Highlights from the 2013 ISHRS (International Society of Hair Restoration Surgery) Scientific Meeting in San Francisco, California
Every year the International Society of Hair Restoration Surgery (ISHRS) holds its annual scientific meeting to discuss hair loss and advancements in medical and surgical hair restoration. This year, the ISHRS meeting was held in San Francisco, CA and the topics discussed were in stark contrast to those that were on the agenda at the first San Francisco meeting 14 years ago.
In 1999, hot topics included whether microscopes were necessary for graft dissection; scalp reduction, extension and flaps; and the evolution from mini-grafts to follicular unit transplantation. There was no mention of follicular unit extraction (FUE), a topic that dominated this year’s meeting.
Refinements in FUE tools and techniques have led to increasing patient demand for the procedure over the past few years. Accordingly, much of this year’s meeting was devoted to discussing the evolution and current techniques in FUE. This includes comparing advanced FUE to state of the art follicular unit strip surgery (FUSS) and automated FUE hair transplant surgery. Other hot topics included updates on Dr. Wesley’s new Pilofocus scarless hair transplantation, ACell, Platelet Rich Plasma (PRP), the safety and efficacy of Propecia (finasteride) and an update on low level laser therapy for hair loss.
The below highlights from this year’s conference come from presentations and interviews with Coalition members; Dr. Mike Beehner, Dr. Robert Bernstein, Dr. Jerry Cooley and Dr. Carlos Wesley and recommended hair restoration physicians; Dr. Shelly Friedman, Dr. James Harris and Dr. Parsa Mohebi. A special thanks to these expert physicians for providing this community with their feedback on the latest innovations discussed at the 2013 ISHRS meeting.
With so many topics discussed during the five day conference it’s virtually impossible to cover every topic. Thus, we have summarized below those topics that we thought would be most relevant and interesting to hair loss sufferers.
Background on the ISHRS
The International Society of Hair Restoration Surgery (ISHRS) is the most prominent professional organization for hair restoration in the world. Their primary mission is to educate hair surgeons ranging from the novice to the expert. Their recently renovated 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. Vincenzo Gambino of Milan, Italy replaced Dr. Carlos Puig as the acting President of the ISHRS for the coming year. Congratulations to Dr. Gambino for receiving this honor.
Physician Recognition and Awards
Congratulations to the following award recipients:
Coalition physician Dr. Sharon Keene of Tucson, AZ was awarded the coveted Platinum Follicle Award. The Platinum Follicle recognizes “Outstanding achievement in basic scientific or clinically-related research in hair pathophysiology or anatomy as it relates to hair restoration.” It is one of the highest honors given to leading surgeons in hair restoration by the ISHRS at each meeting.
Recommended hair transplant surgeon Dr. James Harris was awarded the ISHRS Research Award. Congratulations to Dr. Harris for all his successful research as it relates to the success in hair restoration outcomes and results.
The Distinguished Assistant Award went to Aileen Russell of Carolina Dermatology Hair Center for all her hard work and dedication to teaching other hair transplant technicians from around the world about the surgical best practices for optimal growth and patient results. Aileen has worked as the leading technician for Coalition member Dr. Jerry Cooley for many years.
Presentations of Interest to Hair Loss Sufferers
Follicular Unit Extraction (FUE) versus Follicular Unit Strip Surgery (FUSS)
Recently, FUE hair transplantation has enjoyed a dramatic rise in popularity. However, very little data exists comparing growth of FUE grafts to those from state of the art harvested strip surgery (FUSS) under microscopic dissection. This year, Coalition member Dr. Mike Beehner presented results from a controlled study on two patients designed to determine if follicular unit extraction (FUE) does indeed produce the same growth as follicular unit strip surgery (FUSS).
This study was conducted in the exact same manner on each of two hair transplant patients. Study boxes were drawn in the frontal region of the scalp just behind the frontal hairline zone (see image below).
