A B S T R AC T B OO K

OCT 17-20

2012

New Trends in Hair Restoration: Surgery and Science

2012 Ann uAl Scientific Mee ting

coM M it te e
Francisco Jimenez, MD
Chair

Advanced/Board Review Course Chair

Rober t H. True, MD, MPH Jonathan L. Ballon, MD

Basics Course Chair

Workshops & Lunch Symposia Chair Live Patient Viewing Chair Live Patient Viewing Co-Chair

Marcelo Pitchon, MD

Nicole E. Rogers, MD

Ber tram M. Ng, MBBS

Glenn M. Charles, DO Jean M. Devroye, MD Neil S. Sadick, MD Melvin L. Mayer, MD

Immediate Past-Chair

Surgical Assistants Chair Newcomers Program Chair

Brandi Burgess

Paul C. Cotterill, MD

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

001 Program Chair Welcome & Announcements

Francisco Jimenez, MD NA, Las Palmas Gran Canaria, Spain

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

Dr. Jimenez is a dermatologist and hair transplant surgeon. Trained in Dermatology in Madrid, in Dermatopathology at the University of Miami, in Mohs surgery at Duke University and in Hair Restoration Surgery with Dr. Dow Stough in Hot Springs, Arkansas. Currently working in private practice in Gran Canaria, Canary Islands, Spain. Author of 44 publications in peer review journals and past Editor of the Hair Transplant Forum (2008-2010). Dr. Jimenez received the 2011 ISHRS Platinum Follicle Award. F.Jimenez: None. ABSTRACT: Not applicable.

Disclosure of Conflict of Interest Block Abstract

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

2012 International Society of Hair Restoration Surgery

ABSTRACTS
20th Annual Scientific Meeting of the International Society of Hair Restoration Surgery

October 17-20, 2012 Atlantis Conference Center The Bahamas

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.

Learning Objectives
The learning objectives are listed on the adjacent page as well as by each General Session listing within this Abstract Book.

Continuing Medical Education (CME) Credit

The International Society of Hair Restoration Surgery is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The International Society of Hair Restoration Surgery designates this live activity for a maximum of 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
Opening Session o Demonstrate understanding of basic biology of follicular stem cells. o Identify the role of these cells in hair cycle regeneration. o Formulate ideas for the role of HF stem cells in applications of hair regeneration, wound healing, and in regenerative medicine. Research Presentations o Describe various research projects on the subject of hair and how they may impact therapies or treatments for hair loss. Advanced Surgical Techniques I o Compare and contrast different surgeons approaches to various aspects of the hair transplant procedure. o Discuss the surgical approaches to hair transplantation in special situations. Finasteride Symposium 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. o Develop guidelines for use of finasteride in a hair restoration practice: best candidates for finasteride, type of information that should be delivered to the patient about side effects, combination therapy of finasteride with other FDA approved medications. Operation Restore and Repair Cases o Discuss the surgical approaches to several repair cases, including several that were supported by the ISHRSs Operation Restore pro bono program. Coffee with the Experts o Discuss various hair restoration surgery topics in-depth in small groups. Advanced Surgical Techniques II o Compare and contrast different surgeons approaches to various aspects of the hair transplant procedure. o Discuss the surgical approaches to hair transplantation in special situations.

FRIDAY
Norwood Lecture o Explore the contribution of the follicular cells in dermal repair and re-epithelialization of cutaneous wounds. o Demonstrate the influence of the hair follicle cycle in the acceleration or retardation of the wound healing response. o Discuss the possible effects of cutaneous wounding on hair follicular neogenesis. o Understand the importance of the hair follicle in the biological mechanisms involved in the wound healing response. Emerging Therapies: Different Strategies to Induce Hair Growth o Describe ongoing studies involving pharmacologic agents being tested for treatment of androgenetic alopecia. o Discuss various research projects on the subject of hair and how they may impact therapies or treatments for hair loss.

FRIDAY (continued)
Non-Surgical Free Papers o Discuss the diagnosis and therapy of several non-androgenetic alopecias. o Discuss different non-surgical alternatives to hair transplantation. Poster Review Session o Review key points relating to a variety of studies and surgical pearls regarding hair restoration surgery. How I Do It Videos: Practice Tips and Surgical Gems o Compare and contrast different surgeons approaches to various aspects of the hair transplant procedure.

SATURDAY
Breakfast with the Experts o Discuss various hair restoration surgery topics in-depth in small groups. Controversies and Hot Topics in Hair Restoration Surgery o Recognize and discuss a variety of hot topics as indentified by ISHRS membership, including donor area safety in FUE, hair graft survival in FUE compared with FUT, and robotic hair harvesting. Food for Thought o Critically analyze how certain scientific presentations make us think twice about basic concepts that are taken for granted. o Understand how new tools and new surgical approaches oblige us to perform a critical revision of assumed dogmas. o Discuss new methods to objectively evaluate the outcome of HRS, and where the future of HRS is heading. Advanced Surgical Videos o Compare and contrast different surgeons approaches to various aspects of the hair transplant procedure. 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 planners, teachers, and authors have with commercial interests related to the content of the activity Commercial support (funding or in-kind resources) of the activity Anecdotal content
Approved by CME Committee, 03/02/05 Approved by Board of Governors, 06/20/05

The ISHRS gratefully acknowledges the following corporate supporters of the 20th Annual Scientific Meeting for their generosity.

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

Silver
Bosley Cytomedix, Inc. Hair Club Medical Group Ziering Medical Worldwide

Bronze
Cole Instruments Restoration Robotics, Inc.

In-Kind
A to Z Surgical Ellis Instruments, Inc. HSC Development Robbins Instruments

Summary of Disclosures of Conflict of Interest

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

The following faculty have reported real or apparent conflicts of interest that have been resolved through a peer-review process. (Listed in alpha order by last name.)
Part of Meeting Lunch Symposium Poster Publishing Title Lunch Symposium 311 - Business Development: Marketing The Mythical FUE Learning Curve- Observations After Training 75 Doctors In FUE Methods How I Do FUE Using a New Extractor Punch Breakfast with the Experts, Table Leader on the Topic of "Ischemia-reperfusion injury and Hair Follicle Viability" Finasteride: So Tell Me Doctor - Are There Any Side Effects? Coffee with the Experts, Table Co-Leader on the Topic of "Finasteride" How I Do Eyebrow HT: Pearls for Succes Workshop 202: High Tech HT: The Best High Technological Devices in My Practice - See your workshop director for specifics and format of this workshop Coffee with the Experts, Non-CME Table Leader on the Topic of "SAFE System" FUE Hands-On Course faculty Coffee with the Experts, Table Leader on the Topic of "Minoxidil: Use It or Lose It and Other Facts that Patients Need to Know" Lunch Symposium 213 - FUT versus FUE: Personal preference and how to explain advantages and disadvantages to patients Denovo Hair Follicle Formation: Possible Applications in Clinical Situations Disclosure Block R. Baxter: Employment; Surgeons Advisor, Inc.; Our firms provide services to aesthetic physicians. T. Bhatti: Ownership Interest (owner, stock, stock options); My center runs a training program for which doctors are charged a fee for training. P. Boudjema: Ownership Interest (royalty, patent, or other intellectual property); royalty, patent, or other intellectual property. W.D. Ehringer: Employment; Energy Delivery Solutions. Ownership Interest (owner, stock, stock options); Founder, Energy Delivery Solutions. Ownership Interest (royalty, patent, or other intellectual property); Inventor, VitaSol US Pat# 7056529. S. Freedland: Research Grant (principal investigator, collaborator or consultant); GSK. S. Freedland: Research Grant (principal investigator, collaborator or consultant); GSK. R.S. Haber: Ownership Interest (royalty, patent, or other intellectual property); Haber Spreader- Ellis Instruments. R.S. Haber: Ownership Interest (royalty, patent, or other intellectual property); Haber Spreader, Ellis Instruments.

General Session Breakfast with the Experts

General Session Coffee with the Experts General Session Workshop

Coffee with the Experts FUE Hand-On Course Coffee with the Experts

Lunch Symposium

General Session

General Session

Scalp Injection of Active Embryonic-like Cellsecreted Proteins and Growth Factors

Lunch Symposium General Session

Lunch Symposium 311 - Business Development: Marketing Refinement of the Rose Tissue Spreader

J.A. Harris: Ownership Interest (owner, stock, stock options); HSC Development - producer of FUE device. J.A. Harris: Ownership Interest (owner, stock, stock options); Owner of company producing an FUE device. R.T. Leonard: Speakers Bureau/Honoraria (speakers bureau, symposia, and expert witness); JOHNSON AND JOHNSON. Consultant/Advisory Board; JOHNSON AND JOHNSON. Other; LASERCAP INC. R.T. Leonard, DO: Speakers Bureau/Honoraria (speakers bureau, symposia, and expert witness); JOHNSON AND JOHNSON. Consultant/Advisory Board; JOHNSON AND JOHNSON. Other; LASERCAP INC. G. Lindner: Ownership Interest (owner, stock, stock options); I am a co-founder of TissUse GmbH. Under agreements between the Technische Universitt Berlin (TUB), TissUse GmbH is entitled to a share of the royalties received in future by the TUB.. Ownership Interest (royalty, patent, or other intellectual property); The technology for generating hair-follicle-like organoids is the subject of a patent from the Technische Universitt Berlin that includes me (Gerd Lindner) as an inventor.. G.K. Naughton: Employment; Histogen, Inc. C. Ziering: Consultant/Advisory Board; Histogen Scientific Advisory Board member. M. Hubka: Employment; Histogen. D. Ehrlich: Employment; Histogen. M. Zimber: Employment; Histogen. M. Ramsey: Employment; I disclose that I am a partner with PAI Medical Nashville and have been so for 17 years.. P. Rose: Ownership Interest (royalty, patent, or other intellectual property); Developed the design of the instrument with Cutting Edge Instruments in Canada.

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Part of Meeting Coffee with the Experts General Session FUE Hand-On Course Breakfast with the Experts Publishing Title Coffee with the Experts, Non-CME Table CoLeader on the Topic of "The Role of Vitamins & Supplements in Hair Loss and HRS" How I Do Body Hair Transplants FUE Hands-On Course - faculty Breakfast with the Experts, Table Leader on the Topic of "Prerequisites for a New Hair Transplant Practice" Disclosure Block L. Shapiro: Ownership Interest (owner, stock, stock options); Owner of Help Hair line of nutritional products. S. Umar: Ownership Interest (royalty, patent, or other intellectual property); UGraft, Upunch. S.H. Umar: Ownership Interest (royalty, patent, or other intellectual property); Patent applications on FUE device. S.A. Vasa: Ownership Interest (owner, stock, stock options); Vasa Innovations, Vasa Surgiart Pvt Ltd, Vasa Hair Academy. Ownership Interest (royalty, patent, or other intellectual property); intellectual property rights like patent, design registry, trade marks, copy rights for 10 patents. K. Washenik: Employment; Aderans Research Institute/Bosley. Research Grant (principal investigator, collaborator or consultant); Allegran, Johnson and Johnson. Speakers Bureau/Honoraria (speakers bureau, symposia, and expert witness); Merck. Ownership Interest (owner, stock, stock options); Aderans Research Institute/Bosely. Ownership Interest (royalty, patent, or other intellectual property); Aderans Research Institute/Bosley. K. Washenik: Employment; Bosley/Aderans. Ownership Interest (owner, stock, stock options); Bosley/Aderans. Ownership Interest (royalty, patent, or other intellectual property); Bosley/Aderans. K. Washenik: Employment; Aderans Research Institute/Bosley. Research Grant (principal investigator, collaborator or consultant); Allergan, Johnson and Johnson. Speakers Bureau/Honoraria (speakers bureau, symposia, and expert witness); Merck. Ownership Interest (owner, stock, stock options); Aderans Reserach Institute/Bosely. Ownership Interest (royalty, patent, or other intellectual property); Aderans Research Institute/Bosley.

General Session

Finasteride Persistent Sexual Dysfunction Controversy: Update

Coffee with the Experts General Session

Coffee with the Experts, Table Co-Leader on the Topic of "Research Challenges in Hair Biology" Update on Cell Based Regeneration Studies

Planners and managers who have reported real or apparent conflicts of interest:
Name of Planner or Manager Robert S. Haber, MD James A. Harris, MD Position CME Committee CME Committee, Webinars Chair Reported Areas of Conflict Ownership interests (owner, stock, stock options), Ellis Instruments, Inc. - Transdermal Light Cap, Inc. Ownership interests (owner, stock, stock options), HSC Development, Restoration Robotics; Consultant/Advisory Board, Restoration Robotics. Ownership interests (owner, stock, stock options), Dermagenoma; Consultant/Advisory Board, Dermagenoma. Speakers Bureau/Honoraria (speakers bureau, symposia, and expert witness), Allergan; Ownership Interest (royalty, patent, or other intellectual property), A-Z. Speakers Bureau/Honoraria (speakers bureau, symposia, and expert witness), ParaPro-Natroba head lice medication, and WebMD-hair & skin expert; Other, JNJ via Ink & Roses PR/interviews Research Grant, Allergan; Speakers Bureau/Honoraria, Histogen; Ownership Interests (owner, stock, stock options), Histogen; Consultant/Advisory Board, Allergan, Histogen. K. Washenik: Employment; Aderans Research Institute/Bosley. Research Grant (principal investigator, collaborator or consultant); Allergan, Johnson and Johnson. Speakers Bureau/Honoraria (speakers bureau, symposia, and expert witness); Merck. Ownership Interest (owner, stock, stock options); Aderans Reserach Institute/Bosely. Ownership Interest (royalty, patent, or other intellectual property); Aderans Research Institute/Bosley.

Sharon A. Keene, MD Matt L. Leavitt, DO

CME Committee CME Committee, LSW Committee Chair CME Committee, Live Patient Viewing Chair CME Committee, 2012 ASM Cmt

Nicole E. Rogers, MD

Neil S. Sadick, MD

Ken Washenik, MD, PhD

CME Committee

In addition, the ISHRS reports the following relationships with commercial interests associated with this activity:
Name of Commercial Interest Johnson & Johnson Healthcare Products, Division of McNEIL-PPC, Inc. Bosley Type of Financial Relationship Provided unrestricted educational grant Provided unrestricted educational grant

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8

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Cytomedix Hair Club Medical Group Ziering Medical Worldwide Cole Instruments Restoration Robotics, Inc. A to Z Surgical Cole Instruments Ellis Instruments HSC Development Robbins Instruments Provided unrestricted educational grant Provided unrestricted educational grant Provided unrestricted educational grant 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

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

Planners and managers that have reported no conflicts of interest:

Name of Planner or Manager Jonathan L. Ballon, MD Marco Barusco, MD Brandi Burgess Victoria Ceh, MPA Glenn M. Charles, DO Paul C. Cotterill, MD Jean Devroyre, MD Francisco Jimenez, MD Melvin L. Mayer, MD Bertram M. Ng, MBBS Marcelo Pitchon, MD Carlos J. Puig, DO Melanie Stancampiano Robert H. True, MD, MPH Bradley R. Wolf, MD Position CME Committee, Basics Course Chair CME Committee CME Committee, Surg Asst Chair Executive Director, CME Director (planner and manager) CME Committee, 2012 ASM Cmt CME Committee Chair CME Committee, 2012 ASM Cmt CME Committee, 2012 ASM Cmt CME Committee, 2012 ASM Cmt CME Committee, Live Patient Viewing Co-Chair CME Committee, Workshops & Lunch Symposia Chair CME Committee Program Manager (planner and manager) CME Committee, Advanced/Board Review Course Chair CME Committee Reported Areas of Conflict 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 Safety and Efficacy of Finasteride 2.5 mg in Postmenopausal Women with Androgenetic Alopecia: Pilot Study in 52 Patients Panelist for Finasteride Symposium Updated Clinical Experience With Hair Duplication Breakfast with the Experts, Table Leader on the Topic of "Ischemia-reperfusion injury and Hair Follicle Viability" Presenting Author Abdulmajeed Alajlan, MD Robert Bernstein, MD Jerry Cooley, MD William Ehringer, PhD Off-label Disclosure Finasteride from MSD

General Session General Session Breakfast with the Experts

propecia made by merck MatriStem, ACell VitaSol, Hypothermosol (Energy Delivery Solutions), UW Solution (BTL), DMEM (Sigma-Aldrich, Gibco), Normal Saline (Braun) finasteride, Merck ROGAINE FOAM; JOHNSON AND JOHNSON Acell

General Session Coffee with the Experts

General Session

How Finasteride Should be Used in a Hair Transplant Practice Coffee with the Experts, Table Leader on the Topic of "Minoxidil: Use It or Lose It and Other Facts that Patients Need to Know" Preliminary Results Using ECM in a Split-Body Fashion

Edwin Epstein, MD Robert Leonard, DO

Jose Lorenzo, MD

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Part of Meeting Workshop/Course Faculty General Session General Session General Session Publishing Title Peri-surgical Drug Management and Safety Treatment of Eyebrow Hypotrichosis with ACellMatriStem + PRP Finasteride in the Long Run - Surprising Data from the Sato Study How I Do Body Hair Transplants Presenting Author Robert Niedbalski, DO Robert Niedbalski, DO Akio Sato, MD Sanusi Umar, MD Off-label Disclosure MatriStem MicroMatrix from ACell, Inc. MatriStem MicroMatrix Propecia Minoxidil

Listed below are those who answered that they DO NOT have a financial interest or other relationship with the manufacturer(s) of any of the products(s) or service(s) they intend to discuss:
Publishing Title Breakfast with the Experts, Table Leader on the Topic of "Donor Harvesting for Asian Patients" Dihydrotestosterone-Inducible IL-6 Inhibits Elongation of Human Hair Shafts by Suppressing Matrix Cell Proliferation and Promotes Regression of Hair Follicles in Mice Safety and Efficacy of Finasteride 2.5 mg in Postmenopausal Women with Androgenetic Alopecia: Pilot Study in 52 Patients Breakfast with the Experts, Table Co-Leader on the Topic of "Eyelash HT: Pearls & Pitfalls" The New Wave of Complications in the Follicular Unit Era Poster Review Session, Posters 16-30 Basics Course in FU Hair Restoration Surgery - Chair Photographic Review of Factors That Make FUE Cases Difficult Workshop 205 - Surgical Assistants Dissecting & Implanting Workshop (Dissecting Station) Ergonomics Tips and Resources to Design, Conduct and Publish a Scientific Study in Hair Restoration Medical Treatments: OTC's Graft Preparation and Survival Workshop 202: High Tech HT: The Best High Technological Devices in My Practice (Workshop Director) Breakfast with the Experts, Table Leader on the Topic of "Leveraging Social Media for Patient Relations" Lunch Symposium 311 - Business Development: Marketing The Use of Hair Bundle Cross-Section Trichometry to Confirm Success in the Medical Management of Hair Loss Lunch Symposium 213 - FUT versus FUE: Personal preference and how to explain advantages and disadvantages to patients Lunch Symposium 311 - Business Development: Marketing Recipient Site Angulation and Follicle Survival Anesthesia Panelist for Finasteride Symposium Coffee with the Experts, Table Leader on the Topic of "Robotic FUE" W-Trichoplasty Closure For Better Strip Scars- A New Technique Does FUE Technique Grow Better Hair? - Anagen Selective FUE Traction Alopecia In Sikh Males- A Review of 213 Cases Managed With Hair Transplant FUE Hands-On Course faculty The Role and the Placement for the Robotic Arm in Hair Transplants- Our Initial Experience Ethics in Hair Restoration Surgery Welcome and Introductions Workshop 205 - Surgical Assistants Dissecting & Implanting Workshop (Workshop Director) Welcome & Workshop Details Advance Technologies Panel Discussions: Graft Placement Techniques Workshop 202: High Tech HT: The Best High Technological Devices in My Practice Application and Evaluation of the Cross Section Trichometer, Follicular Density, Hair Density, Hair Shaft Diameter and Surface Area Measurement to Predict Suitability of Candidates for Hair Transplantation, as Well as to Predict Results From Hair Transplantation Follicular Density Comparison by Reticule Surface Area Size Hair Mapping: A Comparison of Caucasian and Korean Hair Density, Follicular Density and Calculated Density; A Three Year Follow Up Using New Methods. Coffee with the Experts, Non-CME Table Leader on the Topic of "Cole FUE Device" How I Do FUE: Tips to Maximize Speed & Efficiency Breakfast with the Experts, Table Leader on the Topic of "How to Manage Big FUE Cases" Lunch Symposium 213 - FUT versus FUE: Personal preference and how to explain advantages and disadvantages to patients Panelist for Controversies and Hot Topics in Hair Restoration Surgery FUE Hands-On Course faculty Updated Clinical Experience With Hair Duplication 10 Disclosure Block G. Abbasi: None. M. Kwack: None. J. Ahn: None. Y. Sung: None. A. Alajlan: None. B.A. Arocha: None. M.R. Avram: None. M.R. Avram: None. J.L. Ballon: None. J. Bang: None. D. Barron: None. D. Barron: None. M.N. Barusco: None. M.N. Barusco: None. M.N. Barusco: None. M.N. Barusco: None. M. Batt: None. M. Batt: None. A.J. Bauman: None. A.J. Bauman: None. A.J. Bauman: None. M.L. Beehner: None. M.M. Behnke: None. R.M. Bernstein: None. R.M. Bernstein: None. T. Bhatti: None. T. Bhatti: None. T. Bhatti: None. C.N. Bisanga: None. M.A. Bishara: None. K. Rodriguez: None. R. Green: None. S.A. Boden: None. B.J. Burgess: None. D. Carmona Baez: None. D. Carmona Baez: None. G.M. Charles: None. B. Cohen: 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.P. Cole: None. J.P. Cole: None. J.P. Cole: None. J.E. Cooley: None.

Publishing Title Graft Survival Panelist for Operation Restore and Repair Cases Session Breakfast with the Experts, Table Leader on the Topic of "Hair Transplantation in Women: How to Choose the Candidate and Surgical Planning" Frontal Fibrosing Alopecia: a Variant of Lichen Planopilaris or Distinct Clinical Entity? Comparative Study of Ten Cases Untouched Strip Technique, A Procedure Combining FUE and Strip Surgery While Preserving an Untouched Area: Analysis of 18 Cases Combination of Strip Surgery and Follicular Unit Extraction to Improve the Number of Follicular Units Harvested in Primary and Secondary Hair Transplantation Asymmetric Two-Layer Closure in Trichophytic Closure for Wide Donor Wound Advance Technologies Panel Discussions: Donor Removal Techniques (strip) FUE Hands-On Course faculty A Split Comparison Study of Trichophytic Versus Non-Trichophytic Closure of Donor Site in Follicular Unit Hair Transplantation (FUT) Female Hair Loss Work Up & Non Androgenetic Hair Loss Workshop 205 - Surgical Assistants Dissecting & Implanting Workshop (Dissecting Station) Panelist for Operation Restore and Repair Cases Session Breakfast with the Experts, Table Leader on the Topic of "My Experience with Different FUE Devices" Scalp Burning and Tenderness: How Important is it to Ask During the Consultation? Lichen Planopilaris Following Hair Transplantation The Initial Consultation: Androgenetic vs. Non-AGA Hair Loss Workshop 203: To Transplant or Not to Transplant: How Not to Get into Trouble with Mimickers of Androgenetic Alopecia (Workshop Director) FUE Evaluation in Patients with Previous HT Procedure FUE Hair Transplant in Traction Alopecia in Sikh Population Advance Technologies Panel Discussions: Recipient Sites How Finasteride Should be Used in a Hair Transplant Practice Panelist for Operation Restore and Repair Cases Session Hairline Advancement in Women: Surgical Hairline Advancement Versus Hair Grafting Eyebrow Transplantation: Techniques and Outcomes of Over 350 Cases Advanced Practice Management Techniques for the Established Hair Transplant Surgeon Hair Transplants to the Beard, Chest and Other Areas- A Review of Over 400 Procedures Workshop 204: Eyebrow HT Lunch Symposium 211 - Business Development: Practice Management (Lunch Symposium Director) Lunch Symposium 311 - Business Development: Marketing Moderator Introduction, Advanced Surgical Techniques II Cell Therapy and Hair Genetics Lunch Symposium 211 - Business Development: Practice Management Coffee with the Experts, Table Co-Leader on the Topic of "Hair Transplantation in Young Patients: My Personal Approach" Workshop 204: Eyebrow HT Breakfast with the Experts, Table Co-Leader on the Topic of "Eyelash HT: Pearls & Pitfalls" Lunch Symposium 212 - If I knew then what I know now - Experts share the wisdom they wish they'd been told when they were beginners Video Presentation of Slivering and Follicle Dissection Under Stereo Microscope, and Innovative Technique to Train Staff Workshop 205 - Surgical Assistants Dissecting & Implanting Workshop (Dissecting Station) The Latest Discovery: Is PGD2 the Real Target to Cure Androgenetic Alopecia? Breakfast with the Experts, Table Co-Leader on the Topic of "Advances in Hair Biology: PGD2 and Other Stories" Scarless Galeal Closure Temporal Peaks Aesthetic Implication Lunch Symposium 212 - If I knew then what I know now - Experts share the wisdom they wish they'd been told when they were beginners Breakfast with the Experts, Table Leader on the Topic of "Spanish Speaking Table: Tips for FUE, Manual and Power, Indications" FUE Hands-On Course faculty The Method of Direct Hair Implantation Workshop 205 - Surgical Assistants Dissecting & Implanting Workshop (Slivering Station) Panel of Pearls Panelist Moderator Introduction, Poster Review Session Advance Technologies Panel Discussions: FUE Breakfast with the Experts, Table Leader on the Topic of "Getting Strarted with Adding FUE to Your Practice" Anatomy of the Hair Follicle for the Surgical Assistant Intrapatient Graft Length Differences Influencing Depth Controlled Incisions A Case of Trichorrhexis Nodosa After Hair Transplantation Coffee with the Experts, Table Leader on the Topic of "Hairline Design for Asian Patients" 11

Disclosure Block J. Cooley: None. P.C. Cotterill: None. P.C. Cotterill: None. M. Crisstomo: None. D. Tomaz: None. M. Crisstomo: None. E. Andrade: None. K. Nogueira: None. M. Crisstomo: None. M. Crisstomo: None. D. Tomaz: None. M. Crisstomo: None. M. Crisstomo: None. D. Tomaz: None. A. Afonso: None. M. Crisstomo: None. K. Dae-young: None. M.S. Dauer: None. J. Devroye: None. N. Dhepe: None. K. Prabhune: None. N. Bhalerao: None. D. Didocha: None. M.Dieta: None. M.S. DiStefano: None. M.S. DiStefano: None. J.C. Donovan: None. J.C. Donovan: None. J.C. Donovan: None. J.C. Donovan: None. J.C. Donovan: None. A. Dua: None. K. Dua: None. K. Dua: None. A. Dua: None. V.W. Elliott: None. E.S. Epstein: None. E.S. Epstein: None. J.S. Epstein: None. J.S. Epstein: None. J.S. Epstein: None. J.S. Epstein: None. J.S. Epstein: None. J.S. Epstein: None. J.S. Epstein: None. B. Farjo: None. N.P. Farjo: None. S.P. Gabel: None. V. Gambino: None. M. Gandelman: None. M. Gandelman: None. M. Gandelman: None. A.K. Garg: None. S. Garg: None. J.A. Garner: None. L.A. Garza: None. G. Cotsarelis: None. L.A. Garza: None. J.I. Gaviria: None. J.I. Gaviria: None. M. Morales De Bournigal: None. J.D. Gillespie: None. A. Ginzburg: None. A. Ginzburg: None. C.P. Giotis: None. L. Gorham: None. L. Gorham: None. R.S. Haber: None. J.A. Harris: None. J.A. Harris: None. J. Hoffman: None. P.C. Cotterill: None. S. Hwang: None. S. Hwang: None. S. Hwang: None.

Publishing Title Breakfast with the Experts, Korean-Speaking Table: How to Reduce Folliculitis after Hair Transplantation Multiple Scar Extractions "Plugged" by FUE Grafts - A Reliable Way to Improve Scars in the Scalp Lunch Symposium 211 - Business Development: Practice Management Hair and the Psyche: Arm and Beard Hair Implant Program Chair Welcome & Announcements Moderator Introduction, Norwood Lecture Current Status of Research and Therapy to Prevent Chemotherapy Induced Alopecia Lunch Symposium 212 - If I knew then what I know now - Experts share the wisdom they wish they'd been told when they were beginners Comparing the Graft Survival and Growth Keeping in PRP to the Saline in Hair Transplantation Social Media for Business Scientific Evidence that Environment, Diet and Lifestyle Contribute to Epigenetic Regulation of Hormones and are Likely to Influence Hair Growth Beyond Finasteride Side Effects: Alternate Risks for Sexual Dysfunction and Spermatic Abnormalities via Genetics, Physiology, and Environment Poster Review Session Panelist for Controversies and Hot Topics in Hair Restoration Surgery Commentary On, "Updated Clinical Experience with Hair Duplication" The Study of Storage Solutions for Hair Follicle Protection During Hair Transplantation Surgery Moderator Introduction, Advanced Surgical Videos Lunch Symposium 212 - If I knew then what I know now - Experts share the wisdom they wish they'd been told when they were beginners Lunch Symposium 213 - FUT versus FUE: Personal preference and how to explain advantages and disadvantages to patients Lunch Symposium 211 - Business Development: Practice Management Protection of Human Hair Follicles Viability by Coculture with Mesenchymal Stem Cells Coffee with the Experts, Table Leader on the Topic of "Adding HT to a Cosmetic Practice or Adding Costmetic Procedures to a Hair Transplant Practice" Lunch Symposium 211 - Business Development: Practice Management Lunch Symposium 311 - Business Development: Marketing (Lunch Symposium Director) Receipient Site Anesthesia and Tumescence Workshop 205 - Surgical Assistants Dissecting & Implanting Workshop (Implanting Station) Assistants Role in FUE I Workshop 204: Eyebrow HT Lunch Symposium 212 - If I knew then what I know now - Experts share the wisdom they wish they'd been told when they were beginners (Lunch Symposium Director) Preliminary Results Using ECM in a Split-Body Fashion Implantation With Implanter Pen II Live Patient Viewing Case Coffee with the Experts, Table Leader on the Topic of "Spanish Speaking Table: FUE" FUE Hands-On Course faculty Advance Technologies Panel Discussions: Tissue Expansion & Flaps Panelist for Operation Restore and Repair Cases Session Coffee with the Experts, Table Co-Leader on the Topic of "Flap Surgery and Use of Expanders & Operation Restore" Hair Transplantation Into Scars President's Address Advance Technologies Panel Discussions: Trichophytic Closures Moderator Introduction, Controversies and Hot Topics in Hair Restoration Surgery Lunch Symposium 212 - If I knew then what I know now - Experts share the wisdom they wish they'd been told when they were beginners Basic Principles of Donor Anesthesia & Donor Harvesting Moderator Introduction, Research presentations Panelist for Operation Restore and Repair Cases Session Medical Treatments: Medical Therapies Moderator Introduction, Non-Surgical Free Papers Overview of BLS with AED The Effects of Delay in Extracting Follicular Units on the Viability of FUE Grafts Harvesting Hair From Temporal Area - Limitations and Advantages Oral/IV/IM Sedation Workshop 202: High Tech HT: The Best High Technological Devices in My Practice Follicular Unit Transplantation: Comparison of Three Cuttings Techniques From Stem to Hair: Deciphering and Exploiting the Instruction Set That Guides Follicle Regeneration Coffee with the Experts, Table Co-Leader on the Topic of "Research Challenges in Hair Biology" Panelist for Emerging Therapies Session Case Report: Treating an Extensive Burn Injury of the Scalp in a Child Coffee with the Experts, Table Co-Leader on the Topic of "Flap Surgery and Use of Expanders & Operation Restore" 12

Disclosure Block S. Hwang: None. M.G. Ingers: None. M. Sjorin: None. A. Tallaaker: None. L.E. Ishii: None. K.I. Jebai: None. F. Jimenez: None. F. Jimenez: None. J.J. Jimenez: None. S.S. Kabaker: None. H. Kahnamuee: None. M. Kearney: None. S.A. Keene: None. S.A. Keene: None. S.A. Keene: None. S.A. Keene: None. S.H. Khan: None. M. Kim: None. J. Oh: None. J. Kim: None. R.G. Knudsen: None. R.G. Knudsen: None. G. Koher: None. G.M. Kuka: None. M.F. Kulahci: None. S.M. Lam: None. S.M. Lam: None. S.M. Lam: None. S. Lam: None T. Lardner: None. T. Lardner: None. B.L. Limmer: None. B.L. Limmer: None. J.F. Lorenzo: None. J.F. Lorenzo: None. J.F. Lorenzo: None. J.F. Lorenzo: None. J.F. Lorenzo: None. E. Mangubat: None. E. Mangubat: None. E. Mangubat: None. J.H. Martinick: None. J.H. Martinick: None. M. Marzola: None. M. Marzola: None. M. Marzola: None. M.L. Mayer: None. M.L. Mayer: None. M.L. Mayer: None. P.J. McAndrews: None. P.J. McAndrews: None. W.M. McKenzie: None. P. Mohebi: None. P. Mohebi: None. P. Mohebi: None. P. Mohebi: None. M.H. Mohmand: None. D. Ahmed: None. B.A. Morgan: None. B.A. Morgan: None. B.A. Morgan: None. F.G. Neidel: None. K.B. Leonhardt: None. F.G. Neidel: None.

Publishing Title Where to Put the Grafts When Not Enough - Frontal Core vs. Parting Side Approach The Simplest Way to Prevent and Manage Postoperative Follicultis Moderator Introduction, "How I Do It" Videos: Practice Tips and Surgical Gems Breakfast with the Experts, Table Leader on the Topic of "Donor Harvesting for Asian Patients" Peri-surgical Drug Management and Safety Treatment of Eyebrow Hypotrichosis with ACell-MatriStem + PRP Workshop 203: To Transplant or Not to Transplant: How Not to Get into Trouble with Mimickers of Androgenetic Alopecia Commentary On, "Application and Evaluation of the Cross Section Trichometer, Follicular Density, Hair Density, Hair Shaft Diameter and Surface Area Measurement to Predict Newly Developed Hair Transplanter OKT (Optimally Kept Transplanter) That Improves the Hair Survival Rate No Temporal Point Peak, 2 Peak Sideburns and No Peak S-line Hairline Design in Woman Golden Rules to be Observed for Enhancing the Survival Rate in Hair Transplant Using a Choi-Hair Transplanter Workshop 201: Scalp Micro-Pigmentation FUE Hands-On Course faculty The Effects of Williams E Media on Follicular Unit Graft Survival Compare to Normal Saline as a Storage Solution Hair Transplantation in Frontal Fibrosing Alopecia: A Report of Two Cases FUE Hands-On Course faculty Camouflaging the Posterior Zygomatic Arch Protrusion After Zygoma Reduction Surgery Using Hair Transplantation in Infratemple Area Both-Hand Slit Technique ( Both-Hand No-Touch Technique) Workshop 205 - Surgical Assistants Dissecting & Implanting Workshop (Slivering Station) The History of Hair Transplantation for the assistant Workshop 202: High Tech HT: The Best High Technological Devices in My Practice Scarring Alopecia (Chemical Burns) Secondary to Hair Highlighting: An Under Reported Entity Lunch Symposium 212 - If I knew then what I know now - Experts share the wisdom they wish they'd been told when they were beginners Commentary On, "Personal Hair Growth Index" Trichoschisis: an Uncommon Complication from Hair Transplantation Does Epinephrine Influence Post-Surgical Effluvium?, A Pilot Study Workshop 204: Eyebrow HT (Workshop Director) The Hair Follicle - Wound Healing Connection Moderator Introduction, Emerging Therapies; Different Strategies to Induce Hair Growth Breakfast with the Experts, Table Co-Leader on the Topic of "Advances in Hair Biology: PGD2 and Other Stories" Moderator Introduction, Operation Restore and Repair Cases Personal Growth Index: Transforming the Unknown Variable Element of the Hair Transplant's Quality Equation into a Stable Constant Expanding Needle Concept For Better Extraction of Body Hair Grafts Impossible Hair Transplant Repair - A Different Approach to Treat a Difficult Repair Patient When FUE Goes Wrong Use of Body and Beard Hair as Additional Donor in Extensive Hairloss Moderator Introduction, Food for Thought Moderator Introduction, Advanced Surgical Techniques I Evaluation of Body Dysmorphic Disorder in Hair Loss Patients and Benefit After Hair Transplant Accurate & Error Free Counting of Recipient Sites and Grafts Using Novel Electronic Counter Update on Recipient Site Staining, Better Stain Formulation Viscosity Improves Sites Visibility by 100 % Scalp Micropigmentation as a Complement and an Alternative to Hair Transplantation Workshop 201: Scalp Micro-Pigmentation (Workshop Director) Panelist for Controversies and Hot Topics in Hair Restoration Surgery FUE Hands-On Course faculty The Initial Consultation: Patient Selection Commentary On, "Scientific Evidence That Environment, Diet and Lifestyle Contribute to Epigenetic Regulation of Hormones and Are Likely to Influence Hair Growth" Pre and Post-op Management Workshop 205 - Surgical Assistants Dissecting & Implanting Workshop (Implanting Station) The Role of the Assistant in Hair Transplantation How I Inject PRP in Patients with Hair Loss and HRS Coffee with the Experts, Non-CME Table Co-Leader on the Topic of "The Role of Vitamins & Supplements in HairLoss and HRS" Workshop 203: To Transplant or Not to Transplant: How Not to Get into Trouble with Mimickers of Androgenetic Alopecia Micro-Incisonal Graft Removal Technique Workshop 205 - Surgical Assistants Dissecting & Implanting Workshop (Slivering Station) Sales vs. Education Higher Temporal Recession - Why? When? and How to Convince Patients 13

Disclosure Block B.M. Ng: None. B.M. Ng: None. B.M. Ng: None. B.M. Ng: None. R.P. Niedbalski: None. R. Niedbalski: None. B.P. Nusbaum: None. B.P. Nusbaum: None. K. Oc: None. K. Oc: None. K. Oc: None. J. Pak: None. J.P. Pak: None. R. Panchaprateep: None. R. Panchaprateep: None. E. Papanikolaou: None. J. Park: None. J. Park: None. J. Moh: None. M.W. Parsley: None. M.W. Parsley: None. W. Parsley: None. W. Parsley: None. W. Parsley: None. W. Parsley: None. D. Pathomvanich: None. D. Pathomvanich: None. D. Pathomvanich: None. R. Paus: None. R. Paus: None. R. Paus: None. D. Perez-Meza: None. M. Pitchon: None. A. Poswal: None. . Poswal: None. A. Poswal: None. A. Poswal: None. A. Poswal: None. C.J. Puig: None. H.N. Radwanski: None. R.J. Rajput: None. M.N. Rashid: None. M.N. Rashid: None. W. Rassman: None. W.R. Rassman: None. W.R. Rassman: None. W.R. Rassman: None. W.H. Reed: None. W.H. Reed: None. R.J. Reese: None. F. Reynoso: None. F. Reynoso: None. F. Rinaldi: None. N.E. Rogers: None. N.E. Rogers: None. P. Rose: None. B. Nusbaum: None. A.W. Russell: None. A.W. Russell: None. A. Ruston: None.

Publishing Title Pitfalls for the Beginner: Panel Discussion and Audience Q&A - Panelist Finasteride in the Long Run - Surprising Data from the Sato Study Re-innervation and APM Formation of FU after HT Lunch Symposium 311 - Business Development: Marketing Workshop 205 - Surgical Assistants Dissecting & Implanting Workshop (Implanting Station) Guide to Photo Documentation of HT Results Low Anabolic Profile in Assessing a Patient's Overall Hair Loss Program Advance Technologies Panel Discussions: Hairline Design Breakfast with the Experts, Table Leader on the Topic of "How to Design a Correct Hairline" Workshop 203: To Transplant or Not to Transplant: How Not to Get into Trouble with Mimickers of Androgenetic Alopecia Pitfalls for the Beginner: Panel Discussion and Audience Q&A - Panelist Moderator Introduction, Finasteride Symposium Coffee with the Experts, Table Co-Leader on the Topic of "Finasteride" Lunch Symposium 212 - If I knew then what I know now - Experts share the wisdom they wish they'd been told when they were beginners Commentary On, "The New Wave of Complications in the Follicular Unit Era" Creating a Natural and Pleasing Hair Transplant Ergonomics Stamp for the Operation Planning How I Do FUE at 2,000 Extractions/Hour Advanced/Board Review Course - Chair Test Taking Strategies Lunch Symposium 213 - FUT versus FUE: Personal preference and how to explain advantages and disadvantages to patients Commentary On, "FUT vs FUE What is the Future?" Workshop 205 - Surgical Assistants Dissecting & Implanting Workshop (Slivering Station) Graft Preparation I Coffee with the Experts, Table Co-Leader on the Topic of "Hair Transplantation in Young Patients: My Personal Approach" Lunch Symposium 212 - If I knew then what I know now - Experts share the wisdom they wish they'd been told when they were beginners Workshop 205 - Surgical Assistants Dissecting & Implanting Workshop (Dissecting Station) Staff Training Big FUE Sessions, Evaluation of the Donor Site Workshop 205 - Surgical Assistants Dissecting & Implanting Workshop (Implanting Station) Graft Preparation II Ryan Welter Hair Loss Classification Coffee with the Experts, Chinese-Speaking Table: Pearls for Asian Hair Transplants FUE Hands-On Course faculty VIDEO: Neograft: Personal Experience, Capabilities and Limitations Quantifying the Perception of HairAmount: An Analysis of Hair Diameter and Density ChangesWith Age in Caucasian Women A Case Study Follow Up: Graft and Hair Counts at One Year: Side by Side FUE/Strip FUT Transplants in a Frontal Scalp Genomics Comparison of Hair Follicles from Punch Biopsies, Follicular Unit Extraction (FUE) Hands-On Course: Manual and Motorized (Course Chair) How I Repair Wide Donor Scars Using FUE and 0.75mm Punches FUT vs FUE What Is The Future ? Can We Do DFUs On Asians? Atrial Fibrillation and Guidelines for Perioperative Antithrombotic Therapy High Density Implantation for Secondary Cicatricial Alopecia How I Make Recipient Sites Usng Micropunches Donor Closure Technique Using Both EdgesTrichophytic Closure: A Video Presentation Asian Female Hairline Surgery Using Follicular Unit Extraction Principles of Choosing the Follicles During the Surgery Intend to Increase the Density A 4*100 Relay system of surgery consulting Coffee with the Experts, Table Leader on the Topic of "Zones for Surgical Planning in Men and Women According to Their Degree of Alopecia" Lunch Symposium 211 - Business Development: Practice Management Scar Repair For A 16 Year Old Male Patient Using FUE How the Outgrowth Angle of Hair Follicles Infuences the Injury of the Skin of the Donor Area in FUE. A Mathematical Approach of the Problem

Disclosure Block A.S. Ruston: None. A. Sato: None. A. Takeda: None. A. Sato: None. K. Toyoshima: None. A. Takeda: None. T. Tsuji: None. D. Seigel: None. J. Shafer: None. J. Shafer: None. L. Shapiro: None. R. Shapiro: None. R. Shapiro: None. M.K. Singh: None. D.B. Stough: None. D.B. Stough: None. D.B. Stough: None. D.B. Stough: None. D.B. Stough: None. E. Suddleson: None. P. Tafoya: None P. Tesauro: None. L.R. Trivellini: None. R.H. True: None. R.H. True: None. R.H. True: None. R.H. True: None. A. Ullrich: None. A. Ullrich: None. W.P. Unger: None. W.P. Unger: None. S. Vadachkoria: None. S. Vadachkoria: None. J.F. Lorenzo: None. X. Vila: None. A.D. Watts: None. A.D. Watts: None. R. Welter: None. W. wen yi: None. K.L. Williams: None. K.L. Williams: None. B.R. Wolf: None. T. Dawson: None. B. Wolf: None. B. Wolf: None. T. Dawson: None. B. Hulette: None. P. Hu: None. B. Wolf: None. B. Wolf: None. W. Wu: None. W. Wu: None. K. Yagyu: None. K. Yagyu: None. K. Yamamoto: None. K. Yamamoto: None. S. Yi: None. J. Zhang: None. C. Zhao: None. C.L. Ziering: None. C.L. Ziering: None. G. Zontos: None. C. Davies: 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.

14

day-by-day PrOGraM I Thursday

Thursday I OcTOber 18, 2012

6:30AM-6:00PM 7:00AM-6:00PM 7:00AM-8:00AM 7:30AM-8:30AM 7:30AM-7:30PM 7:30AM-7:30PM 8:15AM-6:00PM 8:15aM-9:15aM registration speaker ready room Newcomers Orientation breakfast
(invitation only)

9:22AM-9:32AM 10 how to critically evaluate research and esearch Tips and resources to design, conduct 005 and Publish a Scientific Study in Hair restoration Marco N. Barusco, MD 9:32AM-9:39AM
006 7 The effects of Williams e Media used

continental breakfast exhibits Poster Viewing GeNeraL sessION 9:40AM-9:47AM

007

as a storage solution to enhance Graft survival in comparison to Normal saline aline Ratchathorn Panchaprateep, MD survival Michael L. Beehner, MD

7 recipient site angulation and Follicle

Opening SeSSiOn
Moderator: Francisco Jimenez, MD
LeARning obJecTiveS Demonstrate understanding of basic biology of follicular stem cells. Identify the role of these cells in hair cycle regeneration. Formulate ideas for the role of HF stem cells in applications of hair regeneration, wound healing and in regenerative medicine.

9:47AM-9:57AM 10 Q&a 9:57AM-10:04AM

008 7 Quantifying the Perception of hair

amount: an analysis of hair diameter and density changes with age in caucasian Women Bradley R. Wolf, MD Effluvium? Damkerng Pathomvanich, MD reticule surface area size John P. Cole, MD

10:04AM-10:11AM
009

7 Does Epinephrine Influence Post-Surgical

8:15AM-8:20AM
001

5 Program chair Welcome

Francisco Jimenez, MD
8 Presidents address

10:12AM-10:19AM
010

7 Follicular density comparison by

8:20AM-8:28AM
002

Jennifer H. Martinick, MBBS

10:20AM-10:30AM 10 Q&a 10:30AM-10:45AM coffee break

Generously suppor ted by a grant from Johnson & Johnson Healthcare Products, Division of McNEIL-PPC, Inc.

8:30AM-9:05AM 35 adVaNces IN haIr bIOLOGy LecTurer From stem to hair: deciphering and 003 exploiting the instruction set that guides follicle regeneration Featured Guest Speaker: Bruce A. Morgan, PhD
Associate Professor, Department of Dermatology, Harvard Medical School; Cutaneous Biology Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA
The Advances in Hair Biology Lectureship is generously suppor ted by a grant from BOSLEY.

10:45aM-12:00PM

advanced SuRgical techniqueS i

Moderator: Henrique N. Radwanski, MD
LeARning obJecTiveS Compare and contrast different surgeons approaches to various aspects of the hair transplant procedure. Discuss the surgical approaches to hair transplantation in special situations.

9:05AM-9:15AM 10 Q&a 9:20aM-10:30aM

10:45AM-10:47AM
011

2 Moderator Introduction

ReSeaRch pReSentatiOnS
Moderator: Melvin L. Mayer, MD
LeARning obJecTive Describe various research projects on the subject of hair and how they may impact therapies or treatments for hair loss.

Henrique N. Radwanski, MD haiRline deSign

and

SuRgical planning

10:47AM-10:54AM
012

7 hairline advancement in Women:

9:20AM-9:22AM
004

2 Moderator Introduction

surgical hairline advancement versus hair Grafting Jeffrey S. Epstein, MD When? And How to Convince Patients Antonio S. Ruston, MD

Melvin L. Mayer, MD

10:54AM-11:01AM
013

7 Higher Temporal Recession Why?

THURS
15

day-by-day PrOGraM I Thursday

11:02AM-11:09AM
014

7 No Temporal Point Peak, 2 Peak

sideburns and No Peak s-Line hairline design in Women Kun Oc, MD

2:18PM-2:38PM 20 Finasteride: so tell me doctor are there any side effects? 022 Featured Guest Speaker: Stephen Freedland, MD
Associate Professor of Urology and Pathology; Vice Chief of Research, Urological Surgery; Associate Director of Clinical Research, GU Program, Duke Cancer Institute; Editor-in-Chief, Prostate Cancer and Prostatic Diseases; North American Editor, European Urology; Durham, North Carolina, USA

11:10AM-11:20AM 10 Q&a d OnOR a Rea h aRveSting 11:20AM-11:27AM

015 7 harvesting hair from the Temporal area

Limitations and advantages Parsa Mohebi, MD Paul T. Rose, MD, JD

11:27AM-11:34AM
016

7 Refinement of the Rose Tissue Spreader 7 use of body and beard hair as additional

2:38PM-2:48PM 10 Q&a 2:48PM-2:58PM 10 Finasteride in the Long run surprising data from the sato study 023 Akio Sato, MD, PhD
Director of Tokyo Memorial Clinic Hirayama (invited speaker)

11:34AM-11:41AM
017

donor in extensive hairloss Arvind Poswal, MBBS

11:42AM-12:00PM 18 Q&a 12:00PM-12:30PM 12:30PM-1:45PM break for hotel to set the room for lunch, attendees can visit exhibits Ishrs General Membership business Meeting Luncheon and service awards
For all registered attendees (except exhibitors). Included with paid registrations.

2:58PM-3:05PM
024

7 Safety and Efficacy of Finasteride

2.5mg in Postmenopausal Women with androgenetic alopecia: Pilot study in 52 Patients Abdulmajeed Alajlan, MD hair Transplant Practice Edwin S. Epstein, MD

3:06PM-3:13PM
025

7 how Finasteride should be used in a

2:00PM-3:30PM
019

FinaSteRide SympOSium
Moderator: Dow B. Stough, MD Panelist: Robert M. Bernstein, MD
LeARning obJecTiveS Review the latest studies on the efficacy and safety of finasteride 1mg 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. Develop guidelines for use of finasteride in a hair restoration practice: best candidates for finasteride, type of information that should be delivered to the patient about side effects, combination therapy of finasteride with other FDA approved medications.

3:13PM-3:30PM 17 conclusions by dr. stough and audience Q&a 3:30PM-3:55PM

027 028 029, 030 031

OpeRatiOn ReStORe and RepaiR caSeS

Moderator: David Perez-Meza, MD Panelists: Paul C. Cotterill, MD, Mark S. DiStefano, MD, E. Antonio Mangubat, MD, Edwin S. Epstein, MD and Melvin L. Mayer, MD
LeARning obJecTive Discuss the surgical approaches to several repair cases, including several that were supported by the ISHRSs Operation Restore pro bono program.

2:00PM-2:02PM
018

2 Moderator Introduction

3:30PM-3:50PM 20 Ishrss Operation restore 026 David Perez-Meza, MD and panelists 3:50PM-3:55PM
032 5 Treating an extensive burn Injury of the

Dow B. Stough, MD
7 Finasteride Persistent sexual dysfunction

2:03PM-2:10PM
020

controversy: update Ken Washenik, MD, PhD

scalp in a child Frank G. Neidel, MD

2:10PM-2:17PM
021

7 beyond Finasteride side effects:

alternate risks for sexual dysfunction and spermatic abnormalities via Genetics, Physiology and environment Sharon A. Keene, MD

16

day-by-day PrOGraM I Thursday

4:00PM-4:45PM

or Visit the exhibits

cOFFee with the e xpeRtS

LeARning obJecTive Discuss various hair restoration surgery topics in-depth in small groups. No extra fee. Open to all attendees on a first-come, first-served basis. This is an informal session for small groups to discuss a specific topic. Come with your questions. Round banquet tables will be set in the back of the General Session room. Each table will be labeled with a topic and experts name. Get your coffee and then sit at the table of your choice to have coffee with an expert.

4:45PM-6:00PM

advanced SuRgical techniqueS ii

Moderator: Bessam K. Farjo, MBChB
LeARning obJecTiveS Compare and contrast different surgeons approaches to various aspects of the hair transplant procedure. Discuss the surgical approaches to hair transplantation in special situations.

4:45PM-4:47PM
053

2 Moderator Introduction

Bessam K. Farjo, MBChB R ecipient a Rea

4:47PM-4:54PM
033 034 051 035 036 037 038 039 040 041 042 043 044 1) robotic Fue Robert M. Bernstein, MD 2) spanish-speaking Table: Fue Jose F. Lorenzo, MD 3) chinese speaking Table: Pearls for asian hair Transplantation Wen Yi Wu, MD 4) research challenges in hair biology Bruce A. Morgan, PhD & Ken Washenik, MD, PhD 5) Finasteride Stephen Freedland, MD & Dow B. Stough, MD 6) Minoxidil: use It or Lose It and Other Facts that Patients Need to Know Robert T. Leonard, Jr., DO 7) hair Transplantation in young Patients: My Personal approach Walter P. Unger, MD & Vincenzo Gambino, MD 8) Flap surgery and use of expanders & Operation restore E. Antonio Mangubat, MD & Frank G. Neidel, MD 9) hairline design for asian Patients Sungjoo Tommy Hwang, MD, PhD 10) Zones for surgical Planning in Men and Women according to Their degree of alopecia Craig L. Ziering, DO 11) adding hT to a cosmetic Practice or adding cosmetic Procedures to a hair Transplant Practice Samuel M. Lam, MD
NON-CME TABLES

7 The Influence of Intrapatient Graft

054

Length differences on depth controlled Incisions Sungjoo Tommy Hwang, MD, PhD

4:55PM-5:02PM
055

7 Where to Place the Grafts When There

are Not enough Frontal core vs. Parting side approach Bertram M. Ng, MBBS Muhammad N. Rashid, MD

5:02PM-5:09PM
056

7 Making recipient sites the Fast Track Way

5:10PM-5:20PM 10 Q&a h aiR t RanSplantatiOn 5:20PM-5:27PM

057
in

S pecial S ituatiOnS

7 hair Transplant to the beard, chest and

Other areas: review of 400 Patients Jeffrey S. Epstein, MD

5:27PM-5:34PM
058

7 hair Transplantation into scars

Jennifer H. Martinick, MBBS

7 Micro-incisional Graft removal Technique

5:35PM-5:42PM
059

Paul T. Rose, MD, JD

7 eyebrow Transplantation: Techniques and

5:42PM-5:49PM
060

045

Outcomes of Over 350 cases Jeffrey S. Epstein, MD

5:50PM-6:00PM 10 Q&a 6:00PM-7:30PM Welcome reception (in Exhibit Hall)

046

047 048 049 050

12) saFe system for Fue James A. Harris, MD 13) cole Fue device John P. Cole, MD 14) The role of Vitamins & supplements in hair Loss and hrs Lawrence J. Shapiro, MD & Nicole E. Rogers, MD 15) assistants Issues Brandi Burgess, Margaret Dieta & Lil Carr

THURS
17

16
18

001 Program Chair Welcome & Announcements

Francisco Jimenez, MD NA, Las Palmas Gran Canaria, Spain Dr. Jimenez is a dermatologist and hair transplant surgeon. Trained in Dermatology in Madrid, in Dermatopathology at the University of Miami, in Mohs surgery at Duke University and in Hair Restoration Surgery with Dr. Dow Stough in Hot Springs, Arkansas. Currently working in private practice in Gran Canaria, Canary Islands, Spain. Author of 44 publications in peer review journals and past Editor of the Hair Transplant Forum (2008-2010). Dr. Jimenez received the 2011 ISHRS Platinum Follicle Award. F. Jimenez: None.

002 President's Address

Jennifer H. Martinick, MBBS Salvado Medical, Nedlands, Australia. Dr Martinick is a past Program Chair of the ISHRS, past editor of Cyberspace Chat and currently serves as President of the ISHRS. She is deeply committed to its mission of promoting the highest ethical standards in professional hair restoration. In 2003 she received the Platinum Follicle award, the 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. ABSTRACT: President's Address for 20th Annual Scientific Meeting Bahamas October 17-20, 2012

19

003 From Stem to Hair: Deciphering and Exploiting the Instruction Set That Guides Follicle Regeneration
Bruce A. Morgan, PhD Harvard Medical School, Boston, MA, USA. Dr. Morgans laboratory studies the development and regeneration of cutaneous appendages in model organisms. Recent work has focused on the role of the dermal papilla (DP) in guiding hair morphogenesis and follicular regeneration. Mouse models that allow manipulation of gene expression specifically in the DP after the follicle has formed have been exploited to probe the role of specific signals between follicular keratinocytes and the DP. This work with model systems is integrated with a collaborative effort to understand the genetic variation driving the diversity in cutaneous appendage form and function within different human populations. B.A. Morgan: None. ABSTRACT: Much research on the mechanisms that regulate hair growth and cycling has focused on keratinocyte stem cells and their progeny, in part because of the powerful genetic tools available to study this compartment in vivo. More recently, we have developed analogous tools and methods to analyze the role of the follicular papilla (DP) in these processes in the mouse. In humans, a correlation between DP size and hair shaft size has been noted both during normal growth and in the follicular decline observed with aging or progressive alopecia. However, whether this was the cause or an effect of follicular decline remains controversial. Using mouse genetic models that allow manipulation of DP cell numbers in otherwise healthy follicles in vivo, we show that DP cell number dictates both hair follicle size and hair shaft morphology. DP cell number also regulates the frequency of re-entry into the anagen phase of the hair cycle. Although the mechanism by which the DP is damaged in this mouse model may differ from that in, for example, androgenetic alopecia in humans, the downstream mechanisms that mediate follicular decline are likely to be conserved. Our experiments with this mouse model of hair thinning and loss have also revealed mechanisms that act to restore DP cell number and hair size after further damage to the DP is prevented. Related work during normal development and cycling has identified genetic pathways that act in the DP to specify DP cell number and hair morphology. While this talk will focus on mechanisms that regulate DP size and activity in the context of normal development and cycling and the response to DP damage in vivo, their potential application in hair restoration efforts will also be briefly discussed.

004 Moderator Introduction, Research presentations

Melvin L. Mayer, MD Bosley Medical, San Diego, CA, USA.

20

He has served as an Examiner and Past President of the ABHRS and member of many committees in the ISHRS through the years. He has been awarded research grants by the ISHRS. Areas of interest include follicular regeneration of bisected follicles, graft yield at varying densities, classification and surgical techniques of the temporal points, scalp elasticity scale and understanding its importance in maximizing donor width and minimizing donor scars, and techniques to maximize the quality of transplants in Black patients. He was awarded the Platinum Follicle Award in 2004. San Diego is home. M.L. Mayer: None.

005 How to Critically Evaluate Research and Tips and Resources to Design, Conduct and Publish a Scientific Study in Hair Restoration
Marco N. Barusco, MD Tempus Hair Restoration, PA, Port Orange, FL, USA. Marco N. Barusco, MD Founder & Medical Director - Tempus Hair Restoration, PA Chairman & Trustee - American Society of Hair Restoration Surgery (ASHRS) Chairman of the Written Exam Committee - American Board of Hair Restoration Surgery (ABHRS) Chief Section Editor for Hair Restoration - The American Journal of Cosmetic Surgery (AJCS) Member of the Board of Trustees - American Academy of Cosmetic Surgery (AACS) Member of the Board of Directors - American Board of Hair Restoration Surgery (ABHRS)Member of the Live Surgery Committee - International Society of Hair Restoration Surgery (ISHRS)Port Orange Office: 5537 S. Williamson Blvd, Suite 752 Port Orange, FL 32123 Phone: 1-877-877-5200 - Fax: 1-888-877-5200 M.N. Barusco: None. ABSTRACT: As a member of the Editorial Board of the American Journal of Cosmetic Surgery and as a Consultant for REUTERS Insight I am often asked to review scientific studies submitted for publication in the area of hair restoration surgery.

Over the years I have participated in many scientific studies involving different aspects of hair restoration surgery including, among others, studies on hair growth and survival, hair density studies, graft angulation studies and donor

21

area healing studies. My experience has taught me that it is exceedingly difficult to produce scientifically-sound studies in hair restoration surgery, particularly when it involves hair growth and survival. Accurate hair counts and hair measurements are exceedingly difficult tasks to perform accurately and consistently, leaving room for error and criticism if not done properly.

Another issue with hair studies reside on the fact that most of the time photographs are used at least in part to demonstrate results. What I see very often is that pictures of hair growth may be very misleading To accurately prove or refute a clinical hypothesis using photographs, the investigator must adhere to strict rules of consistency to ensure that adequate visual interpretation of results is afforded, making the data obtained trustworthy. These mistakes and inconsistencies may make an excellent study invalid and unfit for publication in a major peerreviewed journal.

In this presentation I intend to highlight these and some other issues and provide participants with an insight on how to avoid these pitfalls so that more consistency may be obtained when drafting and conducting a study protocol. Also, insights will be given as to protocol writing and use of an IRB.

22

                                

             
 






  

  
            



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26

006 The Effects of Williams E Media on Follicular Unit Graft Survival Compare to Normal Saline as a Storage Solution
Ratchathorn Panchaprateep, MD Chulalongkorn University/ DHT Clinic, Bangkok, Thailand. Ratchathorn Panchaprateep, MD Division of Dermatology Department of Medicine Faculty of Medicine King Chulalongkorn Memorial Hospital Rama 4 Road Bangkok 10330 Thailand Email Address: Nim_bonus@hotmail.com, Nim_bonus@yahoo.com Education - Medical degree (First Class Honours), Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand - Dermatology,Division of Dermatology, Department of Medicine, Chulalongkorn University, Bangkok, ThailandClinical fellow in Laser and Dermatologic Surgery, Division of Dermatology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand - Phd. Study in skin and hair stem cell\, Chulalongkorn University, Bangkok, Thailand - Fellowship in Hair Restoration Surgery (ISHRS), DHT Clinic, Bangkok, Thailand. Academic Appointment: 2008Now: Instructor in Dermatosurgery, Chulalongkorn University, Bangkok, Thailand Hospital Appointment: 2011-Now: Dermatologist, hair transplantation surgery, Bumrungrad General Hospital R. Panchaprateep: None. ABSTRACT: Introduction: Until now, there have been several attempts to look at the best storage solution for holding the grafts during hair restoration procedure. There is still controversy regarding its usage. Currently, most hair surgeons use normal saline or ringer lactate. This has led to the development of new storage solutions that have been shown to support hair growth after transplantation eg. Platelet rich plasma (PRP), Hypothermasol, ACell, etc. Successful hair follicle organ culture has been established for more than 20 years, the isolated human scalp follicles can grow up to 10-14 days. The Williams E media has been used as a standard culture media in hair organ culture and also as a transported media in hair biologic research. This media contains the glucose, amino acids, vitamins, salts, buffers and antioxidants that tissue requires. So our study used Limmers 1992 study as a model for testing the survival of follicular unit (FU) graft holding in Williams E media solution compared to standard normal saline at various period of time. Objective: To study the survival of follicular unit grafts preserved in Williams E media compared to saline over a period of time. Materials and methods: A-47-year-old Norwood type VI male Asian, who had few miniaturized hairs scattered on the top of his head was

27

chosen for the trial. He was generally healthy, non-smoking/drinking and not on any hair loss medication. Five separated 1x1cm study boxes were marked off in each half of scalp with total of 10 study boxes and the corner of each boxes were tattoo. After strip harvesting, half the number of grafts were stored in normal saline and another half in Williams E medium (Gibco BRL, Paisley, Scotland) supplement with 10 g of insulin, 10 ng/ml of hydrocortizone and 200 mmol/L Lglutamine at 4C. The grafts were placed at 2, 4, 6, 24 and 72 hours out of body, at the density of 30 grafts per square meter. The scalp was split into half, NSS on the right side and William E medium on the left side of the patient (as shown in picture). For the front row, 30 grafts contain of 15 FUG of 1 hair and 15 FUG of 2hairs. The back row, 27 FUG of 2 hairs and 3 FUG of 3 hairs were inserted per box. Wiliams E NSS 0.9% Each of the study boxes were photographed pre-operative, immediately after insertion, then at 4, 6, 8, 10 and 12 months after surgery. The hair count was done at each visit by counting both full terminal hairs and slightly thin hairs, but extremely vellus hairs were not included. The hairs diameter was measured by micrometer (Mitutoyo Corp, Japan). Results: Preliminary report of the hair counts at 4 and 6 months is showed in table 1. The grafts survival in William E media was significantly superior to those in saline except at 72-hours showed poor growth in both groups. Table 1: Percentage of growing hairs at 4 and 6 months post transplant Saline (n = 108) William E media Time 4 mo 2 hr 64.8 6 mo 4 mo 6 mo 97.2% 98.1% 93.5% 100% 5.5%

74.1% 88.9%

4 hr 49.1% 58.3% 98.1% 6 hr 54.6% 67.8% 88% 24 hr 31.5% 37.9% 94.4% 72 hr 6.5% 6.5% 5.5%

We also observed most of the hairs growing at William E side were coarser than in saline. At 6 months, the mean hair diameter of William E and saline group was 60.4 compared to saline 52 m. Conclusion: The preliminary data showed that William E solution as a storage solution can significantly improve graft survival comparing to the standard normal saline at 2, 4, 6 and 24 hours time point. We still wait for the final hair counts at 12 months after surgery.

28

29

Disclosures
The effects of Williams E media as a holding solution on the follicular unit graft survival comparing to normal saline
Ratchathorn Panchaprateep Division of Dermatology, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand Damkerng Pathomvanich DHT Clinic, Bangkok, Thailand.

I have no relevant financial relationships or conflicts of interest to declare.

Introduction
Until now, there have been several attempts to look at the best storage solution for holding the grafts during hair restoration procedure. There has not been a conclusion on the type of medium to use. Several studies of efficacy of storage solution in vitro via elongation study it remains unclear whether elongation is truly a good indicator of graft viability. Currently, most hair surgeons use normal saline or ringer lactate.

Introduction
Successful hair follicle organ culture has been established for more than 20 years, the isolated human scalp follicles can grow up to 10-14 days. The Williams E media has been used as a standard culture media in hair organ culture and also as a transported media in hair biologic research. This media contains the glucose, amino acids, vitamins, salts and buffers that tissue requires.

Objective
To study the viability of hair follicular unit grafts preserved in Williams E media compared to saline over a period of time via using box study (Limmers 1992 study).

Materials and methods

A-47-year-old Norwood type VI male patient with few miniaturized hairs scattered on the top of his head He is generally healthy non-smoking/drinking not on any hair loss medication

30

Materials and methods

Williams E medium (Gibco BRL, Paisley, Scotland) supplement with
200 mmol/L L-glutamine 10 g of insulin 10 ng/ml of hydrocortizone

The grafts were placed at 5 different time points as 2, 4, 6, 24 and 72 hours out of body at the density of 30 grafts per square meter.
NSS Williams E media

Materials and methods

10 separated 1x1cm study boxes were marked off in each half of scalp with total of 20 study boxes and the corner of each boxes were tattooed.

Density = 30 FUG/cm2

Front role

Back role

6 rolls

15FUG x 1h 15FUG x 2h

27FUG x 2h

5 columns

3FUG x 3h

Immediate post-op

Evaluation
Each study boxes were photograph before, immediate after transplant and at 4, 6, 8, 10 and 12 months follow-up period. The hair count was done at each visit by counting both full terminal hairs and slightly thin hairs, but extremely vellus hairs were not included by 2 blinded hair transplant surgeons and 1 registered nurse. The hair diameter was measured by micrometer (Mitutoyo Corp, Japan).

72hr

72hr

72hr 24hr 6hr 4hr 2hr 2hr 4hr 6hr

72hr 24hr

NSS

Williams E

31

Immediate post-op

P/O 1 mo

P/O 10 mo

P/O 12 mo

P/O 4 mo

P/O 12 mo

P/O 12 mo

P/O 12 mo

Post-operative
Time 2 hr 4 hr 6 hr 24 hr 72 hr
P/O 6 mo P/O 10 mo P/O 12 mo

Result
Percentage of growing hairs at 4 and 12 months post transplant Saline (n =108)
4 mo 12 mo

William E (n =108)
4 mo 12 mo

64.8% 49.1% 54.6% 31.5% 7.4%

72.2% 65.7% 66.7% 46.3% 8.3%

97.2% 98.1% 93.5% 100.0% 3.7%

97.2% 98.1% 91.7% 100.0% 1.9%

Comparison of graft survival across 72 hours

12 months follow up
120.0% 97.2% 100.0% 98.1% 91.7% 100.0%

Results
At 12 months follow-up period, the graft survival in William E media was significantly superior to those in saline except for at the 72-hours insertion. At 72-hours time point shows poor growth of the FU graft in both groups.

Growth Rate (percentage)

80.0%

72.2% 60.0% 65.7% 66.7% 46.3%

40.0%

20.0% 8.3% 0.0%

NSS WE

1.9%
2h 72.2% 97.2% 4h 65.7% 98.1% 6h 66.7% 91.7% 24h 46.3% 100.0% 72h 8.3% 1.9%

32

2 hrs
2 hour insertion
100.0% 97.2% 88.9% 90.0% 80.0% 80.0%
Growth Rate (percentage) Growth Rate (percentage)

4 hrs
4 hour insertion
110.0% 101.9% 100.0% 90.0% 98.1% 96.3% 101.9% 98.1% 95.4% 93.5%

97.2%

70.0% 60.0% 50.0% 40.0% 47.2% 30.0% 20.0% 10.0% 0.0%

NSS WE

72.2% 73.1% 64.8% 45.4% 37.0% 72.2% 72.2%

70.0% 60.0% 48.1% 50.0% 40.0% 30.0% 33.3% 20.0% 10.0% 0.0% 30.6% 38.0% 49.1% 58.3% 68.5% 65.7% 66.7%

43.5%

1 mo 47.2% 45.4%

2 mo 43.5% 37.0%

4 mo 64.8% 88.9%

6 mo 73.1% 97.2%

8 mo 72.2% 93.5%

10 mo 72.2% 95.4%

12 mo 72.2% 97.2%

1 mo 33.3% 38.0%

2 mo 30.6% 48.1%

4 mo 49.1% 101.9%

6 mo 58.3% 98.1%

8 mo 68.5% 96.3%

10 mo 66.7% 101.9%

12 mo 65.7% 98.1%

NSS WE

6 hrs
6 hour insertion
100.0% 90.0% 80.0% 70.0%
Growth Rate (percentage)

24 hrs
24 hour insertion
100.0% 91.7% 91.7% 100.0% 91.7% 95.3% 90.0% 80.0% 70.0% 97.2% 97.2% 100.0%

93.5% 88.0%

67.6% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%

NSS WE

66.7% 63.0%

Growth Rate (percentage)

66.7%

54.6% 54.6%

60.0% 50.0% 46.3% 40.0% 30.0% 25.2% 31.5% 17.8% 38.0% 45.4% 31.5%

28.7% 37.0% 27.8%

20.0% 25.9% 10.0% 12.0% 0.0%

NSS WE

1 mo 37.0% 54.6%

2 mo 27.8% 28.7%

4 mo 54.6% 88.0%

6 mo 67.6% 93.5%

8 mo 66.7% 91.7%

10 mo 63.0% 91.7%

12 mo 66.7% 91.7%

1 mo 25.9% 25.2%

2 mo 12.0% 17.8%

4 mo 31.5% 95.3%

6 mo 38.0% 100.0%

8 mo 45.4% 97.2%

10 mo 31.5% 97.2%

12 mo 46.3% 100.0%

72 hrs
72 hour insertion
100.0% 90.0% 80.0% 70.0%
Growth Rate (percentage)

2hr Front
WE NSS

60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%

NSS WE

40.7%

11.1% 33.3% 7.4% 3.7% 10.2% 2 mo 10.2%

11.1%

3.7% 6.5% 2.8% 4.6% 8 mo 4.6%

3.7% 10 mo 6.5% 2.8%

7.4% 1.9% 12 mo 7.4%

1.9%

1 mo 33.3% 40.7%

7.4% 4 mo 7.4%
7.4%

6.5% 6 mo 6.5%
3.7%

33

4hr Front
WE NSS WE

6hr Front
NSS

6hr Front
WE NSS WE

24hr Front
NSS

72hr Front
WE NSS

Results
We also observed most of the hairs growing at William E side were bigger than saline. At 12 months, the mean hair diameter of William E and saline group was 65 and 56.5 m

34

Discussion
Graft preservation is critical in hair growth and survival There are different solutions for graft preservation
Intracellular storage solutions (Hypertonic) Hypothermasol Viaspan Vitasol (liposomal ATP) Custodiol Extracellular storage solutions (isotonic) Normal saline Ringers lactate Tissue culture media BSS PRP

Comparison of graft survival in different chilled storage solutions

William E
2 hr 4 hr 6 hr 8 hr 24 hr 48 hr 72 hr 96 hr 97 % 98 % 91 % -100 % -1.9 % --

NSS
73 % 66 % 67 % -46 % -8% --

Hyp/ ATP
90 % 90 % 92 % 122 % 82 % 84 % 76 % 40 %

Comparison of graft survival when stored in chilled saline

Limmer 1996
2 hr 4 hr 6 hr 8 hr 24 hr 48 hr 72 hr 96 hr 95 % 90 % 86 % 88 % 79 % 54 % ---

Hair follicle viability depends on a variety of factors

1. 2. 3. 4. 5. 6. 7. 8. Energy charge: calcium vs anions Osmotic agents: mannitol, sucrose pH levels Specific nutrients Oncotic proteins: colloid/ dextran 40 Growth factors Hormones Others: amino acids, antioxidants, electrolytes

Beehner 2011 Our study 2012

74 % 64 % 90 % 90 % 74 % 68 % 20 % 12 % 73 % 66 % 67 % -46 % -8% --

Williams' Medium E
Buffer
pH remains constant since it contains NaHCO3 as (neutral)

Conclusion
William E solution as a storage solution can significantly improve graft survival and graft diameter comparing to the standard chilled normal saline at 2, 4, 6 and 24 hours time point.

