October 18–22, 2006
More than 400 physicians from around the world attended the International Society of Hair Restoration Surgery (ISHRS) 14th annual scientific meeting in Coronado, Calif, in October. The meeting offered continuing medical education credit and included lectures, workshops, and hands-on training with cadaver scalp tissue and live surgery observations.
The opening session featured a presentation by Ralf Paus, MD, vice chairman of the department of dermatology at the University of Lubeck, Germany. Paus’ presentation described the molecular signals that turn hair growth on and off and described the molecular targets for future hair drug development. Paus said that topical agents modulating hair growth may be potential new treatments, but actual clinical application appears to be a long shot at this time.
Maria Siemionow, MD, DSc, director of plastic surgery research at the Cleveland Clinic Foundation, discussed composite face and scalp allograft transplantation and the impact of ischemia-reperfusion injury on free tissue transfers, and tolerance-induction protocols for allotransplantation. During her presentation, Siemionow also discussed her 20 years of research experience in the field of composite tissue allografts, as well as the intravital microscopy system for direct in vivo observation of microcirculatory changes in composite allograft transplants.
A panel on optimizing density and growth by Jerry Wong, MD, of Vancouver, British Columbia, Canada, and Ron Shapiro, MD, of Minneapolis, focused on the trends toward long sessions for transplanting 4,500 to 6,000 follicular units and high recipient-site densities of 50 to 60 sites per square centimeter. They also presented a study that found that follicular- unit grafts that are stripped of excessive surrounding tissue (“skinny grafts”) grow as well as grafts that have been dissected to contain more surrounding tissue. The use of skinny grafts facilitates graft placement into small recipient sites, which in turn can be created at higher densities.
Stephen Artandi, MD, PhD, assistant professor of medicine at Stanford University, presented a talk on cell therapy and biotechnology and the role of telomerase in follicular stem-cell proliferation. According to Artandi, telomerase serves a key function in preventing telomere shortening, which is associated with a cell’s inability to continue replicating. Artandi’s research in a mouse model showed that TERT, the protein catalytic subunit of telomerase, stimulates the replication of hair-follicle stem cells and induces resting follicles to enter an active growth phase. These findings may be applicable to ongoing studies on cell-based hair-restoration procedures (hair cloning).
Robert Reese, DO, of Minnetonka, Minn, and David Perez-Mesa, MD, of Heathrow, Fla, presented their independent findings on the use of autologous platelet factors in hair restoration. Their results showed that healing time is shortened; additional studies are being performed to evaluate the effects of platelet factors on hair growth in transplanted follicles.
Dow Stough, MD, of Hot Springs, Ark, presented a study on medical therapy with oral dutasteride in 17 pairs of identical twin males with androgenetic alopecia. In this randomized, double-blind, placebo-controlled study, dutasteride at a dose of 0.5 mg per day significantly improved hair growth at 1 year compared to a placebo. Of the 16 sets of twins who completed the study, observers correctly predicted which twin was receiving the active drug in 15 of the cases. This study provides evidence that dutasteride significantly reduces hair-loss progression in men with pattern hair loss.
Sungjoo Hwang, MD, PhD, of Korea spoke of elucidating recipient-area influences on transplanted hair. Axillary hair transplanted to the frontal area grew longer than in its original site, and scalp hairs transplanted to the lower leg and then retransplanted to the occipital scalp showed growth-rate changes influenced by the recipient site. Hwang notes that these findings have significant impact on the field of hair restoration, which has, as its basis, donor-area dominance. As body-hair-to-scalp transplants gain popularity, recipient-site influences will need to be assessed with increasing scrutiny.
Robert True, MD, of New York City presented his concept of the torso donor index (TDI), which facilitates patient selection for torso-to-scalp hair transplantation. The TDI takes into account chest-hair characteristics such as density, texture, percentage of two- and three-hair follicular units, surface area, and hair length. A composite score that can distinguish among excellent and marginal candidates and noncandidates for torso-to-scalp hair transplantation is tabulated.