Follicular unit grafts containing three hairs: 35 3-hair grafts were harvested via follicular unit extraction (FUE) and 35 3-hair grafts were harvested using traditional follicular unit strip surgery (FUSS). These grafts were then placed in 1.1 mm lateral slit incisions and oriented sagittally (vertically). The incisions were made with a custom-cut slit blade with 45 degree angulation at the tip. The grafts were placed within two study boxes, each measuring 1.2cm x 1.2cm. Each study box had a 1.2mm wide “moat” of bald skin around it and a light brown tattoo dot was placed in each of the four corners of all study boxes for easier later identification. Tumescent solution used in recipient area was normal saline with a 1:180,000 epinephrine concentration.
Follicular unit grafts containing two hairs: 40 2-hair FUE grafts and 40 2-hair FUSS grafts were placed in 1.0mm lateral slit incisions, oriented sagitally, made with the same type of blade described above, with each study box measuring 1.2cm x 1.2cm.
Follicular unit grafts containing a single hair: 35 1-hair FUE grafts and 35 1-hair FUSS grafts were placed in 1cm x 1cm boxes. Incisions were made with 0.9mm slits made with similar blades as described above.
FUE grafts were harvested using both the 0.9mm and the 1.0mm diameter dull punches of the SAFE-II system.
Time “Out-of-Body” for Grafts
The survivability of hair grafts after transplantation is directly related to the time they spend out of the body before being placed. For patient#1, FUE study grafts were placed 4-5 hours after harvesting, and FUSS study grafts were placed 5-7 hours after harvesting. For patient#2, FUE study grafts were placed 5 hours after harvesting, and FUSS grafts were placed 7-8 hours after harvesting.
The grafts were stored in chilled plasmalyte solution from the time they were either harvested by FUE or dissected under the microscopes, and kept at 4 degree centigrade on top of a Cole Cooler. The same technician placed all of the study grafts for both patients.
Results of Hair Counts and Growth Yield
The hairs growing in each study box were counted using a technique published by Dr. Beehner in great detail in the Unger-Shapiro text, “Hair Transplantation”. It was observed that grafts harvested via strip surgery (FUSS) have approximately a 30% improvement in viability over FUE grafts.
Other Factors Affecting FUE Hair Transplant Outcomes
Recommended hair transplant surgeon Dr. Jim Harris, an expert in FUE harvesting, followed up with the results of a study utilizing the HairCheck device to assess the preservation of hair mass after hair restoration surgeries via; strip, dull punch FUE and robotic FUE (ARTAS) graft harvest techniques. Per Dr. Harris:
“The purpose of this study was to evaluate the potential of the hair mass measurement to be used as a metric for hair survival after transplantation. However, the results were inconclusive as the study design involved relatively small numbers of grafts and hairs from each harvest type. Therefore no conclusions could be drawn from the study and further analysis is required.”
Dr. Sara Wasserbauer found, in a retrospective analysis of her surgeries, that there is a tendency to “cherry-pick” FUE grafts. Her observations revealed that this may lead to a significant increase in the number of 3-haired follicular units obtained. A typical strip procedure yielded more 2-haired grafts but there was no significant difference in the number of single-haired follicular units between the two techniques in terms of percentages of the whole surgical yield.
Available data to date demonstrates that follicular unit transplantation via strip surgery (FUSS) still yields higher growth percentages (hair mass) than FUE. Furthermore, FUE and strip procedures contain approximately the same number of total hairs obtained with strip containing slightly more.
Pilofocus Scarless Hair Transplantation
Coalition member Dr. Carlos Wesley presented the first public overview of his piloscopic follicle harvesting technique, which in essence could eliminate hair transplant scarring altogether. Piloscopy involves an endoscopic tool that helps remove hair from below the skin surface. Unlike current surgical hair restoration techniques, Piloscopy can minimize skin hypopigmentation. Most importantly, benefits of the piloscopic follicle harvesting technique include no evidence of scarring in the donor area and enhanced growth rates of piloscopic versus FUE grafts.