Antioxidants
Contains glutathione cellular antioxidant and hydroxyl radical scavenger help metabolize lipid peroxides and H2O2 both are potent free radicals reperfusion injury

Ascorbic acid (vit C) and alpha-tocopherol (vit E)

free radical scarvengers

Amino acids Hormone: insulin

important growth factor

Hydrocortisone
reduce inflammation

reperfusion injury

35

Limitation
This is only box study in one subject These grafts were placed in study boxes, so they might not be simulate the real-world results that a large number of grafts are transplanted

36

007 Recipient Site Angulation and Follicle Survival

Michael L. Beehner, MD Saratoga Hair Transplant Center, Saratoga Springs, NY, USA. Michael Beehner, M.D. has practiced hair transplant surgery in Saratoga Springs, New York since 1989. He obtained his M.D. from the University of Illinois and has residency training in family practice and general surgery. He was co-editor of the Forum from 2002-2005, Platinum Follicle Award recipient in 2001, Manfred Lucas lifetime achievement award recipient in 2007, recipient of 4 Research Grant Awards, and a member of the ISHRS Board of Directors. He is a past diplomate of the American Board of Family Practice (1976-2003) and a current diplomate of the ABHRS. He served as ABHRS President in 2005. M.L. Beehner: None. ABSTRACT: Introduction: This study was designed to see if there was a difference in survival between grafts placed at three different angles Objective: As stated in introduction Materials/Methods: Three study boxes were used in the anterior crown region of a 46 y/o Norwood VI male's scalp. Boxes measure 1.1cm x 1.1cm (1.21cm2) in square area. 25 x 2-hair FU's placed in each box. (50 follicles/hairs per box) Recipient sites made with 19g solid core needle Grafts within the three study boxes placed in sites made at 90 degrees (perpendicular), 45 degrees, and very acute (approximately 10-15 degrees). Study count performed 11 months later. Results: PERPENDICULAR BOX: 55 hairs counted, but two FU sites had 3 hairs exiting. These extra 2 hairs taken off results. 5 of the hairs were slt. miniaturized. Thus, 53 of hairs from the 2-hair FU's present. 106% present 40 DEGREES BOX: 54 hairs present, including one FU exit site with 4 hairs. 6 of the hairs were slightly miniaturized. Thus, 2 hairs subtracted from result. 52 hairs present with 50 having been placed. 104% present ACUTE ANGLE BOX: 42 hairs counted. No 3 or 4-hair FU's. 1 miniaturized hair. 84% present Discussion: In 2000 Dr. Dow Stough conducted a similar study with the three study boxes having recipient sites made at 10, 45, and 60 degrees respectively. The count was performed at 8 months. The results showed 82% survival for the 10 degree box, 76% survival for the 45 degrees box, and 77% survival in the 60 degree box. These three percentages are virtually statistically the same with no significant advantage shown in any of the boxes. They placed 50 x 2-hair FU's in 18g needle sites in 1.5cm x 1.5cm boxes (2.25cm2). Thus the densities of planting in the two studies are almost identical.

37

Our study seemed to show a small but discernible advantage in survival for the 90 and 60 degree boxes, as compared with the acute angle box. The only differences in our studies were the slightly smaller needle sites in our study, the count being done at 11 months instead of 8, and the fact that we used a perpendicular angle instead of 60 degrees in the older study. Obviously, both studies fail to prove anything from a statistical standpoint and only give a glimpse into what may actually be the truth. If further studies continued to show the same result as I obtained, namely, that follicles placed at extremely acute angles did not survive quite as well, the only explanation I could offer to help explain such a relationship would be that the other more upright angled sites (45 and 90 degrees) have the bottom of the site well within the subcutaneoous layer, where the vasculature at the deep floor of the subcutaneous layer is closer. Further studies may give more statistical weight to the true relationship between survival and the angle of the sites. The photos show that, even though the "acute" box had fewer hairs, the "shingling" effect of hairs at that angle give it a much more full appearance that those placed at a perpendicular angle. One final note: If one only considers full terminal hairs in the final count, it would show 50/50 hairs for perpendicular, 48/50 for the 45 degree box, and 41/50 for the acute box.

38

008 Quantifying the Perception of Hair Amount: An Analysis of Hair Diameter and Density Changes With Age in Caucasian Women
Bradley R. Wolf, MD1, Thomas Dawson, PhD2 1 Wolf Medical Enterprises, Cincinnati, OH, USA, 2The Procter and Gamble Company, Cincinnati, OH, USA.

39

Bradley Wolf M.D. has been treating hair loss patients since 1990. He has made over 30 lecture presentations at meetings throughout the world, was director of workshops at the 2002 ISHRS meeting , served as faculty at eight ISHRS workshops, and is the director of the Hands on FUE workshop, ISHRS meeting 2012. 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 Committee, he is a current member of the CME committee. He is ABHRS Board Certified and was a member of the Board of Directors of the ABHRS from 2000-2005.

B.R. Wolf: None. T. Dawson: None. ABSTRACT: Background: It has long been known that women lose satisfaction with their hair as they age. Our data show that Caucasian females perceive an decrease in hair amount in their mid-forties and a further decrease in the mid to late fifties which likely contribute to this dissatisfaction. Neither loss of density (hairs/cm2) nor shaft diameter alone can fully account for the perceived hair loss. A new metric, hair amount (as related to volume), is proposed as a quantitative metric combining the impact of density and diameter on the perception of hair loss. Objective Creation of a single parameter combining the contributions of diameter and density to the perception of age-related female hair loss. Methods 1099 Caucasian women (ages 18 to 66) with self-perceived hair loss and 315 Caucasian women (ages 17 to 86) with no complaints of hair loss were evaluated. Scalp hair diameter was measured using optical fiber diameter analysis, image analysis, linear density, laser, and microscopic methods. Scalp hair density was measured by phototrichogram with manual or automated hair counting. Results Parietal scalp hair diameter increased from approximately 20 to 40-45 years of age then decreased. Hair density was highest in the earliest age group included, 20 to 30 years of age, and decreased thereafter with an increasing rate. In women self-reporting hair loss, the rate of decrease in hair density was significantly faster than for women with no self-assessment of hair loss. The combined metric, hair amount, was relatively constant at younger ages increasing very slightly to age 35, then decreasing significantly beyond 35 in all age groups. Conclusions An increase in hair diameter minimizes the perception of decreasing hair density in the mid-thirties. After that point the combined lower rate of diameter increase with the decrease in density begin to significantly impact the perception of hair amount, so that it becomes increasingly more noticeable in the mid-forties to the mid-to-late fifties. Quantitative determination of hair amount is a useful tool to combine the contributions of hair density and diameter to womens perception of age-related hair loss.

40

Hair health: effect of diameter, density, and age

Outline
Factors affecting optimal hair How they change with age Density
Measurement Results

Diameter
Measurement Results

Summary

Dr. Brad Wolf Thomas L. Dawson, Jr, Paradi Mirmirani, R. Scott Youngquist, Angus McColl, Shuo Wang, and Fangyi Luo

Factors affecting optimal hair

The Amount
Density Diameter

Factors affecting optimal hair

The Amount
Density Diameter

The Color
Pigmentation Fading

The Color
Pigmentation Fading

The Structure
Curvature Strength Damage

The Structure
Curvature Strength Damage

Outline
Factors affecting optimal hair How they change with age Density
Measurement Results

Outline
Factors affecting optimal hair How they change with age Density
Measurement Results

Diameter
Measurement Results

Diameter
Measurement Results

Summary

Summary

41

Factors affecting optimal hair

The Amount
Density Diameter

Factors affecting optimal hair

The Amount
Density Diameter

The Color
Pigmentation Fading

The Color
Pigmentation Fading

The Structure
Curvature Strength Damage

The Structure
Curvature Strength Damage

Outline
Factors affecting optimal hair How they change with age Density
Measurement Results

Hair Ageing
There are five main hair changes that are observed as hair ages

Diameter
Measurement Results

Summary

CHANGES IN HAIR WITH AGING

As we age, we lose: Amount
Diameter
Volume, stiffness

Outline
Factors affecting optimal hair How they change with age Density
Measurement Results

Density
Volume, coverage , g

Diameter
Measurement Results

Color
Melanin
Gray, coverage, manageability

Summary

Structure
Sebum
Shine, protection

Lipids
Dryness, breakage, frizz

42

Hair Count
The setup
Image Acquisition

Density
In hair, precision counts
Blend live with baseline image

Density measures require a high level of precision The location is very important
Occipital and frontal scalp are different

BASELINE

time X

What women see and feel is the frontal scalp

So

Stored Baseline

Reposition image

Blending By Camera Manipulation

To understand the effect of aging on what women perceive one must measure from frontal scalp

Trained operator blends live timepoint image with stored baseline image.

1118R01 1118R00
3 2 2 3 4 4 7 7 8 8 9 9 10 10 37 32 32 36 37 36 3838 39 40 39 41 41 42 42 43 43 44 45 45 55 51 51 55 40 47 47 48 48 49 49 94 78 78 79 80 79 80 82 81 82 81 83 83 84 84 91 91 88 88 87 87 114 114 117 117 115 115 116 116 118 118 119 119 123124 123124 150 150 149 149 144 144 142 143 142 143 145 145 146 147 146 147 148 148 120 120 122 122 121 121 159 159 156 156 157 158 157 158 160 161 160 161 169 169 170 170 171 171 190 184 190 191 192 193 191 192 193 194 194 196 196 197 197 198 198 178 178 179 179 180 181 180 181 182 182 172 174 174 177 177 172 173 175 175 173 92 92 93 93 95 94 96 95 97 96 128 128 125 125 200 200 126 127 126 127 129 130 130 129 99 99 100 100 50 50 52 53 53 52 54 54 57 56 56 57 58 58 63 63 64 64 65 65 101 101 102 102 103 104 104 103 105 106 105 106 44 13 14 15 15 13 14 16 16 17 17 211 211 59 59 60 61 60 61 22 22 24 23 23 24 66 66 67 68 67 68 70 70 5 6 65 12 11 11 11a 11a 12 12a 12a 18 19 19 18 20 20 21 21 26 27 27 28 28 26 29 29 3030 31 31

Large Scale Clinical Confirmation: Density

62 62

71 71 72 72 76 75 75 76

73 74 73 74

Hair Density (hairs/cm2)

33 34 33 34 35 35

300

Hair density decreases continually with increasing rate This cannot explain why women begin noticing hair loss in their early 40s

113 112 113 112

77 77

200

85 85

86 86

89 89

98 97 98 131 131

108 108 107 109 107 109

110 111 110 111 132 132 133 133 176 176 134 136 136 137 137 134 135 135 138 139 138 139 141 141

100

151 152 151 152 153 153 154 154 155 155

185 187 185 188 187 183 184 189 188 183 186 189 186 165 165 166 166 167 167 168 168

20

30

40

50

60

Age (years)

162 163 162 163 164 164 188 189

185 185

1099 Caucasian women self-reporting thinning 2 measures/subject Temporal Sites

Large Scale Clinical Confirmation: Density rate of change

Normal data calculated from Birch et al Self perceived hair loss from P&G internal study. What we found: Hair density decreases with increasing y g rate with age If women think they are thinning, they are.

Outline
Factors affecting optimal hair How they change with age Density
Measurement Results

Diameter
Measurement Results

Summary

Hair density, hair diameter and the prevalence of female pattern hair loss
M.P. Birch, J.F. Messenger and A.G. Messenger
British Journal of Dermatology 2001; 144: 297-304.

43

Diameter Matters

Diameter and Age

Distribution of Hair Diameter (um) Frontal Site Initial Study

0.020

Pre Menopausal Post Menopausal

Low density, But no apparent pp Hair loss

High density, with apparent hair loss

0.015 0.010 0.005 0.0 10 Proportion of hairs P

25

50 100 Hair Diameter (um)

150

In women classified as non-balding with hair densities below the median value for the group, mean hair diameters were significantly higher than in women classified as having Ludwig I hair loss

Distribution of diameters provides more information Menopausal status influences hair parameters Changes accentuated in frontal vs. occipital scalp

Hair density, hair diameter and the prevalence of female pattern hair loss
M.P. Birch, J.F. Messenger and A.G. Messenger
British Journal of Dermatology 2001; 144: 297-304.

Mirmirani, Paradi, Fangyi Luo, R Scott Youngquist, Brian K Fisher, James Li, John Oblong, Thomas L Dawson (2010) Hair Growth Parameters in Pre- and Postmenopausal Women. in Hair Aging, Desmond Tobin and Ralph Trueb, eds., Springer-Verlag New York, LLC

Large Scale Clinical Confirmation: Diameter

100 Hair diameter increases until early 40s Then decreases with increasing rate This still does not alone explain why women l i h begin reporting hair loss in their mid 40s

Large Scale Clinical Confirmation: Diameter

What we found: 1. Hair diameter increases until the early 40s Around the early 40s as women enter peri-menopause, diameter plateaus After the mid-40s hair diameter decreases with increasing rate

Hair Diamete (microns) er

90 80

70

60 50

20

30

40

50

60 1099 Caucasian women 2 measures/subject Temporal Sites

Age (years)

Hair Amount
What really matters

Large Scale Clinical Confirmation: Amount

1099 Caucasian women 2 measures/subject Temporal Sites

Volume = r2 L
For this hair exercise, as length is a factor of style not biology, L=1

Hair amount is stable until the early 40s Then decreases rapidly with increasing rate This correlates best with women's perception of hair loss with age.

Also, and importantly, hair amount varies with he square of the radius this means that small changes in diameter make for big changes in perception.

44

Summary
Multiple scalp hair growth parameters are negatively impacted by age Density and Diameter are both important Precision and accuracy in methods are crucial Location is important
Frontal scalp is regulated differently than occipital scalp

Hair density and hair diameter change more in frontal scalp with age.

OFDA is a reliable, accurate, precise method which enables larger sample set analysis for human hair diameter Large scale sample acquisition quantifies trends with aging If women think they are thinning, they are Treatment of changes seen in aging hair requires consideration of both density and diameter

45

009 Does Epinephrine Influence Post-Surgical Effluvium?, A Pilot Study

Damkerng Pathomvanich, MD DHT Clinic, Bangkok, Thailand. DHT Clinic, Bangkok, Thailand American Board of Hair Restoration Surgery,Diplomate American Board of Surgery,Diplomate Fellow American College of Surgeon Director Fellowship Training Program in Hair Restoration Surgery D. Pathomvanich: None. ABSTRACT: Introduction: Post-operative effluvium or shock loss is unpredictable, it can be just minimal as thinning, moderate as small bald patch or severe as complete baldness. Less commonly, it can also occur at the donor area. Most physicians believe this is due to telogen effluvium, however, we believed it is likely an anagen effluvium in response to injury. The proposed theory include: direct mechanical and chemical injury that interrupted blood supply and induce inflammatory tissue response. Several hair restoration surgeons consider the epinephrine, a vasoconstrictor as one of the causes of post postoperative effluvium since it induces poor circulation. To validate this concept, we performed this controlled study evaluating the effect of post-operative effluvium with and without epinephrine in tumescent anesthesia at the recipient area. Objective: A pilot study, whether epinephrine in tumescent anesthesia contributes to post-operative effluvium at the recipient site. Materials and Methods: To challenge the proposed concept, 8 healthy patients (6 male and 2 female; Mean age 38.8; range 27-60) with clinical diagnosis of androgenetic alopecia were recruited into the trial. Those patients who underwent previous hair transplantation or any scalp surgery were excluded. Four out of eight patients were assigned as the study group, no epinephrine containing solution was injected at the recipient area. Another 4 control patients were matched to the cases by sex, age, Norwood classification and overall hair characteristics. In the control group, the epinephrine was added in the tumescent fluid in the concentration of 1:300,000. At recipient site, we used supraorbital nerve block and ring block with 1 % Xylocaine with 1:100,000 adrenaline. In 4 out of 8 patients, tumescent fluid with a cocktail of normal saline 50 cc and Kenacort (40mg/ml) 0.5 cc without epinephrine was injected in biplana into dermis and superficial subcutaneous fat. On average 30-50 ml was injected. For the other 4 patients that we used as control groups, epinephrine was added in the tumescent solution in the concentration of 1:300,000. We used coronal slit incisions, cutting carefully to avoid damage to the existing hairs. The sites for one, two, three and four hair grafts were made using depth controlled handle for 21, 19, 19 and 18G needle, respectively. The density of the recipient site varied from site to site according to density of native hairs. Dense packing was focused on the area that was nearly bald. Photographs were taken before and 1 month after surgery. Anagen effluvium was observed and severity score was grading post-operatively. The effluvium severity score (ESS) was used to evaluate severity of the post-operative shedding at recipient site by blinded three dermatologists. The assessment of ESS was documented as follows: mild (1= 0-25%), moderate

46

(2=26-50%), marked (3= 51-75%) and severe (4= 76-100%). Results: The 4 pairs of matched patients completed the study. All patients had thinning hairs at the recepient area and no one experienced rapid hair loss pre op. In men who had already taken finasteride, we advised them to continue during surgery. The loss of transplanted and preexisting hairs occurred in the recipient area at 2-6 weeks after operation. The donor area shedding was observed in the same period. In both study and control groups, no one experienced very severe or extensive loss (76-100%). In the study group one reported severe loss (51-75%), two moderate (26-50%), and one mild (0-25%). There were no differences in the severity of effluvium in the two groups. Furthermore, we observed the shock loss or shedding at the temple area was less and most of the transplanted hairs continue to grow, whether the hair that continue to grow dominate the effluvium effect. Conclusion: Our limited study suggested that the epinephrine at appropriate concentration is not the main factor that influences post-surgical effluvium at the recipient area. All involved risks should be cautiously prevented during pre-, intraand post-operative period. This probability must be carefully discussed to the patient prior to surgery to avoid dissatisfaction. More studies are needed regarding this subject.

47

20th ISHRS Annual Scientific Meeting October 17-20, 2012 17Bahamas

Does Epinephrine Influence I fl P tPostPost Surgical Effluvium? A Pilot Study

Damkerng Pathomvanich, MD FACS Ratchatorn MD

I have no conflict of interest to declare

Background
Post-operative effluvium is shedding of the existing

Background
Most physicians believe this is due to telogen

hairs in and around the transplant area following hair restoration procedure. It is unpredictable even in experienced hands. hands Unger reported incidence of 15-20% in men and 4050% in women in his practice.

effluvium, however, we believed it is likely an anagen effluvium in response to injury. The exact etiology is still poorly understood understood. Epinephrine is proposed as one of the causes since it can induce poor circulation.

Objective
To study whether epinephrine in tumescent

Methods & Materials

4 patients were assigned as the study group, no

anesthesia contributes to post-operative effluvium at the recipient site.

epinephrine containing solution was injected at the recipient area during slit incisions . In the control group (4 patients) the epinephrine was patients), added in the tumescent fluid in the concentration of 1:100,000.

48

Methods & Materials

Photographs were taken before and 1 month after

Results
The 4 patients in the control group had thinning hairs

surgery. The quartile effluvium severity score (ESS) was used to evaluate severity of the hair shedding at recipient site by 3 blinded hair transplant surgeons:
Mild (1= 0-25%) Moderate (2 = 26-50%) Marked (3 = 51-75%) Severe (4 = 76-100%)

at the recepient area and no one experienced rapid hair loss. finasteride, In men who had already taken finasteride we advised them to continue during surgery.

The clinical features and effluvium severity score (ESS)

ID Epi use No Sex/Age/ Race NW No of grafts/ hairs Transplated area Thinning hairs from front to crown Thinning hairs from front to crown ESS (1-4) 2 Remarks Finasteride 1mg 3 mos before HT Finasteride 1mg 2 yrs before HT 1 M/32/Caucacian IV 3140 FUG/ 6746 hairs

Results The loss of transplanted and pre-existing hairs

occurred in the recipient area at 2-4 weeks after operation. The donor shedding was observed in the same i d period. In both study and control groups no one experienced very severe or extensive loss (76-100%). In the study group one reported marked hair loss (5175%), two moderate (26-50%), and one mild (0-25%). There were no differences in the severity of effluvium in the two groups

2 (#1)Yes

M/36/Caucacian

4285 FUG/ 9053 hairs

No

F/27/Asian F/30/Asian M/34/Asian M/40/Asian M/60/Asian M/60/Asian

LWII 2299 FUG/ 4309 hairs LWII 2052 FUG/ 4145 hairs III III V VI

4 (#3)Yes 5 No

6 (#5)Yes 7 No

8 (#7)Yes

Thinning hairs at front and top Thinning hairs at front and top Frontal hairline and 3049 FUG/ 5732hairs top Frontal hairline and 3141 FUG / 6109hairs top Thinning hairs from 3242 FUG/ 6696 hairs front to crown Thinning hairs from 2977FUG/5683hairs front to crown

1 1 2 2 3 3

* ESS score (1-4): mild (1= 0-25%), moderate (2=26-50%), marked (3= 51-75%) and severe (4= 76-100%)

Figure 1. A 27-year-old female patient (A) before (B) 1-month after transplantation without adrenaline in the tumescent fluid. The number of transplanted grafts = 2299 FUG/ 4309 hairs. (ESS grade 1 = mild effluvium)

Figure 2. A 30-year-old female patient (A) before (B) 1-month after transplantation with adrenaline in the tumescent fluid. The number of transplanted grafts = 2052 FUG/ 4145 hairs. (ESS grade 1 = mild effluvium)

49

Figure 3. A 60-year-old male patient (A) before (B) 1-month after transplantation without adrenaline in the tumescent fluid. The number of transplanted grafts with 3242 FUG/ 6696 hairs. (ESS grade 3 = marked effluvium)

Figure 4. A 60-year-old male patient (A) before (B) 1-month after transplantation with adrenaline in the tumescent fluid. The number of transplanted grafts = 2977FUG/ 5683hairs. (ESS grade 3 = marked effluvium)

Figure 5. A 32-year-old male patient (A) before (B) 1-month after transplantation without adrenaline in the tumescent fluid. The number of transplanted grafts = 3140FUG/6746hair. (ESS grade 2 = moderate effluvium)

Figure 5. A 36-year-old male patient (A) before (B) 1-month after transplantation with adrenaline in the tumescent fluid. The number of transplanted grafts = 4285 FUG/9053 hair. (ESS grade 2 = moderate effluvium)

Discussion
Postoperative shedding or shock loss is an anagen effluvium

Discussion
An anagen effluvium occurs if there is sufficient injury to the

that may cause temporary or permanent loss of hair in the anagen or rapid growing phase of the hair cycle following hair restoration procedure. It certainly affects the weaker (miniaturized) rather than the residual terminal hairs. If this hair is near the end of its lifespan, it may grow back finer and lighter in color or may not return5. However, the majority of the affected hairs grows back after three to four months6. Shedding is more common and severe if the patient has extremely fine and minimally pigmented hairs7, more preexisting hairs in the transplant area, and grafts densely packed8.

rapidly dividing keratinocytes in the hair matrix. When the cell division stops, it results in thinning and weakening of the hair shaft that is susceptible to fracture with minimal trauma when it reaches the surface of the scalp. H i b Hair breakage i an anagen effluvium occurs within d k in ffl i ithi days t to weeks (typically 1 - 3 weeks) following the injury. Post-surgical effluvium is somewhat different from the classic chemotherapy or radiation induced anagen effluvium. In classic form, hair loss occurs from broken hair shafts rather than shedding, however in some types of anagen hair loss, the entire hair shaft including the root sheaths are shed9-10. Microscopic examination of shed hair is required to confirm the type of hair loss.

50

Discussion
Based on the causes that was discussed above, many

Discussion
True and Dorin4 established a protocol to prevent shock loss

surgeons try to reduce the incidence of effluvium by: Avoiding transection of native hairs while making incisions g Using tumescent fluid Depth-control incision to avoid disruption to deep vasculature Minimizing doses of anesthetic and vasoconstrictive agents or eliminating epinephrine in the tumescent fluid Avoiding dense packing in areas not completely bald

including: identifying patients at high risk, lowering the risk preoperatively (place high risk male to take finasteride 6-12 months prior to surgery, continue minoxidil lotion during surgery), avoid using l i local anesthetic or epinephrine-containing solutions l th ti i hi t i i l ti injected in the recipient area and creating low-impact receptors. In their study, 40 high-risk women were treated with this protocol and no one reported extensive loss, one moderate shedding and the rest had minimal to no shedding. Cooley used de-epithelialized graft to make it shorter and inserted into shallow slit incision and has seen minimal shedding12.

Discussion
Recipient site tumescence with normal saline is hypothesized

Discussion
The impact of tumescent fluids containing epinephrine on post-

to improve graft survival and prevent post-surgical effluvium by protecting deeper vessels from transection13-14. Adding corticosteroid or epinephrine to such solutions may have additional effects. dditi l ff t Triamcinolone acetonide is used to help reduce postoperative edema and inhibit the inflammatory response from tissue injury. In addition to reduced intra-operative bleeding, epinephrine also prolongs the duration of anesthesia by slowing removal of the anesthesia from surgical field and increase the intensity of anesthetic blockage15.

surgical effluvium has been debated16.

Several hair restoration surgeons projected that epinephrine

interrupts blood circulation that might cause ischemic injury to the rapidly dividing cells of hair follicles. Rassman and Bernstien17 speculated that high epinephrine concentrations precipitate post-operative effluvium, frontal recipient area necrosis and poor graft growth. Beehner13 has published anecdotal report that post-operative effluvium occurs with higher epinephrine concentration. He described five cases with severe post-operative effluvium from using 1:60,000 epinephrine tumescent solution.

Results
Our results show that the severity of post-operative effluvium

Results
Based on the limited number of patients from this pilot study,

between two groups was not different when using low concentration epinephrine (1:100,000). The shock loss was observed even when the epinephrine was not added into tumescent fluid. However, no one experienced very severe or extensive loss (76-100%). Moreover, the omission of epinephrine in tumescent fluid creates more bleeding at the time of surgery and thus interferes with visibility and making it harder to place the grafts precisely among the existing hairs and also increasing operative hours.

we believe that epinephrine at appropriate concentration (1:100,000), is not the main factor that contributes to develop post-surgical effluvium. There should be many factors involved during pre-, intra- and post- operative period.

51

Protocol to prevent postoperative effluvium

Conclusion
Our pilot study suggested that the epinephrine at appropriate

Identify and reduce the risk preoperative A id i t Avoid intra-operative pitfalls ti itf ll Proper post-operative care
Hair Transplant Forum International May/June 2012; 22(3):100

concentration is not the main factor that influences post-surgical effluvium at the recipient area. All involved risks should be cautiously prevented during pre-, intra- and post-operative period. This probability must be carefully discussed to the patient prior to surgery to avoid dissatisfaction.

More studies are needed regarding this subject.

Thank you

52

010 Follicular Density Comparison by Reticule Surface Area Size

John P. Cole, MD Cole Hair Transplant Group, Alpharetta, GA, USA. Private Practice Hair Transplant Surgery since 1990. J.P. Cole: None. ABSTRACT: Introduction: There are many different reticules and devices available to measure the follicular density. Some feel that only larger surface areas should be used to insure an accurate density. Others feel that such efforts take more time than is necessary. Smaller surface areas and smaller reticules are faster and more accurate due to a lower probability of double counting or under counting follicular groups. No one has compared the different surface areas to date to compare the accuracy of smaller reticules to larger reticules with respect to the follicular density. This study evaluates follicular density in 40 patients to determine the follicular density of three different size reticules: 10 mm2, 0.5 cm2, and 1.0 cm2. Methods: Study population consisted of 40 male patients ranging from 23 to 50 years of age. Only virgin scalps were considered- those without previous hair transplants or procedures. All measurements were made using a Dermalite Pro HR attached to a Nikon Coolpix P5100 camera. Figures 1 and 2. A photograph was taken of the area 7.5 cm lateral to the central point of the donor area between the occipital protuberance and 3.0 cm above the auricle. A separate photograph was taken for each reticule size: 10mm2, 0.5 cm2, and 1.0 cm2. Follicular groups were circled and numbered one at a time. Figures 3, 4, and 5. Only groups inside the black line of the reticule were counted. Follicular units on the line or just outside the perimeter of the black circle were not considered. The units counted in the 10 mm2 were be multiplied by ten and those in 0.5 cm2 by two to determine the number of follicular units per cm2. We summarized and compared the findings in the 10 mm2 and the 0.5 cm2 with the 1.0 cm2 area. The 1.0 cm2 surface area was considered the gold standard. With each patient we performed a high estimate and a low estimate for each reticule size to take into account the difficulties associated with counting follicular units. Results: The results showed there was very little difference overall between the 10 mm2, the 0.5 cm2, and the 1.0 cm2. The results are summarized in Table 1. Patient Follicular Units in 10 sq mm Follicular Units in 0.5 sq cm Follicular Units in 1 sq cm high 90 88

low difference high difference low difference high difference low 1 2 80 8 90 -2 90 90 0 -2 94 -6 92 -4 96 92 -6 -4 88 88

53

3 4 5 6 7 8 9 10 11 12

70 -1 80 -2 70 10 90 6 70 21 60 11 70 -8 80 4 100 3 110 -14

80 90 80

-11 -10 1

72 -3 80 -2 86 -6 102 -6 94 -3 64 7 64 -2 82 2 104 -1 98 -2

76 84 90

-7 -4 -9

69 78 80 96 91 71 62 84 103 96

69 80 81 98 94 73 70 86 106 100

100 -2 80 70 80 90 14 3 -10 -4

106 -8 106 -12 65 64 84 8 6 2

100 6 120 -20

108 -2 98 2

13 14 15 16 17 18 19 20 21 22 23 24

80 90 80 90 100 80 120 90 100 80 90 110

5 8 -5 -9 -15 1 -16 -8 -8 0 3 -24

90 90 80 100 100 100 130 90 110 80 90 110

0 11 -2 -17 -11 -15 -21 -5 -16 6 10 -19

70 86 64 80 94 78 106 86 96 74 106 92

15 12 11 1 -9 3 -2 -4 -4 6 -13 -6

80 100 72 84 100 81 110 88 102 80 114 92

10 1 6 -1 -11 4 -1 -3 -8 6 -14 -1

85 98 75 81 85 81 104 82 92 80 93 86

90 101 78 83 89 85 109 85 94 86 100 91

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25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40

60 80 100 90 100 70 80 90 50 70 90 90 90 70 60 70

-1 7 -8 8 3 9 -3 -18 15 8 12 -13 -19 20 11 -7

60 80 100 90 100 80 90 90 50 70 90 90 90 70 60 70

2 13 -8 13 6 1 -12 -14 15 10 15 -12 -19 20 11 -7

60 88 92 88 104 80 86 76 78 76 114 74 70 96 80 70

-1 -1 0 10 -1 -1 -9 -4 -13 2 -12 3 1 -6 -9 -7

64 92 92 92 108 86 90 78 78 78 116 76 70 96 80 70

-2 1 0 11 -2 -5 -12 -2 -13 2 -11 2 1 -6 -9 -7

59 87 92 98 103 79 77 72 65 78 102 77 71 90 71 63 83.30 11.94

62 93 92 103 106 81 78 76 65 80 105 78 71 90 71 63 86.00 12.58

83.50 -0.20 15.11 10.83

88.00 -2.00 15.72 11.56

84.90 -1.60 13.36 6.52

88.45 -2.45 14.01 6.46

Table 1. Follicular density measurements using 10 mm2, 0.5 cm2, and 1.0 cm2 reticules. The measurements include a high and low estimate for each reticule. FOLLICULAR DENSITY - LOW 0.5 mean 84.9 1 83.30 10 83.50

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std dev 13.35856587

11.94

15.11

FOLLICULAR DENSITY - HIGH 0.5 mean 88.45 1 86 10 88

std dev 14.00540189 12.58203848 15.72194286

COMBINED LOW AND HIGH Anova: Single Factor SUMMARY Groups Count Sum Average Variance .5 low 1 low 40 40 3396 84.9 3332 83.3 3340 83.5 3538 88.45 3440 86 3520 88 178.4512821 142.6769231 228.4615385 196.1512821 158.3076923 247.1794872

10 low 40 .5 high 40 1 high 40 10 high 40

ANOVA Source of Variation SS Between Groups Within Groups df MS F P-value F crit

967.2833333 5 44897.9

193.4566667 1.008262302 0.413491548 2.252620041

234 191.8713675

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Total

45865.18333 239

Since the Fobs= 1.008 is less than the Fcrit = 2.25262, -Ho is true, the means are not significantly different and no effects are said to be discovered. P-Value is the probability of getting F P-value > Alpha Ho not rejected, No significant difference Discussion: We found that there are complex donor areas and donor areas that are simple. Complex donor areas consist of a higher density of follicular units. Often times the follicular units in the complex donor area are so irregularly spaced and so close to one another that it may be difficult to determine whether they consist of one follicular unit or two follicular units. Simple donor areas tend to have fewer follicular units that are more equally spaced between one another. It is much easier to determine the follicular densities with a higher degree of accuracy in simple donor areas. Donor areas often have a more random distribution of follicular units than a consistent, uniform distribution of follicular units. For these reasons we made two groups for each reticule size, the high estimate and the low estimate. When we compared the high estimate for each patient in the groups, we found that the estimates were very close to one another regardless of reticule size especially with less complex donor areas. When we compared the low estimate for each patient in the groups, we found that the estimates were very close to one another regardless of reticule size. The differences between reticule size were less when the donor area was simple. When the donor area is more complex, there is a greater probability that the measurements for the smaller reticule size will not match those of the 1 cm2 size. In these more complex settings, one might desire to use the larger reticule size to assure greater accuracy especially when conducting a scientific study. In most instances the accuracy of the 10 mm2 is very close to that of the 1 cm2. The mean density for both the high and low groups were similar regardless of reticule size. While the data was not statistically significant, there was significant overlap between the two groups for all reticule sizes. Based on this study, it is acceptable to use a 10 mm2 reticule for evaluating the follicular density. This measurement compares well to the 0.5 cm and the 1.0 cm. The 10 mm2 reticule is much easier and much faster. The 10 mm2 reticule does not require a photograph to insure a reliable count. When larger reticule sizes are used, the only way to insure a degree of accuracy in the follicular density count is to photograph, count the follicular groups one at a time, and mark off follicular units as they are counted. Such measurements are probably slightly more accurate, but unnecessary in most instances. The measurement of the follicular density in 10 mm2 is very close to the follicular density in a larger reticule. The advantage of using a smaller reticule is that you can more rapidly determine the follicular density. The smaller reticule also allows you to accurately estimate the follicular density without requiring the use of a printer. When the larger reticule size is used, the number of follicular units is so great that one might count one unit more than once or miss counting a unit(s) unless a printed image is created. With the larger reticule each follicular unit that is counted should mark to avoid counting more than once and to insure that each FU is counted. The disadvantage to a smaller reticule is the impact on errors. Every error by one follicular unit extrapolates to an error of 10 follicular units. It is common for small areas on the scalp to have random distributions of follicular units rather than symmetric distributions. For this reason, it is best to insure you are viewing a representative area rather than a small area that is might have a density of follicular units that is higher or lower than the mean density.

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One might consider using the smaller reticule size in most evaluations of follicular density. The larger size reticule might be used only in cases where a higher degree of accuracy is required such as in research projects. Follicular unit density is a very important aspect of the hair transplant evaluation. It allows the physician the capacity to estimate the number of grafts possible from a procedure, the quantity of donor area required to produce a proposed number of grafts, and the suitability of a patient for hair transplant surgery. A larger reticule requires more physician time to obtain an accurate count. Therefore, it is beneficial for physicians to know that a smaller reticule size is just as accurate in most instances. This may stimulate more physicians to include this measurement in their pre-operative assessment.

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Follicular Density Comparison by Reticule Surface Area Size

John P Cole MD P. Cole, Kathy Lue Tesfaye Gutema

Background
Some feel the larger reticule size is the only way to
obtain an accurate follicular density Requires printing to count the follicular density More time consuming More costly

A smaller reticule size is easier and faster

Does not require printing

Null Hypothesis: There is no difference in follicular

density regardless of reticule size

Methods
Dermlite Pro Varied Reticule Size
1 cm2, 0.5 cm2, and 10 mm2

Dermlite II Pro and Sony Camera with 10 mm2, 0.5 cm2, and 1.0 cm2 reticules

Discarded anything on the reticule margin Range from High to Low

6 Follicular unit densities for each patient

Circled each FU as it was counted to avoid duplication Summarized Results

Measurement Methods
10 mm2 Box 7 X 10 = 70 / cm2 1 2

Complex Donor Areas

3 6 4 5 7 70 / cm2

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10 mm2

1 cm2 and 0.5 cm2

1 cm2 and 10 mm2

Means and Standard Deviations for Follicular Unit Measurements

Reticule Size/Follicular Density 10 sq mm Low High 83.5 88 0 88.0 15.11 1 2 15.72 40 0 40 Mean Std. Deviation N

0.5 sq cm Low High 84.9 88.5 13.36 14.01 40 40

1 sq cm Low High 83.3 86 0 11.94 12 58 40 40

Mean Results for 40 Patients

10 Mean mm2 10 mm2 0.5 cm2 0.5 cm2 1 cm2 1 cm2 Low 83.5 High 88.0 Low 84.9 High 88.45 Low 83.3 High 86.0

Low Follicular Density

Low Mean

10 mm2 83.5

0.5 0 5 cm2 84.9

1.0 1 0 cm2 83.30

High Mean

10 mm2 88.0

0.5 cm2 88.45

1.0 cm2 86.0

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High Follicular Density

Interaction between Reticule Size and Follicular Density

F (2,38) = 2.65, p = 0.083

Lack of Main Effect for Reticule Size and Follicular Density

Results
SPSS Statistics version 17.0 (IBM,2008) Repeated measures ANOVA conducted to compare FU
estimates for 40 patients

Two within-factors variables incorporated p Results revealed a significant interaction between

reticule size and follicular density, F (2,78)=9.83, p=0.000

Results from analyses of the main effect for each

variable were not significant

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011 Moderator Introduction, Advanced Surgical Techniques I

Henrique N. Radwanski, MD private clinic, Pilos Clinic, Rio De Janiero, Brazil. Henrique N, Radwanski MD is assistant professor of plastic surgery at the Ivo Pitanguy Institute, Rio de Janeiro, Brazil. This is a post-graduate course, credentialed by the Brazilian Society of Plastic Surgery, of which he is full member. He also belongs to the International Society of Aesthetic Plastic Surgery [ISAPS] and the Brazilian Association of Hair Restoration Surgery [ABCRC]. H.N. Radwanski: None.

012 Hairline Advancement in Women: Surgical Hairline Advancement Versus Hair Grafting
Jeffrey S. Epstein, MD University of Miami, Miami, FL, USA. Jeffrey S. Epstein, M.D., FACS, Founder and Director of the Foundation for Hair Restoration, has been in private practice in Miami and NYC since 1994. A board certified facial plastic surgeon, Dr. Epstein is a Voluntary Clinical Instructor at the University of Miami, and Past President of the Florida Society of Facial Plastic and Reconstructive Surgery. He has as special expertise in the repair of prior hair transplants, eyebrows and facial hair work, hair loss in women, and large procedures of 3000 plus grafts. J.S. Epstein: None. ABSTRACT: For more than 15 years, the author has primariy relied on hair grafting in over 300 cases as the technique for advancing the overly high female hairline. Transplanting 1200 to as many as 2800 grafts in a single procedure is a reliable and effective technique when performed properly and aesthetically for achieving patient satisfaction. Over the past two years, the surgical hairline advancement procedure has also been utilized, now on over 25 patients, permitting virtually instantaneous forehead shortening with hairline lowering of 2 to as much as 5 cm in 90 minutes of surgery.

The author wishes to present what he has learned about both of these techniques, in terms of patient selection, technique peals, advantages and disadvantages, and risks. The goal of the presentation is to provide hair replacement

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physicians with the knowledge of how to choose a technique, and the most important steps for perform hair grafting and the surgical hairline advancement for the overly high female hairline.

013 Higher Temporal Recession - Why? When? and How to Convince Patients
Antonio Ruston, MD Clinica Ruston, Sao Paulo / SP, Brazil. Dr. Antonio Ruston, plastic surgeon, clinical director of Ruston Clinic. Has been working with HRS for the last 16 years. Active member of ISHRS since 2000. A. Ruston: None. ABSTRACT: Introduction Ive been working with HRS for almost 17 years and recently I did a study about what consumes most of our time in the educational process. The conclusion was: explaining the side effects of finasteride and trying to convince patients to accept higher hairlines. Objective: In this presentation, with the aid of 3-D animation, the author will show celebrity hairline simulations and some corrective cases to demonstrate how he has been convincing his patients to not only accept, but choose, a higher temporal recession or a higher hairline. Materials and/or methods We know that it is very difficult to convince our patients, mainly those who are young, to opt for higher temporal recession, even after explaining to them the risks after their baldness progresses. This is because they are worried about what they see at that particular time and most of them do not take into consideration the future. It would be great if we could show them their own picture after 20 or 30 years but unfortunately we cannot do that. What the author has been doing in the last 10 years, which has been very helpful, is using 3-D animation to show the risks of lowering the hairline in young patients and cases that have still not stabilized. This 3-D animation shows in a simple manner not only the risks of lowering the hairline but also the hair density reduction. So the patients can better visualize those risks. The other helpful strategy that the author has been using is to show some celebrities with low and dense hairlines and a simulation of the same persons with their hairlines at the same level (lower) but sparse vs. their hairlines higher and dense. It is obvious that the most aesthetic and attractive is the second case. For those who insist on putting their hairlines lower than recommended the author has been giving a simple consent

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form that shows in just one picture the suggested hairline (in one color) and the desired hairline chosen by the patient (in another color). The patient signs the form, assuming the risks of his expectations in terms of density which may not be achieved as well as the risks of donor vs. recipient area balance in the future. Of course this lower hairline has a limit, taking into consideration the aesthetic sense and the donor vs. recipient area balance. In other words the author never changes the design of the suggested hairline, he just agrees to lower the hairline by 1 to 2 cm. maximum. Interestingly, after adopting this consent form, most of the patients have agreed with the suggested hairline. Conclusion: We have to give to our patients all of the knowledge, material and visual effects available to help them to understand our strategy and not just accept it, but believe they are participating and making the right choice for themselves.

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014 No Temporal Point Peak, 2 Peak Sideburns and No Peak S-line Hairline Design in Woman
Kun Oc, MD Oc Kun Hairline Hair Transplant Center, Seoul, Korea, Republic of. Kun Oc MD has been committed to hair transplant since 2005. The major area of interest is hair transplant not only for male-pattern hair loss but also for cosmetic purpose. K. Oc: None. ABSTRACT: Introduction: In the authors country, hairline correction has already been conducted for several years in women who do not have hair loss. Because the peoples hair color is all black in this country the hairline is contrasted with skin color, and so hairline is regarded as one of important factors determining ones impression. Most of patients visit for broad forehead and unattractive hairlines as the chief complaints, and their main purposes are narrowing the forehead and making the face small so that they have full back hairstyle. As such patients do not have hair loss they need to be approached in a way different from that for hair loss patients. Objective: The author is going to explain the design method in womens hairline correction studied clinically for the latest several years using real cases and the photographs of star actresses in the authors country. As this must be the same in other countries, most hospitals especially in the authors country tend to make the hairline in an ordinary form at an ordinary position like they design it for hair loss patients. According to the authors experience, however, it would be better to create artificially a beautiful hairline going well with the patients face. From this viewpoint, the author tried to explain a design that reduces the cheekbone in appearance through correcting the sideburns hairline of women, many of whom have protruding cheekbones. Method: The author is going to skip the general hairline design method for convenience and to explain the authors specific hairline design. In Asian women in the authors country, the usual hairline has M-shaped indentions on both sides of the midline of the forehead as in the photograph f1 and the hairline on the sideburns part below the temporal point retreats backward. If there is no hair below the temporal point and the cheekbone protrudes, the protrusion of the cheekbone is even emphasized. Thus, the author designs the hairline like photograph f2 so that the running-down hairline does not make a peak at the temporal point and the whisker below the temporal point runs along the line similar to the hairline on the forehead and covers part of the cheekbone. The part where the sideburns ends is given a peak at an acute angle as in photograph f2. In order to connect the newly made sideburns to the existing sideburns, a large number of hairs are required because the space between the new sideburns and the existing sideburns is large and, on the other hand, the connected sideburns becomes look like a mans whisker. Thus, as an option to create a womanly hairline from the side view, two sideburns peaks are created: one on the side of the existing sideburns and the other on the newly created hairline. The hairline on the forehead is given a smooth S-line wave without peaks, and the M-shape part is designed to be of an inverse U shape and connected to the sideburns part. Photograph f3 was taken 10 days after operation according to no temporal point peak, 2 peak sideburns and no peak S-line design.

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Discussion: The part of hairline design in the book Hair Transplant written by Robert S Haber & Dowling B Stough shows photographs of womens normal hairlines. However, here normal means common but not beautiful. That is, if the purpose of operation is cosmetic, the hairline to be created should not be common but uncommonly beautiful. Photograph f4 is introduced as a normal hairline in that book, and f5 is a photograph taken 5 months after hairline correction at our hospital. Although the result was not final, this case was selected because the shape above the eyebrows was similar. It is not easy to say which is better objectively because beauty is subjective to some degree, but according to the authors experience for Asian women whose forehead is rather broad than round, personal satisfaction is higher when the hairline is designed in a wave form without notable peaks as shown in the normal case. Photograph f6 is a famous actress in the authors country. The left is womens typical hairline, and the right is mens hairline with M-shaped indentions. Only with difference in hairline, the right photograph looks more boyish than the left one. Photograph f7 is also a famous actress in the authors country. The left photograph gives the feeling of a boyish warrior woman because of the M-shape part and temporal point peak, but the right photograph treated using Photoshop based on the no temporal point peak and no peak S-line artificial hairline design shows the image of a pure pitiable woman like Olivia Hussey. F8 - f13 are a photograph taken just after operation based on the no temporal point peak and no peak S-line hairline design, and another taken 17 months after the operation. As the hairline was designed artificially in S-line without peaks, it is more beautiful and womanly than normal not only just after the operation but also after over a year. Conclusion: Different from that of normal hair loss cases, the purpose of womens hairline correction should be on the creation of the hairline that is not just normal but more beautiful. However, if hairline design is approached from the viewpoint of beauty, it is hard to say which method is absolutely more beautiful. The author has carried out over 400 cases of hairline correction for women and can say all the patients were satisfied almost without exception, when the no temporal point peak and no peak S-line artificial hairline design was applied or the 2 peak sideburn hairline design in case the cheekbone was broad,

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69

70

71

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Why we perform hair transplantation Try cho1 in woman without hair loss
No Temporal Point Peak, 2 Peak Sideburns and No Peak S-line Hairline Design in Woman

Kun Oc MD Oc Kun Hairline Hair Transplant Center Seoul, South Korea

Which is more feminine?

Normal (X) Beauty beyond normal (O)

Why every hair transplant surgeons pursues the normal hairline? What is more important for woman is to look more beautiful than normal

Beauty is Some kind of Subjective thing

Temporal point peak is a Symbol of Male

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htnoM

Try cho1 What is Beautiful beyond normal ?

Normal Temporal Point Peak Try cho1

htnoM

Try cho1 The way Hairline design should go

Try cho1 The way Hairline design should go

htnoM

htnoM htnoM

Should we make temporal point peak ?

Should we make temporal point peak ?

Which is more feminine?

Temporal point peak is a Symbol of Male No Temporal point peak is more beautiful in woman in most cases

Should we make macro-irregularity ? SURE BUT Rather than irregularity But No peak S-line I propose in woman

Which is more beautiful?

Normal macro-irregularity vs No peak S-line hairline design

No peak S-line hairline design

Which is more feminine and beautiful?

Right after OP POD 18 months

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No peak S-line hairline design

No peak S-line hairline design

Right after OP

POD 18 months

Right after OP

POD 18 months

Should we make macro-irregularity ?

Hairline Design In case of protruding broad cheek bones

No peak Artificial S-line is more beautiful Than Normal macro-irregularity In woman hairline

No Temporal Point Peak 2 Peak Sideburns No peak S-line hairline design

No Temporal Point Peak 2 Peak Sideburns No peak S-line hairline design

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Forehead Face Face line

Smaller Smaller More beautiful

In female hairline correction surgery Besides such hairline designs Hair survival rate is very important Because she has no hair loss So poor hair growth as if looks like hair loss will be miserable result for her

There are my golden methods that make higher survival rate with the Choi-hair transplanter and newly invented transplanter OKT, the upgrade version of Choi-transplanter, which can make hair depth control precisely in my poster sections if you are interested

Thank you !

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015 Harvesting Hair From Temporal Area - Limitations and Advantages

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 internship at University of North Dakota followed by residency at University of New Mexico and York Hospital. He also served as a 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. ABSTRACT: Introduction: When examining the limitations and advantages of harvesting hair from the temporal area, there are three pertinent questions to be examined.

1. 2. 3.

What is considered safe in temporal areas? How much can donor area be extended anteriorly through FUE or strip? Can decreasing temporal hair help the aesthetic outcome?

The determination of the anterior borders of the permanent zone have long been a matter of controversy in hair transplantation. Mega and Giga session hair transplants are increasingly becoming popular . Hair transplant surgeon may have to maximize the donor resources by extending the strip anteriorly. Removing hair from temporal area is contraindicated in some patients while in others it may be a necessity to minimize the contrast between the transplanted area and the temporal zone that may otherwise look too dense. Premise: It is conventionally accepted that the anterior border of the safe zone is determined by drawing a line perpendicularly from the external auditory canal. Not every patient recedes or thin out hair in the temporal area; for that reason it might be safe to move forward with the borders of the permanent zone in some patients. Some patients may even benefit from minimizing the density of hair temple hair. Substantiating data: Although the scalp permanent zone generally follows a typical pattern in men with male patterned hair loss. The boundaries of permanent zone in temporal area may not be easily defined. Many men never lose temporal hair. Recession of temporal hair can age the look of a patient's face drastically in most cases. That is why restoration of temporal hairline is usually one of the most satisfying components of a hair restoration.

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Determining the boundaries of permanent zone helps surgeons understand the maximum number of available grafts for a surgery. It helps avoid harvesting hair from the areas that don't have permanent hair. Finally, it prevents the exposure of the donor scar of a strip surgery in the future. A hair transplant surgeon may need to harvest hair from temporal areas if possible in order to:

1. 2.

Increase the number of hair grafts when there is a high demand Minimize the density of hair in temporal areas when dense temporal areas can undermine the density of transplanted hair on front and top.

Creating of thirty to forty percent density in front and top can be very satisfying for a hair loss patient. However presence of a very dense temporal area can undermine these great results. The contrast between a very dense temporal area with adjacent transplanted area with less than forty percent density may be too noticeable. A hair transplant surgeon may choose to remove hair from temporal area not only to supply a larger source of hair, but also to create a balanced and natural final result. Discussion: We recommend a complete evaluation of hair in temporal areas. Adequate determination may be achieved after a thorough review of family history and physical examination. A microscopic evaluation or miniaturization study can assist the surgeon in establishing the levels of hair loss activity in temporal areas. It is critically important to note that a hair transplant surgeon needs to avoid removing hair from temporal areas with a significant risk of future hair loss. If temporal area has a high density with no significant miniaturization, reducing its density can minimize this contract. Minimizing the contrast between these two areas can facilitate establishment of a non-balding appearance in many men.

016 Refinement of the Rose Tissue Spreader

Paul Rose, MD Hair Transplant Institue Miami, Coral Gables, FL, USA. Dr Rose is a Board Certified Dermatologist. He has served as President of the ISHRS and has made numerous contributions to the field of hair restoration. P. Rose: Ownership Interest (royalty, patent, or other intellectual property); Developed the design of the instrument with Cutting Edge Instruments in Canada.

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ABSTRACT: Introduction Various devices have been employed to assist in spreading the donor area incisions in an effort to avoid transections. Such devices include the Haber Spreader, the Tycozinski tissue separator, the RTS Tissue Spreader and the use of hemostats as described by Sandoval.The author presents the latest refinement of the RTS Spreader.MethodThe latest revision of the RST allows for easier insertion of the instrument into the donor tissue. The new prongs are designed to provide some undermining of tissue and allow for separation of tissue while enhancing hemostasis, ease of dissection,and minimizing transection.The reverse action of the instrument is controlled by an adjustable screw.The author will show proper use of the instrument to optimize its purposeDiscussionThe new RST instrument is an improvement over the past device. It makes it easier to divide the tissue and minimize bleeding and transection. It is an inexpensive instrument compared to other devices.

017 Use of Body and Beard Hair as Additional Donor in Extensive Hairloss
Arvind Poswal, MBBS Dr. A S Clinic Pvt. Ltd., New Delhi, India. 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. As 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. A. Poswal: None. ABSTRACT: Introduction: Follicular unit transplant (FUT) is a widely used surgical treatment for androgenic alopecia. Wherein scalp donor hair grafts are used to cover the balding area. However, for patients with extensive hairloss (Norwood 5 and above), scalp donor hair may not be sufficient to cover all areas of baldness as per the patients desires. Follicular Unit Separation Extraction (FUSE/fue) makes it possible to extract the individual follicular units from the body and beard donor areas without strip excision and suturing. Body and beard donor hair differ in characteristics (length, calibre, color, growth cycles etc.), from the scalp donor hair. However, with proper planning it is possible to use robust body and beard donor hair to augment donor hair resources, thus, giving fuller hair restorations. Here are a few documented examples of patients who had very robust and well endowed body and beard/facial hair that were utilized for their hair restoration.

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Objective: The various aims of this study are: - To observe and analyze change in body and beard hair characteristics (calibre, length, color, texture) after transplantation in the scalp. - To assess patient acceptability of the different donor hair on the scalp. - To assess the best way of using various donor hair. Fig. a to fig. f Material & Methods: Male patients in various stages of hairloss underwent body and beard hair to scalp transplant. Three of these had previously undergone hair restoration surgeries elsewhere. Patient nicknamed Argentine (a Caucasian of German descent) was a Norwood 6 and had undergone 2 strip FUT surgeries at some other clinic, leaving two wide scars in donor area and scanty growth in recipient area. He visited us for a repair hair transplant procedure using FUSE grafts from scalp, beard and body donor area. A megasession transplant was performed to cover the entire vertex and crown area. In the frontal area, a high, mature hairline was recreated. Almost 1000 beard donor grafts were also transplanted in the previous strip scars. Grafts details Beard/facial - 6873 grafts (including 207 moustache grafts) Scalp - 2000 grafts Chest (+ abdomen) - 2285 grafts Armpit - 302 grafts Total - 11460 FUSE grafts. Fig. 1.1 - Fig. 1.7 After 8 months, the patient shared pictures of his progress and is happy with the results. The donor areas had healed very quickly in less than 1 week and the patient still shaves his face every day because of the remaining beard hair. There is no trace of any surgery. Important - The body and beard hair retained their original characteristics (length, calibre, diameter and color). Patient nicknamed Francis was in an early Norwood 6 level when he approached us. Before visiting us he had undergone a strip/FUT hair transplant at some other clinic, where a full length strip had been taken. The grafts that grew from his first hair transplant had pitting and were mostly minigrafts. This gave rise to a pluggy look. The grafts had been placed in the front hairline areas.In his first stage of repair hair transplant, - Francis prefers to go for a NW 1 hairline and concentrate the grafts in the frontal area. - A small beard hair to scalp transplant was performed at the same sitting to help him to evaluate the healing and growth of beard hair grafts firsthand. He visited us nine months after his first repair hair transplant. He was happy with the progress in all respects. This is the time he had come for the next stage of his corrective surgery and decided to use a combination of scalp and beard grafts to fill the remaining top and crown areas at a moderate density. Grafts details First stage repair hair transplant Scalp strip/FUT - 3500 grafts Beard/facial FUSE/fue - 12 grafts Total - 3512 grafts Second stage repair hair transplant Beard/facial FUSE/fue - 2526 grafts Scalp FUSE/fue - 859

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grafts Total - 3385 FUSE/fue grafts Fig. 2.1 - Fig. 2.6 An Australia based patient nicknamed Pop of Afghan descent presented a very peculiar situation. He had undergone numerous scalp reductions as well as strip FUHT procedures from some other clinic before visiting us. These repeated surgeries had led to -

1. Raising of the hair margin above the ear and in the back of the scalp by 1 to 2 cms. 2. Scanty hair on the recipient area on top and vertex 3. Scar tissue in the centre stretching from frontal area to occiput due to multiple scalp reductions. 4.
Multiple scalp reduction also led to hair pointing unnaturally sideways on the vertex.

5. Multiple strips had been taken leaving separate scar for each strip.
His scalp donor had been totally depleted and the scar tissue was visible even when he kept his hair long. The unnatural direction of hair on almost all parts of scalp makes it difficult to cover the scars and hide the unnatural appearance even with the hair grown long. In the Ist stage of his repair hair transplant procedure - A total of 3983 FUSE/fue grafts were placed in scar tissue of which a majority of (2140) grafts were from the facial/beard donor areas. Grafts details First stage repair hair transplant Beard/facial - 2140 grafts Scalp - 312 grafts Chest - 1101 grafts Pubic - 143 grafts Thigh - 17 grafts Total - 3983 FUSE/fue graftsPop visited us 16 months after his 1st stage hair transplant repair procedure. He was happy with the progress and the donor area has also healed without any visible scarring. Pop has gone ahead to get the remaining scalp scars filled with donor hair from the beard. Chest, thigh and pubic hair were not used in the second stage of hair transplant repair. Second stage repair hair transplant Beard/facial - 1028 grafts Total - 1028 FUSE/fue grafts Fig. 3.1 - Fig. 3.15 Patient nicknamed Veer has a NW 6

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level of hairloss when he approached us. He decided to go for a megasession. In his first stage of hair transplant 6212 FUSE grafts were transplanted to cover the front half of his area of hairloss. Grafts details Scalp FUSE/fue - 2338 grafts Beard/facial - 2850 grafts Chest - 1024 grafts Total - 6212 FUSE/fue grafts Fig. 4.1 - Fig. 4.8Eleven months after his hair transplant, he was happy with the progress and plans to go for the next session to fill in the crown-swirl area too. Patient nicknamed A15 was Norwood 6/7 when he approached our clinic for hair transplant procedure. He planned to go for multisession transplant to cover his vast bald scalp area. In his first session a total of 4350 FUSE grafts were used to cover the front bald scalp area. A15 visited us 39 months after his 1st stage hair transplant procedure. The transplanted hair had grown well, but they had retained their original characteristics. He was happy with the results. This was the time he had come for the next stage of his surgery and decided to use a combination of scalp and beard grafts to fill the entire bald scalp areas. The chest grafts were not used in the 2nd stage of his hair transplant. Grafts details First stage hair transplant Scalp strip/FUT - 2025 grafts Beard/facial FUSE/fue - 1890 grafts Chest - 435 grafts Total - 4350 grafts Second stage hair transplant Beard/facial FUSE/fue - 2444 grafts Scalp FUSE/fue - 2999 grafts Total - 5443 FUSE/fue grafts Fig. 5.1 - 5.14Results:The growth and characteristics of the transplanted body and beard hair was monitored. In all the patients, there was no change in the color or calibre of the transplanted hair. They maintained the same characteristics as in their original location. The beard hair, due to its thicker calibre provided cosmetically better coverage in the bald scalp area, compared to the thin calibre body hair. The curl of the hair is significant factor in patient acceptability of beard/body hair, if the beard/body donor hair is used alone in a slick bald area of the scalp, if the patients own scalp hair is straight. The patient acceptability of different donor source was highest when the beard and/or body donor hair were mixed with scalp donor hair. This held true even in cases where the patients scalp hair was fine calibre and

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straight, while the beard donor hair was thick calibre and wavy. Discussion: In suitable patients, with ample beard and body hair growth, these can be used to augment the scalp donor resources to provide a fuller hair restoration. However, when using body and beard areas as the additional donor source, it is important to observe the difference in the characteristic of these hair compared to the scalp hair. It must also be impressed on the patient that the body and beard donor hair are not going to change their characteristic, color and calibre after being transplanted to the scalp. Due care needs to be devoted to use a mix of the various donor hair in any bald area of the scalp. This will avoid the situation where different areas of the recipient scalp may have differing hair types. The thicker calibre beard hair should not be transplanted in the hairline and the temples as these areas typically have finer calibre hair. The ideal hair combination in these areas would be a mix of scalp and finer caliber body hair.Use of beard donor hair for previous strip scars This is another area where the beard donor hair can be used very effectively. However, in cases where the scalp and beard donor hair differ widely in terms of calibre and color, it is not advisable to transplant the thicker calibre, different colored beard hair at a high density all along the strip scar. This will lead to the strip scar being replaced with a linear zone of thick calibre, different color hair. In such patients, its advisable to transplant the beard hair at a low density (<20 grafts per sq cm), and to mix them with donor hair follicles derived from the scalp and other parts of the body.Conclusion:Body and beard hair can be used as additional donor resource for treating androgenic alopecia. These hair, however, do not change their color and shaft diameter (calibre). Thus, proper planning is a must when using this different type of donor hair for transplanting. Further studies need to be carried out to study whether transplanting body and facial /beard hair to scalp affects their anagen/telogen ratios, duration of anagen, speed of growth and length of the transplanted hair.

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Dr. Arvind Poswal

New Delhi

Introduction
For patients with extensive hairloss (Norwood 5 and above), scalp donor hair may not be ff ll f b ld sufficient to cover all areas of baldness as per the patients desire. Follicular Unit Separation Extraction (FUSE/fue) makes it possible to extract the individual follicular units from the Beard and body donor areas without strip excision and suturing.

Characteristics Of Body Hair

The beard and body donor hair differ in characteristics in terms of length, calibre, color, growth cycles, speed of growth, predisposition to greying etc., from the scalp donor hair hair.
However, with proper planning it is possible to use beard donor hair to augment donor hair resources, thus, giving fuller hair restorations.

Picture Showing Beard And Scalp Hair

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Picture Showing Chest And Scalp Hair

Picture Showing Beard And Abdomen Hair

Objective
Here are a few documented examples of patients who had very robust and well endowed body and beard/facial hair that were utilized for their hair restoration.

To observe and analyze change in body and beard hair characteristics (calibre, length, color, texture) after transplantation in the scalp. T assess patient acceptability of the different donor ti t t bilit f th diff td To hair on the scalp. To assess the best way of using various donor hair.

Male patients in various stages of hairloss underwent body and beard hair to scalp transplant. Three of these had p p previously y undergone hair restoration surgeries elsewhere.

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Case I - 11,460 FUSE grafts

[6873 beard(including 207 moustache grafts), 2000 scalp, 2285 chest and abdomen grafts and 302 armpit FUSE grafts] in one session.

Before Picture

Before Picture

A Comparison Picture

After 8 Months Picture

Case II - 6897

(stripFUHT + FUSE) grafts

(3500 scalp FUHT, 859 scalp FUSE and 2538 beard FUSE grafts) in two sessions.

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After 9 Months Picture

Case III - 5011 FUSE grafts

(3438 beard, 312 scalp, 1101 chest, 143 pubic and 17 thigh FUSE grafts) in two sessions.

Beard Hair Into Scar Transplant

After 16 Months Picture

Case IV - 6212 FUSE grafts (2338 scalp, 2850 beard and 1024 chest FUSE grafts) in one session.

After 11 Months Picture

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Case V 6233 FUHT + FUSE grafts

(3490 scalp and 2743 beard grafts)

A Comparison Picture

A Comparison Picture

A Comparison Picture

The growth and characteristics of the transplanted body and beard hair was monitored. In all the patients, there was no change in the color or calibre of the transplanted hair. They maintained the same characteristics as in their original location. The beard hair, due to its thicker calibre provided cosmetically better coverage in the bald scalp area, compared to the thin calibre body hair.

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The curl of the hair is significant factor in patient acceptability of beard/body hair, if the beard/body donor hair is used alone in a slick bald area of the scalp, especially if the patients own scalp h i i straight. h i l hair is i h

The patient acceptability of different donor source was highest when the beard and/or body donor hair were mixed with scalp donor hair. This held true even in cases where the patient s patients scalp hair was fine calibre and straight, while the beard donor hair was thick calibre and wavy.

Additional Cases

Beard hair transplanted into strip scar

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 Body and beard hair can be used as additional donor resource for treating androgenic alopecia. These hair, however, do not change their color, curl, texture and shaft di h i l l d h f diameter (calibre). Thus, proper planning is a must when using these different types of donor hair for transplanting.

More work needs to be done to determine whether there will be any changes in: - Anagen telogen ratio - Duration of Anagen & telogen after transplant - Predisposition to greying.

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018 Moderator Introduction, Finasteride Symposium

Dow B. Stough, MD The Stough Clinic for Hair Restoration, Hot Springs, AR, 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.B. Stough: None.

019 Panelist for Finasteride Symposium

Robert M. Bernstein, MD Bernstein Medical PC, New York, NY, USA. Clinical Professor of Dermatology, Columbia University. Co-author of: Update on the Cause and Medical Treatment of Patterned Hair Loss. J of Drugs in Dermat 2010; 9(11): 1-8. R.M. Bernstein: None.

020 Finasteride Persistent Sexual Dysfunction Controversy: Update

Kenneth J. Washenik, MD, PhD Bosley, Beverly Hills, CA, USA.

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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; Aderans Research Institute/Bosley. Research Grant (principal investigator, collaborator or consultant); Allegran, Johnson and Johnson. Speakers Bureau/Honoraria (speakers bureau, symposia, and expert witness); Merck. Ownership Interest (owner, stock, stock options); Aderans Research Institute/Bosely. Ownership Interest (royalty, patent, or other intellectual property); Aderans Research Institute/Bosley.

021 Beyond Finasteride Side Effects: Alternate Risks for Sexual Dysfunction and Spermatic Abnormalities via Genetics, Physiology, and Environment
Sharon A. Keene, MD Physician's Hair Institute, Tucson, AZ, USA. Dr. Sharon Keene trained in general surgery at the University of AZ, and subsequently applied her skills to the mastery of hair restoration surgery. Since 1995 she has practiced HRS full time in Tucson, AZ. She is a pioneer in follicular unit grafting, and lectures and writes on topics of follicular unit megasessions, ergonomics and instrumentation, as well as optimal density. She has designed many tools for megasessions, including the first multi recipient site scalpel. More recently she has performed research and written about on variants in the androgen receptor gene and predicting anti androgen medication response for hair loss, as well as epigenetic factors that may influence hair loss. S.A. Keene: None. ABSTRACT: Much attention recently has been focused on the potential sexual side effects of finasteride to treat androgenetic alopecia. However, in the absence of a medical evaluation for sexual function and sperm analysis there are many

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known alternate reasons including genetics, physiologic function and environmental factors that may be contributing. A review of relevant literature, and a look at the role of 5 alpha reductase inhibitors in perspective.

022 Finasteride: So Tell Me Doctor - Are There Any Side Effects?

Stephen Freedland, MD Durham, NC, USA. Dr. Stephen Freedland is a Urologist at Duke University. He is an Associate Professor of Surgery (Urology) and Pathology and holds an appointment at the Durham VA Hospital. He specializes in the diagnosis, treatment, and management of prostate cancer and benign prostatic hyperplasia. He has extensively evaluated 5-alpha reductase inhibitors as treatment and prevention for prostate related problems and their side effects including sexual side effects and possible risk of high grade prostate cancer. He completed his undergraduate at UCLA, medical school at UC Davis, residency in Urology at UCLA and a urological oncology fellowship at Johns Hopkins. He currently runs an active research program with funding from the National Cancer Institute and the Department of Defense. S. Freedland: Research Grant (principal investigator, collaborator or consultant); GSK. ABSTRACT: Finasteride is an FDA-approved drug used to treat men with symptomatic enlarged prostates and effectively improves urinary flow under the name Proscar (5mg). Finasteride is also FDA-approved for the treatment hair loss under the trade name Propecia (1mg). The effects on the prostate of 1mg and 5mg appear similar. Thus, it is reasonable to conclude that the side effect profiles would be similar. Common side effects will be reviewed with special attention to sexual side effects, alterations in PSA that is used for prostate cancer screening, with much emphasis on the possibility that finasteride may increase the risk of aggressive prostate cancer.

023 Finasteride in the Long Run - Surprising Data from the Sato Study
Akio Sato, MD, PhD1, Akira Takeda, MD2

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Department of Regenerative Medicine, Plastic and Reconstructive Surgery, Kitasato University School of Medicine, KAnagawa, Japan, 2Department of Plastic and Aesthetic Surgery, Kitasato University School of Medicine, Kanagawa, Japan. Dr Akio Sato is a Professor of Department of Regenerative Medicine, Plastic and Reconstructive Surgery of Kitasato University School of Medicine. His private practice is in Tokyo where he is director of a fellowship in hair restoration surgery and no surgery. He is the president of Japanese Society of Clinical Hair Restoration from 2011. He has published over 30 medical publications, Hes current research is Hair cloning. A. Sato: None. A. Takeda: None.

