Highlights from the 2012 ISHRS (International Society of Hair Restoration Surgery) Scientific Meeting in the Bahamas
Each year, the publishers of the Hair Transplant Network bring you highlights from the annual International Society of Hair Restoration Surgery (ISHRS) scientific meeting. This year, hair restoration physicians, medical assistants and others in the hair restoration profession from around the globe came together in Paradise Island (the Bahamas) to discuss the latest advancements in medical and surgical hair loss treatments.
It’s virtually impossible to cover all topics discussed at each year’s ISHRS meeting. Thus, below we’ve presented topics that we felt hair loss sufferers would find most interesting and relevant.
Due to the increased patient demand for FUE and advancements made over the last several years, approximately 50% of this year’s meeting was devoted to discussing the evolution and current techniques in follicular unit extraction (FUE). This includes comparing advanced FUE to the traditional “strip harvesting” method of follicular unit hair transplantation (FUT). Other hot topics include updates on hair duplication (autocloning) and ACell, robotic assisted hair transplantation using the ARTAS Hair Restoration System, hair multiplication (HM), scalp micropigmentation (SMP) and the safety and efficacy of Propecia (finasteride).
The below highlights from this year’s conference come from presentations and interviews with recommended hair restoration physicians Dr. Parsa Mohebi, Dr. James Harris, and Coalition members Dr. Damkerng Pathomvanich, Dr. Jerry Cooley and Dr. Robert True. A special thanks to these expert physicians for providing this community with their feedback on the latest innovations discussed at the 2012 ISHRS meeting.
Background on the ISHRS
The primary mission of the ISHRS (International Society of Hair Restoration Surgery) is to educate hair surgeons ranging from the beginner to the master. It is by far the most prominent hair restoration professional organization in the world and the host of the five day annual scientific meeting. Their website (www.ISHRS.org) provides useful information about hair restoration and profiles and contact information for its 700 plus worldwide physician members.
At the meeting, Dr. Carlos Puig replaced Dr. Jennifer Martinick as the acting President of the ISHRS for the coming year. Congratulations to Dr. Puig for receiving this high honor.
Physician Recognition and Awards: The “Golden” and “Platinum” Follicles
The “Golden” and “Platinum” follicle awards are the highest honors given to leading surgeons in hair restoration by the ISHRS at each meeting. These awards recognize outstanding achievement in basic clinically-related or scientific research in hair pathophysiology or anatomy as it relates to hair restoration.
Congratulations to Coalition physicians Dr. Nilofer Farjo and Dr. Bessam Farjo of London, England who together were awarded the Platinum Follicle and Dr. Carlos Puig of Houston, Texas who received the Golden Follicle.
Congratulations as well to Dr. Marcelo Gandelman for winning the coveted Manfred Lucas Award for his many contributions to the advancement of physician and staff education.
This year, the Distinguished Assistant Award went to Tina Lardner for her unparalleled dedication to teaching hair restoration assistants from around the globe the surgical “best practices” for optimal patient outcomes. Tina has worked with Dr. James Harris at Hair Science Center in Colorado for 16 years.
To learn more about these prestigious awards and to congratulate highly esteemed physicians and their staff visit the Q&A blog articles below:
Presentations at the ISHRS meeting of particular interest to Hair Loss Sufferers
Follicular Unit Extraction (FUE) versus Follicular Unit Transplantation (FUT)
The debate regarding which of the two revolutionary hair transplant techniques (follicular unit extraction FUE or follicular unit transplantation FUT) is best continues to be a hot topic among hair restoration patients and physicians alike. While the less invasive FUE is highly coveted among prospective hair transplant patients for its minimal scarring and fast healing, surgeons remain divided when it comes to graft viability as compared to FUT.
This year, the ISHRS established its FUE Science Committee with the purpose of improving FUE hair transplants through scientific research and education. The committee contains 3 subcommittees and 16 members that will be reviewing articles, standardizing terminology and planning for future studies to enhance the quality and effectiveness of FUE procedures.
At present, FUE seems to be more common among hair restoration physicians in Europe and Asia while, in the United States, FUT is still the procedure of choice for many leading physicians. Dr. James Harris (amongst many other leading hair transplant surgeons) feels that follicular unit extraction, when done right can produce results on par with today’s strip harvesting procedures.
