese (40male & 2 female) with ARTAS SYSTEM. Age of patients: youngest 22 oldest 70 average 36 All patients are male.1067 punches were done and 798 grafts were got in average. 500 grafts were got per hour in average. We removed all grafts by forceps and checked under microscope and also trimming is done if needed. Small slits are made with 1mm surgical knife for single hair follicles and 1.2mm for more than double hair follicles. The average of transection rate is 5.9% (minimum 2.0% and maximum 12.0%) Discussion: Artas System is very useful for FUE hair restoration surgery for Japanese AGA.

Hair restoration Surgery by ARTAS


Follicular extraction Manual method:depending on the doctors technic ARTAS Robotic System:no depending on the doctors technic?

Introduction

PATIENTS &METHODS
Seventy eight patients were treated with hair restoration surgery using ARTAS Robotic System from Dec. 2012 to May 2013. Four eyebrow cases and three scar cases and one pubic hair case are excluded from this study and seventy patients were evaluated.

Results 1-2

Seventy patients Sex: 66male and 4 female Age:mean 36.8(19-72) Recipient area:M 43cases M+P 3cases M+V9cases M+V+P7cases P 2cases V 4cases V+P 1case Harvest Performed Total: 85,644 times Mean:874( minimum 359-maximum 2841) Good Grafts obtained Total: 62,060 grafts ( minimum 266-maximum 16003) Mean percentage 74.0%(43.4 - 104.1)
female

Disclosures
Dr.Kasai is doing hair restoration surgery for this five years at Shonan Cosmetic Surgery Clinic in Japan. He is a board certified neurosurgeon.

P21 Non-Absorbable Buried Sutures in HT to Minimize Donor Scars


Manoj Khanna, MD. Enhance Aesthetic & Cosmetic Studios Pvt Ltd, Kolkata, India.

DR. MANOJ KHANNA Dr. Manoj Khanna is a Board- certified plastic and cosmetic surgeon, practicing in Kolkata. The APSI 'Visiting Professor in Cosmetic Surgery' for the year 2006-2007, he has been invited to give lectures and do workshops in various parts of India & abroad. He has designed a special instrument called the "Kolkata Slit" which is being patented and is very useful for Follicular Unit Hair Transplantation. He was the President of the Association of Hair Restoration Surgery of India in 2012. Dr. Manoj Khanna is a regular commentator on TV and All India Radio for cricket and tennis for more than 20 years. He was a commentator on the live telecast of Mother Teresas funeral. Dr. Khanna is a very keen sportsman, regularly plays tennis and cricket even now, and was a College Blue for his sporting activities. M. Khanna: None. TAKE HOME MESSAGE: Use of non-absorbable sutures like 2-0 Nylon in deeper layer below hair roots minimizes stretching of the wound and reduces scars in the donor area of HT to minimal visibility. ABSTRACT: Donor area scars are a major concern of patients undergoing hair transplant (HT). Aggressive campaigning of FUE,often misleading, has further confused the balding man about donor morbidity. Any cut in the human body always leaves a scar. Scars stretch with time and tension, and can be made finer and less noticeable by proper surgical technique and minimal tension on the suture line. Any absorbable suture material does not have tensile strength to hold the wound for more than 4-6 weeks. But scars stretch for 6 months or more. I have been using 2-0 Nylon in the deeper layer below the hair roots after strip harvesting to approximate the wound since 2006 in more than 2500 cases. Trichophytic closure in the skin has minimized donor scar to almost minimal, if not invisible in most cases of HT.

P22
Jino Kim, MD. New Hair Institute Korea, Seoul, Korea, Republic of.

An Easy Method to Minimize Transection with Fine Blade Angle Adjustment in FUSS

Dr. Jino Kim is a board certificated plastic surgeon and ABHRS, practices hair restoration surgery since 2007 in Seoul. He is a secretary of KAHPS(Korean Academic Association of Hair Plastic Surgeon), and a director of KHRS(Korean Association of Hair Restoration Surgeon). J. Kim: None. TAKE HOME MESSAGE: If only hair shafts are observed without hair bulbs being seen on inferior incision side, the blade angle against to the scalp is likely to obtuse. If hair bulbs and partial hair shafts are observed along the inferior incision side margin, the blade angle to the scalp is likely to acute. ABSTRACT: Background Follicular unit strip surgery (FUSS) is the most popular method for hair transplantation. With some exceptions, most surgeons who enter into the business learn the FUSS method as the primary method of harvesting grafts. A troublesome fact that novice surgeon face is the transection of hair follicles along the incisions of the donor tissue. Purpose There are a few methods to minimize transection of hair follicles for the FUSS method. For example, utilization of either Haber spreader or skin hooks to separate the donor tissue along a 1 to 2 mm deep incisional line. Both methods are very efficient at lowering the trasnection rates. However, the use of Haber spreader may result in crush injury to the donor margins if the patient carries fibrotic scalp tissue or multiple hair transplantation surgeries, and use of skin hooks will lengthen the overall operating time. Methods The donor strip is harvested using a #10 or 15 blade scalpel with a 4 to 5 mm incision depth while keeping close attention to the intact hair follicles along the incision line. When I observe a transection of hair follicles, I immediately change the angle of blade according to prevent further transection. When I observe incision margin over an Inferior incision side, if only hair shafts are observed without hair bulbs being seen, the blade angle against to the scalp is likely to obtuse. Correction should be made so that the blade angle should become more acute. Conversely, when hair bulbs and partial hair shafts are observed along the inferior incision side margin, the blade angle to the scalp is likely to acute. Correction should be made so that the blade angle becomes more obtuse. Discussion I suggest that the blade is intact to the incision margin at all times in a single incision line, and a surgeon must observe the wound margin if even a single hair follicles is transected. The harvesting time of a donor strip can be shorter when a blade angle is carefully watched not to touch the hair follicles. The use of a more 3 times magnifying loupe is strongly recommended to have a clear view of the hair follicles along the incision. Suction should be well utilized to obtain a clean unobstructed view from bleeding

ISHRS
Background

An Easy method to Minimize Transection with Fine Blade Angle Adjustment in FUSS
Stopper

Jino Kim, Md, ABHRS (Seoul, Korea)

* Follicular unit strip surgery(FUSS) is the most popular method for hair transplantation. * With some exceptions, most surgeons who enter into the business learn the FUSS method as the primary method of harvesting grafts. * A troublesome fact that novice surgeon face is the transection of hair follicles along the incisions of the donor tissue.

Methods

Methods

Result
* The blade is intact to the incision margin at all times in a single incision line * A surgeon must observe the wound margin if even a single hair follicles is transected. * The harvesting time of a donor strip can be shorter when a blade angle is carefully watched not to touch the hair follicles.

* When I observe incision margin over an Inferior incision * When hair bulbs and partial hair shafts are observed along side, if only hair shafts are observed without hair bulbs being the inferior incision side margin, the blade angle to the scalp seen, the blade angle against to the scalp is likely too obtuse. is likely too acute. * Correction should be made so that the blade angle should becomes more acute * Correction should be made so that the blade angle becomes more obtuse

Tips
* The use of a more 3 times magnifying loupe is strongly recommended to have a clear view of the hair follicles along the incision. * Suction should be well utilized to obtain a clean unobstructed view from bleeding. * Well trained assistants are surely helpful for entire procedure

Summery

8 times magnifying loupe

DISCLOSURES
Dr. Jino Kim is a Plastic Surgeon and ABHRS, has been exclusively practicing hair transplantation in Seoul, Korea. He received his undergraduate degree from the Yonsei University in Seoul, Korea with a major in medicine. After four years of Plastic Surgery residency at Yonsei University Graduate School of Medicine, Dr. Kim practiced that specialty. The author has no relevant financial relationship or conflicts of interest to declare.

P23 Differences in Preferences for Female Hairline Between Doctors and Patients
Juyong Kim, MD.1, Inho Park, MD1, Jaehun Jung, MD2. 1 Mojelim Plastic Surgery Clinic, Seoul, Korea, Republic of, 2Gangnam Yonsei Hair Transplantation Center, Seoul, Korea, Republic of. Mojelim Plastic Surgery Clinic, Seoul National University Hospital, Bundang, Hair Center, Reserarcher J. Kim: None. I. Park: None. J. Jung: None. TAKE HOME MESSAGE: Preferences of female hairline is different between doctors and patients. Doctors must ask more for what the patients truly want. ABSTRACT: Background Hair transplantation for female takes much more popularity with correcting hair line than for treating alopecia in Korea. For achieving it, aesthetic frontal hairline design is the most important factor. Facial beauty is a representation of ones self esteem along with social recognition of oneself. The definition of beauty solely depends on nationality, races, social atmosphere and personal aspects. However, generalized definition of beauty is not a proper way of determining one. Between doctors and patients, with more gaps in education, economy, and social levels are reasons of differences in perspectives of beauty. Purpose We researched among two groups, doctors and patients, on the subject of defining proper standards of beautiful female frontal hairline. Using the final data of this paper, consulting doctors can understand more with what patients truly want. Methods We sent survey emails of to the female patients who were consulted or received hairline correcting surgeries and hair transplantation doctors asking to answer it. Finding out favorable frontal hairline shape and portion, the survey email included standardized photos with various hairline types and height and width of forehead to distinguish differences between two groups. Survey material was categorized into sex, age, education, marriage status, occupation, and so on to differentiate further. The standardized photo was followed by 5 types of categories which was first published by JH Jung. Results Between doctors and patients, the following differences were come out as we studied over the survey materials. The biggest difference was received from the shape of hairline. M-shaped hairline contour was the most preferred. Rectangular was the second preferred, round was the third and triangular was the least preferred one. However, age group of 50s favored the round shape as the second favorite shape. Conclusion M-shaped hairline pattern was the most preferred design according to the survey. Rround shape which is current

operating design mostly chosen by doctors should be changed. So that pre operative consultation must focus more to patients needs rather than doctors suggestion.

P24 Restoration of Hair-Inducing Capacity of Cultured Human Dermal Papilla Cells by Three Dimensional Spheroid Culture

Moonkyu Kim, MD, PhD, Young Kwan Sung, PhD, Bo Mi Kang, Jung-Chul Kim, MD., PhD. Hair Transplantation Center, Kyungpook National University School of Medicine, Daegu, Korea, Republic of. 1999-Present Professor Hair Transplantation Center, Kyungpook National University School of Medicine M. Kim: None. Y. Sung: None. B. Kang: None. J. Kim: None.

TAKE HOME MESSAGE: In hair reconstitution assay, sphere formation of the cultured human DP cells increases the ability of inducing hair follicles in nude mouse. ABSTRACT: The neogenesis of the hair follicle through follicular cell implantation for the treatment of hair loss is believed to greatly depend on the ability to reproducibly expand hair-inductive dermal cells in vitro. Two-dimensional (2D) cultured dermal papilla (DP) cells are known to gradually lose hair-inductive capacity during subculture. Recent studies showed that sphere formation enhances hair-inductive activity of cultured murine vibrissal DP cells. These results strongly suggest that hair-inducing capacity of human DP cells can also be restored by three-dimensional (3D) spheroid cultures. This suggestion prompted us to evaluate the hair-inducing capacity of cultured human DP spheres. We observed hair follicle formation when DP spheres from various passages (p3, p4, p6 and p10) of culture are mixed with newborn mouse epidermal cells. In contrast, hair follicles were never observed when 2D cultures from the same population are employed. To demonstrate that the origin of the DP cells in reconstituted hair follicles was of human origin, DP cells were labeled prior to sphere formation with the fluorescent dye, DiI. We observed that 25/32 (78%) of DP were completely labeled. In conclusion, using a hair reconstitution assay, we show that sphere formation increases the ability of cultured human DP cells to induce hair follicles from mouse epidermal cells.

P25 Body Hair Transplant (BHT) - a Good Supplement to Traditional Hair Transplantation
Jerzy Kolasinski, MD., Malgorzata Kolenda, MD. Klinika Kolasinski - Hair Clinic Poznan, Swarzedz, Poland.

Dr. Jerzy Kolasinski, a member of the American Academy of Cosmetic Surgery, American Society for Hair Restoration Surgery and International Society of Hair Restoration Surgery is the founder and director of Klinika Kolasinski Hair Clinic Poznan in Swarzedz, Poland. Dr. Kolasinski is an author of 140 articles and presentations concerning cosmetic surgery. He has practiced cosmetic surgery since 1984. J. Kolasinski: None. M. Kolenda: None. TAKE HOME MESSAGE: Follicular units harvested from other body parts perfectly supplement procedures performed earlier with grafts collected from the head. In selected cases BHT is a technique of choice. ABSTRACT: Introduction Hair transplant procedures performed nowadays are characterized by an increasing number of follicular units collected at donor sites and grafted in recipient sites. This tendency applies to both strip technique and FUE method.

Higher and higher patient expectations are met by constantly advancing skills of teams of surgeons. Premise In many patients with advanced stages of androgenic alopecia abundant hair growth is observed in other areas of the body such as back, torso or facial hair. This is hair growing in follicular units which positively react to androgens with growth. This fact makes them a potentially good material for transplants in balding sites on the head. Substantiating Data Advances made in FUE technique enable collection of follicular units from areas of the body other than the head. Scars invisible to the eye make it possible to apply this technique in exposed areas such as facial hair, torso or back. An aspect which needs to be taken into account while selecting donor areas is varying duration of anagen phase of hair in different body parts. Discussion Rapid development of FUE technique in recent years made it possible to precisely collect follicular units from the head as well as other parts of the body. This has significantly increased the size of potential donor area. Obviously, however, occipital area is still the best source of grafts. But the fact that its potential has been exhausted does not mean that balding patients cannot be treated anymore. Follicular units harvested from other body parts perfectly supplement procedures performed earlier with grafts collected from the head. In selected cases BHT is a technique of choice, e.g. in eyebrow corrections with grafts collected from the torso, or correction of upper lip scars with grafts collected from the beard. As the skin on the torso, tibia, forearms or face has different thickness and character, FUE technique differs slightly from that used in occipital areas of the head. It may be speculated that forthcoming years will bring not only further advances in BHT technique but also better understanding of the processes underlying alopecia and its treatment.

Body hair transplant (BHT) a good supplement to traditional hair transplantation


Jerzy Kolasinski MD,PhD, Malgorzata Kolenda MD,PhD

POLAND Advances made in FUE technique enable collection of follicular units from areas of the body other than the head Obviously occipital area is still the best source of grafts Follicular units harvested from other body parts perfectly supplement procedures performed earlier with grafts collected from the head In selected cases BHT is a technique of choice, e.g. in eyebrow corrections with grafts collected from the torso, or correction of upper lip scars with grafts collected from the beard It may be speculated that forthcoming years will bring not only further advances in BHT technique but also better understanding of the processes underlying alopecia and its treatment

P26 Surgeon and Trichologist Collaboration - A State-of-the-Art Contemporary Hair Restoration Surgery
Jerzy Kolasinski, MD. Kinga Estera Jach-Skrzypczak, MD. Klinika Kolasinski - Hair Clinic Poznan, Swarzedz, Poland.

Dr.Jerzy Kolasinski, a member of the American Academy of Cosmetic Surgery, American Society for Hair Restoration Surgery and International Society of Hair Restoration Surgery is the founder and director of Klinika Kolasinski Hair Clinic Poznan in Swarzedz, Poland. Dr.Kolasinski is an author of 140 articles and presentations concerning cosmetic surgery. He has practiced cosmetic surgery since 1984. J. Kolasinski: None. K. Jach-Skrzypczak: None. TAKE HOME MESSAGE: A close collaboration of surgeon and trichologist creates optimal conditions for management of various types of hair loss ABSTRACT: Introduction Trichology is a branch of medicine which analyzes, diagnoses and treats diseases of scalp and hair. A trichologists job is to detect underlying causes and determine method of treatment by means of case history and a range of diagnostic tests whose results are indispensable for accurate diagnosis. Frequently, it is through close collaboration of several specialist doctors that a right treatment can be determined, right therapy chosen and in final stages the achieved result maintained. The trichologists activities in a natural way complement the mission of hair restoration surgeon practice. Premise A priority in trichological treatment is to make a correct diagnosis, and based on it, closely implement the complex therapy in the course of outpatient clinic management. Additionally, trichology prepares patients scalp for transplantation and administers care after surgical procedures. Creation of such a vast backup base considerably improves the effectiveness of reconstructive treatments of the scalp. Patients seeking surgical intervention very often require to be treated conservatively (trichologically) as well as to have their scalp prepared for procedure, followed by systematic professional trichological postoperative care, which makes the procedure more effective. Substantiating data We have adopted the following sequence of actions: a patients notices hair problems and consults a trichologist or surgeon. If the trichologist decides that surgical intervention is necessary, the patient is referred to surgeon. If in the process of diagnosing the trichologist notices any conditions that require conservative treatment then appropriate management is implemented such as e.g. application of different medicines, absorption of which is frequently assisted by radiation, laser bio-stimulation, physiotherapy, iontophoresis, light therapy with UVA - UVB of varying spectrums, soft laser therapy, ozone therapy, mesotherapy, or acthyderm treatment. At every stage of treatment the trichologist can consult a surgeon about how to supplement the treatment with reconstructive management. And similarly, the surgeon may qualify a patient directly for reconstructive treatment or may refer him/her to the trichologist for conservative treatment or preparation for surgical treatment. It sometimes happens that a patient must be further treated by the trichologist after reconstructive surgery- then he/she is referred. Discussion

A close collaboration of surgeon and trichologist creates optimal conditions for management of various types of hair loss. Locating both practices in one clinic enables naturally occurring penetration of both specializations to the benefit of the patient. Supplementing this team with an endocrinologist enables complex management of male and female alopecia. One may venture to say that this is a state-of-the-art alopecia treatment.

Surgeon and trichologist collaboration a statestate-ofof- thethe- art contemporary hair restoration surgery
Jerzy Kolasinski MD,PhD, Kinga Estera Jach-Skrzypczak

POLAND
Trichology is a branch of medicine which analyzes, diagnoses and treats diseases of scalp and hair A priority in trichological treatment is to make a correct diagnosis, and based on it, closely implement the complex therapy in the course of outpatient clinic management. Additionally, trichology prepares patients scalp for transplantation and administers care after surgical procedures If the trichologist decides that surgical intervention is necessary, the patient is referred to surgeon. If in the process of diagnosing the trichologist notices any conditions that require conservative treatment then appropriate management is implemented such as e.g. application of different medicines, absorption of which is frequently assisted by radiation, laser bio-stimulation, physiotherapy, iontophoresis, light therapy with UVA UVB of varying spectrums, soft laser therapy, ozone therapy, mesotherapy, or acthyderm treatment. At every stage of treatment the trichologist can consult a surgeon about how to supplement the treatment with reconstructive management. And similarly, the surgeon may qualify a patient directly for reconstructive treatment or may refer him/her to the trichologist for conservative treatment or preparation for surgical treatment. It sometimes happens that a patient must be further treated by the trichologist after reconstructive surgery then he/she is referred A close collaboration of surgeon and trichologist creates optimal conditions for management of various types of hair loss. Locating both practices in one clinic enables naturally occurring penetration of both specializations to the benefit of the patient. Supplementing this team with an endocrinologist enables complex management of male and female alopecia. One may venture to say that this is a state-of-the-art alopecia treatment

P27
Magorzata Kolenda, MD. Jerzy Kolasinski, MD. Klinika Kolasinski, Swarzedz, Poland.