ABSTRACT: Before now, there has been no study of finasteride use exceeding 1 year in Japanese men with androgenetic alopecia(AGA) except the study subsequently conducted from the development phase. Since the launch of finasteride, no study in a larger population had been reported. Ethnic variation of the onset age, progressive nature and degree of hair loss of androgenetic alopecia are known. The therapeutic effect of oral finasteride (Propecia) was examined on Androgenetic alopecia of Japanese men. The efficacy and safety of finasteride (1 mg tablet) was evaluated in Japanese men with AGA in the long term. The study enrolled 3177 men given finasteride 1 mg day from January 2006 to June 2009 at our clinic. Efficacy was evaluated in 2561 men by the modified global photographic assessment; the photographs were assessed using the standardized 7-point rating scale. Safety data were assessed by interviews and laboratory tests in all men enrolled in the study. The overall effect of hair growth was seen in 2230 of 2561 men (87.1%), in whom hair greatly (11.1%), moderately (36.5%) and slightly (39.5%) increased. In the report of the Turkish study comparing topicalminoxidil (5%) and oral finasteride (1 mg day), the response rate of finasteride was 80%. In our study, the response rate (87.1%) was higher than in the Turkish study. One of the reasons for this could be the characteristics of scalp hair of Japanese men. Japanese subjects generally have less hair density, larger hair diameter, and black color of hair shaft showing a marked contrast of color of hair compared to thinner and lighter color of the scalp hair in Caucasian men. Therefore, subtle changes in scalp hair growth can be easily identified by a global photographic assessment leading to a higher response rate in Japanese men. On the other hand, because our study was conducted in clinical practice, many patients did not receive follow-up examination. This might have affected the higher response rate. According to the supposition, it was assumed that all of the 616 patients who were not able to be assessed by the modified global photo graphic assessment because they had only baseline (first visit) assessment, had decreased hair growth (1-3). The resulting response rate was 70.2% (2230 3177), which is close to that of the previous studies conducted in the USA or the other countries.80%. The response rate improved with increasing duration of treatment. Adverse reactions occurred in 0.7% (23 3177) of men; seven men discontinued treatment based on risk-benefit consider- ations. No specific safety problems associated with long-term use were observed. This study represents data collected at a single institution. Many patients did not receive follow-up examination. In Japanese men with AGA, oral Finasteride used in the long-term study maintained progressive hair regrowth without recognized side-effect.

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024 Safety and Efficacy of Finasteride 2.5 mg in Postmenopausal Women with Androgenetic Alopecia: Pilot Study in 52 Patients
Abdulmajeed Alajlan, MD King Saud University, Riyadh, Saudi Arabia. Abdulmajeed Alajlan Associate Professor Dermatology-Faculty of Medicine King Saud University Riyadh, Saudia Arabia A. Alajlan: None. ABSTRACT: Background: Female androgenetic alopecia (female pattern hair loss) is common hair condition and account for about 50% of postmenopausal women. Finasteride 1 mg showed significant benefit in men with androgenetic alopecia, however it did not showed efficacy in women. Objective: to evaluate the efficacy and safety of higher dose of finasteride (2.5 mg) in postmenopausal women with androgenetic alopecia Method: This is a pilot study for postmenopausal women with a clinical diagnosis of androgenetic alopecia. All patients have to stop all hair therapy for a minimum of 2 moths. Once daily dose of 2.5 mg finasteride was prescribed for all enrolled patients for one year. Objective assessments by the investigator include a pre and post scalp photos, dermatoscope assessment and clinical grading of androgenetic alopecia using Ludwigs scale. Subjective assessment was measured by patient self[[Unsupported Character - &#8208;]]administered questionnaire. Assessment was done at day 0, 3, 6 month and 12 month. Both objective and subjective assessments use the following scale of improvement: none, minimal, good or very good improvement. Blood tests were taken at the beginning of the study and at one year of completion of the study. Result: Out of 59 patients enrolled, Fifty two completed the study. Seven patients lost to follow up. Through the investigator assessment: out of the 52 patients, 5 patients (10%), 16 patients (31%), 11 patients (21%) and 20 (38%) showed very good, good, minimal and no improvement respectively. Patients self assessment showed 4 patients (8%), 13 patients (25%), 8 patients (15%) and 27 patients (52%) with very good, good, minimal and no improvement respectively. Among the good responders there was statistical significance positive correlation to ludwigs grade I in comparison to none responders (p value < 0.05). One year follow up after completion the study, there are decrease in hair density among those discontinued the treatment and stability of the density with those continued it. Pre and post treatment blood tests showed no significant change. One patient experienced mild and transient breast tenderness. Limitations: This is a pilot study with small group of patients, single investigator and with short follow up period after completion of therapy.

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Conclusion: Daily dose of finasteride 2.5 mg showed clear benefit in subset of postmenopausal women with androgenetic alopecia in particular those with of Ludwigs grade I and II. Finasteride was well tolerated and showed minimal adverse effect.

025 How Finasteride Should be Used in a Hair Transplant Practice

Edwin S. Epstein, MD Bosley, Virginia Beach, VA, USA. Edwin S. Epstein, M.D., has been practicing hair restoration since 1990. He earned his M.D. from Georgetown University, and completed residencies at Duke University Medical Center, and Washington University, Barnes Hospital. He is a Diplomate of the American Board of Urology, and a Fellow of the American College of Surgeons. In 2009-2010 he served President of the International Society of Hair Restoration Surgeons. E.S. Epstein: None. ABSTRACT: In April 2012 the US FDA announced product label changes for finasteride to include sexual disorders that continued after discontinuation of the drug, despite the fact that clear causal links have not been established. Their review of post marketing reports from 1998-2011 included only 59 cases of sexual dysfunction that lasted at least 3 months following discontinuation of finasteride 1mg. The FDA advised patients to consult with their health care provider as to the risks and benefits of finasteride for its approved indication for the treatment of male pattern hair loss. Empowering our patients with evidenced-based factual information is paramount for an informed decision on medical drug therapy. The product information material for finasteride (Propecia and Proscar) describes the indications, facts, warnings, and possible side effects. This discussion of risks, benefits, and adverse events should be included in the consultation. It is uncommon to use a patient signed informed consent for FDA approved drugs for the approved indication. However, due to the legal climate in the practice of medicine, some physicians are more comfortable having patients read and sign an informed consent, while others document the discussion in the patient record. Some physicians will discontinue recommending finasteride because of these post-marketing concerns, despite the fact that thousands of men have stabilized hair loss progression with minimal adverse events. Since its FDA approval in 1997, Finasteride has helped thousands of men with androgenetic alopecia with over 6.7 million patient-years of therapy. Because genetic hair loss can be progressive, the goals of medical therapy should focus on prevention and maintenance, while combination therapy with surgery is the ideal approach.

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Discussion: The indications for the use of finasteride in my hair transplant practice have not changed: men experiencing hair loss who wish to stop or slow hair loss progression. Men with hair loss in the BPH age group can also benefit, but should be advised as to the controversy concerning prostate cancer chemoprevention and the importance of yearly PSA and digital rectal examination. I note these discussions in the patient record. Use in women, not at risk for pregnancy, remains an off-label use, and those women who may be responders can benefit from genetic testing to assess this potential. A prior or family history of breast cancer is a contraindication. Concerning Post Finasteride Syndrome, I discuss that no cause and effect relationship with finasteride has been proven, that while no incidence has been reported, it appears to be a rare occurrence (World Health Organization: rare: 1:1,000-10,000); and we do not know who is at risk or why. Indications and efficacy of finasteride vary with age and extent and duration of hair loss. Practical guidelines for the use of finasteride will include: management at various ages and stages of hair loss; variations in dosage; how to monitor efficacy; use with other therapies, contraindications, and management of adverse events.

026 Moderator Introduction, Operation Restore and Repair Cases

David Perez-Meza, MD Permanent Hair Solutions, Mexico City, Mexico. Dr. Perez Meza is graduated from the Military Medical School in Mexico City. He specialized in Plastic and Reconstructive Surgery. He was an active member of the Presidential Medical Corps. He retired with Lt. Colonel Status in 1996 after serving in the Mexican Army for 26 years. He was trained in hair restoration surgery under Drs. Leavitt, Mayer and Ziering. In 2001, he was the first Hispanic Diplomate of the ABHRS. He has been active member of the ISHRS as speaker, moderator and Course Director. He had received nine Research Grant Awards. In 2007, he received the Platinum Follicle Award D. Perez-Meza: None.

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DISCLOSURE
20th ISHRS Bahamas October 17-20, 2012

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

Operation Restore
Overview- Dr. David Perez-Meza Five OR Repair Cases: Drs. Paul Cotterill, Mark DiStefano, Antonio Mangubat, Edwin Epstein and Melvin Mayer ISHRS and BOG Annual Giving Fund

Thank you

ISHRS Members- Donations Our partners- Hotels and Resorts Hair Foundation- Promoting the OR and donation of $1,500 . OR Physicians- 90 of 900 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.

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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 h i d h i hair.

Operation Restore
ISHRS- Provides hotel, meals, transportation (air flights or gas). OR Physician- the physician is expected to waive or , pp , 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 $425,000 worth of FREE Hair Restoration Surgery. 44 applications have been approved so far. 66 surgeries have been performed (some patients 2-4 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

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027 Panelist for Operation Restore and Repair Cases Session

Paul C. Cotterill, MD N/A, Toronto, ON, Canada. Dr. Paul Cotterill is a past president of the ISHRS and is the current Chair of the Continuing Medical Education Committee for the ISHRS as well as being actively involved with Operation Restore. He is a diplomate of the ABHRS and has been practicing hair restoration exclusively for over 25 years. P.C. Cotterill: None.

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Paul C. Cotterill B.Sc., M.D.

Diplomate, American Board of Hair Restoration Surgery Toronto , Canada

Nothing to disclose No conflicts of interest

Lucille R. : At 18 months pulled pot of boiling oil from stove onto her head. Rushed to local hospital , then transferred to Sick Kids Hospital in Toronto. Six weeks of treatment resulting in scarring alopecia to right temple

Lucille R. : 52 year old female Psychologically scarred. Embarrassed, selfconscious, emotionally took its toll. 15 and 17 year old children did not know of the burn.

The older I got the more self conscious I became and constantly combed other hair over it. I hated to let anyone close to me in anyway for fear they would see my scar. The kind of emotional walls I created caused me to make some poor decisions in my life and most often settled for less than I should have if I had only had more confidence in myself. L.R.

Scarring Alopecia

On exam: tight, thin skin, very little flex or give Possible Options: Scalp reduction / +/- tissue expansion Scalp rotational flap Rogaine Camouflage cosmetics Micro pigmentation Hair transplantation

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Hair transplant # 1 1 year later

Planned 2 procedures spread 1 year apart. Fewer grafts per session, spread farther apart than usual. Poor vascularity Added extra N/S tumescent solution to plump up skin Transplant # 1: November 2006 612 grafts: 307 1-3 haired single FU and 305 double FUs Transplant #2: January 2008 564 grafts: 264 single FU and 300 double FUs

BEFORE FIRST SESSION

1 YEAR AFTER SECOND SESSION

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028 Panelist for Operation Restore and Repair Cases Session

Mark S. DiStefano, MD DiStefano Hair Restoration Center, Worcester, MA, USA. Mark S. DiStefano, MD, ISHRS,ABHRS clinical instructor University of Massachusetts Division of Plastic Surgery Member of operation restore since it's inception Have performed numerous cases for OP RESTORE as well as many repair cases. In private practice for 18 years M.S. DiStefano: None.

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Mark S. DiStefano, Sr, MD

Diplomate, ABHRS Clinical Instructor, Division Plastic Surgery University of Massachusetts Medical School Medical Director DiStefano Hair Restoration Center Worcester, Massachusetts, USA

I have no conflict of interest to report

Operation Restore
Why?
Challenges to your skill Learning beyond routine hair transplants Satisfaction of knowing you can help to change someones life Meet new colleagues and widen your referral base Become better known in the community More involved in ISHRS

Blerim G.

Operation Restore
Age 5 Serbia Father wanted by government Protected mother Soldier poured hot oil on head Had hair transplant in Kosovo Grafts too few, too large and too spacey

Health
17 yo white male Pmh
unremarkable except for Hair transplant

Scalp:
Left side of scalp 6X14 cm scar with multiple scattered punch grafts Missing left hairline through ant, mid and temporal scalp

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Operation Restore
Hair Restoration Plan
Fut vs expander vs extender Consult to Umass plastics Expander 2nd expander if necessary Fill in with FUT

April 23 2007 Insertion of Expander

Inflating Expander

Removing expander

October 27, 2008 S/P Expander removal

December 8, 2008

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April 4, 2009 Follow up

May 30,2012 FUE

Comps

Grace Charollette January 12, 2010

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029 Panelist for Operation Restore and Repair Cases Session

E. Antonio Mangubat, MD La Belle Vie Cosmetic Surgery Centers, Tukwila, WA, USA. Dr. Mangubat is a graduated of the University of Washington School of Medicine, studied general surgery at the University of Kentucky and received his cosmetic surgery training from Dr. Richard Webster. Dr. Mangubat performs many different cosmetic surgery procedures but hair-related surgeries remain one of his favorite operations. His long history of service to the ISHRS includes serving as president from 2004-2005. He works tirelessly to promote the positive influence HRS plays in our patients lives. He is currently president of the Hair Foundation that will provide unbiased education raising awareness of hair health worldwide. E. Mangubat: None.

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Operation Restore in Ecuador

u s O ega, Luis Ortega, MD E. Antonio Mangubat, MD

Patient History

3 year old female with long hair Scalp avulsed when pony tail wrapped around drive shaft of truck. Skin graft One attempt at scalp expansion at age 4

infectious complication

Applied to Operation Restore 2009 3 Expanders placed July 2011 Flaps advanced January 2012

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2 MINUTE VIDEO

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030 Panelist for Operation Restore and Repair Cases Session

Edwin S. Epstein, MD Bosley, Virginia Beach, VA, USA. Dr. Epstein has practiced hair restoration surgery since 1990. He served on the Board of Governors of the International Society of Hair Restoration Surgeons from 2005-2011, and was President from 2009-2010.. He is a Diplomate of the American Board of Hair Restoration Surgery, and a Bosley surgeon since 2006. E.S. Epstein: None.

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History: Greg
51 Yr old 25yr veteran Fairfax County Fire Dept. December 15, 2005
Called to hotel room fire While searching the room, flashover occurred Sustained steam burns to exposed areas

Operation Restore Story

Edwin S Epstein, MD Bosley, Associate Surgeon Virginia Beach, VA

OR Application accepted 3/8/10

Flown to Washington Hospital Burn Center Skin grafting to hands x 2 4th day after injury he injury, noticed some discoloration on his pillow and complained that his head hurt On examination, his skin was necrotic from burns that were covered by his hair Skin graft to back and top of head

Hair Transplant:
April 29, 2010

8-12mm x 33cm donor excision 2623 grafts

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When Dr. Epstein told me that I had been accepted to participate in the International Society of Hair Restoration Surgery, Operation Restore program I was both excited and a little apprehensive, as I had three surgeries at the Washington Burn Center. The hair restoration procedure worked great and the results were awesome. The surgery was very easy and Dr. Epstein and his staff were professional and caring. I know it has helped me greatly in my recovery and I am very grateful to Operation Restore.

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031 Panelist for Operation Restore and Repair Cases Session

Melvin L. Mayer, MD Bosley Medical, San Diego, CA, USA. BRIEF BIOGRAGHY Melvin L. Mayer MD ABHRS He has served as an Examiner and Past President of the ABHRS and member of many committees in the ISHRS through the years. He has been awarded research grants by the ISHRS. Areas of interest include follicular regeneration of bisected follicles, graft yield at varying densities, classification and surgical techniques of the temporal points, scalp elasticity scale and understanding its importance in maximizing donor width and minimizing donor scars, and techniques to maximize the quality of transplants in Black patients. He was awarded the Platinum Follicle Award in 2004. San Diego is home. M.L. Mayer: None.

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OPERATION RESTORE
Case Presentation Alexandria 20th Annual Scientific Meeting ISHRS Paradise Island, Bahamas October 17-21, 2012 17Melvin L Mayer MD ABHRS

History
42 yo black female Punch Bx 2001- Mixed suppurative & 2001granulomatous inflammation and plasma cells with dermal fibrosis Punch Bx 2010 Dermal fibrosis

Treatment
Multiple treatments with oral antibiotics,
topical and injectable steroids over years Scalp Reduction in LA 2006 looked great post op but 2 months later lost more hair than before the SR She thinks it was from the post op tension No pix available

Operation Restore
Surgery #1
FU surgery 969 grafts 6/11/2010

Surgery #2
FU surgery 907 grafts 2/23/2011

Before & After Top

Before & After

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032 Case Report: Treating an Extensive Burn Injury of the Scalp in a Child
Frank G. Neidel, MD, Karin B. Leonhardt, MD Hairdoc Germany, Duesseldorf, Germany. Frank G. Neidel, MD, approved surgeon, works on the field of hair transplantation since 1991. He performed since then about 6.000 hair transplant procedures. He has experience with all common procedures, such as micro-holes, micro-slits, laser-assisted hair transplant, strip harvesting, FUE. In his office hairdoc in Dusseldorf, Germany, he does exclusively hair transplantation and reduction of scalp (Frechet Extender). He trained other in this field interested colleges from Germany and Europe and he gives support to different clinics in Europe to secure quality in hair transplantation. Frank Neidel is president of the German Society Hair Restoration Surgery, secretary of European Society Hair Restoration Surgery and member of ISHRS. F.G. Neidel: None. K.B. Leonhardt: None. ABSTRACT: Introduction: In 2011 we treated a girl with an extensive burn injury of the scalp in our clinic. She had lost more than half of her hair due to an accident with boiling water as an infant. Two Expander operations followed in a clinic for plastic surgery, but were not successful resulting in even more scarring and hair loss. Background: Burn injuries are extremely difficult to treat, especially if extensive. The blood supply in the burnt area is insufficient. The skin lacks elasticity and is often glued to the galea. Subcutaneous tissue is often missing. This makes any scalp reduction a challenge. The hair transplantation alone is often a disappointment due to poor growth. Procedure: Until now we have performed 3 scalp reductions using the Frechet-Extender and one hair transplantation. We will present the results. Results/Conclusions: The results exceed our expectations because of the tremendous healing potential in children. The Frechet Extender in the hands of an experienced surgeon provides a tool to use this healing potential. Finding new ways and combining techniques can lead to success where conventional hair transplantation may not. This combined treatment is unknown to most European plastic surgeons, because of the lack of education in the field of hair transplantation and The Frechet Extender procedure.

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033 Coffee with the Experts, Table Leader on the Topic of "Robotic FUE"
Robert M. Bernstein, MD Bernstein Medical - Center for Hair Restoration, New York, NY, USA. Robert M. Bernstein MD, MBA, FAAD, Clinical Professor of Dermatology, Columbia University, is an early adopter of the ARTAS System for Robotic-FUE. Bernstein Medical, PC, serves as a beta-site to study new product features and enhancements. Dr. Bernsteins contributions and expertise have materialized in making the ARTAS System more user friendly, improving the harvesting technique and making the ARTAS procedure more compelling for patients at this early stage of commercialization of the product. Pre-Making Recipient Sites to Increase Graft Survival in Manual and Robotic FUE Procedures, has been submitted for publication. R.M. Bernstein: None.

034 Coffee with the Experts, Table Leader on the Topic of "Spanish Speaking Table: FUE"
Jose F. Lorenzo, MD Hair restoration, Clinica Ceta, Madrid, Spain. Dr. Jos Lorenzo was born in the Canary Islands, Spain. Dr. Lorenzo received his medical degree at the University Complutense of Madrid in 1991. He completed his General Surgery residency in 1996 and the Thoracic Surgery residency in 1998. In the field of hair transplantation since 2003. Currently, Dr Lorenzo is in private practice in his own clinic in Madrid (Spain), coordinating a team that only do FUE technique. J.F. Lorenzo: None.

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035 Coffee with the Experts, Table Co-Leader on the Topic of "Research Challenges in Hair Biology"
Bruce A. Morgan, PhD Harvard Medical School, Boston, MA, USA. Dr. Morgans laboratory studies the development and regeneration of cutaneous appendages in model organisms. Recent work has focused on the role of the dermal papilla (DP) in guiding hair morphogenesis and follicular regeneration. Mouse models that allow manipulation of gene expression specifically in the DP after the follicle has formed have been exploited to probe the role of specific signals between follicular keratinocytes and the DP. This work with model systems is integrated with a collaborative effort to understand the genetic variation driving the diversity in cutaneous appendage form and function within different human populations. B.A. Morgan: None.

036 Coffee with the Experts, Table Co-Leader on the Topic of "Research Challenges 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. Ownership Interest (owner, stock, stock options); Bosley/Aderans. Ownership Interest (royalty, patent, or other intellectual property); Bosley/Aderans.

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037 Coffee with the Experts, Table Co-Leader on the Topic of "Finasteride"
Stephen Freedland, MD Durham, NC, USA. Dr. Stephen Freedland is a Urologist at Duke University. He is an Associate Professor of Surgery (Urology) and Pathology and holds an appointment at the Durham VA. He specializes in diagnosing, treating, and managing prostate cancer and benign prostatic hyperplasia. He has evaluated 5-alpha reductase inhibitors as treatment and prevention for prostate problems and the risk of sexual side-effects and high-grade prostate cancer. He completed his undergraduate at UCLA, medical school at UC Davis, Urology residency at UCLA and urological oncology fellowship at Johns Hopkins. He runs an active research program with funding from NIH and Department of Defense. S. Freedland: Research Grant (principal investigator, collaborator or consultant); GSK.

038 Coffee with the Experts, Table Co-Leader on the Topic of "Finasteride"
Dow B. Stough, MD The Stough Clinic for Hair Restoration, Hot Springs, AR, 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.B. Stough: None.

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039 Coffee with the Experts, Table Leader on the Topic of "Minoxidil: Use It or Lose It and Other Facts that Patients Need to Know"
Robert T. Leonard, Jr., DO Leonard Hair Transplant Associates, Cranston, RI, USA. DR ROBERT LEONARD IS THE FOUNDING SECRETARY OF THE ISHRS AND SERVED AS PRESIDENT. HE IS A GRADUATE OF THE UNIVERSITY OF NEW ENGLAND COLLEGE OF OSTEOPATHIC MEDICINE, A FELLOW OF THE AMERICAN ACADEMY OF COSMETIC SURGERY, AND A DIPLOMATE OF THE AMERICAN BOARD OF HAIR RESTORATION SURGERY. HE HAS PRACTICED IN THIS FIELD FOR THE LAST 26 YEARS. MARRIED FOR 28 YEARS TO DR KATHRYNE LEONARD AND A PROUD FATHER FATHER OF THREE, HE FEELS BLESSED IN MANY, MANY WAYS. R.T. Leonard: Speakers Bureau/Honoraria (speakers bureau, symposia, and expert witness); JOHNSON AND JOHNSON. Consultant/Advisory Board; JOHNSON AND JOHNSON. Other; LASERCAP INC.

040 Coffee with the Experts, Table Co-Leader on the Topic of "Hair Transplantation in Young Patients: My Personal Approach"
Walter P. Unger, MD Toronto, ON, Canada. Dr. Walter Unger is a clinical professor of Dermatology and Director of the Dermatologic Surgery Fellowship Program at Mt. Sinai School of Medicine in New York and is an associate professor (Dermatology) at the University of Toronto. He was adjunct professor (Dermatology) at Johns Hopkins School of Medicine in Baltimore, Maryland from 2003 to 2007. He has private practices in Toronto, Canada and New York City. Dr. Unger is the author of chapters on hair transplantation in 36 medical texts and an editor of five editions of the reference textbook Hair Transplantation, the latest published in 2011. W.P. Unger: None.

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SEMINAR
CURRENT APPROACH IN YOUNG PATIENT

The early appearance of thinning hair is an abrupt and rude awakening for young men.

It is therefore important to make an effort to Young patients are frequently the most demanding patientsexpecting low hairlines similar to their peers and total, relatively dense coverage of the entire scalp. win the patients trust and to convince him that the advice you are offering him has as its goal his long-term welfare.

Young patients are frequently the most demanding patientsexpecting low hairlines similar to their peers and total, relatively dense coverage of the entire scalp.

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Nearly all of the young men I see will agree to a trial on medication or if surgery is carried out, reasonable hairlines and FU/hair densities. The latter is particularly easy to get them to accept because I am adding transplanted hair to an area that usually has a moderate amount of original hair, so the resultant hair density is considerably better than that of FUT into an alopecic area.

Age 29 yrs 30 FU/cm2 17 ms aft 1st FUT (2611 FU) A

How will they look when theyre older and lose the persisting original hair they had when I first did their hair transplant?

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30 FU/cm2

20 FU/cm2

Graft Designation F 1S 1S F2S 2S Parallel 2S

Number of Hairs and Type 1 fine hair 1 average texture hair 1 average texture hair + 1 fine hair (or demi) 2 average texture hairs - splayed 2 average texture hairs - more parallel to each other than usual

Recipient Incision Need 20G 20G 19G usually 19G usually 19G or 20G

I would very rarely transplant the vertex of a young man without a trial on Propecia and/or Minoxidil. I would be more willing to transplant the midscalp + bump in one who

3S F 3S FF Demis

3 average textured hairs 3 hairs with at least one average textured hair 2 FU with any number or type of hair 1 transected follicle

18G usually 18G 18G 20G or 19G

refused medical treatment.

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2356 FU

Limit yourself to two sessions of approximately 1800 2500 (to rarely 3000) FU, 20-30 FU/cm2 and one donor area scar and you are playing it very, very safe.

Use of Clues from Examination and History Re: Severe MPB

In my experience, a family history of severe MPB DOES MATTER; the presence of whisker hair (add photo) other red lights the absence of dense fringe hair and strongly demarcated lateral fringes; the presence of diffuse, non-pattern alopecia; a

The earlier the onset of a disorder, the more severe it is likely to be and the more raipdly it is likely to evolve.

repeatedly higher than average percentage of

miniaturized donor area hairs; MPB beginning in a teenager.

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This is not always the case with MPB beginning in the early 20s.

AFTER PHOTOS NEEDED FOR SAME PT AS ABOVE

18-07-12-MU-7 yrs aft HT-1

18-07-12- MU-7 years after HT-1

These three examples are NOT meant to I began thinning in my vertex area in my early 20s. suggest that one should ignore the possibility of more severe ultimate hair loss in those with early onset of MPB.

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Be humble before an always unknown future but reject the dogma of NEVER, regardless of psychological need combined with reasonable objectives. (Note the repetition of reasonable objectives that is used three times in this lecture) not incidentally.

My experience with regard to younger patients I did hair transplants on 30 to 40 years ago. I have seen a few of them who went on to Types VII and VIII MPB, with their major cosmetic problems primarily in their over-harvested donor areas rather than their recipient areas.

If you speak with the pioneers in hair transplanting, that is uniformly their experience as well. All of the less than halfdozen of those early patients who I seriously regret having operated on so early had older family members who had Types VII or VIII MPB.

SUMMARY

A young man who has only fronto-temporal recessionsespecially if combined with diffuse frontal hair lossbut without any of the following six warning factors can be considered for early hair transplanting given three provisos. 1) You and your surgical team can consistently produce high hair survival rates at 25-30 FU/cm2 and do not exceed that FU density for such patients.

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2) With the possible rare exception, you limit yourself to: a) only 2 sessions of 1500 to 2500 (or rarely 3000) FU typically obtained from two 9mm to 12mm wide strips that are taken from the densest zone of the donor area, b) 20 to 30 FU/cm2. 3)You excise the donor scar from the first session as a component of the second donor strip.

4b) But arbitrary absolute rules about when and for how long they must be used before 4a) Strong encouragement of medical treatment with minoxidil and finasteride should always be part of your management. surgery can proceed are not reasonable, given other factors that should also be considered.

6) Consider Alternative Strategies for Buying 5) Consider A Prospective Forelock Approach Transplantation in the frontal and even midscalp regions, but, no attempt is made to transplant through areas that we think will be lost in the future. Such a design is ideal for younger individuals or for those who are felt to be likely to develop Type VII MPB. a) medical treatment b) camouflage products c) non-surgical hairpiece Time

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During future decades it is highly likely that more effective medical treatments for MPB It is important to stress that such individuals can be considered but not always accepted. will be developed or hair cell therapy perfected, and even more certainly your patients emotional dependence on scalp hair will be considerably reduced.

USE OF ALTERNATIVE DONOR SITES FUE and beard and body hair as donor sources often have different hair characteristics than scalp hair and for this reason, need to be placed in appropriately chosen sites within the transplanted area.

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041 Coffee with the Experts, Table Co-Leader on the Topic of "Hair Transplantation in Young Patients: My Personal Approach"
Vincenzo Gambino, MD NA, Milano, Italy. Vincenzo Gambino M.D. Milan, Italy Dr. Gambino is Secretary Board of Governors International Society of Hair Restoration Surgery (I.S.H.R.S.). He serves as Director of Hair Restoration Surgery at San Raffaele University Hospital in Milan. Currently he serves a three 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 on numerous dermatology text books. V. Gambino: None.

042 Coffee with the Experts, Table Co-Leader on the Topic of "Flap Surgery and Use of Expanders & Operation Restore"
E. Antonio Mangubat, MD La Belle Vie Cosmetic Surgery Centers, Tukwila, WA, USA. Dr. Mangubat is a graduated of the University of Washington School of Medicine, studied general surgery at the University of Kentucky and received his cosmetic surgery training from Dr. Richard Webster. Dr. Mangubat performs many different cosmetic surgery procedures but hair-related surgeries remain one of his favorite operations. His long history of service to the ISHRS includes serving as president from 2004-2005. He works tirelessly to promote the positive influence HRS plays in our patients lives. He is currently president of the Hair Foundation that will provide unbiased education raising awareness of hair health worldwide. E. Mangubat: None.

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043 Coffee with the Experts, Table Co-Leader on the Topic of "Flap Surgery and Use of Expanders & Operation Restore"
Frank G. Neidel, MD Hairdoc Germany, Duesseldorf, Germany. Frank G. Neidel, MD, works in the field of hair transplantation since 1991 and has performed about 6.000 hair transplant procedures. He has experience with all common procedures, such as micro-holes, micro-slits, laserassisted hair transplant, strip harvesting, FUE. In his office hairdoc in Dusseldorf, Germany, he does exclusively hair transplantation and reduction of scalp (Frechet Extender). He trained other in this field interested colleges from Germany and Europe and he gives support to different clinics in Europe to secure quality in hair transplantation. Frank Neidel is president of the German Society Hair Restoration Surgery, secretary of European Society Hair Restoration Surgery and member of ISHRS. F.G. Neidel: None.

044 Coffee with the Experts, Table Leader on the Topic of "Hairline Design for Asian Patients"
Sungjoo (Tommy) Hwang, MD Dr. Hwang's Hair Hair Clinic, Seoul, United Kingdom. Sungjoo Tommy Hwang, MD, PhD Board of Governors , ISHRS Vice-President of KSHRS Immediate Past President of AAHRS S. Hwang: None.

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045 Coffee with the Experts, Table Leader on the Topic of "Zones for Surgical Planning in Men and Women According to Their Degree of Alopecia"
Craig L. Ziering, DO Ziering Medical, Beverly Hills, CA, USA. CEO and Medical Director of Ziering Medical. Practicing Hair Restoration for 20 years. C.L. Ziering: None.

046 Coffee with the Experts, Table Leader on the Topic of "Adding HT to a Cosmetic Practice or Adding Cosmetic Procedures to a Hair Transplant Practice"
Samuel M. Lam, MD Lam Facial Plastics, Plano, TX, USA. Dr. Sam Lam is a triple board-certified facial plastic surgeon (American Board of Facial Plastic & Reconstructive Surgery, American Board of Otolaryngology, and American Board of Hair Restoration Surgery) authoring 6 medical textbooks, including Hair Transplant 360, and over 150 scientific articles and book chapters. He is national course director for a Hair Transplant Workshop in St. Louis each year. Dr. Lam is the owner of the 27,000 square-foot wellness center in Plano, Texas that houses his other two businesses, a spa and salon. Dr. Lams newest venture is a skin care line named Ova that features plant-derived stem cells. S.M. Lam: None.

047 NON-CME TABLE Coffee with the Experts, Non-CME Table Leader on the Topic of "SAFE System"
James A. Harris, MD

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Otolaryngology/ Head and Neck Surgery, 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: Ownership Interest (owner, stock, stock options); HSC Development - producer of FUE device.

048 NON-CME TABLE Coffee with the Experts, Non-CME Table Leader on the Topic of "Cole FUE Device"
John P. Cole, MD International Hair Transplant Institute, Alpharetta, GA, USA. Private Practice Hair Transplant Surgery since 1990 J.P. Cole: None.

049 NON-CME TABLE Coffee with the Experts, Non-CME Table Co-Leader on the Topic of "The Role of Vitamins & Supplements in Hair Loss and HRS"
Lawrence J. Shapiro, MD Dr. Shapiro's Hair Institute, Florida, Delray Beach, FL, USA. Dermatologist in practice for 23 years in Delray Beach, Florida. Performed over 11,000 hair transplants. Graduated Phi Beta Kappa and Summa Cum Laude from Syracuse University. Inventor and Developer of Help Hair Shake and S.H.A.P.I.R.O. Chart. A nutritional whey protein supplement when used with the Low Anabolic profile has lead to

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early regrowth after hair transplants in over 800 patients. Growth starting at 6-8 weeks and full growth by 5-6 months. Clinics from around the world have reproduced the results and are using it on a regular basis. L. Shapiro: Ownership Interest (owner, stock, stock options); Owner of Help Hair line of nutritional products.

050 NON-CME TABLE Coffee with the Experts, Non-CME Table Co-Leader on the Topic of "The Role of Vitamins & Supplements in HairLoss and HRS"
Nicole E. Rogers, MD NA, Metairie, LA, USA. Dr. Nicole Rogers is a board certified dermatologist and fellow of the American Academy of Dermatology. She is in private practice in the New Orleans area where she specializes in hair loss and hair restoration for both men and women. She completed an ISHRS fellowship in hair transplantation with Dr. Marc Avram in New York City. Together, they co-edited a textbook on hair transplantation and have authored numerous papers on medical and surgical treatments for hair loss. She is assistant clinical professor of dermatology at Tulane and enjoys teaching the residents about various forms of alopecia. N.E. Rogers: None.

051 Coffee with the Experts, Chinese-Speaking Table: Pearls for Asian Hair Transplants
Wen Yi Wu, MD NA, Taipei, Taiwan. Wu Wen Yi, M.D. W. wen yi: None.

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052 Breakfast with the Experts, Korean-Speaking Table: How to Reduce Folliculitis after Hair Transplantation
Sungjoo (Tommy) Hwang, MD Dr. Hwang's Hair Hair Clinic, Seoul, United Kingdom. Sungjoo Tommy Hwang, MD Vice-President of KSHRS Immediate Past -President of AAHRS BOG of ISHRS S. Hwang: None.

053 Moderator Introduction, Advanced Surgical Techniques II

Bessam Farjo, MBChB Farjo Medical Centre, Manchester, United Kingdom. Bessam Farjo, MBChB, graduated in 1988 from the Royal College of Surgeons in Ireland. After general surgery training, in 1993, he trained in hair surgery in Canada and co-founded the Farjo Medical Centre in Manchester and London exclusively practicing hair restoration surgery. Past President of ISHRS (07-08), Past President and co-founder of the British Association of Hair Restoration Surgeons, Diplomate and Board Director of the American Board of Hair Restoration Surgery, Fellow, Board Governor & Medical Director of the Institute of Trichologists, Fellow of the International College of Surgeons. B. Farjo: None.

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054 Intrapatient Graft Length Differences Influencing Depth Controlled Incisions

Sungjoo (Tommy) Hwang, MD1, Paul C. Cotterill, MD2 1 Dr. Hwang's Hair Hair Clinic, Seoul, United Kingdom, 2N/A, Toronto, ON, Canada. Tommy Hwang : President of Asian Association of Hair Restoration Surgeons, BOG of ISHRS Paul Cotterill : Past president of ISHRS P.C. Cotterill: None. S. Hwang: None. ABSTRACT: Background: It is known that failed depth controlled graft placement yields problems such as pitting, tenting, poor survival, folliculitis, cyst and etc.. No matter how carefully we make proper depth incisions , problems still occur . The graft length can differ from person to person. But we do not have enough information about the graft length differences in the same individual. Objective: The purpose of this study is to evaluate whether there is a significant difference in the length of the grafts in the same individual. Method: After graft preparation, each 100 grafts of 1-, 2- 3 hairs FU were taken randomly and the length was measured on the ruler(Fig 1 A, B). 119 Korean patients and 24 Caucasian patients were taken. Result: 1. Asian (Korean) patients result: The difference(mm) between the longest and shortest graft in the same individual 0.5mm 1-hair FU 2(1.7%) 1.0mm 1.5mm 2.0mm 2.5mm 3mm total

42(35.3 %) 46( 38.6%) 22(18.5 %) 5(4.2 %) 2(1.7%) 119(100%) 1(0.8 %) 3( 2.5%) 119(100%) 0(0%) 0(0%) 119(100%)

2-hair FU 12(10.1%) 57(47.9%) 36(30.3%) 10(8.4%) 3-hair FU 43(36.1%) 43(36.1 %) 26(21.9%) 7(5.9%)

2. Caucasian patients result: The difference(mm) between the longest and shortest graft in the same individual 0.5mm(%) 1-hair FU 5(4.2%) 1.0mm 12(50.0 %) 1.5mm 4(16.76%) 2.0mm 2.5mm 3mm total

1(4.2 %) 2(8.3%) 0(0%) 24(100%)

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2-hair FU 5(20.8%) 3-hair FU 9(37.5%)

9(37.5%) 11(45.8%)

8(33.3%) 4(16.7%)

2(8.4%) 0(0%)

0(0 %) 0(0%)

0(0%) 24(100%) 0(0%) 24(100%)

It showed that there is a significant difference in the length of graft in the same individual in both Asian and Caucasian patients. Discussion: Most of us know that the graft length varies from patient to patient but believe that there will be little difference in the graft length in the same individual. According to our research, the length of the graft varied much in the same individual and if we make the same depth incision in the same individual, then the longest grafts will fit in the slit but the short grafts will be placed in the deeper layer. For example, if a single patient has 6 mm-, 5mm-, 4 mm- and 3 mm- length grafts in the donor area, and if we make slits at a 6 mm depth, then a 6 mm- graft will fit in the slit adequately but a 3mm-graft will be located at 3 mms deeper than the proper depth and could result in folliculitis, cyst, pitting, poor survival. Transection of the grafts can sometimes occur during graft preparation with FUT and FUE. These transected follicles should also be placed superficially, compared to the intact hair follicles to avoid deeper location in the recipient site Therefore, in order to prevent the complications mentioned, we need to classify the grafts, in the same individual, into same length groupings(Fig 2) and make proper slit depths according to each group. With this method, I have reduced or prevented folliculitis, cyst, and pitting in most of my personal cases during the last 6 months. Conclusion: Creating depth-controlled incisions according to the intrapatient graft length differences can yield a superior result and help to minimize complications such as folliculitis, pitting, and poor survival

140

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144

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145

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055 Where to Put the Grafts When Not Enough - Frontal Core vs. Parting Side Approach
Bertram M. Ng, MBBS Dr Bertram Hair Transplamnt, Kowloon, Hong Kong. Bertram Ng is a Certified ISHRS Fellow and ABHRS Diplomate. He served as examiner for ABHRS and Co-editor for the ISHRS Forum. His special interest is in hairline restoration. In 2008 he first designed a hand-held laser device for hairline placement, which is now in production. In 2009 ISHRS Scientific Meeting he introduced a new system in setting the hairline anterior-most point when the Golden Rule of Third cannot apply. Knowing that not all patients are candidates for giga-session, he is finding a way to achieve the best result with the minimal number of grafts. B.M. Ng: None. ABSTRACT: Introduction: Those coming for hair transplant want to look good. The best result of course is full coverage of all the thinning/balding areas. In order to meet the desired density and the total number of grafts, Mega- or Giga-session was believed to be the solution. However in reality Mega- or Giga-session is not possible in all cases. Reasons are: -Financial affordability -Discrepancy between balding area and available number of donor hair, especially in advanced stage of MPB. -Young patients when some donor hair must be left for future session -Lack of surgical skill or manpower So the question is then how to achieve the best possible result with the least number of graft. We initially adapted the Frontal core / forelock approach to frame the face (Unger and Beehner). A larger number of grafts, especially 3-hair FU, were added to these areas. Unfortunately many patients were not happy with this design: -They always complained that hair in the front parting side is too thin. -They did not want any gap between the frontal and temporal hairlines (the apex). -They want to cover as much balding scalp as possible, not just in the middle. -Many still prefer to part their hairs rather than combing forward or backward.. Premise: We then slowly developed the parting-side approach, which is composed of the followings: -Hairs are placed along the hairline extending backwards into the parting side (Image 2). -Higher hair density is planned at the parting side rather than the frontal core (Image 3). -An area of lower density is created as the locking zone (Image 1: Fig 5 & 6) -The hairs are inserted to follow the natural flow of existing hair rather than all pointing forward . (Image 1: Fig. 4) -Less or no grafts are inserted in between the parting side and the locking zone (Image 1: Fig. 6). -The parting area can be extended to create the lateral hump (Image 1: Fig 4). -Transplanted hairs at the parting side are kept long to comb over the frontal core and midscalp (Image 4:). -Cosmetic improvement is achieved even when the scalp is just partially covered.

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Substantiating Data: This design is based on 3 principles in hair transplant: 1.Overlapping 2.Locking 3.Bridging Overlapping (Image 1: Fig. 1) By transplanting hair close to each other and fall into the same direction, an illusion of density can be achieved (when compared to spreading the follicles). Locking Hair lying on the oily scalp cannot be kept in place. Hair locking into hair can resist wind and gavity. (Image 1: Fig. 6) Bridging By combining overlapping and locking, less hair has to be inserted in between (when compared to even spacing ) to create an illusion of density (Image 1: Fig. 7). Case study 46 years old Asian gentleman with Class VI and a retained frontal tuff. Had a FUE session in 2007 with 3000 hairs transplanted all over the balding area but with no visual improvement (Image 5). He requested to add density to bridging the gap in the parting side (Image 6). 1828 grafts were obtained by strip. There was obvious donor area depletion (donor density 40 FU per sq.cm; 48% 1 hair-FU; hair-graft density 1.6). The parting side approached was used (Image 7, 8) and result at 14 months (Image 9). A second procedure was performed using the same approach (Image 10, 11) The patient was pleased with the final result after a total of 3,639 grafts (5929 hair) were transplanted (Image 12, 13). Discussion: We have been using this approach since 2009. Patients were Class V to VI and the number of grafts is between 2000-3000 per session. Overall result is satisfactory. Some patients returned for a second procedure to extend the parting side into the crown for a fuller coverage. We recommend this parting side approach as an alternative to the

147

frontal core design.

148

Where to Put the Grafts when not enough

- Frontal Core vs. Parting Side Approach Conflict of Interest

Ihavenoconflictofinteresttodeclare

Dr Bertram Ng (Hong Kong)

MBBS, Certified Fellow ISHRS, ABHRS Diplomate

Introduction
Thosecomingforhairtransplantwanttolookgood Bestresultofcourseisfullcoverageofallthethinning/baldingareas Tomeetthedesireddensityandthetotalnumberofgrafts,Mega or Gigasessionwasbelievedtobethesolution RecenttrendinHRSistoincreasethenumberofgraftspersession i.e.atechnicalapproach i e a technical approach

Introduction (cont)
InrealityMega orGigasessionisnotpossibleinallcases. Reasonsare: Financialaffordability Notenoughdonorhair Furtherhairlossanticipated,somedonorhairmustbepreserved Lackofsurgicalskillormanpower

Introduction (cont)

Frontal Core / Forelock Approach

Theotheralternativeistoplacethegraftsincrucialareainorderto achievethebestpossiblevisualimpactwiththeleastnumberofgraft i.e.Anartisticapproach Howeverthisapproachhasbeenoverlookedinrecentyears.

WeinitiallyadaptedtheFrontalcore/forelockapproachtoframetheface (UngerandBeehner) Alargernumberofgrafts,especially3hairFU,wereaddedtotheseareas. UnfortunatelymanyAsianpatientsweredissatisfiedwiththisapproach complainedthathairinthefrontpartingsideistoothin. didnotwantgapbetweenthefrontalandtemporalhairlines(theapex) wanttocoverasmuchbaldingscalpaspossible,notjustinthemiddle. prefertoparttheirhairsratherthancombingforwardorbackward.

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The Parting Side Approach

Ourdesignconsiststhefollowings: Hairsareplacedalonghairlineextendingbackwardsintopartingside(Fig.6) Higherhairdensityisplannedatthepartingsideratherthanthefrontalcore Anareaoflowerdensityiscreatedasthelockingzone(Fig.5)

The Parting Side Approach

Thehairsareinsertedtofollowthenaturalflowofexistinghairrather thanallpointingforward Thepartingareacanbeextendedtocreatethelateralhump

The Parting Side Approach

Substantiating Data
Thisdesignisbasedon3principlesinhairtransplant:

Lessornograftsareinsertedinbetweenthe partingsideandthelockingzone(Fig.6) Transplantedhairsatthepartingsideare keptlongtocomboverthefrontalcoreand midscalp (Fig.4) Cosmeticimprovementachievedevenwhen scalpisjustpartiallycovered.

Overlapping Locking Bridging

Overlapping
Bytransplantinghairclosetoeachotherandfallintothesamedirection, anillusionofdensitycanbeachieved (whencomparedtospreadingthefollicles).

Locking
Hairlyingontheoilyscalpcannotbekeptinplace. Hairlockingintohaircanresistwindandgavity.(Image1:Fig.6)

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Bridging
Bycombiningoverlappingandlocking,lesshairhastobeinsertedinbetween tocreateanillusionofdensity (whencomparedtoevenspacing)

Case Studies
46yearsoldAsiangentleman,ClassVIandaretainedfrontaltuff HadaFUEsessionin2007 3,000hairs(About1,500grafts)weretransplantedalloverthebaldingarea Complainednovisualimprovement(left) Requestedtoadddensitytobridgingthegapinthepartingside(right)

Case Studies
1828graftswereobtainedbystrip Obviousdonorareadepletion donordensity40FUpersq.cm; 48%1hairFU;hairgraftdensity1.6 Thepartingsideapproachedwasused

Case Studies
Resultat14monthsafter1828grafts

Case Studies

Case Studies

Asecondprocedurewasperformedusingthesameapproach

Thepatientwaspleasewiththefinalresultafteratotalof3,639grafts (5929hair)

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Case Studies
Thepatientwaspleasewiththefinalresultafteratotalof3,639grafts (5929hair)

Discussion
Wehavebeenusingthisapproachsince2009 PatientswereClassVtoVI Numberofgraftsisbetween20003000persession Overallresultissatisfactory. Somepatientsreturnedforasecondproceduretoextendthepartingside intothecrownforafullercoverage into the crown for a fuller coverage Thispartingsideapproachmayserveasanalternativetothefrontalcore design.

Thank You !

DrBertramHairTransplant(HongKong)

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056 Making Recipient Sites,The fast track way:New Multi-blade handle, a highly effective new tool for making coronal recipient sites in shortest time
Muhammad N. Rashid, MD HAIR TRANSPLANT SURGERY, HCI, LAHORE, Pakistan. Pakistan's 1st Hair Transplant Surgeon to become member of ISHRS also the first and the only Surgeon who represented Pakistan in the Travelling Workshop of ISHRS held in ASIA in 2000.The most experienced Hair Restoration surgeon in the region with an unmatched experience of more than 11 years in Hair Transplant.He also introduced the most latest and innovative method of doing Hair Transplant called NO TOUCH SURGERY which results in most NATURAL HAIRLINE with 0 % damage risk due to Human Factor due to the use of Special HAIR IMPLANTER DEVICE instead of forceps.He holds the exclusive rights for this NO TOUCH TECHNOLOGY for Single follicle transplant in Pakistan. At present he is using the most advanced technology that uses state of the art computerized Local Anaesthesia system called Compumed. He is also the President of HAIR CLUB INTERNATIONAL, the largest chain of Hair transplant clinics in Pakistan. D.N. Rashid: None. ABSTRACT: Introduction: Hair transplant has been successfully being performed for the last many decades and many tools have been developed over the period of evolution in the past many years.But there has not been a major advancement in expediting time required in the recipient site making. There have been tools/handles with more than one blades developed by some surgeons and companies but not very effective or successful due to multiple reasons like higher cost , special and expensive disposable blade cartridges etc. etc. and all such previous devices made sagittal multiple sites with one stroke of the handle but could nt be used to make coronal. There was one device introduced by a company that can fit multi blades and make 6 coronal sites with one stroke but the mechanism of placing the blades and adjusting them in proper spacing and aligning them properly was not an easy job and therefore did not become popular with surgeons.Putting cut to size micro blades individually without blunting them was a challenge besides precisely controlling the inter blade distance. Handles that can accommodate more than one blade and can make several sites with one stroke are need of the hour as with session sizes touching 4000-5000 follicles in single day and even more,substantial time is spent on recipient making, plus with such a huge number of sites ensuring a uniform spacing and staggered pattern becomes a time consuming job.Specially if you want to do two sessions in day parallel then the speed in recipient site making is a must. Objective: Our team took the challenge of developing a multi blade handle that could make 6 coronal sites with one stroke and would not need to put cut to size blades individually but instead put a cartridge with pre set inter blade distance and inter row spacing to make 6 recipient sites in staggered pattern with controlled inter-blade and inter blade-row distance. Materials and Method: Prototype was developed couple of years back and put to use in our multiple locations , several improvements were

153

evolved over these months of experimental use and incorporated into the original design to make it more efficient. feedback was taken from our surgeons to make the multi blade handle user friendly with little adjustments needed from the surgeon. disposable and highly cost effective Pre-made blade cartridges were developed in different sizes and inter blade spaces predefined so that surgeon can select his preference according to the required follicle density and follicle size.

We did a small study to compare the time required to make recipient sites with a single blade handle versus the one s made with the multi blade handle. Recipient area was divided into equal two halves ( right and left ) and in one half recipient sites were made using a single blade handle and in the other with the new multi blade handle Assessments were done by noting the time required in each half for making the same number of recipient sites. Photographs were taken intra operatively immediately after making the recipient sites and then at 6 months and 1 year to assess and compare the final appearance of both the halves .Not only the total time required to make sites dropped to less than half as compared with a single blade but on comparing the two patterns the one made with the multi blade handle were more uniform and the staggering of the rows was also more accurate. Discussion: The concept of cut to size blade cartridges with pre-set inter blade distance was extremely liked by our surgeons, as it saved a lot of time putting the 6 cut to size micro blades individually into a multi blade handle as was required by the other devices,plus there is always variation in the inter blade distance when putting the cut to size blades individually and therefore the distance between two blades can either get dangerously close or leave more than the required gap. This is not the case with a cartridge. This individual placement of the blades was mostly the reason of blades getting blunt even before use due to the unseen contact with the metal forceps or blade holder required to to insert the blades in older devices. This new multi blade handle system does not require any tool to place the blade cartridge in the multi blade handle and is done by using finger tip which eliminates the risk of blades getting blunt during insertion into the handle.These are some of the reasons that previous devices failed to get the due appreciation in spite of making the recipient site making process faster. Results: Its been more than a year that we converted the prototype into a final finished device which has been in use at all of our practice locations and has revolutionized our recipient sites making not only in terms of time but the quality and consistency in the recipient sites pattern with absolute control and uniformity in the inter follicular distance making it a highly effective and efficient tool.It has now replaced all other tools that we used in the past. The time required to make the recipient sites has dropped to less than half as compared to the time required while using a single blade handle.

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057 Hair Transplants to the Beard, Chest and Other Areas- A Review of Over 400 Procedures
Jeffrey S. Epstein, MD University of Miami, Miami, FL, USA. Jeffrey S. Epstein, M.D., FACS, Founder and Director of the Foundation for Hair Restoration, has been in private practice in Miami and NYC since 1994. A board certified facial plastic surgeon, Dr. Epstein is a Voluntary Clinical Instructor at the University of Miami, and Past President of the Florida Society of Facial Plastic and Reconstructive Surgery. He has as special expertise in the repair of prior hair transplants, eyebrows and facial hair work, hair loss in women, and large procedures of 3000 plus grafts. J.S. Epstein: None. ABSTRACT: In his review of over 400 beard/goatee, chest, axilla, and pubic area transplants performed over the prior 10 years, the author has put together a presentation of the indications, techniques for minimizing complications, and aesthetic and technical aspects of these procedures. Especially valuable is a review of what can go wrong and how to avoid these complications, which include: scarring; bump formation; ethnic risk factors; prolonged healing and how to deal with this; and poor aesthetic design, all based on the authors experience with his own cases as well as dealing with the complications incurred by other surgeons.

058 Hair Transplantation Into Scars

Jennifer H. Martinick, MBBS Salvado Medical, Nedlands, Australia. Dr Martinick is a past Program Chair of the ISHRS, past editor of Cyberspace Chat and currently serves as President of the ISHRS. She is deeply committed to its mission of promoting the highest ethical standards in professional hair restoration. In 2003 she received the Platinum Follicle award, the 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. ABSTRACT:

155

Hair transplantation into scar tissue has been noted by many doctors to be unpredictable in outcome. This appears to be especially so if the scar is thickened or tethered to underlying structures. The author will discuss methods used by her over the last eight years in order to attain more predictable outcome in growth.

156

HairTransplantation intoScarsandScar Tissue

NoConflictofinterest
Jennifer Martinick MBBS President ISHRS ISHRS Bahamas 17-21October 2012

UnpredictableOutcomes

HealingofSkinTrauma
Intact ECM scaffold = Regeneration

Healing H li

variable proportions i bl ti

ECM damaged = Fibrous Tissue

ExtracellularMatrix(ECM)
Consistsof: Collagen:triplehelixof3polypeptidechainswithtensile strengthfromcrosslinking Elastin:createstissuerecoil Cell Adhesion Molecules (CAMS): CAMS creates blood clot CellAdhesionMolecules(CAMS):CAMScreatesbloodclot ProteoglycansandHyaluronicAcid:Bindsalotofwater therebyresistingcompression forces

Healing:FirstIntention
Stages: inflammatory responseremoving damagedcells proliferationandmigrationof connectivetissuecells connective tissue cells angiogenesisandgranulationtissue synthesisofECMproteinsand collagendeposition tissueremodeling woundcontraction acquirewoundstrength

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Healing:SecondIntention
intenseinflammatoryreaction largeramountsofgranulationtissue woundcontraction substantialscarformationandthinningof epidermis

FactorsThatRetardWoundHealing
Local Factors Blood supply Denervation Local infection Foreign body Haematoma Systemic Factors Age Anemia Drugs (steroids, cytotoxic medications, intensive antibiotic therapy) Genetic disorders (osteogenesis imperfecta, Ehlers-Danlos syndromes, Marfans syndrome) Hormones Diabetes Malignant disease Malnutrition Obesity Temperature Trauma, hypovolemia and hypoxia Mechanical stress Necrotic tissue Protection (dressings) Surgical techniques Type of tissue

Uremia Vitamin deficiency (vitamin C) Trace metal deficiency (zinc, copper)

Adapted from Schwartz SI: Principles of Surgery. New York, McGraw Hill, 1999

SpecialConsiderationsWhen TransplantingScars
Assessbloodsupplyandthickness ofthescalp/scar Usesmaller,lessdensesessionsinlarge,widescars UseMinoxidil5%solutionfrom2weeksprioruntil6weeksafter transplant Tumesce thescarwithnormalsalinebeforemakingrecipientsites Using a needle or blade make incisions perpendicular to the Usinganeedleorblade,makeincisions perpendiculartothe directionofhairgrowth.Especiallyimportantifscarisatrophic, orstuckdownonbone. MakeapocketshapedlikeaJbyburrowingunderatrophicscars onanacuteangle Sitesmustbedeepenoughthattheybleed Graftsshouldnotbeskinny Inmyexperience,0.60.75mmpunchcreatesmorepredictable growth thanneedle/bladerecipientsitesinhypertrophicor tetheredscars.

Maturescarcomprisesdensenon stretch collagen bundles with poor collagenbundleswithpoor bloodsupply

PostOperatively
Clark RAF 2nd ed,NY Plenum Press, 1996

Transplantedfolliclestakeupspace. 1cmtestareaincreasesto1.21cm

Postsurgicaloedema andbleeding Placedfolliclesoccupyspace Leads to increase Leadstoincrease intrascarpressure inhypertrophicscars

Can result in death of follicles early post-op

Result from OLSW Density Studies 04

158

FollicleKillingCombination
Nonstretchscar + Spaceoccupyingfollicle + Postsurgicaloedema =DEADFOLLICLES

NeedleRecipientSites
Atrophic Hypertrophic

Outcome: Probably will grow because most of the graft is in a pocket under the skin

Outcome: Probably will not grow pressure crushing follicle

Using0.60.75mmpunch
Atrophic Hypertrophic

WhySmallPunch?
Spaceforgraft SpaceforP/Oedema Oxygencandiffuseeasily Nopressureongraft Innature,folliclesare1mm apart. If0.7mmpunch removedfromeach1mm, 38.5%ofthescar debulked(r). If0.6mmpunch removed fromeach1mm,28.28%of scardebulked(r).

Outcome: Both have room to grow because there is no pressure on the transplanted follicle

Follicularunitsarefull thicknessskingrafts.Skin renewalfromthebulge. Fullthicknessgraftsin scarsactuallyconditions thescar. Atfollowup,evidence gg f suggestsareversalofscar tissuetonormalskin architecture: increasedthicknessand pinkness(angiogenesis) increasedmobilityand pigment

Blade Recipient Sites

Post Facelift

159

Blade Recipient Sites

Needle Recipient Sites

Superficial temporal artery trauma 40 yrs ago

2 procedures Artificial Hair Scarring

0.75mm punch posterior + blade slits anteriorly for burn

0.7mm punch posterior + blade slits anteriorly

Hypertrophic scars 0.7mm punch posteriorly Blade slits anteriorly 7 months post-op

0.7mm punch -Flap Necrosis

0.7mm Punch - Donor Beard Hair

Before After

2 transplants, 0.7mm punch

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0.7mm Punch

0.7mm Punch PH No Growth Needle Sites

Atrophic Scars (Burns)

Scar Before Post Op 0.7mm punch 7 Months Post Op P/O 0.7mm punch

Scar After

0.6 & 0.7mm Punch Traction Alopecia

GeneralRuleforInstrumentChoice
Ifthin,pigmented,mobileandpink, Usebladeincisions Ifthick,white,immobile, Use0.60.7mmpunchtodebulk

One year post-op

161

059 Micro-Incisonal Graft Removal Technique

Paul Rose, MD, Bernard Nusbaum, MD Hair Transplant Institute Miami, Coral Gables, FL, USA. Dr Rose is a Board Certified Dermatologist who has been performing hair replacment procedures for over twenty years. He has served as President of the ISHRS and has made numerous contributions to the field of hair restoration. Dr Nusbaum is a Board Certified Dermatologist. He serves on the ISHRS BOG and has served as Co-Editor of the FORUM.He has been performing hair restoration procedures for over twenty years and is also known for his work involving female hair loss. P. Rose: None. B. Nusbaum: None. ABSTRACT: Introduction:Hair restoration surgeons sometimes need to remove grafts that have previously been placed in a patient. These are grafts that may be too large and prominent and/or positioned in an incorrect location.A common method to remove the grafts is to use a punch to attempt to remove the graft and recover hairs that can be relocated. Oftentimes the rate of transection is high and few hairs are actually recovered. This may in part be due to the fact that the grafted hairs have a significant change in direction in the skin as opposed to the exit angle. Also fibrous attachments may make removal difficult.The authors have devised a novel way to remove grafts or parts of grafts with low transection rates and minimal scarring.Technique:The micro incisional graft removal technique is based on using custom made blades from a blade making device. These blades are placed in a commonly used blade holder employed for making recipient sites.Incisions are made in a quadrangular or triangular array and angled away from the graft hairs. The graft is lifted up and freed from any attachments with the blade or 20 or 18g needle. Discussion:The authors to describe a novel way to remove grafts or part of a graft while minimizing scarring and maximizing hair recovery.

162

ConflictofInterest
Noneapplicable

MicroExcisional GraftRemoval
PaulT.Rose,MDJD

NeedforGraftRemoval
Misplacedgrafts Increasedhairlossexposinggrafts Largegrafts

Techniquesforremovalofgrafts
IPL,Laser Enblocexcision Punchremoval
Handheldpunchormechanizeddevice

ProblemswithGraftRemoval
Transection inabilitytoaccountforhair angles,contractileforces, Buryingofgraft Inabilitytoremoveduetotethering/scarring bili d h i / i Punchrequiresentireedgebeplacedaround hairsandtrytofindoptimalangle

Microincisional Technique
Useofcustommadeblades Bladescanbecuttosizeattachedtovarious bladeholders,0.7 1.2mm,chiseltip D h Depthcanbeset b Haircutto12mm LocalAnesthesia TheincisionsaredirectedAWAYfromthehairs Threetofourincisionsaremadethesemayneed tobejoined,triangularorsquarewound

163

Microincisional technique
Graftisliftedwithforceps attimestwoare needed Thebladecanbeinsertedintothespace createdtocutanyfibrousstrands created to cut any fibrous strands 20gneedlecanbeusedtocutfibrous strands Woundisallowedtohealviasecondintention healing

AdvantageofMicroincisional technique
Decreasedrateoftransection morehairsfor locationtoothersites Lesschanceofregrowth ofhairs S ll Smallwoundslimitedscarring d li i d i

164

060 Eyebrow Transplantation: Techniques and Outcomes of Over 350 Cases

Jeffrey S. Epstein, MD University of Miami, Miami, FL, USA. Jeffrey S. Epstein, M.D., FACS, Founder and Director of the Foundation for Hair Restoration, has been in private practice in Miami and NYC since 1994. A board certified facial plastic surgeon, Dr. Epstein is a Voluntary Clinical Instructor at the University of Miami, and Past President of the Florida Society of Facial Plastic and Reconstructive Surgery. He has as special expertise in the repair of prior hair transplants, eyebrows and facial hair work, hair loss in women, and large procedures of 3000 plus grafts. J.S. Epstein: None. ABSTRACT: Through the performing of over 350 eyebrow transplant procedures over the past eight years, the author has accumulated a large amount of know-how and experience in techniques for achieving the most aesthetic results. Presented will be a review of the subtleties in achieving the most consistent and aesthetic results, and a review of patient candidacy- including the use of this technique on patients with a variety of etiologies of eyebrow loss. Through the presentation of numerous case examples, the goal is to help the hair transplant surgeon become more adept at performing this very specialized and challenging procedure.

165

16
166

day-by-day PrOGraM I FrIday

FrIday I OcTOber 19, 2012

6:00AM-6:30PM 6:00AM-6:30PM 7:00AM-8:30AM 8:15AM-9:15AM 8:15AM-6:00PM 8:15AM-6:00PM 9:00AM-10:00AM 9:00AM-6:00PM 9:00aM-9:40aM registration speaker ready room Workshops 201, 202, 203, 204, 205
(ticket required)

9:40AM-9:42AM
063

2 Moderator Introduction

Ralf Paus, MD

9:42AM-9:54AM 12 update on cell based hair regeneration egeneration studies 065 Ken Washenik, MD, PhD
Aderans Research Institute (invited speaker)

continental breakfast exhibits Poster Viewing surgical assistants Program committee

(invitation only)

9:54AM-9:59AM

5 Q&a

10:00AM-10:12AM 12 de novo hair Follicle Formation: Possible air applications in clinical situations 066 Gerd Lindner, PhD
Dept. of Biotechnology, Technische Universitt Berlin, Germany (invited speaker)

GeNeraL sessION

nORwOOd lectuRe
Moderator: Francisco Jimenez, MD
LeARning obJecTiveS Explore the contribution of the follicular cells in dermal repair and re-epithelialization of cutaneous wounds. Demonstrate the influence of the hair follicle cycle in the acceleration or retardation of the wound healing response. Discuss the possible effects of cutaneous wounding on hair follicular neogenesis. Understand the importance of the hair follicle in the biological mechanisms involved in the wound healing response.

10:12AM-10:17AM

5 Q&a

10:18AM-10:30AM 12 scalp Injection of active embryonic-like cell-secreted Proteins and Growth Factors ell-secreted 067 Gail K. Naughton, PhD, Histogen (invited speaker) 10:30AM-10:35AM
5 Q&a

10:36AM-10:48AM 12 The Latest discovery: Is PGd2 the real target to cure androgenetic alopecia? 068 Luis Garza, MD, PhD
Dept. Dermatology, University of Pennsylvania and Johns Hopkins University School of Medicine (invited speaker)

10:48AM-10:53AM 10:55AM-11:15AM 11:15aM-12:15PM

5 Q&a

9:00AM-9:02AM
061

2 Moderator Introduction

coffee break

Francisco Jimenez, MD

9:02AM-9:32AM 30 NOrWOOd LecTurer The hair Follicle 062 Wound healing connection Featured Guest Speaker: Ralf Paus, MD
Professor of Dermatology and Experimental Dermatology; Head, Experimental Dermatology, Dept. of Dermatology, University Hospital Schleswig-Holstein, Campus Luebeck, University of Luebeck, Germany, and Professor of Cutaneous Medicine, Institute of Inflammation and Repair, University of Manchester, Manchester, UK

nOn -SuRgical FRee papeRS

Moderator: Paul J. McAndrews, MD
LeARning obJecTive Discuss the diagnosis and therapy of several nonandrogenetic alopecias. Discuss different non-surgical alternatives to hair transplantation.

11:15AM-11:17AM
069

2 Moderator Introduction

Paul J. McAndrews, MD
7 Treatment of eyebrow hypotrichosis

9:32AM-9:40AM 9:40aM-11:00aM

8 Q&a

11:17AM-11:24AM
070

emeRging theRapieS: diFFeRent StRategieS tO induce haiR gROwth

Moderator: Ralf Paus, MD Panelists: Bruce A. Morgan, PhD
LeARning obJecTiveS Describe ongoing studies involving pharmacologic agents being tested for treatment of androgenetic alopecia. Discuss various research projects on the subject of hair and how they may impact therapies or treatments for hair loss.

with ubM + PrP Robert P. Niedbalski, DO

064

11:24AM-11:34AM 10 scalp Micropigmentation as a complement and an alternative to hair air 071 Transplantation William R. Rassman 11:35AM-11:42AM
072 7 Lichen Planopilaris Following hair

Transplantation Jeffrey Donovan, MD, PhD

FRi
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day-by-day PrOGraM I FrIday

11:43AM-11:50AM
073

7 scarring alopecia (chemical burns)

secondary to hair highlighting: an under reported entity William M. Parsley, MD

4:30PM-6:00PM

hOw i dO it videOS: pRactice tipS and SuRgical gemS

Moderator: Bertram M. Ng, MBBS
LeARning obJecTive Compare and contrast different surgeons approaches to various aspects of the hair transplant procedure.

11:50AM-12:02PM 12 current status of research and therapy to prevent chemotherapy induced alopecia 074 Joaquin Jimenez, MD
University of Miami (invited speaker)

4:30PM-4:32PM
078

2 Moderator Introduction

12:02PM-12:15PM 13 Q&a 12:30PM-2:00PM Lunch symposia 211, 212, 213

For all registered attendees except exhibitors. No extra fee required, but you must sign-up for the symposium of your choice during the registration process so we can properly plan for food and room size.

Bertram M. Ng, MBBS

5 how I do Fue: Tips to Maximize speed

4:32PM-4:37PM
079

& Efficiency John P. Cole, MD

4:37PM-4:42PM
080

5 how I do Fue at 2,000 extractions/hour

Luis Roberto Trivellini, MD

5 how I do Fue using a New

2:30PM-4:00PM

p OSteR R eview S eSSiOn

New the year! The poster presentations will be summarized and briefly reviewed by the moderators. Poster presenters are expected to sit in the first two rows of the audience so they may answer possible questions on the roving microphone. Following this session is the Poster Inquiry Session during the coffee break where audience members may wish to further study posters of interest.

4:43PM-4:48PM
081

extractor Punch Pascal J. Boudjema, MD

4:48PM-5:02PM 14 Q&a 5:02PM-5:07PM

082 5 how I do body hair Transplants

Sanusi H. Umar, MD
5 how I repair Wide donor scars using

Moderators: Robert S. Haber, MD, Marc R. Avram, MD and Sharon A. Keene, MD

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

5:08PM-5:13PM
083

Fue and 0.75mm Punches Bradley R. Wolf, MD Jose F. Lorenzo, MD

5:13PM-5:18PM
084

5 Implantation with Implanter Pen II

2:30PM-2:32PM

2 Moderator Introduction

5:18PM-5:32PM 14 Q&a 5:32PM-5:37PM

085 5 how I do eyebrow hT: Pearls for

Robert S. Haber, MD 2:32PM-3:00PM 28 Posters 1-13 075 Robert S. Haber, MD 3:00PM-3:30PM 30 Posters 14-25 076 Marc R. Avram, MD 3:30PM-4:00PM 30 Posters 26-38 077 Sharon A. Keene, MD 4:00PM-4:30PM coffee break & Poster Inquiry session

success Robert S. Haber, MD

5:38PM-5:43PM
086

5 how I Make recipient sites using

Micropunches Kazuhito Yamamoto, MD

5:43PM-5:48PM
087

5 how I Inject PrP in Patients with hair

Loss and hrs Fabio M. Rinaldi, MD

5:48PM-6:00PM 12 Q&a 7:15PM-8:45PM Presidents annual Giving Fund reception

(ticket required)

18 SAT
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061 Moderator Introduction, Norwood Lecture

Francisco Jimenez, MD NA, Las Palmas Gran Canaria, Spain. Dr. Jimenez is a dermatologist and hair transplant surgeon. Trained in Dermatology in Madrid, in Dermatopathology at the University of Miami, in Mohs surgery at Duke University and in Hair Restoration Surgery with Dr. Dow Stough in Hot Springs, Arkansas. Currently working in private practice in Gran Canaria, Canary Islands, Spain. Author of 44 publications in peer review journals and past Editor of the Hair Transplant Forum (2008-2010). Dr. Jimenez received the 2011 ISHRS Platinum Follicle Award. F. Jimenez: None.

062 The Hair Follicle - Wound Healing Connection

Ralf Paus, MD University of Luebeck, Luebeck, Germany, Germany. -- Medical studies and internship at the Universities of Wrzburg, Berlin, Vienna, Basle and Zurich (MD, Berlin: 1987) -- Post-doc: Yale University, New Haven, CT (1987-90) -- Dermatology residency and junior faculty appointments in Berlin, Germany (1990-98) -- Professor and Vice-Chair, Dept. of Dermatology, University of Hamburg, Germany (1999-2004) -- Visiting Professor, Max-Planck-Inst. f. Biochemistry, Martinsried (2005) -- Head, Exp. Dermatology, University of Luebeck (since 2005) -- Editor, Experimental Dermatol (since 2007) -- secondary appointment as Professor of Cutaneous Medicine, University Manchester (20%, since 2008) -- Main areas of research interest: Biology & pathology of the hair follicle, hair follicle stem cells, skin neuroendocrinology, wound healing R. Paus: None. ABSTRACT: EXPLORING THE HAIR FOLLICLE-WOUND HELAING CONNECTION While it is now well-established that hair follicle-associated epithelial stem cells play an important role in epidermal regeneration, the full extent of the pilosebaceous unit's contribution to cutaneous wound healing remains to be comprehensively explored. First, we dissect the multiple levels on which the cycling hair follicle impacts on skin function, ranging from

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epidermal proliferation via skin angiogenesis to cutaneous innervation and the skin immune system. Next, we portray the pilosebaceous as an amazingly productive "factory" for the differential, hair cycle-dependent release of multiple hormones, growth factors, peptides and other bioregulatory molecules many of which are known to impact on wound healing and/or angiogenesis, yet are not systematically exploited for the promotion of wound healing. We then briefly revisit the multiple distinct, but as yet incompletely defined and understood stem cell populations that are associated with the human pilosebaceous unit. This is done by focusing on the potential role of human keratin 15+ or nestin+ progenitor cells, their possible contribution to skin regeneration, and slowly emerging insights into their controls. After having delineated the intimate interdependence of skin wounding, hair follicle cycling, hair follicle neogenesis, and wound healing, we emphasize that skin with a maximal percentage of terminal anagen hair follicles heals best, and discuss why this may be so. A simple, but clinically relevant organ culture system of wounded human skin is reported that allows one to further explore preclinically the hair-skin regeneration connection. New data generated with this human skin organ culture assay are presented on how hair follicle-associated neuroendocrine signaling systems may be exploited to promote wound healing. This leads over to concluding perspectives and speculations on how hair follicle transplants, selected skin appendage-derived cell populations, and the manipulation of hair follicle cycling may be harnessed to promote cutaneous wound healing in the future, namely in chronic ulcer management.