Dr. Wen Yi Wu feels that while FUE has increased in popularity and has improved substantially over the last couple of years, FUE has inherent problems that may produce suboptimal results. Problems Dr. Wu presented include but are not limited to increased risks for transection, desiccation (dehydration), splayed follicles and an increased difficulty in handling the grafts. Dr. Wu also presented several advantages and other disadvantages of both FUE and FUT. He believes that FUE will only replace FUT if and when there is a unanimous consensus amongst hair restoration physicians that results produced by FUE are better than FUT. At this point, FUT remains the gold standard in hair restoration while FUE continues to evolve and improve. In conclusion, Dr. Wu believes that both FUT and FUE have a place in hair transplant surgery and will continue to peacefully co-exist.
Coalition member Dr. Robert True followed up with a brief commentary on Dr. Wu’s lecture. Dr. True congratulated Dr. Wu for giving a realistic and sound appraisal on where we are today with follicular unit extraction procedures. Dr. True agrees that the popularity of FUE is growing at a rapid rate even faster than traditional FUT. He is particularly struck by the reality that a number of the surgeons taking the ABHRS (American Board of Hair Restoration Surgery) board exams in Korea this year were only familiar with the FUE procedure. He also commented on the reality that there are certain parts of the world that now only offer follicular unit extraction. Dr. True recognizes that some of the most impressive FUE results have generated a lot of enthusiasm. However, he firmly believes that some of the enthusiasm may be a bit over-exaggerated when you consider the inconsistency of FUE results across the board. In conclusion, Dr. True feels that the focus of hair transplant surgeons at this point should be on how to produce the best FUE results across the board with minimal donor impact, donor optimization and optimal growth yield.
Dr. Parsa Mohebi also presented test results on the viability of FUE grafts when extracted over a period of time on 3 patients. In this study, FUE grafts were initially punched and then removed in 5, 30, 60 minutes and 4 hours. Dr. Mohebi states:
“This study was the only study conducted to compare the in-situ viability of the follicular unit grafts. The study showed that keeping the punched grafts in the scalp longer than a few minutes may decrease the survival of the grafts. The results of this study may help the design of the next generation FUE devices and robotic surgery in order to be more efficient with the time that grafts are punched and before they could be removed from the scalp.”
Most leading surgeons agree that more scientific data and evidence is required before concluding that FUE results are as consistent as FUT. Ultimately, it seems apparent that both FUT and FUE will continue to play a significant role in today’s surgical hair restoration for a long time to come.
Robot Assisted Hair Transplantation
The FDA approved ARTAS Hair Restoration System for automating the extraction process of the follicular unit extraction (FUE) procedure was first introduced for sale last year and was quickly put into practice by a number of world-class hair restoration physicians including; Dr. James Harris, Dr. Robert Bernstein, Dr. Jerry Cooley and Dr. Hussain Rahal. The ARTAS attempts to standardize the FUE hair restoration procedure by increasing the speed of extraction (allowing for larger single sessions) while automating the surgical process.
Dr. Harris was the first physician to purchase the ARTAS. To read more about his acquisition and opinion of this revolutionary device, visit “Dr. Jim Harris Purchases the First ARTAS Hair Restoration System for Automating the Follicular Unit Extraction (FUE) Hair Transplant Procedure“. To read an exclusive interview with Dr. Harris about this device, visit “Dr. Harris Answers Critical Questions about the ARTAS Hair Restoration System for Automating the FUE Procedure”.
Several hair doctors who have used the ARTAS in their offices during the past year discussed their personal experience with the device. Some felt that the ARTAS extracted follicles at faster rates than other FUE devices. To date however, there has not yet been a significant evaluation of the quality of grafts as compared to other methods of FUE hair harvesting or to grafts from strip hair transplants. Furthermore, the transection rate (damage to the follicles from the cutting tool) with the ARTAS is still as high as 5-10% which many leading surgeons would consider significantly higher than that of follicular unit transplantation.
Coalition member Dr. Robert Bernstein shares his expert knowledge of this topic in the article, “Advantages of the ARTAS Robotic Assisted Hair Transplant for Follicular Unit Extraction (FUE): By Dr. Robert Bernstein.
Stem Cell Therapy and Hair Multiplication
Hair multiplication and stem cell therapies are both highly anticipated and often rumored. At the present time however, no one has yet started phase III (the critical phase for determining efficacy) of research in these areas. Unfortunately for hair loss sufferers, this means that a hair loss cure or even new and revolutionary hair loss treatments based on these procedures are unlikely to become available within the next 8 to 10 years.