Standard follicular unit extraction (FUE) is often mistakenly called a “scarless” procedure. In fact, though scarring can be very minimal with FUE, small dot-like scarring is normal and can be visible when hair is closely cropped. In order to minimize these dot scars, small punches 1mm or less in diameter must be used. However, this increases the risk of graft transection resulting in lower yield. A 1-mm punch may result in a transection rate ranging from 2% to 8.5%, while a 0.75-mm punch may lead to a more detrimental 3% to 10% transection rate.
Additionally, it has been shown that leaving a generous amount of protective tissue around follicular unit grafts (chubby) results in greater yield and a greater number of hairs at six months than closely trimmed (skinny) grafts. Also, the smaller the grafts, the more susceptible they are the effects of traumatic handling.
How Piloscopy Works
Piloscopy allows for the harvesting of chubby grafts from below the surface of the skin without any external evidence of trauma to the overlying skin surface (i.e. “scarless”).
Steps in the Pilofocus process:
- Create a working cavity within the subgaleal plane of the scalp using an initial blunt dissection
- Insert the endoscopic hair follicle harvesting tool (piloscope) via a 1cm incision anywhere along the safe donor area of the scalp
- Once aligned, the piloscope cores around the desired follicle, clips within 1mm of the skin surface, and immediately transports (via a saline flush) the ready-to-be-placed “chubby” FU outside of the scalp
Dr. Wesley’s video presentation below is password protected. The required password is “piloscopy”.
Comparative photographs were taken during the donor harvest to carefully document the presence and absence of hair follicles before and after they were harvested using a beneath-the-skin-surface approach and separated from their native environment approximately 1mm from the overlying skin surface (See image below).
In each instance, the beneath-the-skin-surface harvesting approach of these 10-25 follicles (indicated by yellow arrows) resulted in full maintenance of the integrity of the overlying skin surface and contrasts sharply with the 10-25 follicles excised by traditional 1.0mm FUE punch.
Transplanted Graft Survival
The table below depicts the growth of piloscopic grafts versus those that were harvested via traditional FUE. Patient 5, the lone subject in whom FUE grafts demonstrated superior viability, had 100% growth of FUE grafts.
Potential Advantages of Piloscopy
- Less out of body time for grafts
- Less graft manipulation
- Multiple grafts harvested at once
- Increased graft survival
- No trauma to skin surface in donor area
- Position of patient allows for immediate implantation
- Patients do not have to shave their head
- Color and curl of hair is not a deterrent
While very exciting, it is important to note that further research and development of this procedure is necessary before it is made available to the public.
ACell MatriStem and PRP (Platelet Rich Plasma): Bioenhancements of Hair Transplantation
Bioenhancements are biologically based treatments and techniques based on sound scientific principles designed to enhance the results of hair restoration surgery. These include; growth factors like ACell MatriStem and platelet rich plasma (PRP); graft holding solutions such as HypoThermosol FRS; and energy delivery solutions like VitaSol liposomal ATP.
ACell MatriStem is a type of extracellular matrix made of porcine urinary bladder and available in both powder and sheet form. The potential benefits of ACell to hair transplant patients are many. First, it stimulates the physiological process through which new blood vessels form from pre-existing vessels. Second, it inhibits the formation of excess fibrous connective tissue in organs or tissue in a reparative or reactive process. Finally, it recruits progenitor-stem cells.
Uses for ACell in Hair Restoration Surgery
- Scar revision/donor strip healing
- Follicular unit extraction (FUE)/punch sites
- Follicular unit grafting
Platelet Rich Plasma (PRP)
Platelet Rich Plasma (PRP) is a process that involves extracting blood from a patient and separating into its natural components: red blood cells, white blood cells, platelets, and plasma. After another separation process (centrifugation), a portion of the blood plasma that is enriched with platelets (the molecules responsible for creating “blood clots” in the body) is isolated and preserved. The platelet enriched plasma containing growth factors that promote hair growth is then injected back into the patient.