Optimization of Hair Transplantation Using FUE Method

Malgorzata Kolenda MD, PhD has been performed hair restoration surgery since 1995. She is an active member of International Society of Hair Restoration Surgery. She is founding member and actual President of Polish Society of Hair Restoration Surgery. In her career she published and presented more than 50 publications and presentations of cosmetic surgery and hair restoration surgery. M. Kolenda: None. J. Kolasinski: None. TAKE HOME MESSAGE: The fact that patient is operated simultaneously by three person's teaml, significantly shorten the length of FUE hair transplant procedures. ABSTRACT: Introduction The number of hair transplantation procedures carried out using FUE technique is growing every year. More and more patients find this method worthwhile. Its huge advantage is lack of visible scarring in donor area. Additionally, in this technique the number of irrevocably lost hair follicles is considerably lower than in traditional strip technique. A major downside of FUE technique is that it is very time-consuming. This tires both patient and operating team. It also limits the number of grafts carried out in one session. Premise Our experience allowed us to define a set of factors and improvements which significantly shorten a FUE hair transplantation procedure. Using them makes it possible to carry out a higher number of grafts in a relatively shorter period of time. Knowledge of these parameters before attempting to carry out the procedure helps to better plan the work of operating team on a given day. Substantiating Data Factors which improve the speed of a FUE procedure include: patient age over 40, positive attitude to procedure (patient is calm and placid), good blood coagulation parameters, arterial blood pressure immediately before procedure at or below 130/80 mmHg, well defined follicular units with thick and dark hairs. Operational improvements which quicken a FUE procedure include: complete shaving of patients scalp, application of powerassisted technique, good synchronization of surgeon and assisting team while collecting grafts, simultaneous graft placement by a third person while grafts are collected (three pairs of hands working at the same time), application of four-hand-stick-and-place technique in the process of graft placement. All these parameters put together make it possible to carry out 1500 FUE grafts in four hours, and 2000 grafts in 5.5 to 6 hours. Discussion In recent years a considerable interest in FUE hair transplantation procedures has been noticed. Approximately five years ago they constituted only about 10% of all hair transplantation procedures. Now this number has reached 50% to 60% . Its undoubted advantage is its scar-less character. Its major disadvantage, however, is its duration, so every even minute improvement is of great value. The parameters defined by us and implemented improvements, particularly the fact that patient is operated simultaneously by three person's team, significantly shorten the length of FUE hair transplant procedures.

Optimization of hair transplantation using FUE method


Malgorzata Kolenda MD,PhD, Jerzy Kolasinski MD,PhD

POLAND In recent years a considerable interest in FUE hair transplantation procedures has been noticed. Approximately five years ago they constituted only about 10% of all hair transplantation procedures. Now this number has reached 50% to 60% Factors which improve the speed of a FUE procedure include: patient age over 40, positive attitude to procedure, good blood coagulation parameters, arterial blood pressure immediately before procedure at or below 130/80 mmHg, well defined follicular units with thick and dark hairs Operational improvements which quicken a FUE procedure include: complete shaving of patients scalp, application of power-assisted technique, good synchronization of surgeon and assisting team while collecting grafts, simultaneous graft placement by a third person while grafts are collected, application of four-hand-stick-and-place technique in the process of graft placement. All these parameters put together make it possible to carry out 1500 FUE grafts in four hours, and 2000 grafts in 5.5 to 6 hours

P28
Seung Yong Lee, MD. Jae Hyun Park, MD. Dana Plastic Surgery Clinic, Seoul, Korea, Republic of.

Micropigmentation: Camouflaging Scalp Alopecia and Scars in Asians

Private practice in Dana Plastic surgery clinic, Dermatologist S. Lee: None. J. Park: None. TAKE HOME MESSAGE: Micropigmentation is considered to be one of the good method to camouflage MPB, FPHL, and scalp scar for Asians. ABSTRACT: Introduction Regardless of Men and Women, hair loss gives a certain image that looks older and decreases the attraction of the appearance. Hair transplant surgery and drug treatment is well recognized as a standard treatment in AGA with good therapeutic effects. But, in case of donor depletion due to several session of previous hair transplant surgery, ,and even though there is alopecia but they don't want to have a surgery because of the extreme phobia and a variety of other reasons, But, somehow they wanted to hide the hair loss other than the way of the surgery. In addition, in the case of a whitish skin colored scar in scalp, the whitish color sometimes makes more contrast effect with black hair of Asian and see through appearance is more prominient and very often we can see relatively disappointing results because of the lower survival rate in scar tissue in the hair transplant surgery. In these cases, the micropigmentation can be a good way of camouflage. Objective This study is to evaluate the usefulness of micropigmentation in camouflaging alopecia and scalp scar in Asian. Method From November 2011 to October 2012, 45 Korean patients had micropigmentation procedure using professional medical tattoo machine. Follow up after the procedure was scheduled on 2 weeks, 6 weeks, 12 weeks after procedure and, if necessary, additional touch-up procedures were performed. Evaluation of the treatment by the objective physician assessment who did not involved in the procedure was done after 12 weeks post-op, and the patient's own subjective satisfaction degree after the procedure and presence of side effects were analyzed. Satisfaction statistics measurement tool used SPSS (Statistical Package for the Social Sciences) V12.0. Results / Discussion There were 17 FPHL(Female pattern hair loss) and 13 MPB(Male pattern baldness), and scalp scar were 15 patients. There was previous hair transplantation surgery history 5 out of 17 in FPHL patients, MPB were 8 out of 13 patients, and scalp scar were 2 out of 15 patients. Touch-up procedure were done in 19 patients (42%). Assessment about the procedure was done in 12 weeks after procedure. It was consisted of objective assessment of the another physician who did not participated in the procedure and the patient's own subjective assessment. Within both assessment, it showed satisfactory result and there were no side effects or complications. In western countries, mainly flat head style is relatively popular, especially in the black people is regarded as a good choice. But in Asia, especially in Korea, the indication itself was very different. In case of FPHL, even if hair loss progresses, the hairline does not retreat backward like in MPB, so there is no chance that micropigmentation can be barely exposed. That's why it can be performed more safely in FPHL. The surgery can be performed without cutting hair short and also the procedure never interfere with normal life. The patient can return to normal life right after the procedure.

Also, FPHL patients usually have lower donor density and thinner donor hair, so micropigmentation can help making to be look like higher density of the recipient area if micropigmentation is combined with hair transplantation. In MPB case, if the hair loss continues, the micropigmentation might be shown or exposed, so physician should give a warning in advance and recommend taking finasteride medication. It is possible to do Laser removal later but the laser removal procedure may require several times and problems such as scarring which must be taken into consideration. If non-hair bearing area is too wide, it could be awkward with micropigmentation alone, so do combination of hair transplantation and micropigmentation will show great synergic effect. Conclusion Micropigmentation is considered to be one of the good method to camouflage MPB, FPHL, and scalp scar for Asians.

P29 Hair Plastic Surgery Not Only Restoration


Yi-Jung I. Lin, MD. Victoria Fa-Hair Clinic, Taipei, Taiwan.

Dr. Yi Jung (Irene) Lin is an aggressive aesthetic hair restoration surgeon from Victoria Fa-Hair Clinic, Taipei, Republic of Taiwan (R.O.C.) that she started in 2009. She has worked in cosmetic trichology profession for more than 9 years. She has been the Director and Chief Physician of Cosmetic and Hair Loose Department of Country Hospital, Taipei, since 2005. Dr. Lin received her hair transplant training in Kyungpook National University Hospital Hair Center, South Korea from 2007. She is the elected Chairperson of both Taiwan Society of Hair Restoration Surgery and Taiwan Trichologists Federation. Dr. Yi Jung (Irene) Lin has attended ISHRS since 2008. Y.I. Lin: None. TAKE HOME MESSAGE: Hair Transplantation Could Be a Better Safe Plastic Surgery to Construct New Face Image. ABSTRACT: Asian males are usually born with face shape of more soft-lined and less facial hair of side burn, mustache, and goatee as western males. These elements make they look more gentle and tender. Under the influence of Western aesthetic conception, asian males also want to bring the image of power and strong. By way of hair transplantation of eye brow, mustache, hair line and so on , they could change the contours of face shape in one day. Hair transplantation is not only just for hair loss improvement but more over cosmetic purpose recently. Objective: The author will present photographs of different cases to demonstrate variations of before and after image. Most patients want to change the image by facial hair transplantation of eyebrow, hair line, sideburn, and mustache in one day. Understanding what they want to be and how to design the hair pattern compatibly with patients face is very important. Discussion: Most patients satisfied the result of facial hair transplantation. Some patients may even want more hair after one session. If the patient wants to do more, the author will check the patients family history of hair loss and explain a variation in the future . Hair transplantation of full face style needs great skills. The physician must have substantial experience, transplant techniques, aesthetic design concept on different place of the face. Besides, the physician should control the local anesthetic condition of different location. Adequate communicating with the patient before surgery , and understanding the expectation of the patient, occupation, environment, and so on are all key factors. Full face hair transplantation will improve the appearance and self esteem of the patient if we do a good construction, but significant distress suffers both patient and doctor on unsatisfied result.

2013 ISHRS Conference Yi Jung (Irene) Lin, MD. 2013-G42-ISHRS

Dr. Yi Jung (Irene) Lin is an aggressive aesthetic hair restoration surgeon from Victoria Fa-Hair Clinic, Taipei, Republic of Taiwan (R.O.C.) that she started in 2009. She has worked in cosmetic trichology profession for more than 9 years. She has been the Director and Chief Physician of Cosmetic and Hair Loose Department of Country Hospital, Taipei, since 2005. Dr. Lin received her hair transplant training in Kyungpook National University Hospital Hair Center, South Korea from 2007. She is the elected Chairperson of both Taiwan Society of Hair Restoration Surgery and Taiwan Trichologists Federation. Dr. Yi Jung (Irene) Lin has attended ISHRS since 2008.

Hair Plastic Surgery Not Only Restoration


Goal and Objective
It is significant to understand the needs and anticipations of trichology patients to design the hair pattern compatible with patients faces. Asian males are usually born with sophisticated shape of face line, with fewer having large quantity of facial hair of side burn, mustache, and goatee as western male. Face with less hair features, such as these, makes Asian male appear more gentle and tender. It is under the influence of Western aesthetic, many of the oriental males attempt to bring up their image of strength and power by ways of hair transplant on eyebrows, mustache, hairlines, and so on. Through hair transplant, most of these Asian males are able to change the contour of face shape and features in one quick day of hair follicle implantation surgery. The recent trend of expectation of Hair transplant is not only for hair loss improvement, but more significantly for cosmetic purposes.

Aesthetic Design and Creativity


Full facial hair aesthetic design needs immense skill; it requires more than surgical operation. Doctor is not just a physician to restore and transplant hair follicles and redistribution, but artist to perform all cosmetic creativity and facial hair design. Dr. Yi Jung Lin has performed many notable methods, such as FUE and FUS, for patients to achieve the ideal aesthetic appearances. By using the various latest equipment, such as portable handheld digital magnify analyzer and South Korean style implanter (pen) for insertion are some examples of delicate tools utilized. For surgical pictorial references of cosmetic aesthetic hair transplant, please refer to photos listed below.

Results and Outcomes


There is a strong growing tendency of hair transplant patients who have came for aesthetic facial hair design and implantation, rather than hair restoration purposes only. Most patients are satisfied with the results of cosmetic facial hair transplant. Some patients may even ask for more than one hair implants to design and rearrange the whole facial hair composition with enhanced augmentations after noticing their first hair transplants successes. If a patient wants additional transplant for cosmetic reason, Dr. Lin will further investigate the patients family history of hair loss, analyze and evaluate all possible options, and explain the different variations of hair plastic surgery to clients. Some key points to pay attention includes: 1. Identify the total amount of hair follicle needed for transplant: it is recommended that physicians have substantial experiences, be able to account for the needed hair amount. of follicle lives, while too little is not sufficient to make up the cosmetic beauty; therefore, experience and creativity are very important. Overly excessive extraction is a waste

2. Different parts of recipient sites, such as eyebrows, sideburns, and beard, need different type of hair follicle, select the compatible options will provide the finer results.

3.

Implantation sequence: full facial design requires at least two different facial recipient sites. Time, level of difficulty, and anesthetic amount applied are different, as each case is customary and uniquely premeditated to tailor the needs of individual; consequently, the implant sequence becomes very important to ensure the smooth face change transition of facial hair cosmetic makeup. 4. The physician should be able to control the local anesthetic condition that will be applied to different physical locations.

5.

Overall touchup and care:

post operation care and follicle survival are important, as visual beauty are also primary concerns of aesthetic hair transplant.

To reemphasize the importance of cosmetic hair implant, it is very important to have adequate communication with patients before surgery, and understand the expectation of patient needs, their occupation, lifestyle, overall conditions, and so on, as they are all influential factors. Full face hair transplant is able to dramatically improve the appearance and self esteem of patients, as I have successfully conducted various trichology surgeries.

Before

After

Before

After

Before

After

Before

After

Before

After

Before

After

P30
Muhamamd Ahmad, MD. Humayun Mohmand, MD. Hair Transplant Institute, Islamabad, Pakistan.

Extended Hair Transplant: Old Techniques with a New Combination

Dr Muhammad Ahmad has been working at the Hair Transplant Institute, Pakistan since 2006. He has performed more than 600 cases of hair restorative surgeries independently. He has more than Fifty national and international publications in the field of plastic and hair restorative surgery. His various articles have been published in the Hair Transplant Forum International. He also has various national and international presentations to his name and is a regular presenter. M. Ahmad: None. H. Mohmand: None. TAKE HOME MESSAGE: The combination of strip surgery with FUE is new technique which helps the patients to have maximum number of grafts in one session. The quality of donor scar can also be kept to minimally visible by using various techniques. ABSTRACT: Objectives: To extend the number of grafts in one session Materials and Methods: The study was conducted at the Hair Transplant Institute, Pakistan. Ten patients were selected with informed consent. All the procedures were performed as outpatient. The patients underwent a combination of strip surgery and FUE at the same session. First, the markings were done in the recipient area according to the number of grafts expected. Then the donor area for strip and FUE was marked. The tumescent anaesthesia was used for the donor area. The strip was removed in a routine method taking care to avoid any extra-stretch on the closure line. Then the FUE was performed leaving 1 cm all around the closure line. The donor area was temporarily dressed for overnight. Results: Ten patients underwent the extended hair transplant surgery. The average number of grafts harvested by strip was 2185 and 1370 by FUE. Majority of the patients (60%) underwent the combined surgery in the 2nd session, one patient underwent in 3rd session and 3 patients underwent the combined surgery in the 1st session. The patients were satisfied with the outcome. Conclusion: Extending the number of grafts in strip surgery results in a wider donor scar. To avoid this, we have combined these two techniques with good results which practically decreases the number of sessions required and also the morbidity of the session.

P31 Embryonic-like Cell-Secreted Proteins Induce Hair Growth in a Phase I/II trial in Male Pattern Baldness
Gail K. Naughton, PhD1, Mark Hubka, DC1, Michael P. Zimber, PhD1, Danielle Ehrlich1, Jonathan M. Mansbridge, PhD1, Julieta Peralta-Arambulo, MD2, Theresa M. Reyes-Cacas, MD3. 1 Histogen, Inc., San Diego, CA, USA, 2Asian Hair Restoration Center, Pasig City, Philippines, 3Marc Medical Group, Manila, Philippines.

Dr. Gail Naughton founded Histogen, Inc. in 2007, and currently serves as CEO. She has spent more than 25 years extensively researching the tissue engineering process, holds more than 95 U.S. and foreign patents, and has been extensively published in the field. During her tenure at Advanced Tissue Sciences she oversaw the design and development of the world's first up-scaled manufacturing facility for their 3 FDA approved tissue engineered products. In 2000, Dr. Naughton received the National Inventor of the Year award by the Intellectual Property Owners Association in honor of her pioneering work in the field of tissue engineering. G.K. Naughton: Ownership Interest (owner, stock, stock options); Dr. Naughton is a shareholder of Histogen, Inc. M. Hubka: Employment; Histogen. M.P. Zimber: Employment; Histogen. D. Ehrlich: Employment; Histogen. J.M. Mansbridge: Employment; Histogen. J. Peralta-Arambulo: None. T.M. Reyes-Cacas: None. TAKE HOME MESSAGE: Following the Proof-of-Concept clinical study, HSC has continued to show a strong safety and efficacy profile in additional clinical trials. ABSTRACT: Introduction: Recombinant and autologous growth factors have shown different degrees of efficacy in supporting new hair growth in subjects with androgenetic alopecia. Objective: A Phase I/II clinical trial was performed to study the safety and efficacy of a bioengineered human cell-derived formulation, termed Hair Stimulating Complex (HSC), in stimulating hair growth in subjects with male pattern baldness. Materials and Methods: Closed bioreactor systems were used to growth neonatal fibroblasts in suspension cultures under hypoxia to induce the cell transformation into multipotent stem cells and the collection of the cell conditioned medium (HSC). HSC contains naturally secreted growth factors known to be important in hair growth, including Follistatin, KGF, and VEGF. The clinical study was a double-blind, randomized, two center trial in 56 subjects. Results/Discussion: All subjects tolerated the eight 0.1cc intradermal injections at baseline and 6 weeks well, and no signs of productrelated severe adverse reactions were reported. Blood and urine samples taken before and after each injection set showed no liver, kidney, or bone marrow toxicity. Trichoscan image analysis of treated sites were taken at baseline, and 12, 24, 36 and 48 weeks. At the 12 week time point significant improvements in total (p=0.0013), terminal (p=0.0135) and vellus (p=0.033) hair growth over baseline were seen as was an increase in cumulative thickness density (p=0.026). The primary efficacy endpoint of increased terminal hair at 12 weeks was met, with a 19.5% increase seen, a 49.5% increase over the same endpoint in our proof-of-concept trial. In addition, unlike currently approved products, HSC induced hair growth in the temporal recession as well as vertex and mid scalp regions, and

was highly effective in men over 40 years of age. At the 48 week time point there continued to be a significant increase in total hairs over baseline (p=0.028). Testing is being conducted to see if there is a correlation between serum testosterone levels and response to HSC. In addition, ADA testing is being completed to finalize the safety aspect of this trial. Further in vitro and preclinical testing is being done to evaluate the role of each individual growth factor and morphogen in inducing hair growth. Data to date supports the partial reactivation of synchronous hair growth mode in alopecic scalp, and that the first synchronous anagen induced by HSC is relatively short and is followed by a second anagen with extended duration and hair terminalization. Conclusion: These results clearly demonstrate the safety and efficacy of intradermal injections of HSC in subjects with androgenetic alopecia.