063 Moderator Introduction, Emerging Therapies; Different Strategies to Induce Hair Growth
Ralf Paus, MD ISHRS, Geneva, IL, USA. -- Medical studies and internship at the Universities of Wrzburg, Berlin, Vienna, Basle and Zurich (MD, Berlin: 1987) -- Post-doc: Yale University, New Haven, CT (1987-90) -- Dermatology residency and junior faculty appointments in Berlin, Germany (1990-98) -- Professor and Vice-Chair, Dept. of Dermatology, University of Hamburg, Germany (1999-2004) -- Visiting Professor, Max-Planck-Inst. f. Biochemistry, Martinsried (2005) -- Head, Exp. Dermatology, University of Luebeck (since 2005) -- Editor, Experimental Dermatol (since 2007) -- secondary appointment as Professor of Cutaneous Medicine, University Manchester (20%, since 2008) -- Main areas of research interest: Biology & pathology of the hair follicle, hair follicle stem cells, skin neuroendocrinology, wound healing R. Paus: None.

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064 Panelist for Emerging Therapies Session

Bruce A. Morgan, PhD Harvard Medical School, Boston, MA, USA. Dr. Morgans laboratory studies the development and regeneration of cutaneous appendages in model organisms. Recent work has focused on the role of the dermal papilla (DP) in guiding hair morphogenesis and follicular regeneration. Mouse models that allow manipulation of gene expression specifically in the DP after the follicle has formed have been exploited to probe the role of specific signals between follicular keratinocytes and the DP. This work with model systems is integrated with a collaborative effort to understand the genetic variation driving the diversity in cutaneous appendage form and function within different human populations. B.A. Morgan: None.

065 Update on Cell Based Regeneration Studies

Kenneth J. 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; Aderans Research Institute/Bosley. Research Grant (principal investigator, collaborator or consultant); Allergan, Johnson and Johnson. Speakers Bureau/Honoraria (speakers bureau, symposia, and expert witness); Merck. Ownership Interest (owner, stock, stock options); Aderans Reserach Institute/Bosely. Ownership Interest (royalty, patent, or other intellectual property); Aderans Research Institute/Bosley.

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066 De novo Hair Follicle Formation: Possible Applications in Clinical Situations

Gerd Lindner, PhD Department of Biotechnology, Technische Universitt Berlin, Berlin, Germany. After assuming his current position as project leader of Organ Modeling at the Department for Biotechnology, Technische Universitt Berlin, Germany in 2006, Gerd Lindner co-founded the German tissue research biotechnology company, Tissues GmbH in 2010. Doktor Gerd Lindner graduated in biochemistry and researches into hair disorders and the science and applications of stem cells residing in the skin and other organs. He could recently succeed to culture a fully in vitro established human hair follicle equivalent for further integration into skin equivalents. He has published several high-ranked peer reviewed articles on hair and skin biology and serves as editorial board member in the journal Hair: Therapy & Transplantation. He is an active member of EHRS, ADF, FEBS societies. G. Lindner: Ownership Interest (owner, stock, stock options); I am a co-founder of TissUse GmbH. Under agreements between the Technische Universitt Berlin (TUB), TissUse GmbH is entitled to a share of the royalties received in future by the TUB.. Ownership Interest (royalty, patent, or other intellectual property); The technology for generating hair-follicle-like organoids is the subject of a patent from the Technische Universitt Berlin that includes me (Gerd Lindner) as an inventor.. ABSTRACT: We recently described the de novo formation of human hair follicle equivalents in vitro. A dermal papilla fibroblast (DPF) condensate resembles the germ of these in vitro formed microfollicles. In contrast to monolayer-cultured DPF, these self-aggregated neopapillae express different panels of growth factors, cytokines and extracellular matrix proteins necessary to induce organoid formation and fiber production comparable to native anagen dermal papillae. Gene expression profiling and quantification, protein secretion and ultra-structural analysis of this neopapillae were performed. In addition, we investigated the developmental stages during microfollicle formation and the onset of fiber production in comparison to normal anagen hair follicles. We also characterized the performance of bioengineered microfollicles introduced into a full-thickness skin equivalent which had been cultured under perfused conditions in a chip-based bioreactor. The self-organized neopapillae showed significant increased growth factor expression than monolayer-cultured DPF as shown by microarray analysis and RT-PCR. In addition, protein secretion by neopapillae described as relevant for hair growth was considerably raised in comparison to 2D -cultured DPF. Transmission electron microscopy showed the peri- and supra papillary localization of fibrous bundle formation giving rise to the onset of hair shaft production originated by dermal papilla fibroblasts developing a medulla-like backbone. We showed that the self-organized formation of human neopapillae and microfollicles in vitro corresponds to basic hair follicle developmental characteristics. The generated microfollicles can successfully been implemented into skin equivalents and culture periods can be significantly prolonged in the described bioreactor rendering this system valuable for in vitro substance testing and to study follicle development in general. With further improvements, the generated hair germs might in future be used as implants for treating reduced hair conditions.

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067 Scalp Injection of Active Embryonic-like Cell-secreted Proteins and Growth Factors
Gail K. Naughton, PhD1, Craig Ziering, MD2, Mark Hubka, MD1, Danielle Ehrlich, MD1, Michael Zimber, MD1 1 Histogen, Inc., San Diego, CA, USA, 2Ziering Medical, Newport Beach, CA, USA. Gail K. Naughton, Ph.D. CEO, Histogen, Inc. Dr. Naughton has spent more than 25 years in tissue engineering, holds more than 95 patents, and has been extensively published in the field. By growing cells under conditions that simulate the embryonic environment, Dr. Naughton discovered that unique proteins and growth factors are produced which are known to stimulate stem cells in the body. In 2007, she founded Histogen, Inc. with a focus on developing this naturally-secreted complex for hair growth and other indications. Among her previous experience, Dr. Naughton oversaw the development of the world's first up-scaled manufacturing facility for tissue engineered products and brought four human cell-based products from concept through FDA approval and market launch. G.K. Naughton: Employment; Histogen, Inc. C. Ziering: Consultant/Advisory Board; Histogen Scientific Advisory Board member. M. Hubka: Employment; Histogen. D. Ehrlich: Employment; Histogen. M. Zimber: Employment; Histogen. ABSTRACT: We have evaluated a bioengineered human cell-derived formulation, termed Hair Stimulating Complex (HSC), on the effects of hair growth activity in male pattern baldness and female diffuse hair loss. HSC is produced by cells grown on beads in hypoxic bioreactors and contains cytokines including KGF, VEGF, and follistatin. Follistatin antagonizes activin and BMPs, which maintain the quiescent state of hair follicle stem cell proliferation. We hypothesized that injection of this medium may increase the supply of progenitor and transit amplifying keratinocytes provided to the growing hair shaft, leading to an increase in the thickness of the hairs and a reversal of the miniaturization process. The initial pilot study was a single site, double-blind, randomized, placebo-controlled trial involving 26 males with androgenetic alopecia. At baseline, one area of the scalp received (4) 0.1cc intradermal injections of HSC and the parallel site received identical treatment with placebo. HSC showed an excellent safety profile and a statistically significant increase in hair shaft thickness (p<0.05) at 3 months and hair density at 3 months (p <0.03) and 1 year (p<0.03) as assessed by Trichoscan image analysis. Increased terminal hairs were seen in the entire treatment region, supporting the hypothesis that HSC stimulated resting and miniaturizing follicles to increase terminal hair growth. A Phase I/II, 55 patient trial with a similar protocol but with 8 injections of HSC and control at baseline, and a repeat dose at week 6, has successfully reached the 12 week primary safety and efficacy time point. At the primary efficacy target, statistical significance was noted in all endpoints which include increase in total hair count (p=0.0013), terminal hairs (p=0.0135), vellus hairs (p=0.033) and cumulative thickness density (p=0.0026). The Phase I/II study showed a 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. Over the first 24 week assessment period no product related adverse effects were reported and no evidence of toxicity was observed in any of the clinical indicators. Blood and urine samples were obtained at baseline as well as after each of the two sets of injections. Clinical evaluation of blood serum chemistry, hematology and urinalysis showed no changes from baseline over the course of the treatment and specifically no kidney, liver, or bone marrow toxicity. Blood samples are being tested for any evidence of anti-drug antibodies to the principle components of HSC. In addition, the overall responder rate over the 24 week assessment has been 96.15%. Subjects are being followed up to the 48 week final safety timepoint. HSC injections have been extremely well tolerated among more than 100 subjects receiving HSC to date, with the

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majority of subjects reporting no discomfort. An additional physician-sponsored study has been initiated by Dr.Craig Ziering to evaluate the safety and efficacy of HSC in 5 women and 5 men with androgenetic alopecia. This trial began as an open-label, FDA-regulated, 12 Week study with 3 visits (Day 0, Week 6 and Week 12). Each subject received 20 injections of HSC (10 injections in 2 treatment areas) at Day 0 and another 20 injections of HSC at Week 6. After patients showed a strong safety profile at week 12, they became eligible for an additional 40 injections at week 18 and 24. All patients who have reached the 12 week endpoint have shown new hair growth, with robust growth seen in several female subjects by week 18. Plans are underway to submit an IND for a Phase I/II study in women as well as a Phase IIB study in men. The safety and efficacy results seen with HSC represent a novel regenerative medicine approach in hair growth treatment by using bioengineered, cell-derived growth factors. This substantiates research around the activity of follistatin and other factors in hair growth stimulation and maintenance. Initial safety and efficacy endpoints were achieved, with statistical significance reached. In addition to the two successful trials with subjects with male pattern baldness, women with diffuse hair loss treated under a physicians IND showed notable new hair growth at 6 weeks, with an additional increase in hair at 12 weeks. These results represent an important advance in the treatment of androgenetic alopecia in both men and women.

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androgenetic alopecia in both men and women.

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068 The Latest Discovery: Is PGD2 the Real Target to Cure Androgenetic Alopecia?
Luis A. Garza, MD, PhD1, George Cotsarelis, MD2 1 Johns Hopkins Medical School, Baltimore, MD, USA, 2University of Pennsylvania, Philadelphia, PA, USA. Dr. Garza is an Assistant Professor at Johns Hopkins Medical school who practices dermatology and also runs a laboratory which studies the molecular biology of the hair follicle in multiple contexts. L.A. Garza: None. G. Cotsarelis: None. ABSTRACT: Testosterone is necessary for the development of male pattern baldness, known as androgenetic alopecia (AGA); yet, the mechanisms for decreased hair growth in this disorder are unclear. We show that prostaglandin D2 synthase(PTGDS) is elevated at the mRNA and protein levels in bald scalp compared to haired scalp of men with AGA. The product of PTGDS enzyme activity, prostaglandin D2 (PGD2), is similarly elevated in bald scalp. During normal follicle cycling in mice, Ptgds and PGD2 levels increase immediately preceding the regression phase, suggesting an inhibitory effect on hair growth. We show that PGD2 inhibits hair growth in explanted human hair follicles and when applied topically to mice. Hair growth inhibition requires the PGD2 receptor G protein (heterotrimeric guanine nucleotide)-coupled receptor 44(GPR44), but not the PGD2 receptor 1(PTGDR). Furthermore, we find that a transgenic mouse, K14-Ptgs2, which targets prostaglandin-endoperoxide synthase 2 expression to the skin, demonstrates elevated levels of PGD2 in the skin and develops alopecia, follicular miniaturization, and sebaceous gland hyperplasia,which are all hallmarks of human AGA. These results define PGD2 as an inhibitor of hair growth in AGA and suggest the PGD2-GPR44 pathway as a potential target for treatment.

069 Moderator Introduction, Non-Surgical Free Papers

Paul J. McAndrews, MD Paul McAndrews, M.D., Inc., Pasadena, CA, USA. Dr. McAndrews is a Board-Certified Dermatologist and Clinical Professor at University of Southern California School of Medicine, teaching the residents the latest advances in hair loss and hair transplantation. Dr. McAndrews was the Chairman for 2010 ISHRS Annual Scientific Meeting and is President of the American Board of Hair Restoration Surgery. Dr. McAndrews has private practices located in Pasadena and Beverly Hills, CA. Dr. McAndrews is a member of the International Society of Hair Restoration Surgery, the American Society of Hair Restoration Surgery, the American Academy of Dermatology, and the American Society of Dermatologic Surgery. P.J. McAndrews: None.

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070 Treatment of Eyebrow Hypotrichosis with UBM + PRP

Robert Niedbalski, DO Northwest Hair Restoration, Tacoma, WA, USA. Dr Robert Niedbalski has been performing hair restoration surgery since 1990 and became a member of the ISHRS in 1993. A Diplomate of the American Board of Hair Restoration Surgery since 2002, Dr. Niedbalski is also the Chairman of the ISHRS Fellowship Training Program Committee. He is the founder and Medical Director of Northwest Hair Restoration in Tacoma, WA R. Niedbalski: None. ABSTRACT: Introduction: ACell is a unique Extracellular Matrix (ECM) device used to repair and remodel damaged tissues. It functions as a biologic scaffold in damaged tissues providing both structural support and biological signals (chemotaxis) for cell adhesion, migration, and proliferation. It is comprised of a naturally occurring non-cross linked, acellular biomaterial, which is completely resorbable. ACell is indicated for the management of surgical wounds, including donor incisions and recipient sites for hair transplantation. In 2010 Dr Gary Hitzig described increased hair growth in patients with hereditary hair loss when he injected their scalps with a suspension of ACell and Platelet Rich Plasma (ACell/PRP). His findings were presented at the International Society of Hair Restoration Surgery Annual Scientific Meeting in Boston 2010. This study will examine the effects of ACell MatriStem in combination with Platelet Rich Plasma (ACell/PRP) on select patients with non-hereditary hair loss (hypotrichosis of the eyebrows). Because thinning eyebrows have nonscalp hairs that have undergone miniaturization not mediated by androgenetic factors, we hope to demonstrate the potential of ACell/PRP as a treatment for a wide spectrum of hair loss disorders. Objective: 12 volunteer test subjects (6 male and 6 female) will be evaluated for qualitative and quantitative improvements in eyebrow hairs up to one year after their brows were injected with a suspension of ACell/PRP. Results will be measured using standardized macro and micro-photography during a series of 6 follow up visits over a one-year period. Materials and Methods: Patients will be screened to meet the outlined selection criteria and will enter the study once they are selected and sign the study consent form. Patient Selection Criteria:

Age >20 and < 65 Total number of patients = 12 for the initial phase Must be able to complete all follow up visits at the author's clinic office Eyebrow thinning should be a chronic and gradual condition with an onset of no less than 1 year ago.

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Patients with a history of thyroid disease who are taking thyroid hormone supplement will be included provided they can provide documentation of normal thyroid levels (within the past 12 months) and no changes have been made to their thyroid hormone medication dosage for at least 6 months.

Patient Exclusion Criteria:

Eyebrow thinning as a result of trauma, scar History of Trichotillomania involving eyebrows or eyelashes New diagnosis of thyroid disease in the past 12 months

Length of the study: one year All test subjects will meet with the author for a consultation and the procedure will be explained in detail along with potential risks and complications. Photographs will be taken using standardized settings established for this study. 6 follow up examinations will be conducted at months 2,4,6,8,10 & 12. At each visit the following information will be gathered:

Macro and micro photographs of the eyebrows according to the study standard Record these observations for the 3 zones for each eyebrow (Medial, Central & Lateral) Monitor for any interim changes in the medical history of the patient especially any changes to their medication regimen (new Rx, change in dose etc)

The test subjects will not receive any remuneration for their participation in this study. They will not be charged for the ACell/PRP injections or the follow up visits. The study will begin with the acceptance of the first test subject and conclude one year after the last test subject has received their treatment. Discussion/Results; The first few follow up exams have demonstrated significant improvement in the four test subjects that have completed their 2 month follow up (100% compliance to date). The remaining 8 test subjects will have begin their treatment as of the writing of thisABSTRACT and will be included in the data by October. As seen in scalp treatment with ACell/PRP, I anticipate continued improvement in qualitative and quantitative measurements over the next 6-8 months. Conclusion; Acell/PRP will prove to be a suitable treatment hypotrichosis of the eyebrows and possibly other non-hereditary hair loss conditions such as Alopecia Areata. Additional study is warranted given the early success seen in this small sample pilot study.

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071 Scalp Micropigmentation as a Complement and an Alternative to Hair Transplantation

William R. Rassman, MD NHI, Los Angeles, CA, USA. Dr. William Rassman received his MD from the Medical College of Virginia. He was stationed as a surgeon in Vietnam and was certified by the American Board of Surgery in 1976. He holds multiple patents in medical devices, computer software and biotechnology. He has published chapters in text books on cardiac surgery and hair transplantation. Included in his published work in the field of hair restoration have been pioneering articles in megasessions, follicular unit transplantation and follicular unit extraction. He recently released a highly ranked consumer book Hair Loss & Replacement for Dummies available on Amazon.com and in major bookstores. W.R. Rassman: None.

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Scalp Micropigmentation (SMP)

William Rassman, M.D. Jae Pak, M.D. Jino Kim, M.D.
Los Angeles, California & Seoul, Korea
ISHRS Presentation October 2012

1. 2. 3.

Patients With Scars Patients P ti t With Thi i H i Thinning Hair Men Who Want The Shaved Look

SMP is a useful tool when used properly It is an easy process to do, but difficult to learn the touch must be light the depth must be controlled and replicated angles are critical in holding the instrument the time the instrument is in the skin is important mistakes in thousands of dots are permanent matching pigment to hair color varies with the
patients expectation often wrongfully drive this patient dissatisfaction is a common problem if

Patient With Alopecia Areata

patients skin tones and the patients problems process

expectations are not set properly

Patients With Scarring Alopecia

Operator: Dr. Jino Kim

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Scalp Reduction Scar Pigmented

Note Color Difference

Old Plugs + Multiple Scalp Reductions

Eyebrows are an external prosthesis

Open Donor Wound & SR Scars

Hair Transplant Strip Surgery Scar

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Detectable Scar Plus Frontal Recession

Transplant Patient Wanted Fuller Look

Woman Patient Wanted Fuller Look

Normal Young Man Wanted To Have The Shaved Look

Normal Young Man Wanted To Have The Shaved Look

Normal Young Man Wanted To Have The Shaved Look

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Normal Middle Age Man Wanted To Have The Shaved Look

Normal Middle Age Man Wanted To Have The Shaved Look

Normal Young Man Wanted To Have The Shaved Look

Normal Young Man Wanted To Have The Shaved Look

Thank You

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072 Lichen Planopilaris Following Hair Transplantation

Jeff C. Donovan, MD PhD Hair Club Medical Group, Toronto, ON, Canada. Jeff Donovan, MD PhD is a dermatologist and hair transplant physician. In addition to his hair restoration practice with Hair Club Medical Group, Dr. Donovan is an Assistant Professor of Dermatology at the University of Toronto. He conducts clinical research in hair loss and runs a weekly hair loss clinic at the Sunnybrook Health Sciences Centre. He has a third consultative practice in hair loss at the Cleveland Clinic Canada. J.C. Donovan: None. J.C. Donovan: None. ABSTRACT: Introduction: At the 2011 meeting of the ISHRS, Dr. Nifoler Farjo and colleagues reported an association between lichen planopilaris and hair transplantation. Objective: To present additional cases of lichen planopilaris developing following hair transplant surgery. Materials and Methods: A retrospective review of the records of all patients referred to a university based Hair Clinic over the period January 2010 - February 2012 with a diagnosis of lichen planopilaris or frontal fibrosing alopecia was performed. Cases associated with prior hair transplantation were extracted for further study. Discussion: The study group included 11 patients (8 men and 3 women). The average age was 41 (range 29-72). 9 cases of lichen planopilaris following hair transplantation and 2 cases of frontal fibrosing alopecia following hair transplantation were identified. None of the 11 patients were thought to have cicatricial alopecia prior to surgery. The average duration between surgery and the development of lichen planopilaris was 2.7 years (range 13 months to 8 years). Eight patients were symptomatic with itching, burning or pain. Three patients reported loss of all transplanted hair. Seven of the 11 patients had classical lichen planopilaris morphology with prominent perifollicular erythema and scale. Conclusion: This study offers further support for a possible association between lichen planopilaris and hair transplantation in some patients. The incidence of this phenomenon and risk factors remain to be clarified.

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073 Scarring Alopecia (Chemical Burns) Secondary to Hair Highlighting: An Under Reported Entity
William Parsley, MD Dr. William Parsley, Louisville, KY, USA. William Parsley, MD graduated from Univ of Tennessee Med School (1969) and completed Dermatology at the Univ of Louisville (1975). Positions: Past President- ISHRS ISHRS BOG and EC Past Chair of the ASHRS Past President of the ABHRS Past moderator of the Hair Transplantation Forum for the AAD Past BOT of the American Academy of Cosmetic Surgery Past Editor- Hair Transplant Forum International BOT- Hair Foundation. Past President- Kentucky Dermatologic Society Diplomate: Am Brd of Dermatology Am Brd of Dermatopathology Am Brd of Hair Restoration Surgery Awards: ISHRS Golden Follicle Award- 2003 Manfred Lucas Award- 2011 ISHRS CME Award W. Parsley: None. ABSTRACT: Hair highlighting is a very frequently performed procedure in hair salons all over the world. Not only does it enhance the cosmetic appearance of the hair, but it also allows a more natural appearance. The most commonly used steps are a dye mixture, hydrogen peroxide, ammonia, a powdered persulfate booster, aluminum foil hair wrappings and the application of heat. The hair is bleached as it is dyed and an alkaline environment is necessary for success. While the procedure is done safely for millions, the treatment is caustic and there have been an increasing number of cases of dramatic scalp ulceration resulting in a scarred hairless patch or patches, usually at or near the vertex. The circumstances that lead to these ulcers are not known but there has been considerable speculation. To date 10 cases have been presented in the world literature. Through the help of ISHRS members, 6 new cases are presented. However, the ISHRS article in Forum 2- 2011 would indicate at least 20 more unreported cases. Thoughts on causes, prevention and treatment will be presented.

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Bahamas

Bahamas

ScarringAlopecia(chemicalburns) SecondarytoHairHighlighting

WilliamM.Parsley,MD Louisville,KY

Bahamas 1StepHighlighting
PermanentDye Ammoniamix HydrogenPeroxide
(developer)
Hydrogen Peroxide
(developer)

Bahamas 2StepHighlighting
Powdered Bleach
(lightener,booster))

Toner
Neutralizing shampoo Coldrinse
Heat?

Foils

Coldrinse
Heat

Foils

Neutralizing shampoo

Age 16yrs Sex female UlcerSize 3x5cm Location vertex

Bahamas

Case1

Dr.Parsley

Age 20yrs Sex female UlcerSize 5.5x3.5cm Location vertex

Bahamas

Case2

Dr.Boden

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Bahamas

Case2

Age 18yrs Sex female UlcerSize 3.8x3.0cm Location vertex

Bahamas

Case3

Dr.Boden

Age 15yrs Sex female UlcerSize 9x3cm Location vertex

Bahamas

Case4

Dr.Bishara

Age 24yrs Sex female UlcerSize 3.5x2.9cm Location vertex PtdevelopedFolliculitisDecalvans

Bahamas

Case5

Dr.Knudsen

Age 17yrs Sex female UlcerSize 5x2.5cm Location lowervertex

Bahamas

Case6

Dr.Collins

Age 34yrs Sex female UlcerSize 10x12cm Location Rfront/midsc

Bahamas

Case7

Dr.Collins

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Bahamas

Bahamas

Bahamas
AllReportCasesinLiterature
Teenagers 11/17(1217) Adults 6/17(2034) Vertex 11/17 Elsewhere 3/17 Notreported 3/17

Bahamas CauseofUlcers? Thermal?

speculatedin1st reportedcasebecauseofpattern& patientssparsehair earlyonsetofsyxs(somelessthan5min) noproof Neededinformation HPconcentrations Haircolor Bleach/HPratio Tempofheat

Ageofpts

Ulcerlocation Foils 13/14

1 bag

Chemical?
suggestedbybiopsy nofracturingofhair relationshiptochemicalconcentrations

Heat allreported

Combinationthermalandchemical?

Bahamas HydrogenPeroxide
(developer,oxidizingagent,catalyst)

Bahamas HydrogenPeroxide
(developer) StoredatacidpH Needsalkalinitytobeactivated Onceactivated,oxidizesthedye Digestshairkeratinandmelanin creatingO2 igests hair keratin and melanin creating O Miximmediatelybeforeuse Bestforoxidizeddyemoleculestoforminhairshaft Increaseinvolumes=increaseinskindamage Creamformlessdamagingthanliquid

3%=10volumes
Digestskeratin,releasingO2

6% 20 volumes 6% =20volumes 9%=30volumes 12%=40volumes

0 0

Bleaches(lifts)thehair

Oxidizesthedye whichis depositedinthecortex

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To thepH 1. Ammonia

Bahamas

Bahamas

PowderedBleach
(booster,activator,lightener)
usedin1225%persulfateconcentration

somedontlikethesmell

moreeffectiveinlighteninghair

2.Creamlighteners

AMP(aminomethylpropanol) MEA(monoethanolamine)

nooffensiveodor canstillbequitedamagingtohair

Usuallycontainpersulfates (sodium,potassiumandammonia) Usedwhenmoreaggressivebleachingisdesired(4levelsormore) C Cancauserespiratoryirritationandcontactdermatitisforthe i t i it ti d t td titi f th stylists ammoniapersulfatetheprimaryoffender Ammoniapersulfateisthemosteffectivebleach Needstobemixedthoroughly Foroffscalpuse(foilsorbag)mostcommonly Professionalscanpurchasestrongerconcentrationsthanpublic

Bahamas

Bahamas

HairColorChart
12 UltraLtBlonde 11 SuperLtBlonde 10 LightestBlonde 9 VeryLtBlonde 8 LightBlonde 8 Light Blonde 7 MediumBlonde 6 DarkBlonde 5 LightBrown 4 MedBrown 3 DarkBrown 2 VeryDarkBrown 1 Black 12 UltraLtBlonde 11 SuperLtBlonde 10 LightestBlonde 9 VeryLtBlonde 8 LightBlonde 8 Light Blonde 7 MediumBlonde 6 DarkBlonde 5 LightBrown 4 MedBrown 3 DarkBrown 2 VeryDarkBrown 1 Black

LiftLevels

Lift Lif

LiftLevels
12 UltraLtBlonde 11 SuperLtBlonde 10 LightestBlonde 9 VeryLtBlonde 8 LightBlonde 8 Light Blonde 7 MediumBlonde 6 DarkBlonde 5 LightBrown 4 MedBrown 3 DarkBrown 2 VeryDarkBrown 1 Black 10vol nolift 20vol 12levels 30vol 23levels

Bahamas

Bahamas

Effectofalkalisolutions
pH 7.0 pH911
ammonia Permdye HP

HydrogenPeroxideLiftLevels Hydrogen Peroxide Lift Levels

Permdye +ammonia HP

190

HairMelanin
Eumelanin
(granules)

Bahamas

HairMelanin
Eumelanin
(granules)

Bahamas

Phaeomelanin
(diffuse)

Hydrogenperoxidein alkalineconditions

diffuse?

Bahamas

LiftLevels
12 UltraLtBlonde 11 SuperLtBlonde 10 LightestBlonde 9 VeryLtBlonde 8 LightBlonde 8 Light Blonde 7 MediumBlonde 6 DarkBlonde 5 LightBrown 4 MedBrown 3 DarkBrown 2 VeryDarkBrown 1 Black 20vol 10vol 30vol

Bahamas RiskFactorsforhairhighlightingulcers
1. Foilwrapping 2. Excessiveheat 3. Highvolumesofhydrogenperoxide 4. Teenagers 5. Continuingprocedureifpaindevelops 6. Lackofimmediate treatment 7. Metalsinhair(gradualdyes,metalinwellwater) 8. Inattentiontoclient 9. Lengthoftreatment 10.Powderedbleach highconcentrations highhydrogenperoxide/bleachratio(2:1orhigher) 11.Redhair? 12.Shampooinghairbeforehairhighlighting 13.Breaksinskinbarrier

HPLiftLevels

Hydrogen Peroxide + Powdered Bleach

Bahamas RiskFactorsforhairhighlightingulcers
*mostsignificant

1. Foilwrapping 2. Excessiveheat 3. Highvolumesofhydrogenperoxide(30orhigher) 4. Teenagers 5. Continuingprocedureifpaindevelops 6. Lackofimmediate treatment 7. Metalsinhair(gradualdyes,metalinwellwater) 8. Inattentiontoclient 9. Lengthoftreatment 10.Powderedbleach highconcentrations highhydrogenperoxide/bleachratio(2:1orhigher) 11.Redhair? 12.Shampooinghairbeforehairhighlighting 13.Breaksinskinbarrier

Bahamas HairHighlightingvsGeneralBleaching whytheulcers? PastewithhighvolHPandpowderedbleach (offhair) Foils Highheat Superheatingoffoilsandcontainedpaste Foilcontactwithskin/spillageofpaste

191

Bahamas Treatment
Stopprocedureatfirstsignofsymptoms(especiallyif painissevere) Immediate treatmentappeartobevital
g g thoroughrinsingwithcoldclearwater neutralizing(acidic)shampoo lengthywetflushingwithacidicsolution(vinegar)

Bahamas Prevention
Communicationbetweenthemedicalfield,cosmetic manufacturersandprofessionalstylists Betteralertsystemforproductandprocedural complications Clarificationofriskfactors Educationastoimmediatecare Reportandinvestigateallcases

Supportivetherapyuntilulcerformsandheals Surgicalrepairlater

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074 Current Status of Research and Therapy to Prevent Chemotherapy Induced Alopecia
Joaquin J. Jimenez, MD University of Miami School of Medicine, Miami, FL, USA. Dr. Joaquin J. Jimenez is an Associate Professor at the University of Miami Miller School of Medicine in the Department of Dermatology and Cutaneous Surgery and in the Department of Biochemistry and Molecular Biology. Dr. Jimenezs primary interest is the study of Chemotherapy-Induced Alopecia. He developed the first animal model of Chemotherapy-Induced Alopecia and has been involved in translational clinical trials to extrapolate research findings to clinical applications in Chemotherapy-Induced Alopecia. J.J. Jimenez: None. ABSTRACT: Alopecia is one of the most distressing side effects of chemotherapy. It has profound psychosocial implications for cancer patients and their families. The young rat model was the first animal model to study chemotherapy-induced alopecia. Indeed, it has been the only model to be used in combination with a human study with the same positive outcomes. While CIA is usually transient, some patients suffer from changes in hair texture, such as thinning, hair discoloration, or in rare cases, permanent alopecia. In this vein, there is evidence that CIA may worsen or precipitate androgenetic alopecia. The current interventional approaches are scalp cooling for the prevention of the ensuing alopecia and 2% minoxidil to aid in the regrowth of hair. Other methodologies such as the use of calcitriol, have been put forth as possible candidates to treat CIA. In spite of promising results, all methods to prevent CIA, including scalp cooling, need to be validated by larger clinical trials comparing chemotherapies that work through different pathways. Another aspect that needs to be addressed is whether any protective agent will have an effect on the efficacy of the antineoplastic agents. Nevertheless, it has become clear that hair transplantation may be a feasible approach in patients who have developed androgenetic alopecia or partial alopecia post-chemotherapy.

075 Moderator Introduction, Poster Review Session, Posters 1-13

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. He has authored ten textbook chapters, 18 original reports, and has presented over 140

193

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.

076 Poster Review Session, Posters 14-25

Marc R. Avram, MD New York, NY, USA. Dr. Marc Avram is a Harvard trained, board certified dermatologist who specializes in hair transplantation and cosmetic skin procedures. He has maintained a private practice in New York City for the past 15 years, and also holds the position of Clinical Professor of Dermatology at The Weill-Cornell Medical School. Dr. Avram has authored three textbooks on Hair and Cosmetic Dermatology: the upcoming Color Atlas of Cosmetic Dermatology, 2nd Edition, published by McGraw-Hill in 2011, Hair Transplantation, published by Cambridge University Press in 2010, and The Color Atlas of Cosmetic Dermatology, which was published by McGraw-Hill in 2007. M.R. Avram: None.

077 Poster Review Session, Posters 26-38

Sharon A. Keene, MD na, Tucson, AZ, USA. Dr Sharon Keene trained in general surgery at the University of Arizona, before eventually establishing a practice focused on hair restoration surgery in the early 1990's. Since then she has focused her practice on refining techniques in follicular unit transplantation, and hair line design--the latter via surveys of normal hair lines in mature men and men without hair loss in order to establish what 'normal 'contours are. She has been an innovator and

194

supports innovation in the field for surgical tools as well as promoting the science of hair loss to improve ability to medically and surgically treat hair loss. S.A. Keene: None.

078 Moderator Introduction, "How I Do It" Videos: Practice Tips and Surgical Gems
Bertram M. Ng, MBBS Dr. Bertram Medical Hair Transplant, Kowloon, Hong Kong. Bertram Ng is a Certified ISHRS Fellow and ABHRS Diplomate. He served as examiner for ABHRS and Co-editor for the ISHRS Forum. His special interest is in hairline restoration. In 2008 he first designed a hand-held laser device for hairline placement, which is now in production. In 2009 ISHRS Scientific Meeting he introduced a new system in setting the hairline anterior-most point when the Golden Rule of Third cannot apply. Knowing that not all patients are candidates for giga-session, he is finding a way to achieve the best result with the minimal number of grafts. B.M. Ng: None.

079 How I Do FUE: Tips to Maximize Speed & Efficiency

John P. Cole, MD International Hair Transplant Institute, Alpharetta, GA, USA. Private Practice Hair Transplant Surgery since 1990 J.P. Cole: None. ABSTRACT: FUE can be a laborious procedure that is very time consuming. Over the years, the author has developed many time saving methods to speed the process of FUE so that the rate of extraction and graft placement is similar to strip

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harvesting. The author will present methods to maximize speed and efficiency in delivering FUE. This includes proper pre-operative planning, maximizing the rate of extraction, getting the most efficient use of staff, and having the most hands working on the patient at any given time.

080 How I Do FUE at 2,000 Extractions/Hour

Luis R. Trivellini, MD Hair Again, Asuncion/, Paraguay. How I do my FUE procedure L.R. Trivellini: None. ABSTRACT: This is a summary of surgical video of follicular unit extraction (FUE) in the same, showed a mechanized system for the extraction of follicular units, aided by suction, compose by a straight handpiece, with a low engine revolutions, a hole punch reusable little edge, inner diameter varies from 0.75 to 1 mm, a microprocessor (which also has discriminated units the number of hairs per unit, extraction time and duration of surgery), controls the system. The handpiece is connected through a hose to a vacuum system. For extraction, we use only local anesthesia with lidocaine 0.20% with epinephrine 1:400,000, without sedation, tumescent infiltration with ringer lactate, the position of the patient in the prone position with the neck flexed at 40 degrees. The punch starts spinning when making contact with the scalp, separating the tissue around the unit, passes through the dermis, from this point the needle virtually stops and performs micro oscillating movements with the aid of the suction unit aligned in parallel within the needle penetrates the adipose tissue 2 mm beyond the hair bulb literally making micro liposuction. Besides the advantage of using the suction (absence of manipulation, 0% of units buried, parallel alignment of the needle within the follicle) present in all systems using the same, our device differs from these by the design of the needle, which is sharp on the inside edge by adopting inside a conical shape with a trap to stop the graft sucked, so I can immediately insert the graft, with the same handpiece previously made [[Unsupported Character - &#8203;]][[Unsupported Character - &#8203;]]incisions in the recipient without any further manipulation and if the patient's position does not allow me to do the removal and insertion while I can download the graft directly from the handpiece to a reservoir waiting to be implemented at the time I have a permanent quality control grafts. Another noteworthy fact is that the needle automatically stops the dermis through adapting to the different types of scalp, so the doctor is freed to coordinate the movement of the hand and foot with adequate precision. The straight handpiece is specifically designed for suction-assisted FUE and allows me to place me so that I can display the address of the unit in the two planes, so that working with this piece, in a position we are naturally accustomed, with a needle that automatically stops, we can extract 2000 or more units in one hour

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extraction rate by low transection surgery less tedious for the doctor and use a punch that penetrates beyond the grafting bulb has more fat around them, giving it greater resistance to possible traumas, primarily to dehydration with the consequent benefit to the patient.

081 How I Do FUE Using a New Extractor Punch

Pascal Boudjema, MD Centre Medico-esthetique, Paris, France. Dr. Boudjema received his Doctor of Medicine degree at the University of Medicine of Paris (France) in 1986. He has pioneered new techniques and patented several inventions in the hair transplant field such as the HTS CALVITRON first automated hair transplant machine, the Multi-bladed MICROTOM which cuts several hundred grafts in few seconds . He also invented the HAIR IMPLANTER PEN, which allows rapid non-traumatic implantation of follicular grafts into the scalp. He also invented the concept of motorized alternate rotation of the punch applied to the FUE technique (FUExtractor). Those techniques have been presented in international scientific meetings. Dr Boudjema continues to push the state of the art of hair transplantation to new horizons. P. Boudjema: Ownership Interest (royalty, patent, or other intellectual property); royalty, patent, or other intellectual property. ABSTRACT: Introduction: This is anABSTRACT for a surgical video. Various techniques have been developed to improve follicular unit extraction. Usually those techniques require two steps: first step consisting in coring the skin with a punch (manually or motorized) and a second step consisting in graft harvesting with forceps. Two well known instruments have been developed to cut and to harvest simultaneously the graft by succion inside the punch: the Calvitron (first automated device developed in 1994) and most recently the Neograft. Unfortunately, in both devices, the harvested grafts may be incomplete or sectioned in their middle portion due to the traction applied by succion on the upper portion of the graft. A new instrument invented by the author, allows cutting and harvesting the graft in one step thanks to a specific proprietary designed punch in which the graft is grasped at its base inside the skin before punch withdrawal. Technique : The technique will describe the concept of the invention and its use during a typical FUE session particularly how the grafts are harvested and well preserved. Discussion: The instrument is different than all conventional punches used in FUE technique. It can be adapted as well on a manual handle or on a motorized hand-piece. The new instrument is easy to use, accurate, and time-saving indicated

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for FUE technique. (*) Patents pending.

082 How I Do Body Hair Transplants

Sanusi Umar, MD FineTouch Dermatology Inc, Redondo Beach, CA, USA. Dr. Sanusi Umar is a diplomat for the American Board of Dermatology, prior diplomat for the American Board of Internal Medicine, a Fellow of the American Academy of Dermatology, and a member of the ASDS.Dr. Umar was fellowship trained with the AACS. His areas of specialty include development of advanced FUE technologies and tools, long-term graft yield of head and non-head sources, hair transplant repair, and the artistry of hairline design. His recent publications in the Annals of Plastic Surgery and Archives of Dermatology report on his use of non-head donor hair Dr Umar holds associate faculty positions at both UCLAs Harbor and David Geffen departments of medicine in the dermatology division.

S. Umar: Ownership Interest (royalty, patent, or other intellectual property); UGraft, Upunch. ABSTRACT Introduction: Nonhead hair for hair transplantation has been successfully used in select cases (1,2), including in those with inadequate scalp donor supply. However, the technique for this procedure has not been well described in the literature. This surgical video describes a method and tools for the extraction of nonhead hair. Technique: The procedure was performed under local anesthesia by subcutaneous injections of epinephrine (1:100,000) and 1% lidocaine/0.25% marcaine in a 5:1 ratio for recipient areas, and a further dilution (5:1) with normal saline for donor areas. No attempt is made to tumesce the area. A customized punch (uPunchTM) was mounted on a rotary tool (uGraftTM Harvester). The uPunchTM was then used to cut around individual hair follicles to a depth exceeding the bulge area. The uGraftTM Harvester incorporates a device that hydrates the grafts during the course of extraction. The freed hair follicle is pulled out effortlessly with occasional aid of blunt needle tip dissection. Wounds created by the uPunchTM widen with depth, hence minimizing injury to follicles and enhancing wound closure. For recipient grafting, slits were created using blades that were custom sized to the size of the extracted grafts.

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Discussion: In select patients, this technique can be used for nonhead hair in hair transplantation.

083 How I Repair Wide Donor Scars Using FUE and 0.75mm Punches
Bradley Wolf, MD NA, Cincinnati, OH, USA. Bradley Wolf M.D. has been treating hair loss patients since 1990. He has made over 30 lecture presentations at meetings throughout the world, was director of workshops at the 2002 ISHRS meeting , served as faculty at eight ISHRS workshops, and is the director of the Hands on FUE workshop, ISHRS meeting 2012. 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 Committee, he is a current member of the CME committee. He is ABHRS Board Certified and was a member of the Board of Directors of the ABHRS from 2000-2005. B. Wolf: None. ABSTRACT Grafting strip FUT scars using FUE grafts into recipient sites made with a 0.75mm punch will be shown by video.

084 Implantation with Implanter Pen II

Jose F. Lorenzo, MD Injertocapilar.com, Madrid, Spain. -Dr. Jos Lorenzo was born in the Canary Islands, Spain. Dr. Lorenzo received his medical degree at the University Complutense of Madrid in 1991. He completed his General Surgery residency in 1996 and the Thoracic Surgery residency in 1998. In the field of hair transplantation since 2003. Currently, Dr Lorenzo is in private practice in his own clinic in Madrid (Spain), coordinating a team that only do FUE technique.

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J.F. Lorenzo: None. ABSTRACT: Introduction: This is a new handing of the implantation technique with the aid of the implanters. In the previous edition, we have explained the general technique without delve too much into complications. In this video we want to focus on the different maneuvers we can carry out when those complications arise, mainly bleeding and popping. We want to introduce a variation of the technique: the modified stick-and-place method with implanter that can help when treating scars or fibrotic tissue. And finally, the role of the implanter as substances carrier like Acell and similar through the dermis. Complications Technique: Bleeding: we normally work in a seated posture with the patient at an angle of 45 degrees or less for the frontal area and 60 degrees or more for the crown area. When there is more bleeding than desired, we must check that the patient is not hyper-extending the neck; we have to elevate the patient trunk and seek an adequate angle of insertion of the needle to find the avascular plane which minimizes the trauma from insertion. All of this together with the adequate dosage of vasoconstriction should give us the desired result. Popping: the most undesirable complication. When it occurs, our best defense is the traction movement carried out by the left hand. Maximizing the angle, looking for the avascular plane, helps to avoid exerting pressure during the insertion. The maximum pressure is applied in the moment that the needle perforates the skin: multiple movements will be described to prevent the output of the units already inserted. Discussion: We have been using the implanters every day since 2003 and we have learned from self-experience, evolving and changing in such a way that the implanter has become an indispensable tool for us during follicular unit implantation. The implanter requires an in-depth knowledge and precise techniques to be beneficial to the surgeon. We hope this video will show some details that can help and improve the technique of those interested in the use of implanters.

085 How I Do Eyebrow HT: Pearls for Success

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

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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: Ownership Interest (royalty, patent, or other intellectual property); Haber Spreader- Ellis Instruments. ABSTRACT Objective Eyebrow transplantation represents an advanced technique that demands knowledge of anatomy, aesthetics, high quality graft preparation, and expert implantation technique. Failure of eyebrow work is both highly obvious and highly stressful for both patient and surgeon. This presentation will review normal eyebrow anatomy, tips for eyebrow placement and design, review of critical aspects of graft preparation, and our approach for anesthesia, site creation, and graft implantation. Methods Key elements will be shown including using video demonstrating variations of normal and design elements. Results An eyebrow transplantation will be presented from start to finish, demonstrating the effectiveness of our technique. Conclusion Eyebrow transplantation is a skill that must be part of an experienced surgeons repertoire. This presentation is intended to share successful design and implementation strategies.

086 How I Make Recipient Sites Using Micropunches

Kazuhito Yamamoto, MD Umeda Beauty Clinic, Osaka-Umeda, AD BLD 9F, 2-15-29, Sonezaki Kita-ku, Osaka, Japan. Dr. Kazuhito Yamamoto has been engaged as the director of the Hair Transplant Clinic in Osaka, Japan, from 2004. He received his medical degree from Kyoto Prefectural University of Medicine in 1999. He is a seven year member of the ISHRS from 2006, a Diplomate of the Japan Surgical Society and the Japanese Society of Gastroenterology. K. Yamamoto: None. ABSTRACT Introduction: We have developed follicular unit (FU) transplant with micropunch incisions for eight years, and the satisfactory result is obtained by the delicate site creation using micropunches in recent years. I would like to present a video

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showing my personal technique that was published in Dermatologic Surgery. Objective: The objective is to demonstrate the techniques about FU transplant with micropunch incisions which we are actually performing at present. Materials and Methods: Graft: Individual FU grafts are usually made as medium size FU grafts that most of the fatty tissue and the epidermis in each graft are removed. Some epidermis is, however, saved depending on the size of the recipient site. Relation between the micropunch size and the chosen graft: For example, 0.75 mm micropunch is used for medium size to large size 2-hair FU graft, small size 3-hair FU graft and 1-hair + 1-hair pairing FU grafts in a case of 100 micron hair caliber on average in Japanese people . Relation between the selected micropunch and the maximum density: For example, the maximum density is 40/cm2 or less in 0.75 mm micropunch. Discussion/Result The use of micropunch has the following advantages: (1) the volume reduction due to the tissue removal and the decompression to the surrounding tissue to accompany it: The graft of larger volume can be chosen for a micropunch as compared to a slit of the same incision length. There is also less popping in micropunches especially in the tight scalp. (2) Since it is easy to distinguish the micropunch incisions, magnifier is not necessarily required at the graft placement process and the holes is not missed even though there are lots of existing hairs in the recipient scalp. Therefore, the speed of graft insertion is generally higher than with the slit technique and the fatigue of the staff is reduced sharply. (3) If the residual skin of the grafts are arranged at the level of the surrounding skin surface, neither pitting nor tenting will happen and the scar also heals physiologically. Conclusion: This method is a safe and effective even if the case is dense-packing or bigger session and can be considered to be valid as one of the site creation techniques because of many advantages that are different from FUT with slit incisions. Reference: Yamamoto, K. Micropunch (0.8 mm or less in Diameter) Hair Transplantation. Dermatol Surg 2011;37(9):1321-6.

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087 How I Inject PRP in Patients with Hair Loss and HRS
Fabio Rinaldi, MD NA, Milan, Italy. Dr. Fabio Rinaldi has been practicing hair restoration surgery at Studio Rinaldi since 1989. F. Rinaldi: None.

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saTurday I OcTOber 20, 2012

6:30AM-5:30PM 6:30AM-4:00PM 6:45AM-8:00AM 7:30AM-2:30PM 7:30AM-12:30PM 7:00AM-8:00AM registration speaker ready room continental breakfast exhibits Poster Viewing breakfast with the experts
No extra fee. Open to all attendees on a first-come, firstserved basis. This is an informal session for small groups to discuss a specific topic. Come with your questions. Round banquet tables will be set in the back of the General Session room. Each table will be labeled with a topic and experts name. Get your breakfast from the exhibit hall and then sit at the table of your choice to have breakfast with an expert.

day-by-day PrOGraM I saTurday

8:15AM-5:00PM 8:15aM-9:45aM

GeNeraL sessION

cOntROveRSieS and hOt tOpicS in haiR ReStORatiOn SuRgeRy

Moderator: Mario Marzola, MbbS Panelists: John P. Cole, MD, Sharon A. Keene, MD and William R. Rassman, MD
LeARning obJecTive Recognize and discuss a variety of hot topics as identified by ISHRS membership, including donor area safety in FUE, hair graft survival in FUE compared with FUT, and robotic hair harvesting.

104 105 106

d OnOR a Rea S aFety

in

Fue

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

088 089 090 091, 092 093 094 095 096 097 098 099

100 052 101 102

1) Getting started with adding Fue to your Practice James A. Harris, MD 2) how to Manage big Fue cases John P. Cole, MD 3) My experience with different Fue devices Mark S. DiStefano, MD 4) advances in hair biology: PGd2 and Other stories Luis Garza, MD, PhD & Ralf Paus, MD 5) Ischemia-reperfusion injury and hair Follicle Viability William D. Ehringer, PhD 6) how to design a correct hairline Ronald L. Shapiro, MD 7) hair Transplantation in Women: how to choose the candidate and surgical Planning Paul C. Cotterill, MD 8) eyelash hT: Pearls & Pitfalls Marcelo Gandelman, MD & Bernardino A. Arocha, MD 9) Prerequisites for a New hair Transplant Practice Sanjiv A. Vasa, MD 10) Leveraging social Media for Patient relations Matt Batt, ISHRS Integrated Communications Manager 11) spanish-speaking Table: Tips for Fue, Manual and Power, Indications Alex Ginzburg, MD 12) Korean-speaking Table: how to reduce Folliculitis after hair Transplantation Sungjoo Tommy Hwang, MD, PhD 13) donor harvesting for asian Patients Gholamali Abbasi, MD & Bertram M. Ng, MBBS

Is there damage to the donor area if the FUEs are taken too close to each other? How much is too close? What is the safe distance from one donor FUE site to the next? What is the real safe donor area? What is the impact of the size of the FUE donor site as it concerns damage to the donor area in relationship to other FUE sites nearby?

8:15AM-8:20AM
103

5 Moderator Introduction

Mario Marzola, MbbS

7 big Fue sessions: evaluation of the

8:20AM-8:27AM
107

donor site Jose F. Lorenzo, MD

8:28AM-8:35AM
108

7 When Fue Goes Wrong

Arvind Poswal, MBBS

7 Fue evaluation in Patients with Previous

8:35AM-8:42AM
109

hT Procedure Aman Dua, MD, MBBS

8:43AM-8:50AM
110

7 how the Outgrowth angle of hair

Follicles Influences the Injury of the Skin of the donor area in Fue: a Mathematical approach of the Problem Georgios Zontos, MD

8:50AM-9:08AM 18 Q&a and discussion

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day-by-day PrOGraM I saTurday

h aiR g ROwth

in

Fue

10:45aM-12:30PM

FOOd FOR thOught

Moderator: Carlos J. Puig, DO
LeARning obJecTiveS Critically analyze how certain scientific presentations make us think twice about basic concepts that are taken for granted. Understand how new tools and new surgical approaches oblige us to perform a critical revision of assumed dogmas. Discuss new methods to objectively evaluate the outcome of HRS, and where the future of HRS is heading.

Is graft survival rate higher in FUT vs FUE or is it technique dependent? Does immediately implanting FUE grafts vs delayed implantation influence graft survival?

9:08AM-9:10AM 9:10AM-9:17AM
111

2 Moderator Introduction

Mario Marzola, MbbS

7 a case study Follow up: Graft and hair

counts at One year: side by side Fue/ strip FuT Transplants in a Frontal scalp Bradley R. Wolf, MD anagen selective Fue Tejinder Bhatti, MD

10:45AM-10:47AM
116

2 Moderator Introduction

9:17AM-9:24AM
112

7 Does FUE Technique Grow Better Hair?

Carlos J. Puig, DO
7 FUT vs FUE What is the future?

10:47AM-10:54AM
117

Wen Yi Wu, MD
2 commentary

9:25AM-9:32AM
113

7 The effects of delay in extracting

Follicular units on the Viability of Fue Grafts Parsa Mohebi, MD Konstantinos giotis

10:55AM-10:57AM
118

Robert H. True, MD, MPH

7 The New Wave of complications in the

10:58AM-11:05AM
119

9:32AM-9:39AM
114

7 The Method of direct hair Implantation

Follicular unit era Marc R. Avram, MD Dow B. Stough, MD

9:39AM-9:57AM 18 Q&a RObOtic Fue: the FutuRe OF dOnOR haRveSting OR nOt? 9:57AM-9:58AM 9:58AM-10:05AM
115 1 Moderator Introduction

11:05AM-11:07AM
120

2 commentary 7 Scientific Evidence that Environment,

11:07AM-11:14AM
121

Mario Marzola, MbbS

7 The role and the Placement for the

diet and Lifestyle contribute to epigenetic regulation of hormones and Are Likely to Influence Hair Growth Sharon A. Keene, MD William H. Reed, II, MD

robotic arm in hair Transplants Our Initial experience Mark A. Bishara, MD

11:15AM-11:17AM
122

2 commentary

11:17AM-11:37AM 20 audience Q&a

10:05AM-10:15AM 10 Q&a 10:15AM-10:45AM coffee break

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day-by-day PrOGraM I saTurday

11:37AM-11:44AM
123

7 updated clinical experience with hair

duplication Jerry E. Cooley, MD Sajjad Khan, MD

Fue and c OmbinatiOn OF d OnOR h aRveSting t echniqueS 3:08PM-3:13PM

133 5 The untouched strip Technique, a

11:45AM-11:47AM
124

2 commentary 7 Personal Growth Index: Transforming the

11:48AM-11:55AM
125

unknown Variable element of the hair Transplants Quality equation into a stable constant Marcelo Pitchon, MD William M. Parsley, MD

Procedure combining Fue and strip surgery to Improve the Number of Fu harvested While Preserving an untouched area for a Future Transplant Marcio R. Crisstomo, MD bh Grafts Arvind Poswal, MBBS

3:13PM-3:18PM
134

5 expanding Needle concept for better

11:56AM-11:58AM
126

2 commentary 7 application and evaluation of the cross

3:19PM-3:24PM
135

5 Neograft: Personal experience,

11:59AM-12:06PM
127

section Trichometer to Predict suitability of candidates for hair Transplantation John P. Cole, MD Bernard P. Nusbaum, MD

capabilities and Limitations Ken L. Williams, DO

3:25PM-3:40PM 15 Q&a g RaFt d iSSectiOn g RaFt i nSeRtiOn 3:40PM-3:45PM

136
and

t echniqueS

FOR

h aiR

12:07PM-12:09PM
128

2 commentary

5 Video Presentation of slivering

12:10PM-12:30PM 20 audience Q&a 12:30PM-2:15PM Lunch on your own or optional, ticketed lunch symposium. Last chance to Visit exhibits Lunch symposium 311 (ticket required) Posters dismantle exhibits dismantle

and Follicle dissection under stereomicroscope, and Innovative staff Training Technique Anil Kumar Garg, MBBS (both-hand No-touch Technique) Jae-Hyun Park, MD

3:45PM-3:50PM
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5 both-hand slit Technique

12:30PM-2:15PM 12:30PM-2:15PM 2:30PM-7:00PM 2:30PM-4:00PM

3:50PM-4:00PM 10 Q&a 4:00PM-5:00PM

advanced SuRgical videOS

Moderator: Russell Knudsen, MBBS
LeARning obJecTive Compare and contrast different surgeons approaches to various aspects of the hair transplant procedure.

live patient viewing

Co-Chairs: Nicole E. Rogers, MD & Bertram M. Ng, MBBS
LeARning obJecTive Assess the results of real live patients from a variety of cases that utilized different approaches and techniques.

2:30PM-2:32PM
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2 Moderator Introduction

Russell Knudsen, MBBS d OnOR c lOSuRe t echniqueS

4:00PM-4:30PM 5:00PM 4:45PM-6:00PM 7:00PM-12:00AM

coffee available Meeting adjourns Ishrs cMe committee Meeting

(invitation only)

2:32PM-2:37PM
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5 asymmetric Two-layer closure in

Trichophytic closure for Wide donor Wound Dae Young Kim, MD

Gala dinner/dance & awards ceremony

(ticket required)

2:37PM-2:42PM
131

5 W-trichoplasty closure for better strip

scars: a New Technique Tejinder Bhatti, MD

2:43PM-2:48PM
132

5 donor closure Technique using both

edges Trichophytic closure Kazuhito Yamamoto, MD

2:48PM-3:08PM 20 Q&a

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16
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088 Breakfast with the Experts, Table Leader on the Topic of "Getting Started with Adding FUE to Your Practice"
James A. Harris, MD Otolaryngology/ Head and Neck Surgery, 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.

089 Breakfast with the Experts, Table Leader on the Topic of "How to Manage Big FUE Cases"
John P. Cole, MD International Hair Transplant Institute, Alpharetta, GA, USA. Private Practice Hair Transplant Surgery since 1990 J.P. Cole: None.

090 Breakfast with the Experts, Table Leader on the Topic of "My Experience with Different FUE Devices"

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Mark S. DiStefano, MD DiStefano Hair Restoration Center, Worcester, MA, USA. Mark S. DiStefano, MD, ISHRS,ABHRS clinical instructor University of Massachusetts Division of Plastic Surgery In private practice for 18 years Developed special instrumentation for FUE Trained numerous physicians in the technique of FUE M.S. DiStefano: None.

091 Breakfast with the Experts, Table Co-Leader on the Topic of "Advances in Hair Biology: PGD2 and Other Stories"
Luis Garza, MD, PhD Johns Hopkins Medical School, Baltimore, MD, USA. Dr. Garza is an assistant professor of dermatology at the Johns Hopkins Medical school. He practices dermatology and runs a laboratory which studies the molecular biology of the hair follicle in multiple contexts. L.A. Garza: None.

092 Breakfast with the Experts, Table Co-Leader on the Topic of "Advances in Hair Biology: PGD2 and Other Stories"
Ralf Paus, MD ISHRS, Geneva, IL, USA.

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-- Medical studies and internship at the Universities of Wrzburg, Berlin, Vienna, Basle and Zurich (MD, Berlin: 1987) -- Post-doc: Yale University, New Haven, CT (1987-90) -- Dermatology residency and junior faculty appointments in Berlin, Germany (1990-98) -- Professor and Vice-Chair, Dept. of Dermatology, University of Hamburg, Germany (1999-2004) -- Visiting Professor, Max-Planck-Inst. f. Biochemistry, Martinsried (2005) -- Head, Exp. Dermatology, University of Luebeck (since 2005) -- Editor, Experimental Dermatol (since 2007) -- secondary appointment as Professor of Cutaneous Medicine, University Manchester (20%, since 2008) -- Main areas of research interest: Biology & pathology of the hair follicle, hair follicle stem cells, skin neuroendocrinology, wound healing R. Paus: None.

093 Breakfast with the Experts, Table Leader on the Topic of "Ischemia-reperfusion injury and Hair Follicle Viability"
William D. Ehringer, PhD University of Louisville, Louisville, KY, USA. Biography of Dr. William D. Ehringer: Dr. Ehringer is an Associate Professor Bioengineering at the University of Louisville, and Founder and CEO of Energy Delivery Solutions. He has published over 120 peer-reviewed publications, book chapters, andABSTRACTs. In 2002, Dr. Ehringer invented a method for delivery of adenosine-5-triphosphate to cells to reduce the affects of ischemia and hypoxia. Dr. Ehringers extensive training in Biochemistry and Physiology has led to an understanding of the molecular, cellular, and tissue effects of ischemia and hypoxia, and potential intervention strategies. Current research interests are hair transplantation, and in cell and tissue preservation. W.D. Ehringer: Employment; Energy Delivery Solutions. Ownership Interest (owner, stock, stock options); Founder, Energy Delivery Solutions. Ownership Interest (royalty, patent, or other intellectual property); Inventor, VitaSol US Pat# 7056529.

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094 Breakfast with the Experts, Table Leader on the Topic of "How to Design a Correct Hairline"
Ronald Shapiro, MD Shapiro Medical Group, Bloomington, MN, USA. Ronald Shapiiro MD has been practicing Hair Restoration for 20 years and is concidered one of the experts in hiarline design. He helped edit the Textbook "Hair Transplantation" with Walter Unger writing the chapter on halirline design. He is currently writing the artical on Hairline design for the Clinics of North America. He has run overe 15 Hairline Workshops and Breakfast with the experts on the subject of hairline design. His on the staff of the University Of Minnsota. R. Shapiro: None.

095 Breakfast with the Experts, Table Leader on the Topic of "Hair Transplantation in Women: How to Choose the Candidate and Surgical Planning"
Paul C. Cotterill, MD Toronto, ON, Canada. Dr. Paul Cotterill is a past president of the ISHRS and is the current Chair of the Continuing Medical Education Committee for the ISHRS as well as being actively involved with Operation Restore. He is a diplomate of the ABHRS and has been practicing hair restoration exclusively for over 25 years. P.C. Cotterill: None.

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096 Breakfast with the Experts, Table Co-Leader on the Topic of "Eyelash HT: Pearls & Pitfalls"
Marcelo Gandelman, MD NA, Sao Paulo, Brazil. Marcelo Gandelman began hair, eyelash and eyebrow transplantation on burn patients in 1967. One of the authors of motorized transplantation, strip harvesting, eyebrow/eyelash reconstruction; graft survival hydration and non-mist motor for hair and dermabrasion surgery. Dr. Gandelman has published more than 100 papers about hair transplantation in books, videotapes, and journals. He is member of Plastic Surgery and Hair Restoration societies in United States and other countries. Received the Platinum Follicle in 1998. President of ISHRS in 2001. In 2003 and 2006 he was elected President of Brazilian Society of Hair Restoration Surgery M. Gandelman: None.

097 Breakfast with the Experts, Table Co-Leader on the Topic of "Eyelash HT: Pearls & Pitfalls"
Bernardino A. Arocha, MD Arocha Hair Restoration, Houston, TX, USA. Bernardino A. Arocha, M.D. is President and Owner of Arocha Hair Restoration in Houston, Texas. Dr. Arocha graduated with a M.D. from the University of Miami School of Medicine. He completed a fellowship in hair restoration surgery with Medical Hair Restoration. B.A. Arocha: None.

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098 Breakfast with the Experts, Table Leader on the Topic of "Prerequisites for a New Hair Transplant Practice"
Sanjiv A. Vasa, MD Vasa Hair Academy, Ahmedabad, Gujarat State, India. Dr. Sanjiv Vasa, M.B., F.R.C.S., F.R.C.S. (Edin) Active member of ISHRS for last 16 years. He is president of Asian association (AAHRS), Founder President AHRS -India and the Director of Vasa Hair Academy. Out of his 35 years of plastic and cosmetic surgery experience (10 years in U.K. and 25 years in India) Dr. Sanjiv Vasa has been exclusively practicing hair transplantation for last 15 years and has performed procedures in more than four figures. He has ownership of many intellectual property rights like patent, design registry and trademarks. He has also innovated unique comprehensive technician training programme on simulators. S.A. Vasa: Ownership Interest (owner, stock, stock options); Vasa Innovations, Vasa Surgiart Pvt Ltd, Vasa Hair Academy. Ownership Interest (royalty, patent, or other intellectual property); intellectual property rights like patent, design registry, trade marks, copy rights for 10 patents.

099 Breakfast with the Experts, Table Leader on the Topic of "Leveraging Social Media for Patient Relations"
Matt Batt ISHRS, Geneva, IL, USA. Matt Batt, Principal and Founder of Pipeline and current Integrated Communications Manager for the ISHRS, has worked in communications for more than 14 years with both agency and corporate experience. Focused on leveraging traditional with new (online) communications, Batt has helped businesses leverage their communications efforts into results that impact key business metrics such as reduced costs, sales and improved customer experience. Batt has worked with brand leaders such as KOHLER Co., redbox and Cancer Treatment Centers of America and is now responsible for the branding and communications efforts of the ISHRS. M. Batt: None.

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100 Breakfast with the Experts, Table Leader on the Topic of "Spanish Speaking Table: Tips for FUE, Manual and Power, Indications"
Alex Ginzburg, MD Unit of Hair transplant Class Clinic, NA, Raanana, Israel. Alex Ginzburg was born and graduated in Argentina. In 1978 Dr Ginzburg immigrated to Israel where he completed his specialization in dermatology in 1987 Israel. Hair transplant remain one of his favorite operations, which doing since 1991. Studied the basics of hair restoration in the USA with Dr. Monheit This was followed by further study with Dr. Bouhana and Dr. Rabineau in Paris and Dr. Unger in Toronto. He has performed over 4000 hair transplants in Israel. Dr Ginzburg is an active participant in many international meetings of hair transplant and dermatologic surgery. Founder and past president of the Israel society for dermatologic surgery. From 2009 is member of the board directors of the International society of hair restoration surgery. A. Ginzburg: None.

101 Breakfast with the Experts, Table Leader on the Topic of "Donor Harvesting for Asian Patients"
Gholamali Abbasi, MD PRIVIT office, office, Tehran, Iran, Islamic Republic of. Dermatology Board certifiedABHRS board DirectorABHRS DiplomatAASHR BOGOLWS scientific member G. Abbasi: None.

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102 Breakfast with the Experts, Table Leader on the Topic of "Donor Harvesting for Asian Patients"
Bertram M. Ng, MBBS The Stough Clinic, Kowloon, Hong Kong. Bertram Ng is a Certified ISHRS Fellow and ABHRS Diplomate. He served as examiner for ABHRS and Co-editor for the ISHRS Forum. His special interest is in hairline restoration. In 2008 he first designed a hand-held laser device for hairline placement, which is now in production. In 2009 ISHRS Scientific Meeting he introduced a new system in setting the hairline anterior-most point when the Golden Rule of Third cannot apply. Knowing that not all patients are candidates for giga-session, he is finding a way to achieve the best result with the minimal number of grafts. B.M. Ng: None.

103 Moderator Introduction, Controversies and Hot Topics in Hair Restoration Surgery
Mario Marzola, MBBS NA, Norwood, Australia. Over 30 years of Hair Restoration, seeing all the changes in that time. One thing that has remained constant however is the need to produce a well balanced hairline for our patients. Some aspects are easily reproduced such as the height of the hairline, while other aspects such as broad or narrow, receding or rounded temples can be more of a judgement on the part of the practitioner. Beauty, balance and harmony are aspects which can be studied and learned. Most often however it is simply an awakening of the innate artistic talents of the observer that is requiered. M. Marzola: None.

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104 Panelist for Controversies and Hot Topics in Hair Restoration Surgery
John P. Cole, MD International Hair Transplant Institute, Alpharetta, GA, USA. Private Practice Hair Transplant Surgery since 1990 J.P. Cole: None.

105 Panelist for Controversies and Hot Topics in Hair Restoration Surgery
Sharon A. Keene, MD na, Tucson, AZ, USA. Dr Sharon Keene trained in general surgery at the University of Arizona, prior to specializing in hair restoration surgery since the early 1990's. She has been performing follicular unit transplantation since that time, and uses both donor harvesting techniques of strip and FUE. S.A. Keene: None.

106 Panelist for Controversies and Hot Topics in Hair Restoration Surgery
William R. Rassman, MD NHI, Los Angeles, CA, USA. Dr. William Rassman received his MD from the Medical College of Virginia. He was stationed as a surgeon in Vietnam and was certified by the American Board of Surgery in 1976. He holds multiple patents in medical devices, computer software and biotechnology. He has published chapters in text books on cardiac surgery and hair transplantation. Included in his published work in the field of hair restoration have been pioneering articles in

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megasessions, follicular unit transplantation and follicular unit extraction. He recently released a highly ranked consumer book Hair Loss & Replacement for Dummies available on Amazon.com and in major bookstores. W.R. Rassman: None.

107 Big FUE Sessions: Evaluation of the Donor Site

Jose F. Lorenzo, MD, Ximena Vila, MD Injertocapilar.com, Madrid, Spain. Dra. Vila born in the Argentina. Graduated in 2004 in the University of Buenos Aires (UBA). Diplomated in General Surgery in 2009. Exclusively practicing FUE Technique since 2009. Currently, she is medical staff in the clinic injertocapilar.com in Madrid, working closely with Dr. Lorenzo J.F. Lorenzo: None. X. Vila: None. ABSTRACT Introduction: Only a few years ago, FUE was used in relatively small procedures where a limited number of follicles were needed. The development of the technique has made frequent cases of more than 5000 units. During these 8 years doing only FUE technique, one of our main concerns has been the treatment of the donor area: the proper use of the resources to be the least traumatic possible. Many reports have talked about the disadvantages of the technique and the impact on the donor area in large sessions. But few studies have been done to confirm or not these assertions. Objective: Study the impact of the surgery in the donor area, in big sessions by FUE technique. To demonstrate that big FUE sessions can be performed allowing the patient to wear any hairstyle fashion when the adequate diameter of punch is used. Method: Taking advantage of this lecture, I have updated my statistics: from Nov 2003 to February 2012 we have harvested 1, 784,687 units in 1074 patients (2nd and 3rd procedures are counted as 1 patient). Our maximum extraction case was 11770 FUs, in four procedures. We analyse the donor site in those HT over 5000 units searching for traces, complication and disadvantages. Conclusion: Following up of our patients and after shaving some of them for 2nd procedures we have been able to evaluate the impact of a surgery on the donor areas. We evaluate them first of all to naked eye and asking the patient how he found himself after the procedure, with his hair real short (whether he or his family - fellows noticed any changes). Second of all, and to be objective, we see the donor area under the USB microscope and evaluate n of grafts per cm2 after the surgery (and compare it to the before surgery images). We document all of the information in photo data. We have found out that big FUE sessions can be perfectly done without damaging donor areas,

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without leaving density changes when all the area is used and the incidence of white dots when the correct punch is used. It is also a great advantage the fact that we can perform a 2nd, a 3rd or even a 4th procedure without dealing with the problem of fibrotic tissue, such small incisions do not leave fibrotic trace on the scalp. Therefore advance alopecia can be treated perfectly by FUE. Discussion: All surgery implies leaving a scar. The art of the surgeon is to find the best way to make this scar the least noticeable in order to offer the patient the possibility to use his hair as short as he wants and to share his surgery only if he wishes so. Leaving no trace of a surgery in the donor area is a real challenge to all of us and it is our duty to improve our techniques of extraction to achieve this goal.

108 When FUE Goes Wrong

Arvind Poswal, MBBS Dr. A S Clinic Pvt. Ltd., New Delhi, India. 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. As 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. A. Poswal: None. ABSTRACT Introduction Follicular unit extraction (FUE) is an accepted method of extracting individual follicular unit grafts for hair transplant surgery. Since follicles are harvested from the back of the scalp using tiny punches resulting in minimal scarring, it has gained rapid acceptance among the patients. In FUE, individual follicular unit grafts are extracted using tiny punches. The punches (of 1 mm or less in diameter) are used to score around the follicular unit till the middermis level. Gentle traction is applied to the graft thus scored. The extracted grafts are then trimmed and placed in the recipient slits created in the bald or balding scalp. Since the extraction sites/holes are very small (1 mm or less), no suturing is required.The wounds heal by secondary intention.However, due care needs to be exercised while performing FUE. FUE should not be confused with the older plug graft extraction methods of coring out hair-bearing skin plugs. Lack of due diligence while performing such extractions can lead to subluxation of the grafts into the subdermal layer of scalp. Overtumescence of the scalp donor area, use of blunt punches and trying to "core" out full thickness grafts can all contribute to this.