PRP may improve hair growth but results vary and are dependent upon a number of factors on both the clinic and patient sides. Clinical factors include; intervals of treatment, methods to activate, ways to inject and differing devices. Patient factors include; different platelet counts, response to growth factors and different balding patterns & hair treatments.
Graft Holding Solutions
Once harvested follicular unit grafts are placed in holding solutions to remain moist until implantation. Holding solutions include; IV fluids, culture media and tissue storage solutions. Survival of grafts in saline decreases as time out of body increases. However, advanced solutions can prolong the time out of body and improve hair growth.
Grafts stored at 40C in Hypothermia-ATP (BioLife Solutions) maintained viability after 5 days of cold storage. This offers a survival benefit compared to saline for shorter times, eg several hours as occurs with a standard hair transplant.
ATP (Adenosine Triphosphate)
ATP is a molecule responsible for transporting chemical energy within cells for metabolism. Cells need oxygen and glucose to produce ATP, which is the cells’ fuel source. Cells in the graft must absorb oxygen at a distance since they do not have their capillary network for several days after surgery. If they don’t get enough oxygen, they can’t make enough ATP to survive.
ATP cannot be effectively delivered to most tissues without protection from degradation. One method of effectively delivering ATP is through encapsulation within liposomal preparations (liposomal ATP). Liposomes are artificially-prepared vesicles composed of a lipid bilayer.
Dr. Cooley recommends liposomal ATP spray after hair transplant surgery to enhance growth factor energy and cell viability.
Concerns such as storage injury to grafts, scarring, blood supply to tissues and graft viability can be greatly reduced through the use of bioenhancements can significantly improve the results of hair restoration surgery.
Partial Trichophytic Closure for Improving the Appearance of Scalp Scar
Recommended hair transplant surgeon Dr. Parsa Mohebi presented a novel approach to follicular unit strip surgery (FUSS) donor wound management which he calls, “Partial Trichophytic Closure”. In this method, a traditional trichophytic closure is performed on the upper edge of the wound, while the lower edge is examined microscopically and only sections that have hair follicles with distal transection are de-epithelialized (removal of the edge of skin that will become hairless).
The advantage of this method is that the hair transplant donor scar will appear smaller because of the lower possibility of transected hair at the edges.
Donor Scar Visibility
Factors that contribute to the visibility of a scalp donor scar are:
- High density of hair surrounding the donor scar
- No hair inside the scar area due to presence of scar tissue and transection of the lower portion of the hair follicles on the edge of the scar. (see image below).
Illustrating How Partial Trichophytic Closure Works
Partial trichophytic closure increases the time to harvest the donor strip by about 10 minutes. However, it may dramatically reduce the visibility of the scar.
The “No-Shave” FUE Technique
Presented by Dr. Marco Barusco and currently performed by only a handful of FUE experts worldwide including Coalition member Dr. Patrick Mwamba of Belgium, this procedure, as the name implies, allows patients to take advantage of follicular unit extraction hair transplantation without shaving the donor site. This may be especially important for female hair loss patients.
One of the major drawbacks with FUE as compared to strip surgery, from the patient’s perspective, is the necessity of shaving the entire (or portions of) the donor area before harvesting, in order to allow better visualization of the follicular units and increase speed of harvesting (see image below).
Although the donor hair tends to grow back in a matter of a few weeks, patients are normally required to refrain from normal professional and social activities until their donor hair has grown back.
This technique is loosely derived from Dr. Jim Harris’ “Microstripping” technique. However, unlike “Microstripping”, it does not require trimming of the microstrips, which causes the patient to have the appearance of a bad haircut in the days following the procedure.