Embryonic-like Cell-Secreted Proteins Induce Hair Growth in a Phase I/II Trial in Male Pattern Baldness
G. K. Naughton, M. Zimber, J. Peralta-Arambulo, T. Reyes-Cacas, M. Hubka, D. Ehrlich, J. Mansbridge
Efficacy in Difficult-to-Treat Hair Loss Groups
Subjects Over 40 Years of Age Subjects Age 40+
Recombinant and autologous growth factors have shown different degrees of efficacy in supporting new hair growth in subjects with androgenetic alopecia. A Phase I/II clinical trial was performed to study the safety and efficacy of a bioengineered human cell-derived formulation, termed Hair Stimulating Complex (HSC), in stimulating hair growth in subjects with male pattern baldness. Closed bioreactor systems were used to grow neonatal fibroblasts in suspension cultures under hypoxia to induce the cell transformation into multipotent stem cells and the collection of the cell conditioned medium (HSC). HSC contains naturally secreted growth factors known to be important in hair growth, including Follistatin, KGF, and VEGF. The clinical study was a double-blind, randomized, two center trial in 56 subjects. All subjects tolerated the eight 0.1cc intradermal injections at baseline and 6 weeks well, and no signs of product-related severe adverse reactions were reported. Blood and urine samples taken before and after each injection set showed no liver, kidney, or bone marrow toxicity. Trichoscan image analysis of treated sites were taken at baseline, and 12, 24, 36 and 48 weeks. At the 12 week time point significant improvements in total (p=0.0013), terminal (p=0.0135) and vellus (p=0.033) hair growth over baseline were seen as well as an increase in cumulative thickness density (p=0.026). The primary efficacy endpoint of increased terminal hair at 12 weeks was met, with a 19.5% increase seen, a 49.5% increase over the same endpoint in our proof-of-concept trial. In addition, unlike currently approved products, HSC induced hair growth in the temporal recession as well as vertex and mid scalp regions, and was highly effective in men over 40 years of age. At the 48 week time point there continued to be a significant increase in total hairs over baseline (p=0.028). Testing is being conducted to see if there is a correlation between serum testosterone levels and response to HSC. In addition, ADA testing is being completed to finalize the safety aspect of this trial. Further in vitro and preclinical testing is being done to evaluate the role of each individual growth factor and morphogen in inducing hair growth. Data to date supports the partial reactivation of synchronous hair growth mode in alopecic scalp, and that the first synchronous anagen induced by HSC is relatively short and is followed by a second anagen with extended duration and hair terminalization. These results clearly demonstrate the safety and efficacy of intradermal injections of HSC in subjects with androgenetic alopecia.
30 25 20

Introduction
Baseline

Results
HSC Significantly Increases Hair Growth
3 month 3 month
Hair count + 62.82% Terminal hair + 79.74% Thickness + 58.65%

HSC Safety Results

Temporal Recession Region

% Change from Baseline

Total

Terminal

Vellus

15 10 5 0 -5 -10

12wk 24wk 36wk


Cosmetically significant results seen in subjects 40-59 years of age in both trials.

19.35 13.39 12.67

39.11 16.96 20.97

15.67 17.26 9.96

Total Hair Count Terminal Density Vellus Density 12 24 36 48 Weeks Weeks Weeks Weeks

S1016

Pilot Trial -Subjects Age 40+


% Change from Baseline

S2001 Temporal Recession treatment area

S2018

Hair count + 35.88% Terminal hair + 45.83% Thickness + 42.76%

Total 12wk 24wk 48wk 8.52 5.42 18.30

Terminal 21.94 12.88 37.17

Vellus 5.09 -0.05 18.34

Increases seen across hair growth parameters. Representative subject samples had notable increases in total and terminal hair counts, as well as hair thickness, as measured by Fotofinder Trichoscan image analysis.

Increased Dose Results in Improved Growth at 12 Weeks 16


14 12 % Change 10 8 6 4 2 0 Honduras

*
46.5%

Robust growth in older subjects across timepoints and hair growth parameters broadens treatment potential. Unlike currently available treatments which have efficacy limited to younger patients in the earlier stages of hair loss, cosmetically impactful hair growth was seen in subjects over 40 in the Phase I/II and Pilot clinical trials of HSC.

Baseline

48 Weeks

HSC treatment showed hair growth in the temporal recession region at 12 weeks, continuing through 48 weeks, with strong efficacy in terminal hair count. Efficacy was seen across treatment locations in the Phase I/II HSC clinical trial. Currently available hair loss treatments have primarily shown efficacy in the vertex region.

Resurgence at 48 Weeks Consistent with Hair Cycling


240

** **** ***

Pilot

Philippines

Phase I/II

*p=0.0013

235 Hair Count 230 225 220 215

Phase I/II shows 46.5% greater increase in total hair count as compared to the Pilot HSC clinical trial at 12 weeks. Results indicate improved efficacy with additional injections; 4 at baseline in pilot trial as compared to 8 at baseline and repeat dose at 6 weeks in Phase I/II.

Clinical chemistry showed no indication of toxicity or blood/urine abnormalities in the general patient population following both sets of HSC injection. Clinical evaluation of blood serum chemistry, hematology and urinalysis showed no changes from baseline over the course of the treatment. Figures above show the serum blood chemistry and hematology values obtained at baseline (pre-treatment), 4 weeks and 12 weeks. No evidence of toxicity is observed in any of the clinical indicators. HSC Phase I/II Clinical Trial Adverse Events
Possible or Probable Relationship to Treatment Severity Mild Mild Mild Mild Mild Mild Number of Subject Experiencing 7 2 2 1 1 3 Adverse Event Outcome Resolved Resolved Resolved Resolved Resolved 2/3* Resolved

Methods
HSC was released by QC on the basis of minimal values of KGF, VEGF, and Follistatin as measured by ELISA. The bioactivity of HSC is also assessed using a cell-based bioassay. The Phase I/II study consisted of 56 male subjects with androgenetic alopecia receiving 8 x 0.1 cc intradermal injections of HSC or placebo into one of two regions on the scalp at baseline and at 6 weeks. Global photographs and hair counts via macro photography (FotoFinderXpert Clinical Trial System, FotoFinder Systems, Columbia, Maryland), were performed at Baseline, Week 6, Week 12, Week 24, Week 36 and Week 48. Independent analysis of macro photography was performed by the TrichoScale Research Edition, FotoFinder Systems, Inc., Columbia, Maryland. TrichoScale evaluation of images measured variables including total hair count, hair shaft thickness and terminal and vellus densities. The cutoff point for terminal hair determination was 40 microns. Serum and urine samples were obtained at the screening visit as well as the 4 Week and 12 Week timepoints to assess liver, kidney, and bone marrow toxicity, and testosterone levels.

Rise in Terminal and Vellus Hairs Supports Multiple Routes of Activity


28 23 18 13 8 3 -2

210

Baseline

12 Weeks

24 Weeks

36 Weeks

48 Weeks
**** p=0.0282

Scalp Pruritus/Itch Numbness/Hypoaesthesia Fever/Pyrexia Wheals/Urticaria (Rash) Body Malaise Seborrheic Dermatitis

* p=0.0013

** p=0.0016

*** p=0.0034

**

% Change

HSC injections stimulate a hair cycling process by triggering synchronous hair growth in the treated regions. HSC treatment increased hair growth at 12 weeks which decreased at 36 weeks and increased again at 48 weeks. This pattern reflects an initial synchronous anagen phase at 12 weeks which is followed by a synchronous resting phase at 36 weeks. A second anagen phase begins and can be observed at 48 weeks. This trend is consistent with the reactivation of a wave-like scalp hair growth mode and stimulation of hair germ progenitor and bulge stem cell populations in the dormant hair follicle critical to prolonged hair growth.

* 1 case of seborrheic dermatitis outcome unknown

All adverse events were transient, mild and quickly resolved. Of the small number of subjects experiencing possibly treatment-related adverse events, all events were mild and likely a result of the injections themselves.

Vellus Hair Count

Terminal Hair Count

Statistically significant increases in both terminal and vellus hair counts at 12 weeks. Growth of both terminal and vellus hairs supports the hypothesis that HSC rescues dormant follicles, in addition to converting vellus to terminal hairs and increasing the number of hairs per follicle.

Efficacy of Treatment Not Linked to Baseline Testosterone Levels


350.00 Terminal Hair Count (% Change) 300.00 250.00 200.00 150.00 100.00 50.00 0.00 -50.00 -100.00
0 2 4 6 8 10 R = 0.0029

Conclusion
The safety and efficacy results seen with HSC in this in-patient controlled human clinical trial represent a novel regenerative medicine approach in hair growth treatment by using bioengineered, cell-derived growth factors.. Initial safety and efficacy endpoints at 12 weeks were achieved, with statistical significance reached. The increased number of injections and the second injection timepoint resulted in an increase in terminal hairs that was 46.5% above the pilot clinical study. In addition, unlike currently approved products, HSC induced hair growth in the temporal recession as well as vertex and mid scalp regions, and was highly effective in men over 40 years of age. At the 48 week time point there continued to be a significant increase in total hairs over baseline (p=0.028), with a resurgence seen from 36 to 48 weeks. Further, an excellent safety profile was seen in the Phase I/II trial, with no indication of toxicity or abnormalities in the blood and urine analysis. All adverse events were mild and transient. These results clearly demonstrate the safety and efficacy of intradermal injections of HSC in subjects with androgenetic alopecia.

Increase in Hair Thickness Indicates Cosmetically Relevant Result


8.80 8.60 8.40 8.20 8.00 7.80 7.60 7.40 7.20 Cm Thickness Density (mm/cm2)

HSC Baseline + 6 wks

Control Baseline + 6 wks

Baseline Testosterone (ng/mL)

Single Treatment Site

Schematic illustrating treatment sites in Phase I/II study. Subjects received 8 injections of HSC, spaced 3mm apart, within a demarcated 1.2cm2 area, of the scalp and 8 injections of placebo in a separate 1.2cm2 area.

Statistically significant increase in hair thickness density at 12 weeks. Increased hair thickness density results from: 1) an increase in hair count, 2) an increase in the number of terminal hairs and 3) an increase in hair shaft diameter, all of which are important to cosmetic impact.

Baseline

12 Weeks

p=0.026

Correlation between Serum Testosterone and Percent Change in Terminal Hair Count from Baseline to 12 Weeks Post-HSC Treatment. Scatter plot reveals no relationship between the change in terminal hair count and baseline testosterone levels, indicating that higher testosterone does not result in hindered HSC efficacy, as may be expected with other hair loss treatments.

P32 Effects of Low-Level Laser Therapy (LLLT) on Cell Proliferation and Insulin-Like Growth Factor-1 (IGF-1) Secretion of Dermal Papilla Cells from Balding Hair Follicles
Ratchathorn Panchaprateep, MD. Chulalongkorn University, Bangkok, Thailand.

Dr.Ratchathorn Panchapratee is a certified dermatologist from Bangkok, Thailand and received American board in hair restoration surgery (ISHRS). She is now working at division of dermatology, department of Medicine, Chulalongkorn University, Bangkok and she is interested in hair disease, hair transplantation, basic science in skin and hair and also cosmetic dermatology. R. Panchaprateep: None. TAKE HOME MESSAGE: Low-level laser therapy (LLLT) should be considered to use as an alternative therapy for AGA and might useful to increase graft survival in hair transplantation. ABSTRACT: Background: Low-level laser therapy (LLLT) has been recently introduced as an alternative therapy for AGA. There are some clinical studies proving its benefits in androgenetic alopecia (AGA) patients. However, to the best of our knowledge, an in vitro study evaluating the effects of LLLT in AGA at a cellular level has not been conducted. Objective: To evaluate the effects of LLLT on culture dermal papilla (DP) cells proliferation and insulin-like growth factor-1 (IGF-1) secretion of DP cells from balding hair follicles. Materials and Methods: Culture DP cells in the third passages were used Two kind of LLLT irradiation were carried out with a narrowband 633 6 nm LED (Omnilux revive, Photo therapeutics limited, UK), and a 655 5 nm LED (HairMax LaserComb, Lexington International, LLC). The study comprised three study groups and a control group. In group 1 and 2, the cells were irradiated with Omnilux revive with the energy density 2 and 4 J/cm2 respectively. HairMax LaserComb was used in group 3 with 2 J/cm2. Group 4 is the control group. The irradiation was carried out twice with 12-hour interval. Cell proliferation was evaluated using MTT assay kit (R&D Systems Inc., MN, USA) at 2 days after the last irradiation, and then every 2 days for 6 consecutive days. Quantifying the secretion of Insulin-like growth factor 1 (IGF-1) by these cells at 48 hours after the last irradiation was performed using human IGF-1 ELISA kit (R&D Systems Inc., MN, USA). Results: The cell proliferation of the irradiated group I and III (low energy density of 2 J/cm2) were statistical significant higher than group II (higher dose of 4 J/cm2) and the control group (P0.001) at 4 and 6 days after irradiation. For IGF-1 secretion study, the highest mean IGF-1 level found in group 3 which is significantly higher than that of group 1 and 2 (p < 0.01 both), but it fails to show statistical difference compared to the control group (p < 0.19). Conclusion: This study demonstrates that LLLT at lower energy density significantly increased the proliferation of balding DP cells, which cannot be observed while using a higher setting. Our result are correspondence to the biphasic dose

response theory of LLLT which inhibitory effect takes place in high dose setting as stated in previous literatures. Furthermore, LLLT 655nm at dose 2 J/cm2 shows tendency to stimulate IGF-1 production from these DP cells.

Effects of low-level laser therapy (LLLT) on cell proliferation and insulin-like growth factor-1 (IGF-1) secretion of dermal papilla cells from balding hair follicles
Ratchathorn Panchaprateep, MD, Kongsak Soontrapa, MD, Pravit Asawanonda, MD. Division of Dermatology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand.
Group LED Device Irradiation mode The author have no conflict of interest to declare

Ratchathorn Panchaprateep, MD, M.Sc.


Dermatologist, Diplomate of American Board of Hair Restoration Surgery. Clinical instructor, Division of Dermatology, Department of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand.

BACKGROUND: Low-level laser therapy (LLLT) has been recently introduced as an alternative therapy for androgenetic alopecia (AGA ). (1) There are some clinical studies proving its benefits in AGA patients.(2) However, to the best of our knowledge, an in vitro study evaluating the effects of LLLT in AGA at a cellular level and the underlying mechanism of action for the treatment of hair loss has not been proved. OBJECTIVE: To evaluate the effects of LLLT on cultured dermal papilla (DP) cell proliferation and insulin-like growth factor-1 (IGF-1) secretion of DP cells from balding hair follicles.

Power output (W) 40 5 40 5 4.5x10

laser irradiation

Power density 2 (mW/cm ) 105 105 4

Irradiation time (sec) 19 38 500

Energy density 2 (J/cm ) 2 4 2

Number of irradiation (12hr interval) 2 2 2

I II III IV

633 6 nm 633 6 nm 655 5 nm

Contact,1 cm from surface Contact,1 cm from surface Contact,1 cm from surface

-3

Sham control

RESULT The cell proliferation of the irradiated group 1 and 3 (low energy MATERIAL AND METHODS: density of 2 J/cm2) were statistically significantly higher than Scalp specimens from balding (frontotemporal) area were collected from 4 men with group 2 (higher dose of 4 J/cm2) and the control group AGA (HamiltonNorwood classifications IIIV anterior). The DP cells were isolated using (p0.001) at 4 and 6 days after irradiation. microdissection and a one-step enzyme digestion technique as previously described. (3) Cultured DP cells in the second or third passages were used for study. The irradiation was carried out using 2 LLLT devices; Omnilux revive, Photo therapeutics Ltd, UK, (narrowband 633 6 nm) and Hair Max Laser Comb, Lexington Inter LLC, USA (655 5 nm). Cell proliferation was evaluated using MTT assay kit (R&D Systems Inc.) at 2 days after the last irradiation, and then every 2 days for 6 days. Quantifying the secretion of IGF-1 by these cells at 48 hours after the last irradiation was performed using human IGF-1 ELISA kit (R&D Systems, MN, USA). DISCUSSION AND CONCLUSION: This study demonstrated the stimulatory effect of LLLT on the proliferation of balding DP cells in biphasic dose response. (4, 5) LLLT at lower energy density significantly increases the number of DP cells while higher density inhibits. Furthermore, LED 655nm at dose 2 J/cm2 stimulates IGF-1 production from these DP cells. Our study proposed that LLLT can be a promising therapy for AGA.
REFERENCES

For IGF-1 secretory study, the level of IGF-1 was highest in group 3 which were significantly higher than those of group 1 and 2 (p < 0.01 both), however it failed to show statistical difference compared to the control group (p < 0.19).
1.Leavitt M, Charles G, Heyman E, Michaels D. HairMax LaserComb laser phototherapy device in the treatment of male androgenetic alopecia: A randomized, double-blind, sham device-controlled, multicentre trial. Clin Drug Investig. 2009;29(5):283-92. 2.Avram MR, Rogers NE. The use of low-level light for hair growth: part I. J Cosmet Laser Ther. 2009 Jun;11(2):110-7. 3.Panchaprateep R, Korkij W, Asawanonda P. Brain-derived nerve factor and neurotrophins in androgenetic alopecia. Br J Dermatol. 2011 Nov;165(5):997-1002. 4.AlGhamdi KM, Kumar A, Moussa NA. Low-level laser therapy: a useful technique for enhancing the proliferation of various cultured cells. Lasers Med Sci. 2012 Jan;27(1):237-49. 5.Saygun I, Karacay S, Serdar M, Ural AU, Sencimen M, Kurtis B. Effects of laser irradiation on the release of basic fibroblast growth factor (bFGF), insulin like growth factor-1 (IGF-1), and receptor of IGF-1 (IGFBP3) from gingival fibroblasts. Lasers Med Sci. 2008 Apr;23(2):211-5.

P33 Clinical Importance of Parietal Whorl in Male Pattern Baldness


Jae Hyun Park, MD. Dana Plastic Surgery Clinic, Seoul, Korea, Republic of. Plastic Surgeon, Private practice in Dana Plastic surgery clinic, Active member of Korean society of plastic and reconstructive surgery, Active member of Koren Society of Aesthetic Plastic Surgery J. Park: None. TAKE HOME MESSAGE: Parietal Whorl's Position Needs to be Considered When Planning the Treatment of MPB. ABSTRACT: Clinical Importance of parietal whorl in male pattern baldness in Asian Background The most important point for hair transplantation in the male pattern baldness is to maximize the use of limited donor area most efficiently. However, there is no known factor to predict the progression degree of alopecia. Objective To identify the significance and the role of the parietal whorl's position in male pattern baldness. Methods 1008 Koren male patients who have the MPB were studied, except 56 patients who lost the PW out of 1008 patient in the survey. In the 952 patients PW existed, from the vertical bimetal line (VM) to PW Distance measure, from the PM to helical rim upper border (HRR) distance, from the PW to the occipital fringe (OF) investigated the distance. We also examined PW ~ OF the distance of the 322 people in the vertex hair loss, hair loss duration and age groups respectively. Statistics used SPSS (Statistical Package for the Social Sciences) V12.0. Results The distances from VM to PW varied from 1.5cm to 11cm, with an average of 6.25cm. Distances of PW~HR were from 3.4cm to 17.5 cm and the average was 14.04cm. PW~OF was from 0.5cm to 5.5cm and the average was 2.37cm Conclusion The results showed that the entire progression of hair loss range varies depending on the location of the PW. PW's position needs to be considered when planning the treatment of MPB. It can be an important clinical factor in predicting maximum alopetic area boundary.