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Objective To avoid certain pitfalls and the adverse consequences that may occur while performing FUE. Materials and Methods Three patients in the age group of 25-30 years approached us for hair transplant repair surgery. All of these normotensive, nondiabetic males had undergone hair transplant surgery at some other clinic, supposedly, by the FUE technique. The common complaints were multiple, slow growing, nodular, painless swellings in the scalp donor area. The patients had approached us 6 months to 2 years after their previous "FUE" hair transplant. InvestigationsAll routine investigations were within normal limits. Gross examination of the scalp donor area revealed nontender, nodular swellings with no signs of inflammation or ingrown hair.Surgery Under aseptic precautions and after the local anesthetic administration, a strip was extracted from the donor area of the scalp. During strip excision, multiple cysts were seen in the subdermal fatty layer of scalp [Figure 1], [Figure 2] and [Figure 3]. Gross examination of the cysts revealed long hair, intact hair bulbs as well as skin tissue, suggestive of full thickness follicular unit grafts [Figure 4] and [Figure 5]. These cysts were excised individually and sent for histopathological examination. The strip donor area was cleaned of all caseous material, hair, etc., and then sutured.HPE report: Gross - showed multiple yellowish fatty to light brown soft tissue bits together measuring 1.8 1.3 0.5 cm.Impression: Dense chronic folliculitis with scattered eosinophils and stromal fibrosis. No granulomas and atypia were noted.Summary The possible reason for the formation of cystic masses subdermally is the subluxation of full thickness scalp grafts below the surrounding dermis which were then left in situ. The surrounding scalp tissue healed by secondary intention, thus, burying the full thickness grafts in the subdermal layer. Discussion/Results FUE should not be confused with the older punch graft excision methods. In the older methods, a 3-4 mm punch was used to cut around the hair bearing scalp tissue, down to the subdermal tissue. This was followed by extracting the hair plug like an excision biopsy.FUE, however, uses much smaller diameter punches (1 mm or less). The punch is not to be used in a "coring" manner and is supposed to be used to score around the individual follicular unit only till the middermis level. In this manner, the follicular unit graft still remains attached to the reticular dermis. The cases presented in this report highlight the pitfalls/drawbacks if these tenets of performing FUE are not followed.Possible contributing factors for the formation of subdermal cysts in the above cases could be as follows:

1. Lack of due diligence on part of the extractor who failed to locate and extract all punched grafts. 2. Over tumescence of the scalp donor tissue: Excess use of the tumescing fluid leads to a ballooning of the
subdermal layer. When the subdermal layer expands to the thickness of the entire dermis, it is easy for the "cored" and detached graft to slip below the surrounding dermis.

3. Use of blunt punches leading to subluxation of grafts in the subdermis along the surrounding tissue. Using blunt
punches requires more force to be exerted in the vertical direction for cutting. This reduces the tactile sensitivity of the extractor and contributes to cutting to deeper layers of the dermis. The punches used for scoring around the follicular unit graft must be very sharp.

4. Deep coring through the entire depth of the reticular dermis should be avoided. The punch must be used to score
around the follicular unit graft till the reticular dermis. Since, the reticular dermis is denser than the overlying papillary dermis; the extractor will feel increased resistance when he/she reaches that layer. Scoring should not be carried beyond that point. The attachment to the reticular dermis will ensure that the graft does not "sink"

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and remains in position till extracted.

Conclusion FUE is a refined extraction technique that, while being minimally invasive and stitchless, needs to be mastered and performed meticulously. FUE should not be considered a variant of the older punch graft excision methods. Meticulous dissection, use of sharp punches only, and avoiding overtumescence will help avoid inadvertent subluxation of follicular unit grafts below the dermis.

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Dr. Arvind Poswal

New Delhi

Introduction

He had minimal growth in the recipient area

A young patient approached us for hair transplant repair surgery. He had undergone hair transplant surgery, supposedly, by the FUE technique 2 years ago.

Visible scarring in the recipient as well as donor area

Before Picture

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Patient Complaints

The donor area with the hair buzz cut to 1mm

Multiple, slow growing, non tender nodules in the scalp donor area as well as recipient areas. Visible scarring in the recipient area as well as the scalp donor area area. Scanty growth in the recipient areas.

The initial strip incision reveals one of the cyst (pointed with the yellow arrow) lying close to the edge of the strip.

Under aseptic precautions and after the local anesthetic administration, a strip was extracted from the donor area of the scalp.

During strip excision, multiple cysts were seen in the sub dermal fatty layer of scalp

Intraoperative picture of strip excision showing the subdermal cyst

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Gross examination of the cysts revealed long hair, intact hair bulbs as well as skin tissue, suggestive of full thickness follicular unit grafts.

These cysts were excised individually and sent for histopathological examination.

Dissected Cyst

Histopathological Result
HPE report: Gross - showed multiple yellowish fatty to light brown soft tissue bits together measuring 1.8 1.3 0.5 cm. Impression: Dense chronic folliculitis with scattered eosinophils and stromal fibrosis. No granulomas and atypia were noted.

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A Comparison Picture

Excess use of tumescing fluids leading to ballooning of the subdermal layer. Use of punch to core out instead of only cutting till the reticular dermis. Use of blunt punches leading to subluxation of grafts into the subdermal layer.

Lack of due diligence on part of the extractor who failed to locate and extract all punched grafts. The donor scalp healed by secondary intention burying the intact follicular unit graft in sub dermis.

The operating physician and team should keep the following in mind : Meticulous dissection. Once sharp punch becomes blunt, replace it. Avoid over tumescence.

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109 FUE Evaluation in Patients with Previous HT Procedure

Aman Dua, MD, MBBS, Kapil Dua, MD A K Clinics, Ludhiana, India. Dr Aman Dua is MBBS MD (Dermatology). She has eleven years clinical experience in dermatology and cosmetology. She is a practicing Hair transplant surgeon since five years doing primarily FUE Hair Transplant and has done more than a thousand sittings of Hair Transplant. She is a member of ISHRS since 2007 and on Board of Governor and Ex- editor of Association of Hair Restoration Surgeons - India (AHRS), Life Member Indian Association of Dermatologists, Venerologists &amp; Leprologists (IADVL). Presently working as Consultant Hair Transplant Surgeon at AK Clinics, Ludhiana, Punjab, India. A. Dua: None. K. Dua: None. ABSTRACT Introduction: FUE Hair Transplant has come a long way in establishing itself as an alternative technique of hair extraction. A lot of scientific papers have been presented on the technique but the data on an objective assessment of revision/ redo cases in FUE is still very less. This prompted us to carry out a scientific study to analyse variables in these cases. Objective: Of the study is to assess the clinical variables such as Follicular Transection Rate, Ease of extraction, Number of hair per follicular unit and time taken while doing revision FUE. Materials & Methods: Forty Three patients were undertaken from January 2011 to January 2012. All were males and had undergone revision FUE Hair Transplant. They were divided into 3 groups. 1. FUE following FUE 2. FUE following Strip surgery 3. FUE flollowing Punch Grafting Results were analysed scientifically and data prepared. Although we are in the process of adding a few more patients till the final presentation in the Annual meeting to have more patients but a preliminary data is being sent as anABSTRACT. Results: The data till date shows that the average FTR in FUE after FUE cases is more as compared to virgin cases. In cases of FUE following Strip surgery the FTR is slightly more than average, whereas in FUE following punch grafting the FTRs are remarkably high and the ease of extraction is less and time taken is more (exact figures are being calculated).

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Discussion: Our preliminary data shows that revision FUE yields lesser number of grafts the second time over with higher Follicular Transection Rates and less ease of extraction.

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TITLE
FUE EVALUATION IN PATIENTS WITH PREVIOUS HT PROCEDURE.
MBBS, MS (ENT & HNS) Member, ISHRS; AAHRS; Hony. Secretary - AHRS ( INDIA)

Introduction
FUE HT has come a long way in establishing itself as an alternative technique of hair extraction.A lot of scientific papers have been presented on the technique but the data on an objective assesment of revision / redo cases in FUE is still very less.This prompted us to carry out a scientific study to analyse variables in these cases.

DR. KAPIL DUA

DR. AMAN DUA

MBBS, MD (DERMATOLOGY) Fellowship (Hair Transplant): Tel Aviv University, Israel Member, ISHRS; Board of Governor - AHRS ( INDIA) AK CLINICS, LUDHIANA, NEW DELHI

Objective
Study is to assess the clinical variables such as follicular transection rate , ease of extraction number of hair per follicular unit and time taken white doing revision FUE.

Material and Methods

43 pts were undertaken from jan 2011 to jan 2012.All were male pts undergone revision FUE HT . They were divided into 3 grafts FUE following FUE. FUE following Strip surgery. FUE following Punch grafting.

1. 2. 3.

Results
Results were analysed scientifically and data prepared. AV FTR in FUE after FUE is more as compared to virgin cases. FUE following Strip FTR > Average FUE following punch grafts FTR remarkably - Ease of Extraction less - Time taken is more.

Discussion
Revision FUE yields lesser no. of grafts the second time over with higher FTR & less ease of extraction.

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No of patients
30 25 20 15 10 5 0
Strip Fue Puch grafts

Avg. no of FTR
6 5 4 3 5.13 2 3.45 3.66

27

12 4

1 0
Strip punch graft Fue

Avg. No of Grafts
1800 1600 1400 1200 1000 800 600 400 200 0
Strip Punch grafts FUE

Avg. No of hair Per Grafts

2.5 2 1.5

1691.6 1250 1407.4 1 0.5 0

Stip Punch Grafts FUE

1.97

1.94

1.76

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110 How the Outgrowth Angle of Hair Follicles Infuences the Injury of the Skin of the Donor Area in FUE. A Mathematical Approach of the Problem
Georgios Zontos, MD Haarklinikken, Copenhagen, Denmark. Dr Georgios Zontos has studied Medicine and Physics at the University of Patras and he holds an M.Sc degree in Medical Physics. e has been working on the field of Hair Restoration since 2002 and he is the medical director of Hair Restoration Clinic - Haarkliniken in Copenhagen, Scientific consultant of GHR Global Hair Restoration Company in Nicosia, and Scientific Consultant of Z.D Hair Restoration Clinic in South Africa. His research interest is being focused at the moment in mathematical models of FUE Hair Transplantation and how the application of physical principles and the contribution of advanced mathematics are able to improve important issues like extraction ,density ,optimal distribution of hair follicles and mathematical prediction of hair growth. G. Zontos: None. ABSTRACT Objective: -In FUE it is well-known that the injury of the skin of the donor area during extraction depends on the cross section of the punch. But still the outgrowth angle of hair follicles influences the percentage of this injury a lot. -This study is trying to address this problem mathematically, by determining all these factors which are responsible for the injury and to find out a specific formula in order to calculate the quantity of trauma of the donor area and finally how this can be controlled. Materials and Method: -Studying figure 1 which represents the contact of the punch with the plane of the skin during the extraction, we can see that although the surface of punch cross section is a perfect circle the shape of wound is elliptic. -Calculating the surface of ellipsis S2=**=**=**/sinz=S1/sinz (1) Where S1=the surface of punch cross section and z =the angle between the punch and the plane of the skin, or z =the outgrowth angle of hair follicles. Discussion: Because sinz varies between 0 and 1 the fraction S2=S1/sinz is always higher than S1. That means the higher the angle z the smaller the surface of wound S2 and vice versa! If the angle z becomes 90 degrees as is shown in figure 2 ,the punch causes to the skin wound equal to the surface of its cross section .In a different case the wound is always higher. For example if z=30 degrees using formula 1 we find that the surface of wound S2=S1/(1/2)=2*S1.That means the trauma of the skin becomes 100% more !!! -This remarkable increase of injury to the donor area is responsible for 1) Increased friction between the punch and the skin and high transection rate . 2) Stimulating the fibrosis process, which creates very visible scar spots, disturbs the elasticity of donor area, and makes the extraction for the next sessions more difficult. (Picture 5) A simple way to overcome the problem of small outgrowth angle is to inject subcutaneously normal saline .As is shown in figures (3,4) the injection of normal saline makes the hair follicles more vertical reducing at the same time the injure of the donor area .

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Conclusions: The trauma to the skin of the donor area using FUE method depends on the outgrowth angle .Sometimes the trauma of the skin could be 100% more than the trauma of the cross section of the punch could cause. The injection of normal saline subcutaneously increases the outgrowth angle of hair follicles ,decreases the skin damage ,controls the fibrosis and improves the extraction .

231

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HOWTHEOUTGROWTHANGLEOFTHE HAIRFOLLICLESINFLUENCESTHE DONORAREAINJURYUSINGFUE Amathematicalapproachtothe problem

Georgios Zontos MD, BSc, MSc
DISCLOSURES: The speaker has no relevant financial relationships or conflicts of interest to declare.

Haveyouseenthisbefore?

Georgios Zontos MD, BSc, MSc

TheFactorswhichdeterminethedonor areainjuryinFUEmethodare:
The cross section of the punch (punch size) The number of the extracted hair follicles The transection rate The previous operations The distance between the holes The outgrowth angle of the hair follicles
Georgios Zontos MD, BSc, MSc 3

Objective
The aim of this study is to address the effect of the outgrowth angle on the donor area injury mathematically: - By determining all the factors which are responsible ibl - By finding out a specific mathematic formula - By calculating the exact percentage of the skin trauma - Ultimately, how the trauma can be controlled
Georgios Zontos MD, BSc, MSc 4

ThesurfaceoftheWoundisbigger thanthesurfaceofthePunch
The shape of the wound (S2) is elliptic although the punch cross section is circular (S1) It is proven that S2 = S1/ sinz Because sinz < 1 => S2 is bigger than S1 The higher the angle z, the smaller the wounds surface.
Georgios Zontos MD, BSc, MSc 5

Iftheoutgrowthangleisat90o,thenthesurfaceof thePunchisequaltothesurfaceoftheWound
- This happens when the axis of the punch is perpendicular to the surface of the donor area

Georgios Zontos MD, BSc, MSc

233

- Very often the outgrowth angle is at 30o. In that case sinz = => S2 = 2 S1 - There is a 100% increase in the trauma which is caused by the punch

Acommonexample

TheDamageAlgorithm
Small Outgrowth Angle -Fibrosis -Visible scars

Increase in friction

More diffi lt next session M difficult t i

High transection rate

High Injury Post operative pain Delayed healing process

Georgios Zontos MD, BSc, MSc

Georgios Zontos MD, BSc, MSc

Howcanwemanagetheproblem?
By Injecting subcutaneously or intradermally normal saline

Injectingsubcutaneouslyor intradermallynormalsaline

Georgios Zontos MD, BSc, MSc 9

The skin becomes firmer The hair follicles are more vertical The direction of the hair follicles is now more predictable Decrease in transection rate More intact hair follicles can be extracted
Georgios Zontos MD, BSc, MSc 10

Asimpleexample
Based on the principles that the surface of the circle s1 is given by the formula: s1 = r 2 and the surface of the wound s2 is given by the formula: s2 = s1 / sinz we find that Georgios Zontos MD, BSc, MSc 11

Asimpleexample
- Punch size 0.8 mm (surface = 0.5024 mm2 ) and angle 30o causes wounds surface 1.0048 mm2 - Punch size 1.0 mm (surface = 0.785 mm2) and angle 90o after injecting normal saline causes wounds surface 0.785 mm2
- Even by using 56.25% larger surface punch, the skin injury is decreased by 22%
Georgios Zontos MD, BSc, MSc 12

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1.20 Surfaceinsqua aremillimeters(mm2 ) 1.00 0.80 0.60 0.40 0.20 0.00 0.502

1.005 0.785 0.785

CONCLUSION
Taking into consideration the outgrowth angle of the hair follicles and modifying it by injecting normal saline intradermally, we can: j g y, Improve the quality of the extracted hair follicles using a larger punch size, while maintaining minimum skin injury

Punchsize0.8mm
PunchSurface

Punchsize1.0mm
SkinInjury
13 Georgios Zontos MD, BSc, MSc 14

Georgios Zontos MD, BSc, MSc

235

111 A Case Study Follow Up: Graft and Hair Counts at One Year: Side by Side FUE/Strip FUT Transplants in a Frontal Scalp
Bradley Wolf, MD Wolf Medical Enterprises, Cincinnati, OH, USA. Bradley Wolf M.D. has been treating hair loss patients since 1990. He has made over 30 lecture presentations at meetings throughout the world, was director of workshops at the 2002 ISHRS meeting , served as faculty at eight ISHRS workshops, and is the director of the Hands on FUE workshop, ISHRS meeting 2012. 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 Committee, he is a current member of the CME committee. He is ABHRS Board Certified and was a member of the Board of Directors of the ABHRS from 2000-2005.

B. Wolf: None. ABSTRACT IntroductionFollicular Unit Transplants (FUT) microscopically dissected from a harvested strip is currently the gold standard in hair transplants. In recent years Follicular Unit Extraction (FUE) has become more popular due to less visible donor scarring. There remain questions concerning growth rates, transaction rates, difficulty placing, and numbers of hairs per graft obtained using the FUE method. Questions also exist concerning the relative amount of donor scarring from the two techniques. To compare these two harvesting techniques a case study was performed in which one half of a hairline and frontal scalp was transplanted using grafts dissected from a strip. The contra lateral side was transplanted using grafts harvested using FUE. Eighteen months after surgery the data, results, and photographs will be studied and a comparison between the two sides will be presented. The donor areas will be also be compared and presented. ObjectiveAfter eighteen months of growth, the two sides will be compared to see if one donor harvesting technique resulted in more effective coverage of the frontal scalp. The number of grafts, number of hairs per graft, and transection rates from the two techniques will be compared. Before and after photos will be compared; in particular after photos of the two sides will be compared. The growing hairs on both sides will be counted and compared to presurgery hair counts. The hair counts of the two sides will be compared after growth. The patient will be questioned as to which side he thinks provided the best coverage and feel. The donor area will be photographed to compare the scarring incurred by the two techniques. Materials and/or MethodsIn January 2011, a 50 year old patient underwent two successive days of surgery. On day one, 970 grafts (2237 hairs) harvested by FUE were transplanted to the left half of the scalp. This included 179 one, 358 two, and 403 three to four hair grafts. Grafts were placed into incisions made by chisel point blades of 0.8, 1.0, and 1.1mm widths respectively. Approximately 952 hairs were present in the left half of the frontal scalp prior to grafting. A mechanical rotatory punch handle was used at 2500rpm. A 1.05mm diameter outside diameter punch was used. The average density of the donor area was 68FU/cm2. On day two 1006 grafts (2218 hairs) harvested by strip excision and microscopically dissected under 10X power were transplanted to the right half of the scalp. This included 200 one, 557 two, and 289 three to four hair grafts. Grafts were placed into incisions made by the same instruments of 0.8, 1.0, and 1.2mm widths respectively. Approximately 378 hairs were present in the right half prior to grafting. A

236

strip 7-9mm wide X 15 cm long was harvested from the right half of the occipital scalp. The average density of the donor area was 64FU/cm2. The same assistant placed all the grafts on both sides. D. Discussion/Results- In July 2012, eighteen months after surgery, photographs will be taken and used to compare the coverage obtained from the two techniques. The data will be analyzed to compare the growth of the hairs and effective coverage on the two sides of the scalp. The number of grafts, number of hairs per graft, and transection rates of the two techniques, FUE and FUT will be analyzed. The donor areas will be compared to show the scarring incurred from the two techniques. ConclusionThis is one case study. The results shown and analyzed will fairly compare two donor harvesting techniques, FUE and FUT from strip excision. Data will not be analyzed and photos will not be taken until July 2012 and are not available at this time.

112 Does FUE Technique Grow Better Hair? - Anagen Selective FUE
Tejinder Bhatti, MD Darling Buds Hair Transplant Center, Chandigarh, India. Founder Secretary, Association of Hair Restoration Surgeons of India; Governing Council Member, Indian Asso. of Aesthetic Plastic Surgeons; Governing Council Member, Association of Plastic Surgeons of India; Member International Society of Hair Restoration Surgeons;Member, Asian Society of Hair Restoration Surgeons (AHRS);Moderator, India Hair Forum; Joint Editor, Indian Journal of Plastic Surgery Dr Tejinder Bhatti has been in hair transplant practice for over 15 years. T. Bhatti: None. ABSTRACT With the advent of mechanization of FUE grafts harvest, the myth that FUE megasessions cannot be done has been proved wrong. There are a number of FUE motors and punches available in the market today. At this center the author routinely performs 1500-3000 grafts daily using James Harris SAFE technique. In the present study, the author analyses results over past 2 years in 416 patients and compares the technique with FUT method. The author demonstrates his anagen selective FUE technique of rapid FUE harvest through video.

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113 The Effects of Delay in Extracting Follicular Units on the Viability of FUE Grafts
Parsa Mohebi, MD US Hair Restoration, Los Angeles, CA, USA. Parsa Mohebi, MD, is the medical director of US Hair Restoration (USHR). He completed his surgical residency at the University of New Mexico and York Hospital, Pennsylvania. Dr. Mohebi served as a 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. He completed his fellowship in surgical hair restoration at the New Hair Institute. Parsa Mohebi, MD is a Diplomate of the American Board of Hair Restoration Surgery. P. Mohebi: None. ABSTRACT Introduction: The techniques of Follicular Unit Extraction (FUE) hair transplantation have been improved over the last several years with the emergence of motorized and automated FUE devices. Since FUE is relatively a new technique in hair restoration, there are many questions that have yet to be answered. Objective: To determine how long can FUE grafts survive inside scalp skin after punching and before extraction? The importance of this question is further underscored when using automated FUE devices. In many cases it is more efficient to score a large number of FUE grafts before pulling them out in both manual and automated FUE procedures. But how long can grafts stay in place before they are extracted and transplanted? Five minutes, ten minutes; or perhaps a surgeon and team can wait for one or even several hours before extracting the grafts. At present we do not have an adequate scientific answer to the optimum duration or time lapse from punching the grafts until necessary extraction. The FUE Delayed Extraction study was designed and performed to answer these crucial questions. Methods: We performed hair transplant on study patients with FUE or strip as we do routinely. Along the main operation, we punched (scored) several FUE grafts on the permanent zone of the occipital area. Then we extracted hair follicular units from the scored areas in intervals of 5 min., 30 min. 1 Hr and 4 Hrs after initial scoring. For the purpose of this study and to be consistent with our results, we chose only grafts that have two intact hair follicles. The grafts were placed into four marked areas on the top or crown areas where no terminal hair was present. We implanted ten, 2-hair grafts in each one square centimeter marked box. We placed the marked areas around a tattooed dot for ease of locating them in follow up visits. We did not transplant any grafts in 0.5cm space between and around each box in order to be able to view and assess the follicular units in the study boxes. Patients were scheduled for one day, ten days, 6 and 12 months post hair transplantation evaluation and assessment. We utilized the following inclusion criteria to select the patients for this study. 1.Men with Typical Male Patterned Baldness 2.Patients with at least one 3 x 3 cm area on the top and crown with total baldness (No visible hair) 3.Patients with at least 50% pigmented hair.

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Results: The results of the FUE delayed Extraction Study will be discussed during the ISHRS annual meeting. Conclusion: Survival of grafts during a hair transplant procedure is one of the most essential elements for optimum outcome. It might be presumed by many hair transplant surgeons that scoring and leaving the grafts in place do not affect the survival of the grafts due to the presence of perfusion around the grafts. However, this has never been previously documented. We will discuss the ideal timing between the scoring; extracting and implanting FUE grafts in subsequent presentation.

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ParsaMohebi,MD LosAngeles,CA

Disclosure:None

ThetechniquesofFollicularUnitExtraction(FUE) hairtransplantationhavebeenimprovedoverthe lastseveralyearswiththeemergenceofmotorized andautomatedFUEdevices.

SinceFUEisrelativelyanewtechniqueinhair restoration,therearemanyquestionsthathaveyet tobeanswered.

Objective:

Objective:

HowlongcanFUEgraftssurviveinsidescalpskin afterpunchingandbeforeextraction?

Canwebemoreefficientbyscoringalarge numberofFUEgraftsandpullingthemallatonce?

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Objective:

Materialandmethods:

Ifthereisanydifferenceintheextractiontime. Whatistheoptimumtimetoremovegraftsfrom thescalp?5,10min,1hourormore?

FUEgraftsscoredatthe beginningofthesurgery afterremovalofthestrip nexttothem

Materialandmethods:

Materialandmethods:

Anareaofatleast3x3cm completelybaldwithno terminalhairwasselected 4boxesof1squareCM markedonthebalding areaandacentraltattoo wasplacedtoidentify them

FUEgraftsscoredearly, butextractedin:
5min 30min 1h 1hour 4hours

Materialandmethods:

Materialandmethods:

Weimplantedten,2 hairgraftsineachone squarecentimeterbox thatweremarkedwith acentraltattooeddot

Patientswere scheduledforpostop evaluationson: D 1 Day Day 10 Month 6 Month 8 Month 12

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Materialandmethods:

Results:

Inclusioncriteria
MenwithTypicalMalePatternedBaldness Patients with at least one 3 x 3 cm area on the top and Patientswithatleastone3x3cmareaonthetopand

TheresultsoftheFUEdelayedExtractionStudy willbediscussedduringtheISHRSannual meeting.

crownwithtotalbaldness(Novisiblehair)
Patientswithatleast50%pigmentedhair.

Conclusion:
WefocusedonthelongevityandsurvivalofFUE graftsafterscoringandleavingthegraftsinplace thathasneverbeenpreviouslystudiedand documented. Wewilldiscusstheidealtimingbetweenthe scoring;extractingandimplantingFUEgrafts.

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114 The Method of Direct Hair Implantation

Constantine P. Giotis DHI Global Medical Group, Athens, Greece. K.P. Giotis established the DHI Global Medical Group 41 years ago.DHI has since grown to become a global group performing a unique technique called Direct Hair Implantation in over 30 locations around the World. Mr P. Giotis is the founder of the renowned International Hair Society (IHS) and American Society of Cosmetic Surgery and has lectured and presented at numerous medical and non-medical related forums. In 2012 and beyond Mr. P. Giotis will establish DHI Training Academy, a training school dedicated to teach and train people on hair restoration methods and practices. The sole aim of the Academy is to set the benchmarks for hair restoration and provide experts and specialists in DIRECT HAIR IMPLANTATION C.P. Giotis: None. ABSTRACT The method of Direct Hair Implantation consisting in sequentially harvesting single hair follicles from a donor region and directly implanting the same at a recipient region of the scalp, wherein the method employs a hair harvesting instrument with a sterile disposable punch of appropriately small diameter adapted to successively perform cutting of a single hair follicle when it is brought in contact with the root of the hair follicle and is manually rotated around the perimeter of the same. A micro gripper means is thereafter used for the extraction of the cut hair follicle and for loading a forwardly projecting tubular needle of a hair implanting instrument with the extracted hair follicle. A hair implanting instrument is then employed for a selective placement of said hair follicle in the appropriate direction and at an appropriate position on a demarcated recipient region of the scalp. The process of single hair follicle harvesting, extraction and direct implantation is repeated until completion of the planned direct hair implantation procedure.

243

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245

246

247

248

D.A. Case study - Direct Implantation 710 FU -1633 hairs

249

250

251

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F.U.E:Theendlesstripofthehairfollicle DIRECTHAIRIMPLANTATION
Mr.Konstantine Giotis,DHIChairman DHIInternationalMedicalGroup
Placementof the hairfollicles Cutting& extraction ofthehair follicles Processingof thehair follicles underthe microscope

Total time out of the body 3-5 hours

Preservationof thehair follicles incoldsaline for34hours

Creationof reception holes

THEQUESTION
Isitpossibletoincreasethesurvivalofthegraftsby

Study comparing
1-the Semi Direct Hair Implantation Technique 2-the Direct Hair Implantation Technique

diminishingthehandlingofthegraftsandthetimethey diminishing the handling of the grafts and the time they remainoutofthebody?

Extraction ofthehair follicles

Preservation ofthehair follicles oncoldsaline for34hours

1STEP
Placementof the hairfollicles

Extractionand placementof the hairfollicles

Placement is done DIRECTIN Without incisions [holes or slits] prior to the implantation

Placement is done DIRECTIN Without incisions [holes or slits] prior to the implantation

1
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EXTRACTION&PLACEMENT
(clicktoseetheattachedvideoswithFLVorVLCmediaplayer)

CASEA:1 SemiDirectTechnique
Extraction Placement

DHI Direct Hair Implantationflv

extraction & placement.wm

GRAFTS 366 fu = 866 hairs Covered: 16 cm2

2 100%Direct HairImplantation
Beforeextraction Placement

3daysafter
Semi Direct Direct

GRAFTS 386 fu (without counting the hairs) Covered 16 cm2

2monthsafter
Semi Direct Direct

9monthsafter
Semi Direct Direct

2
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Finalresultsofbothtechniques
Before After

Dataofbothtechniques
SEMIDIRECT 800hairsplaced in 16CM2 Growth of740 hairs =85% 100%DIRECT 880hairsplaced in 16CM2 Growth of800 hairs =91%

Non i ifi N significant diff t differences

CaseB:Crown area No1

Crown area No1

TOTALAREATOCOVER: 38cm2 38 cm2 19cm(Top)Semi Direct 19cm2(Bottom)Direct

CrownareaNo1Totalhairs/fuimplanted
Direct (Bottom) 599FU1134HAIRS 63HAIRS/cm2 33FU/cm2 1,93HAIRS/FU.
Immediately aftersession

CaseC:Crown areaNo2.
Crowntotalarea 12cm2 12 cm2 Leftarea6cm2 (DIRECT) Rightarea6cm2 (SEMI DIRECT)

SEMIDirect(Top)

600FU1020HAIRS 57HAIRS/cm2 33FU/cm2 1,7HAIRS/FU

2monthsafter session

Caseinprogress

3
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CrownNo2.Hairs/fuImplanted
Leftarea(DIRECT)

CrownNo.2after9months

159fu=430hairs 26,5fu/cm2 71hairs/cm2 71 hairs/cm2

Rightarea(SEMI DIRECT) 159fu=439hairs 26,5fu/cm2 71hairs/cm2

Dataofbothtechniques
100%DIRECT
Totalgrowth390Hairs 65HAIRS/cm2 23,5FU/cm2 91%FROMTOTAL

CaseD: DirectinCZone SemiDirectinAZone

SEMI DIRECT

Totalgrowth315HAIRS 52HAIRS/cm2 19,5FU/cm2 73%FROMTOTAL

Age:25 25% more growth with Direct Pattern:Norwood4 Previoussessions:NO

100%DirectinCZone
Before
DirectinZoneC Coveredarea:36cm2 Totalfu:436fu/1040 hairs 12fu/cm2 29hairs/cm2 Existingdensity:30hairs cm2

CZone100%Direct
After

4
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CaseD:SemiDirectinAZone
Before
Coveredarea53cm2 Totalfu:627=1504hairs 12fu/cm2 29hairs/cm2 Existingdensity:25hairs/ cm2

AZone SemiDirect
After

CZone Directdata
TotalGrowth 950Hairs=91%
11% more growth with Direct

Conclusions
TheresultsofthecasesperformedwiththeDirectHair ImplantationTechniquelookverypromising Earlyfinalgrowthisevident(lessthansixmonthsin somecases)

AZoneSemiDirectdata
TotalGrowth 1200Hairs =80%

5
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115 The Role and the Placement for the Robotic Arm in Hair Transplants- Our Initial Experience
Mark A. Bishara, MD, Kevin Rodriguez, Rebecca Green Bishara Cosmetic Surgery, Mansfield, TX, USA. After completing a fellowship in Aesthetic and Reconstructive Plastic Surgery at Harvard Medical School, Mark A. Bishara, MD completed additional training in hair transplantation with Dr. Mark Distefano in Worcester, Massachusetts. Dr. Bishara practices at Bishara Medical Clinic in Mansfield, Texas. Kevin Rodriguez is the Research Coordinator and Surgical Technician at Bishara Cosmetic Surgery. Rebecca Green is the Surgical Coordinator and Surgical Technician at Bishara Cosmetic Surgery. M.A. Bishara: None. K. Rodriguez: None. R. Green: None. ABSTRACT Introduction: Advances in hair transplantation continue to occur more expeditiously than ever. For the last twelve years significant research and developement has led to the introduction of thenew technological Robotic Arm that has been specifically designed for surgical hair transplantations. The new Artas Robotic Arm that has been engineered by Robotic Restoration was designed and based on years of extensive research & clinical trial. As the field is continually growing and more medical professionals are joining the industry, each ones passion and medical expertise are constantly challenging the status quo in regards to the accuracy and proficiency of each surgical case. Many factors and have been integrated for the Robotic Arm for its conception. These factors include but are not limited to: Average degree of angulations of the follicles throughout the entire donor regions (left/right/lower obsuctible); manual adjustments of puncture depths to accommodate in-depth follicles. Premise: The feasibility and integrity of the Robotic Arm is unremarkable. The fact that it is robotic, allows more grafts to be harvested and to remain intact on a more precise level. Logically, it allows more follicles per follicular unit extraction. Discussion: Much data has been gathered from various types of hair transplant surgeries in order to compare the best possible results. Although traditional transplants tend to give the patient more harvested grafts, some patients tend to benefit more from the robotic arm. The Robotic Arm is less invasive, no visible linear scarring and more grafts per follicular unit on the first harvest attempt versus the manual FUE method. In regards to patients who have several transplants, they are the most beneficial for the Robotic Arm. There are no sutures involved which means less tension on the scalp which happens when having multiple surgeries and very little of the grafts resurface after implantation. Many of the grafts that were harvested with the Robotic Arm were of 1 follicular unit to groupings of 6 hairs. Which is almost is impossible to accomplish with the manual FUE method. I believe that the Robotic Arm can perform not just on the same playing field as other hair restoration methods, but above and beyond as well.

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TheRoleandPlacementfortheRoboticArminHairTransplants Our InitialExperience Authors:KevinRodriguez,S.A.,RebeccaGreen,S.A.,MarkABishara, M.D.Mansfield,TX

Advances in Hair Transplants in the last 12 years

Benefits of Artas

Follicular Unit Transplant (FUT) Manual Follicular Unit Extraction (FUE) Robotic Follicular Unit Extraction (RFUE)

Minimally invasive / Better Aesthetics No Linear Scar Faster Procedure Less Discomfort Rapid Healing Outpatient Basis No Disruption of Normal Routine

Linear scar vs. Artas

259

A look at the data

First 30 Robot case individually analyzed by the following:

Graft Analysis: Follicular Units (grouping 1-5 hairs)

Before & After

260

Before & After

Before & after

Conclusion

Open the floor to questions

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116 Moderator Introduction, Food for Thought

Carlos J. Puig, DO 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. 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, currently is the Vice President of the ISHRS. He recently joined the staff at the Baylor College of Medicine,Baylor Facial Plastic Surgery Center. C.J. Puig: None.

117 FUT vs FUE What Is The Future ?

Wen Yi Wu, MD Taiwan Hair Transplant, Taipei, Taiwan. Wu Wen Yi, MD W. Wu: None. ABSTRACT FUE has gained increased popularity recently. Improved techniques and instrumentation are the major contributing factors. More involvement among novice physicians is another cause. As it is difficult to start an FUT setting, doctors can easily start with FUE, thus making FUE more popular . Over exaggeration in marketing by the manufacturers is another cause. Disadvantages of FUE 1. Transaction is still a major issue. 2 Less optimal results 3 Limit to small session

All these disadvantages will be discussed in details. Indications for FUE A general indications will be briefly reviewed, including the body hair transplant Will FUT be replaced by FUE in the future? The answer is NO. FUT has been performed for many years and has been proven to be effective and

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highly successful. All suitable candidates for hair transplants can receive FUT. Patients with extensive hairloss can receive one pass surgery with FUT and the results are promising. There is no doubt that physicians mastering only one technique will claim superiority of their techniques over any other and vice versa. Nowadays, there is increasing trend that a patient will receive both technique in the whole course of treatment. For instance, patients receive multiple strip surgeries with minimal or no laxity remaining. FUE can allow surgeons to harvest additional grafts if needed. FUT will remain as the mainstream surgery. FUE will continue to rise to a state of equilibrium with FUT. There are patients who are candidates only for FUT; some only for FUE; some for either one; and some for a combination of both. It is imperative that hair transplant physicians should master both techniques. Inability to perform just one technique and not the other results in failure to provide the best treatment options to perspective patients. FUT and FUE will stay as they are now. NO PK, NO KNOCK OUT

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FUT vs FUE WHAT IS THE FUTURE ?

No Conflict

FUE PROBLEMS

TRANSACTION
Punch insertion Shearing during the extraction phase

FUE has gained increased popularity because of :
improved techniques and instrumentation. more practitioners involvement, especially the novice. marketing

WEN YI WU M.D. Diplomate ABHRS Taiwan Hair Transplant

FUE PROBLEMS
FUE grafts are essentially stripped of any investing tissue
dessication grafts handling more difficult allow follicles to splay grafts kinked at distal ends

may produce suboptimal results

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Other FUE Problems:

potential use of non-safe area slower and tedious technique white walling and hypopigmentation technique difficult to master/ long learning curve
FUT and FUE scars

Fibrosis prior FUE

Courtesy of DR. Bertram Ng

White walling/ hypopigmentation

Courtesy of DR. Bertram Ng

Indications/ Advantages of FUE:

patients with no available scalp laxity for strip harvesting patients who heal with thickened or wide linear scar patients requiring Body Hair Transplant combine FUT & FUE for bigger single session avoidance of linear donor scaring no suture, less post-operative pain ability to wear hair short minimizing staff numbers

Problems encountered with FUT:

linear donor scar/ widened scar big team needed for mega, giga sessions physicians out of control of every single step

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FUT facts:
performed for more than 10 years high patients satisfaction relatively easy to master the technique all suitable candidates for HT can receive FUT

Shall we replace FUT to FUE because of donor scar issue

It should be replaced until there is unanimous consensus that FUE produces better results than FUT.

Majority of patients come back for MORE HAIR ; not for donor scar issue

Before

Before
1 session 3527 g 1 session FUT 3780 g 1 session FUT 3527 g

After
FUE 1 session 1423 grafts FUE 1 session 1423 grafts

After
1 session 3520 g FUE 1 session 1203 grafts 1 session FUT 3460 g 1 session FUT 3520 g

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There are candidates suitable for :

FUT only FUE only either one technique combination of both

Physicians mastering one technique will claim superiority of the technique over any other and vice versa

1 session Combination graftings FUT 3758 grafts +FUE 500 grafts beard

AT THIS POINT Master both techniques

FUT will remain as mainstream surgery FUE will continue to rise

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Both are winners

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NO PK

NO KNOCK OUT

SUN MOON LAKE Taiwan

THANK YOU

118 Commentary On, "FUT vs FUE What is the Future?"

Robert H. True, MD, MPH True & Dorin Medical Group, P.C., New York, NY, USA. Dr. Robert True practiced hair restoration surgery in New York City as the senior partner in True and Dorin Medical Group.He as written and lectured extensively on hair restoration techniques over the past 20 years. In recent years he has focus in development and refinement of FUE techniue. He is a past President of the American Board of Hair Restoration Surgery. R.H. True: None.

119 The New Wave of Complications in the Follicular Unit Era

Marc R. Avram, MD Clinical Professor Dermatology Weill Cornell Medical School, New York, NY, USA. Marc Avram MD is in private practice in New York City. He is a Clinical Professor of Dermatology at Weill Cornell Medical School M.R. Avram: None. ABSTRACT The era of follicular unit transplantation has allowed both men and women to benefit from consistently natural appearing hair. The era of unnatural pluggy appearing transplant hair is over, but unfortunately, iatrogenic induced complications occur with follicular unit transplantation. The use of follicular units rather than larger plugs have lowered the fear of long-term complications from hair transplant surgery. Unfortunately, this is not true. Follicular units present the same potential long-term complications that larger graft surgery did in the past. Poorly designed hairlines that are often too low or too straight, and placing hair in areas that will not be cosmetically appropriate in the future can occur. Transplanting hair follicles in the vertex of the scalp in younger patients may appear natural for several years but, as hair loss continues, they do become unnatural appearing. All procedures have medical and surgical complications. In the era of follicular unit transplantation, the rate of medical and surgical complications are extremely low. The best way to avoid cosmetic complications, whether using follicular units or large grafts, is to plan the transplant assuming ongoing hair loss and a limited amount of donor

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hair. By planning a transplant for ongoing hair loss and limited resource the amount of iatrogenic induced unnatural transplanting hair will greatly diminish.

120 Commentary On, "The New Wave of Complications in the Follicular Unit Era"
Dow B. Stough, MD The Stough Clinic for Hair Restoration, Hot Springs, AR, 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. Dr. Stough is a Clinical Assistant Professor of Dermatology at the University of Arkansas for Medical Sciences. 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.B. Stough: None.

121 Scientific Evidence that Environment, Diet and Lifestyle Contribute to Epigenetic Regulation of Hormones and are Likely to Influence Hair Growth
Sharon A. Keene, MD Physician's Hair Institute, Tucson, AZ, USA. Dr. Sharon Keene, M.D. trained in general surgery at the University of AZ, and some years after completion, committed her skills to the full time practice of hair restoration surgery, and has done so for over 17 years. She is a pioneer of follicular unit grafting techniques, as well as instrumentation to improve ergonomics, methods to improve visibility of gray hair, and investigation of genetics to influence female response to finasteride therapy. She has lectured on these and many other issues pertaining to surgical techniques and density, and remains heavily involved in continuing medical education for members of the ISHRS. Her practice is in Tucson, AZ. She is currently a member of the ISHRS executive committee. S.A. Keene: None.

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ABSTRACT Androgenetic Alopecia (AGA) is a polygenic entity. For many years it has been assumed that the determinants for the expression of AGA were genetic, and controlled by the various unidentified genes involved. However, the new branch of burgeoning science in genetics deals with the epigenetic, non genomic regulation of genes which can activate and silence them, or, for example, up and down regulate hormonal pathways. By knowing and understanding what some of these epigenetic regulators are (environmental, dietary or lifestyle), and how they affect the hormones which influence hair growth, we may be able to offer advice or additional therapies to slow the progression of hair loss in AGA.

122 Commentary On, "Scientific Evidence That Environment, Diet and Lifestyle Contribute to Epigenetic Regulation of Hormones and Are Likely to Influence Hair Growth"
William H. Reed, II, MD La Jolla Hair Restoration, La Jolla, CA, USA. Bill Reed, MD has been practicing hair transplantation exclusively since 1994. He has studied and presented grafted hair survival since a ISHRS supported study in 1999. Since then he has participated in studies, presentations and panels on over a dozen occasions with the ISHRS, Am.College of Cosmetic Surgery and the American Society of Dermatologic Surgery.He is currently coeditor of Hair Transplant Forum International. He is recipient of the Platinum Follicle Award in 2010. W.H. Reed: None. ABSTRACT Recent developments of analytical tools and subsequent discoveries have made clear that gene expression is dependent upon environmental triggers. With respect to our beloved field, hair, the recent revival of the interest in inflammation's action in alopecia in combination with identification of receptors for environmental triggers that result in inflammation are compelling evidence for the role of environmental influences upon hair loss. This role of epigenetics literally changes what constitutes the organism and is an exciting and radical progression in the field of genetics. The resulting increased complexities will challenge the best of supercomputers to decipher.

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123 Updated Clinical Experience With Hair Duplication

Jerry E. Cooley, MD Carolina Dermatology Hair Center, Charlotte, NC, USA. Dr. Cooley, a Past President of the ISHRS, is in private practice in Charlotte, North Carolina J.E. Cooley: None. ABSTRACT Hair duplication, or autocloning, is a procedure in which plucked hair follicles containing outer root sheath epithelial cells are used as grafts. Initial pilot studies by the author showed variable success in hair regeneration when used in combination with a wound healing agent (ACell MatriStem). Further clinical experience over the past year sheds more light on this potentially promising technique. Procedures have ranged from small repair situations as well as larger stand alone grafting procedures. Results have ranged from promising success to complete failure. Clinical observations point to the possible explanation for this variability as the proximity of healthy hair follicles to the implanted plucked follicles, suggesting that dermal sheath stem cells from adjacent follicles participate in follicle regeneration. This theory would explain the near complete failure of plucked grafts in wide scars and bald scalp, as well as the promising success in areas with good pre-existing hair density. Building on this theory, we have modified the procedure so that intact FU grafts are implanted in the same site as plucked grafts, allowing the grafted FU stem cells to assist in regeneration. Clinical examples are presented. Complications include retained hair shafts and folliculitis. In no cases have decreased density from plucked donor sites been observed. Hair duplication using plucked grafts is a promising new technique that requires further clinical experience and study before gaining wide spread applicability.

124 Commentary On, "Updated Clinical Experience with Hair Duplication"

Sajjad H. Khan, MD ILHT, Lahore, Pakistan. Diplomate of American Board of Hair Restorative Surgery and co author

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of three text books. Formerly UCLA Visiting Assist Professor. Over 20 years of hair tansplant experience. S.H. Khan: None. ABSTRACT: After the learning curve as in any other technique, the Auto Cloning offer very good promise. The FUE and strip method is the redistribution of hair while auto cloning is unique, it adds up more hair .

125 Personal Growth Index: Transforming the Unknown Variable Element of the Hair Transplant's Quality Equation into a Stable Constant
Marcelo Pitchon, MD Dr. Marcelo Pitchon, Belo Horizonte, M.G., Brazil. Plastic surgeon, exclusively devoted to hair restoration for the last 20 years. Medical degree from the Federal University Medical School UFMG Belo Horizonte, Brazil (1985). Plastic Surgery residency at the Mater Dei Hospital, Belo Horizonte, Brazil (1985/1990). Follicular Unit Transplantation exclusively since 1992. ISHRS member since 1993. Author (article) - Preview Long Hair Follicular Unit Transplantation - Hair Transplant Forum International, July/August 2006, Volume 16, Number 4. Author (chapter) - Preview Long Hair Follicular Unit Transplanting UngerWP.; Shapiro R. Hair Transplantation, 5th edn. Informa Healthcare, New York, p 438-44, chapter 16A) Attended 17/20 International Society of Hair Restoration Surgery annual meetings since Dallas 1993, including Bahamas 2012. President - Brazilian Association of Hair Restoration Surgery, 2009 -2011 Chairman - Brazilian Congress of Hair Restoration Surgery, 2010 Chairman - Workshopsand Lunch Symposia, ISHRS 20th Meeting, Bahamas 2012 M. Pitchon: None. ABSTRACT The hair transplant maximum efficiency equations were first presented by the author in the poster presented at the Alaska ISHRS 2011 meeting: Preview Long Hair Transplantation, The P Constant, the Patient Maximum Efficiency Equations and the Therasession Many are the generic and individual elements that contribute to, or reduce the potentiality for the best possible result and, then, the maximum efficiency result in each hair transplant patient. All the elements that play a role in the hair transplant best possible individual final result work as elements of the Patient Maximum Efficiency Equations (PMEE).

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Before a hair transplant procedure, the vast majority of the variable elements of the PMEE are previously known by the surgeon (patients individual hair characteristic). By being previously known, the surgeon knows how those variables will positively or negatively interfere with the final result. Among those variable known elements are the patients average hair caliber, waviness and his average donor area hair density. The higher their values the better those elements may positively impact the result. The lower the values the worse will they negatively impact the result. The higher the number of known variables taken in consideration by the surgeon the higher the precision at predicting the the result. And the higher the precision of how will each patients result be, the better and more efficient the planning of distribution strategy for each patient. There are two main variables that are not known by the surgeon before any given patients hair transplant. They are: 1. the real precise Coverage Behavior(CB) of the patients hair shafts in the recipient area (not the one at the donor), and: 2. the Patients Growth Index(PGI), the individual biological personal ability of each patient to convert the hair transplanted during surgery, under constant non variable technical high quality conditions, into grown, definitive hair, some months after (concept previously described and presented by the author in other meetings and papers). Preview Long Hair Transplantation (PLHT) plays a determinant role in objectively accessing those unknown variables so that their values may help preview and predict patients future scenarios and hence, previously determine the best optimized strategies for each patient, based on objective elements. The CB is accessed during each surgery session revealing the Best Distribution Strategy for each patient, since the very first session, with the viewing of the hair shafts coverage behavior enabled by PLHT. The PGI is accessed by comparison between the final definitive result and the immediate post-operative temporary result, only after the first surgery of every patient. The discovery of the PGI and the fact that poor growth became objectively measurable after that, defines the authors previously recommended strategy of avoiding extremely large sessions in the first hair transplant session in all patients, since some patients will unavoidably be diagnosed as low PGI patients (technically unavoidable poor growth, of individual biological causes origin) and, in this case, multiple smaller sessions would be advantageous than an extremely large initial session, for those patients. An extremely large session performed in a patient that will be diagnosed after some months with a very low PGI (under 50% PGI confirmed growth by PLHT) will very probably prevent this patient from achieving a consistent aesthetic not sparse result that could be provided by a well planned, desired, repetition of two or more previously predicted poor growth result sessions in a reduced strategic area like the frontal area. The advent of the PGI concept also impacts the definition of size of sessions in the second and subsequent hair transplant sessions: high PGI patients (close to 100% PGI confirmed growth by PLHT) may be submitted to any desired size of session, as large as desired, without the risk of poor growth for the patient - even a Therassession, as described by the author in the Alaska poster. Every patient has its own maximum efficiency equation that will lead to his best possible visual improvement. The previous knowledge of the maximum available number of factors, elements and indexes makes hair transplantation more efficient and less risky to all patients.

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126 Commentary On, "Personal Hair Growth Index"

William Parsley, MD 310 E. Broadway Street, Louisville, KY, USA. William Parsley, MD graduated from Univ of Tennessee Med School (1969) and completed Dermatology at the Univ of Louisville (1975). Positions: Past President- ISHRS ISHRS BOG and EC Past Chair of the ASHRS Past President of the ABHRS Past moderator of the Hair Transplantation Forum for the AAD Past BOT of the American Academy of Cosmetic Surgery Past Editor- Hair Transplant Forum International BOT- Hair Foundation. Past President- Kentucky Dermatologic Society Diplomate: Am Brd of Dermatology Am Brd of Dermatopathology Am Brd of Hair Restoration Surgery Awards: ISHRS Golden Follicle Award- 2003 Manfred Lucas Award- 2011 ISHRS CME Award W. Parsley: None. ABSTRACT Presentation will be a brief commentary on the Hair Growth Index system by Dr. Pitchon.

127 Application and Evaluation of the Cross Section Trichometer, Follicular Density, Hair Density, Hair Shaft Diameter and Surface Area Measurement to Predict Suitability of Candidates for Hair Transplantation, as Well as to Predict Results From Hair Transplantation
John P. Cole, MD Cole Hair Transplant Group, Alpharetta, GA, USA.

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Private practice in hair transplant surgery since 1990. J.P. Cole: None. 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. 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 = 2(Pi) (radius). 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 = Pi (radius2)] 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 four square 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

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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 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.

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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. Discussion: While we do not know the CSTI value of our patients before hair loss began, a loss much greater than 50% as compared to the donor area is often required before hair loss is apparent in the front and top of the scalp. Perhaps, it may be inaccurate to assume that we can calculate a percentage of loss based on the measurement of the donor area CSTI and recipient area CSTI. We might be able to estimate the percentage of hair loss progression and response to treatment, but we cannot be certain with regard to the percentage of loss. What we do know is that one may have a far lower CSTI on the top and front than in the donor area, yet have the illusion of full coverage. In fact, replacing only 24% of the donor area hair mass may result in the illusion of full coverage in some patients. This certainly voids the 50% loss theory by Marritt. Strip harvesting reduces the CSTI. Patients and physicians are interested in predicting coverage. Hair density measurements are often inaccurate. Measurement of hair diameter is often difficult because hairs tend to be elliptical or irregular in shape. Measurement of CSTI provides clues to the hair shaft diameter and hair density. Combining Hermes surface area calculations and CSTI may allow rapid and precise assumptions regarding coverage.

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The CSTI donor area range was much greater than has been previously reported by Bauman and Cohen. Far lower donor area CSTI values exist and the mean donor CSTI was below the range.

128 Commentary On, "Application and Evaluation of the Cross Section Trichometer, Follicular Density, Hair Density, Hair Shaft Diameter and Surface Area Measurement to Predict
Bernard P. Nusbaum, MD n/a, Coral Gables, FL, USA. Dr. Nusbaum has been widely published in the fields of dermatology and hair transplantation and has been extremely active in research and professional societies. He is a Diplomate of the American Board of Dermatology and The American Board of Hair Restoration Surgery. B.P. Nusbaum: None. ABSTRACT Will provide commentary on this adaptational use of cross section trichometry

129 Moderator Introduction, Advanced Surgical Videos

Russell G. Knudsen, MBBS Private Practice, Sydney, Australia.

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Dr Knudsen is a Past-President of ISHRS and practices full-time in hair restoration surgery in Australia and New Zealand. R.G. Knudsen: None.

130 Asymmetric Two-Layer Closure in Trichophytic Closure for Wide Donor Wound
Kim Dae-young, MD, PhD Yonsei Hair Transplant Center, 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 16th and 17th ISHRS annual meetings in Montreal and Amsterdam. These papers were also printed in the FORUM of ISHRS and the 5th edition of Walter Unger's text book. At the 18th annual meeting in Boston, he presented "20x digital video microsopic dissection" and "Placing 1500 grafts per hour with Choi implanters." K. Dae-young: None. ABSTRACT: Introduction: Hair transplantation sessions with larger than 3,000 follicular units (FUs) often require donor strips of greater than 1.5 cm high. We believe that wide excisions are best closed with a two-layer closure to minimize scarring. The use of a subcutaneous suture did not have enough strength to hold the wound edges together. With only subcutaneous closures, a resulting gap appeared between the upper and lower edges when the skin was sutured. This gap could cause tension and make a triangle dead space under the skin suture line. For solution to circumvent this problem, we devised a asymmetric two-layer closures, transferring tension from the superficial level to the deep subdermal level. One of the aims of our technique was to produce a faulting effect: elevation of upper lip (Fig. 1).This elevated upper lip sufficiently cover the de-epithelized lower lip edge in trichophytic closure of wide donor excision. Technique: Our design for a trichophytic closure of the donor wound required de-epithelialization of the lower lip margin with an in-house developed device, Kims trichoblade. It consisted of a 5cc syringe as a blade handle with a bent razor blade pushed into the syringe cylinder (Fig.2). The exposed sharp blade was used to cut at a constant depth of 0.2 to 0.5 mm and width of 1 to 2 mm from the lower skin edge(Fig.2). The dermal space was closed with an asymmetric suture technique where a height of one side was distinctly higher from the height of the other side. After the trichophytic strip was extracted, asymmetric dermal-subdermal suturing was performed by 4-0 Vicryl suture, with the first bite being inserted in the subcutaneous fat layer of the upper lip while exciting about 2mm below the skin

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surface (Fig. 3). The needle was then re-inserted at the inner border of the de-epithelialized edge of lower lip leading to the subcutaneous fat layer (Fig. 3). The knot was tightened to pull both margins in the deep subcutaneous tissue to produce the final effect, in a way which the upper lip was elevated 1-2 mm higher than the lower lip(Fig. 4). The tension was fixed as the knots were tied. Sutures were placed every 2.5 cm which was that a distance close enough to approximate in between and far enough to avoid too much damage to follicles along the wound with the dermal layers to approximate both wound edges.Continuous skin suturing was performed to complete the trichophytic closures by 4-0 Ethilon. Because the upper lip was already elevated by our suture technique, (after the suture was moved from the lower lip to the upper lip via the faulted plane), the suture thread was pulled in the upward direction. This allowed the lower lip to slide underneath the upper lip(Fig. 5). Discussion:| This Asymmetric two-layer closure technique deeply moved the tension and also produce a faulting effect: elevation of upper lip,and this allowed sufficient cover-up of the de-epithelialized lower lip edge with minimal tension in the trichophytic closure of the wide donor wound (Fig. 1). At a 1-year follow-up assessment, several small while spots were apparent where hair was partially absent along the donor scar. These were so minimal as to be considered barely evident (Fig.6 ). We had performed over 400 cases during past 4 years with our introducing suturing technique in trichophytic for donor wounds of wider than 1.5 cm. We randomly picked up 40 cases out of 400 cases of donor excision that were 2 cm and more in width at the midline and measured the scar width in mm and got the photos. The scar was 1-2 mm in all patients and cosmetically acceptable. Fig. 1 Diagram of a comparison between the fault, a planar discontinuity in a volume of rock, across which there has been significant displacement along the fractures as a result of earth movement, and asymmetric 2-layer closure. Fig. 2 . De-epthelizalization of lower edge with in-house developed trichophytic device: Kim's trichoblade. The width of donor ellipse was 2.5 cm at the midline. Fig. 3 Diagram of asymmetric dermal-subdermal suture. The needle then inserted by the inner border of the deepithelialized edge of lower lip later leading to the subcutaneous fat layer. Fig. 4 Diagram of trichophytic closure after asymmetric dermal-subdermal suturing. Fig. 5 Trichophytic closure of wide donor wound (2.5 cm wide at the midline) after asymmetric dermal-subdermal suturing. Pulling the thread upward direction to let the lower edge slide underneath the upper edge in trichophytic closure . Fig. 6 Several spots seen along the donor scars,both 2 year after hair transplantation, trichophytic closures of donor wound (2.5 cm wide at the midline) were done followed by asymmetric 2-layer closures. Enlarged view of several white spots above where the asymmetric dermal-subdermal knots were buried.

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131 W-Trichoplasty Closure For Better Strip Scars- A New Technique

Tejinder Bhatti, MD Darling Buds Hair Transplant Center, Chandigarh, India.

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Founder Secretary, Association of Hair Restoration Surgeons of India ; Governing Council Member, Indian Association of Aesthetic Plastic Surgeons ; Governing Council Member, Association of Plastic Surgeons of India Moderator, India Hair Forum Joint Editor, Indian Journal of Plastic Surgery Dr Tejinder Bhatti is in the practice of hair transplant surgery for the past over 15 years T. Bhatti: None. ABSTRACT: Z-plasty (w-plasty) is an accepted technique for better scars commonly used by plastic surgeons in their daily practice. This has been now routinely assimilated in our practice for producing better strip surgery scars in Indian patients due to their peculiar skin characteristics. The conventional ledge trichophytic closure entails excision of the epidermal overhang of one edge of the donor incision. This is done keeping the bulge area of the follicular unit intact. The hairs so transected grow through the final scar, camouflaging the stigmata of strip surgery. Linear scars carry the risk of higher visibility especially in pigmented skins. Traditional ledge trichophytic closure has addressed this problem to a great extent in non- pigmented skin types. However, traditional trichophytic closure has not been successful in India patients in our practice. Therefore the need to seeking solutions within the ambit of accepted plastic surgical techniques. The advantages of this new technique of trichophytic closure are manifold1.Closure along relaxed skin tension lines leads to a better scar. 2.Z-plasty distributes the tension of the wound preventing scar creep (stretch). 3.Transected hair grow through the scar camouflaging its short limbs. 4.A wider strip upto 20 mm in size can be obtained in some cases thereby maximizing harvested grafts. 5.The patient can wear his hair shorter than in the traditional trichophytic closure due to absence of a straight line scar. 6.Since there is no excision of epidermis there is a decreased incidence of- erythema, cyst formation and crust formation. This center has been performing trichophytic closures using this technique for the past 2 years with very

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encouraging results. The trichophytic closure is routinely done in all cases done using the strip technique area. Unlike in the traditional ledge trichophytic closure, this technique gives better results in all cases. The author presents his technique through video.

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Linear scar more visible W-Trichoplasty Closure

Tejinder Bhatti, MCh Chandigarh, India Founder Secretary, AHRS-India

W-plasty
y Borges, 1959

What does Z/W-plasty have to offer?

Benefits in strip scar
y Lengthens a linear

y Imbrication of triangles of skin on each side of the excised

Z-plasty principle

scar.

scar(tight scalp) y Disperses the scar breaking up the straight line y Realigns the scar along lines of minimal tension

W-Trichoplasty Closure

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3mm triangles 60angle of each trough

Advantages of W-Trichoplastic Closure

y Closure along relaxed skin tension lines leads to a better scar

y Z-plasty distributes the tension of the wound preventing scar

y y y y
Traditional Closure Closure with W- Trichoplasty

creep (stretch) Transected hair grow through the scar camouflaging its short limbs A wider strip upto 20 mm can be obtained in some cases thereby maximizing harvested grafts The patient can wear his hair shorter than in the traditional trichophytic closure due to absence of a straight line scar Since there is no excision of epidermis there is a decreased incidence of- erythema, cyst formation and crust formation

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Greetings from Chandigarh

Thank you

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132 Donor Closure Technique Using Both Edges Trichophytic Closure: A Video Presentation
Kazuhito Yamamoto, MD Umeda Beauty Clinic, Osaka-Umeda, AD BLD 9F, 2-15-29, Sonezaki, Kita-ku, Osaka, Japan. Dr. Kazuhito Yamamoto has been engaged as the director of the Hair Transplant Clinic in Osaka, Japan, from 2004. He received his medical degree from Kyoto Prefectural University of Medicine in 1999. He is a seven year member of the ISHRS from 2006, a Diplomate of the Japan Surgical Society and the Japanese Society of Gastroenterology. K. Yamamoto: None. ABSTRACT: Introduction Many hair transplant surgeons have recognized the positive results of trichophytic closure after strip harvesting. We have performed very effective double-sided trichophytic closure, which we reported at the 17th Annual Scientific Meeting in Amsterdam in July 2009. In addition, this unique intra-epidermal wavy suture yields better results. Objective The objective is to demonstrate the techniques about the authors suturing method performed after the deepithelialization technique of both wound edges. Materials and Methods After the donor excision is performed strictly parallel to the follicle under open technique, the scalp laxity examinations are carried out and the safety of closing the donor wound without any tension is confirmed. The procedures do not include additional undermining and a controlled removal of both wound edges follows the subcutaneous continuous or interrupted suture with 3/0 polydioxanone (deep-layer closure). Using surgical scissors, each thin strip of epithelium is cut 1 mm and 1.5-2.0 mm in width in upper and lower edges of de-epithelialization, respectively. Following these techniques, a running wavy suture is performed with 5/0 absorbable suture. This method involves not dermal but rather intra-epidermal suture. The initial buried suture is carried out in between the follicles of the one side of the wound end. In the intra-epidermal suture, the needle enters perpendicularly to the wound at the boundary between the skin surface and the wound plane and passes through to a depth of 1 mm from the skin surface as the suture forms a big arc, and then leaves from its boundary. The suturing technique is repeated toward the other side of the wound end and the knot is buried at the wound end as well. The final aspect of the wound is wavy. Discussion When the Intra-Epidermal Wavy Suture (IEWS), which is named after its characteristics, was added to trichophytic closure of both edges, very positive results were obtained1,2. The perpendicular vector of the tensile strength to the wound is dispersed partly in the horizontal direction by the wavy suture and the tension of the superficial wound decreases. The wavy wound is also held without spreading by no removal of stitches for 2 to 3 weeks. This method does not use dermostitches except for both wound ends so as not to damage the bulge area and the bulb. There is neither permanent loss of hairs nor stitch marks due to the pressure of stitches.As a result, the final wavy line achieves narrower scars and camouflages them effectively. Conclusion The author has experienced even better results in terms of the appearance of the donor scars by using an additional superficial layer suture (IEWS) for double-sided trichophytic closure.

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Reference 1.Yamamoto, K. Trichophytic closure of both wound edges after strip excision for hair transplantation. Hair Transplaant Forum Intl. 2009; 19:185, 190-1. 2. Yamamoto, K. Double Trichophytic Closure with Wavy Two-Layered Closure for Optimal Hair Transplantation Scar. Dermatol Surg (in press).

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133 Untouched Strip Technique, A Procedure Combining FUE and Strip Surgery While Preserving an Untouched Area: Analysis of 18 Cases
Mrcio Crisstomo, MD, MS, Marilia Crisstomo, MD, Denize Tomaz, MD Clin - Plastic Surgery, Dermatology, Baldness Treatment, Fortaleza, Brazil. Dr. Mrcio Crisstomo is a plastic surgeon post-graduated during 3 years at the Ivo Pitanguy Institute (Rio de Janeiro - Brazil), with master degree in surgery (research in oxidative stress during hair transplant) and was plastic surgery staff professor University Hospital in Cear during five years. For more than ten years Dr. Crisstomo has been practicing hair restoration and has a special interest in larger surgeries as mega and gigasessions. Actually he is dedicated to procedures combining follicular unit extraction with strip surgery to improve the number of follicular units transplanted in one procedure. M. Crisstomo: None. M. Crisstomo: None. D. Tomaz: None. ABSTRACT: Introduction Even in mega and gigasessions, the number of Follicular Units (FUs) obtained with the Strip harvesting (SH) is limited by scalps density and elasticity. As FUE doesnt need scalp elasticity, the author suggests an approach to the donor area combining both SH and FUE in the same surgery to improve the number of FUs transplanted in a single procedure. The FUE is done inside the patients Safe Donor Area and it is advised also preserving a strip of 1,5cm just below the suture of the first strip without harvesting FUs, avoiding anatomical changes such as fibrosis or density decrease in this region. This area is and can be used in a future procedure and is called Untouched Strip. Objective The aim of this presentation is to describe the technique, to show statistics as number of FUs transplanted (total, with Strip and with FUE), duration of the procedure, post-operative management, complications and aesthetic results. Materials and/or Methods 18 surgeries performed in mens with average age of 43 years (range from 32 to 59) and baldness grades Norwood V, VA, VI and VII were analyzed in the following aspects: total number of FUs, percentage of increase with FUE, duration of the procedure with and without FUE, complications and final aesthetic results. The data were compared with student t test. Results/ Discussion The average FU number transplanted was 3,832 (range from 2,967 to 5,085), the strip harvesting had an average of 3,076 FUs and the FUE harvesting 756 FUs, an increase of 24,6% (range from 12,5 to 42%). In advanced degrees of baldness, an increase in the number of FUs is always beneficial and with the Untouched Technique it is possible to do a surgery almost one quarter larger. The downtime in the post-operative period is longer as the patient has his had shaved and its not possible to hide the scar for three to five weeks. In 22% of patients it was observed a temporary loss of hair in the FUE area superior to the suture, probably due to overharvesting leading to a shock loss. The most important issue is that the strip where the surgeon doesnt do the FUE keeps its original anatomical features and can be used in a future procedure of strip surgery. Conclusion with the Untouched Strip Technique the surgeon can harvest a significant higher number of FUs in one procedure thus giving more hair and density, and preserving an untouched area of the donor area for a future strip harvesting.

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134 Expanding Needle Concept For Better Extraction of Body Hair Grafts
Arvind Poswal, MBBS Dr. A S Clinic Pvt. Ltd., New Delhi, India. 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. As 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. A. Poswal: None. . Poswal: None. ABSTRACT: Introduction: In traditional follicular unit extraction technique, 0.8 - 1.4mm punch is used to cut the dermis to the level of attachment of erector pili muscle, so that the intact follicular unit grafts can be extracted. However, the larger extraction sites and higher hair root transection rates are some difficulties encountered while using the punch to extract body hair grafts. To overcome these difficulties, expanding needle concept has been devised. It approaches the extraction process by customizing the extraction wound to the architecture of the follicular unit and by performing most of the dissection of the dermal attachments to the donor follicular unit under direct magnified vision. Difficulties encountered during extraction of body hair grafts by a rigid punch were as follows: Skin, in most body areas, is freely mobile over the underlying surface. The extraction is performed by using a rigid punch to cut around the follicular unit. The cutting of the tissue is done by the rotational motion of the punch. This results in torsion of the follicular unit due to this excessive laxity of the skin, leading to higher percentages of hair follicle transection.The loosely arranged hair follicles in the body donor areas mean that the individual hair follicles in the follicular unit may be spread out over 1.5 to even 2mm (as shown in fig. 1.1 and 1.2). This necessitates larger diameter punches that leave larger extraction wounds giving rise to more visible scarring. Hair follicles in most body donor areas lie at very acute angle. Therefore, in traditional punch method the downward pressure of the punch causes damage to the follicular unit due to splaying of the roots as pressure is applied on the punch. To overcome these difficulties using the traditional rigid punch method, a non-punch based body hair graft extraction technique has been devised. Technique: In expanding needle concept (ENC), a hypodermic needle is used as a cutting instrument in place of traditional rigid punch. The needle tip is used to first score around the follicular unit. Then, using a small tooth forceps to hold the top of the follicular unit, the tip of the needle is used to cut the adhesions of the follicular unit to deep dermal tissues and underlying fat under direct magnified vision. This dissection under direct vision ensures minimal transection of the hair roots on one hand, and being able to extract a graft with surrounding fatty tissue (thus increasing graft survival rates) on the other. Approach used in ENC for extraction of body hair grafts is described in

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A diagrammatic representation:Fig. 1.3 The extraction occurs as if the needle had expanded as it went inside, adjusting to the shape and diameter of the follicular unit. Fig. 1.4 Actual pictorial presentation: Fig. 1.5 - 1.13Advantages of using needle for extraction of body hair grafts were: Needle tip is used to score around the follicular unit. 3 to 4 strokes are used to score around the entire circumference. Discussion: Using needle tip for scoring and dissecting around the hair follicle of the body donor area hair grafts has certain advantages: 1.The extraction of body hair grafts by a needle tip removes the need of rotary motion thus removing the ill effects of torsion on the hair follicle. 2.There is no significant downward pressure when using the needle as compared to when the punch is used. That reduces the transection rate of the hair follicle. 3.Less damage to follicular units by scoring with needle, as the direction of the needle tip can be customized to the direction of emergence of individual hair follicle of the follicular unit. 4.Smaller extraction sites (as the scoring around the body donor area hair graft can be customized as per the shape/lie of the individual hair follicles, and overall smaller extraction wound results). 5.Major part of the extraction/dissection of the deep dermal adhesions is done under direct magnified vision. This improves the yield of the intact grafts from the body donor areas. The use of the needle tip as a cutting instrument in the expanding needle concept is especially beneficial in the more difficult body donor areas as it has reduced the difficulty posed by larger extraction sites and at the same time lowered the transection rates of the body donor hair.

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EXPANDING NEEDLE CONCEPT

FUSE / FUE in extraction of body hair grafts

Traditional punch based FUE extraction of the body hair grafts has following disadvantages Large extraction sites Higher transection rates. A non punch based grafts extraction technique has been, therefore, devised.

Expanding needle concept

Use of hypodermic needle instead of a traditional punch.

Difficulties in extraction of body hair grafts

The reasons for difficulties in extraction of body hair graft are attributable to Laxity of skin(skin in most body area is freely mobile over the underlying surface) Acute angle of hair shaft (hair follicles in most body donor areas lie at very acute angles) Loose arrangement of follicles in the follicular units (in some places the hair follicles of the follicular unit are spread 1.5-2mm apart)

Disadvantages of traditional punch

When using the traditional punch for body donor follicular unit graft extraction, the following are some common difficulties encountered Torsion of the follicular units(due to excess skin laxity) Downward pressure of the punch. Damage to the Follicular units due to splaying of the roots(during downward motion of the Punch) Due to the loosely arranged hair follicle in the body donor area follicular units, larger diameter punches are required giving rise to more visible scarring.

Scalp donor area

Chest donor area

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A different approach (Expanding needle concept)

The extraction occurs as if the needle/ punch had expanded as it went inside, adjusting to the shape and diameter of the follicular unit.