Hair Duplication (Auto-Cloning) and ACell MatriStem
Coalition member Dr. Jerry Cooley’s introduction of hair duplication (autocloning) and ACell which provides the potential for an unlimited supply of donor hair for transplanting back in 2010 was met with great enthusiasm by hair loss suffering men and women worldwide. At this year’s 2012 ISHRS scientific meeting, Dr. Cooley provided an update on his clinical experiences and findings with ACell in traditional hair transplantation and hair duplication (autocloning).
The three main functions of Acell is to stimulate angiogenesis (the physiological process of growing new blood vessels from pre-existing vessels), inhibit fibrosis (scarring that may be microscopic and below the skin surface) and recruits progenitor stem cells (a particular type of stem cell that can only be divided a limited number of times). ACell comes in both a powder and sheet form and is well known for its assistance in wound healing. Dr. Cooley uses both forms of ACell in his practice and feels strongly that ACell provides several relevant applications in hair restoration surgery. This includes its use in FUE punch sites, donor strip healing, FUT grafting and hair duplication (autocloning).
Evidence at Dr. Cooley’s practice suggests that ACell can assist in tissue regeneration, which can be seen by the temporary discoloration (redness) seen in the photo below. Thus, Dr. Cooley feels strongly that using ACell during follicular unit extraction and FUT hair transplant surgery can greatly assist in wound healing and producing optimal hair growth yield.
Hair Duplication (autocloning) works on the principle that a hair, when plucked properly, will emerge with its epithelial cells and follicular stem cells intact. According to Dr. Cooley, applying ACell to the plucked hair and then implanting it into the scalp “stimulates the body’s innate regenerative potential” to rebuild a completely new follicle including sebaceous gland and dermal papilla. Since plucked hairs also regrow in the original site, a potentially limitless donor supply is created, providing hair loss sufferers with the possibility of restoring a full head of hair.
Some of Dr. Cooley’s early results were successful in using plucked scalp and beard hair in generating new hair growth in balding areas. However, after ongoing studies, he ran into a road block and several failures. In particular, Dr. Cooley saw low success rates when using plucked hairs to treat balding crowns and some areas of frontal hair loss. However, after ongoing trials, Dr. Cooley had several successes, in particular in areas where hair was previously transplanted. See the below photographs demonstrating this.
One of the complications of transplanting plucked hairs (or hairs in general) is folliculitis, which you can see in the 7 months photo above. However, by 15 months, all signs of infection were gone and results were excellent.
Critics of Dr. Cooley’s hair duplication procedure have asked why the success rate of using plucked hairs appears to be higher near transplanted hair. Dr. Cooley believes cells from prior grafts facilitate follicle regeneration, maximizing growth yield of the plucked hairs when transplanted in and around previously transplanted hair.
Dr. Cooley’s theory of regeneration is that plucked hairs need to be transplanted near healthy follicles in order to draw from those stem cells. As a result, Dr. Cooley is primarily using hair duplication in repair cases and in patients who’ve had prior grafting. Potential complications of hair duplication using plucked grafts and ACell include folliculitis (which goes away), telogen effluvium (shock loss) with use of non-fine ACell power injected into the scalp and Erythema (temporary discoloration/redness which is an indication of angiogenesis rather than a complication).
Due to the variable results, Dr. Cooley feels that more work is needed before the hair duplication procedure is ready for widespread use.
Scalp Micropigmentation (SMP)
This past year, interest in Scalp Micropigmentation or SMP (the process of tattooing the scalp to promote an appearance of naturally growing hair) has simply exploded. This is due in large part to advancements in techniques and inks that have resulted in a finer and more natural looking results. Additionally, a number of well-respected hair transplant surgeons have begun to offer or have considered offering SMP in their hair restoration clinics: These include, Dr. William Rassman, Drs. Ron Shapiro and Paul Shapiro, and Dr. William Lindsey among others.
Dr. Rassman hosted a workshop on SMP demonstrating how detailed the procedures can be as well as some common pitfalls including; blurring or bleeding of the ink sites, poor color matching and fading over time. He concludes that most people need 3-5 procedures to obtain long-term results. Moreover, correction via laser tattoo removal due to ink “bleeding” is required in a good number of patients based upon a combination of patient physiology and technique issues.
When done correctly, the results of scalp micropigmentation (SMP) can be stunning. However, like any procedure, SMP comes with a laundry list of advantages, disadvantages and limitations and is not for everyone.
Coalition member Dr. Robert Bernstein also provided his insight from the meeting on this popular topic. View “Scalp Micropigmentation (SMP) at the 2012 ISHRS (International Society of Hair Restoration Surgery) Scientific Meeting – Dr. Robert Bernstein Provides His Input” for more information.