P34 Using Single Follicles Divided from Multi-hair Follicular Unit for Natural Result in Asians
Jung-Wook Hwang, MD1, Soo-Ho Park, MD, ABHRS2. 1 Mojelim Plastic Surgery, Seoul, Korea, Republic of, 2Mojelim Plastic Surgery, Ulsan, Korea, Republic of.

Making a natural appearance for Asians is harder than for Westerners. So, we try to refine that. We were also awarded the 2012 Research Grant by ISHRS for the study "Comparison between the survival rate of original single follicular units and single follicles divided from two or three-hair follicular units". J. Hwang: None. S. Park: None. TAKE HOME MESSAGE: We think the volume is more important than the naturalness and concluded that this method should be used only for the patients who have very thick hair or the special parts such as hairline, temporal area, side burn etc. ABSTRACT: Introduction Hair of East Asians is thicker than Caucasians'. Thick hair is helpful for density, but it can result to unnatural appearance. Two or three-hair follicular units (FU) can seem just one thick hair at the orifice, and remaining epidermis between hairs can cause pitting scar. Objective To make a more natural appearance, we tried to use the single follicles divided from multi-hair FU for mild to moderate male pattern baldness (MPB) patients. Materials and Methods From September 2011 to December 2011, 13 men who have no severe MPB and no severe family history of MPB underwent hair transplantation using single follicles devided from multi-hair FU. We used the graft implanters and made the density of 35-40 FU/cm2. Discussion/Results Three patients haven't come back until now. The table below shows the result of 10 patients except three missing patients. Advantages 1. There was no cobblestoning which can be caused by larger needles. 2. Epidermis between two or three hairs is difficult to remove. but epidermis of single follicles is easy to trim. Therefore, the pitting scars can be prevented. 3. There was no thcik and unnatural appearance at the hair orfice due to overlapping of the hairs. Disadvantages 1. Decreased volume and more see-through. 2. The operation time was 1.5 times longer. Conclusion We tried this procedure to improve thick and unnatural appearances, pitting scar and cobblestoning. However, only four cases can meet our expectations. Two cases even needed the secondary operations. Surely, we made a result more naturally with this method. However, we think volume is more important than naturalness and conclude that this method should be used only for patients who have very thick hair or special parts such as hairline, temporal

area, side burn etc.

Using Single Follicles Divided from Multi-hair Follicular Unit for Natural Result in Asians
Park Soo-ho, M.D., Hwang Jung-wook, M.D.
There is nothing to disclosure Objective East Asians hair is thicker than Caucasians'. Thick hair is helpful for volume, but it can cause unnatural appearance in hair transplantation. Two or three-hair follicular units (FU) can seem like just one thick hair at the orifice, and the epidermis between hairs can cause pitting scar. Methods From September 2011 to December 2011, 13 men who have no severe male pattern baldness (MPB) and no severe family history of MPB underwent hair transplantation using single follicles divided from multihair FU. We used the graft implanters and made the density of 35-40 FU/cm2. 1 2 3 4 5 6 7 8 9
1)

Results age 33 27 28 35 36 35 24 31 34 Norwood type N/A III II II III III IV N/A IV

Park Soo-ho, M.D. Plastic Surgeon ABHRS Lead Researcher of 2012 ISHRS grant

Pre-op

10 months

No. of grafts 1470 1346 1093 1079 1571 1418 1484 1112

Postop. days 325 327 338 343 343 359 406 458 459

Result1)

Conclusions

Result: ( ), Poor ( ), 10 26 Excellent III ( ), Good 1370 479 Secondary operation should be needed ( )

1708

Pre-op

11 months Good density But Less volume & More see-through

Pre-op

10 months Additional operation should be needed

Pre-op

6 months

We tried this procedure to avoid thick and unnatural appearances, pitting scar and cobblestoning. However, only four cases were able to meet our expectations. Two cases are even needed the secondary operations. We think volume is more important than naturalness and concluded that this method should be used only for patients who have very thick hair or for special parts such as hairline, temporal areas, side burns, etc.

P35 Complication and Solution for Severe Folliculitis after Eyebrow Transplantation
Damkerng Pathomvanich, MD, FACS. DHT Clinic, Bangkok, Thailand.

American Board of Hair Restoration Surgery, Diplomate American Board of Surgery, Diplomate Fellow, American College of Surgeon Director, ISHRS Fellowship Training Program in Hair Restoration Surgery D. Pathomvanich: None. TAKE HOME MESSAGE: Severe folliculitis post eyebrow transplantation is a rare complication.I&D, culture and appropriate antibiotic, early aggressive medical treatment with oral isotretinoin and systemic steroid to reduce inflammation. Finally, refer the patient to a dermatologist for post acne scar treatment. ABSTRACT: Back ground Eyebrow transplantation is on the rise with esthetic pleasing outcome. Complication however despite rare can occur and result in scarring and facial disfigure. Objective To report a rare complication after eyebrow transplantation and its correction. Material and method 36 years old male underwent eyebrow transplantation for thinning eyebrow and also hair transplantation for receding hair line. He desired to have thick long and big eyebrow. 355 grafts ( 1 hair=330 grafts, 2 hairs=25 grafts )were transplanted on each side using stick and place technique with 23 G for 1 hair graft and 21 G for 2 hairs graft. This was done after hair transplant was completed without complication. He was seen the following day and one week later with smooth post op course. Result The patient noted to have pimples on both medial aspect of each eyebrow with pustule. He was placed on antibiotic (Doxycycline 100 mg bid for 2 weeks) and advice to have wet warm compress without improvement. He returned to the clinic 4 weeks after surgery with yellowish dry crusting and papule involved the entire aspect of medial eyebrow with area of erythema and unhappy face. The antibiotic was changed to Ciprobay for 2 weeks with minimal improvement in redness but no new pimple. The area appeared like acne scar. No hair was growing at this site but some growth at mid and lateral eyebrow. Scar from acne appear to be permanent. He was improved 4 months post op with more hair growth except at medial brow. He was seen by dermatologist and 50% TCA was applied lightly to the scar with some improvement. He was happy with the outcome of hair transplant on the scalp without complication and good growth. He also underwent Erbium YAG laser treatment of the scar at medial aspect of the eyebrow 7 months post op and was given oral isotretinoin. Eyebrow transplant was performed 10 months after the first session, more grafts at medial aspect of the eyebrow and spread out the entire brow, 127 single hair graft on right side and 107 single hair on left side. He will return for follow up after this abstract is submitted and will show the result at the meeting. Discussion

Severe folliculitis post eyebrow transplantation is a rare complication, this might be a nightmare for both physician and patient due to facial disfigure. The cause of folliculitis is not known whether too dense packing in the small area with flat angle, however we have done a few patients in the past with closed to 400 grafts per side with no complication. Were the grafts been placed too superficial with flat angle and the dermal papilla sit in the dermis cause this complication? This patient grafts were placed elevated in all. Folliculitis might occur if the grafts were planted too deep or buried graft but not in this case since the pimples confined to the medial aspect only on both side. We used sterile glove with no powder, foreign body reaction is out. Is there anything to do with pre-existing small pimples all over the entire forehead? Its remained unclear for the cause of severe folliculitis in this patient.

Complication and solution for severe folliculitis after eyebrow transplantation


Damkerng Pathomvanich MD FACS, Prapote Asawaworarit, MD DHT Clinic, Bangkok, Thailand

Introduction: Eyebrow transplantation is on the rise with esthetic pleasing outcome. Complication can result in scarring and facial disfigure.
Objective: To report a rare complication after eyebrow transplantation and its correction. Case:
36 years old male underwent eyebrow transplantation for thinning eyebrow and also hair transplantation for receding hair line. He desired to have thick long and big eyebrow. 355 grafts (1 hair = 330 grafts, 2 hairs = 25 grafts) were transplanted on each side using stick and place technique with 23 G for 1 hair graft and 21 G for 2 hairs graft. He was seen the following day and one week later with smooth post op course.

Dr. Prapote Asawaworarit DHT Clinic,Thailand

Result:

Figure 1. Pre operation

Figure 2. Immediate post operation

Figures 3. Four-week post operation

The patient had pimples on both medial aspect of eyebrow with pustule 2 weeks after surgery. He was placed on Doxycycline 100 mg bid for 2 weeks and wet warm compress without improvement. He came back 4 weeks after surgery with yellowish dry crusts and papules involved the entire aspect of medial eyebrow with area of erythema. The antibiotic was changed to Ciprobay for 2 weeks with minimal improvement in redness but no new pimples. The area appeared like acne scars. No hair was growing at this site but some growth at mid and lateral eyebrow. Scar from acne appeared to be permanent. There was an improvement 4 months post op with more hair growth except at medial brow. He was seen by a dermatologist and 50% TCA was applied lightly to the scar with some improvement. He was happy with the outcome of hair transplant on the scalp without complications. He also underwent Erbium YAG laser treatment of the scar 7 months post op and was given oral isotretinoin. Another eyebrow transplant was performed 10 months after the first one with more grafts at medial aspect of the eyebrow and spread out the entire brow, 127 single hair graft on right side and 107 single hair on left side. Three months later , he still has post-inflammatory erythema medially. His eyebrows are as dense as he would like to have and he is now happy with the result.

Discussion: Severe folliculitis post eyebrow transplantation is a rare complication, this might be a nightmare for both physician and patient due to facial disfigure. The cause of folliculitis is not known whether too dense packing in the small area with flat angle, however we have done a few patients in the past with closed to 400 grafts per side with no complication. Were the grafts been placed too superficial with flat angle and the dermal papilla sit in the dermis cause this complication? This patient grafts were placed elevated in all. Folliculitis might occur if the grafts were planted too deep or buried graft but not in this case since the pimples confined to the medial aspect only on both sides. We used sterile glove with no powder, foreign body reaction is out. Is there anything to do with pre-existing small pimples all over the entire forehead? Its remained unclear for the cause of severe folliculitis in this patient.

Figure 4. Pre operation (second session)

Figure 5. Three-month post operation (second session)

P36 Withdrawn P37 Less is More Approach - A Novel Hair Transplant Approach for Patients with Extensive Hairloss (NW 6/7)
Arvind Poswal, MD. Dr. A S Clinic Pvt. Ltd., New Delhi, India.

BIOGRAPHY: Dr. (ex- Capt.) ARVIND POSWAL Dr. Arvind Poswal, completed his medical studies from the prestigious Armed Forces Medical College, Pune (India). Over the past 15 years, he has contributed immensely in the field of hair transplant, whether it is technique, instrumentation or training. He is also the inventor of the stitch-less FUSE technique that has enabled numerous recent advances in the field of modern hair transplants. He has also trained numerous doctors in the field of hair transplant, some of whom now work in the USA.He is a founder Vice President of The International FUE society and Member of ESHRS,ISHRS, and Association of Hair Restoration Surgeons India etc. He is been presented with numerous prestigious awards nationally and internationally. He delivers lectures and presentations on latest Hair Transplant technologies at various Medical colleges and at National and International conferences.Besides this, he has appeared on multiple national TV channels. D. Poswal: None. TAKE HOME MESSAGE: FUE enables patients with extensive hairloss to get aesthetic improvement while retaining the option to keep a buzz cut, using scalp, body and beard hair. ABSTRACT: Introduction Advances in hair restoration surgeries provide hope of aesthetically pleasing results even to patients who would be considered unsuitable in earlier times. FUSE/fue technique enables use of a wide array of donor hair follicles, coupled with a different aesthetic approach, to provide dramatic improvement in such patients. A case study of patient nicknamed Arjun with extensive hairloss showcased the use of the "less is more approach". Figs 1.1 - 1.4 The patient is a true Norwood class 7 and has a slick bald recipient scalp with very limited scalp donor reserves. A combination of scalp, beard and body donor hair was used augment the donor hair supply. Keeping the transplanted hair kept at a buzzcut (2mm) enables Arjun to benefit from the less is more approach Objective To achieve an aesthetic hair restoration for patients who would be considered unsuitable for hair restoration surgery due to limited donor hair supply. Fig 1.5 - 1.6 Materials and Methods

The patient named Arjun, in his early 30s, has extensive hairloss, Norwood Class 7 and limited scalp donor. The hair transplant was performed following the less is more approach strategy. The less is more approach refers to a) hair grafts being transplanted at a low density (30-35 follicular unit grafts in the hairline area tapering to 10 - 15 follicular unit grafts going to the vertex/crown areas) Fig 1.7 - 1.15 b) the scalp hair, (transplanted as well as native), being cut to a short/less length (buzz cut) to give an appearance of fullness. Fig 1.5 - 1.6 c) hair grafts being used from scalp, beard and robust body donor areas to augment the total transplantable hair. Fig 1.16, 1.17, 1.20, 1.21

Keeping the transplanted hair cut to a short length enables benefit from the Less is more approach. Keeping the hair buzzcut gives an illusion of more hair if the face is framed with a hairline and there is hair growth in the entire Norwood areas of hairloss. Arjuns hair transplant journey In 1st session - 5217 grafts were transplanted in the front and top areas. The hairline at a higher density and gradually reducing the density while going back. The density ranges from 30 to 10 grafts per sq cm. In Arjun's 1st HT, graft details Scalp 1402 grafts Beard 1801 grafts Chest 1083 grafts Abdomen 646 grafts Pubic 230 grafts Thigh 55 grafts Total - 5217 grafts Fig 1.18 (a,b,c) - 1.19 Discussion/Results The patient is in Norwood class 7 and desiring an appearance of full hair coverage. The approach used was: The grafts were placed at a low density. A combination of scalp, beard and body donor hair was used augment the donor hair supply. Keeping the transplanted hair cut to a short length enables Arjun to benefit from the less is more approach In 1st session, the front and top areas were transplanted. The hairline at a higher density and gradually reducing the density while going back. The density ranges from 30 to 10 grafts per sq cm. 5. Thinning the extra dense scalp donor area, (the upper half), plays a beneficial role by reducing the contrast and gives a uniform appearance. Its one of the aspects of the "less is more" approach that Arjun's HT has incorporated. 6. Extreme care needs to be exercised in patient and treatment compatibility. Patient awareness, thorough planning, the correct HT philosophy are some of the things to keep in mind. Follow-up The recipient and donor areas were observed at five month interval. At fifth month post op, the recipient area showed cosmetically acceptable hair growth in the front and the top area of the scalp. Fig - 1.7, 1.11, The patient also visited us for follow up 18 months later at that time he had grown his hair long. 1. 2. 3. 4.

As can be seen in Figs 1.22, 1.23 A comparative video showing :1. 2. Before and after 5 months with hair buzz cut and after 18 months with hair grown long is attached. Body hair grafts were extracted using expanding needing concept (FUSE technique). Video showing Expanding Needle Concept is attached. http://www.youtube.com/watch?v=GA6C-Glh2Q0&feature=youtu.be http://www.youtube.com/watch?v=0VglC0Oieg4

Conclusion 1. With Follicular unit separation extraction (FUSE)/fue, donor reserves from the beard and body areas can be used in suitable patients to augment the scalp donor hair. 2. Thinning out the scalp donor, (in the denser part), reduces the contrast and gives a uniform appearance. 3. The patients shall retain the option to shave/buzz cut, thus, benefitting from the "less is more approach.

LESS IS MORE APPROACH a novel hair transplant approach for patients with extensive hairloss (NW 6/7)
Introduction:
A young patient Arjun with extensive hairloss Norwood class 6/7 and has a slick bald recipient scalp with very limited scalp donor reserves.

The approach used was:


Patient awareness, thorough planning, the correct HT philosophy are some of the things to keep in mind.

Less Is More Approach


Hair grafts transplanted at low density (30-35 fu grafts in the hairline area tapering to 10- 15 follicular unit grafts going to the vertex/crown areas).

Follow-up
The recipient and donor areas were observed at five month interval. At fifth month post op, the recipient area showed cosmetically acceptable hair growth in the front and the top area of the scalp.

A combination of scalp, beard and body donor hair was used augment the donor hair supply.

Grafts used from scalp, beard and robust body donor areas to a u g m e n t the total transplantable h a i r .

The scalp hair, (transplanted as well as native), cut to a short length(buzz cut) to give an appearance of fullness. Thinning the extra dense scalp donor area, reduces the contrast and gives a uniform appearance. Its one of the aspects of the less is more" approach that Arjun's HT has incorporated.

The patient also visited us for follow up 18 months later at that time he had grown his hair long.

Material & methods:


Expanding needle concept (ENC) used for extraction of body hair. Video available at http://vimeo.com/52214081

Keeping the transplanted hair kept at a buzzcut (2mm) enables Arjun to benefit from the Less Is More Approach.

Extreme care needs to be exercised in patient and treatment compatibility.

Conclusion:
1. With Follicular unit separation extraction (FUSE)/fue, donor reserves (beard and body) used in suitable patients to augment the scalp donor hair. 2. Thinning out the scalp donor, (in the denser part), reduces the contrast and gives a uniform appearance. 3. The patients shall retain the option to shave/buzz cut, thus, benefitting from the "less is more approach.

Objective:
To achieve an aesthetic hair restoration for patients who would be considered unsuitable for hair restoration surgery due to limited donor hair supply.

Buzzcut gives an illusion of more hair if the face is framed with a hairline and there is hair growth in the entire Norwood areas of hairloss.

Transplanted hair cut to a short length enables benefit from the Less is more approach.

Dr. Arvind Poswal, MBBS (AFMC), completed his medical studies from the Armed Forces Medical College and was commissioned as a medical officer in the Indian Army Medical Corps in 1990. He started Dr. A's Clinic in 1997 and has been performing hair transplants since then. He has published articles in The Indian Journal of Dermatology and made presentations at the European Society of hair transplant surgeons, the Association of Hair Restoration Surgeons India. He frequently delivers lecture presentations for medical students at various medical colleges.

Biography

Dr. (ex. Capt.) Arvind Poswal

P38 A Mathematical Way of Graft Estimates in a Patient Customized Manner


Arvind Poswal, MD. Dr. A S Clinic Pvt. Ltd., New Delhi, India.