Hypodermic needle (20 gauge )

Needle tip is used to score around the follicular unit. 3 to 4 strokes are used to score around the entire circumference.

NEEDLE TIP IS USED TO SCORE AROUND THE BODY DONOR AREA FOLLICULAR UNIT

Steps showing extraction of follicular unit using expanding needle technique

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The adhesions of the follicular unit to deep dermal tissue and underlying fat are cut by the needle tip under direct magnified vision, further lowering transection rates.

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Video

Advantages of using needle for extraction

Using needle tip for scoring and dissecting around the hair follicle of the body donor area hair grafts has certain advantages No rotation motion (no torsion). No significant downward pressure. Less damage to follicular units by scoring with needle, as the direction of the needle tip can be customized to the direction of emergence of individual hair follicle of the follicular unit. Smaller extraction sites(as the scoring around the body donor area hair graft can be customized as per the shape/lie of the individual hair follicles, and overall smaller extraction wound results. Part of the extraction/dissection of the deep dermal adhesions is done under direct magnified vision. This improves the yield of the intact grafts from the body donor areas.

Conclusion
Use of the needle tip as a cutting instrument in the expanding needle concept is especially beneficial in the more difficult body donor areas.

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135 Neograft: Personal Experience, Capabilities and Limitations

Ken L. Williams, DO

136 Video Presentation of Slivering and Follicle Dissection Under Stereo Microscope, and Innovative Technique to Train Staff
Anil Kumar Garg, MD, Seema Garg, MBBS Rejuvenate Hair Transplant Centre, Indore, India. Dr.anil kumarg garg MBBS.,MS.,MCh Plastic Surgeon Member ISHRS, AASRH, AIHRS Fellow peripheral nerve surgery EVMS,Norfolk,USA Fellow microsurgery CGMH,Taiwan Member World society of microsurgery . E mail anil@anilgarg.com www.anilgarg.com www.rejuvenatehairtransplant.com A.K. Garg: None. S. Garg: None. ABSTRACT: This is a video presentation of slivering and follicle dissection under stereo microscope. Another is an interesting video to train the staff. These recordings were made by a built in camera in stereo microscope. Magnification has great role in hair transplant. Harvesting, slivering, dissection and implantation of follicles under magnification is a standard practice. We are using stereo microscope for slivering and follicle dissection and loupe magnification for implantation of follicles. Advantage of Stereo microscope is better depth perception, virtual colour of tissue, 3D image and relatively faster learning. Cost of microscope and space required for this microscope is smaller limitation as compare to advantage in terms of follicle transaction rate. Other advantages of stereo microscope over conventional microscope are its ergo metric design and the large screen gives negligible strain over neck. I have been using microscope in micro surgery for twenty years, and have trained many fellows in this field. But to train a person for stereo microscope even without medical back ground is easier and quick. This is greatest

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advantage I realised other than those I mentioned above. I have developed a very simple and innovative technique to train the staff. First day they draw simple straight line in a box, and then this is done under stereo micro scope. Then a plant leaf is prepared as a raw material for follicles as shown in picture. Then plant leaf is cut under micro scope. After a weeks exercise over plant leaf they are given follicle to dissect. We realised that initially speed may be slow but follicle transaction is almost zero and quality of dissected follicle is good even at initial stage. While in conventional dissection and slivering speed may be fast but transaction of follicles is seen.

137 Both-Hand Slit Technique ( Both-Hand No-Touch Technique)

Jae Hyun Park, MD, Jae Seong Moh, MD, PhD DaNa Plastic Surgery Clinic, Seoul, Korea, Republic of. Plastic Surgeon, Private practice in DaNa Plastic Surgery Clinic, Seoul, Korea J. Park: None. J. Moh: None. ABSTRACT: Introduction A new technique using needle and implanter simultaneously with surgeon's both hands, called "Both-hand slit technique or Both-hand No-touch technique" Technique "Both-hand slit technique or Both-hand No-touch technique" Discussion Follicular unit hair transplant method can be broadly classified into two following techniques; one is a slit method using forceps on a premade incision, and the other one is a method using implanter. Apart from the existing two techniques stated above, authors have used the No-touch technique since 2008, which generates premade incisions using needles and inserts hair follicles using implanter into a premade recipient site. Recently many hair transplant surgeons in Korea try to use the No-touch technique, as it can take advantage of benefits from both slit and implanter techniques. However, we sometimes encounter such problems as follows. 1. severe popping caused by hard skin 2. graft popping out caused by easily bleeding skin even after premade incisions are generated to insert graft into the recipient site 3. increased chances of missing sites since premade incisions are difficult to find between the preexisting long hairs (The implanter technique can transplant hair into the recipient area without cutting hair short, which is an advantage

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of the technique.) The situations stated above can cause long operation time and lead to unfavorable results. In these cases, authors resolve those problems by taking measures using Both-hand Slit Technique, or Both-hand No-touch Technique. The advantages of this method are as follows. 1. almost no pitting scar 2. easier to create higher density 3. no popping even in hard and/or bleeding cases 5. do not touch the hair bulb = atraumatic surgery The disadvantages of this method are 1. it is difficult to conduct by two hands at the same time in temple area because of a slit direction and 2. relatively long learning curve 3. intensive labor of physician.

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Both-hand Slit Technique ( (Both-hand Notouch Technique) q )

Jae Hyun, Park M.D. DaNa Plastic Surgery Clinic Seoul, Korea

Jae Hyun, Park M.D. - Plastic Surgeon, - Private practice in DaNa Plastic Surgery Clinic, Seoul, K Cli i S l Korea

Methods of Graft placement

The author has no relevant financial relationships or conflicts of interests to declare. Slit Technique - MIF -S&P - Spreader & place technique Implanter Technique Slit + Implanter Technique - Notouch technique(by Ron Shapiro) - Both-hand Notouch technique(NEW)

Advantage of S&P
1. less bleeding 2. no missed sites or piggy backing 3. smaller incision/less vascular trauma 4. easier to identify and follow the exact andgle and direction of incision 5. ability to adjust incision size 6. more relaxed procedure for the assistant

Disadvantages of S&P
1. Greater demand on physician time 2. only one team placing at a time 3. long learning curve to achieve speed 4. less control over pattern and distribution

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Notouch Technique
First introduced by Ron Shapiro Combination of Slit + implanter technique C de classified as subtype of S&P Can d l ifi d b f

Both-hand Notouch Technique

Introduction For some doctors who is familiar with implanter technique, the method of No-touch technique proposed by Dr. Ron Shapiro may sometimes b a good choice. But the "Nobe d h h touch technique" is still have some trouble with popping up due to hard skin, or some bleeding cases or in the case of transplanting between the pre-existing hair, it is difficult to apply S&P or Notouch technique.

Advantage of both-hand notouch technique

1. Between preexisting long hairs, it is hard to transplant graft into pre-made incision prone to missing site; (Ex) The important advantage of implanter! it is possible to transplant graft without having to cut the long preexisting hairs. You may encounter severely popping-out cases using implanter with patients long hair state, then you can simply change your method to both-hand Notouch technique and very easily can solve the popping-out problem. 2 2. In case of popping is very severe due to very hard skin. skin 3. In case of popping-out due to easily bleeding skin, even with the pre-made incision. In such a case, sometimes hair surgeon might meet the issues. In these cases, surgeon is having very embarrassed time, the surgery time take much longer and a bad result may come out. In these cases, the author uses the both-hand slit technique", or "Twohanded No-touch technique" in which we named and the way problems are solved.

Operation method
1. Patient lay down comfortably in supine position in bed. 2. Physician is positioned at the top of the patient head, if physician is right-handed (the author is right-handed) assistants are located on the right side of the physician. 3. 1~2 loaders, 1 passer, 1 physician system. Passer is located right next to the physician, and the rest of the 1-2 loader sits next to passer. 4. Physician holds the slit needle on the left hand, and grips the implanter on the right hand. 5. With your left hand, produces slit and immediately followed by inserting implanter into the incision site and insert hair follicle by your right hand (This process is almost done in the same time, the incision site which is left with an empty time shorter than the S & P, almost no bleeding). 6. With Passer's right hand takes an empty hair injector back from physician's right hand quickly and immediately follow by hand-out the hair injector (loaded hair follicle) to the physician to the direction of a physician's hair injecting way. 7. In the meantime, surgeon places the new site incision and re-inserts the graft by implanter.

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scientific Poster PresentAtion

Scientific PoSter PreSentationS

The scientific poster presentations will be on display in the Grand Ballroom Foyer, outside of the General Session Room. The posters will be reviewed and rated, and certificates of recognition will be awarded to the highest scoring posters. New this year! The poster presentations will be summarized and briefly reviewed by the moderators during a Poster Review Session in the General Session on Friday from 2:30PM-4:00PM.
Poster set-uP By Poster owners

P22 Newly Developed Hair Transplanter OKT (Optimally Kept Transplanter) that Improves the Hair Survival Rate - Kun Oc, MD P23 Hair Transplantation in Frontal Fibrosing Alopecia: A Repor t of Two Cases - Ratchathom Panchaprateep, MD P24 Camouflaging the posterior zygomatic arch protrusion after zygoma reduction surgery using hair transplantation in infratemple area - Jae Hyun Park, MD P25 Trichoschisis: an Uncommon Complication from Hair Transplantation - Damkerng Pathomvanich, MD P26 Impossible hair transplant repair - a different approach to treat a difficult repair patient - Arvind Poswal, MBBS P27 Oral Evaluation of Body Dysmorphic Disorder in Hair loss patietns and benefit after Hair transplant - Rajendrasingh J. Rajput, MD P28 Update on recipient site staining, Better stain formulation viscosity improves sites visibility by 100 % - Muhammad N. Rashid, MD P29 Re-innervation and Arrector Pili Muscle Formation of Follicular Unit after Hair Transplantation - Akio Sato, MD, PhD P30 Low Anabolic Profile in Assessing a Patient's Overall Hair Loss Program - Lawrence J. Shapiro, MD P31 Stamp for the Operation Planning - Piero Tesauro, MD P32 Ryan Welter Hair Loss Classification - Ryan J. Welter, MD, PhD P33 Can we do DFUs on Asians? - Wen Yi Wu, MD P34 Genomics Comparison of Hair Follicles from Punch Biopsies, Follicular Unit Extractions, and Plucks - Bradley R. Wolf, MD P35 Atrial Fibrillation and Guidelines for Perioperative Antithrombotic Therapy - Kuniyoshi Yagyu, MD P36 High Density Implantation for Secondary Cicatricial Alopecia - Kuniyoshi Yagyu, MD P37 Asian female hairline surgery using Follicular Unit Extraction - Sung Jae Yi, MD P38 Scar Repair for a 16 year old male patient using FUE - Georgios Zontos, MD

wednesday I october 17, 2012

scientific Poster Viewing Hours

1:00PM-7:00PM 7:30AM-7:30PM 8:15AM-6:00PM 7:30AM-12:30PM 2:30PM-4:00PM 4:00PM-4:30PM

thursday I october 18, 2012 friday I october 19, 2012 saturday I october 20, 2012
Poster reView session in generAl session

friday I october 19, 2012

Poster inquiry session (during coffee break)

friday I october 19, 2012

P01 Dihydrotestosterone-Inducible IL-6 Inhibits Elongation of Human Hair Shafts by Suppressing Matrix Cell Proliferation and Promotes Regression of Hair Follicles in Mice - Ji-sup Ahn, MD P02 Photographic review of factors that make FUE cases difficult - Jisung Bang, MD P03 The Use of Hair Bundle Cross-Section Trichometry to Confirm Success in the Medical Management of Hair Loss - Alan J. Bauman, MD P04 Traction Alopecia in Sikh Males- a review of 213 cases managed with hair transplant - Tejinder Bhatti, MD P05 The Mythical FUE Learning Curveobservations after training 75 doctors in FUE methods - Tejinder Bhatti, MD P06 Hair Mapping: A comparison of Caucasian and Korean Hair Density, Follicular Density and Calculated Density; A three year follow up using new methods. - John P. Cole, MD P07 Combination of Strip Surgery and Follicular Unit Extraction to Improve the Number of Follicular Units Harvested in Primary and Secondary Hair Transplantation - Mrcio Crisstomo, MD P08 Frontal Fibrosing Alopecia: a variant of Lichen Planopilaris or distinct clinical entity? Comparative study of ten cases. - Mrcio Crisstomo, MD P09 A split comparison study of trichophytic versus non-trichophytic closure of donor site in follicular unit hair transplantation (FUT) - Niteen V. Dhepe, MD

P10 Scalp Burning and Tenderness: How Impor tant is it to Ask during the Consultation? - Jeffrey C. Donovan, MD, PhD P11 FUE Hair Transplant in Traction Alopecia in Sikh Population - Kapil Dua, MD, MBBS P12 Scarless Galeal Closure - Jorge Gaviria, MD P13 Temporal Peaks Aesthetic Implication - Jorge Gaviria, MD P14 A case of Trichorrhexis Nodosa after hair transplantation - Sung joo Tommy Hwang, MD, PhD P15 Hair and the Psyche: arm and beard hair implant - Khalil I. Jebai, MD P16 Comparing the graft survival and growth keeping in PRP to the saline in hair transplantation - Hamidreza Kahnamuee, MD P17 The study of storage solutions for hair follicle protection during hair transplantation surgery - Moonkyu Km, MD, PhD P18 Protection of Human Hair Follicles Viability by Coculture with Mesenchymal Stem Cells - Melike Kulahci, MD P19 Follicular unit transplantation: comparison of three cuttings techniques - Mohammad H. Mohmand, MD P20 The Simplest Way to Prevent and Manage Postoperative Follicultis - Bertram M. Ng, MBBS P21 Golden Rules to be Observed for Enhancing the Survival Rate in Hair Transplant Using a Choi-Hair Transplanter - Kun Oc, MD

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3 Dihydrotestosterone-Inducible IL-6 Inhibits Elongation of Human Hair Shafts by Suppressing Matrix Cell Proliferation and Promotes Regression of Hair Follicles in Mice
Mihee Kwack1, Ji-sup Ahn, MD. PhD2, Young-kwan Sung1 1 Department of Immunology, School of Medicine, Kyungpook National University, Daegu, Korea, Republic of, 2Dr. Ahn Medical Hair Clinic, Seoul, Korea, Republic of. Ji-sup Ahn, M.D., Ph.D. Dr. Ahn Medical Hair Clinic 2th floor, Gangnam Bldg, #211-20 Nonhyun-dong, Gangnam-gu 135-996, Seoul, South Korea Phone : 82-2-543-4646, Fax : 82-2-543-4640 Email : drahn@hairmedical.co.kr General Information: Education 1995 Feb. BA, Keimyung University School of Medicine 1999 Feb. Master of Medicine, Keimyung University School of Medicine 2005 Feb. Doctor of Medicine, Department of Immunology, Kyungpook National University School of Medicine Career (May 2004-April 2006) Clinical Assistant Fellowship at the Hair Transplantatin Center, KNUH (May 2004 - Now) 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) M. Kwack: None. J. Ahn: None. Y. Sung: None. ABSTRACT: Autocrine and paracrine factors are produced by balding dermal papilla (DP) cells following dihydrotestoster-one (DHT)-driven alterations and are believed to be key factors involved in male pattern baldness. Herein we report that the IL-6 is upregulated in balding DP cells compared with non-balding DP cells. IL-6 was upregulated 3hours after 10-100nM DHT treatment, and ELISA showed that IL-6 was secreted from balding DP cells in response to DHT. IL-6 receptor (IL-6R) and glycoprotein 130 (gp130) were expressed in follicular keratinocytes, including matrix cells. Recombinant human IL-6 (rhIL-6) inhibited hair shaft elongation and suppressed proliferation of matrix cells in cultured human hair follicles. Moreover , rhIL-6 injection into the hypodermis of mice during anagen caused premature onset of catagen. Taken together, our data strongly suggest that DHT-inducible IL-6 inhibits hair growth as a paracrine mediator from the DP.

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Dihydrotestosterone-Inducible IL-6 Inhibits Elongation of Human Hair Shafts by Suppressing Matrix Cell Proliferation and Promotes Regression of Hair Follicles in Mice

Ji Sup Ahn2, Mi Hee Kwack1 , Moon Kyu Kim1, Jung Chul Kim1, Young Kwan Sung1

1Department

of Immunology, School of Medicine, Kyungpook National University, Daegu, Korea and 2Dr.Ahn Medical Hair Clinic, Seoul, Korea
Introduction Objective
To investigate whether DHt-indcible IL-6 inhibits hair growth as a paracrine mediator from the DP.

Abstract

Androgenetic alopecia (AGA) or male-pattern baldness, is a progressive disorder. It is the most common type of hair loss in men. There are two key features in AGA that are well established by androgens. One of the key features of AGA is shortening of the anagen period [1]. Another feature is follicular miniaturization in which large terminal hairs are transformed into vellus-like hairs [2]

Materials and Methods

Cultured DP cells & human hair follicles
RT-PCR
detection of IL-6 level in B and NB DP cell detection of IL-6 level by DHT treatment

Circulating androgen at the blood enter the follicle via the DPs capillaries, bind to androgen receptors (AR) in DP cells, and then activate or repress target genes [3]. Some of them contr ol the follicular keratinocytes that make the hair or the melanocytes which produce pigment b y paracrine regulators [3,4]
Immunocytochemistry

Natural mouse model

ELISA
measurement of IL-6 concentration in B and NB DP cell

Autocrine and paracrine factors are produced by balding dermal papilla (DP) cells following dihydrotestosterone (DHT)-driven alterations and are believed to be key factors involved in male pattern baldness. Herein we report that the IL-6 is upregulated in balding DP cells compared with non-balding DP cells. IL-6 was upregulated 3 hours after 10100 nM DHT treatment, and ELISA showed that IL-6 was secreted from balding DP cells in response to DHT. IL-6 receptor (IL-6R) and glycoprotein 130 (gp130) were expressed in follicular keratinocytes, including matrix cells. Recombinant human IL-6 (rhIL-6) inhibited hair shaft elongation and suppressed proliferation of matrix cells in cultured human hair follicles. Moreover, rhIL-6 injection into the hypodermis of mice during anagen caused premature onset of catagen. Taken together, our data strongly suggest that DHT-inducible IL-6 inhibits hair growth as a paracrine mediator from the DP. Several evidences indicated that cultured DP cells from balding scalps secret TGF-1/TGF2/DKK-1 which inhibits the epithelial cell growth in response to DHT [5-7]

Western
detection of IL-6R and gp130 in human hair follicle detection of IL-6R and gp130 in cultured cells

Hair organ culture

measurement of hair elongation detection of ki67 in cultured hair follicles

Recombinant IL-6 injection

Figure 1. Upregulation of IL-6 in cultured balding DP cells compared with the non-balding DP cells and IL-6 induction in response to DHT

(a) Seven pairs of matched balding and non-balding dermal papilla (DP) cells were analyzed by reverse transcription (RT)PCR. (b) IL-6 levels in conditioned medium of balding (B) and non-balding (NB) DP cells from four matched pairs in duplicate measurements were made by ELISA and the relative fold change of IL-6 in each cases (B/NB) are shown. (c) Balding DP cells were treated with varying concentrations of DHT, and concentrations of IL-6 were measured by ELISA. Cells were also treated with varying concentrations of DHT for 6 hours (d) or 100 nM DHT for varying times (e) and analyzed by RT-PCR

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Figure 4. Effect of rhIL-6 on cultured human hair follicles
Isolated human hair follicles were cultured for 6 days in the absence or presence of rhIL-6, and hair shaft elongation was measured (a) Human hair follicles were treated in the absence (c and e) or presence of 50 ng/ml rhIL-6 (d and f) for 2 days and stained with Ki-67 immunofluorescence staining. Corresponding DAPI nuclear staining is also shown (e and f). Ki-67positive proliferative cells (red) in the hair bulb were counted (b).

Results R lt
Figure 5. Effect of rhIL-6 on catagen onset.

Conclusion Concl sion

Figure 2. Expression of IL-6R and gp130 in hair follicles and cultured cells

Dihydrotestosterone (DHT)- inducible IL-6 from dermal papilla functions as an inhibitory paracrine mediator that inhibits hair shaft growth by suppressing matrix cell proliferation.

Referance
(a) The back skins of C57BL/6 mice (n=6) were shaved at 5 weeks of age and the vehicle (b) or 100 ml of 500 ng/ml of rhIL-6 (c) was injected once a day for 3 days. [1] Kaufman K D. Androgens and alopecia. Mol Cell Endocrinol 2002: 198: 89-95. [2] Rushton D H, Ramsay I D, Norris M J, Gilkes J J. Natural progression of male pattern baldness in young men. Clin Exp Dermatol 1991: 16: 188-92. [3] Randall V A, Thornton M J, Hamada K, Messenger A G. Androgen action in cultured dermal papilla cells from human hair follicles. Skin Pharmacol 1994: 7: 20-6. [ ] p [4] Imperato-McGinley J, Guerrero L, Gautier T, Peterson R E. Steroid 5alpha-reductase deficiency in man: an y p y inherited form of male pseudohermaphroditism. Science 1974: 186: 1213-5. [5] Inui S, Fukuzato Y, Nakajima T, Yoshikawa K, Itami S. Androgen-inducible TGF-beta1 from balding dermal papilla cells inhibits epithelial cell growth: a clue to understand paradoxical effects of androgen on human hair growth. FASEB J 2002: 16: 1967-9. [6] Hibino T, Nishiyama T. Role of TGF-beta2 in the human hair cycle. J Dermatol Sci 2004: 35: 9-18. [7] Kwack M H, Sung Y K, Chung E J et al. Dihydrotestosterone inducible dickkopf 1 from balding dermal papilla cells causes apoptosis in follicular keratinocytes. J Invest Dermatol 2008: 128: 262-9.

Human scalp hair follicles were immunostained with antibodies against IL-6 receptor (IL-6R, a) and glycoprotein 130 (gp130, b). High-powered images of IL6R and gp130 expression in hair bulb regions are also shown in c and d,respectively. Close-up images of boxed regions of c and d with emphasis on the follicular matrix are also shown in e and f. Bar0.1 mm. Immunoblot analysis (g) of IL-6R and gp130 protein expression in cultured hair cells. Actin expression was measured to check the quantity and integrity of the protein samples.

3 Photographic Review of Factors That Make FUE Cases Difficult

Jisung Bang, MD Forhair Korea, Seoul, Korea, Republic of. ABHRS FORHAIR KOREA (CHIEF DOCTOR) J. Bang: None. ABSTRACT: There are some FUE cases that are difficult to manage. I found it beneficial to identify certain factors that usually complicate FUE procedures beforehand. Subsequently, I classified these factors into various skin types and follicular unit characteristics. As for skin factors, I will show pictures and discuss thick skin, tough skin, rubbery skin and skin with a bleeding tendency. For follicular unit factors, diverse shapes, inconsistent or blunt angle of hair, irregular arrangement, inconsistent gap between units, weak contrast between skin and hair color and weak/strong skin-follicular unit bonding power will be displayed. With the above mentioned determination factors in mind, I found it possible to take a better approach to handle demanding FUE cases.

3 The Use of Hair Bundle Cross-Section Trichometry to Confirm Success in the Medical Management of Hair Loss
Alan J. Bauman, MD Bauman Medical Group, Boca Raton, FL, USA. Alan J. Bauman, M.D. is a full-time Hair Restoration Physician and Diplomate of the American Board of Hair Restoration Surgery. He is the Medical Director of Bauman Medical Group, located in Boca Raton, Florida. Dr. Bauman has used cross-sectional bundle measurements since 2009 to aid in the management of medical/nonsurgical treatments for hair loss. A.J. Bauman: None.

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ABSTRACT: Introduction: The quantitative evaluation and tracking of changes in hair growth can be a challenging task. Current methods are fraught with inaccuracies and inefficiencies. Diagnosis based on global photographic patterns of hair coverage provide little information on the progression of early hair loss or a patients subtle response to treatment over time. Even with a standardized and dedicated in-office photography studio, global photography can be inconsistent due to changes in hair length and styling (e.g. cut, color, curl). Video magnification (30x-200x) and hair count densitometry of the scalp provide some additional information and raw data but also have their limitations, including having to trim hair to obtain accurate measurements. Additionally, research confirms that a decrease of up to 50% hair density can occur without significant changes in coverage. Therefore, in general, these tools often fail to be sensitive enough to quantitatively track changes in hair caliber and length which can dramatically alter coverage of the scalp and total overall hair volume. Prior research suggests that combined cross-sectional measurement of hair bundles may be a useful method for evaluating the severity of a patients hair loss and tracking his/her response to treatment. Being able to simultaneously measure both density and diameter and expressing them as a single numeric value, i.e Hair Mass Index or HMI in a matter of minutes offers distinct advantages over tedious hair counts and traditional clinical photography. In addition, previously unobtainable data regarding hair breakage, Hair Breakage Index, was measured and tracked in a select patient group. Hair bundle cross-section trichometry adds a new diagnostic dimension to the medical management of the hair loss patient in a clinic environment and in clinical research and can be used to improve compliance and demonstrate successful hair regrowth in the non-surgical patient. Our practical real-world experience in performing 570 cross sectional hair bundle measurements from 12/2009 to 12/2011 in 439 patients will be presented. Specific information on 131 patients (34 male and 97 female) who had frontal and/or vertex area comparison measurements during the interval in question will demonstrate an overall improvement in Hair Mass Index using a multi-therapy approach to hair loss. A detailed explanation of the resources required, implementation pearls and how to information, patient feedback, interesting and unexpected data as well as physician commentary will also be reviewed. Purpose: Improving a physicians diagnostic ability when faced with the evaluation and tracking of hair loss may have a significant effect on patients understanding of his/her current condition and early subtle response to treatment, improving both patient compliance and outcomes. Our goal was to determine through implementation the pros and cons of hair bundle cross sectional trichometry in the medical management of our hair loss patients. Materials and Methods: During the two-year interval December 2009 until December 2011, patients who presented for medical management of their hair loss condition and who had over 4cm of hair length were evaluated using hair bundle cross section trichometry. 131 patients returned at least one time during the interval for comparison measurements. Results:

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570 measurements were performed with the HairCheck device (Divi International) in addition to our standard medical hair loss consultation which includes medical history, hair loss history, hair and scalp physical exam, laboratory tests/biopsies when appropriate, video microscopy, global photos. Their regimen of FDA-approved and non FDA-approved hair growth treatments were recorded, scalp condition, patients subjective impression of hair loss status prior to the measurement as well as a physician-recorded subjective treatment-compliance assessment. At the conclusion of each visit, patient was presented with a take-home graphical report of their HairMass data a verbal explanation of the data along with their printed diagnosis-summary and treatment plan. When possible, follow-up measurements were scheduled at 90-day intervals. Data: Occipital HMI Averages: 75-100 Midscalp > Occiput = normal or diffuse loss Midscalp < Occiput = pattern loss Very Low Occipital HMI = ultra-fine hair Resources: Cost of device Cost of disposable cartridges In-service training/practice Two Technicians 5-10 minutes for 2-3 measurements/patient Data recording / Printing Explanation to Patient Case Presentations of interest: Female: Midscalp > Occiput; history of hair extensions Female: Frontal, improvement with pure LLLT Male: donor area assessment before and after FUE Male: Vertex, improvement on Finasteride Female: Hair Breakage Index changes with chemical processing Female: HMI changes with consistent hair extension use Average improvement in Frontal HMI comparison=+8.4 (n=130) with a range of -33 to +82 Average improvement in Vertex HMI comparison=+8.2 (n=114) with a range of -19 to +66 Conclusions: The implementation of any new diagnostic tool requires an investment in time, effort, personnel and other resources. Each physician must make his own judgment whether these investments are worth the return of the benefits received in terms of patient care. In our opinion, hair bundle cross-section measurement has provided us and our patients with easily understandable clinical information within minutes that was previously not attainable. For example, during this initial trial period we were able to detect and quantify non-visible thinning in male patients with early balding and quickly differentiate diffuse from pattern balding in females with hair loss. We have able to track patients with thinning, telogen effluvium, and we were able to critically evaluate our patients response to minoxidil, finasteride, dutasteride, low level laser therapy and nutritional modification in a shorter timeframe than ever possible before. We also discovered that when patients related to their hair loss in quantitative terms and could see hair growth changes in shorter intervals than previously obtainable, communication and education were significantly improved and this resulted in

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enhanced compliance and treatment outcomes. As a practice, we are proud to be able to communicate to patients our track record and success rate in the medical management of hair loss in not only stopping its progression, but also offering patients proof of significant improvement in their condition without surgical intervention.

3 Traction Alopecia In Sikh Males- A Review of 213 Cases Managed With Hair Transplant
Tejinder Bhatti, MD Darling Buds Hair Transplant Center, Chandigarh, India. Founder Secretary, Association of Hair Restoration Surgeons of India; Governing Council Member, Indian Association of Aesthetic Plastic Surgeons; Governing Council Member, Association of Plastic Surgeons of India; Member International Society of Hair Restoration Surgeons; Member, Asian Society of Hair Restoration Surgeons; Moderator, India Hair Forum; Joint Editor, Indian Journal of Plastic Surgery Dr Tejinder Bhatti has over 15 years experience in hair transplant T. Bhatti: None. ABSTRACT: Traction alopecia in the Sikh male is often referred to as Turban Alopecia, which it is not. Sikhs are a distinct religious group of North India primarily residents of Punjab. This is the dominant immigrant Indian community in the Americas, Australia, and UK. Sikhs are forbidden to cut their hair. The alopecia results from continuous unrelieved stress on the hair shaft for many years due to the Sikh religious tradition of sporting long hair tidied up as a top knot on the head. This is a permanent form of alopecia in Sikh males suffering from it. It is also seen in other racial groups like African-Americans and some Hispanics who tie their hair in braids, ponytails, etc. Scarring of the tissue leads to loss of hair roots in cases of continuous unrelieved stress. In many cases traction alopecia is associated with seborrheic dermatitis and psoriasis. The treatment of long standing traction alopecia in the Sikh male is hair transplantation.

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The author presents his experience with 218 cases of Sikh traction alopecia in his practice in the Punjab heartland of India.

3 The Mythical FUE Learning Curve- Observations After Training 75 Doctors In FUE Methods
Tejinder Bhatti, MD Darling Buds Hair Transplant Center, Chandigarh, India. Founder Secretary, Association of Hair Restoration Surgeons of India; Governing Council Member, Indian Association of Aesthetic Plastic Surgeons; Governing Council Member, Association of Plastic Surgeons of India ;Member International Society of Hair Restoration Surgeons;Member, Asian Society of Hair Restoration Surgeons (AHRS);Moderator, India Hair Forum; Joint Editor, Indian Journal of Plastic Surgery Dr Tejinder Bhatti has been in active hair transplant practice for over 15 years T. Bhatti: Ownership Interest (owner, stock, stock options); My center runs a training program for which doctors are charged a fee for training. ABSTRACT: It is a conception, though misconstrued, that FUE techniques are difficult to learn and that mastering the technique takes a long time, sometimes 6-12 years. This is often contrasted to the FUT technique in which the doctor does not spend a lot of time harvesting the grafts. Beginners have been discouraged in India and other countries from FUE technique since most practitioners in such countries perform only the strip technique. In my practice in India where we run a comprehensive and popular FUE/FUT training program for doctors from Asia, our observations regarding the learning curve in FUE are very different from current belief. Our experience in training doctors in FUE is brought out in this paper.

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3 Hair Mapping: A Comparison of Caucasian and Korean Hair Density, Follicular Density and Calculated Density; A Three Year Follow Up Using New Methods.
John P. Cole, MD Cole Hair Transplant Group, Alpharetta, GA, USA. Private Practice Hair Transplant Surgery since 1990 J.P. Cole: None. ABSTRACT: Introduction: Numerous investigators have estimated donor area hair density and follicular density over the years using a variety of methods to derive their findings in both Caucasian and Korean men with Androgenic Alopecia. No published study has attempted to objectively quantify the total follicular density in the donor area. Furthermore no study has compared Korean densities with Caucasian densities using similar objective methods to measure these densities. The purpose of this study is to more accurately estimate hair density and follicular density in a finite surface area of the donor region and to compare these results in both Korean and Caucasian populations using the same method of measurement and an identical surface area. Following the initial study, I retrospectively evaluated my data in hundreds of additional patients to see if there was any change in the data. Finally, I changed reticules to the Dermlite II Pro/HR to see if this made any difference in the calculations. Methods: This study consisted of 64 Caucasian patients and 30 Korean Patients. The donor area was divided into 14 regions consisting of 8 major regions and 6 minor regions based on size and location. The total surface area was 203 square centimeters. Region one and five were 17.5 square centimeters, Regions two, three, four, six, seven, and eight were 21 square centimeters, and regions nine through fourteen were 7 square centimeters. Hair density and follicular density were measured using a 30x hand held microscope and a surface area of 10 square millimeters (Radio Shack Cat No 63-851). Calculated density was determined by dividing hair density by the follicular density. Individual follicular groups were harvested by using a sharp punch. Each follicular group was examined at 10X magnification using a Meji EMT microscope. We sorted each follicular group by the number of hairs in each graft and the totals were summarized. The mean was noted for each region. The total number of hairs in the 203 square centimeter donor area was the product of the total surface area and the mean calculated density. I subsequently evaluated over 100 patients using the Dermlite II PRO/HR to see if the data changed. I grouped these into various ethnic groups. All of these patients had virgin donor areas that had never been harvested for the purpose of hair transplant surgery. Results: The average age for Caucasian patients was 36 with a range of 24 to 63. The average age for Koreans was 37 with a range of 25 to 75. In the follow up 121 patient Caucasian follicular density study, the patient range was 22 to 69 with a mean age of 40. The mean number of follicular groups for the eight major regions in Caucasians is summarized as follows:

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Region 1

Average 1490 1762 1710 1608 1482 1735 1687 1634

The mean number of follicular groups for the six minor regions in Caucasians is summarized as follows: Region 9 10 11 12 13 14

Average 602 575 545 592 555 639

The mean number of follicular groups for the eight major regions in Korean patients was as follows: Region 1 2 3 4 5 6 7 8

Average 1386 1708 1603 1449 1691 1652 1526 1512

The mean follicular number of follicular groups for the six minor regions in Korean patients is summarized as follows: Region 9 10 11 12 13 14

Average 586 539 490 579 523 475

The total number of follicular groups by population is summarized as follows: Total Major Regions Total Minor Regions Grand Total Caucasian 13133 Korean 12527 3508 3191 16649 15718

A comparison mean follicular density, hair density, and calculated density for Caucasian and Korean patients is summarized as follows: Mean Follicular Density in cm2 Mean Hair Density in cm2 Mean Calculated Density in mm2 Caucasian 81.37 Korean 74.81 193.07 165.29 2.37 2.21

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All follicular groups were extracted by individual follicular group harvesting (IFGH), which most call FUE. The distribution of follicular groups as a function of size and percentage in Korean Patients is summarized below: Number of hair 1 Percentage 2 3 4 5 6

2.15% 44.71% 47.02% 5.57% 0.55% 0%

In the follow up study using a 10 square millimeter Dermlite reticule in 121 Caucasian patients, we found the follicular density decreased to 15,395. The data for each major region is presented below. Region 1 2 3 4 5 6 7 8

Average 1418 1618 1653 1575 1419 1578 1536 1534

The data for the six minor regions in the follow up 121 Caucasian patient 10 square millimeter Dermlite follicular density study is depicted below. Region 9 10 11 12 13 14

Average 574 503 468 558 499 461

The comparison of the total follicular density in 64 Caucasian patients using the Rassman densitometer and 121 Caucasian patients using the Dermlite 10 square millimeter reticule resulted in the following difference. Rassman Densitometer 16,649

Dermlite 10 Square Millimeter Densitometer 15,395

Discussion: This study involved a similar protocol and the use of similar instruments to measure all densities. These similarities allowed for a comparison study between Korean and Caucasian patients. Prior studies of Caucasian patients by the author using the same protocol showed a statistically significant similarity between the Caucasian follicular density from this protocol and previous protocols. This study shows that the total mean follicular density is lower for Korean people with androgenetic alopecia than the mean follicular density in Caucasians, but it is much higher than in previous papers. In addition, the total number of follicular groups available for transplant is similar for both populations, but slightly higher in Caucasians. Hair density for Koreans was noted to be higher in this study than in previous studies of Korean patients. The total follicular density in the donor area has been estimated up until this study. With this study, Strip surgery procedures previously reported showed a much larger percentage of grafts containing one hair and two hair follicular groups with an absence of five hair follicular groups. IFGH produces more hair per graft, which

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results in more transplanted hair when the graft counts are similar for strip surgery and IFGH. This suggests that Koreans are particularly well suited for IFGH because they have adequate density and achieve better coverage with a similar number of grafts. IFGH has the added advantage of eliminating the complication of a strip scar. The total number of hairs available for transplantation was shown to be much higher in Korean patients than previously reported. The original densitometer was originally recommended by Dr. Rassman and called the Rassman densitometer. A follow up study using a more accurate densitometer with a precise visual field revealed that the donor area density was 1254 follicular units greater. The Rassman densitometer resulted in an average of 7.5% more follicular units most likely due to an inaccurate, larger visual filed. The author recommends that physicians choose a more accurate means of measuring follicular density. The Rassman densitometer is no longer available for sale.

3 Combination of Strip Surgery and Follicular Unit Extraction to Improve the Number of Follicular Units Harvested in Primary and Secondary Hair Transplantation
Mrcio Crisstomo, MD1, Marlia Crisstomo, MD2, Denize Tomaz, MD2, Adriana Afonso, MD2, Manoela Crisstomo, MD2 1 Clin - Plastic Surgery, Dermatology,Baldness Treatment, Fortaleza, Brazil, 2Clin - Plastic Surgery, Dermatology, Baldness Treatment, Fortaleza, Brazil. Dr. Mrcio Crisstomo is a plastic surgeon post-graduated during 3 years at the Ivo Pitanguy Institute (Rio de Janeiro - Brazil), with master degree in surgery (research in oxidative stress during hair transplant) and was plastic surgery staff professor University Hospital in Cear during five years. For more than ten years Dr. Crisstomo has been practicing hair restoration and has a special interest in larger surgeries as mega and gigasessions. Actually he is dedicated to procedures combining follicular unit extraction with strip surgery to improve the number of follicular units transplanted in one procedure. M. Crisstomo: None. M. Crisstomo: None. D. Tomaz: None. A. Afonso: None. M. Crisstomo: None. ABSTRACT: Introduction: Usually the hair transplant surgeon harvest the donor area using the Follicular Unit Extraction (FUE) or the excision of a strip. The Strip Surgery gives more follicular units (FUs) than the FUE but is limited by the scalps elasticity especially in secondary cases where the previous scar limits this elasticity. In opposite, the FUE gives a more limited number of FUs, but it does not depend of elasticity. In some secondary cases where there is limited density or elasticity the combination of FUE and a Strip harvesting can produce a higher number of FUs. This combination can be useful in primary surgeries also, mainly in advanced grades of baldness and/or with unfavorable donor area.

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Objective: The aim of this poster is to present statistics of combined procedures in scondary and primary hair transplants analyzing the increase obtained with this strategy, technical details, post operative management and long term results. Materials and/or Methods: 22 combined hair transplants where analyzed in the following aspects: total number of FUs, percentage of increase with FUE, duration of the procedure with and without FUE, complications and final aesthetic results. In secondary cases it was carried a comparison between the primary strip surgery and the secondary combined procedure. The data were compared with student t test. Results/ Discussion: In primary surgeries, the total average FUs number transplanted was 3,832 (range from 2,967 to 5,085), the strip harvesting had an average of 3,076 FUs and the FUE harvesting 756 FUs, an increase of 24,6% (range from 12,5 to 42%). In secondary cases it was observed a decreased number of FUs when compared the secondary Strip harvesting with the primary Strip (average = 22,4%). After the complementary FUE, the number of FUs increased in 32,8% (average) and the secondary procedure, in a more unfavourable donor area, become larger than the primary surgery. Conclusion: The procedure combining FUE and Strip surgery can significantly increase the number of FUs harvested in one procedure, in primary and in secondary surgeries.

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Combination of Strip Surgery and Follicular Unit Extraction to Improve the Number of Follicular Units Harvested in Primary and Secondary Hair Transplantation
Mrcio R. Crisstomo, Marlia G. R. Crisstomo, Denize C. C. Tomaz , Adriana A. O. Lopes, Manoela C. C. Crisstomo
Conflict of Interests: The authors have no conflicts of interests to declare. Fortaleza / Cear Brazil marcio@implantecapilar.med.br

INTRODUCTION
In primary surgeries, the total average FUs number In primary surgery it was performed the Untouched Strip Technique2,3, where a strip with 1.5cm is preserved below the

PRIMARY SURGERY (Untouched Strip Technique) RESULTS AND DISCUSSION

The combined procedure presented an increase of 70% in surgical time (average: Strip 5 hours; Strip + FUE 8,5 hours). The main complication was a delayed hair growth in donor area in 22.7% of patients, probably because of overharvesting and shock loss. Total recovery of this area was observed in all cases (Figure 8).

There are two main ways of harvesting the donor area: Follicular Unit

Extraction (FUE) and Strip surgery.

The Strip Surgery gives more follicular units (FUs) than FUE but is suture to keep the local anatomical features for a possible from 2,967 to 5,086), the strip harvesting had an average of 3,076 harvesting increase of 24,6% (range from 12,5 to 42%). Figure 5. 756 FUs, an FUs and the FUE future procedure (Figures 2 and 3).

transplanted was 3,832 (range

limited by scalps elasticity. In opposite, FUE gives a more limited

number of FUs, but it does not depend of elasticity.

In some secondary cases where there is limited density or elasticity,

the combination of FUE and Strip harvesting can produce a higher

number of FUs. This combination can be useful in primary surgeries

as well, mainly in advanced grades of baldness and/or with

FIGURE 5: Primary surgeries Increase in FUs number with FUE (average = 24.6%)

5 months PO FIGURE 8: Delayed hair growth in donor area. A: 1st PO; B: 2 months PO; C: 5 months PO.

unfavorable donor area (Figure 1).

FIGURE 2: Untouched Strip Technique. A: Schematic drawing; B: Surgical Planning

In secondary cases it was observed a decreased number of FUs

when compared the secondary Strip harvesting with the primary

Strip (average = 22,4% less). After the complementary FUE, the number of FUs increased in 32,8% (average) and the secondary procedure, in a more unfavorable donor area, become larger than the primary surgery (Figures 6 and 7).

CONCLUSION
The procedure combining FUE and Strip surgery can safely
increase the number of FUs harvested in one procedure, in primary and iecondary surgeries.
Author biography:
Dr. Mrcio Crisstomo is a Brazilian Plastic Surgeon graduated in the Prof. Ivo Pitanguy Institute Rio de Janeiro, with master degree in surgery (research in oxidative stress during hair transplant). 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.

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FIGURE 3: 35 M, NW VI, 3,836 FUs (Strip) + 1,250 FUs (FUE). Increase of 32.6%. Total = 5,086 FUs A: Pre-op; B: Donor area 1st PO; C: 7 months PO

FIGURE 1: A: Larger Baldness NW VI; B: unfavorable donor area; C: Secondary cases.

OBJECTIVE
SECONDARY SURGERY
In Secondary procedures, the FUE was realized in all safe donor area, above and below the suture (Figure 4).

To present the combined procedure (FUE + Strip Surgery) in secondary

FIGURE 6: Secondary surgeries Decrease in FUs number (Strip) related to 1st surgery (average = 22.4%). Increase with FUE complementary (average = 32.8%)

and primary hair transplants and its technical details.

MATERIAL AND METHODS

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

The authors analyzed 22 combined hair transplants in the following

2,812 FUs 2,881 FUs
1.

aspects: total number of FUs, percentage of increase with FUE,

REFERENCES
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. 2. Crisstomo, MR. 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):p. 12-14. 3. Crisstomo MR, et al. Untouched Strip: a technique to increase the number of follicular units in hair transplants while preserving na untouched area for a future surgery. Surg Cosmet Dermatol 2011;3(4):361-4.

duration of the procedure, complications and final aesthetic results. In

secondary cases it was carried a comparison between the primary strip

surgery and the secondary combined procedure.

FIGURE 4: 36 M, NW VA, Second Surgery. A: low elasticity, low density with previous scar donor area. B: Strip = 2,015 FUs; C: FUE 866 FUs (increase of 43%).

FIGURE 7: 36 M, NW VA. A: pr-op; B: 11 months PO, 1st Surgery (Strip = 2,812 FUs); C: 9 months PO, 2nd surgery: Strip = 2,015 FUs (decrease of 28.3%) + FUE 866 FUs (increase of 43%). Total 2nd surgery = 2,881 FUs.

3 Frontal Fibrosing Alopecia: a Variant of Lichen Planopilaris or Distinct Clinical Entity? Comparative Study of Ten Cases
Mrcio Crisstomo, MD, Denize Tomaz, MD, Marlia Crisstomo, MD, Evelyne Andrade, MD, Kaline Nogueira, MD Clin - Plastic Surgery, Dermatology, Baldness Treatment, Fortaleza, Brazil. Dr. Mrcio Crisstomo is a plastic surgeon post-graduated during 3 years at the Ivo Pitanguy Institute (Rio de Janeiro - Brazil), with master degree in surgery (research in oxidative stress during hair transplant) and was plastic surgery staff professor University Hospital in Cear during five years. For more than ten years Dr. Crisstomo has been practicing hair restoration and has a special interest in larger surgeries as mega and gigasessions. Actually he is dedicated to procedures combining follicular unit extraction with strip surgery to improve the number of follicular units transplanted in one procedure. M. Crisstomo: None. D. Tomaz: None. M. Crisstomo: None. E. Andrade: None. K. Nogueira: None. ABSTRACT: Introduction: Frontal fibrosing alopecia (FFA) is a primary lymphocytic cicatricial alopecia more common in postmenopausal women. Clinical examination revealed a band of symmetric recession of the frontoparietal hairline extending to the preauricular areas associated with erythema, perifollicular hyperkeratosis, and had partial or total loss of eyebrows. It is currently considered as a variant of Lichen Planopilaris (LP) by having the same pattern of lichenoid lymphocytic infiltrate, although usually without clinical signs of this entity. The LPP is a hairy skin disorder that affects mainly middle-aged women.It is caused by chronic lymphocytic inflammation around the upper portion of the hair follicle, and although it is a rare disorder, is a frequent cause of cicatricial alopecia. Perifollicular erythema and follicular keratotic papules are commonly found in clinical examination of the scalp in the early stages of the disease. The early diagnostic and therapeutic interventions are extremely important to delay the progression of these diseases and, consequently, the prognosis for the patient. Objectives: Conduct a literature review on Frontal fibrosing alopecia and lichen planopilaris and make a comparative 10 cases study with patients with these entities. Discuss whether the FFA is a variant of lichen planopilaris or a distinct clinical entity. Materials and Methods: Review was made of national and international literature using the databases PubMed, MEDLINE, LILACS and COCHRANE-BIREME, and selected articles published in the last ten years, approaching frontal fibrosing alopecia and lichen planopilaris. The literature search included original articles, review articles, editorials, guidelines and textbooks written in English, Spanish and Portuguese, were selected according to their relevance. Performed a comparative study of cases of patients diagnosed with frontal fibrosing alopecia and lichen planopilaris with data obtained through anamnesis, dermoscopy and research in electronic medical records in the months September to December of 2011, the author's clinic. Discussion: The initial phase of many boards and non-scarring alopecia scar must be managed as an emergency trichological, for the early diagnosis and immediate therapeutic intervention are essential to block hair loss and disease progression. Although AFF was first described less than two decades, the increased number of cases reported recently in the literature suggests that this disease was misdiagnosed or wrongly diagnosed. The results of the cases of both clinical entities presented are similar to those reported in literature, but there are several cases being treated as androgenetic alopecia. So it is valuable prior knowledge of the subject, with detailed physical examination of the patient, including the distribution pattern of alopecia (single board, multifocal,), the involvement of other hairy areas (eyebrows, armpits other body hair), and the histopathology of the lesion in cases of doubt, in order to obtain a correct and early diagnosis. Conclusion: The authors conclude that, although the two entities have a quite different clinical presentation, yet the FFA is considered a variant of the LP by its histopathological similarities.

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Frontal Fibrosing Alopecia: a variant of Lichen Planopilaris or distinct clinical entity? Comparative study of ten cases.
Mrcio R. Crisstomo, Manoela C. C. Crisstomo, Denize C. C. Tomaz, Evelyne M. F. Andrade, Kaline S. F. Nogueira, Marlia G. R. Crisstomo Conflict of Interests: The authors have no conflicts of interests to declare. Fortaleza / Cear Brazil marcio@implantecapilar.med.br

INTRODUCTION MATERIALS AND METHODS COMPARATIVE STUDY OF CASES

TABLE 1 - Clinical data of all patients (n = 10)
n Age Gender Clinical Eyebrow diagnosis loss

DISCUSSION AND CONCLUSION

Although rare, both entities are frequent causes of cicatricial alopecia, follicular destruction irreversible permanent loss of hair
3,4,5,6

Frontal Fibrosing Alopecia (FFA) is a primary lymphocytic The authors performed a review of selected articles published in the last ten years, approaching FFA and LPP. The literature search included original articles, review articles, editorials, guidelines and textbooks. It was performed a comparative study of ten cases of patients diagnosed with FFA and LPP with data obtained research in electronic medical records from September to December of 2011 in the Dermatology Division of the Clinic treatment of baldness, located in Fortaleza - Ceara, Brazil.
Average Average

cicatricial alopecia more common in postmenopausal women1.

leading

to . Increasing number of reported cases of FFA seems to indicate that this disease is underdiagnosed because it is constantly confused with androgenetic alopecia . Among the ten cases studied, in the literature. Despite the great histopathological and dermoscopy similarity, FFA and LPP exhibit very different clinical features. More research, studies and discussions are needed for a consensus if FFA is variant of LPP or a distinct dermatological entity.
Author biography:
Dr. Mrcio Crisstomo is a Brazilian Plastic Surgeon graduated in the Prof. Ivo Pitanguy Institute Rio de Janeiro, with master degree in surgery (research in oxidative stress during hair transplant). 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.

Clinical examination revealed a band of symmetric recession of

the frontoparietal hairline extending to the preauricular areas

associated with erythema, perifollicular hyperkeratosis, and had through anamnesis, dermoscopy and

partial or total loss of eyebrows2. It is currently considered a

variant of Lichen Planopilaris (LPP) by having the same pattern

the

clinical,

dermoscopy

and histopathological findings were similar to those presented

of lichenoid lymphocytic infiltrate, although usually without Clin Plastic Surgery, Dermatology and

1 2 3 4 5 6 55 65 48 73 64 57 60,3 F F F F F F FFA FFA FFA FFA FFA FFA

++ + + ++ + +

Peri Peri Recess Central Fronto alopecia follicular folicular erythema Erythema temporal with and multifocal scaling plaques + + ++ + + + +++ +++ + + + ++

clinical signs of this entity2,6.

7 8 9 10 52 43 46 40 45,3 M M M M LPP LPP LPP LPP -

325
CASE OF LPP
FIGURE 4 A,B: , 43 yr, extensive area of cicatricial alopecia with atrophic erythematous-brownish skin with tufts of hair. FIGURE 5: Dermoscopy showed scarring skin with follicles forming tufts on its surface, and perifollicular erythema and scaling.

OBJECTIVES

+ + + +

+ + + +

+ + + -

Literature review on FFA and LPP and a comparative study of 10

cases with these entities. Discuss whether the FFA is a variant of

FIGURE 7: Clinical aspects of FFA patients (n 1 to 6)

LPP or a distinct clinical entity.

CASE OF FFA

FIGURE 1 A,B,C: , 55 yr, postmenopausal, regression of hair line in frontotemporal and occipital region with uniformly pale skin due to loss of hair follicles and total alopecia of the eyebrows.

FIGURE 2: Dermoscopy showed: reduced follicular ostia, perifollicular erythema and scaling; absence of yellow spots, miniaturized and vellus hairs.

FIGURE 8: Clinical aspects of LPP patients (n 7 to 10)

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

FIGURE 3: Histological section of scalp stained by HE with follicular hyperkeratosis, decreased thickness of the dermis, thinning of follicular structures, capillary telangectasia, several fiber tracts, perivascular and periinfundibular mononuclear inflammatory reaction.

FIGURE 6: Histological cuts stained by HE with corneal compact layer. Dilated paraceratotic follicular ostia, follicular walls infiltrated by lymphocytes with enhanced number of apoptotic keratinocytes. Epidermis with numerous necrotic keratinocytes. Superficial dermis with melanophages. Deposition of fibrous matrix in the follicular tracts.

REFERENCES
1. Shapiro J et al. Update on primary cicatricial alopecias. JAAD, Jul, 2005 53(1): 1-37. 2. Macdonald A et al. Frontal fibrosing alopecia: A review of 60 cases. JAAD, Apr 2012. 3. Chieregato C et al. Lichen planopilaris: report of 30 cases and review of the literature. Int J of Derm, 2003; 42: 342345. 4. Moure ERD et al. Primary cicatricial alopecias: a review of histopathologic findings in 38 patients. Clinics. 2008; 63(6): 747-752. 5. Poblet E et al. Frontal fibrosing alopecia versus lichen planopilaris: a clinicopathological study. Int J Dermatol. 2006 Apr;45(4):375-80. 6. Crisstomo et al. Hair loss due to lichen planopilaris after hair transplantation: a report of two cases and a literature review. An Bras Dermatol. 2011;86(2):359-62.

3 A Split Comparison Study of Trichophytic Versus Non-Trichophytic Closure of Donor Site in Follicular Unit Hair Transplantation (FUT)
Niteen V. Dhepe, MD, Kaustubh Prabhune, MS,MCh, Nachiket Bhalerao, PGDCR Skin City, Pune, India. Biography: The non-trichophytic areas had worse scar outcomes compared with the trichophytic areas. Though, the observers were more likely to rate the outcomes better in the trichophytic areas, patients themselves did not report any such significant differences between the two sides. We did not have sufficient power to test the differences. The observer was not blinded to the type of surgery; trichophytic and non trichophytic sides are not randomized. Nonetheless, this is an important study within the Indian context as it quantifies the differences in scar outcomes in FUT patients. We propose a bigger study to substantiate these findings so as to help the surgeon plan clinical procedures in patients requiring hair transplants. N. Dhepe: None. K. Prabhune: None. N. Bhalerao: None. ABSTRACT: Introduction: Follicular unit transplantation (FUT) involves removal of a strip of permanent hair from the occipital scalp and reimplanting it piecemeal into the recipient area. Thus, the long term outcome of FUT surgery not only depends on the growth of planted grafts but also on the quality of donor site closure. Though many studies have assessed the graft outcomes in the recipient area, few have discussed the donor area outcomes. The donor site consequences seem to have a pervasive effect. Scar visibility, texture, vascularization, and pliability will help the surgeon to plan the future possible transplant session. In addition to the clinical decision, it may have a potential psychological effect related to the cosmetic disfigurement & a question of aesthetics to the patient. Trichophytic closure has been developed over years since its introduction and is being used as a standard technique by many surgeons; however still more evidence is needed on the benefits of this type of closure. Not much literature is available on the benefits of trichophytic closure, thus we are making an attempt to compare trichophytic & nontrichophytic closure on the same patient. Another important factor that we have concentrated upon is the scar assessment following the current standard management. For this we have used Vancouver scale (VS), and the Patient and Observer scar assessment scale. We believe that the combination of these two would give us reliable assessment. Objective: Primary objective is scar assessment by using the Vancouver & Patient and Observer scar assessment scale. Materials and methods: The present study is a pilot comparative analysis of the scars following trichophytic and non-trichophytic closure of the donor area after the FUT. It is a secondary data analysis of data collected from clinical observation in 11 patients who underwent the FUT.

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Procedure: Informed consent was obtained from the patients of hair transplant. Single strip dissection, with the strip centered on occipital protuberance. Width & length of the strip was decided depending upon the elasticity of the scalp as well as number of grafts required, which is calculated by determining the follicular units by densitometer. A single strip is excised with elliptical excision. Suturing of the strip is done in two layers; inner layer is sutured with Vicryl (dissolving) (3.0) & the outer layer with Prolene (4.0) continues. Right half of the strip is closed with trichophytic closure and the left half with non-trichophytic closure. For the right half a triangular strip measuring 1mm is cut along the entire length of the inferior edge following the normal closure. Following transplantation the patient was called up for the follow up visits. On follow up patient was assessed on Vancouver and patient and observer scar assessment scale by the trained dermatologist. Serial photographs of the scar where taken by a trained photographer, and these where shown to the patient for the marking on the patient assessment scale. Data analysis: Data were collected in a clinical sheet and entered in MsExcel for further analysis. We calculated the mean scores and standard deviations (SD) for each of the assessment criteria in these Scar Assessment Scales (Observer Scar Assessment Scale, Patient Scar Assessment Scale, and Vancouver Scar Scale). The means (of Trichophytic and Non-Trichophytic areas) were compared using t-test. We also compared the mean total scores in each of the scales using a t-test. We used random effects (RE) regression models to assess the mean differences in the scores according to the type of closure. Since, the trichophytic and non-trichophytic procedures were conducted in the same individual, the data were correlated. The RE models are useful alternatives for correlated data. Scar assessment scales Discussion and results: The mean age (SD) of the subjects was 28.7 (4.3) years. All the subjects in the present analysis were males. About 55% (6/11) patients were observed after six months of surgery and the rest were within the six month period following surgery. We have shown the mean values for each of the assessment points according to the Observer Scar Assessment Scale in Table 1. As seen in the table, the mean scores were higher (indicating a worse response) in the non-trichophytic area; however, these differences were not statistically significant. The mean (SD) total score for the non-trichophytic area was higher compared with the trichophytic area [14.0 (8.2) versus 10.6 (7.6), p=0.25] (Figure 1a). Similarly, we have shown the mean scores (SDs) for the Patient scar assessment scale and Vancouver scar scale in Tables 2 and 3. The total scores for these scales are shown in Figures 1b and 1c respectively. Using the RE models we found that the mean total score of non-trichophytic area was higher by 3.36 units (95% confidence intervals [CI]: 0.15 to 6.58) compared with the trichophytic areas in the Observer Scar Assessment Scale. Thus, the observer had recorded worse scar outcomes in the non-trichophytic area compared with the trichophtyic area. However, this mean difference between non-trichophytic and trichophytic areas was not statistically significant in the Patient Scar Assessment Scale (0.72, 95% CI: -0.23 to 1.68). Conclusion: The non-trichophytic areas had worse scar outcomes compared with the trichophytic areas. Though, the observers were more likely to rate the outcomes better in the trichophytic areas, patients themselves did not report any such significant differences between the two sides. We did not have sufficient power to test the differences. Furthermore, the observer was not blinded to the type of

327

surgery; there may be a reporting bias by the individuals who scored the scars, trichophytic and non trichophytic sides are not randomized. Nonetheless, this is an important study within the Indian context as it quantifies the differences in scar outcomes in FUT patients. We propose a bigger study to substantiate these findings so as to help the surgeon plan clinical procedures in patients requiring hair transplants. Table 1: Observer Scar Assessment Scale Title Trichophytic Non-trichophytic p.value mean (SD) Vascularisation 2.1(1.4) Pigmentation Thickness Relief Pliability Total 2.8(1.5) 2.0(1.1) 1.8(0.9) 1.9(1.1) 10.6(4.5) mean (SD) 2.7(1.8) 3.7(2.2) 2.7(1.8) 2.4(1.7) 2.5(1.5) 14(8.2) 0.37 0.28 0.26 0.38 0.35 0.25

Table 2: Patient Scar Assessment Scale Title Trichophytic Non-trichophytic p.value mean (SD) Painful Itching 1.0 (0) 1.3(0.9) mean (SD) 1.3(09) 2.0(1.7) 1.3(0.9) 1.2(0.2) 1.3(0.9) 1.5(0.7) 8.5(4.7) 0.33 0.23 1.00 1.00 0.84 0.63 0.69

Colour of scar 1.3(0.9) Stiff Thickness Irregular Total 1.2(0.2) 1.4(1.2) 1.6(1.0) 7.7(3.6)

328

Table 3: Vancouver Scar Scale Title Trichophytic Non-trichophytic p.value mean (SD) Vascularity Pliability 1.0(0.6) 1.3(1.0) mean (SD) 1.2(0.6) 1.5(0.9) 1.7(0.9) 1.0(0.9) 5.5(2.8) 0.50 0.52 0.17 1.00 0.40

Pigmentation 1.2(0.9) Height Total 1.0(0.9) 4.5(2.7)

Figure 1: Figures showing the mean total scores according to the three scar assessment scales a) b) c)

329

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3 Scalp Burning and Tenderness: How Important is it to Ask During the Consultation?
Jeff C. Donovan, MD PhD Hair Club Medical Group, Toronto, ON, Canada. Jeff Donovan, MD PhD is a dermatologist and hair transplant physician. In addition to his hair restoration practice with Hair Club Medical Group, Dr. Donovan is an Assistant Professor of Dermatology at the University of Toronto. He conducts clinical research in hair loss and runs a weekly hair loss clinic at the Sunnybrook Health Sciences Centre. He has a third consultative practice in hair loss at the Cleveland Clinic Canada. J.C. Donovan: None. ABSTRACT: Introduction: Symptoms of scalp itching, burning or tenderness should raise the transplant surgeons suspicion for another diagnosis besides androgenetic alopecia. In my practice, patients with significant symptoms of scalp burning or tenderness typically receive a scalp biopsy to exclude cicatricial alopecia and diffuse alopecia areata. Objective: To review the sensitivity of the symptoms of scalp burning and pain in identifying patients with a possible contraindication to hair transplant surgery. Materials and Methods: A retrospective review of the records of 315 consecutive patients (201 men and 114 women) seeking advice on hair restoration was performed. Information regarding current symptoms of itching, burning and tenderness was evaluated and compared with the final diagnosis rendered. Discussion: Occasional itching was documented in 79 of 315 (25 %) of patients and was more likely in those currently using minoxidil and those with dandruff and seborrheic dermatitis (p<0.05). 23 patients (7 %) reported having burning and/or tenderness in the scalp and 15 of these patients (65 %) ultimately were diagnosed with a condition that presented a contraindication to hair transplant surgery. These included diagnoses of active cicatricial alopecia (either lichen planopilaris, folliculitis decalvans, central centrifugal cicatricial alopecia) or alopecia areata. In 5 of 23 (21 %) patients with burning and/or tenderness, the diagnosis was not clinically obvious and the clinical tool served as a helpful method to exclude patients with contraindications to surgery. Conclusion: Burning and tenderness are important scalp symptoms which should not be ignored by the hair transplant surgeon. A quick screening of scalp symptoms should always be sought.

331

Scalp Burning and Tenderness: How important is it to ask?

Jeff C. H. Donovan MD PhD FRCPC FAAD1,2,3 of Dermatology, University of Toronto, 2Hair Club Medical Group 3Cleveland Clinic Canada (jeff.donovan@ymail.com)

1Division

Background Table 2: Clinical Diagnoses in Patients with Scalp Itching Table 4: How important is it to ask about burning and tenderness ?
No. of Patients1 Patients with burning/tenderness 17/23
Biopsy result Lichen planopilaris Comment In this case, challenging to distinguish from AGA

No. of Patients1 Total Patients Minoxidil Use 46 79 23 Diagnosis was clinically obvious even LI GLGQW DVN DERXW EXUQLQJWHQGHUQHVV Diagnosis likely missed without asking about burning and tenderness 5/23

38 M; anterior and vertex hair loss; Tenderness in vertex

Seborrheic dermatitis/dandruff
Trichotillomania Cicatricial alopecia Alopecia areata Contact dermatitis
may exceed 79 as some patients with itching had 2 or more reasons for their itch.
1Total

35
3 6 2 1

The most common indication for hair transplantation is androgenetic alopecia (AGA) AGA is asymptomatic Coexistent seborrheic dermatitis and pityriasis capitis (dandruff) are not uncommon and can lead to itching and scalp redness Although itching itself is not necessarily a cause for concern, patients with scalp burning or pain/tenderness raise suspicion for a variety of other hair loss conditions In my practice, patients with scalp burning or tenderness receive a scalp biopsy to exclude conditions which are likely not to respond well to hair restoration (cicatricial alopecia and diffuse alopecia areata)

Case Examples:
28 M; vertex and temporal recession x 6 years Mild itching and burning
Biopsy result Comment Biopsy result Comment Alopecia areata (diffuse form) In addition to burning, the man reported 40-50 % hair loss over 1 year period. Lichen planopilaris In this case, very challenging to diagnose clinically. No perifollicular erythema/scale.

Purpose

332
Table 3: Clinical Diagnoses in Patients with Scalp Burning and/or Tenderness
No. of Patients1 Total Patients Lichen planopilaris Folliculitis decalvans Central centrifugal ciciatricial alopecia 2 3 6 23

To review the sensitivity of the symptoms of scalp burning and pain in identifying patients with a possible contraindication to hair transplant surgery

26 M; mid scalp and vertex hair loss; Only symptom was mild burning (2/10)

Methods

A retrospective review of 315 consecutive patients (201 male and 114 female) seeking advice on hair restoration

Conclusions

Alopecia areata
Chronic telogen effluvium Red scalp syndrome Post herpetic neuralgia Minoxidil -related Seborrheic dermatitis Psoriasis Contact allergen 1 3 1 2 1 1 1

Results

32 M; frontal hair loss; Scalp burning (1/10) and tenderness (2/10)

Table 1: Scalp Symptoms in Consecutively Evaluated Transplant Patients

Patients with scalp burning and tenderness often have a contraindication to surgery Scalp biopsy should be considered in patients with significant burning and/or tenderness before proceeding to surgery
Biopsy result Comment Lichen planopilaris

No. of Patients

Total Patients

315

Scalp itching

79 (25%)

Burning/Tenderness 23 (7 %)

The patient initially denied symptoms and after a normal scalp exam I drew a hairline. After further discussion, he admitted to burning and tenderness EUXLVHG-OLNH IHHOLQJ DQG VR , ELRSVLHG

Conflicts of Interest
The author has no conflicts of interest to declare.

3 FUE Hair Transplant in Traction Alopecia in Sikh Population

Kapil Dua, MD, MBBS, Aman Dua, MD, MBBS A K Clinics, Ludhiana, India. Dr Kapil Dua MBBS MS ENT &amp; HNS is a practising Hair Transplant Surgeon at AK Clinics, Ludhiana, Punjab India. He specializes in both FUE and FUT since 2007 and has done more than thousand sittings of Hair Transplant. He is currently a member of ISHRS since 2008. He is on Board of Governors and current Secretary of Association Hair Restoration Surgeons India (AHRS). K. Dua: None. A. Dua: None. ABSTRACT: Introduction: Traction Alopecia is a commonly seen condition in sikh population where tight binding of hair into a knot leads to recession of fronto- temporal hairline. FUE Hair Transplant is a relatively new technique and its role in providing satisfactory results in traction alopecia have been evaluated in the study. Objective: To evaluate the role of FUE Hair Transplant in twenty eight patients of Traction Alopecia in sikh population. Materials and Methods: Twenty eight patients of Traction alopecia were evaluated randomly from January 2011 to January 2012. The results were compiled as per time since surgery. Results: FUE Hair Transplant shows satisfactory results in traction alopecia as the condition is non progressive and the donor area has excellent density.

3 Scarless Galeal Closure

Jorge I. Gaviria, MD Pure Restoration, Miami, FL, USA. A Hair Transplant Surgeon who has completed two accredited fellowship programs in Hair Restoration, both with world renowned physicians: Dr. Walter Unger from New York City and Toronto, Canada, and Dr. Matt Leavitt, from Orlando, Florida. Brings a research background to his craft. Is the principal investigator and has authored/

333

several protocols, on the topics of: evidence based medicine, donor site closure, dense packing and survival rates and digital medical hair. He has authored and published some of the largest studies ever done in hair restoration. His most well known is his study on trichophytic closures. This closure procedure is the closest to scarless surgery as possible. J.I. Gaviria: None. ABSTRACT: Introduction: Evidence based medicine is essential in cosmetic surgery. Donor harvesting and donor closure has being a prime topic in hair transplant surgery in the last 8 years. Described by Dr. Jose Jury in 1975; Trichophytic closure, Frechet closure and Marzola closure is a standard technique when achieving Scarless donor areas. Statistically significant work has being done to support this technique. This was our trigger point to find an easy, feasible technique to create an Scarless wound. Objective: Evaluation of long-term cosmetic results after hair transplant strip harvesting. Aesthetic result is the end-point of wound care. The aim of this study is to demonstrate wound cosmetic results from a novel surgical technique using digital imaging by blinded hair transplant surgeons, patients and physicians. Material: This is a prospective, linear, multicenter study done at private office practices of 4 hair transplant surgeons. Exclusive criteria include patients with more than 3 procedures. Patients with previous scars that need scar repair and patients with hypertrophic or keloid scarring. Scar appearance has being evaluated at 4,6,8 and 12 months after surgery closure. Using a previously validated 0-10 mm visual analog scale (VAS) score. Patient performed self VAS (VASpt), Digital Imaging by trained hair transplant surgeons; correlation coefficients were performed using mean values. Methods: The strip is extracted is two times. First half od strip is extracted and closed; subsequently the second half is removed and galeal anchorage used. The final goal is to obtain a greatest amount of follicular units, decrease the tension at closure phase (Unger scale 0 to -2) and create an Scarless scar. Discussion: Objective evaluation of the responsiveness of galeal closure in terms of aesthetic outcome is used in our study. Inclusion of tools such as digital imaging modalities, 3-D Cameras, high dynamic range and MRI evaluation of soft tissue after closure, for evaluation of scar aesthetics is very important. Our ongoing closure technique shows very important results, from a aesthetic perspective Scarless wounds after strip harvesting can be achieved when using deep galeal anchoring closure at the donor area. Conclusions: Deep galeal suture eliminates tension at closure. Harvesting the strip using the 2-phase technique creates a wider diameter that produces a larger amount of follicular units. The learning curve for the technique is less than one of the trichophytic closure. Although further comparative studies should be done, deep galeal anchorage shows better results that trichophytic and Frechet closures. Digital medical imaging can be an excellent tool for objective

334

evaluation of any closure technique

335

Scarless Galeal Closure Surgeons Signature

Jorge Gaviria, M.D., Leoncio Moncada, M.D.
Miami Beach, Florida. Caracas, Venezuela

Methods

336

- The strip is extracted in two times. - First half of strip is extracted and closed - Subsequently the second half is removed and galeal anchorage used. - Two times halves. To avoid galeal distention (resilience} -The final goal is to obtain a greatest amount of follicular units, - Decrease tension at closure phase (Unger scale 0 to -2) and create an Scarless scar. - Decrease the transected hairs. Also Important control at opening,

3 Temporal Peaks Aesthetic Implication

Jorge I. Gaviria, MD1, Maria del Carmen Morales De Bournigal, MD2 1 Pure Restoration, Miami, FL, USA, 2Pure Restoration, Centro Internacional de Ciruga Plstica Avanzada, Dominican Republic. Dr. Jorge Gaviria, is a Hair Transplant Surgeon who has completed two accredited fellowship programs in Hair Restoration, both with world renowned physicians: Dr. Walter Unger from New York City and Toronto, Canada, and Dr. Matt Leavitt, from Orlando, Florida. Dr. Gaviria brings a research background to his craft Dr. Gaviria is the principal investigator and has authored/ several protocols, on the topics of: evidence based medicine, donor site closure, dense packing and survival rates and digital medical hair. He has authored and published some of the largest studies ever done in hair restoration. His most well known is his study on trichophytic closures. This closure procedure is the closest to scarless surgery as possible. J.I. Gaviria: None. M. Morales De Bournigal: None. ABSTRACT: Introduction: Medicine and Cosmetic Medicine in particular articulates interest equilibrium between art and science. Reconstruction of the hairline and the frontal area has being the focus in hair transplant. Temporal peak reconstruction has being neglected Objective: Evaluation of cosmetic results after hair transplant surgery including temporal peaks reconstruction. Aesthetic result is the end-point of any hair transplant surgery. The aim of this study is to demonstrate cosmetic results when temporal peaks are included in the procedure, that small triangle area trying to converge with the eyebrow creates a very young and fresh face. Material: This is a prospective, linear, multicenter study done at private office practices of 3 hair transplant surgeons. Preoperative and postoperative images evaluating face appearance has being evaluated at 6,8 and 12 months after surgery. Using a previously validated 0-10 mm visual analog scale (VAS) score. Patient performed self VAS (VASpt), Digital Imaging by trained hair transplant surgeons. Methods: When designing the temporal peaks in our patients, previous photographs were asked in order to make a personal reconstruction of hairline and temporal peaks. We also used Dr. Mel Meyer temporal peaks design method and patients were involved as well. Discussion: Objective evaluation of the temporal peaks reconstruction in terms of aesthetic outcome was used in our study. To obtain objective measurements we included tools such as digital imaging modalities and 3-D Cameras. Our study goal is to create a youthful appearance from an aesthetic perspective.