James Harris, MD, of Denver presented methods and instrumentation for follicular-unit extraction. His serrated-tip punch allows single-step dissection of follicular units with a maximum extraction rate of approximately 400 grafts per hour in his hands. Graft burial rates varied from 2% to 10% depending on the scalp location, and the average transection rate ranged from 2.8% to 4%.
The Donor Strip Harvesting Panel focused on studies that evaluate trichophytic closure of the donor area. The closure technique involves de-epithelialization of a 1-mm edge of the upper or lower wound flap with the goal of redirecting the de-epithelialized follicles to grow through the scar.
Frank Neidel, MD, of Germany described his double-blind study of 100 patients treated with conventional versus trichophytic closure (trimming the lower edge) with excision of strips of 1 cm or less wide. The study concluded that the trichophytic technique was superior to standard closure with regard to scar width and overall appearance of the scar. Mohammad Mohmand, MD, of Pakistan presented his study of 150 procedures that involved excision of wider strips to a maximum of 2 cm, again showing the aesthetic advantage of the trichophytic closure technique.
The ethnic panel led by Damkern Pathomvanich, MD, of Thailand, opened with a talk describing pearls for transplanting Asian patients. Highlights of Pathomvanich’s talk included the need for a larger number of single-hair grafts at the hairline, the general desire for rounder frontotemporal angles, which require impeccable control of hair direction, and the need for tension-free closure in the donor area due to Asians’ propensity to form keloids.
Kyle Seo, MD, of Korea described the combination of follicular-unit hair transplantation with a hair-removal laser to make a more natural hairline in Asian females. The technique involves a long-pulsed Nd:YAG laser at a short pulse duration and low power settings to create finer-looking hairs at the hairline zone.
In her presentation on hair transplantation in women, Jennifer Martinick, MBBS, of Australia described her technique for eyelash transplantation using overlapping coronal slits. Eyelash transplantation is generally requested by patients who have suffered from trichotillomania, as well as by Asians who generally have little body hair. The technique involves transplanting 60 to 75 hairs into each upper eyelid and 45 to 60 hairs into each lower eyelid.
The Scalp Dermatology and Hair Loss Diagnosis Panel, led by Thomas L. Dawson Jr, PhD, principal scientist at Proctor & Gamble Co, featured a lecture on hair cosmeceuticals. The lecture focused on the recognition of aesthetic hair disorders and identified appropriate pharmacology to mitigate aesthetic hair problems. The goal was to better inform physicians that they can counsel patients on effective aesthetic therapeutic strategies.
Andreas Finner, MD, of the Department of Dermatology, University of British Columbia, Canada, described the use of digital imaging to make hair-density measurements by evaluating hair-transplantation results. Bernard Cohen, MD, of Coral Gables, Fla, described his technology using a handheld device to measure hair mass in an office setting. The device measures the cross-sectional area of all the hair in a 2-cm x 2-cm area of scalp, and results in a score that will be called the hair-quantity index or the density-diameter index.
In the panel on revisions and repairs, Bradley Wolf, MD, of Cincinnati described the use of permanent subepidermal gold sutures to remove and prevent the recurrence of wide donor scars. When patients treated with subepidermal metal sutures were compared with those that were treated with 3-0 polyglactin, narrower scars were seen in the gold-suture-treated patients. A patient must have sufficiently thick skin and subcutaneous tissue to be able to fully bury and cover the knot of the metal suture. The application for US Food and Drug Administration approval of the gold suture is pending.
A panel led by Wong described a six-blade handle to create lateral slits. According to Wong, the handle that holds the blades has a spacing that creates sites 40 to 45 slits per square centimeter. The use of this device makes dense packing for large sessions quicker and ergonomically superior.
Marcelo Pitchon, MD, of Brazil described his technique for performing long-hair follicular-unit transplantation. Pitchon notes that the technique involves leaving the donor hair grafts long and transplanting them to the recipient area. At the end of the procedure, the patient can see a preview of how the hair transplant will look. This preview is temporary because, as in traditional hair transplantation, the transplanted hair will gradually fall out 2 to 6 weeks after the procedure.
Pitchon advocates his technique based on the positive emotional impact that it provides for the patient immediately after the procedure. In addition, the visibility of the crusting postoperatively is almost eliminated by the camouflage provided by the long hair.