BIOGRAPHY: Dr. (ex- Capt.) ARVIND POSWAL Dr. Arvind Poswal, completed his medical studies from the prestigious Armed Forces Medical College, Pune (India). Over the past 15 years, he has contributed immensely in the field of hair transplant, whether it is technique, instrumentation or training. He is also the inventor of the stitch-less FUSE technique that has enabled numerous recent advances in the field of modern hair transplants. He has also trained numerous doctors in the field of hair transplant, some of whom now work in the USA. He is a founder Vice President of The International FUE society and Member of ESHRS,ISHRS,and Association of Hair Restoration Surgeons India etc. He is been presented with numerous prestigious awards nationally and internationally. He delivers lectures and presentations on latest Hair Transplant technologies at various Medical colleges and at National and International conferences.Besides this, he has appeared on multiple national TV channels. D. Poswal: None. TAKE HOME MESSAGE: A SCIENTIFIC AND ACCURATE METHOD OF GRAFT ESTIMATION WHICH WILL ALSO PREVENT PATIENT DISSATISFACTION ABSTRACT: Given current advances in hair transplant technologies, it should be incumbent on the doctor to not limit the graft estimates solely on his or her expertise. He should first educate the patient about the actual number of follicular unit grafts that exist on the non balding scalp, that have been lost or miniaturized. Then tell him graft counts that would be required for a near complete/complete hair restoration and the actual number of grafts available (whether by strip FUHT method, FUSE/fue method from scalp, beard and robust body donor areas). Introduction: Over the period of decades the concept of graft estimation still continues to create confusion in the mind of new Hair transplant Doctors and the patient as well. It is seen that speaking of graft estimates by doctors often means how many grafts he /she can extract and transplant (not necessarily covering all the bald areas), while the patient on the other hand may think that graft estimate given will restore his previous non balding look (irrespective of the extent of hair loss he/she currently has). The main aim of this abstract is that the patient should be able to decide how many grafts he/she wishes to go for ( based on his economic situation and what sort of restoration that number of grafts would be able to accomplish for him both in terms of coverage and density). The other aim is for the doctor and prospective patient to know the density at which they would like the grafts to be transplanted. Objective: 1. To make accurate and scientific graft estimation for desired result by doctors and prospective patients 2. To customize the follicular unit graft density based on the patients nonbalding scalp density Material and methods: A very simple and helpful tool which is used is a centimeter grid made on transparent flexible cellophane. It

contains squares and each smallest square measures 1 sq.cm. Fig 1.1 After marking the proposed recipient area, this transparent grid can be super imposed on the patients recipient area and number of squares can be counted. Then whatever the follicular unit graft density is proposed for the particular patient (example 40 follicular unit grafts per square cm.) is multiplied by the number of squares, thus giving grafts estimates. It must be remembered that hair transplant is not necessarily performed at a uniform follicular unit graft density in the entire recipient area. For e.g. The hairline and forelock area are kept at the higher density and as going towards vertex and crown area, the follicular unit graft density may decrease. Regarding the proposed follicular unit graft density in the recipient area to achieve a dense look, it is recommended that the density should be customized by making it a factor of the patients own follicular unit density in the non balding scalp donor area. The reason for this is the vast difference seen in the follicular unit densities in non balding people of different races. Example 1. Blond Caucasian - average density = 80 - 100 follicular units grafts per sq. cm. 2. Red hair Caucasian - average density = 70 to 80 follicular unit grafts per sq.cm 3. East Asian/oriental - average density = 40 - 50 follicular units per sq cm. 4. Negroid origin - average density = 40 - 50 follicular units per sq cm. A density that may be necessary to give a dense appearance in a Caucasian may be an unnecessary waste of grafts in a person of Oriental descent. Dense packing and medium density too should be a factor of the individual patients non balding follicular unit density. In my experience, transplanting at 70-75% of the non balding density is sufficient to give an appearance of fullness, whether the hair is kept wet or dry. I suggest that dense packing or medium density etc., should be customized as %age of the patients own non balding follicular unit density rather than being empirical/random number per sq cm. It is recommended to make atleast 3 measurements for the density - in the mid occipit region, 2 cms above the ear and midpoint between these two. An average of these 3 should be used for the purpose of calculations. The Fig 1.2 can help the doctor and patient know how to calculate follicular unit density per square cm in the non balding scalp. Discussion How to do graft estimates: There is a wide variation in the follicular unit densities, individual hair follicles diameter and number of hair per follicular unit in different races and types. The following steps shows the mathematical way of graft estimate in a patient. 1. Mark out the proposed recipient area. 2. Calculate the number of follicular unit per sq cm in non balding scalp of the patient. 3. Calculate the sq cm in proposed recipient area of the patient (A). 4. Decide the density at which the graft is to be transplanted (B). 5. Graft estimate = A x B . Fig 1.3

Concept of dense packing: It is preferred that hair to be transplanted should be at a sufficiently high density so that same area need not require another surgical procedure to strengthen the density. It is mistakenly believed by many patient and doctors that there is particular number like 70 to 80 fu grafts per sq cm that could be called as dense packing. Because of presence of racial differences in fu grafts density in non balding area in people of different races, such a number could be misleading and also account for graft wastage. Thus it is advised instead of a number, a percentage based on a fu density in patients own non balding scalp should be used, 60 to 70 % is that magic figure i.e. dense packing should be said to have been accomplished if fu grafts are placed at 60 to 70 % density when compared to the individual patient own fu density in his non balding scalp donor area. Also placing grafts at 40 to 50 % should be termed moderate packing and 20 to 30 % low density. Results Given below are examples of the different patients having undergone different number of grafts at varying densities, depending upon their requirement and choice. Fig 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, 1.10 1.11, 1.12, 1.13, 1.14 Conclusion: Earlier grafts estimation was given by the Norwood classification of the patient. Given current advances in hair transplant technology, it should be incumbent on the doctor to not limit the grafts solely on his her expertise. He should first educate the patients about a) The actual number of follicular unit grafts that exist on the non balding scalp. b) The actual number of follicular unit grafts that have either been lost or miniaturized due to the effect of pattern baldness. c) The actual number of follicular unit grafts that would be needed to replace the lost grafts where the patients need to go for complete hair restoration. d) The actual total number of grafts available (either by strip or FUSE). Fig. 1.15 Once these four figures are available, an educated person will be better able to understand the complexities involved in the ART of hair transplant.

P39 Withdrawn P40 Withdrawn

P41 Combination Techniques for Donor Strip Wound Closure


Hyo Sub Ryu, MD. PhD. Hairdream Hair Clinic, Seoul, Korea, Republic of.

Director of Hairdream Hair Clinic Member of International Society of Hair Restoration Surgery Member of Asian Society of Hair Restoration Surgery Member of Korean Society of Hair Restoration Surgery Dermatologist, Repubilc of KOREA (previous) Associate Professor of Seoul National University Bundang Hospital H. Ryu: None. TAKE HOME MESSAGE: Combination techniques for donor strip wound closure which is composed of deep subdermal sutures, dermal sutures, skin sutures and skin staplers. Author have applied each different techniques for decreasing donor strip scars and these combination techniques were superior than any single method of wound closure. They produced excellent wound healing and diminished scar formations at the donor strip wound. ABSTRACT: There have been many wound closure techniques for donor strip harvesting. Simple closures were enough for many cases but there were several patients with wide scar especially who had great scalp laxities and tensions on wound edges. Author uses combination techniques which are composed of deep sub dermal sutures, dermal sutures, skin sutures and staples. After donor strip harvesting, hemostasis was done by minimal electrocoagulations. Interrupted absorbable 4-0 vicryl sutures were passed through galea aponeurotica and fibrotic deep tissues and tied. Absorbable 4-0 monofilament maxon sutures were passed through dermal tissues and tied. Deep sub dermal and dermal sutures were placed about 2cm apart and carefully done avoiding damages of nerves, vessels and hair follicles. These sutures minimize subdermal dead spaces and wound tensions which cause wound infection, scar formation and widening. They maintain tension within the deep area rather than at the superficial borders. And they also prevents delayed wound widening before absorption and minor inflammatory tissue reactions during absorption make fibrotic anchoring points which decrease scar widening. Vertical mattress sutures using nonabsorbable 4-0 nylon are placed about 2cm apart to secure the skin tissues. vertical mattress suture is a excellent technique for exactly approximating skin edges. Finally skin staples are used

for compactly close skin wound. Author removes skin sutures early at 3 or 4 days after the operation and removes skin staples at 7 to 10 days after the operation. Slightly elevated wound edges made by vertical mattress suture diminishes wound widening of patients with great scalp laxities. Usually skin staples are not good for exact approximation of skin wound edges and cause more postoperative discomfort, but they put less stresses on the wound sites compared with skin sutures. Patients are educated to avoid neck exercises which can cause excessive tension on wound site for 3 months after operation. We have applied each different techniques for decreasing donor strip scars but these combination techniques were superior than any single method of wound closure. Author has experienced excellent wound healing with minimal acute effluvium and diminished scar formations using this combination techniques.

P42
Sandro N. Salanitri, Md1, Flavia helena Junqueira Lopes, Anestesiologist1, Gilberto Lopes, Anestesiologist2, Celma Fernandes da Silva, Nurse3. 1 Santa Casa de So Paulo, So Paulo, Brazil, 2Clnica Sandro Salanitri, So Paulo, Brazil, 3Clinica Sandro Salanitri, Sao Paulo, Brazil. Vennturi effect; Brazil, Wikipedia, updated 27 Feverreiro 2013, accessed March 3, 2013; Venturi effect; available http://pt.wikipedia.org/wiki/Efeito_Venturi S.N. Salanitri: None. F.H. Lopes: None. G. Lopes: None. C.F. da Silva: None. TAKE HOME MESSAGE: We demonstrate how easily obtain a device that will help the cleansing of the scalp during the hair transplanting ABSTRACT: The non bleeding surgery decreases the surgical time, but its not always easy and possible. The possibility for an efficient and fast cleaning method in the surgical field is desirable. There are lots of options for cleaning the surgical area during surgery, it can include needles to sophisticated and expensive equipment. The utilization of sprays is a cheap, simple and efficient solution, but ANVISA (Brazilian organ similar to FDA) prohibited the utilization of materials submitted to multiples sterilization processes. Our work consists in describing one easy solution: an equipment made inside the surgical room using only components that are disposable, and are disponible in every hospital. The equipment can be constructed using: one bottle of destilated water, two fluid infusion lines, one tap (tree ways tap), a compressed air font and a needle.

Instrument Cleaning Scalp

The equipment is simple, cheap and produces an exuberant spray of water easily controlable, based in the Venturi principle. It's extremely efficient and don't requires extra trainment to use on surgical field.

Hair Transplantation Surgery is accompanied by relative bleeding which complicate and increase surgical time. In Brazil an ANVISA (National Agency of Sanitary Surveillance) standard banned the use of reesterilized sprinklers in surgical procedures. It has forced us to develop a method to allow the scalp clean during the intraoperative and immediate postoperative. System Equipment Compressed air or oxygen font; plastic air line; connector for the air line; infusion lines (2 units); 3-way stopcock (1 unit); 1L destiled water; 14G Venous Catheter. Riding the System Connect the equipment as showed. Open the air (or oxygen) flow system. Use the 3way stopcock to control the air/fluid flow.

Hair Wash

Water

Air or O2 Air or O2 Water

Venturi System The Venturi effect is the reduction in fluid plessure that results when a fluid flows throught a constricted section of pipe, which aspirate the water and creats the spray and also keeps the scalp clean during surgery, contributing to improve the surgical time by using an efficent, simple method at a lower cost.

Salanitri, S. N. MD. Plastic Surgery - dr.salanitri@gmail.com. Department of Surgery, Santa Casa de Misericrdia de So Paulo(Brasil); Lopes, G.; Lopes, F. H. J. (anesthetists of Sandro Salanitri's Clinic)

Hair Wash

P43 Hair Removal Laser for Creating Fine Hairs


Kyle Koo-Il Seo1, Jae Yoon Jung1, Hyun Sun Park2, Jin Yong Kim2, Jee Soo Ahn1. 1 Modelo clinic, Seoul, Korea, Republic of, 2Seoul National University Boramae Hospital, Seoul, Korea, Republic of. Dr. Seo graduated and got Ph.D from Seoul National University College of Medicine. He finished his residency and fellowship in Department of Dermatology, Seoul National University Hospital. He is now director of Modelo clinic in Seoul and also works for Department of Dermatology, Seoul National University Hospital as a clinical associate professor. He used to be vice president of local organizing committee for the 22nd World Congress of Dermatology (2011, Seoul) and is now general secretary of local organizing committee for the 35nd annual meeting of International Society for Dermatologic Surgery (2015, Seoul). For hair restoration surgery, he is American board of hair restoration surgery and member of Asian society of hair restoration surgery. He got poster award 2nd place on Method of Creating Fine hairs Using hair removal laser after FU transplantation in female with M-shaped foreheadat annual meeting of International Society of Hair Restoration (Las Vegas). K. Seo: None. J. Jung: None. H. Park: None. J. Kim: None. J. Ahn: None. TAKE HOME MESSAGE: Hair removal laser can be a good method for creating fine hairs for correction of hairline in females with thick donor hairs ABSTRACT: Background: Fine hairs at the foremost hairline are a critical in hair transplantation for correction of hairline (HTCH) in females with thick donor hairs. We have already developed and reported novel method to create fine hair using hair removal laser. Objectives: To investigate efficacy and safety of creating fine hairs with hair removal laser (HRL) in Asian females with thick donor hairs. Methods: A retrospective chart review was done. The parameters of the HRL, hair diameter measured by a micrometer before and after procedures, subjective assessment of treatment after procedures, adverse effects, and number of procedures were investigated. The reduction rate of hair diameter was calculated. And, we also performed a prospective clinical study to evaluate the dose-effect relationship of HRL in the healthy participants occipital area. Hair diameter and hair count change were evaluated. Results: Twenty-four females who received HRL therapy after HTCH were included in the retrospective study. The HRL parameters were: delivered laser fluence ranged from 35 to 36 J/cm2, pulse duration 6 ms, and spot size 10mm. The mean number of laser sessions was 2.6. Mean hair diameter significantly reduced from 80.011.5m to

58.413.2m (P=0.00). A number of laser sessions and hair diameter after procedure revealed negative correlation. (r=-0.410, P=0.046) Most of the patients (87.5%) reported subjective improvement. Most complications were transient and mild. And, in the prospective study, ten participants received one session of HRL treatment. The HRL parameters were: delivered laser energy ranged from 20 to 50J/cm2, pulse duration 5-10 ms, and spot size 10mm. The hair diameter was reduced after 24 weeks of treatment above the 40 J/cm2 of fluence. However, the hair count was unchanged. Conclusions: HRL can be a good method for creating fine hairs for correction of hairline in females with thick donor hairs.

Hair Removal Laser for Creating Fine Hairs


Jae Yoon Jung , 2Hyun Sun Park, 2Jin Yong Kim, 1Wonseok Han, Jee Soo Ahn, Kyle K. Seo Modelo Clinic, 1Hanhui Clinic ,2Department of Dermatology, Seoul National University Boramae Hospital, Seoul, Korea

Introduction
Conventional hair transplantation Use the thickest diameter hairs from the occipital scalp Asian females: thicker hairs compared to Caucasian or African Unnatural hairline and necessitates a special technique to create fine hairs in Asian females A few surgical methods to make natural hairline Grafting of bisected hair follicles Follicular unit transplantation of body or leg hairs Refined hairline correction technique: sorting one-hair follicular unit with small diameter from the occipital strip-excision and transplanting them in the front-most hairline. Limitation: poor yield, longer operation time, need for higher skill, variations in hair angulation or quality, and lack of sufficient body hair Few studies upon a non-surgical revisionary method to improve an unnatural foremost hairline with thick donor hairs after hair transplantation for hairline correction (HTHC)

(A)

(B)

Fig. 1 (a) A factitious hairline after HCHT in an Asian woman with thick donor hairs (b A more natural hairline after revision by creating fine hairs with HRL (long-pulse Nd:YAG) (A) (B)

Objective
Fig. 2 Another patient. (a) A factitious hairline after HCHT in an Asian woman with thick donor

Investigation of the efficacy and safety of creating fine hairs with hair removal laser (HRL) in Asian females with thick donor hairs

hairs (b) A more natural hairline after revision by creating fine hairs with HRL

Change of hair diameter

Materials & methods


101 patients received HRL screened
77 patients failed to meet inclusion criteria Female pattern hair loss (n=6) Treated with HRL other than long-pulse Nd:YAG (n=3) Data was not sufficient (n=68)

Mean hair diameter: 80.0 11.5m(before procedures)

58.4 13.2m (after procedures:

measured mean 6.3 months (range 3-14 months) after the last session) (P=0.00) Mean reduction rate of hair diameter: -25.7%. (from -44.6 to 5.7) A number of laser sessions and hair diameter after procedure: negative correlation. (r=-0.410, P=0.046) Patients treated with single session: median post-laser diameter of 69.6m (n=6) Two sessions 55.8 m (n=14), more than three 50.8m (n=4). Median of reduction rate of a hair diameter according to the number of laser procedures showed the same tendency, 18.0%, 27.6%, and 30.5%.

24 patients met the criteria

Retrospective chart review


Age Parameter of HRL Hair diameter measured by a micrometer (Mitutoyo, Kawasaki, Japan) before and after procedures Number of procedures Subjective assessment of treatment Adverse effects

(A)

(B)

Fig. 3 (A) An example of fine hairs created with HRL. The fine hairs were used for eyebrow hair transplantation. (B) Statistically significant reduction of hair diameter after laser treatment. (*P < 0.05 by paired t-test )

Adverse effects
Acute adverse reactions: erythema or swelling - most of the patients. tolerable and transient. Chronic adverse reactions: folliculitis (n=1), focal alopecia (n=1). no HRL-associated

Results
Basic information
mean age of 28.8

chronic adverse effects. (n=22)

Discussion and conclusion


HRL using long-pulse Nd:YAG can create fine hairs in Asian female patients with thick donor hairs. It can be a useful alternative method when the patients do not want additional surgery to revise their hairline formed by previous conventional HTHC. It can reduce the diameter of foremost hairs and increase patient satisfaction of HTHC. The limitation of this study includes the retrospective and uncontrolled nature of the study without long-term follow up data.

5.4 years (range 22-45)

donor hairs for HTHC were acquired from strips of occipital scalp and one-hair follicular units were transplanted in the foremost hairline. They were generally satisfied with previous HTHC but wanted to improve the thick hairs of the foremost hairline

Laser treatment procedure to create fine hairs


A long-pulse Nd:YAG laser (Coolglide, San Francisco, California, USA) Initial procedure: at least 5 months after HTHC (mean 15.7 months, range 5-36 months). Treated area: foremost anterior two to three rows of hairline Treatment parameters: fluence 35 ~36J/cm2; pulse duration 6 ms; spot size 10mm Mean number of laser sessions were 2.6 (range, 1 to 5 times) Laser treatment interval: 3-month to check regrowth of hairs

References
1. Swinehart JM. "Cloned" hairlines: the use of bisected hair follicles to create finer hairlines. Dermatol Surg 2001;27:868-72. 2. Jones R. Body hair transplant into wide donor scar. Dermatol Surg 2008;34:357.

P44 Low Anabolic Profile in Assessing a Patient's Overall Hair Loss Program and S.H.A.P.I.R.O. Chart
Lawrence Shapiro, DO. Dr. Shapiro's Hair Institute, Florida, Hollywood, FL, USA.