337

Conclusions: When designing the first line and the frontal areas is of vital importance to design the temporal peaks. Keep in mind that a very small amount of fine hairs planted in a very acute angle will have a great cosmetic reward. We demonstrated that a facial harmony and a youthful appearance are achieved when a detailed temporal peak is present after a hair transplant surgery. As hair transplant surgeons we should be aware of the impact we create on patients self-esteem and appearance.

338

Temporal Peaks Aesthetic Implication

Jorge Gaviria, M.D., Maricarmen Morales, M.D. Miami Beach, Florida. Santo Domingo, DR

Introduction

339

Objective

- Medicine and Cosmetic Medicine in particular articulates interest equilibrium between art and science. - Reconstruction of the hairline and the frontal area has being the focus in hair transplant. -Temporal peak reconstruction has being neglected

Evaluation of cosmetic results after hair transplant surgery including temporal peaks reconstruction. Aesthetic result is the endpoint of any hair transplant surgery. The aim of this study is to demonstrate cosmetic results when temporal peaks are included in the procedure, that small triangle area trying to converge with the eyebrow creates a very young and fresh face.

Discussion
-Objective evaluation of the temporal peaks reconstruction in terms of aesthetic outcome was used in our study. To obtain objective measurements we included tools such as digital imaging modalities and 3-D Cameras. Our study goal is to create a youthful appearance from an aesthetic perspective.

3 A Case of Trichorrhexis Nodosa After Hair Transplantation

Sungjoo Tommy Hwang, MD, PhD Dr. Hwang's Hair Hair Clinic, Seoul, United Kingdom. President of AAHRS, BOG of ISHRS S. Hwang: None. ABSTRACT: Background: Trichorrhexis nodosa is common hair shaft defect disease which is characterized by intermittent whitish swelling nodes of hair fiber and split of the tips that make the hair snap off easily. Trichorrhexis nodosa may have a genetic basis but appears to result from the repeated physical and chemical trauma such as hair permanent liquid and blow drying. Although hair transplantation is a relative safe procedure comparing other surgical correction for alopecia, mild or severe complications could occasionally result from malpractice or poor quality control. Objective and method: Herein we experienced trichorrhexis nodosa after hair transplantation which has not yet been reported and tried to evaluate this condition with blood test, dermatoscope, scanning electron microscope, skin biopsy and hair mineral analysis. Result: A 38 years old man visited our dermatologic clinics with a breakage and no growth of the transplanted hairs for 3 years. His hairs started to loose and thin since 2,000 and he had Norwood-Hamilton Class IV male pattern baldness when received hair transplantation at local clinic in 2008. Hairs were harvested in occipital donor area with strip surgery and about 1600 follicular unit was transplanted in the frontal balding area using implanter. However, transplanted hairs failed to grow and broke easily although 1 year passed since hair transplantation. Overall survival rate of the transplanted hairs was very low and the recipient area exhibits sparse hair coverage. Transplanted hairs were distributed sparsely, short and lusterless on frontal area of scalp(Fig. 1a).

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On dermoscopic examination, intermittent whitish discolored nodes of hair shaft was shown and the ends of hair thinned or weathered on close observation(Fig. 1b).

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There are a lot of transplanted hairs with pits on the recipient area. The tips of hairs were severely split and the nodular swelling of hair shaft looks like so called a crushed paint brush with scanning electron microscopic analysis(Fig. 2a,b).

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Histopathologic examination of the scalp biopsy showed fibrous tract around the previous transplanted follicles and moderate inflammation with numerous neutrophiles. We could also examined the transplanted hairs located more deeply than surrounding existing normal hairs(Fig 2c).

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The blood and hair mineral analysis including thyroid function test, cupper and sulfur was normal. The patient had not anything else of note in his family history. His scalp hairs besides of frontal scalp, nails and teeth were normal. Discussion : Trichorrhexis nodosa may develop from genetic problem such as argininosuccinic aciduria, Menkes disease, Tricho-hepato-enteric syndrome, and trichothisodystropy. There is also acquired form which is more common and caused mainly by the repeated trauma to the hair shaft. Removal of causative factor can usually recover hair shaft in acquired form . Although repeated hair shaft trauma is major cause of acquired TN, a lot of acquired TN remains uncertain about their cause1. In the present case, acquired TN developed and persisted in the transplanted hairs although the patient did not give any physical or chemical trauma to hair shaft after hair transplantation. We could not find any systemic change in the blood and hair analysis which might result in TN. However, we found a lot of pits surrounding transplanted follicles, which means graft placed too deeply. In addition, we examined the transplanted hairs located more deeply than surrounding existing hairs in the examination of scalp biopsy. Deep location of transplanted graft caused unsatisfactory results like ingrown hairs, pitting or inclusion cyst. So, it is speculated that failure of depth control or poor graft handling during implanting hairs could lead to TN. Another possible mechanism is errors in graft dissection. Problematic graft handling such as trauma to hair bulb, desiccation, transection or excessive trimming of graft usually lead to poor graft quality including kinky hair, poor growth, pitting and ingrown hair. In the present case, aggressive and careless graft handling during hair dissection for hair transplantation might give mechanical stress to the hair follicles which could affect hair follicle and cause trichorrehxis nodosa. Conclusion: hair transplantation is a team approach, and poor quality in physician or surgical assistants might cause disastrous results. So, physician and surgical staff should monitor quality goals during graft slivering, insertion and patient follow-up to ensure that quality control in hair restoration should be addressed in a systematic approach to meet a good outcome. Legends Fig.1a Short and sparsely distributed hairs cover the frontal scalp inspite of the hair transplantation.. Fig.1b Several glistening white nodes and split ends of hair shaft was shown on dermoscopic examination.(X10) Fig.2a The tips of hair shaft looks like a flayed paint brush on scanning electron microscopic view.(X500) Fig.2b The white swelling nodes resembles the broomstick pushed into one another on scanning electron microscopic analysis.(X 500) Fig.2c The transplanted hair follicle and sebaceous gland(arrow) restively more deeply located than surround normal follicular unit, and moderate inflammation with neutrophiles was shown on histopathologic examination.(H&E X20)

3 Hair and the Psyche: Arm and Beard Hair Implant
Khalil Ibrahim Jebai, MD Lebanese Hair Center, Beirut, Lebanon.

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Founder of the Lebanese Hair Center established on 1992 and it is the first center in Lebanon which treats hair baldness and offers the most advanced and effective technique in hair transplant. K.I. Jebai: None. ABSTRACT: The aim of this presentation is to establish the link between hair and its psychological aspect and impact on pateint's life, especially in those patients who feel insecure about their hair whether it is on the head, beard, chest, or even arm. We will be showing a case for an arm hair implant which was done at our center and disscussing its impact on the patient's life. Another case is about a Lebanese artist who was discouraged by the lack of hair on his beard. After the operation his career improved dramatically and he was known by his new look with beard in the national and regional area. Thus, concluding that hair matters, even in places we rarely think it matters. (ex. arms)

3 Comparing the Graft Survival and Growth Keeping in PRP to the Saline in Hair Transplantation
Hamidreza Kahnamuee, MD Iranian Hair Transplantation,Laser & Beauty Centre, Isfahan-Iran, Iran, Islamic Republic of. Dr Hamidreza Kahnamuee started hair transplatation since 2000.At first he trained in France by standard punch graft method.,then shifting to mini and micrografts in 2004.He upgraded his experience in the United States in 2007.He received American Board of Hair Restoration Surgery (ABHRS) in 2011. Dr Kahnamuee is a full time hair transplant practicioner and has done more than 3500 surgeries. H. Kahnamuee: None. ABSTRACT: Because of the interest that has been stimulated by previous hair restoration physicians, Carlos Uebel, Joseph Greco and Jerry Cooley who reported improved healing and graft survival with use of PRP we did this study. Materials and Methods:From March 2011 to January 2012, 30-40-year-old-men,Norwood V-VII,were chosen. Utilizing PRP which were taken in the same condition 2 hours before operation,as a keeping solution for grafts.After harvesting donor area, some(30-40) grafts were kept in PRP and then transplanted in marked area on the scalp(1*1 cm). They were studied after 6,8,10 months with dermatoscope and evaluated their pictures with the control area

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that their grafts kept in saline. Result:In 2 patients,the grafts that were kept in PRP grew less than control area. In 8 patients there was no significant difference between 2 groups. Conclusion: The authors noticed that there is no difference between marked area with PRP solution and the control with saline in graft survival and growth.

3 The Study of Storage Solutions for Hair Follicle Protection During Hair Transplantation Surgery
Moonkyu Kim, MD, PhD, Ji Won Oh, MD, Jung Chul Kim, MD, PhD Kyungpook National University School of Medicine, Daegu, Korea, Republic of. Since graduating from Kyungpook National University(KNU) School of Medicine at 1989, I have focused on the study of Androgenetic Alopecia. As hair transplantation surgeon, I have handled lots of patients in Kyungpook National University hospital Hair Transplantation Center from 1991. As scientific researcher, I have elucidated molecular mechanism involved in Androgenetic Alopecia in Department of Immunology Kyungpook National University School of Medicine since 1999. M. Kim: None. J. Oh: None. J. Kim: None. ABSTRACT: Introduction: The hair follicle is a complicated organ, which has cyclic changes from anagen, catagen to telogen. In hair transplantation surgery, the survival rate of transplanted hair follicle is the most important factor for patients. What controls the survival rate after and during sessions is main question for a group of hair transplantation physicians. Though the proficiency that each surgeon has is crucial in point of result, the handling and the additional treatment of the hair follicles during session may be also significant especially for skillful surgeons. However, there is little study about supplement treatment during hair transplantation session for protection of human hair follicle. Objective: The aim of this study is to speculate the effect on human hair follicle after using several storage solutions. This study focuses on a basic fundamental study for enhancing the survival rate of transplantation session using them. Materials and Methods: 1) Histological analysis; to search the histological difference after treatment, we carried out H&E stain as well as

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immunohistochemistry of several important genes related with apoptosis, regeneration at each stages. 2) Hair organ culture (ex vivo) ; We used hair organ culture for checking the effect of several candidate drugs. TUNEL assay was used for apoptosis after organ cilture. 3) Hair graft biopsy after hair transplantation; mouse is sacrificed at the time point we wish to check for speculating the survival rate. We basically took biopsy after hair follicle regeneration. After biopsy, we could stain several important genes at each stage according our formal study. Results/Discussion: Histological analysis demonstrated that some genes be altered by drugs we had inserted. Especially organ culture showed intriguing results. Once we used pre-treatment drug during 2 weeks, the hair follicle grow less in point of shaft length, however, they show better proliferative gene expression pattern using ki-67 immunostain. As well as proliferation, the follicle under the drugs demonstrated less apoptotic feature using TUNEL assay. These results imply that there is other mechanism in hair organ culture system and the shaft length may not be related with the condition of hair follicle. Conclusion: This method and storage solutions can identify the genes those are differentially regulated at different stage of the hair follicle. Using storage solution during session can enhance the survival rate of transplantation session.

3 Protection of Human Hair Follicles Viability by Coculture with Mesenchymal Stem Cells
Melike Fazilet Kulahci, MD Transmed Clinics, Istanbul, Turkey. Melike Klahci, MD. Founder and Medikal Director of Transmed Education - Istanbul University, Cerrahpasa Medical School, Istanbul, 1989- Istanbul University, Resident for specialization, Faculty of Medicine, Department of Anesthesiology and Reanimation Istanbul,1989-1993 Experience - Transmed Hair and Cosmetic Surgery Clinic, Medical Director, Istanbul, 1994-Today- Work experience in hair restoration clinics in Germany and USA, 1993 - 1994- University of Erlangen, Faculty of Medicine, Assistant Surgeon, 1986 - 1988- Ataturk Airport, Obligatory service at Center of Health Inspection, Istanbul, Istanbul, 1984 1986 Memberships - Member, European Society of Hair Restoration Surgery (ESHRS)- Committe member, European Society of Hair Restoration Surgery (ESHRS) 1998-2001- Member, International Society of Hair Restoration Surgery, (ISHRS)

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M.F. Kulahci: None. ABSTRACT: Therapeutic effects of mesenchymal stem cells (MSC) are believed to occur not only by direct differentiation into injured tissue but also by production of secreted factors. MSCs at the injured tissue environments can promote the secretion of a variety of cytokines and growth factors that have both paracrine and autocrine activities 1-4. Despite the recent improvements in hair transplant surgery techniques, the methods for preservation of hair-follicles until the transplantation do not change over decades. In the conventional methods, in which the hair-follicles were rested in physiological saline for a while, the loss of viability of each follicle in different rates is probably one of the biggest challenges of the surgery because that may affect end result of the surgery dramatically. In this study, we used two novel approaches to maintain viability of the hair-follicle. In the first approach, follicles and hBM-MSCs were cultured, separated by a membrane preventing any direct interaction, but allowing transfer of soluble factors. In the next approach, conditioned medium (CM) was prepared by incubating the culture media with hBM-MSCs for 3 days. This CM was used to improve the viability of hair-follicles. The viability of cells was determined by both WST-1 and FDA/PI stainings. Both CM and coculture were significantly effective in preserving the viability for 24 h respective to PBS and PS. On the other hand, the CM turned out to be ineffective in prolonged incubation for 72 h, presumably due to the short life time of soluble factors. Consequently, both methods for cell viability confirmed that the use of both CM and especially indirect coculture with hBM-MSCs was improved the viability of hair-follicles significantly. References 1. Xu YX, Chen L, Wang R, Hou WK, Lin P, Sun L, et al. Mesenchymal stem cell therapy for diabetes through paracrine mechanisms. Med Hypotheses 2008; 71: 390-393 2. Ichim TE, Alexandrescu DT, Solano F, Lara F, Campion Rde N, Paris E, et al. Mesenchymal stem cells as antiinflammatories: implications for treatment of Duchenne muscular dystrophy. Cell Immunol 2010; 260: 75-82 3. Gnecchi M, He H, Noiseux N, Liang OD, Zhang L, Morello F, et al. Evidence supporting paracrine hypothesis for Akt-modified mesenchymal stem cell-mediated cardiac protection and functional improvement. FASEB J 2006; 20: 661-669 4. Karaoz E, Gen ZS, Demircan P, Aksoy A, Duruksu G. Protection of Rat Pancreatic Islet Function and Viability by Coculture with Rat Bone-Marrow Derived Mesenchymal Stem Cells. Cell Death Dis., 2010; 22;1(4):e36 Figure 1. Estimation of viable cells by WST-1. The viable cells in hair follicles were measured after incubating the cells in the medium with WST-1 for 4 h. Figure 2. Viability of cells in hair follicles. After incubation in appropriated media, the viability of cells in hair follicles was determined by PI/FDA staining. The viable cells were appeared in green due to FDA (fluorescein diacetate) stain; the non-viable cells were appeared in red due to the PI (propidium iodide) stain.

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3 Follicular Unit Transplantation: Comparison of Three Cuttings Techniques

Mohammad H. Mohmand, MD, Mohammad Ahmed, MBBS Dr Humayun's Hair Transplant Institute, Islamabad, Pakistan.

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DR Mohammad Humayun Mohmand, a plastic surgeon by training, did his MBBS from Ayub Medical College, Abbottabad, Pakistan then FRCS from Edinburgh and finally his ABHRS. He has been practicing hair restoration since 2000, and till to-date have done about 6000 surgeries. He has been actively involved in advancing the work of hair restoration. His poster was awarded the best technique award in 2006 annual meeting. During his carrier he was also selected as the Surgeon of the month. At present he runs a very busy state of the art clinic in Pakistan and is involved in one to one teaching sessions for the new commers. M.H. Mohmand: None. D. Ahmed: None. ABSTRACT: Objective: To know the difference of graft numbers by using three cutting techniques Materials and Methods: This study was prospective, randomized and double-blind. Only those patients were included who underwent their first transplant session. The donor strip was marked in sitting position, a mixture of xylocaine and epinephrine was used for donor strip anaesthesia. The donor strip was harvested in the prone position. The donor defect was closed primarily using 3-0 non-absorbable, monofilament suture and trichophytic closure. Supra-orbital/supra-trochlear nerve blocks were instituted be4fore the infiltration of tumescent anaesthesia in the recipient areas. Dissection of the strip The strip was divided into three equal parts. A one cm sq piece was marked in the each part of the strip to undergo the dissection technique. The parts were photographed preoperatively and then sere allotted the dissection technique randomly (double-blind). After the dissection, the number of grafts of each technique were counted individually. Dissection techniques Group A consisted of slivering the piece under microscope and cutting under microscope as well. Group B consisted of slivering under microscope and cutting under loupe magnification. Group C consisted of cutting under loupe magnification and cutting under loupe magnification as well. The standard microscope magnification was at 10X power and standard loupe magnification was No. 5 magnification. Results: Table 1 describes the number and composition of FUs prepared using the three techniques in 15 patients. Full microscope slivering and cutting (group A) produced 18.69% more grafts on the average, whereas slivering under microscope and cutting under loupe magnification (group B) produced only 1.89% more grafts as compared to the slivering and cutting under loupe magnification (group C). The average number of hair was 24.34% higher in group A, whereas it was 10.38% higher in group B as compared to group C. Conclusion: It is essential to justify the advantages of microscope with the disadvantages, as the over judicious use can be

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harmful. This warrants the results from multiple centres before it is to be unanimously decided in the favour of or against the microscope usage.

3 The Simplest Way to Prevent and Manage Postoperative Follicultis

Bertram M. Ng, MBBS Dr Bertram Hair Transplamnt, Kowloon, Hong Kong. Bertram Ng is a Certified ISHRS Fellow and ABHRS Diplomate. His special interest is in hairline restoration. In 2008 he first designed a hand-held laser device for hairline placement, which is now in production. In 2009 ISHRS Scientific Meeting he introduced a new system in setting the hairline anterior-most point when the Golden Rule of Third cannot apply. He served as examiner for ABHRS and Co-editor for the ISHRS Forum. B.M. Ng: None. ABSTRACT: Introduction: This article is referring to follicultis that appears two to three months postoperatively. This is believed to be related to hair growth. The severity ranges from a mild, superficial inflammation with mild erythema and scattered pustules (Image 1 - one month after); to deep inflammation with widespread erythematous induration and numerous cysts, pustules, and papules. Though not any life-threatening condition, folliculitis is not welcomed by patients due its unsightly and alarming appearance. Most want to keep their transplant a secret without drawing any attention. They also concern that the folliculitis may affect final growth. The reported incidence of folliculitis was reported to vary between 1.1% to 20%. Recommended treatment includes warm compresses, topical antibiotic ointment, topical midpotency corticosteroid, incision and drainage, and systemic antibiotic. In daily practice prescribing antibiotics through email is impractical, while asking the patient to see the local GP creates a feeling of imcompetency. Surprisingly one very simple and effective measure is rarely mentioned in textbooks or journals - the removal of hair spicules. Premise: There may be a fear that removal of hair spicules may harm the implanted follicle. From our experience this practice is rather safe. Since 2009 we have slowly developed a protocol in preventing folliculitis.

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-The patients are asked to return 1 month and 4 months after the procedure. These are the times when folliculitis peaks. -The doctor and assistants check the recipient site for pimples and loose hairs. -All hairs that can be pulled up with ease using a pair of #6 jewellery forceps are removed (Image 2) . Image 3 and 4 compare the appearance of the recipient site at 4 week before and after hair spicule removal. -Betadine is applied to any inflamed pores. -In case there is widespread folliculitis Betadine shampoo is provided to be used at home for 2-3 days. -Oral antibiotic was not required. -For those patients who cannot come back for follow-up, written instruction is given showing how to remove the hair spicules, either by family or local GP. -A video clip is being produced for better demonstration Substantiating Data: This protocol is based on the followings observations: 1.Most postoperative folliculitis is an inflammation rather than infection. Wound swabs usually yielded no growth or just scanty growth of staphococcal aureus, and settled with topical or systemic antibiotic. 2.The inflammation can either be a foreign body reaction, or from obstruction of the orifice. 3.The hair shaft is a foreign body, and wound that contains hair would not heal. Image 5 was taken from a gapped donor wound. Despite daily dressing for 3 weeks the wound failed to granulate until all the hair spicules were removed. 4.Transplanted hair follicles settled in 7 days according to Ng and Pathomvanich study (2008), not easy to pull out with forceps. 5.It is well known that transplanted hair would shed starting from 3 weeks. The hair spicules we removed had the same typical appearance seen in naturally shed hair. - the J hair or umbrella hair, which contained no dermal papilla (Image 6). 6.Hair spicule is always found in the center of a pimple. Discussion Removing the loosen hair spicules prevents and relieves folliculitis. Since adopting this protocol we reduce the incidence to less than 1%, though the occurrence is higher for those who did not return for hair removal. We never came across ingrown hair. There is no evidence that pulling out hair spicules as early as 4 week would damage the transplanted follicles or adversely affected the outcome. This is the simplest DIY measure we would like to recommend.

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P21 Golden Rules to be Observed for Enhancing the Survival Rate in Hair Transplant Using a Choi-Hair Transplanter
Kun Oc, MD Oc Kun Hairline Hair Transplant Center, Seoul, Korea, Republic of. Kun Oc MD has been committed to hair transplant since 2005, and in 2010 was awarded the Best Practical Tip in the poster section by the International Society of Hair Restoration Surgery for the authors paper entitled A Method for Making the Sutural Plane Even: Two-angle Suture Using Vector in Strip Donor Harvesting. The major area of interest is hair transplant using a hair transplanter not only for male-pattern hair loss but also for cosmetic purpose. K. Oc: None. ABSTRACT: Introduction: This paper is to tell a number of tips used by the author that may be useful to improve the hair survival rate and the outcomes in operation using a Choi-hair transplanter. Objective: What is most important but easily neglected in using a hair transplanter is the adjustment of the depth of transplanted hair. The author explains the characteristic of hair transplanter affecting the depth of transplanted hair, and operation know-how for producing the best effect in operation using such a hair transplanter. Method: Golden rules in using a hair transplanter First, the depth of transplanted hair should be determined based on the length of each patients own hair follicle. 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 vevel from the frontal view. 2. Different from the length of the transplanter 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 hair transplanter is pressed its level is the same as or slightly lower than the end of the hair transplanter as in M2. 3. When a hair is loaded on the hair transplanter, the optimal depth is that at which the root of the hair is visible slightly in the vevel, and the hair follicle should not be visible from the side. See M1a and M1b. 4. 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. 5. For the optimal position in which the transplanter needle enters the scalp, as in M5a, make the vevel point at the ceiling to make a small laceration on the scalp using the tip of the transplanter needle, and rotate the hair transplanter half way around while thrusting the needle in the desired direction and angle. At the final position, the transplanter needle vevel should point at the floor as in M5b. 6. It is also important when to press the button on the tip of the hair transplanter. It should be pressed at the point of time when the transplanter 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.
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Discussion: The following explains the reasons for observing each golden rule. 1 a) In case the needle of transplanter is too long, D1a The transplanted hair can be placed deeper than the reference depth, and the tip of the transplanter needle can damage the tissue underneath the hair papilla. b) In case the needle of transplanter is too short, 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. 2 a) In case the core protrudes, D2a The root is pressed and crushed and a trauma can happen and the hair is highly likely to be curly. b) In case the core is too deep, D2b The transplanted hair is placed shallower than the reference depth, and part of the root is exposed to the air. 3. a) In case the hair follicle is placed too deep, D3a The transplanted hair goes less deep than the reference depth. b) In case the loaded follicle is exposed, D3b When the transplanter needle goes into the scalp, the root can be damaged. 4 If a hair is transplanted vertically, the depth of the transplanted hair becomes deeper than that of existing hair follicles as in D4a, and if it is transplanted at the acuter angle as in D4b its depth becomes shallower and may cause a low survival rate. 5 In order to minimize the contact area of the needle and the scalp and to make it easier to insert the needle, the vevel of the transplanter needle should point at the ceiling as in M5a. In addition, the vevel should point upward during insertion in order to minimize impact on the end of the hair follicle in the needle. Because force is applied downward during transplantation, the resisting force of the scalp goes upward. In this situation, if the vevel points downward, it can damage the end of the hair follicle. The reason that the direction of the vevel should turn downward at the last moment is to minimize damage on the tissue beneath the root of the transplanted hair by keeping the blade of the transplanter needle from entering deeper than the end of transplanted hair root as seen in D5a and D5b. 6. In case the scalp is soft or hair is transplanted on the face like eyebrow, if the button is pressed too early, the scalp extends after the transplanter needle is withdrawn and then the transplanted hair is buried completely in the scalp (D6a), and if the button is pressed too late the hair root is exposed (D6b). Most of hospitals do not adjust depth, and only some hospitals adjust the depth of transplanted hairs using forceps after planting but this is only the second best. If incision is too deep it has already damaged the tissue beneath the root and if it is too shallow the adjustment of depth after the insertion of hair can crush the hair follicle. The consequence is a low survival rate and the curly growth of surviving hairs. Conclusion: The author has used a hair transplanter for 7 years and improved the operation method by correcting its shortcomings, and based on these experiences, can say with confidence that operation using a hair transplanter, if done properly by the golden rules, can product a better result than any other operation.

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3 Newly Developed Hair Transplanter OKT (Optimally Kept Transplanter) That Improves the Hair Survival Rate
Kun Oc, MD Oc Kun Hairline Hair Transplant Center, Seoul, Korea, Republic of. Kun Oc MD has been committed to hair transplant since 2005, and in 2010 was awarded the Best Practical Tip in the poster section by the International Society of Hair Restoration Surgery for the authors paper entitled A Method for Making the Sutural Plane Even: Two-angle Suture Using Vector in Strip Donor Harvesting. The major area of interest is hair transplant using a hair transplanter not only for male-pattern hair loss but also for cosmetic purpose. K. Oc: None. ABSTRACT: Introduction: Asian people in the authors country have conducted surgery using a Choi-hair transplanter from the early days of hair transplant. However, early hair transplanters have been used today for 27 years without any major functional change. This suggests the excellence of the early invention but, on the other hand, indicates that there have been few research efforts by practitioners using a hair transplanter. Objective: One of major shortcomings of transplantation using a Choi-hair transplanter compared to the slit method is that it cannot adjust the depth of transplanted hair. All of the existing hair transplanters can adjust the length of the hair planting needle and the depth of the hair transplanter core, but because the depth and the length are not fixed they are often changed during the operation and as a result the root of transplanted hair is placed at an inadequate depth. The author has continued research on the operation method that can overcome such a shortcoming of hair transplanters and now introduces a newly developed OKT that can enhance the survival rate based on the theory on the optimized depth of transplanted hair. Method: Existing hair transplanters is generally divided into three parts a, b and c as in Photograph P1, but OKT consists largely of 7 parts a, b, c, d, e, f and g as in P2. The parts in P2 are assembled as follows: insert part c in b; screw d and e on the right end of b; insert a into c; and screw f and g on the right end of c. The principle that the length of the hair planting needle is maintained uniform during operation can be explained with a bolt and two nuts as follows. P3 is the right end of part b. It has spiral grooves as in a bolt. Part d and e have such spiral grooves in their inside as in a nut. As in P4, screw d and e onto b and fasten them completely until the nuts do not turn any longer. Then, they are fixed at a position on the bolt. In this photograph, they have not been fastened completely. There is a stair-like level on the middle of part c as in P5. This part is lodged on the end of part e and makes uniform

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the length of the hair planting needle. It is the basic principle to screw the two nuts on the bolt completely and to lodge the transplanter needle on the fixed nut so that length of the hair planting needle does not change during operation. The method to maintain uniform the depth of the hair transplanter core is similar to that for the length of the hair planting needle. As in P6, the end of part c has spiral grooves. Parts f and g have spiral grooves inside themselves. Because one end of part g is blocked, the end of part a, which is the core of hair transplanter, is lodged on part g so that the depth of the transplanter core is fixed, see P7. P8 is completely assembled OKT. Part c penetrates through the entire length of the hair transplanter. With this form, the transplanter needle does not shake during operation different from existing hair transplanters. Discussion: In P9, a is one of conventional hair transplanters and b is OKT. The two transplanter needles have the same inner diameter. The best hair transplanter 1. The slit should be narrow so that only a hair can pass through. In P9, the slit width of OKT is only almost half of the existing hair transplanter. If the slit is wide, when the transplanter needle penetrates into the scalp the hair follicle inside the hair transplanter may not be planted properly because of its friction with surrounding scalp tissue and this results in the exposure of the root out of the scalp. 2. The vevel should be short. In P9, OKT has a short vevel than the conventional hair transplanter. If the vevel is short it may feel somewhat blunt when it is inserted into the surface of the scalp, but if it is long, the scalp tissue below the follicles will be damaged more. 3. The material metal should be thin. If the metal is thin, the transplanter can cut the scalp easily with a less serious damage. OKT used thin metal in order to supplement the shortcoming of the somewhat blunt blade due to its short vevel. 4. The length of the hair planting needle should be adjustable and fixed. Because each individual has a different length of hair root, the needle should be adjusted to each patients length of hair root and then fixed. 5 The depth of the hair transplanter core should be adjustable and fixed. It is because the depth into the scalp at which the tip of transplanted hair follicle is placed is different according to the depth of the hair transplanter core. Conclusion: OKT (Optimally Kept Transplanter) was named so because the length of the transplanter needle and core is maintained optimally. Because of its shorter duration of surgery compared to the slit method, hair transplant using

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transplanters may be considered to be an easy job to the doctor but it requires intensive concentration in a short duration of surgery because there are many things to be careful about. If the shortcomings of conventional hair transplanters are supplemented with OKT introduced here and the procedure is conducted by experienced medical staff, hair transplant using transplanters can be rather more advantageous than the slit method. What is more important than the operation method is the outcome of operation and the survival rate after operation. There is a theory showing that OKT can raise the survival rate, but it may not be easy to produce accurate statistics on the survival rate. For your reference, at the authors hospital where hair transplant is conducted using OKT, only 5% of patients who received the 1st surgery using OKT requested another session for increasing hair density.

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3 Hair Transplantation in Frontal Fibrosing Alopecia: A Report of Two Cases

Ratchathom Panchaprateep, MD Chulalongkorn University, Bangkok, Thailand. Ratchathorn Panchaprateep, MD. Work Address Division of Dermatology Department of Medicine Faculty of Medicine King Chulalongkorn Memorial Hospital Rama 4 Road Bangkok 10330 Thailand Email Address Nim_bonus@hotmail.com, Nim_bonus@yahoo.com Education - Medical degree (First Class Honours), Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand - Dermatology, Division of Dermatology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand - Clinical fellow in Laser and Dermatologic Surgery, Division of Dermatology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand - Phd. Study, Chulalongkorn University, Bangkok, Thailand March 2010 - Fellowship in Hair Restoration Surgery (ISHRS), DHT Clinic, Bangkok, Thailand Academic Appointment - Instructor in Dermatosurgery, Chulalongkorn University, Bangkok, Thailand Hospital Appointment: - Dermatologist, hair transplantation surgery, Bumrungrad General Hospital R. Panchaprateep: None. ABSTRACT: Background: Frontal fibrosing alopecia (FFA) is categorized as cicatrical alopecia, considered as a variant of lichenplano pilaris. Medical therapy reported including topical/ intralesional/ oral corticosteroids; antimalarial agents; topical minoxidil solution; topical/ oral retinoids; Oral finasteride and dutasteride;and griseofulvin. Surgical management of cicatricial alopecia is still debate and not much explored. Naubaum and Jimenez tried test grafting in frontal fibrosing alopecia and lost all the grafts many years later. In the present study we did complete hair restoration surgery instead of test patch as our two patients insisted for complete surgery even after explaining the consequences of total hair loss if the disease recurred. Objective: To evaluate the long term result of hair transplantation in FFA in conjunction with medical treatment. Material and methods: As it is an ongoing study, at present we have included three patients in the study group, of which two patients underwent surgery and third patient is waiting for surgery.

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Case 1 A 63-year-old Caucasian female had marked recession of frontal and both temporal hairline with thinning and ptosis of both eyebrows Hair loss began at the age of 59 in frontal area initially then slowly progressed but stable since 2 years. She has not used any medication for hair loss. No similar disease was seen in her family. She was not a known diabetic, hypertensive and generally in good health. She had receding hairline at frontal and temple areas until pre-auricular region with complete baldness. Skin over the bald area and the remaining parts of body had no obvious skin lesions. Routine investigations and thyroid profile were within normal limits. The skin biopsy was done with 4mm punches from 2 site. One from the bald area 1cm in front of hair line, showed normal epidermis, perivascular and periadnexal mild to moderate lymphocytic infiltrate with destructive hair infundibulum with fibrosis and the other one from transitional zone with hair at the right temporal area showed normal epidermis with normal hair follicles which means, no activity of the disease. Dermatopathologist provisionally diagnosed as lupus erythematosus but clinical findings were consistent with frontal fibrosing alopecia. Nature of the disease and possibility of poor growth was explained to the patient before taking consent for hair transplantation. Ultra refined follicular unit grafting was performed. Frontal area was restored with 1611 FUGs which consist of 491 of 1hair, 913 of 2hair and 207 of 3hair follicular unit grafts. Temporal region was restored with total of 990 follicular unit grafts, 590 grafts on left side (150-1hair ,340-2hairs and 100-3hairs) and 400 grafts on right side (120-1hair and 2802hairs). Another 334 follicular unit grafts were transplanted at eyebrows (156 on left and 178 on right side). Total of 2935 follicular unit grafts consist of 4748 hairs were transplanted over the frontal, temporal areas and also both eyebrows over an area of 61 cm2. Post operative period was eventless. Case 2 A 69-year-old Asian female presented with extensive hair loss over the frontal, both temporal and partial loss of both eyebrows and eyelashes. Hair loss began at the age of 60 years and slowly progressed with receding of frontotemporal hair line up to midscalp but stable since 2 years. She was a known case of hypertension and diabetes with hypertriglyceredimia. She has been on felodipine 5 mg, atorvastatin calcium and methyl cobalamine. No family members were affected with similar disease. Her complete blood count, liver function test, blood uria, serum creatinine and thyroid profile were normal. On examination she has diffuse alopecia with band of symmetric recession of frontotemporal hair line extending up to mid-scalp with smooth skin without any skin lesions. Partial loss of eyebrows was noticed. The skin biopsy was done from 3 sites with 4 mm punch (right temporal area, transitional zone and frontal area.) Histological features of all the three biopsies were similar with follicular epithelium replaced by fibrous tissue with minimal inflammatory cell infiltrate, and the features were consistent with cicatricial alopecia. Based on clinical features and histological findings, final diagnosis of frontal fibrosing alopecia was made. Dermatopathologist informed that the disease was burnt out. After detailed discussion of the clinical course of the disease and possibility of poor prognosis and recurrence of the disease, the patient consented for hair restoration surgery. Frontal area was restored with 2508 follicular unit graft consist of 525 of 1hair, 1557 of 2hair and 426 of 3hair follicular unit grafts. Total of 2508 FUGs bearing 4927 hairs were transplanted over the frontal area measured 61 cm2 over a period of 6hours and 40 minutes. Post operative period was uneventful. Results: Case 1: One year post operative showed excellent response of both scalp and eyebrows. At one and a half post op, we noticed visible loss of hair at temporal hairline and also at the medial end of both eyebrows but there was no change in frontal hair line. At this point, we advised her to apply topical pimecrolimus 0.1% ointment once daily at the transplanted site and take oral dutasteride 0.5mg daily. She refused to take dutastaride but willing to try pimecrolimus. Six months follow up photographs depicted some hair growth on medial aspect of both eyebrows, more hair loss on both temples and some grafts loss on frontal hair line but no posterior advancement of hairline. Though the patient is happy and feels that there is no hair loss on frontal hair line but on careful examination, we can make out thinning of frontal hairline in 2nd year follow up photograph when compared to 1 and 1 year photographs.

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Case 2: She came for follow-up after 8 months with good growth of grafts and she did not notice any shock loss. In spite of good growth of transplanted grafts, we advised simultaneous use of dutasteride 0.5mg one tablet daily and topical pimecrolimus 0.1% ointment twice daily for external application with the previous case experience. She wanted to undergo second transplant due to large area of baldness and to add on density to previous transplant. So we performed second session with 1785 follicular unit grafts bearing 3498 hairs with a little lowering of hairline and also temporal restoration after 10 months from 1st session while she was continuing dutasteride and pimecrolimus. Immediate postoperative period was uneventful. Discussion: FFA commonly occurs in post-menopausal woman, however it can also be seen in premenopausal and men too. It can be associated with androgenetic alopecia, alopecia areata, vitiligo and central centrifugal cicatricial alopecia and lichen planus. Alhough both the patients involved are postmenopausal, there was no involvement of axillary, pubic and body hairs. Both the patients had no symptoms of pruritus, pain or burning. Careful examination of involved scalp skin may show variable presentation of perifollicular erythema, loss of follicular orificies and follicular kerastosis. Though, only loss of follicular orifices was reported in these cases. Perifollicular erythema at the receeding hairline is an important sign and indicates active follicular inflammation. Disease was stable in both the cases for more than 2 years before transplantation. No specific medication for hair loss was used previously. No family history was noted, as in a study familial occurrence was reported in two sisters. Although it is considered a variant of lichen planopilarisis, its exact pathogenesis is still not clear. Pattern involvement and response to oral finasteride in some cases raise the speculation that etiology can be hormone mediated, like androgentic alopecia with genetic component. But this speculation does not explain associated involvement of eyebrows, eyelashes, axillary hair, body hair, upperlimbs, lower limbs and occipital posterior hairline. Another hypothesis states that targeted follicles might express specific antigens that induce a Tlymphocyte-mediated reaction leading to follicular destruction. Miteva et al, the development of FFA on areas affected by vitiligo in their study indicates a common pathogenic background for vitiligo and FFA. On immunophenotyping studies in lichen planus and vitiligo, most of the infiltrate consist of CD8+ cytotoxic lymphocytes. These cells conjugate to the basal layer keratinocytes via adhesion molecules to induce cell-mediated interactions and apoptosis. On application of these findings to FFA, outer root sheeth keratinocytes probably express similar adhesion molecule necessary for attachment of the lymphocytes in affected follicles because these keratinocytes are in continuous with the epidermal keratinocytes. This suggests role of autoimmune cytotoxic damage in FFA. Furthermore it seems to have appeared recently, an environmental factors are thought to possibly be involved in the etiology. Histopathologically both patients showed similar features involving follicular epithelium replaced by fibrosis, with minimal lymphocytic infiltrate. Natural course of the disease is not known but frontal recession may progress upto midscalp and occasionally beyond. The rate and extent of progression is highly variable. Tan and Messenger observed that the progression of frontotemporal recession was very slow with an average rate of only 0.9mm per month. Many Medical therapies were tried for FFA, but they showed variable results. Medical therapy is mainly focused to arrest the disease progression rather than growth of hair on balding area. Hence hair transplantation can be considered for bald area. But surgical management of frontal fibrosing alopecia is not much explored yet as the natural course of disease is not known. Nusbaum and Jimenez had attempted test grafting in a case of frontal fibrosing alopecia and the grafted follicles showed good growth initially but over a period of time, only few grafts were left behind. Long term results of both the studies were not appreciating. Kossard and shiell reported a case of development of FFA in transplanted hair follicles 5 years after undergoing multiple hair transplantations for androgenetic alopecia. In our study, we performed complete hair transplantation in two cases even though long term results of the test patch in FFA was not encouraging but there were reports supporting medical treatment for FFA. In the first case, medical

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therapy, 0.1% pimecrolimus were started when we noticed loss of grafts on temple and eyebrows which may be due to recurrence of disease. She denied to take dutasteride. We noticed some hair growth on medial aspect of eyebrows and not much difference in frontal hairline. On the contrary, more loss of grafts was noticed on the temple. Katoulis et al observed similar result on eyebrows with pimecrolimus. The reason for variable effect of pimecrolimus on different sites is not known. It is presumed that pimecrolimus serves to suppress inflammation and therefore impedes destruction of follicular stem cells and the sebaceous gland, and ultimately the destruction of the hair follicle. Why minimal hair regrowth is seen on eyebrow and why hair re growth is not seen on the temporal hair line, is not yet clear. Apart from this we feel that if we start medical therapy right from the beginning or treat preoperatively for a period of time before performing hair transplantion, it may suppress the disease and can lead to long term good results. According to Nusbaum, the patient selected for test grafting should exhibit long term disease stability for at least 5 years. Whereas minimal recommended stability for surgical management of cicatricial alopecia is one year. In our cases, 2 years stability was noted in both the cases. To our knowledge, no case in the literature was reported yet for eyebrow transplantation in frontal fibrosing alopecia. In second case, medical therapy was started 8 months after surgery. She was very happy with the results and she wanted second transplant which was done 10 months after first transplantation. In first case, if she had used and responded to dutasteride, we might have prevented loss of grafts on hairline. Conclusion: Hair transplantation in frontal fibrosing alopecia should be carefully performed only after stabilization of the disease. Medical treatment pre and post operatively can give appreciating long term results. However, as this is an ongoing study, long term results of these cases need to be analyzed. Lastly, it is very important to inform all the patients of frontal fibrosing alopecia about its nature, recurrence, variable response to medical therapy and subsequent graft loss, can occur at any time of life.

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3 Camouflaging the Posterior Zygomatic Arch Protrusion After Zygoma Reduction Surgery Using Hair Transplantation in Infratemple Area
Jae Hyun Park, MD DaNa Plastic Surgery Clinic, Seoul, Korea, Republic of. Plastic Surgeon, Private practice in DaNa Plastic Surgery Clinic J. Park: None. ABSTRACT: Introduction: We presents a superb result achieved by reducing the transverse width of the face, still remaining protruded posterior area even after the zygomatic reduction surgery, by covering the protruded area of the posterior zygomatic arch through single hair graft method. Objective: To reduce the transverse width of the face of remaining protruded posterior zygomatic arch area even after disappointment of zygomatic reduction surgery by covering the protruded area of the posterior zygomatic arch through hair graft Materials and methods: The operation was performed to 28 patients among the 326 female hairline correction cases during 2009 and 2011 who complained of remaining protrusion at the posterior zygomatic arch area after zygoma reduction surgery from other clinics. The average age was 29.4 years old, and all were females. Average of 3.4 years was post surgery on the zygoma reduction. The indication was targeted only to those cases of having protrusion of the posterior zygomatic arch through medical photos and palpation before operation. The protruded posterior zygomatic arch at the rear side of osteotomy area was checked by palpating the front and the lateral side with each patient pre-operatively in front of a mirror. The operation design was completed to cover the remaining protruded posterior zygomatic arch area. Infratemple area design was done with round shaped frontal hairline design. Discussion and Results: In all patients, the transverse width of posterior zygoma area was effectively reduced at frontal view, and cosmetically satisfactory result was gained. There were no cases of re-surgery and side effect of asymmetry or unnaturalness etc. A zygoma is a structure articulating a wide-ranging part of the facial contour and appearance, and influencing great effect on the shape of the frontal view and oblique view. Asians generally portray a facial structure with wider transverse width than upper and lower length compared to Caucasians. Protruded zygoma presents a robust and unattractive impression. To turn this impression to a softer and attractive one, zygoma reduction has been very common in Asia. The technique of zygoma reduction was first introduced by Onizuka et. al in 1983. Then the zygoma reduction

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surgery has been conducted by many surgeons in a various ways. However, the posterior zygomatic arch at about 1cm at the temporozygomatic suture area cannot be reduced due to the temporomandibular joint space, so if the posterior zygomatic arch is more protracted than the zygoma at anterior & middle part, satisfactory results could be rarely achieved as the face width is not satisfactorily reduced, and step deformity is generated even after zygoma reduction surgery. The authors' technique could effectively reduce the transverse width of face around zygoma area for the patients who were not satisfied after Reduction Malarplasty through intraoral approach. It is an effective and simple method to conduct in case of there remaining any complex protraction at posterior zygomatic arch to reduce due to the temporomandibularjoint space after zygoma reduction surgery. Conclusion: We presents a superb result achieved by reducing the transverse width of the face, still remaining protruded posterior area even after the zygomatic reduction surgery, by covering the protruded area of the posterior zygomatic arch through single hair graft method.

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3 Trichoschisis: an Uncommon Complication from Hair Transplantation

Damkerng Pathomvanich, MD DHT Clinic, Bangkok, Thailand. DHT Clinic, Bangkok, Thailand American Board of Hair Restoration Surgery,Diplomate American Board of Surgery,Diplomate Fellow American College of Surgeon Director Fellowship Training Program in Hair Restoration Surgery D. Pathomvanich: None. ABSTRACT: Intoduction: Trichochisis is the hair shaft abnormality resulting in increased fragility. Its characterized by complete transverse fracture of hair shaft, both cuticle and cortex, are involved. It is an interesting, unusual complication and can be a cause of poor cosmetic result after hair restoration surgery. Materials and Methods: 42 years old Asian male, was seen for evaluation of his hair loss for the past 3 years .Its stable at present. He was on finasteride plus minoxidil 5% lotion without improvement and would like to proceed with hair transplantation, since he witness his friend who looked alike him, has good result of surgery just one session. Examination showed receding frontotemporal hairline and central crown baldness as in Norwood III vertex and good donor density. His hairs were coarse, straight and black. The hairline was drawn; the balding area measured 27 cm2 at front and 21 cm2 at crown. A total of 2302 grafts were transplanted (1702 grafts at front and 600 grafts were at crown). Results: Patient was seen 7 month post op and very happy with the outcome. He was seen again at 2 years, complaint of the hair grafts at crown never grow long. Close examination showed dense growth of hair to the length of cm at crown, the front hairs were growing well and long with good density. He denied of habitual tic, aggressive hair combing, scalp massage, chemical application or hair perm. Biopsy was taken, showed peribulbar lymphocytic infiltration, the number of catagen and telogen were present. Diagnosis was Alopecia Areata. He was treated with 5%minoxidil lotion and steroid cream and was seen again 6 months later with no improvement. I referred him to see my good old friend, dermatologist in Singapore and was informed that he has AGA not AA by another biopsy. Since we have reported a case of trichorhexis nodosa, it prompted us to check the hair shaft with trichoscan . It showed classic complete transverse fracture of numerous hair shaft as seen in Trichochisis. Conclusion: Trichoschisis is a very rare complication that appears like stunning of the hair growth from fracture of the hair shaft cause poor cosmetic result after hair transplantation. Post-op trichoscan is useful for accurate diagnosis if patient has poor or abnormal hair growth.

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Trichoschisis: Poor Cosmetic Outcome after Hair Transplantation or a Consequence of Concomitant Alopecia Areata
Jocelyn Theresa P. Navalta, MD DPDS; Damkerng Pathomvanich MD FACS DHT Clinic, Bangkok, Thailand

Jocelyn Theresa P. Navalta, MD Fellow, DHT Clinic, Bangkok, Thailand Diplomate, PDS Member, ISD Dermatologist Philippines

Introduction: Trichochisis is a hair shaft abnormality resulting in increased fragility and a complete transverse fracture of the hair shaft along weak areas of the cuticle. We present an interesting, unusual, and rare occurrence of Trichoschisis after hair restoration surgery causing poor cosmetic outcome.

Objectives: 1. To report an unusual case of Trichoschisis after hair transplant surgery on a patient diagnosed with Androgenetic alopecia 2. To report the occurrence of Alopecia areata with Androgenetic alopecia and its possible effect on the growth of transplanted grafts from hair transplant surgery
Figures 4a-4d. 7 months Post-op

Case: A 42 year-old Asian male had a 2-year history of hair loss over the hairline and crown. He had been on daily oral finasteride and topical minoxidil 5% for a year without improvement and wanted to proceed with hair transplantation. He reported no family history of hair loss and was generally healthy. On initial consultation, physical examination showed receding frontotemporal hairline and thinning hairs at the crown (Norwood class IIIv) and with good donor density (Fig. 1a-1d). There were no visible signs of unusual hair color, texture, or changes in length of the hair shaft. The recipient areas measured 27 cm2 at hairline and 21 cm2 at the crown.
Figures 4e-4f. (upper) 4-5cm growth, (lower) 1cm growth Figures 5a-5b. 1.4 yrs Post-op Figures 1a-1d. Initial consult

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At 3 years follow-up (Fig 7a), close examination showed length of the hairs up to cm at crown. He denied having habitual tics, aggressive hair combing, scalp massaging, use of chemical agents, or hair straightening/perms. Trichoscan showed complete transverse fractures of numerous hair shafts (Figure 7b-7c) classically seen in Trichoschisis.
Figure 7a. 3 years Post-op
Figures 7b-7c Clean break across the hair shaft and lLJKW DQG GDUN WLJHU WDLO EDQGV XVLQJ trichoscan

7 months later, the patient came for hair transplant surgery. On P.E., he had further hair loss on the frontotemporal areas and crown (Fig. 2a2d). On closer inspection, there were numerous follicular orifices and miniaturized hairs (Fig. 3a-3b). He underwent hair transplant surgery (total 2302 grafts: 1702 hairline, 600 crown). Oral finasteride 1mg daily and topical 5% minoxidil were continued.

At 1 year and 4 months, there was Figures 6a-6b. good hair growth at the hairline but peribulbar lymphocytic the patient noted hairs at the crown infiltration, with had failed to grow (Fig. 5a-5b). presence of a number Diagnosis was Alopecia areata (AA) of catagen and telogen hairs by biopsy (Fig. 6a-6b). Treatment with topical and intralesional steroids plus 5% minoxidil for 1 year showed no improvement. A repeat biopsy was taken with a diagnosis of Androgenetic alopecia (AGA) (terminal:vellus ratio of 2.5:1), without evidence of Alopecia areata. The patient was maintained on oral finasteride and topical 5% minoxidil.

Figures 2a-2d. Immediately Pre-op

Figures 3a-3b. Close-up: (L) Left temple, (R) Crown

Discussion: Trichoschisis can occur as an autosomal recessive disease (Trichothiodystrophy) or sporadically as a result of excessive manipulation and use of chemical agents resulting in brittle hairs1,2. Microscopy shows clean transverse hair shaft breakage WLJHU WDLO alternating light and dark bands) due to low sulfur content. AA show on histopathology presence of bulbar lymphocytes surrounding terminal hairs in early episodes and miniaturized hairs in repeated episodes. In the chronic stage, there is a decrease in terminal and an increase in miniaturized hairs, with variable inflammation3. Histopathology of AGA show a significant increase in telogen hairs and decrease in anagen/telogen ratio and terminal/vellus hair ratio (<4:1 ratio). Perifollicular inflammation is a constant feature in early cases whereas perifollicular fibrosis is seen in advanced cases4. In our case, biopsies showed the presence of AA initially, which could have resolved upon taking the second biopsy showing a diagnosis of AGA. Thus far, there have been no reports of AA predisposing to Trichoschisis or vice versa. There have been several associations previously made, however, between AA and another hair shaft abnormality (Pili annulati)5-10. The temporal relationship between AA and Pili annulati differed among these cases and causality between these two clinical entities remains unclear and has been discounted as coincidental rather than true associations in recent studies10-11. To our knowledge, there has been no report of cases of AA with other forms of hair shaft abnormalities such as trichoschisis. The question of whether hair transplant surgery can cause hair shaft abnormalities remains speculative. A case of Trichorrhexis nodosa after hair transplantation was recently reported, however, no clear and direct association can still be made12. Conclusion: This is the second case of hair shaft abnormality observed after hair transplant surgery. No pathologic explanation can be concluded in this case and further investigation is necessary to determine a causal relationship between hair transplant surgery and hair shaft abnormalities. There is the possibility that Trichoschisis is a consequence of a concomitant Alopecia areata causing poor cosmetic outcome from hair transplant surgery. Post-op trichoscan is useful for accurate diagnosis of patients with poor or abnormal hair growth after hair transplantation.
References: 1 Brown AC, Belser RB, Crounse RG, Wehr RF. Congenital Hair Defect: Trichoschisis with Alternating Birefringence and Low Sulfur Content. J Invest Dermatol. 1970 Jun;54(6):496-509. 2 Khumalo NP, Stone J, Gumedze F, McGrath E, Ngwanya MR, de Berker D. 'Relaxers' damage hair: evidence from amino acid analysis. Journal of the American Academy of Dermatology, 2010 March;62(3):402-408. 3 David A. Whiting. Histopathologic Features of Alopecia Areata: A New Look. Arch Dermatol, 2003;139(12):15551559 4 El-Domyati M, Attia S, Saleh F, Abdel-Wahab H. Androgenetic alopecia in males: a histopathological and ultrastructural study. J Cosmet Dermatol. 2009 Jun;8(2):83-91. 5 Green J, Sinclair RD, de Berker D, Sinclair RD. Disappearance of pili annulati following an episode of alopecia areata. Clin Exp Dermatol, 2002 Sep;27(6):458-60. 6 Cruz AP, Liang CA, Gray JP, Robinson-Bostom L, McDonald CJ. The appearance of pili annulati following alopecia areata. Cutis. 2012 Mar;89(3):145-7. 7 Reyn A. Pili annulati occurring as a family disorder. Br J Dermatol 1934;46:168-175. 8 Price VH, Thomas RS, Jones FT. Pili annulati: optical and electron microscopic studies. Arch Dermatol 1968;98:640-647. 9 SmithSR,KirkpatrickRC,KenJH,MezebichD.Alopecia areata in a patient with pili annulati. J Am Acad Dermatol 1995;32:81&818. 10 D. L. Moffitt, J. T. Lear, D. A. R. de Berker, R. D. G. Peachey. Pili Annulati Coincident with Alopecia Areata 11 Giehl KA, Schmuth M, Tosti A, De Berker DA, Crispin A, Wolff H, Frank J. Concomitant manifestation of pili annulati and alopecia areata: coincidental rather than true association. Acta Derm Venereol. 2011 Jun;91(4):459-62. 12 Pathomvanich D, Caroli S, Amonpattana K, Pathomvanich O, Kumar A. Trichorrhexis nodosa: an unusual hair transplant complication. Hair Transplant Forum International, 2012 Jan/Feb;22(1):10-11. 13 Faghri S, Tamura D, Kraemer KH, DiGiovanna JJ. Trichothiodystrophy: a systemic review of 112 published cases characterizes a wide spectrum of clinical manifestations. J Med Genet 2008;45:609621.

7-months post-op, outcome was satisfactory, with good growth and coverage from the transplanted hairs at the frontotemporal hairline and the crown (Figures 4a-4d). Hairs at the hairline measured 4-5cm long hairs at the crown measured approximately 1cm (Fig. 4e-4f).

3 Impossible Hair Transplant Repair - A Different Approach to Treat a Difficult Repair Patient
Arvind Poswal, MBBS Dr. A S Clinic Pvt. Ltd., New Delhi, India. 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. As 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. A. Poswal: None. ABSTRACT: Introduction: Androgenic alopecia (pattern baldness) is a condition in which there is androgen mediated progressive miniaturization and loss of genetically susceptible hair follicles in an individual. A 29-year-old male patient with moderate hairloss (Norwood classification 4 category) wanted to go for hair restoration surgery. He underwent a scalp expansion and flap procedure with some other doctor. But due to mistakes in the flap procedure and in patient selection, the results were not aesthetically acceptable. The procedure also depleted the scalp donor reserves making this a difficult, if not impossible, repair case. A combination of mostly beard and chest donor hair was used in this patient to augment the donor hair supply. A different approach to hairline design was also used to blend the new hair growth with the previous scalp flaps. Objective: To use body and beard donor hair to augment the donor hair supply, and to design a new hairline that blends the new hair growth with the previous scalp flaps to give a natural look. Materials and Methods: The patient, 29 year old normotensive, nondiabetic approached our clinic. The patient wanted to go for hair restoration surgery. He had already undergone a scalp expansion and flap procedure before coming to us when he had moderate hairloss (Norwood 4 level) at some other centre. The surgery resulted in a very unusual look because of asymmetry of the flaps used, the scar visibility in front of the hairline, the loss of hair in a part of the flap and the patients hairloss progression to a Norwood 6 level over time after his flap procedure. This was a challenging case because of the following difficulties: x The two flaps extracted while doing a flap procedure were asymmetrically aligned in the recipient area which gave an unaesthetic look. In addition, the growing hair in the flap pointed unnaturally backwards exposing the suture line in front of the flap. One of the flaps was not taken from the safe donor area. As a result, when patient reached a Norwood 6 level of hairloss, he lost a portion of the hair from that flap and at the same time, the suture scar became visible in the donor area.

374

x x

Due to tissue contraction, the hair density in the flap is higher than the hair density in patients scalp donor area. The unnaturally backward pointing hair in the also made it difficult to plan a hairline

Discussion/Results: As the scalp donor area got used up in scalp expansion and the flap procedure, it necessitated the use of alternate donor hair resources. The approach used was: 1. 2. A combination of mostly beard and chest donor hair was used to augment the donor hair supply. The direction of hair in the hairline was designed to incorporate the flap hair direction and to cover the scar visibility in the hairline in the revised hair restoration procedure.

Surgery: Under proper aseptic precaution and after local anesthesia administration, follicular units were extracted from the beard and chest area of the patient. These follicular units were kept in chilled ringers lactate (4C). Recipient sites were made in the premarked anaesthetized recipient area on the scalp, followed by the systematic placement of the beard and chest hair grafts in those sites. At the end of the procedure antiseptic dressing was applied over the recipient as well as the donor areas. The dressing was removed from the recipient area after 18 hours. The patient was put on antibiotics for five days postoperatively. Follow-up: The recipient and donor areas were observed at one-month, two-month and eight-month interval. At eight-month, the recipient area showed cosmetically acceptable hair growth in the hair line. The misalignment of the flaps and the visible scar also got covered with the growing hair. Conclusion: 1. Flap procedures, if performed, should be limited to carefully screened candidates (older patients with no family history of extensive hairloss and a stabilized hairloss progression). 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. Uncommon hairline designs also need to be mastered by hair transplant practitioners to treat such patients.

2.

3.

375

376

3 Evaluation of Body Dysmorphic Disorder in Hair Loss Patients and Benefit After Hair Transplant
Rajendrasingh J. Rajput, MD Hair Restore, Mumbai, India. Body dysmorphic disorder is excessive concern about physical appearance leading to mental, social & functional distress. Patients seek cosmetic surgery not psychiatry & remain dissatisfied after surgery. Study includes 100 hair transplant patients from 1st Jan to 31st July 2010. BDD questionnaires used in psychiatry & cosmetic surgery were modified for hair loss. Patients Personal Evaluation, Yale Brown Obsessive Scale, Sheehan Lifestyle Disability Scale & Derriford Appearance Scale. Patients were reassessed 8 months after hair transplant to judge the benefit. BDD prevalence in hair loss is 27%, higher than rhinoplasty 20.7%. Preoccupation of hair loss on their mind is higher. After hair transplant 32% patients, had milder perception of their defect but 16% continue to feel they have less hair. R.J. Rajput: None. ABSTRACT: Body dysmorphic disorder (BDD) can be defined as excessive concern about an imaginary or marginal defect in physical appearance leading to thoughts or actions creating distress, with social and /or functional impairment of routine life (1, 2, 3). The patients believe that not psychiatric help but cosmetic surgery is required for permanent correction of their problem (4). Often they will still find a residual deformity after the surgery and continue to be dissatisfied (3). Studies have reported a prevalence of BDD in 0.7-3% of general population, 2.5 -5.3% in college going students and 6-15% in those approaching for cosmetic surgery (5, 6, 7, 8, 9). The present day exposure to media, the display of well groomed bodies, seen from an early age, often distort the perceived body image and promote a feeling of mismatched body proportions. Most common areas of concern in BDD are skin, hair and nose (10,11,12). We often find patients who will refuse to remove their cap or use hair pieces in young age, though having a good amount of hair on their head. Patients refusing social events and photographs with friends or insisting for photos only at a certain angle where the hair looks good. Many women refusing to have a change in hair style even in slight thinning on the frontal or temporal area. Hair transplant surgeons should be more aware of BDD. Patient and Methods All patients aged 18 years and above who approached for hair transplant between 1st Jan 2010 to 31st July 2010, were explained and asked to participate in the study. After reading the questions, 19 patients felt uncomfortable answering the questions and were allowed to refuse. In fact these would be the ones who were most concerned about the dysmorphic appearance and shunned even at the mention of the condition. We decided to have 100 patients in the study and reassess them, 8 months after the hair transplant. There are standard questionnaires available and used for evaluation of BDD in psychiatry and cosmetic surgery. Four different questionnaires were modified and prepared to suite the study for hair loss. Patient Evaluation Patients had a personal evaluation of the extent of their deformity (Table 1). All the patients scored their deformity as severe to extreme going with the fact that they were concerned about it and had come to request a correction of the real or the perceived defect. The surgeons assessment of most deformities was mild to moderate indicating that

377

they need a more careful perception that though the defects look mild they mater more seriously to their patients. Majority of the patients 94% agreed to have corrections as per doctors guidelines and when explained as planning being as per good transplant practices. Very small number 6% patients were adamant about a particular shape or area being transplanted more preferentially, their requests were accommodated within limits of the procedure. Yale - Brown Obsessive Compulsive Scale - modified (Table 2) We did not use scale for compulsive actions as the obsessive evaluation delivered good insight into severity of the problem. A similar five point rating can be used to evaluate compulsive actions as well. The Yale- Brown Scale is a global standard used in evaluation, follow up and improvement in severity of the dysmorphic thoughts and behavior. More often used for cosmetic surgery patients (14, 15). Patients were asked to rate their obsessive feelings as - Looking into the mirror, spending more time to get the hair set perfectly, wanting to adjust slightest disturbance in their hair, wearing cap all the time, refusing dance, games etc where the hair may fly off and look undone, avoiding photographs and social events. Sheehan Disability Scale (Table 3) Evaluates the quality of life and functional impairment at school / work, social and family life (14, 15). The Derriford appearance Scale (Table 4) This scale has 59 items or questions designed to assess the effect or concern of your appearance on your everyday living, personal relations, self esteem and emotional distress (16). The scale has a subscale for general self consciousness, social self consciousness, sexual and bodily appearance, facial appearance and negative self concepts. A short version of the scale is utilized in most applications. A 24 point and 12 point scale is already available in several references (17,18), we used a 20 point scale modified for hair loss assessment. Evaluation References from previous studies were used to decide a score to be labeled as BDD (14, 15, 16, 17, 18). A score of 10 or above on the Yale-Brown Scale or DASS score of 30 or above showing preoccupation of the mind were considered to have Body Dysmorphic disorder. Patients with minimal defect requesting complete correction can clinically be considered to have BDD. The Sheehan disability Score of 30 and above indicated that the perception of the deformity affected the routine life of the patients. Prevalence of Body Dysmorphic Disorder Younger patients in the age group of 18 to 30 had higher perception of their deformity. The Grade of hair loss and extent of thinning or baldness did not show direct correlation with the prevalence of BDD. On the Yale - Brown scale 32% scored as mild, while moderate score was seen in 40% patients. Severe Yale - Brown Scale score of 10 and above indicating a BDD, was seen in 27% patients who had varying degrees of hair loss and grade III to grade VI of baldness. Only one patient who refused to attend college scored as extreme. Therefore the prevalence of BDD in hair loss patients as per Yale - Brown Scale is 27%. The incidence is higher when compared to patients in cosmetic surgery. The highest incidence of BDD reported in a study done for patients requesting rhinoplasty is 20.7% (13). Sheehan Scale showed that none of the patients had mild score, 78% had moderate influence on their routine life, 20% scored as severe and 2% agreed to have extreme effect on their routine life. Indicating that though the incidence of BDD in hair loss patients is low the effect on daily life is more than generally perceived.

378

The criteria of DASS were selected and modified more to fit the hair loss patients. The modification may be one of the reasons that a very high number of patients 82% had a score of 31 or above indicating severe preoccupation of their hair loss and baldness on their mind. Rest 18% had extreme effect and none had mild or moderate effect. The study indicates that the loss of hair and change in appearance has a higher and deeper impact on the minds and social lifestyle of our patients than we think. We reassessed the patients 8 months after the hair restoration procedure. The Yale-Brown scores improved showing 48% mild, 36% moderate, 16% severe and no extreme (figure 1). The Sheehan scale showed 32% mild, 56% moderate, 12% severe and no extreme (figure 2). There was a 12 - 32% shift towards mild perception, 11 - 22% shift towards moderate perception, 8 -11% improvement in severe perception and none regarded the deformity as extreme. The shift indicates that hair restoration surgery does help to a large extent in improving the appearance, routine lifestyle and perception of the deformity in hair loss patients. The DASS modified scores reassessed after hair transplant revealed a slightly different outlook. Though the scores of 12% mild, 27% moderate and 45% severe indicated benefit from the procedure. A good 16% still scored as extreme (figure 3). Compared to 18% extreme score before the surgical correction, these patients who were in extreme category before were still preoccupied in their mind that they have had a hair transplant, others may notice the transplanted hair, the residual thinning may still be seen, areas of less hair could be visible to others and anyway they will always have less hair than others around them. These are the patients to look out for. These patients may continue to be unhappy after the procedure and notice faults or incomplete execution of the procedure, holding on to residual deformities or perception of the deformities. Comparing 27% incidence of BDD and 16% still considering the deformity preoccupied in their thoughts, should we conclude that only 11% of the BDD could be corrected or helped by surgery? Patients who improved on their scores were feeling confident, could concentrate better at work, were socially more active, had stopped using caps and concealers, though some still have their favorite angle for photographs. Some of them had taken to a fitness regimen given qualifying exams and had promotions. The families found an emotionally improved and better bonding person. Younger patients and patients in lower grades of hair loss, with higher initial evaluation scores of the deformity scored less on reassessment of the improvement, showing to be less satisfied and still had one or two residual areas to be addressed. The inverse proportion is due to high expectations. Since patient satisfaction and quality of life are the prime concern in hair restoration, further research in correlation to BDD is necessary.

60 50 40 30 20 10 0

Yale BrownObsessiveScaleShift towardsMilderPerceptionof deformityafter Before HairRestoration

8monthsPost Transplant

MajorityPatientsshiftedtoMild&Moderate, noneinExtreme

379

100 80 60 40 20 0

SheehanScaleShifttowardsMilder PerceptionofDisabilityafterHair Restoration

Before 8monthsPost Transplant

MajorityPatientsshiftedtoMild&Moderate, noneinExtreme

100 80 60 40 20 0

DASSScaleShifttowards MilderPerceptionofDisability afterHairRestoration

Before 8monthsPost Transplant

MajorityPatientsshiftedtoMild&Moderate, somecontinuedtoperceiveasExtreme

Table 1 Patients Evaluation Criteria Level of the hairline Shape of the hairline Score 0 Score 1 Acceptable with marginal correction Acceptable with marginal correction Acceptable with marginal correction Correction in directly visible areas Correction in directly Score 2 Correction as per doctors Guidelines Correction as per doctors Guidelines Correction as per doctors Guidelines Correction as per doctors Guidelines Correction as per Score 3 Unusual expectations or own ideas Unusual expectations or own ideas Unusual expectations or own ideas Very high Density all over Very high Density all

Good as it is

Good as it is

Temporal receding To match the hairline

Thinning and Scalp Average correction show to look better Baldness in one or Average correction

380

more areas Total Scores

to look better Mild 0 to 5,

visible areas Moderate 6 to 8,

doctors Guidelines Severe 9 to 11,

over Extreme 12 to 15

Table 2 Yale - Brown Obsessive Scale Modified Obsession Time spent on Obsession Interference from Obsession Score 0 Score 1 Score 2 Score 3 Score 4

0 hours

0 1 hours

1 3 hour

3 8 hours

more than 8 hours

None

Mild

Definite manageable Moderate manageable Sometimes can resist

Substantial impairment

Incapacitating

ObsessionDistress from None

Mild

Severe

Constant and Disabling

Resistance to the Obsession Control over the Obsession

Always Resist Often resists

Only try to resist

Cannot resist

Complete control

Much control

Little control

Some control

No Control

Total Score

Mild 0 to 5,

Moderate 6 to 9,

Severe 10 to 14,

Extreme 15 to 20

Table 3 Sheehan Disability Scale Mild - Continue No routine but Disturbance concerned 0 123 Moderate worry makes routine incomplete 456 Severe worry stops or reduces routine activity 789 Extreme cannot carry on routine life 10

Criteria

Score Work or School Social Life Family /

381

Home Total Score Mild 0 to 9, Moderate 10 to 18,

Severe 19 to 27,

Extreme 27 to 30

Table 4 Derriford Appearance Short Scale - Modified Criteria Feeling loss of Confidence Distress at Reflection Irritable at Home Feel Hurt, Feel Rejected Self Conscious of appearance Distress at Pubs Restaurants or Social events Misjudged due to appearance Feel incomplete masculine or feminine Felt I wasn't worth much as a person Adjust the hair if it flies or gets disturbed Adopt Concealing Gestures Difficult to work up the initiative to do things Tended to over-react getting upset by quit terivial situations Found others preferred over me for important assignments Could have done better with proper looks Felt sad and depressed sometimesFound myself getting impatient when I was delayed in any way(eg, lifts, traffic lights, being kept waiting) Score 0 Score 1 Score 2 Score 3

382

Felt that I had nothing to look forward to Found it difficult to relax Felt nervous in situations, with raised heart rate sweating or shaking feet Mild 0 Moderate to 10, 10 to 30, Severe 31 to 50, Extreme 51 to 60,

Total Score

3 Update on Recipient Site Staining, Better Stain Formulation Viscosity Improves Sites Visibility by 100 %
Muhammad N. Rashid, MD HAIR TRANSPLANT SURGERY, HCI, Lahore, Pakistan. Pakistan's 1st Hair Transplant Surgeon to become member of ISHRS also the first and the only Surgeon who represented Pakistan in the Travelling Workshop of ISHRS held in ASIA in 2000.The most experienced Hair Restoration surgeon in the region with an unmatched experience of more than 11 years in Hair Transplant.He also introduced the most latest and innovative method of doing Hair Transplant called NO TOUCH SURGERY which results in most NATURAL HAIRLINE with 0 % damage risk due to Human Factor due to the use of Special HAIR IMPLANTER DEVICE instead of forceps.He holds the exclusive rights for this NO TOUCH TECHNOLOGY for Single follicle transplant in Pakistan. At present he is using the most advanced technology that uses state of the art computerized Local Anaesthesia system called Compumed. He is also the President of HAIR CLUB INTERNATIONAL, the largest chain of Hair transplant clinics in Pakistan. M.N. Rashid: None. ABSTRACT: Introduction: The author introduced the concept of recipient site staining back in a previous meeting and since then have been working on various ways to improve the staining process further to make it user friendly and more effective.We presented in 2007 ISHRS a customized high viscosity formulation made exclusively for recipient site staining as our staff feedback suggested the commercially available concentrations and viscosity of the gentian violet is not optimal for staining recipient sites and does not give consistent results.Initially the described technique required to make all

383

the recipient sites first and then apply stain to increase their visibility but later it was observed that such a method was more cuber some as it was very difficult to remove the residual stain from the skin. Material/Method: We worked on a new formulation of the stain to make it more viscous so that it can be used while making the recipient sites instead of applying after making the sites first. After repeating this on several patients it was found that this method proved far better than the previous one as the sites were more deeply stained and it was very convenient to remove the residual stain left on the skin,Plus the added advantage was that the sites become visible even during the time they were being made ,making the recipient site making process also faster specially when U have to create thousands of them in Mega sessions of 4000 follicles. The blades are dipped into the new thicker formulation of the stain before inserting them in the skin.this creates a thin layer of highly viscous stain on the horizontal surface of the blades and when they are inserted into the skin the stain on their surface stains the orifice of the site as they are withdrawn while limiting the application of the stain on the adjacent skin as contrast to the older method of painting the skin after making all the sites first. Discussion/Results: After several years of using this technique our staff found it to be very helpful in the placing of the follicles as there enhanced visibility made the placing extremely comfortable for the techs because the empty sites appear dark violet spot against the skin tone.The technique eliminates the risk of piggy packing and reduces the incidence of missed sites.Plus the speed of placing is increased two folds as the techs do not have to look for the tiny micro sites.This is specially useful in dark skin patients and when doing transplant within the existing hair Conclusion: Recipient site staining is an extremely useful technique specially when recipient sites are made in high density using cut to size micro blades as small as 0.7mm.