Propecia (Finasteride) Safety and Efficacy
Persistent and troubling rumors about Propecia causing devastating and irreversible sexual dysfunction continue to be a hot topic of discussion on our hair restoration forum and social community. View “Can Propecia (Finasteride) Cause Permanent Sexual Side Effects” for more information.
A presentation led by Dr. Ken Washenick of Bosley / Aderans Research Institute revealed statistics from a study showing side effects of men on finasteride versus a placebo over a one year period. Statistics show reports of increased side effects in men who took Propecia over the placebo however, some men who took the placebo also reported side effects. The specifics can be found in the below chart.
Approximately 3.8% of men who took finasteride experienced some kind of sexually related side effect while only 2.1% of men on the placebo experienced sexual dysfunction. While this is considered statistically significant, it was noted that 58% of the subjects experiencing side effects who elected to continue taking the medication stopped experiencing sexual problems. Moreover, the incidents of sexual side effects decreased after the first year of the study. Most importantly, every single man who was part of the study who experienced sexual side effects stopped experiencing them after discontinuing finasteride.
After reviewing the data regarding the link between finasteride and ongoing sexual side effects, The Sexual Medicine Society of North America published the following statement, “SMSNA recognizes that an association exists between these drugs and persistent undesirable symptoms after termination of treatment and that men with these symptoms are suffering. However, at this time, human scientific evidence does not allow us to define the prevalence or the cause of these symptoms.” They further stated, “…it is currently impossible to definitively link, as cause and effect, these medications to the long-lasting symptoms these men experience”. Unfortunately, only the first half of the first statement was broadcasted in the media and thus, created unnecessary panic in hair loss suffering men currently or considering taking the drug.
While the FDA mandated Merck to change the label on all drugs containing finasteride, the FDA maintains that finasteride is safe and effective, but notified health care professionals about the data review and warning changes. The FDA also released the following statement:
“It’s important to note that these labeling changes are not new warnings, as characterized by other news reports. Sexual adverse events were reported in clinical trials, and this information was included in the finasteride drug labels at the time of approval.”
Moreover, from 1998 to 2011, of the 6 to 7 million patients who used finasteride, there were 59 cases of reported adverse sexual side effects that lasted longer than three months after drug discontinuation.
In summary, Dr. Washenick reports that there are patients who have taken finasteride who suffer from persistent sexual dysfunction. No causal relationship between the two has been established however, these patients do deserve a thorough evaluation and treatment. Furthermore, hair loss suffering men should be given every opportunity to obtain informed consent related to the above issues while considering finasteride therapy.
Another noteworthy presentation by Coalition physician Dr. Sharon Keene revealed information that suggests the studies that reviewed the permanent side effects of finasteride did not adequately and objectively evaluate the health status of those patients studied. This includes the diagnosis of depression or anxiety, smoking, use of marijuana or cocaine, alcohol consumption, etc.
Dr. Keene also reported statistics from July, 2012 showing 30% of young men between the ages of 18 to 25 had erectile dysfunction and 11% had premature ejaculation without taking finasteride. In an even larger study including 27,000 men in 8 different countries, 8% of men between the ages of 20 to 29 and 11% of men between the ages of 30 to 39 experienced erectile dysfunction.
In conclusion, Dr. Keene noted there are many organic causes of erectile dysfunction and sexually related problems. While there is no evidence based data linking finasteride directly to permanent sexual side effects, Dr. Keene agrees that patients experiencing lasting sexual side effects after discontinuing finasteride treatment should be thoroughly evaluated for possible organic causes, lifestyle factors and possible psychosocial and mental health related issues.
Many hair loss suffering men have used Propecia for years with little or no adverse effects. However, we encourage anyone considering medical hair loss treatments to educate themselves thoroughly on the potential risks as well as benefits before adding any drug to their regimen. For more information on the potential side effects of Propecia see “Class Action Lawsuit Filed against Manufacturer of the Hair Loss Drug Propecia”.
For more information, view the article, “Is Propecia Safe? Dr. Robert Bernstein Discusses the Efficacy and Safety of Finasteride” by Coalition hair restoration physician Dr. Robert Bernstein.
Skilled and dedicated hair restoration experts like those recommended by the Hair Transplant Network, continue to advance and improve medical and surgical options for balding men and women around the globe. A special thank you to those physicians who attended this year’s ISHRS meeting in the Bahamas and contributed to this presentation.
Editorial Assistant and Forum Co-Moderator for the Hair Transplant Network, the Coalition Hair Loss Learning Center, and the Hair Loss Q & A Blog.
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