Dr. Lawrence Shapiro has been in practice in Florida for over 20 years as a dermatologist and hair restoration surgeon. He has performed thousands of hair transplant surgeries. He has encountered patients who suffer from hair loss from anabolic and work out products such as creatine, andro, fat burners, testosterone patches, growth hormone and whey protein isolate. He formulated a special nutritional blend to promote and sustain healthy hair and nails that could be used to work out. Dr. Shapiro discovered that when a hair transplant is followed by regular consumption of his formulation, there is less dormancy after the procedure and hair grew back more quickly with fuller looking results. He coined the term "Accelerated Follicular Restoration(TM)" (AFR (TM)). L. Shapiro: None. TAKE HOME MESSAGE: Anabolics that alter hormone levels may be an overlooked cause of hair loss. The research referenced in this paper points to anabolic workout and lifestyle products that could contribute to hair loss, including anabolic steroids, creatine, growth hormone, androstenedione or similar prohormones, Whey Protein Isolate, weight gainer, arginine and orthonine, DHEA and the HCG diet. This paper shows all the pathways in a single chart and describes how anabolics could be contributing to alopecia. Placing a patient on a low anabolic profile could help reduce hair loss and increase patient satisfaction. ABSTRACT: Introduction In more than 2 decades of practice, I noticed an acceleration of hair loss with the use of certain lifestyle products. So as part of my H&P, I usually review with patients their history of workout and lifestyle products. Premise As part of an overall hair loss program, I put them on a low anabolic profile by telling them to consider eliminating or reducing certain supplements in their diet. A review of the common supplements possibly causing hair loss includes: Anabolic Steroids (Chart Pathway 1) Creatine (increases DHT ) (Chart Pathway 3) Growth Hormone (Chart Pathway 2) Androstenedione or similar prohormones (Chart Pathway 1) Whey Protein Isolate (WPI) (Chart Pathway 1) Weight gainers (Chart Pathway 1) Arginine and Orthonine (Chart Pathways 2, 3) DHEA (Chart Pathway1, 2) HCG diet (Chart Pathway 1) Substantiating Data See chart image. Pathway 1 a) "Anabolism" is defined as "any state in which nitrogen is differentially retained in lean body mass, either through

stimulation of protein synthesis and/or decreased breakdown of protein anywhere in the body."(1) Anabolic steroids are extremely common and almost 1.5% of 12th graders have tried them at least once(2). Anabolic steroids are technically called anabolic-androgen steroids (AAS).(1) b) The BCAA's in whey protein isolate(WPI) are the real culprit in raising the testosterone levels during and after exercise as shown in the Sharp(3) study. In the Sharp study, subjects consumed high branched chain amino acids (BCAA) with high-intensity total-body resistance training. Blood serum was analyzed for testosterone. "Serum testosterone levels were significantly higher in the BCAA group during and following resistance training."(3) c) Homeopathic concentrations of HCG is a new fad weight loss diet that has been banned by the federal government.(4) Regular concentrations of HCG have been shown to increase testosterone levels. (5,6,7) Pathways 1, 2: DHEA is a supplement used mostly by pre- and post-menopausal women. DHEA is extremely anabolic because it raises testosterone AND androstenedione, and DHT levels.(8) In women, but not in men, serum A, T and DHT were increased to levels above gender-specific young adult ranges.(9) This is due to peripheral conversion(10) because DHEA is a precursor to androstenedione. DHEA has also been shown to raise IGF-1 levels(10) which has been shown to raise DHT(11) and testosterone(14,15) but had no effect on GH or IGFB-3.(11) Pathway 2: There is a secondary pathway referred to as a "parallel axis" which consists of both GH and insulin-like growth factor-I (GH-IGF-I).(11) Growth hormone is another very common supplement and is synergistic with testosterone(14,15). Both boost IGF-1(15,16) levels which can affect DHT directly by increasing 5AR.(12) IGF-1 is increased in men with vertex baldness.(17) Both increased GH(18) and IGF lower Sex Hormone Binding Globulin (SHBG) and release free testosterone (T)(19,20,21) into the bloodstream to produce an anabolic effect. Hair loss can occur from growth hormone because the serum levels of elevated IGF-1 cause hair loss directly through increased DHT(12) even though the cytokines papilla are producing their own IGF-1 independently(22,23) of serum IGF-1 and may cause growth.(22,24,25). There is no evidence that growth hormone affects the dermal papilla directly, however, "there is mounting evidence that suggests that GH exerts its anabolic affect mainly by locally produced IGF-1 rather than liver - derived circulating IGF-1."(15) Growth hormone increases both serum IGF-1(15,26) and IGFBP-3(27) and this binding molecule binds both serum(27) and cellular IGF-1 to reduce the concentration of IGF-1 cellular available for hair stimulation.(28,29,30) IGFB3-1 is less sensitive than IGF-1 to growth hormone stimulation.(26) Pathway 3: Some workout products can lead to hair loss. Creatine is a common OTC product used by weight lifters to gain muscle mass and in addition, it is used as a weight gainer.(31,32) Creatine is made up of three amino acids: arginine, glycine and L-methionine. It raises DHT directly without affecting serum testosterone levels(30, ) although IGF-1 is elevated.(32) The effect of IGF-I was about 100x that of androgen.(12) Even though IGF-1 increases DHT(18) and T(19) there may be an increased rate of conversion from T to DHT since IGF-1(30,18) increases 5AR. Pathway 3: Androstenedione is a naturally occurring OTC drug used by muscle builders. This is the most common performance enhancing drug on the market in professional sports. "Androstenedione appears to be a major prehormone of plasma dihydrotestosterone, accounting for at least two-thirds plasma dihydrotestosterone by

peripheral conversion in adult females."(10) Testosterone conversion accounts for at least 70% of plasma DHT in the male, but less than 20% in the normal female. Pathways 2, 3: Arginine and ornithine are extremely anabolic amino acids and increase both growth hormone and IGF-1 levels. However, leucine, found in WPI had no affect on GH and IGF-1 levels.(34,35,36) Arginine is one of three amino acids found in creatine which affects DHT directly (30). Interesting though is Arginine and orthonine decreased IGFBP-3 levels.(35) Discussion In summary, younger patients should be warned of supplements that affect hormone levels , especially WPI and creatine and older patients who go to men's/women's health clinics that prescribe growth hormone or other anabolic precursors that can cause hair loss. Reviewing a patient's Anabolic Profile and removing or eliminating supplemental use is a further step in preventing hair loss. Image Captions: Image 1 - HAPIRO Chart Image 2 - This 27 year old used creatine for 4-5 months. The hair loss is very typical of anabolic creatine use since it has a very even, diffuse pattern and the hair has a change in texture. Image 3 - Identical twin took creatine and had more hair loss. He has a very even, diffuse-looking MBP. When you get very even, diffuse-looking hair loss it is a real indicator of supplement use since the hair loss is systemic. Image 4 - Identical twin did not take anabolics. He has patchy, healthier areas of hair still remaining. Image 5 - References for abstract

1"Anabolic Steroids" by Cynthia M. Kuhn. Department of Pha rmacology and Cancer Biology, Duke University Medical Center, Durham, NC,USA Recent Progress in Hormone Research 57:411-434 (2002) 2 "Steroids (Anabolic)." National Institute on Drug Abuse website from the National Institute of Health

3 "Amino Acid Supplements and Recovery from High-Intensity Resistance Training." by Sharp C, Pearson DR. Journal of Strength and Conditioning Research 2010 April vol. 24 num.4 pp. 1125- 1130. 4 "Feds Crack Down on Homeopathic Weight Loss Remedy." Associated Press. December 6, 2011.

5 "Testicular responsiveness to hCG during infancy measured by salivary testosterone." by Dunkel L,Huhtaniemi I. Children's Hospital, University of Helsinki, Finland. Acta Endocrinol (Copenh). 1990 Dec;123{6):633-6. 6 "Androgen action on the restoration of spermatogenesis in adult rats: effects of human chorionic gonadotrophin, testosterone and flutamide administration on germ cell number." by Meachem SJ, Wreford NG, Robertson DM,Mclachlan RI. Prince Henry's Institute of Medical Research, Monash Medical Centre, Clayton, Victoria, Australia. Int J Androl. 1997 Apr;20(2):70- 9. 7 "Testicular response to HCG stimulation and sexual maturation in mice." by Jean-Faucher C, Berger M, de Turckheim M,Veyssiere G, Jean C. Horm Res. 1983;17(4):216-21. 8 "The effects of oral dehydroepiandrosterone on endocrine-metabolic parameters in

postmenopausal women." by Mortola JF, Yen SS. Department of Reproductive Medicine, School of Medicine ,University of California-San Diego, La Jolla, CA, USA. J Clin Endocrinol Metab. 1990 Sep;71(3):696-704. 9 "The effect of six months treatment with a 100 mg daily dose of dehydroepiandrosterone (DHEA) on circulating sex steroids, body composition and muscle strength in age-advanced men and women." by Morales AJ, Haubrich RH, Hwang JY, Asakura H, Yen SS. Department of Reproductive Medicine, School of Medicine, University of California San Diego, La Jolla, USA. Clin Endocrinol (Oxf). 1998 Oct;49(4):421-32. 10 "The Source of Plasma Dihydrotestosterone in Man." by T. Ito and R. Horton. Department of Medicine, University of Southern California, School of Medicine, Los Angeles, CA, USA .J Clin Invest. 1971 August; 50(8): 1621-1627. 11"Effects of replacement dose of dehydroepiandrosterone in men and women of advancing age." by Morales AJ, Nolan JJ, Nelson JC, Yen SS. Department of Reproductive Medicine, University of Ca lifornia School of Medicine, La Jolla, CA, USA. J Clin Endocrinol Metab. 1994 Jun;78(6):1360-7. 12 "Androgen induction of steroid 5 alpha-reductase may be mediated via insulin-like growth factor-I." by Horton R, Pasupuletti V, Antoni pillai I. Department of Medicine, University of Southern California School of Medicine, Los Angeles. Endocrinology. 1993 Aug;133(2):447-51. 13 "Short-term exposure to insulin-like growth factors stimulates testosterone production by testicular interstitial cells." by DeMellow JSM, Hendelsman DJ, Baxter RC. Acta Endocrinol {Copenh). 1987 Aug;115(4):483-9. 14 "Synergistic effects of testosterone and growth hormone on protein metabolism and body composition in prepubertal boys." by Mauras N, Rini A, Welch S, Sager B, Murphy SP. Nemours Children's Clinic Division of Endocrinology and Nemours Research Program, Jacksonville, FL 32207,USA. Metabolism. 2003 Aug;52(8) :964-9. 15 "The Effects of Growth Hormone and/or Testosterone on Whole Body Protein Kinetics and Skeletal Muscle Gene Expression in Healthy Elderly Men: A Randomized Controlled Trial" by Manthos G. Giannoulis, Nicola Jackson, Fariba Shojaee-Moradie, K. Sreekumaran Nair, Peter H. Sonksen, Finbarr C. Martin,and A. Margot Umpleby. J Clin Endocrinol Metab. 2008 August ; 93(8): 3066-3074.

16 "Growth hormone increases IGF-1, collagen I and collagen Ill gene expression in dwarf rat skeletal muscle." by Wilson VJ, Rattray M,Thomas CR, Moreland BH,Schulster D. Division of Biochemistry and Molecular Biology, UMDS, Guy's Hospital, London, UK. Mo/ Cell Endocrinol. 1995 Dec 29;115(2):187-97. 17 "Vertex balding, plasma insulin-like growth factor 1,and insulin-like growth factor binding protein 3." by Elizabeth A. Platz, Michael N. Pollak, Walter C. Willett,and Edward Giovannucci . Journal of the American Academy of Dermatology Volume 42, Issue 6 ,Pages 1003-1007, June 2000. 18 "Continuous subcutaneous infusion of low dose growth hormone decreases serum sex hormone binding globulin and testosterone concentrations in moderately obese middle-aged men." by Oscarsson J, Lindstedt G, Lundberg PA, Eden S. Department of Physiology and Pharmacology, Sahlgrenska Hospital, Goteborg University, Goteborg,Sweden. Clin Endocrinol {Oxf). 1996 Jan;44(1):23-9. 19 "Acne vulgaris: a disease of Western civilization." by Corda in L, Lindeberg S, Hurtado M, Hill K, Eaton SB, Brand-Miller J . Department of Health and Exercise Science, Colorado State University,Fort Collins,CO, USA. Arch Dermatol. 2002 Dec;138(12}:1584-90. 20 "Acne vulgaris: a disease of Western civilization." by Corda in L, Lindeberg S, Hurtado M, Hill K, Eaton SB, Brand-Miller J . Department of Health and Exercise Science, Colorado State University,Fort Collins,CO, USA. Arch Dermatol. 2002 Dec;138(12}:1584-90. 21 "Effect of D-thyroxine on serum sex hormone binding globulin (SHBG), testosterone, and pituitary-thyroid function in euthyroid subjects." by Yosha S, Fay M, Longcope C, Braverman LE. J Endocrinol Invest. 1984 Oct;7(5) :489-94. 22 "The Role of Insulin-Like Growth Factor I in the Regulation of Growth." by D.R. Clemmons, M. Dehoff,R. Mccusker, R. Elgin and W. Busby. University of North Carolina, Chapel Hill,NC, USA. Journal of Animal Science 1987, 65:168-179. 23 "The influence of testosterone propionate on the expression of several growth factors in scalp dermal papilla cell" by Kyung-Ho Kim, Yong-Jun Piao, Ki-Beom Suhr, Jeung-Hoon Lee, Jang Kyu Park. Department of Dermatology, Chungnam National University College of Medicine, Daejeon, Korea. Korean Journal of Investigative Dermatology . 2002;vol. 9, No. 1. pp. 29 - 34. 24 "Purification of Androgen Receptors in Human Sebocytes and Hair" by Marty E Sawaya. University of Miami School of Medicine, Department of Dermatology and Cutaneous Surgery, Miami,FL, U.S.A .Journal of Investigative Dermatology (1992) 98, 92S-96S 25 "The control of hair growth." by Slobodan M. Jankovic and Snezana V. Jankovic. From the Center for clinical and experimental pharmacology Clinical Hospital Centre, Kragujevac, Serbia, Yugoslavia. Dermatology Online Journal 4(1): 2 1998 26 "Growth hormone increases IGF-1, collagen I and collagen Ill gene expression in dwarf rat skeletal muscle." by Wilson VJ, Rattray M, Thomas CR, Moreland BH, Schulster D. Division of Biochemistry and Molecular Biology,UMDS, Guy's Hospital, London, UK. Mal Cell Endocrinol. 1995 Dec 29;115(2):187-97. 27 "Dose-response study of GH effects on circulating IGF-1 and IGFBP-3 levels in healthy young men and women" by E. Ghigo, G. Aimaretti, M. Maccario, G. Fanciulli, E. Arvat , F. Minuto, G. Giordano, G. Delitala, and F. Camanni. Accepted in final form 23 February 1999.American Journal of Physiology - Endocrinology and Metabolism..

28 "The control of hair growth." by Slobodan M. Jankovic and Snezana V.Jankovic. From the Center for clinical and experimental pharmacology Clinical Hospital Centre, Kragujevac, Serbia, Yugoslavia . Dermatology Online Journal 4(1}: 2 1998 29 "Acne vulgaris: a disease of Western civilization." by Corda in L, Lindeberg S, Hurtado M, Hill K, Eaton SB, Brand-Miller J . Department of Health and Exercise Science, Colorado State University, Fort Collins,CO, USA. Arch Dermatol. 2002 Dec;138(12):1584-90. 30 IGFBP-3 the most abundant IGFBP type in dermal papilla cells forms a complex with free IGF-1

to reduce the concentration of IGF-1 available for stimulation of hair elongation and maintenance of the anagen phase. Hembree JR, Harmon CS, Nevins TD, et al. Regulation of human dermal papilla cell production of insulinlike growth 31 "Three weeks of creatine monohydrate supplementation affects dihydrotestosterone to testosterone ratio in college-aged rugby players." by van der Merwe J, Brooks NE, Myburgh KH. Department of Physiological Sciences, Stellenbosch University ,Stellenbosch ,South Africa . Clin J Sport Med. 2009 Sep;19(5) : 399-404 . 32 "Creatine monohydrate supplementati on on body weight and percent body fat." by Kutz MR, Gunter MJ. Department of Physical Education and Athletic Training,Palm Beach Atlantic University, West Palm Beach, FL, USA. J Strength Cond Res. 2003 Nov; 7(4) :817-21. 33 "Effect of creatine supplementation and resistance-exercise traini ng on muscle insulin-like growth factor in young adults." by Burke DG, Candow DG, Chilibeck PD,MacNeil LG, Roy BD, Tarnopolsky MA, Ziegenfuss T. Department of Human Kinetics, St. Francis Xavier University, Antigonish, NS, Canada . Int J Sport Nutr Exerc Metab. 2008 Aug;18(4) :389-98 . 34 Supplements as Ergogenic Aids. Understanding Nutrition" 2005 by Whitney, E., & Rolfes, S. 35 "Arginine increases insulin-like growth factor-I production and collagen synthesis in osteoblast-like cells." Chevalley T, Rizzoli R, Manen D, Caverzasio J, Bonjour JP. WHO Collaborating Center for Osteoporosis and Bone Diseases, Department of Internal Medicine, University Hospital,Geneva, Switzerland. Bone. 1998 Aug;23{2) :103-9. 36 "Arginine and ornithine supplementation increases growth hormone and insulin-like growth factor-1 serum levels after heavy-resistance exercise in strength-trained athletes." by Zajac A, Poprzecki S, Zebrowska A, Chalimoniuk M, Langfort J . Department of Sports Training,Academy of Physical Education Katowice, Poland. J Strength Cond Res. 2010 Apr;24(4):1082-90 .

P45 New Approaches to the Surgical Treatment of Secondary Cicatricial Alopecia


Diana G. Papaskiri, Author, Aleksiy A. Makharashvili, Professor, Alexander Ephimovich Shestopalov, Doctor Professor, Nodari N. Kakiashvili, Author. Clinica Maka Med, Moscow/Russia, Russian Federation. D.G. Papaskiri: None. A.A. Makharashvili: None. A.E. Shestopalov: None. N.N. Kakiashvili: None. TAKE HOME MESSAGE: Taking into account of morphological features of the scar skin, application of a special micro-surgical tools and the operative techniques, follicular microautotransplantation is an effective method of surgical treatment of cicatricial alopecia. ABSTRACT: Introduction: cicatricial alopecia, arising as a result of various injuries (traumas, burns, etc.) is the main cause of functional and aesthetic defects, reduction in the level of social adaptation and quality of life. Existing surgical methods of correction of scarring of the scalp (transplant free skin graft, tissue expansion method, etc.) do not solve the problem completely and accompanied by a number of complications. Microsurgical auto transplantation of hair, successfully and widely used in the correction of androgenetic alopecia, as a method of surgical treatment of cicatricial alopecia, still doesn't have the evidence base. Objective: The aim of this work was the identification of opportunities and the efficiency of surgical treatment of cicatricial alopecia method of microsurgical follicular transplantation. Materials and methods: The research was carried out in 2 groups of patients. 1-St (main) group consisted of 62 patients (51.6% of men and 48.4% of women), in the age of from 9 till 60 years, with secondary cicatricial alopecia (RA) of different etiology. Area of cicatricial alopecia ranged from 30 to 132 (36,80.2) cm2. Terms of the existence of scars from 0,5 to 40 years. The comparison group (2nd group) consisted of 115 patients males with androgenetic alopecia (AGA) at the age from 21 to 67 years. Area of baldness - 77,40,5 cm2, duration of baldness - 5,72.1 years. The degree of hair loss according to the classification of the Hamilton - Norwood - from III to V. Surgical treatment by using the method of hair FUT has been performed in both groups under local anesthesia. Time of observation after the operative intervention 9 - 12 months. The efficiency of surgical treatment is based on the analysis of the immediate and remote results. Results: The survival of transplanted in scars grafts amounted to 93.8 % 1.2%. In 6 months after operations noted the positive cosmetic effect, and after 12 months - full restoration of hair. The viability of the transplanted in scarring of the follicles and the positive dynamics of changes in the structure of the scar tissue after surgery confirmed by morphological studies. At the same time the data of morphological researches of the scar tissue before the operation identified new approaches to surgical technique - minimizing the trauma of tissues, the use of microsurgical blades, a certain number of (14 of 42) of transplanted grafts per 1 cm2 of skin. In addition, of great importance is the type of scar. The most significant positive results of surgical treatment of cicatricial alopecia identified when transplanted grafts in normal trophic and atrophic scars. Conclusions:

The analysis of the received results has shown, that taking into account of morphological features of the scar skin, application of a special micro-surgical tools and the operative techniques, follicular microautotransplantation is an effective method of surgical treatment of cicatricial alopecia.