3 Re-innervation and APM Formation of FU after HT

Akio Sato, MD1, Koh-ei Toyoshima2, Akira Takeda3, Takashi Tsuji2 1 Department of Regenerative Medicine, Plastic and Reconstructive Surgery, Kitasato University School of Medicine, Kanagawa, Japan, 2Research Institute for Science and Technology, Tokyo University of Science, Tokyo, Japan, 3Department of Plastic and Aesthetic Surgery, Kitasato University School of Medicine, Tokyo, Japan. Dr Akio Sato is a Professor of Department of Regenerative Medicine, Plastic and Reconstructive Surgery of Kitasato University School of Medicine. His private practice is in Tokyo where he is director of a fellowship in hair restoration surgery and no surgery. He is the president of Japanese Society of Clinical Hair Restoration from 2011. He has published over 30 medical publications, Hes current research is Hair cloning.

384

A. Sato: None. K. Toyoshima: None. A. Takeda: None. T. Tsuji: None. ABSTRACT: The autologous transplantation of hair follicles that have been separated into single follicular units is an accepted treatmentfor androgenetic alopecia. Recent studies demonstrate that the multiple stem cell populations and surrounding cutaneous tissues coordinately regulate the hair follicle functions and skin homeostasis. Therefore, the critical issues for consideration regarding functional hair restoration therapy are reproduction the correct connectivity and cooperation with host cutaneous tissues, including the arrector pili muscle (APM) and nerve system. We report successful establishment of mouse single follicular transplantation model and autonomous restoration of transplanted hair follicle piloerection in mouse skin. Transplanted hair follicles were responsive to the neurotransmitter acetylcholine and formed proper connections with surrounding host tissues such as APM and nerve fibers, which in turn connect with not only the hair follicle bulge region but also the APM. These results demonstrate that the piloerection ability of transplanted hair follicles can be estimated quantitatively. This study makes a substantial contribution towards the development of transplantation therapy that will facilitate future functional regeneration therapy for skin and skin appendages.

3 Low Anabolic Profile in Assessing a Patient's Overall Hair Loss Program
Lawrence Shapiro, DO Dr. Shapiro's Hair Institute, Florida, Hollywood, FL, USA. Dermatologist in practice for 23 years in Delray beach. Performed over 11,000 hair transplants.Graduated Phi Beta Kappa and Summa Cum Laude from Syracuse University. L. Shapiro: None. 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)

385

 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

386

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.

387

Low Anabolic Prole in Assessing a Patient's Overall Hair Loss Program

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1 Steroids (Anabolic). National Institute on Drug Abuse website from the National Institute of Health - http://www.drugabuse. gov/drugs-abuse/steroids-anabolic 2 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. 3 Effect of creatine supplementation and resistance-exercise training 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. http://www.ncbi. nlm.nih.gov/m/pubmed/18708688/ 4 Dose-response study of GH effects on circulating IGF-I 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 nal form 23 February 1999. American Journal of Physiology - Endocrinology and Metabolism.. http://ajpendo.physiology.org/content/276/6/ E1009.full 5 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 Childrens Clinic Division of Endocrinology and Nemours Research Program, Jacksonville, FL 32207, USA. Metabolism. 2003 Aug;52(8):964-9. 6 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): 30663074. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2515076/ 7 Androgen induction of steroid 5 alpha-reductase may be mediated via insulin-like growth factor-I. by Horton R, Pasupuletti V, Antonipillai I. Department of Medicine, University of Southern California School of Medicine, Los Angeles. Endocrinology. 1993 Aug;133(2):447-51. http://www.ncbi.nlm.nih.gov/m/pubmed/8344190/ 8 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. http://www.sciencedirect.com/science/article/pii/S0190962200902937 9 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, Edn S. Department of Physiology and Pharmacology, Sahlgrenska Hospital, Gteborg University, Gteborg, Sweden. Clin Endocrinol (Oxf). 1996 Jan;44(1):23-9. http://www.ncbi.nlm.nih.gov/m/pubmed/8706289/ 10 Hormones and hair patterning in men: a role for insulin-like growth factor 1? by Signorello LB, Wuu J, Hsieh C, Tzonou A, Trichopoulos D, Mantzoros CS. Department of Epidemiology and Harvard Center for Cancer Prevention, Harvard School of Public Health, Boston, Massachusetts 02115, USA. J Am Acad Dermatol. 1999 Feb;40(2 Pt 1):200-3. http://www.ncbi.nlm.nih. gov/pubmed/10025745 11 (J Am Acad Dermatol. 1999 Feb;40(2 Pt 1):200-3.) 12 Acne vulgaris: a disease of Western civilization. by Cordain 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. http://www.worldhairresearch.com/?p=162 13 High Dose Growth Hormone Exerts an Anabolic Effect at Rest and during Exercise in Endurance-Trained Athletes. by M. L. Healy, J. Gibney, D. L. Russell-Jones, C. Pentecost, P. Croos, P. H. Snksen and A. M. Umpleby. The Journal of Clinical Endrocrinology & Metabolism, November 2003 |Healy et al. 88 (11): 5221 http://jcem.endojournals.org/content/88/11/5221.abstract 14 Androgen induction of steroid 5 alpha-reductase may be mediated via insulin-like growth factor-I. by Horton R, Pasupuletti V, Antonipillai I. Department of Medicine, University of Southern California School of Medicine, Los Angeles, CA USA. Journal Endocrinology. 1993 Aug;133(2):447-51. 15 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. http://jas. fass.org/content/65/Supplement_2/168.full.pdf 16 Purication 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, 92S96S http://www.nature.com/jid/journal/v98/n6s/abs/5612066a.html 17 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 http:// dermatology.cdlib.org/DOJvol4num1/original/jankovi.html 18 Testosterone and Insulin-like Growth Factor (IGF) I Interact in Controlling IGF-Binding Protein Production in Androgen-Responsive Foreskin Fibroblasts Atsuko Yoshizawa and David R. Clemmons. Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA. April 2000 |Yoshizawa and Clemmons 85 (4): 1627 http://jcem.endojournals. org/content/85/4/1627.full 19 Dihydrotestosterone inhibits hair growth in mice by inhibiting insulin-like growth factor-I production in dermal papillae. by Zhao J, Harada N, Okajima K. IGF Res. 2011 Oct;21(5):260-7. Epub 2011 Aug 11. http://www.hairloss-research.org/UpdateIGF10-11.html 20 Regulation of human dermal papilla cell production of insulin-like growth. by Hembree JR, Harmon CS, Nevins TD, et al. Department of Physiology and Biophysics, Case Western Reserve University School of Medicine, Cleveland, OH USA. J Cell Physiol. 1996 Jun;167(3):556-61. http://www.ncbi.nlm.nih.gov/pubmed/8655609 IGFBP-3 the most abundant IGFBP type in dermal papilla cells forms a complex with free IGF-I to reduce the concentration of IGF-I available for stimulation of hair elongation and maintenance of the anagen phase. 21 17beta-hydroxy-5alpha-androst-1-en-3-one (1-testosterone) is a potent androgen with anabolic properties. by Friedel, et al. Toxicol Lett, Aug 2006; 165(2): 149-55. http://www.ncbi.nlm.nih.gov/pubmed/16621347 22 The biological activity of undenatured dietary whey proteins: role of glutathione. by Bounous G, Gold P. Department of Surgery, Montreal General Hospital Research Institute, Quebec. Journal Clin Invest Med. 1991 Aug;14(4):296-309. http://www. ncbi.nlm.nih.gov/m/pubmed/1782728/ 23 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. 11251130. http://www.ncbi.nlm.nih.gov/pubmed/20300014 24 Effects of amino acids supplement on physiological adaptations to resistance training. by William J Kraemer; Disa L Hateld; Jeff S Volek; Maren S Fralgala; Jakob L Vingren; Jeffrey M Anderson; Barry A Spiering; Gwendolyn A Thomas; Jen Y Ho; Erin E Quann; et al. Medicine and science in sports and exercise 2009;41(5):1111-21. 25 Protein--Which is Best? by Jay R. Hoffman and Michael J. Falvo. The Department of Health and Exercise Science, The College of New Jersey, Ewing, New Jersey, USA. International Society of Sports Nutrition Symposium, June 18-19, 2005, Las Vegas NV, USA - Symposium - Macronutrient Utilization During Exercise: Implications For Performance And Supplementation. 01 September 2004. http://www.jssm.org/vol3/n3/2/v3n3-2pdf.pdf 26 Rosenthal, J., Angel, A., and Farkas, J. (1974) Am. J. Physiol. 226, 411418. Pg 124 chapter 8.1 from the textbook BCAAS metabolized by the skeletal muscles. 27 Modulation of Muscle protein Metabolism by Branched Chain Amino Acids in Normal and Muscle-Atrophying Rats. by Hisamine Kobayashi, Hiroyuki Kato, Yuri Hirabayashi, Hitoshi Murakami, and Hiromi Suzuki. Applied Research Department, AminoScience Laboratories, Ajinomoto Co., Kawasaki, Japan. The Journal of Nutrition 136: 234S236S, 2006 http://jn.nutrition.org/content/136/1/234S.full.pdf Wpi raises T in serum resting Bccas especially leucine increases muscle protein synthesis 28 Effect of leucine metabolite b-hydroxy-b-methylbutyrate on muscle metabolism during resistance-exercise training. by S. Nissen, R. Sharp, M. Ray, J. A. Rathmacher, D. Rice, J. C. Fuller, Jr., A. S.Connelly and N. Abumrad. J Appl Physiol 81:20952104, 1996. http://jap.physiology.org/content/81/5/2095.full.pdf 29 Taken From: Nutritional role of the leucine metabolite ?-hydroxy ?-methylbutyrate (HMB). by Steven L. Nissen and Naji N. Abumrad. J. Nutr. Biochem. 8:300-311, 1997. http://www.jnutbio.com/article/S0955-2863%2897%2900048-X/abstract 30 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. http://www.ncbi.nlm.nih.gov/pubmed/20300016 31 Supplements as Ergogenic Aids. Understanding Nutrition 2005 by Whitney, E., & Rolfes, S. 32 Arginine increases insulin-like growth factor-I production and collagen synthesis in osteoblast-like cells. by 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. http://anabolicminds.com/forum/ supplements/27359-arginine-increase-igf.html 33 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. http://www.ncbi.nlm.nih.gov/pubmed/2144295?dopt=AbstractPlus 34 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 California School of Medicine, La Jolla, CA, USA. J Clin Endocrinol Metab. 1994 Jun;78(6):1360-7. http://www.ncbi.nlm.nih.gov/m/pubmed/7515387/ 35 Short-term exposure to insulin-like growth factors stimulates testosterone production by testicular interstitial cells. De Mellow JS, Handelsman DJ, Baxter RC. Acta Endocrinol (Copenh). 1987 Aug;115(4):483-9.

36 Feds Crack Down on Homeopathic Weight Loss Remedy. Associated Press. December 6, 2011. http://news.yahoo.com/feds-crack-down-homeopathic-weight-loss-remedy-155001085.html 37 Testicular responsiveness to hCG during infancy measured by salivary testosterone. by Dunkel L, Huhtaniemi I. Childrens Hospital, University of Helsinki, Finland. Acta Endocrinol (Copenh). 1990 Dec;123(6):633-6. http://www.ncbi.nlm.nih. gov/m/pubmed/2284888/ 38 Androgen action on the restoration of spermatogenesis in adult rats: effects of human chorionic gonadotrophin, testosterone and utamide administration on germ cell number. by Meachem SJ, Wreford NG, Robertson DM, McLachlan RI. Prince Henrys Institute of Medical Research, Monash Medical Centre, Clayton, Victoria, Australia. Int J Androl. 1997 Apr;20(2):70-9. http://www.ncbi.nlm.nih.gov/m/pubmed/9292316/ 39 Testicular response to HCG stimulation and sexual maturation in mice. by Jean-Faucher C, Berger M, de Turckheim M, Veyssire G, Jean C. Horm Res. 1983;17(4):216-21. http://www.ncbi.nlm.nih.gov/m/pubmed/6884984/ 40 Adverse effects of anabolic steroids in athletes. by Kibble MW, Ross MB. Department of Pharmacy Services, Kaiser Foundation Hospital, Redwood City, CA. Clin Pharm. 1987 Sep;6(9):686-92. http://www.ncbi.nlm.nih.gov/m/pubmed/3315401/ 41 Anabolic Steroids by Cynthia M. Kuhn. Department of Pharmacology and Cancer Biology, Duke University Medical Center, Durham, NC, USA Recent Progress in Hormone Research 57:411-434 (2002) 2002 The Endocrine Society http://rphr.endojournals.org/cgi/content/full/57/1/411 42 The Potent Synthetic Androgens, Dimethandrolone (7?,11?-Dimethyl-19-Nortestosterone) and 11?-Methyl-19-Nortestosterone, Do Not Require 5?-Reduction to Exert their Maximal Androgenic Effects. by Barbara J. Attardi, Sheri A. Hild, Sailaja Koduri, Trung Pham, Laurent Pessaint, Jean Engbring, Bruce Till, David Gropp, Anne Semon, and Jerry R. Reel. J Steroid Biochem Mol Biol. 2010 October; 122(4): 212218. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2949447/ 43 Creatine monohydrate supplementation 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;17(4):817-21. http://www.ncbi.nlm.nih.gov/m/pubmed/14636103/ 44 Effects of phenylalanine, histidine, and leucine on basal and GHRH-stimulated GH secretion and on PRL, insulin, and glucose levels in short children. Comparison with the effects of arginine. by Bellone J, Valetto MR, Aimaretti G, Segni M, Volta C, Cardimale G, Baffoni C, Pasquino AM, Bernasconi S, Bartolotta E, Mucci M, Ghigo E. Department of Internal Medicine, University of Turin, Italy. J Pediatr Endocrinol Metab. 1996 Sep-Oct;9(5):523-31. http://www.ncbi.nlm.nih.gov/m/pubmed/8961128/ 45 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. http://www.ncbi.nlm.nih.gov/m/pubmed/9876338/?i=4&from=/7608381/ related 46 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): 16211627. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC442061/ 47 Identication and molecular characterization of insulin-like growth factor binding proteins (IGFBP-1, -2, -3, -4, -5 and -6). by Shimasaki S, Ling N. Department of Molecular Endocrinology, Whittier Institute for Diabetes and Endocrinology, La Jolla, CA, USA. Prog Growth Factor Res. 1991;3(4):243-66. 48 Shimasaki S., Ling N. (1991) Identication and molecular characterization of insulin-like growth factor binding proteins (IGFBP-1, -2, -3, -4, -5, -6). Prog. Growth Factor Res.3:243266. 49 Insulin-like growth factor binding protein-1: recent ndings and new directions. by Lee PD, Giudice LC, Conover CA, Powell DR. Department of Pediatrics, Baylor College of Medicine, Houston, TX USA. Proc Soc Exp Biol Med. 1997 Dec;216(3):319-57. http://www.ncbi.nlm.nih.gov/pubmed/9402139 50http://jn.nutrition.org/content/136/1/269S.abstract?ijkey=d86f6491d65a7dd116fbd4c1fbbbf3d75b8636cd&keytype2=tf_ipsecsha Branched-Chain Amino Acids Activate Key Enzymes in Protein Synthesis after Physical Exercise Branched-Chain Amino Acids Activate Key Enzymes in Protein Synthesis after Physical Exercise 51 Branched-Chain Amino Acids Activate Key Enzymes in Protein Synthesis after Physical Exercise. by Eva Blomstrand, Jrgen Eliasson, Hkan K. R. Karlsson and Rickard Khnke. American Society for Nutrition J. Nutr. 136:269S-273S, January 2006 http://www.jssm.org/vol3/n3/2/v3n3-2pdf.pdf 52 during resistance-exercise training. by S. Nissen, R. Sharp, M. Ray, J. A. Rathmacher, D. Rice, J. C. Fuller, Jr., A. S.Connelly and N. Abumrad. J Appl Physiol 81:2095-2104, 1996. By Heath H. Himstedt, Jamie A. Hestekin, Ralph E. Martin. Department of Chemical Engineering, University of Arkansas, Fayetteville, AR, USA. ISBN13: 9780841226180eISBN: 9780841226203 Publication Date (Web): October 31, 2011 http://pubs.acs.org/doi/abs/10.1021/bk2011-1078.ch011 53 Differential effects of casein versus whey on fasting plasma levels of insulin, IGF-1 and IGF-1/IGFBP-3: results from a randomized 7-day supplementation study in prepubertal boys. by C Hoppe, C Mlgaard, C Dalum, A Vaag and K F Michaelsen. European Journal of Clinical Nutrition (2009) 63, 10761083. http://www.nature.com/ejcn/journal/v63/n9/abs/ejcn200934a.html 54 Growth hormone increases IGF-I, collagen I and collagen III 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, Guys Hospital, London, UK. Mol Cell Endocrinol. 1995 Dec 29;115(2):187-97. http://www.ncbi.nlm.nih.gov/pubmed/8824894 55 Correlation between serum levels of insulin-like growth factor 1, dehydroepiandrosterone sulfate, and dihydrotestosterone and acne lesion counts in adult women. by Cappel M, Mauger D, Thiboutot D. Department of Internal Medicine, The Medical College of Wisconsin, Milwauke, WI, USA. Arch Dermatol. 2005 Mar;141(3):333-8. http://www.ncbi.nlm.nih.gov/m/pubmed/15 781674/?i=2&from=/7608381/related 56 http://www.ncbi.nlm.nih.gov/m/pubmed/15781674/ DUPE? 57 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. http://www.ncbi. nlm.nih.gov/m/pubmed/6542576/ 58 Testosterone increases insulin-like growth factor-1 and insulin-like growth factor-binding protein. by Ashton WS, Degnan BM, Daniel A, Francis GL.Department of Pediatrics, Walter Reed Army Medical Center, Washington, DC, USA. Ann Clin Lab Sci. 1995 Sep-Oct;25(5):381-8. http://www.ncbi.nlm.nih.gov/pubmed/7486812 59 Insulin-Like Growth Factor Binding Protein-3 Is Regulated by Dihydrotestosterone and Stimulates Deoxyribonucleic Acid Synthesis and Cell Proliferation in LNCaP Prostate Carcinoma Cells. by Janet L. Martin and Stacey L. Pattison. Kolling Institute of Medical Research, University of Sydney, Royal North Shore Hospital, St Leonards, New South Wales, Australia. Endocrinology July 1, 2000 vol. 141 no. 7 2401-2409 http://endo.endojournals.org/content/141/7/2401.abstract 60 Isoavone Composition of American and Japanese Soybeans in Iowa: Effects of Variety, Crop Year, and Location. by H. Wang, Patricia A. Murphy. J. Agric. Food Chem., 1994, 42 (8), pp 16741677 http://pubs.acs.org/doi/abs/10.1021/jf00044a017 61 Goitrogenic and estrogenic activity of soy isoavones. by Daniel R Doerge and Daniel M Sheehan. Division of Biochemical Toxicology, National Center for Toxicological Research, Jefferson, AK, USA. Environ Health Perspect. 2002 June; 110(Suppl 3): 349353. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1241182/ 62 Effects of soy protein and soybean isoavones on thyroid function in healthy adults and hypothyroid patients: a review of the relevant literature. by Messina M, Redmond G. Department of Nutrition, School of Public Health, Loma Linda University, CA, USA. Thyroid. 2006 Mar;16(3):249-58. http://www.ncbi.nlm.nih.gov/m/pubmed/16571087/ 63 Isoavone supplements do not affect thyroid function in iodine-replete postmenopausal women. by Bruce B, Messina M, Spiller GA. Division of Immunology and Rheumatology, Department of Medicine, Stanford University, Palo Alto, CA USA. J Med Food. 2003 Winter;6(4):309-16. http://www.ncbi.nlm.nih.gov/m/pubmed/14977438/ 64 Studies on the Biotin-Binding Site of Streptavidin: Tryptophan Residues Involved in the Active Site. by Gerry Gitlin, Edward A. Bayer and Meir Wilchek. Department of Biophysics, The Weizmann Institute of Science, Rehovot, Israel. Biochem. J. (1988) 256,279-282 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1135399/pdf/biochemj00219-0275.pdf 65 Residual Avid in Activity in Cooked Egg White Assayed with Improved Sensitivity. by T. D. Durance. Journal of Food Science, Vol 56, #3, pp 707-709, May 1991 http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2621.1991.tb05361.x/abstract;jsessionid=1B8358944D3232733150ADF9AD 9E4F0D.d01t01 66 Dose Effect of Caffeine on Testosterone and Cortisol Responses to Resistance Exercise by C. Martyn Beaven, William G. Hopkins, Kier T. Hansen, Matthew R. Wood, John B. Cronin, Timothy E. Lowe. International Journal of Nutrition and Exercise Metabolism Vol 18 Issue 2, April http://journals.humankinetics.com/ijsnem-back-issues/IJSNEMVolume18Issue2April/ DoseEffectofCaffeineonTestosteroneandCortisolResponsestoResistanceExercise 67 Effect of Exercise on Serum Sex Hormones in Men: A 12-Month Randomized Clinical Trial. by Vivian N. Hawkins, Karen Foster-Schubert, Jessica Chubak, Bess Sorensen, Cornelia M. Ulrich, Frank Z. Stancyzk, Stephen Plymate, Janet Stanford, Emily White, John D. Potter, And Anne Mctiernan. Med Sci Sports Exerc. 2008 February; 40(2): 223233. http://www.ncbi. nlm.nih.gov/pmc/articles/PMC3040039/ 68 Serum levels of total and free IGF-I and IGFBP-3 are increased and maintained in long-term training. by L. P. Koziris, R. C. Hickson, R. T. Chatterton Jr., R. T. Groseth, J. M. Christie, D. G. Goldies, and T. G. Unterman. Journal of Applied Physiology April 1999 vol. 86 no. 4 1436-1442 http://jap.physiology.org/content/86/4/1436.full 69 Hormones and Diet: Low Insuline-like Growth Factor-I but Normal Bioavailable Androgens in Vegan Men. by NE Allen, PN Appleby, GK Davey and TJ Key. British Journal of Cancer (2000) 83(1),95-97 http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2374537/pdf/83-6691152a.pdf 70 IGF-1 and IGFBP-3 Levels in Individuals with Varied Kidney Function and the Relation to Dietary Protein Intake by San-

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3

Stamp for the Operation Planning

Piero Tesauro, MD N/A, Milano, Italy. Dr. Piero Tesauro is president of the Italian Society of Hair Restoration Surgery. He graduated from the University of Naples in 1990. He did his specialization in plastic surgery in Milan and after earning a PhD in Microsurgery in 1996 he built up his practice of hair restoration surgery with a team of six nurses. P. Tesauro: None. ABSTRACT: Introduction: The planning of a hair transplant is deeply important. The number of patients requesting high-density transplants is quickly increasing, this kinds of surgeries, whose design is more complex and elaborate, lead even the most experienced surgeons to sometimes make mistakes. It 's always been stressed that the hair transplant is a surgery that has a strong artistic component but it is also made up of many stages in which rules and standards must be put in first place. From this concept came the idea to create an innovative instrument, capable of providing surgeons essential guidelines both in the design stage and during the execution of the transplant. Objectives: The goal was the one to realize a tool able to offer a new precise and versatile method of planning, which would: accurately measure the area to be transplanted create a surgical guide for a faster and more accurate creation of the slits. Materials and Methods The instrument is a stamp with an innovative use. The stamping of the scalp can measure the area to be treated in cm2 and transfer this information to the patient so that he can understand the real dimension of the surgery that has been proposed. In the pre-operative stage the interested area will be stamped in order to create guidelines for the individual incisions that may have different densities depending on surgeons choice. The changing of density will be obtained by using interchangeable patterns created ad hoc for the purpose. The stamp has other complementary functions regarding: The length and width of the harvesting technique in strip surgeries. The grid for tricopigmentation treatment (shaved effect) to implement the naturalness of the final effect. Particular attention was given to developing different inks, easy washable or resistant to disinfectants and bleeding at the incision. The method can be applied to all patients who require intervention on bald or shaved areas.

389

Results The consequences coming from the use of this tool and its related method of work are: 1. Improving the quality of the results in gigasession 2. Save time and reduce physical and visual fatigue 3. Focusing attention on other aspects of the surgery, often underestimated, and significant reduction of disomogenities. 1) Quality improvement is the result coming from the application of precise patterns that respect the tissues of the recipient by an homogeneous distribution of perfectly equidistant follicular units. This method ensures an adequate amount of tissue around each UF capable to improve its yield. Moreover, the process prevents from making slit junctions usually caused by poor visibility. 2) The incisions are performed without the need to count as the stamp allows to calculate and program the exact number and their arrangement in advance. The visibility of the pattern in blue or black creates a contrast that can significantly reduce eyestrain. 3) The attention that the surgeon applies to obtain a homogeneous distribution of the incisions and to perform the count is shifted to other aspects of the procedure that are very important from a technical point of view and often overlooked, such as the inclination of the slits, changes in follicle direction and preservations of existing follicles. As a matter of fact, the inclination of the slits requires an observation from the lateral side which is favored by the use of this pattern. Discussion The instrument has brought significant benefits that can be equally appreciated by novice and experienced surgeons. It 's an economical, practical and handy tool, which has some obvious limitations in patients who do not wish to be shaved or in areas with multiple changes of direction (like the vertex), however still valuable in most of the operations. You might think that the application of constant patterns of slits, executed with speed, could reduce the surgeons awareness of the existing hair, whereas instead it revealed an old mistake. It is clear from the results that our excessive respect for the existing hair, specifically those highly miniaturized, has sometimes led us to dishomogeneous results, while the increased visibility provided by the stamp will allow you to choose exactly what to save without the useless attempt to preserve follicles that are destined to disappear anyway. The pattern allows to avoid many of the errors caused by repetitive movements like the lightening of the hand: when the soft pressure on the blade leads to shallow incisions it can cause problems during grafts placement. The focus of our attention on the inclination of the incisions has also revealed some details of this well-known step that are worthwhile to stress. The inclination will obviously copy that of the existing hair, however the actual route taken by our instrument depends not only on the choice of the surgeon, but also on the speed of the gesture, the thickness of the dermis and the thickness of the blade used, since we frequently have no time to observe it clearly. Conclusions In this project we started with the idea of saving time and make clear our decisions to the patient during consultations. After a few months we realized that besides reducing the fatigue and increasing the precision of our work we had in our hands a tool that can generate a new view of our technique of hair transplantation. A real opportunity to defocus - refocus the entire procedure.

390

By reducing the effort we put in some of the transplant phases we have more time to engage in other steps that require more creativity and originality. The instrument allows us to make the whole process with great precision by reducing the working hours of the whole staff. The handling of this tool, that is in our opinion a brilliant "creative standardization", will be shown during the presentation. In conclusion we think that the stamp with its various patterns and using inks represents a useful and innovative tool, that for is flexibility and simplicity, is able to achieve a breakthrough compared to other marking methods previously used. The instrument is still being patent.

391

3 Ryan Welter Hair Loss Classification

Ryan Welter, MD, PhD New England Center for Hair Restoration, North Attleboro, MA, USA. Ryan Welter, M.D., Ph.D. is an active member of the International Society of Hair Restoration Surgery. He has private practices through out Southeast Massachusetts through the Tristan Medical Network and performs hair restoration surgery at the New England Center for Hair Restoration in North Attleboro, Massachusetts. R. Welter: None. ABSTRACT: Despite the advances to date, hair transplant surgeons, clinicians and patients alike are often frustrated by the lack of a scientific standardized hair loss classification. We present a uniform standardized objective hair loss classification that covers all the different combinations and patterns of hair loss. It is time for ISHRS to adopt a clinically objective uniform hair loss classification system whether for scientific presentation, discussion, the academe or for the public in general. Our objective is a uniform standardized hair loss classification system that conforms with scientific and medical standards such as exists in other fields of medicine. Current textbooks and literature do not provide a wholly objective standard basis of hair loss classification. The discussion will review current subjective methods as they are presently employed and illustrate a new classification that is scientific, objective and easily applied to clinical practice.

392

3 Can We Do DFUs On Asians?

Wen Yi Wu, MD Taiwan Hair Transplant, Taipei, Taiwan. Wu Wen Yi, M.D. W. Wu: None. ABSTRACT: Total Follicular Unit Transplantation (TFUT) has been done for the past 15 years. Unquestionably, FUT can produce an appearance of unparalleled naturalness. Initially, however, a major complaint arose which had to do with the need for increasing hair density. In response, dense packing techniques were later developed to meet that challenge. Unfortunately, after these were implemented, contradictory results were observed in some patients. Some of those deficiencies in outcome were attributed to compromised circulation; or from the use of only extremely small-sized grafts. Considering the persistent request for higher hair density among patients, the pendulum may be swinging away from the exclusive use of FUGs toward a combination of FUGs and DFUs (double follicular units grafts). This method combines standard FUGs distributed in the periphery of the transplanted zone (like the hairline) to maintain a soft appearance and DFUs to impart strong central hair density without compromising naturalness. Using both FUGs and DFUs during a hair transplant session is referred to as Combination Grafting. DFU grafts are more rapidly dissected and require a similar amount of time to implant when compared to individual FU grafts. The key advantages for surgeons to employ this approach include increased efficiency and a greater density outcome for patients. Asians hairs are coarse, straight and have a high color contrast between the hair and scalp. All of these characteristics do not favor combination grafting due to the fear of creating a pluggy look. However, Asians can also receive a combination of the two different grafting forms when some of the following guidelines are adhered to. 1. DFUs are only used in areas where they will not be directly visible leaving the skin. The central forelock behind the hairline and midscalp are ideal places. 2. DFUs should be placed with very acute exit angles to create shingling. 3. DFUs should be placed in an interlocking pattern rather than in rows. 4. Spaces between the DFUs should be in-filled with FUGs. 5. DFUs should not be used when the goal is to create a sparse see-through look. 6. All DFUs clusters should be surrounded by FUGs along their periphery

393

7. Adequate recipient-site tumescence is critical when making these larger DFU sites because the size and depth of the blade used for their creation carry with them a higher risk of vascular damage, especially toward the midline where the blood supply can be more tenuous.

3 Genomics Comparison of Hair Follicles from Punch Biopsies, Follicular Unit Extractions, and Plucks
Bradley Wolf, MD1, Thomas Dawson2, Ben Hulette2, Ping Hu2 1 Wolf Medical Enterprises, Cincinnati, OH, USA, 2The Procter and Gamble Company, Cincinnati, OH, USA. Bradley Wolf M.D. has been treating hair loss patients since 1990. He has made over 30 lecture presentations at meetings throughout the world, was director of workshops at the 2002 ISHRS meeting , served as faculty at eight ISHRS workshops, and is the director of the Hands on FUE workshop, ISHRS meeting 2012. 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 Committee, he is a current member of the CME committee. He is ABHRS Board Certified and was a member of the Board of Directors of the ABHRS from 2000-2005. B. Wolf: None. T. Dawson: None. B. Hulette: None. P. Hu: None. ABSTRACT: Introduction: Gene chip analysis of tissue samples from clinical trial has become common and the results are routinely being used to gain a deeper understanding of changes in biologic processes which occur as a result of treatment. For genetic analysis of tissues containing hair, sample collection can vary and this variation can affect the milieu of genes which are expressed as a result of which tissues are present. To this end, we report here genomics analysis from hair follicle tissue samples collected using three differing techniques: 1micro-dissect Philpot follicles from 4 mm punch biopsies (biopsies), 2follicular unit extractions (FUEs), and 3hair plucks (plucks). An overview of histology will be presented to illustrate tissue differences among these various methods of follicle isolation. Materials & Methods: Hair bearing tissue samples were collected from 30 pre-menopausal women aged 35-50 with 40-60% gray hair in the sampling area. From the 30 subjects, 10 were self-perceived as thinning, and 20 were self-perceived as nonthinning. Five samples were collected from each subject. Within the biopsies and plucked samples, both gray and pigmented follicles were collected. FUEs were obtained from follicles which contained pigment. Samples were placed immediately in RLT Lysis Buffer. RNA was isolated according to Qiagens standard operating procedure and gene chip analysis was performed using the Illumina platform.

394

Results: Gene chip analysis from all three tissues revealed substantial overlap in the expression levels of detected genes and all tissues expressed genes consistent with common biology. The FUEs and biopsies expressed similar gene expression patterns, while plucks held demonstrably different genetic signatures. Specifically, hair specific keratins were detected in the plucks, while markers of bioenergetics and lipid metabolism were detected in the biopsies and FUEs. Markers of melanogenesis were detected from all three tissues, but the biological themes were stronger from biopsies and FUEs. Oxidative stress markers were detected by all three isolation methods, but more than half of the oxidative stress probes were expressed at a significantly higher level in FUEs and biopsies than plucks. Conclusions: Our results illustrate the importance of understanding the correlation of tissue specificity with variations in genetic expression from biopsies, FUEs, and plucks. Overall, results obtained from FUEs resembled those obtained from biopsies, whereas both of these were substantially different from results obtained from plucks. In general, we were better able to detect genes of metabolism and keratins 1,2,10 in FUEs and biopsies. In contrast, we were better able to detect lysosomal, cell junction, and hair keratin genes more readily in plucks. When comparing gray versus igmented follicles, plucks returned more significantly changed genes and biological themes, while biopsies generated fewer but relatively more clean and more focused themes. Together, our results suggest the importance of defining the different follicle sample collection methods based on the types of biological changes being examined. Hair fiber specific genes are well represented by plucks, while FUEs and biopsies are more useful in determining changes in epidermal differentiation, oxidative stress, immune function, and metabolism.

395

Genomics Comparison of Hair Follicles from Punch Biopsies, Follicular Unit Extractions, and Plucks

2012-G-128-ISHRS

Bradley R. Wolf, Xingtao Wei, Debora J. Whittenbarger, Kenton D. Juhlin, Elizabeth A. Jewell-Motz, Rachel L. Adams, Jeanette A. Richards, Jay P. Tiesman, Lin Fei, Scott M. Hartman, Thomas L. Dawson, Jr., and Ben C. Hulette

Orange F/b (follicles from biopsy Pale Blue FUE Pink Pluck

Total Keratin probes 223

FUE vs Pluck

[B] [A]

169 p<=0.05; 150 down, 119 fc <=0.8; 19 up, 11 fc >=1.25;

Figure 2. Gene expression heat map. Higher expression (red) and lower expression (green) cluster F/b and FUE, while F/p remain separate.

396

Introduction: The expansion of biotechnology tools has generated a resurgence in investigation of hair follicle biology . This includes whole transcriptome gene chip analysis of various follicle related clinical samples. The results are routinely used to gain deeper understanding of basic biologic processes and treatments. Sample collection techniques for genetic analysis of tissues relevant to hair vary considerably. This affects the milieu of genes expressed, as hair follicles are complex and contain multiple cells types which are differentially included by differing collection techniques. To this end, we report transcriptomic gene expression analysis of hair follicles isolated by common but different techniques: 1micro-dissected Philpott follicles from 4 mm punch biopsies (F/b), 2follicular unit extractions (FUEs), and 3hair plucks (F/p). An overview of histology is also presented to illustrate the differing cellular components present in each sample.
[C]

Results: Gene expression analysis revealed consistent overlap in gene expression, consistent with common biology. The FUEs and F/b expressed similar patterns, while plucks held a demonstrably different signature. Specifically, hair specific keratins were detected in F/p, while markers of bioenergetics and metabolism were more highly expressed in the F/b and FUEs.

Materials & Methods: Hair bearing tissue samples were collected from 30 pre-menopausal women aged 35-50 with 40-60% gray hair in the sampling area. From the 30 subjects, 10 were self-perceived as thinning, and 20 were self-perceived as non-thinning. Five samples were collected from each subject. FUEs were obtained from follicles which contained pigment. Samples were placed immediately in RLT Lysis Buffer. RNA was isolated according to Qiagens standard operating procedure and gene chip analysis was performed using the Illumina platform.
[D] [E]

[F]

Bradley Wolf M.D. has been treating hair loss patients since 1990. He has made over 30 lecture presentations at meetings throughout the world, was director of workshops at the 2002 ISHRS meeting , served as faculty at eight ISHRS workshops, and is the director of the Hands on FUE workshop, ISHRS meeting 2012. 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 Committee, he is a current member of the CME committee. He is ABHRS Board Certified and was a member of the Board of Directors of the ABHRS from 2000-2005.

[G] Figure 1. Physical Characterization of Different Samples. [A] 4mm punch biopsy. [B] Histology of 4mm biopsy. [C] Philpott follicle. [D] FUE. [E] FUE histology 25x. [F] FUE Histology - 100x. [G] Pluck.

Conclusions: Our results illustrate the importance of understanding tissue specificity and variations in gene expression from isolated follicles, FUEs, and plucks. Overall, FUEs closely resembled isolated follicles, whereas both were substantially different from plucks. Genes related to metabolism and keratins 1,2,10 were more strongly expressed in FUEs and biopsies. In contrast, lysosomal, cell junction, and hair keratin genes were more highly expressed in plucks. Plucks returned more statistically significant genes and biological themes Biopsies generated fewer but relatively more clean and focused biological themes. These results highlight the importance of planning sample collection based on clinical or experimental needs. Plucks primarily express genes associated with hair fiber production, while FUEs and biopsies represent more complex biology such as epidermal differentiation, oxidative stress, immune function, and metabolism. These data also imply that the components necessary to regenerate a new follicle are most likely found in isolated follicles and FUEs, but not in plucks.

3 Atrial Fibrillation and Guidelines for Perioperative Antithrombotic Therapy

Kuniyoshi Yagyu, MD Kioicho Clinic, Tokyo, Japan. Kuniyoshi Yagyu, M.D., has been exclusively practicing hair transplantation in Tokyo. He serves on the Board of Governors of the International Society of Hair Restoration Surgery, and Asian Association of Hair Restoration Surgeons. He is a Diplomate of the American Board of Hair Restoration Surgery, Past President and Board Governor of the Japan Society of Clinical Hair Restoration, and a Winner of the ISHRS Research Award in 2010. He has authored 47 research and clinical publications in books and journals. He had specialized in the field of cardiac surgery for 22 years. He is a board certified Cardiac Surgeon, Cardiologist and Respiratory Physician as well. K. Yagyu: None. ABSTRACT: Introduction: Atrial fibrillation is one of the most common arrhythmia. Sometimes patients with atrial fibrillation visit our clinic for the treatment of male pattern baldness. Patients with atrial fibrillation have a risk of ischemic stroke or systemic embolism. Especially patients with paroxysmal atrial fibrillation have increased risk of ischemic stroke and they need prestroke anticoagulation treatment. The decision of hair transplant surgery with oral anticoagulants needs to be made with caution. Can anticoagulant drug be stopped for one week before surgery? Interruption of antithrombotic drugs may cause serious ischemic stroke or systemic embolism. Objectives: According to the recent guidelines of the American Heart Association, the American College of Cardiology Foundation, etc., antithrombotic therapy should not be stopped before surgery. The update on guidelines for control of prestroke anticoagulation and perioperative antithrombotic treatment will be discussed in order to achieve safe hair transplantation in patients with atrial fibrillation. Patients & Methods: Ten hair transplant operations were performed in four patients with atrial fibrillation. Six operations were in two patients with permanent atrial fibrillation and five of them were in a patient with history of cerebral infarction, hemiplegia and speech disturbance. Four operations were in two patients with paroxysmal atrial fibrillation. Every patient took warfarin as one of maintenance drugs before surgery. Results: Maintenance warfarin was continued before surgery and prothrombin time-international normalized ratio (PT-INR) was controlled around 1.5 on the day of surgery. Safe surgery was performed without thromboembolic events or bleeding tendency in every operation. Discussion: Risk of bleeding vs. Risk of thrombosis: Risk of bleeding and risk of thrombosis should be compared in patients under antithrombotic therapy. Risk of thrombosis is low in patients with permanent atrial fibrillation, and oral antithrombotic drugs can be stopped for a few days. Risk of thrombosis is high in patients with paroxysmal atrial fibrillation. Ischemic stroke or systemic

397

embolism may lead to serious outcome. Antithrombotic drugs should be continued before hair transplantation in patients with paroxysmal atrial fibrillation. Ischemic stroke in patients with atrial fibrillation is often serious with severe brain damage. Thrombus detached from fibrillated left atrial appendage is large in size and it occludes large cerebral artery, which results in serious cerebral infarction in a wide area. This is different from ordinary atherosclerotic stroke, which will result in brain damage in a small area. This is the reason why anticoagulant drugs should not be stopped before surgery in patients with atrial fibrillation, especially in whom with a history of cerebral infarction or paroxysmal atrial fibrillation. Guidelines for Anticoagulant Drug: Warfarin (Coumadin) is commonly used as an anticoagulant drug. In the therapeutic usage of warfarin, PT-INR is controlled from 2.0 to 3.0 to prevent thrombotic events. In patients under maintenance warfarin therapy, prothrombin time should be tested before surgery. If PT-INR is between 2.0 and 3.0, dosage of warfarin can be reduced to 1/2-2/3 for three days before surgery but not longer. If PT-INR is around 1.5, we should keep the dosage of warfarin before surgery. PT-INR is kept around 1.5 in low-intensity warfarin therapy, and there will be little possibility of ischemic stroke or systemic embolism with this PT-INR. There will also be little possibility of bleeding tendency during major surgery with low-intensity warfarin. The low-intensity oral anticoagulants can be continued in the maintenance dose before surgery. Safe hair transplant surgery will be possible with low-intensity warfarin even in patients with atrial fibrillation. We dont need to stop prestroke anticoagulation before surgery. If we stop warfarin for more than 4 days, the risk of perioperative ischemic stroke will increase, which may lead to unfavorable outcome in patients with atrial fibrillation. Conclusion: Safe surgery was possible even in patients with atrial fibrillation. Anticoagulant drug should not be stopped before surgery in patients with paroxysmal atrial fibrillation. Dosage of warfarin can be reduced to 1/2-2/3 for three days and PT-INR should be controlled around 1.5 on the day of surgery. Low-intensity warfarin will not cause hemorrhagic tendency and it will prevent ischemic stroke or systemic embolism during surgery. Low-intensity warfarin should be continued before surgery in patients with atrial fibrillation.

398

Atrial Fibrillation and Guidelines for Perioperative Antithrombotic Therapy

Kuniyoshi Yagyu, MD, ABHRS (Tokyo, Japan)

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Guidelines for Anticoagulant Drug

The update on guidelines for control of prestroke anticoagulation and

both Anticoagulant & Antiplatelet combination of warfarin & aspirin, ticlopidine, etc.

perioperative antithrombotic treatment were discussed in order to achieve safe hair transplantation in patients with atrial brillation.
According to the recent guidelines of the American Heart Association, the

Risk of Bleeding

Patients & Methods

Ten hair transplant operations were performed in patients with atrial

American College of Cardiology Foundation, etc., prestroke anticoagulation and perioperative antithrombotic treatment should be continued in patients with atrial brillation.
There will be little possibility of hemorrhagic tendency and ischemic stroke during

brillation.

Six operations were in two patients with permanent atrial brillation.

Five of them were in a patient with history of cerebral infarction, hemiplegia and speech disturbance. Four operations were in two patients with paroxysmal atrial brillation. Every patient took warfarin as one of maintenance drugs before surgery.

strict anticoagulation

surgery with low-intensity warfarin and low-dose aspirin.

DISCLOSURES no op

Results

Summary

Maintenance warfarin (Coumadin) was continued before surgery.

Safe surgery was possible in patients with atrial brillation.

Low-intensity warfarin and low-dose aspirin were continued before

surgery.

These did not cause hemorrhagic tendency during surgery.

Dr. Yagyu has been exclusively practicing hair transplantation in Tokyo. He serves on the Board of Governors of the ISHRS, AAHRS and JSCHR. He is a Diplomate of the ABHRS, Past President of the Japan Society of Clinical HR, and a Winner of the ISHRS Research Grant in 2010. He has authored 47 research and clinical publications in books and journals. He had specialized in the field of cardiac surgery for 22 years. He is a board certified Cardiac Surgeon, Cardiologist and Respiratory Physician as well. The author has no relevant financial relationship or conflicts of interest to declare.

Prothrombin time-international normalized ratio (PT-INR) was controlled around 1.5 on the day of surgery. Low dose aspirin (75-300mg/day) was continued before surgery. Safe surgery was performed without thromboembolic events or bleeding tendency in every operation.

Ischemic stroke and systolic embolism were prevented during surgery.

3 High Density Implantation for Secondary Cicatricial Alopecia

Kuniyoshi Yagyu, MD Kioicho Clinic, Tokyo, Japan. Kuniyoshi Yagyu, M.D., has been exclusively practicing hair transplantation in Tokyo. He serves on the Board of Governors of the International Society of Hair Restoration Surgery, and Asian Association of Hair Restoration Surgeons. He is a Diplomate of the American Board of Hair Restoration Surgery, Past President and Board Governor of the Japan Society of Clinical Hair Restoration, and a Winner of the ISHRS Research Award in 2010. He has authored 47 research and clinical publications in books and journals. He had specialized in the field of cardiac surgery for 22 years. He is a board certified Cardiac Surgeon, Cardiologist and Respiratory Physician as well. K. Yagyu: None. ABSTRACT: Introduction & Objectives: Hair transplantation for secondary cicatricial alopecia is a challenge for many hair transplant specialists. Low density implantation is usually recommended because of poor blood flow in the recipient area. Is high density hair transplantation not suitable for secondary cicatricial alopecia? Does inadequate scalp blood supply really influence the growth of transplanted hair? Patients with secondary cicatricial alopecia and destroyed hair follicles will be happy if high density implantation becomes possible in the scarred scalp. The objective of this study was to confirm useful strategies for high density implantation in patients with secondary cicatricial alopecia. Patients & Methods: Sixty-four hair transplantation operations in 41 patients (mean age 45.211.1 years old) were performed as the treatment for secondary cicatricial alopecia. The primary causes of cicatricial alopecia were repeated artificial hair implantation with infection and inflammation in 54 sessions, burn scar in seven, and alopecia following dermatitis in three. Hair transplantation using follicular unit grafts and combination of follicular unit and double follicular unit grafts were performed. Details of the procedures were the same as usual sessions except for the low concentration of epinephrine (1:800,000) in the tumescent solution. Results: Implantation density was mainly decided by the donor amount and the area of alopecia. Low density implantation (<20 grafts/cm2) was performed in 51 sessions and the average density was 14.32.1 grafts per cm2. Slightly low density implantation (20-30 grafts/cm2) was performed in 8 sessions with average density of 24.72.9 grafts per cm2. Standard density implantation (30-40 grafts/cm2) in 1 session with density of 36.6 grafts per cm2. High density implantation (40< grafts/cm2) in 4 sessions with average density of 43.92.1 grafts per cm2. The highest density was 46.7 grafts per cm2. Results of hair growth were satisfactory in every session and poor hair growth was not observed in any case. Low concentration epinephrine did not cause a problem of bleeding during surgery. Super juice was not necessary in every case. Discussion: In the hair transplantation, hair follicular cells dont get normal blood supply immediately after the implantation. Graft ischemic time may last for several days until capillary vessels are reconstructed. Hair graft is nourished by

400

infiltration of plasma from the surrounding tissue through the outer layer of the graft into the hair follicular cells. Plasma is supernatant of blood after removal of red blood cells. Plasma contains oxygen, many growth factors and proteins. Therefore, hypothesis can be set up that hair graft placed in the scar tissue will grow, if plasma exudate is preserved in the scar tissue. The results of this study showed that hair grafts grow after standard density implantation and high density implantation in the recipient area of secondary cicatricial alopecia. Prevention of graft dislodging was important in scarred tissue. Strategies for high density implantation in the scarred tissue were as follows: 1. Injection of tumescent solution was important in the cicatricial area. Usual amount of tumescence should be injected in order to increase scalp thickness and to obtain enough depth of slits, even if injection of tumescent solution was difficult in the scarred scalp with adhesion to the cranium. 2. Epinephrine in the tumescent solution could be reduced to less than half of the usual dose, because the recipient area was poorly vascularized scar tissue. 3. Slits should be made at an acute angle in order to maintain enough depth to house grafts in scarred thin scalp. Direction and angle of adjacent slits should be kept parallel with each other. 4. Slit in the scar tissue does not dilate or contract, and the recipient tissue around the graft does not grasp the graft. Width and depth of a slit should just fit the size of a graft in order to prevent dislodging of transplanted grafts. Selection of blade size and depth control was crucial to house and keep the grafts within the slits. 5. Slits were directed parallel to the vessels under the skin in order to prevent possible injury of vessels and ischemia of the scar tissue. Sagittal slits was preferred in the front and mid-scalp areas, lateral slits in the temporal and parietal areas, and radial slits from the whorl in the vertex area. 6. Short graft ischemic time seemed to be important in the poorly vascularized scar tissue. Graft storage solution might be beneficial to better graft survival if ischemic time becomes longer. 7. Follicular unit grafts and double follicular unit grafts were used with satisfactory hair growth. 8. We should wait at least one year before the next session in order to secure graft fixation in the scar tissue. 9. In patients after artificial hair implantation, residual artificial hair in the recipient area should be removed before the hair transplantation. Oral antibiotics should be given for at least one week, and then we should wait for one to three months before the hair transplantation in order to cure persistent infection in the scalp. Conclusion: Even if there was no bleeding from slits, hair grafts grew as in the normal scalp if plasma exudate was observed from the slits in the scar tissue. Following careful strategies, graft dislodging could be avoided, and hair transplantation with standard implantation and high density implantation went successfully in the secondary cicatricial alopecia. High density implantation and standard density implantation were effective options in the hair restoration for secondary cicatricial alopecia.

401

+LJK 'HQVLW\ ,PSODQWDWLRQ IRU 6HFRQGDU\ &LFDWULFLDO 6FDUULQJ $ORSHFLD +LJK 'HQVLW\ ,PSODQWDWLRQ IRU 6HFRQGDU\ &LFDWULFLDO 6FDUULQJ $ORSHFLD Clinic, Tokyo, Japan) Kuniyoshi Yagyu, MD ABHRS (Kioicho
H igh D e n s it y I m pla n t a t io n H igh D e n s it y I m pla n t a t io n
Dermatitis (34M)
1st Session 28.9 grafts/cm2 29.4 grafts/cm2 58.3 grafts/cm2 1st Session 41.2 grafts/cm2 2nd Session Total

H igh D e n s it y I m pla n t a t io n
Injury (33M)
1st Session 44.7 grafts/cm2

M iddle D e n s it y I m pla nt a t io n
Burn Scar (54F)

M iddle D e n s it y I m pla n t a t io n
Artificial Hair Implant (4x) (28F)
1 st Session 2 nd Session 3 rd Session Total 26.5 grafts/cm2 24.6 grafts/cm2 29.4 grafts/cm2 80.5 grafts/cm2

Injury (32F)

1st Session

40.9 grafts/cm2

2nd Session

44.3 grafts/cm2

Total

85.2 grafts/cm2

before before 1st session before 1st session

1st session 2nd session before 1st session 2nd session 3rd session

before

1st session

2nd session

Aims

Density
S e c o nda r y C ic a t r ic ia l (S c a r r ing) A lo pe c ia
(grafts/cm2)

The objective of this study was to conrm useful strategies for high density implantation for secondary cicatricial alopecia with poor blood supply.

, 03 / $ 1 7 $ 7 , 21 '( 1 6 , 7 <
cicatrical alopecia artificial hair
Results
In patients with wide area of alopecia, only low density implantation was possible because of limited donor amount. In patients with small area of alopecia, high density implantation was performed, if enough amount of donor was available.

Pearls to Achieve Successful High Density Implantation in the Scar Tissue Prevention of graft dislodging is crucial.
1. To obtain enough depth of slits, injection of tumescent solution was important even in the scarred scalp with adhesion to the pericranium. 2. Acute angled slits maintained depth to house grafts.

Patients:120 hair transplant operations in 98 patients (mean age 45.211.1 years old)

80

Causes: 51 Articial Hair Implantation 36 Injury 14 Burn scar 19 Unknown

The lesion should not be active, and the alopecia should be stable for more than 2-3 years.

60

402
40 20 0 20 40 60 80 100 120 L o w D e n s it y I m pla nt a t io n
Burn Scar (61F)
1st Session 14.8 grafts/cm2 9.9 grafts/cm2 12.8 grafts/cm2 2nd Session 3rd Session

Summary

Even if there was no bleeding, hair grafts grew if plasma exudate was observed from the slits in thescar tissue.

Following careful strategies, graft dislodging could be avoided.

Implantation with density higher than  grafts/ was performed in  sessions. Implantation density higher than  grafts/ in  sessions. The highest density was  grafts/. Hair growth was satisfactory in every session. All patients were satised after the high density implantation, and none of them complained of poor hair growth.

High density and standard density transplant were eective options for secondary cicatricial alopecia.

3. Scar tissue does not contract nor grasp the graft. Width and depth of slits should just t the size of grafts. Selection of blade size and depth control was crucial to house and keep grafts within slits. 4. Direction and angle of adjacent slits were kept parallel.

Hypothesis

Plasma is supernatant of blood after removal of red blood cells.

Plasma contains oxygen, many growth factors and proteins.

Therefore, hypothesis can be set up that hair graft will grow even after high density implantation, if plasma exudate is preserved in the scar tissue.

5. Direction of slits should coincide with that of subcutaneous vessels to avoid vessel injury. Sagittal slits in the front and mid-scalp areas. Lateral slits in the temporal and parietal areas. Radial slits in the vertex area.

Hair Graft Revascularization in the Normal Scalp

(D. Perez-Meza, Hair Transplant Forum Int l. 2007: 17(5): 173-5)

140
Alopecic Area
(cm2)

6. Wait at least one year before the next session.

L o w D e n s it y I m pla nt a t io n
Burn Scar (56M)
1st Session 16.8 grafts/cm2

L o w D e n s it y I m pla nt a t io n
Artificial Hair Implant (20x) (41M)
1 st Session 2 nd Session Total 13.2 grafts/cm2 15.0 grafts/cm2 28.2 grafts/cm2

1. Plasmatic Imbibition Phase (1-3 days postop.) Plasma inltration; 2. Primary Inosculation Phase (3-7 days) Early capillary revascularization; Inadequate blood supply 3. Secondary Inosculation Phase (7-14 days) Capillary vessels reconstruction; Nearly normal blood supply

Capillary vessels are not anastomosed in the hair transplantation. Hair follicular cells don t receive normal blood supply for several days after the graft implantation.

DISCLOSURES
Dr. Yagyu has been exclusively practicing hair transplantation in Tokyo. He serves on the Board of Governors of the ISHRS, AAHRS and JSCHR. He is a Diplomate of the ABHRS, Past President of the Japan Society of Clinical HR, and a Winner of the ISHRS Research Grant in 2010. He has authored 47 research and clinical publications in books and journals. The author has no relevant financial relationship or conflicts of interest to declare. This study was supported by the ISHRS Research Grant in 2010.

Hair graft is nourished by plasma, which inltrates from the surrounding tissue through the outer layer of the graft into the hair follicular cells.

before
before 3rd session 3rd session

Hair graft survives in the warm ischemia without blood supply until capillary vessels are reconstructed at about one week after the implantation.

1st session
before 1st session 2nd session

3 Asian Female Hairline Surgery Using Follicular Unit Extraction

Sung-Jae Yi, MD Supervising doctor, hair transplantation centre, Mojelim Hair Transplantation Centre, Seoul, Korea, Republic of. Sung Jae Yi, M.D. is a supervision doctor in the Mojelim Hair Transplantation Center(Seoul, South Korea) since 2007. He graduated from KyungPook National Univ.,(DaeGu, South Korea) and completed a residency in plastic surgery at Daegu Catholic Univ. medical center(DaeGu, South Korea). He is a member of the ISHRS, ABHRS, AAHRS(Asian Association of Hair restoration surgery), KSPRS(Korean Society of Plastic and Reconstructive surgery) and KSHRS(Korean Society of Hair Restoration Surgery). S. Yi: None. ABSTRACT: Introduction: Follicular Unit Extraction(FUE) is now used popularly for hair restoration surgery. There are several benefits in this technique: Almost no noticeable postoperative donor scar , short down time, easy to sort out projected specific hair follicle(e.g thin single hair follicular unit only or double hair follicular unit only). Most of FUE cases are male cases, especially for restroration of male pattern hair loss. But recently the proportion of female hairline surgery by FUE is increased due to aforementioned advantages of this method. Of course, there are several limits or pitfalls which surgeon have to keep in mine in introducing FUE for Asian female hairline surgery Author will present how to get optimal operative result and several pitfalls and limitations associated with using FUE for Asian female hairline surgery Objective: To present specific features of Asian female hairline surgery, especially for patient with thick, stiff and coarse hair and surgical techniques and tips which are needed for harvesting, trimming of harvested hair follicles, implantation of graft in appropriate angle. Materials and/or Methods: Between July 2009 and November 2011, 64 female hairline surgery were done using FUE. All of these cases were Korean female cases and the age was between 22 to 76. Main purposes or demands of patients were 1. Lowering hairline(because higher hairline looks like older or bigger of the face) 2. To have more round hairline( patients with acute fronto-tempolar angle or with regression in the fronto-tempolar triangular area) 3. Shortening distance between both temple area 4. Combination of above 1,2,3

403

Harvesting of donor hair was done using electrical follicular unit extraction equipment which rotating punch with electrical motor. Most cases of donor area were shaved usually micro-strip pattern (width 2-3mm) exception of 3 cases( this exceptional cases were shaved wide shave window pattern). 1mm and 0.82mm micro-punches were used according to patients hair characteristics and rotation of micro-puches were continous clockwise rotation. Extracted hair follicles sometimes were needed extra trimming of epidermis or dissection of 2 or 3hair-follicular unit to single hair follicles for most anterior area of recipient site. Hairline design was done with 3 steps: 1. Drow guideline with solid line pattern 2. Make irregularity on guideline with serration pattern(which include lateral peaks and areas for scattering with very thin or vellus hairs). 3. Marking for scattering area which area were implanted by using vellus hairs or very thin single hairs. Creation of slit were done with hypodermic needle. 21- guage hyperdermic needle was used in the creation of the slit for single hair follicle and 20- guage for double hair follicular unit. Insertion of graft into the pre-made slit site was done by using Choi-needle or forceps. EGF(Epidermal growth factor) was applied on recipient site and donor site both for prompting wound site healing. Discussion/result There is a belief that some pitfall and limitations associated in FUE method made physicians to be reluctant in using FUE method to the Asian female hairline surgery. Most concered factor is: The harvested hair follicles by FUE are usually very short cut hair in the length of 1-2mm which make difficult for surgeons to estimate precise curl direction of hair when implantating graft which is critical, especially for Asian female case, for satisfactory operative result in the area of the recipient site. Authors opinion is somewhat different with general belief. Authors can confirm through this research that insertion angle which is usually decided during creation of slit is more critical part compared with naturally occurring curl direction of hair shaft, and short cut hair of harvested hair follicle dont make any different for this step. Because Asian female patients usually have stiff and thick hair shaft, mistakes in the direction of graft make noticeable and aesthetically un-acceptable result. But authors can find out that the direction of implanted graft which were decided in the step of the creation of slit is the most important and critical and there was weak relationship between curl direction of graft itself and satisfactory operative result. Authors believe that several key points in the Asian female hairline surgey for optimal operative result are: 1. Acuate angle between the direction of slit(or the direction of graft implantation) and scalp surface(usually within 15 degrees). 2. Use of the very thin single hair follicle exclusively in the most anterior area of recipient site and the dimension of single hair follicle implanted is relatively wider than that of male cases. 3. Design of hairline in shape of the serration form pattern and make appropriate scattering zone

404

4. Very thin or vellus hair follicle are sorted out and used in the scattering zone. 5. Dense paking with single hair follicle ,especially most anterior part, is better compared with using double or triple hair follicle whick can be result in barbie dolls hair appearance which is most scared result in the Asian female hairline surgery

405

406

3 Scar Repair For A 16 Year Old Male Patient Using FUE
Georgios Zontos, MD, Catherine Davies, MD ZD Hair Clinic, Johannesburg, South Africa. Dr Georgios Zontos has studied Medicine and Physics at the University of Patras and he holds an M.Sc degree in Medical Physics. e has been working on the field of Hair Restoration since 2002 and he is the medical director of Hair Restoration Clinic - Haarkliniken in Copenhagen, Scientific consultant of GHR Global Hair Restoration Company in Nicosia, and Scientific Consultant of Z.D Hair Restoration Clinic in South Africa. His research interest is being focused at the moment in mathematical models of FUE Hair Transplantation and how the application of physical principles and the contribution of advanced mathematics are able to improve important issues like extraction ,density ,optimal distribution of hair follicles and mathematical prediction of hair growth. G. Zontos: None. C. Davies: None. ABSTRACT: Objective: A 16 year old South African male patient visited our clinic presenting with a big scar on his head ,which was caused by surgical removal of hairy congenital nevus.(picture 1,2) -From the medical history of the patient we learned that he underwent serial excisions in order for the lesion to be removed . (5 operations in total).The first one took place when the patient was 4 months old ,the last one took place on 2009 ,and the others inbetween. In 2011 the patient was examined by our medical team ,and we decided to restore his scar using FUE hair transplantation method . Material and Methods: -The scar was located in the middle of the back of the head and its surface was about 20-22 cm2.As we can see the scar is long and narrow. That means the blood circulation around the scar was normal. The elasticity of the recipient was characterized as very low. Using FUE method we extracted from the healthy donor area 509 hair follicles , which corresponds to 1535 hairs .The ratio of the extraction was 3.02 which means that on average each hair follicle corresponds to 3 hairs .The recipients sites were made using blade 0.9mm and all of them were lateral .At this point we should mention that the depth of the recipient sites penetrated the layer of the scar tissue. For the placement we used implanters. The average density which was achieved was about 70 hairs per cm2. The procedure was completed in 3 hours without complications. Discussion: Many methods have been used for scar restoration for example surgical reduction, excision with or without expansion of the skin ,hair transplantation or combination .The first 2 are invasive ,and the third one does not usually offers the best cosmetic result because the hair growth is sometimes very poor. The main reasons are the poor circulation of scar tissue and the depth of the scar. This is the reason that many surgeons prefer to use an invasive technique instead of using hair transplantation for scar cases. On the other hand strip method it is not a scar free method as it is invasive as well. But FUE it is not only a minimally invasive technique but is repeatable .That means the patient can more easily accept a second session in order to achieve an acceptable cosmetic result.

407

Results and Conclusion: The result of the patient as we can see after 9 months is excellent.The difference of optical density between normal and transplanted area is very small.(picture3). We believe that the FUE is the best choice for narrow scar covering because it is a minimally invasive method ,can be repeated many times ,and protects the patient from the bad experience of a new surgical excision . We believe strongly that the depth of the recipient sites must penetrate the layer of scar tissue in order the hair follicles to develop successful circulation. According to our opinion density higher than 70 hairs per cm2 increases the risk of failure and does not offer so much to the cosmetic result.

408


 
  



 
 
        

 
     
 
   

 

  
    

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409

16
410

AUTHOR INDEX
Faculty, moderators and panelists for the General Session and Posters are listed with corresponding Abstract Number. All contributing authors of abstracts are also listed. A bold Abstract Number indicates the presenting author.

Abbasi, G.; Afonso, A.; Ahmed, D.; Ahn, J.-S.; Alajlan, A.; Andrade, E.; Arocha, B. A.; Avram, M. R.; Bang, J.; Barusco, M. N.; Batt, M.; Bauman, A. J.; Beehner, M. L.; Bernstein, R. M.; Bhalerao, N.; Bhatti, T.; Bishara, M. A.; Boudjema, P.; Cole, J. P.; Cooley, J. E.; Cotsarelis, G.; Cotterill, P. C.; Crisstomo, M.; Dae-young, K.; Davies, C.; Dawson, T.; Dhepe, N.; DiStefano, M. S.; Donovan, J. C.; Dua, A.; Dua, K.; Ehringer, W. D.; Ehrlich, D.; Epstein, E. S.; Epstein, J. S.; Farjo, B.; Freedland, S.; Gambino, V.; Gandelman, M.; Garg, A. K.; Garg, S.; Garza, L. A.; Gaviria, J. I.; Ginzburg, A.; Giotis, C. P.; Green, R.; Haber, R. S.; Harris, J. A.;

101 P07 P19 P01 024 P08 097 076, 119 P02 005 099 P03 007 019, 033 P09 112, 131, P04, P05 115 081 010, 048, 079, 089, 104, 127, P06 123 068 027, 054, 095 133, P07, P08 130 P38 008, P34 P09 028, 090 072, 072, P10 109, P11 109, P11 093 067 025, 030 012, 057, 060 053 022, 037 041 096 136 136 068, 091 P12, P13 100 114 115 075, 085 047, 088

Hu, P.; P34 Hubka, M.; 067 Hulette, B.; P34 Hwang, S.; 044, 052, 054, 054, P14, P14 Jebai, K. I.; P15 Jimenez, F.; 001, 061 Jimenez, J. J.; 074 Kahnamuee, H.; P16 Keene, S. A.; 021, 077, 105, 121 Khan, S. H.; 124 Kim, J.; P17 Kim, M.; P17 Knudsen, R. G.; 129 Kulahci, M. F.; P18 Kwack, M.; P01 Lam, S. M.; 046 Leonard, R. T.; 039 Leonhardt, K. B.; 032 Lindner, G.; 066 Lorenzo, J. F.; 034, 084, 107 Mangubat, E.; 029, 042 Martinick, J. H.; 002, 058 Marzola, M.; 103 Mayer, M. L.; 004, 031 McAndrews, P. J.; 069 Moh, J.; 137 Mohebi, P.; 015, 113 Mohmand, M. H.; P19 Morales De Bournigal, M.; P13 Morgan, B. A.; 003, 035, 064 Naughton, G. K.; 067 Neidel, F. G.; 032, 043 Ng, B. M.; 055, 078, 102, P20 Niedbalski, R.; 070 Nogueira, K.; P08 Nusbaum, B. P.; 059, 128 Oc, K.; 014, P21, P22 Oh, J.; P17 Panchaprateep, R.; 006, P23 Park, J.; 137, P24 Parsley, W.; 073, 126 Pathomvanich, D.; 009, P25 Paus, R.; 062, 063, 092 Perez-Meza, D.; 026 Pitchon, M.; 125 Poswal, .; 134 Poswal, A.; 017, 108, 134, P26 Prabhune, K.; P09 Puig, C. J.; 116

411

Author Index (continued)

Radwanski, H. N.; Rajput, R. J.; Rashid, D. N.; Rashid, M. N.; Rassman, W. R.; Reed, W. H.; Rinaldi, F.; Rodriguez, K.; Rogers, N. E.; Rose, P.; Ruston, A.; Sato, A.; Shapiro, L.; Shapiro, R.; Stough, D. B.; Sung, Y.-K.; Takeda, A.; Tesauro, P.; Tomaz, D.; Toyoshima, K.-E.; 011 P27 056 P28 071, 106 122 087 115 050 016, 059 013 023, P29 049, P30 094 018, 038, 120 P01 023, P29 P31 133, P07, P08 P29 Trivellini, L. R.; True, R. H.; Tsuji, T.; Umar, S.; Unger, W. P.; Vasa, S. A.; Vila, X.; Washenik, K.; Welter, R.; Wen Yi, W.; Williams, K. L.; Wolf, B. R.; Wu, W.; Yagyu, K.; Yamamoto, K.; Yi, S.-J.; Ziering, C. L.; Zimber, M.; Zontos, G.; 080 118 P29 082 040 098 107 020, 036, 065 P32 051 135 008, 083, 111, P34 117, P33 P35, P36 086, 132 P37 045, 067 067 110, P38

412

TOPIC INDEX
Artistry and Aesthetics: 013, 015, P13 Avoiding poor graft growth: 054 Basic science update: 003, 035, 062, 064, 068, 091, 121, 127, P01, P29, P34 Complications: 052, 073, 119, 120, P14, P20, P25, P35 Consultation and Evaluation: 128, P10, P27, P31 Density issues: 010, 126, P06 Donor harvesting and donor closure: 047, 083, 101, 105, 107, 110, 130, 131, 132, P09, P12, Endocrinology of hair loss: 049, P30 Flaps, reductions, expansion: 029, 032, 042, 043 Graft preparation, survival and growth: 006, 093, 112, 113, P16, P17, P19 Hair cloning, duplication, and growth factors: 066, 067, 070, 123, P18 Hair loss in women and ethnic variations: 008, 012, 024, 031, 095, P04 Hairline and Crown design: 014, 044, 055, 094, P24 Instrumentation: 016, 033, 081, 090, P22 Marketing and internet issues: 046, 099 Non-surgical or medical therapies: 019, 021, 022, 023, 025, 037, 039, 050, 069, P03, 065, 071 Other: 001, 002, 004, 005, 017, 018, 020, 026, 028, 030, 038, 040, 041, 045, 048, 051, 058, 061, 063, 074, 075, 076, 077, 087, 088, 089, 092, 097, 098, 100, 102, 103, 104, 108, 116, 117, 122, 124, 125, 136, P05, P08, P15, P26, P32 Post-operative issues: 009, 072, P23 Recipient site techniques: 007, 056, 086, 137, P21, P28, P33, P36 Surgical techniques: 011, 027, 034, 036, 053, 057, 059, 060, 078, 079, 080, 082, 084, 085, 096, 106, 109, 111, 114, 115, 118, 129, 133, 134, 135, P02, P07, P11, P37, P38

413

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414

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