It avoids the shaving of the donor hair and allows the patient to completely hide the scars from the FUE harvesting; resuming regular activities sooner (see images below). It also allows females to become candidates for FUE procedures, since most women will not agree to have their scalp shaved for this procedure.
How No-Shave FUE Works
Patients are prepared in the usual fashion for FUE surgery. The safe donor zone is identified and marked. After the patient is sedated and local anesthesia is administered, the hair restoration physician begins going through the patient’s donor hair, identifying the best follicular units for harvesting.
The patient’s hair is kept at its normal length. Once a FU is identified, it is carefully trimmed with scissors and harvested. The next graft is harvested in the vicinity of the first in a random fashion in order to avoid the appearance of a shaved head. About 15% of the available FUs are harvested from any given area in a single session.
Once completed, patients are able to exit the clinic with no bandages and no visible signs of surgery.
Propecia (Finasteride) Safety and Efficacy
Propecia is the brand name for 1mg finasteride. This is the dose that is clinically proven and FDA approved for the treatment of hair loss. However, despite being cleared by the FDA, persistent and troubling reports of severe and permanent sexual side effects remain a hot topic in medical hair restoration.
What is Finasteride?
In men with androgenic alopecia (male pattern baldness), hair follicles that are genetically susceptible to the effects of the hormone dihydrotestosterone (DHT) may begin to wither and die in adulthood. Finasteride helps to prevent this balding process by reducing the enzyme 5 alpha reductase; thus inhibiting the conversion of testosterone to DHT. However, side effects of finasteride may include; weaker and less frequent erections, watery semen, gynecomastia (development of male breasts) or even erectile dysfunction.
Urologist Dr. Wayne Hellstrom presented the results of a pooled summary of all randomized, placebo-controlled trials evaluating 5AR inhibitors (more than 62,827 patients). The analysis revealed slightly increased rates over placebo for decreased libido (1.5%), erectile dysfunction (1.6%), ejaculatory dysfunction (3.4%), and gynecomastia (1.3%).
Finasteride is associated with slightly increased rates of decreased libido, ED, gynecomastia, depression and/or anxiety. However, not enough data has been collected at this time to identify prevalence rates and persistence of symptoms beyond drug discontinuation. More research is necessary.
Low Level Laser Therapy for Treating Hair Loss
Recommended hair restoration physician Dr. Shelly Friedman of Scottsdale, AZ presented a review of his 5 years’ experience treating hundreds of male and female hair loss patients with Low Level Laser Therapy (LLLT) for hair growth.
What Is Low Level Laser Therapy?
LLLT refers to a medical treatment that uses low-level lasers to alter cellular function. These may be large, professional grade machines offered as a service in medical facilities like hair restoration clinics or they may be small, relatively inexpensive devices designed for use in the home such as the HairMax LaserComb.
Laser therapy has been applied to a number of treatments including; wound healing, pain relief, periodontal disease and, of course, hair growth. However, the use of these lasers remains controversial, as their efficacy has not yet been scientifically established.
Dr. Friedman’s Findings
All patients undergoing Low Level Laser Therapy were evaluated prior to treatment and at 3 months, 6 months, 9 months and 12 months using all of the following:
- Global photography
- Video microscopy
- HairCheck® (a patented device designed to precisely and accurately measure hair loss, growth and breakage on any area of the scalp)
According to Dr. Friedman, the data obtained from hundreds of patients utilizing Low Level Laser Therapy for pattern hair loss, demonstrated that LLLT was not only successful in stopping hair loss but, in many patients, reversed the miniaturization cycle and gave the appearance of hair regrowth from converting vellus hairs to terminal hairs.
The fields of medical and surgical hair restoration continue to develop and improve thanks to the efforts of skilled and experienced hair restoration physicians like those recommended on The Hair Transplant Network.
We would like to extend our thanks to those physicians who attended this year’s ISHRS meeting in San Francisco and contributed to the writing of 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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