P46 Optimizing Graft Distribution and Density in Giga Session of Hair Transplant
Suneet Soni, MBBS, MS, MCh. MEDISPA Laser and Cosmetic Surgery Center, Jaipur, Rajasthan, India. Dr Suneet Soni M.B.B.S.,M.S.,M.Ch.(plastic surgery) Director Medispa , Laser and Cosmetic Surgery Center, Jaipur, India S. Soni: None. TAKE HOME MESSAGE: Giga session of hair transplant require precise planning for graft distribution to match patents satisfaction in terms of density and area covered in one session. Keeping frontal density 50to60 FU/cm sq,40to50 in lateral areas and gradually decreasing to 30 as we go posteriorly we can archive good patent satisfaction even in patients of norwood grade 5 or 6 baldness ABSTRACT: Introduction Review of our last 200 cases of giga hair transplant, we found difficulty in distributing 3500 plus follicular units(FU) to match patent satisfaction in relation to density and area covered in one sitting. Initially we tried to increase frontal truft density up to 75 FU/cm2 to give more fuller density but leading to insufficient FU at sides and back areas leading to less area covered in one sitting and unsatisfied patent in relation to area covered. Now we have optimized the frontal truft density up to 50-60 FU FU/cm2 and lateral area 40-50 FU/cm2 and gradually decreasing up to 30 FU/cm2 as we go posteriorly. By optimizing the density distribution in giga sessions, we can get the best possible results in one sitting in grade 4,5 even in 6 baldness. Objective Optimizing the FU density distribution in giga sessions, to get the best possible results in grade NW 4,5 even in 6 baldness so as to match patient satisfaction in relation to density and area covered in one sitting. Materials and/or Methods Review of our last 200 cases of giga hair transplant and pattern of density distribution (density was calculated manually at the time of surgery by making 1 cm squire grid) .we have taken the patent feed back by asking them to grade there result satisfaction giving points out of ten in relation to density and area covered in one sitting after 9 months post surgery. Discussion/Results in initial 75 patients we tried to keep high frontal tuft area density(60to 75 FU/cm2) as per patent demand. In This type of graft distribution patients in fallow up sessions satisfaction in terms of density was high (i.e average 8to 10)but patents satisfaction In terms of area covered was low (i.e3to5.) generally area of baldness covered was less. so total satisfaction score was around 65%(9+4=13/2=6.5) we have optimized the frontal truft density up to 50-60 FU FU/cm2 and lateral area 50-55 FU/cm2 and gradually decreasing up to 30 FU/cm2 as we go posteriorly .next 100 patient were analyzed average density satisfaction score was good (8 to 9),patent were satisfied with the area covered(score 7 to 8). Average satisfaction score (8.5+7.5=16/2=8) was increased from 65% to 80%

Conclusion by strategically distributing grafts and keeping density 50 to 60 in frontal truft area ,50 to 55 in lateral areas , a good satisfaction level can be achieved in patiens of grade 5 or 6 baldness in single sitting.

P47 Vertex Accentuation in Female Pattern Hair Loss in Asians


Rattapon Thuangtong, MD. Siriraj Hospital, Mahidol University, Bangkok, Thailand. Name: Rattapon Thuangtong Address: Siriraj Hospital, Department of Dermatology 2 Prannok Road, Bangkoknoi Bangkok, Thailand, 10700 Phone: (662) 411-2722 Email: rattaponthuangtong@yahoo.com Date of birth: Dec 10, 1972 Academic Appointment 2004-present Assistant Professor, Head of Division of Hair Disorders and Hair Transplantation, Department of Dermatology Faculty of Medicine Siriraj Hospital, Mahidol University Education 1989-1995 MD. Faculty of Medicine Siriraj Hospital Mahidol University, Bangkok, Thailand Postgraduate Education 1996-1999 Resident in Internal Medicine Srinagarind Hospital, Khon Kaen University 1998 Visiting resident, Department of Dermatology Case Western Reserve University, Cleveland, Ohio 2000-2003 Residency in Dermatology Siriraj Hospital, Mahidol University

Certifications 1997 Diploma in Clinical Science, Khon Kaen University 1999 Thai Board of Internal Medicine, 1999 2003 Thai Board of Dermatology, 2003 2008 Dermatology Fellowship, University of California at Los Angeles (Hair transplantation, Hair transplantation for Gene therapy, Bioluminescence) 2009 Dermatology Fellowship, University of Pennsylvania (Hair disorders, Laser-Cosmetic dermatology)

R. Thuangtong: None. TAKE HOME MESSAGE: Vertex accentuation is a possible classification for FPHL. ABSTRACT: Background: The most common type of hair loss seen in women is female pattern hair loss(FPHL), also known as female androgenetic alopecia. It affects the central portion of the scalp, sparing the frontal hairline. Frontal accentuation was also described by Olsen. In Asian women, vertex thinning patterns are frequently developed but there are no report about vertex thinning pattern in female pattern hair loss. Objectives: To find prevalence of vertex accentuation in FPHL in Asian women and propose term vertex accentuation to be another classification for describing FPHL. Materials and Methods: Scalp hair counting(n/cm2) were measured at 3 different areas; vertex, mid scalp and frontal area respectively by digital dermoscope(Dino digital AM-413T). Visual counting and photography were performed. Outcomes were evaluated by gross appearance of vertex thinning and/or hair density < 120 /cm2 in any of 3 areas. Results: 143 patients were evaluated. Mean age was 45.54 years. Of the hair loss type, 36.4% were mid-scalp, 33.6% were vertex accentuation and 30.1% were frontal accentuation respectively. Age was not significantly different among 3 types of hair loss(P- value 0.859) Conclusion: Although the most common female pattern hair loss type is diffuse type(Ludwig type), vertex accentuation pattern is the second most common pattern in this study. This study is the first to mention Vertex accentuation to be another possible classification for FPHL. Key word: Female pattern hair loss, Vertex accentuation


SUPSRISUNJAI C, THUANGTONG R. DEPARTMENT OF DERMATOLOGY, FACULTY OF MEDICINE SIRIRAJ HOSPITAL, MAHIDOL UNIVETSITY, BANGKOK, THAILAND

Vertex accentuation in female pattern hair loss in Asians Results

Background
The most common type of hair loss seen in women is female pattern hair loss(FPHL), as known as female androgenetic alopecia. It affects the central portion of the scalp, sparing the frontal hairline. Frontal accentuation was also described by Olsen. In Asian women, vertex thinning patterns are frequently developed but there are no report about vertex thinning pattern in female pattern hair loss

143 patients were evaluated. Mean age was 45.54 years. Of the hair loss type, 36.4% were mid-scalp, 33.6% were vertex accentuation and 30.1% were frontal accentuation respectively. Age was not significantly different among 3 types of hair loss(P- value 0.859)

Conclusion
Frontal 30% Although the most common female pattern hair loss type is diffuse type (Ludwig type), vertex accentuation pattern is the second most common patten in this study. This study is the first to mentionVertex accentuation to be another possible classification for FPHL

Objectives
To find prevalence of vertex accentuation in FPHL in Asian women and propose term vertex accentuation to be another classification for describing FPHL.

Materials and Methods


Scalp hair counting(n/cm2) were measured at 3 different areas; vertex, mid scalp and frontal area respectively by digital dermoscope(Dino digital AM-413T). Visual counting and photography were performed. Outcomes were evaluated by gross appearance of vertex thinning and/or hair density < 120 /cm2 in any of 3 areas.

References

Figure 3: Percentage of Pattern Hair Loss

1. Birch MP, Lalla SC, Messenger AG. Female pattern hair loss. Clin Exp Dermatol 2002;27:387-92 2. Olsen EA, Messenger AG, Shapiro J, Bergfeld WF, Hordinsky MK, Roberts JL, et al. Evaluation and treatment of male and female pattern hair loss. J Am Acad Dermatol 2005;52:301-11. 3.Han ES, Kim MN, Hong CK, Ro BI. A clinical study of androgenetic alopecia. Korean J Dermatol 1995;33:44-52 4.Ludwig E. Classification of the types of androgenetic alopecia(common baldness) occurring in the female sex. Br J Dermatol 1977;97:247-54. 5.Olsen EA. The midline part: an important physical clue to the clinical diagnosis of androgenetic alopecia in women. J Am Acad Dermatol 1999;40:106-9.

Authors
Figure 2: Vertex Accentuation in Female Androgenetic Alopecia
Name: Chavalit Supsrisunjai, MD Specialty:Dermatology Qualifications: M.D., Faculty of medicine (second class honor) ,Siriraj hospital Diplomate of the Thai Board of Dermatology chervilius@hotmail.com

Figure 1:Target area hair count Dino lite pro (AM-413T)

Name: Rattapon Thuangtong, MD Specialty: Dermatology( Hair disorders and Hair transplantation) Qualifications: M.D., Faculty of medicine, Siriraj hospital Diplomate of the Thai Board of Internal Medicine Diplomate of the Thai Board of Dermatology Certificate in Hair Disorders and Hair Transplantation(USA) Certificate in Laser-Cosmetic Dermatology(USA) Position: Associate Professor , Department of Dermatology, Siriraj Hospital rattaponthuangtong@yahoo.com

P48 A Pilot Study of the Efficacy of 5% Minoxidil Solution Combined with Oral Chelated Zinc Supplement in Treatment of Female Pattern Hair Loss

Rattapon Thuangtong, MD.. Siriraj Hospital, Mahidol University, Bangkok, Thailand.

Curriculum Vitae Name: Rattapon Thuangtong Address: Siriraj Hospital, Department of Dermatology 2 Prannok Road, Bangkoknoi Bangkok, Thailand, 10700 Phone: (662) 411-2722 Email: rattaponthuangtong@yahoo.com Date of birth: Dec 10, 1972 Academic Appointment 2004-present Assistant Professor, Head of Division of Hair Disorders and Hair Transplantation, Department of Dermatology Faculty of Medicine Siriraj Hospital, Mahidol UniversityCertifications1997 Diploma in Clinical Science, Khon Kaen University1999 Thai Board of Internal Medicine 2003 Thai Board of Dermatology, 20032008 Dermatology Fellowship, University of California at Los Angeles (Hair transplantation, Hair transplantation for Gene therapy, Bioluminescence)2009 Dermatology Fellowship, University of Pennsylvania (Hair disorders, Laser-Cosmetic dermatology) 1. Thuangtong R., Suthipinittharm P. Reported case:Hypersensitivity to insect bite with Non-Hodgkins lymphoma, Department of Dermatology, Siriraj Hospital. Annual Meeting of Thai Dermatological Society 2003, Bangkok, Thailand 2. Thuangtong R., Pisutthinusart P., Osangthamnont P., Wanitphakdeedecha R. Prospective randomized controlled trial, Long Pulsed Nd:YAG in Keloid treatment. R. Thuangtong: None. TAKE HOME MESSAGE: Using chelated Zinc 15mg/d as an additional trace supplement in FPHL have an efficacy to improve hair density and hair shaft diameter. ABSTRACT: Background: Zinc supplement is a popular trace element gave to female pattern hair loss (FPHL) patients. But there are few studies about the efficacy and side effects of it. Objective: To determine efficacy and side effect of chelated zinc in FPHL which using 5%minoxidil solution.

Materials and Methods: A total of 18 Thai women (26-61 years old) with female pattern hair loss applied 5% topical minoxidil solution twice daily combined with oral chelated Zinc 15 mg per day for 24 weeks. Then measure growth of hair by global photograph, hair density and hair shaft diameter by using target area hair count and digital micrometer at 24-week of treatment. Results: All 18 female patients were attached to this study at 24-week follow up visit. The mean age was 47.5 9.7 years (range, 26-61 years). Percentage of increasing in hair density and hair shaft diameter at 24-week follow-up visit were 12.2% and 5.5%, respectively. There were statistically significant differences improvement in both hair density and hair shaft diameter (p<0.001 and p<0.001, respectively). Furthermore, the assessment of global photographic review(GPR) by two dermatologists showed 11.1% of patients had moderately improved, 61.1% had minimally improved and 27.8% had no change. There were no statistically significant differences between serum Zinc and serum Ferritin and no side effect of oral chelated Zinc was reported. Conclusions: Using chelated Zinc as an additional trace supplement in FPHL have an efficacy to improve hair density and hair shaft diameter by means of no side effect. Key word: chelated Zinc supplement, 5% minoxidil solution, Female pattern hair loss

A pilot study of the efficacy of 5% minoxidil solution combined with oral chelated Zinc supplement in treatment of female pattern hair loss
Thuangtong R, Suvanasuthi S, Keoprasom N, Manapajon A, Maneeprasopchoke P DEPARTMENT OF DERMATOLOGY, FACULTY OF MEDICINE SIRIRAJ HOSPITAL, MAHIDOL UNIVERSITY, THAILAND
Contact email : rattaponthuangtong@yahoo.com , wonnaj@hotmail.com

Introduction
Zinc supplement is a popular trace element gave to female pattern hair loss (FPHL) patient. But the type of patient, efficacy, and side effect in detail of zinc supplement are not well characterized.The aim of this study was to determine efficacy and side effect of chelated zinc in FPHL who using 5%minoxidil solution.

Results
Percentage of increasing in hair density and hair shaft diameter at 24-week follow-up visit after receiving 5% minoxidil solution combined with 15 mg oral chelated Zinc supplement were 12.2% and 5.5%, respectively. There were statistically significant differences improvement in both hair density and hair shaft diameter (p<0.001 and p<0.001).

Figure1. Target area hair count (TAHC) Dino lite pro (AM-413T)

Figure2.Hair diameter measurement Electronic outside micrometer

Materials&Methods
The assessment of Global Photographic Review(GPR) by two dermatologists showed 11.1% of patients had moderately improved, 61.1% had minimally improved and 27.8% no change. There were no statistically significant differences between serum Zinc and serum Ferritin and no side effect of oral chelated Zinc was reported.

A total of 18 Thai women (26-61 years old) with female pattern hair loss applied 5% topical minoxidil solution twice daily combined with oral chelated Zinc 15 mg per day for 24 weeks Then measure growth of hair by Global photograph, hair density and hair shaft diameter by using Target area hair count and micrometer during 24 weeks of treatment.

Results
All of 20 patients, there have 18 patients, completed treatment and 2 patients, were dropped out due to adverse effects that were pruritus and scaling after receiving 5% topical minoxidil solution. The mean age was 47.5 9.7 years (range, 26-61 years) where as age of onset was 41 years and the duration of hair loss was about 7 months before the study.

Conclusion
5% minoxidil solution combined with oral chelated Zinc supplement have an efficacy in treatment of FPHL so this is a pilot study for further subsequent clinical studies with two arms double blind control study and larger number of participants.

P49 Minimizing the Postoperative Pain in Patients Undergoing Strip Surgery


Asad Toor, MD.1, Humayun Mohmand, MD.2, Muhamamd Ahmad, MD2. 1 Hair Transplant Istitute, Lahore, Pakistan, 2Hair Transplant Istitute, Islamabad, Pakistan.

Hair Transplant Institute, Pakistan is the leading hair transplant institute in Paksitan offering a wide range of hair restorative options including strip surgery, FUE, body hair transplant etc. The surgeons working are experienced, well-renowned. They have been among the authors of various national and international publications. A. Toor: None. H. Mohmand: None. M. Ahmad: None. TAKE HOME MESSAGE: The postoperative pain after strip surgery is a major concern for most of the patients undergoing strip surgery. The pain can be minimized by this simple technique with no long-term complications. ABSTRACT: Objectives: To minimize the postoperative pain in the patients undergoing hair transplant surgery (strip method) Materials and Methods: Ten patients were selected randomly for the study and informed consent was ensured. At the end of the strip surgery, before the wound closure, a fine silicone catheter 12o Fr was inserted on either side of the strip. The injecting portion was left out of the strip wound. Then the closure was performed routinely. To the each end of the catheter, a 20 ml syringe containing 1% xylocaine, bupivacaine and normal saline was filled. The patients were advised to inject 1 ml from each syringe when they experience the pain postoperatively. The patients were advised to note the time of injection of the fluid and also to mark according to the Wong baker Faces pain scale. The catheters were removed 48 hours after the surgery. Results: The mean age of the patients was 33.2 years. Majority of the patients (40%) had type IV of Norwood scale. In the 1st 24 hours, 3 patients injected the fluid once and only 1 patient injected in 4 times. In the next 24 hours, only 2 patients injected in twice whereas none injected in 3 or 4 times. Conclusion: The postoperative pain can be minimized by usingthis simple method which proves to be effective.

P50 A Retrospective Study on the Quality of FUT Scars with a Related Patient Satisfaction Survey
Anastasios Vekris, MD. Advanced Hair Clinics, Athens, Greece.

Dr Anastasios Vekris, MD, is a Plastic Surgeon & expert hair restoration surgeon. He has been involved in hair restoration for the last 10 years and has performed thousands of hair restoration procedures in various countries around the world. He specializes in FUE & scar restoration. He is a member of the ISHRS & has trained many doctors & assistants in FUE procedures in many countries. He is the Medical Director of Advanced Hair Clinics in Athens, Greece. A. Vekris: None. TAKE HOME MESSAGE: Hair restoration experts performing FUT procedures must be conscious of the effect of the scars in the donor area after a hair restoration session and always be trained & prepared to offer a properly informed preoperative consultation as well as to implement their wound closure techniques the best way they can in order to achieve minimal, aesthetically accepted postoperative scars. Properly informed concent of the patients undergoing FUT procedures & the best surgical skills will surely result in better scars & less postoperative problems for the patients. ABSTRACT: Introduction: The evolution of the surgical techniques in FUT hair restoration along with the advanced skills of the experienced hair restoration surgeon performing FUT, should aim to improve the inevitable scar in the donor area, subsequent to a FUT session. However, in everyday practice, hair restoration experts come frequently in contact with patients with large, aesthetically challenging scars. The aim of this study is to estimate the quality of scars from previous FUT sessions, using certain quantitative parameters, while the results of a related patients satisfaction survey based on a questionnaire, will be presented & discussed. Materials. & Methods. All patients that visited our clinic from March 2012 to January 2013 were asked to participate in the study. In total, 438 patients were examined & 424 of them agreed to participate (96.8%). In each patient, certain evaluation steps were followed to gather information about the possible existence of scars from previous hair restoration. Statistic data was gathered, including age, sex, number of previous hair restoration procedures, grade of hair loss etc. Photos were taken, of both the recipient & the donor area, in order to establish if there is a visible scar in the donor area or not. The donor area was examined thoroughly & any visible scar was measured in length & width, in its widest part. The number of visible scars, if more than one, was documented & new photos were taken. Furthermore, it was documented if there were any vertical scars or external suture marks on the edges of the scar. A questionnaire was given to all the patients with a scar, with relative questions concerning their views about their scars, their previous hair restoration procedures & their overall satisfaction. All the data were gathered and sent for statistical analysis with the SPSS software to an outsourced, independent analyzer. Results. Of the 424 patients, 128 (30.2%) had had previous FUT hair restoration procedures. The patients were from different ethnic backgrounds, but mainly of European, Middle Eastern or Indian origin. There were 125 men (97.6%) & only 3 women (2.4%), in comparison to 388 (91.5%) men & 36 women (8.5%) in the total of patients.

The average age of previous FUT patients was 42 years (ranging from 28-75 years), while the average age of all the patients was 37 years (ranging from 22-75 years). In the group of FUT patients, 101 (78.9%) had one FUT session, while the remaining 27(21.1%) had two or more. The average length of the scars was 20.5 cm (ranging from 5-26 cm) and the average width was 1.1 cm (ranging from 0.3-3.9cm). There were 13 patients (10.2%) with multiple or intersecting scars & 34 patients (26.5%) with visible, obvious scars at the time of the consultation. Overall, 6 patients (4.7%) had visible scars within the bald area of their scalp. In the patients survey, 33 patients (25.8%) stated that they were quite satisfied, very satisfied or indifferent to their scars, while the remaining 95 patients (74.2%) were quite unsatisfied or very unsatisfied with their scars. 10 patients (7.8%) stated that, if needed, they would undergo a new FUT procedure, 95 patients (74.2%) stated that they would prefer a FUE procedure and 23 patients (18%) stated they would never again undergo hair restoration surgery. A number of 90 patients (70.4%) stated they would consider a scar revision with the currently available techniques (W-plasty, FUE or medical tattoo). Of the 128 patients with previous FUT scars, 45 (35.2%) stated that, if they knew about the scar they wouldnt go through with their hair restoration session, 21 patients (16.4%) were totally unaware of the existence of the FUE technique and, amazingly, 8 patients (6.2%) stated that they were misled and were treated by FUT rather than FUE, while they were promised the opposite. Discussion. Although most hair restoration surgeons would agree that there has been significant progress in the field of FUT scar management, such as the description of the trichophytic closure technique, the use of absorbable internal sutures, the proper mobilization of the wound edges & the continuous subcutaneous suturing, the matter still remains controversial. It is evident from our findings that there are still issues of poor surgical technique leading to oversized scars, obvious scars from external sutures, intersecting scars from multiple procedures etc. It seems that there is a strong correlation between the number of FUT sessions performed & the quality & quantitative parameters of the scar. At the same time, it seems that better scars were produced in cases where the surgeon has performed a conservative strip harvesting & used techniques as the trichophytic closure or the continuous subcutaneous suture etc. An alarming finding was that in a small number of cases the old FUT scar became visible, as part of the bald area, which indicates poor planning of the initial harvesting & poor estimation of the potential evolution of hair loss. A rather disturbing finding was that in a few cases the patients were not properly informed about their hair restoration procedure, the creation of a scar and in the most extreme cases, certain patients were misled to think that they were having FUE hair restoration & they only found about their scars months later. This fact calls for vigilance & action from the hair restoration community, as it degrades the hair restoration procedures & gives a bad name to hair restoration surgeons. Conclusion. Although scar formation after FUT hair restoration is a fact, the final aesthetic results & the patients satisfaction may vary significantly, based on the surgeons experience, the wound closure technique and, most importantly, the proper education of both doctors & patients, in order to choose each time the right professional & the right technique to solve the hair loss problem.

A RETROSPECTIVE STUDY ON THE QUALITY OF FUT SCARS WITH A RELATED PATIENTS SATISFACTION SURVEY Dr. Anastasios Vekris , M.D Advanced Hair Clinics, Athens , Greece

INTRODUCTION: The evolution of the surgical techniques in FUT hair restoration along with the advanced skills of the experienced hair restoration surgeon performing FUT, should aim to improve the inevitable scar in the donor area, subsequent to a FUT session. However, in everyday practice, hair restoration experts come frequently in contact with patients with large, aesthetically challenging scars. The aim of this study is to estimate the quality of scars from previous FUT sessions, using certain quantitative parameters, while the results of a related patients satisfaction survey based on a questionnaire, will be presented & discussed. MATERIALS & METHODS: All patients that visited our clinic from March 2012 to January 2013 were asked to participate in the study. In total, 438 patients were examined & 424 of them agreed to participate (96.8%). In each patient, certain evaluation steps were followed to gather information about the possible existence of scars from previous hair restoration. Statistic data was gathered, including age, sex, number of previous hair restoration procedures, grade of hair loss etc. Photos were taken, of both the recipient & the donor area, in order to establish if there is a visible scar in the donor area or not. The donor area was examined thoroughly & any visible scar was measured in length & width, in its widest part. The number of visible scars, if more than one, was documented & new photos were taken. Furthermore, it was documented if there were any vertical scars or external suture marks on the edges of the scar. A questionnaire was given to all the patients with a scar, with relative questions concerning their views about their scars, their previous hair restoration procedures & their overall satisfaction. All the data were gathered and sent for statistical analysis with the SPSS software to an outsourced, independent analyzer. RESULTS: Of the 424 patients, 128 (30.2%) had had previous FUT hair restoration procedures. The patients were from different ethnic backgrounds, but mainly of European, Middle Eastern or Indian origin. There were 125 men (97.6%) & only 3 women (2.4%), in comparison to 388 (91.5%) men & 36 women (8.5%) in the total of patients. The average age of previous FUT patients was 42 years (ranging from 28-75 years), while the average age of all the patients was 37 years (ranging from 2275 years). 21.1% more In the group of FUT patients, 101 (78.9%) had one FUT session, while the remaining 27(21.1%) had two or more. 78.9% one FUT The average length of the scars was 20.5 cm (ranging from 5-26 cm) and the average width was 1.1 cm FUT session sessions (ranging from 0.3-3.9cm). There were 13 patients (10.2%) with multiple or intersecting scars & 34 patients (26.5%) with visible, obvious scars at the time of the consultation. Overall, 6 patients (4.7%) had visible scars within the bald area of their scalp. In the patients survey, 33 patients (25.8%) stated that they were quite satisfied, very satisfied or indifferent to their scars, while the remaining 95 patients (74.2%) were quite unsatisfied or very unsatisfied with their scars. Patient Satisfaction Survey 10 patients (7.8%) stated that, if needed, they would undergo a new FUT procedure, 95 patients (74.2%) stated that they would prefer a FUE procedure and 23 patients (18%) stated they would never again undergo hair restoration surgery. NEXT HAIR RESTORATION OPTION
74.2% next step FUE 18% not again 7.8 % again FUT 70.4% scar revision 29,6 % no revision
A number of 90 patients (70.4%) stated they would consider a scar revision with the currently available techniques (W-plasty, FUE or medical tattoo).

74,2% 25,8%

95 people (unsatisfied or very unsatisfied) 33 people (very satisfied, satisfied, indifferent)

Of the 128 patients with previous FUT scars, 45 (35.2%) stated that, if they knew about the scar they wouldnt go through with their hair restoration session, 21 patients (16.4%) were totally unaware of the existence of the FUE technique and, amazingly, 8 patients (6.2%) stated that they were misled and were treated by FUT rather than FUE, while they were promised the opposite.
HOW WELL INFORMED BEFORE A HAIR TRANSPLANTATION PROCEDURE?

no knowledge about the FUT scar

unaware of FUE

misled about FUE

6.2%

16.4%

35.2%

Visible FUT scar

FUT scar in bald area

Multiple intersecting FUT scars

FUT scar restoration with W-plasty

FUT scar restoration with FUE

DISCUSSION: Although most hair restoration surgeons would agree that there has been significant progress in the field of FUT scar management, such as the description of the trichophytic closure technique, the use of absorbable internal sutures, the proper mobilization of the wound edges & the continuous subcutaneous suturing, the matter still remains controversial. It is evident from our findings that there are still issues of poor surgical technique leading to oversized scars, obvious scars from external sutures, intersecting scars from multiple procedures etc. It seems that there is a strong correlation between the number of FUT sessions performed & the quality & quantitative parameters of the scar. At the same time, it seems that better scars were produced in cases where the surgeon has performed a conservative strip harvesting & used techniques as the trichophytic closure or the continuous subcutaneous suture etc. An alarming finding was that in a small number of cases the old FUT scar became visible, as part of the bald area, which indicates poor planning of the initial harvesting & poor estimation of the potential evolution of hair loss. A rather disturbing finding was that in a few cases the patients were not properly informed about their hair restoration procedure, the creation of a scar and in the most extreme cases, certain patients were misled to think that they were having FUE hair restoration & they only found about their scars months later. This fact calls for vigilance & action from the hair restoration community, as it degrades the hair restoration procedures & gives a bad name to hair restoration surgeons. CONCLUSION: Although scar formation after FUT hair restoration is a fact, the final aesthetic results & the patients satisfaction may vary significantly, based on the surgeons experience, the wound closure technique and, most importantly, the proper education of both doctors & patients, in order to choose each time the right professional & the right technique to solve the hair loss problem.

P51 Are Postoperative Antibiotics Necessary in FUE Procedures? A Double-Blind Prospective Study
Anastasios Vekris, MD. Advanced Hair Clinics, Athens, Greece.

Dr Anastasios Vekris, MD, is a Plastic Surgeon & expert hair restoration surgeon. He has been involved in hair restoration for the last 10 years and has performed thousands of hair restoration procedures in various countries around the world. He specializes in FUE & scar restoration. He is a member of the ISHRS & has trained many doctors & assistants in FUE procedures in many countries. He is the Medical Director of Advanced Hair Clinics in Athens, Greece. A. Vekris: None. TAKE HOME MESSAGE: Hair restoration specialists should be aware of the adverse effects of non-essential postoperative antibiotic regimes in cases of minimally invasive FUE hair restoration sessions and reserve the antibiotic prophylaxis only for selected patients with severe immunodeficiency diseases such as HIV, renal failure, insulin dependant diabetes etc. Proper sterilization of the surgical instruments, proper operating clean environment & staff awareness will lead to very low infection rates & increase the safety of hair restoration procedures. ABSTRACT: INTRODUCTION. Hair restoration surgery has progressed significantly within the last years & has become less invasive. While, in the past, flap surgery was considered a major operation with its share in complications & infections, modern hair restoration techniques, as FUE, may be considered as minimally invasive techniques & the overall safety of these procedures has increased significantly. However, there is little scientific evidence on the incidence of local infections after FUE procedures & the necessity of postoperative antibiotic prophylaxis. OBJECTIVE. To estimate the incidence of localized scalp infections after FUE hair restoration procedures & the efficacy of postoperative antibiotic prophylaxis in a group of healthy FUE patients in comparison to a group of healthy FUE patients there received no postoperative antibiotics. MATERIALS & METHODS. In a period of two years, 658 patients that underwent FUE hair restoration were asked to join the study on a voluntary basis. 615 patients (93.5%) accepted. After clinical examination & medical history was obtained, another 18 patients (2.7%) were excluded from the study for medical reasons. People with diabetes under insulin treatment, patients with known immunodeficiency, HIV positives & people with history of heart surgery were not included in the study & were given antibiotic prophylaxis anyway. The remaining 597 patients were separated randomly (one by one basis) in two separate groups A & B. Group A patients were given 1gr cefuroxim P.O. half an hour before the FUE session and no prophylaxis was given postoperatively. Group B patients were given 1 gr cefuroxim P.O. half an hour before their FUE session & 500mg cefuroxim P.O. twice a day for 4 days after the procedure. The patients were followed up in one week & two weeks after their FUE sessions, for signs of local scalp infection (folliculitis).

Photos were taken before & after the session, as well as in the follow ups. All selected patients were operated by the same doctor & team of assistants, in the same operating theatre in an effort to limit as much as possible certain variants that might affect the infection rate. Clinical & personal data were gathered & sent for statistical analysis with SPSS software to an outsourced, independent statistics expert. Manual extraction was performed in all cases & the duration of each session & the number of grafts harvested were documented in the surgical form of each procedure. RESULTS. Of the 597 patients included in the study, as many as 585 appeared in the first weekly follow up and 565 in the second week follow up. Only the 565 patients that completed the follow up were finally included in the statistical analysis. Of these patients, 284 belonged to Group A (no postoperative prophylaxis) & 281 belonged to Group B (postoperative prophylaxis). The sex structure was 533 men (94.3%) & 32 women (5.7%), equally distributed in both groups. The mean age was 38.5 years old (22-75 years) in both groups. There was no incident of generalized scalp infection or other severe infection in the two study groups for the period of study (two weeks postoperatively). There were two incidents of early local folliculitis, one from each group, in the first week follow up and another two late folliculitis incidents, one from each group, in the second week follow up. All 4 cases of local folliculitis were treated with local antibiotic creams & antiseptic shampoo for a week & P.O. antibiotic treatment with Ampicilline+Clavulanic Acid 1gr twice a day for a week. The post treatment course of these cases was uneventful & all patients were free of symptoms within the next week. The average duration of the FUE sessions was 7h15min (ranging from 2h45 to 8h10). The average number of grafts harvested was 1753 (ranging from 805-2252). There was no statistically significant correlation between the number of grafts or the duration of the session with the localized infection cases. The overall infection rate was 0.7%, the same as in both Group A & B. DISCUSSION. There has been so far minimal evidence on the efficacy & the necessity of postoperative antibiotic prophylaxis in minimally invasive procedures in general, and hair restoration procedures in particular. There has been some documentation that in minor surgical procedures (e.g. cyst removal, superficial hernias etc) & other considered as clean surgical procedures, the most effective & needed antibiotic prophylaxis to prevent postoperative infection, is the preoperative dose, particularly 30-45 min before the onset of the procedure, so that sufficient levels of the antibiotic will exist in the blood stream upon the first incision. There is still controversy whether, in minimal procedures should antibiotics been given P.O. or I.V., while many surgeons believe that in clean procedures in areas with abundant blood supply (e.g. the face or the scalp), no postoperative antibiotic is necessary. At the same time, in hair restoration, there are numerous different protocols for prophylaxis & most surgeons follow their own regime, without any real scientific evidence, varying from no antibiotics whatsoever to double-scheme I.V. wide range antibiotics. It is common knowledge that the abuse of antibiotics & the non-substantiated use of them, may result in decreased sensitivity of the infectious bacteria as well as various side effects from the antibiotics themselves (mainly allergic reactions, renal or liver dysfunctions, gastrointestinal disorders etc). This study is an attempt to demonstrate that in minimally invasive FUE hair restoration procedures in healthy individuals, the risk of postoperative infection is really low, probably due to the minimal trauma, the clean nature of the procedure & the abundant blood supply of the scalp. Also, that postoperative prophylaxis after FUE sessions is of minimal significance, as the infection rates are very low, no matter if someone is under prophylaxis or not. Special considerations should be reserved for medically challenged individuals suffering from various diseases causing immunodeficiency & require prophylaxis even in minor surgical procedures. CONCLUSION. The infection rate in FUE procedures is very low & the infections are mostly localized folliculitis cases that respond quickly to treatment. It is recommended that thorough investigation is required to establish if there is any significance at all in following postoperative prophylaxis after FUE sessions, or the antibiotics should be reserved only for selected patients with severe immune diseases.

ARE POSTPERATIVE ANTIBIOTICS NECESSARY IN FUE PROCEDURES? Dr. Anastasios Vekris , M.D Advanced Hair Clinics, Athens , Greece
ISHRS 21st Annual Scientific Meeting October 23-26, 2013 Hyatt Regency San Francisco, California, USA

INTRODUCTION: Hair restoration surgery has progressed significantly within the last years & has become less invasive. While, in the past, flap surgery was considered a major operation with its share in complications & infections, modern hair restoration techniques, as FUE, may be considered as minimally invasive techniques & the overall safety of these procedures has increased significantly. However, there is little scientific evidence on the incidence of local infections after FUE procedures & the necessity of postoperative antibiotic prophylaxis. OBJECTIVE: To estimate the incidence of localized scalp infections after FUE hair restoration procedures & the efficacy of postoperative antibiotic prophylaxis in a group of healthy FUE patients in comparison to a group of healthy FUE patients there received no postoperative antibiotics. MATERIALS & METHODS: In a period of two years, 658 patients that underwent FUE hair restoration were asked to join the study on a voluntary basis. 615 patients (93.5%) accepted. After clinical examination & medical history was obtained, another 18 patients (2.7%) were excluded from the study for medical reasons. People with diabetes under insulin treatment, patients with known immunodeficiency, HIV positives & people with history of heart surgery were not included in the study & were given antibiotic prophylaxis anyway. The remaining 597 patients were separated randomly (one by one basis) in two separate groups A & B. Group A patients were given 1gr cefuroxim P.O. half an hour before the FUE session and no prophylaxis was given postoperatively. Group B patients were given 1 gr cefuroxim P.O. half an hour before their FUE session & 500mg cefuroxim P.O. twice a day for 4 days after the procedure. The patients were followed up in one week & two weeks after their FUE sessions, for signs of local scalp infection (folliculitis). Photos were taken before & after the session, as well as in the follow ups. All selected patients were operated by the same doctor & team of assistants, in the same operating theatre in an effort to limit as much as possible certain variants that might affect the infection rate. Clinical & personal data were gathered & sent for statistical analysis with SPSS software to an outsourced, independent statistics expert. Manual extraction was performed in all cases & the duration of each session & the number of grafts harvested were documented in the surgical form of each procedure. RESULTS: Of the 597 patients included in the study, as many as 585 appeared in the first weekly follow up and 565 in the second week follow up. Only the 565 patients that completed the follow up were finally included in the statistical analysis. Of these patients, 284 belonged to Group A (no postoperative prophylaxis) & 281 belonged to Group B (postoperative prophylaxis). The sex structure was 533 men (94.3%) & 32 women (5.7%), equally distributed in both groups. The mean age was 38.5 years old (22-75 years) in both groups. There was no incident of generalized scalp infection or other severe infection in the two study groups for the period of study (two weeks postoperatively). There were two incidents of early local folliculitis, one from each group, in the first week follow up and another two late folliculitis incidents, one from each group, in the second week follow up. All 4 cases of local folliculitis were treated with local antibiotic creams & antiseptic shampoo for a week & P.O. antibiotic treatment with Ampicilline+Clavulanic Acid 1gr twice a day for a week. The post treatment course of these cases was uneventful & all patients were free of symptoms within the next week. The average duration of the FUE sessions was 7h15min (ranging from 2h45 to 8h10). The average number of grafts harvested was 1753 (ranging from 805-2252). There was no statistically significant correlation between the number of grafts or the duration of the session with the localized infection cases. The overall infection rate was 0.7%, the same as in both Group A & B.

Group A (no postoperative prophylaxis)


284 people 282 no infection 1 incident of early local folliculitis 1 incident of late local folliculitis 281 people 279 no infection 1 incident of early local folliculitis 1 incident of late local folliculitis

Group B (postoperative prophylaxis)

DISCUSSION: There has been so far minimal evidence on the efficacy & the necessity of postoperative antibiotic prophylaxis in minimally invasive procedures in general, and hair restoration procedures in particular. There has been some documentation that in minor surgical procedures (e.g. cyst removal, superficial hernias etc) & other considered as clean surgical procedures, the most effective & needed antibiotic prophylaxis to prevent postoperative infection, is the preoperative