Highlights from the October 2006 ISHRS Meeting in San Diego

[Pat - Community Publisher]

Meeting Report by Pat Hennessey ??“ Publisher of the Hair Transplant Network and the Coalition Hair Loss Learning Center

 

Each year the International Society of Hair Restoration Surgery (ISHRS) hosts a four day meeting that is attended by ISHRS members from around the world. I have attended several of these international meeting as both a guest and as a member of the press. The highlights that I thought would be of interest to hair loss sufferers are presented in this report.

 

The ISHRS is a non profit medical association of over 700 physicians specializing in alopecia and hair loss. The ISHRS has an open membership and does not restrict its membership based on qualitative standards. It provides continuing education to all physicians specializing in hair transplant and restoration surgery. To learn more about the ISHRS or learn about physician members worldwide visit www.ISHRS.org.

 

This year's annual meeting was held in San Diego, California from October 18th to the 22nd. Over four hundred hair restoration physicians from around the world attended this international meeting along with over 100 medical technicians and staff members.

 

It was impressive to see so many physicians sharing and debating the fine points of hair restoration. I found it interesting that many of the issues that have been discussed on our forum over the past couple of years were the hot topics at the meeting. These topics included - optimal session and graft sizes, ultra dense "super" mega sessions vs traditional density mega sessions, sub follicular unit grafting vs follicular unit grafting, growth rates, hair multiplication, FUE, and trichophytic closure techniques.

 

In many ways patient awareness and demand for optimal procedures and techniques has served to accelerate their adoption by many physicians. However, too often promotional hype and misinformation circulate online as scientific truth.

 

As patients we do not need to learn how to perform state of the art surgery. But we do need to be aware of the various techniques and their relative advantages so we can make optimal choices. Like their patients, many physicians are trying to determine what size sessions and techniques are truly optimal and safe.

 

"Ultra Dense Super Mega Sessions" versus "Traditional Density Mega Sessions"

 

Super Mega Session of 4,000 plus grafts challenge the conventional notion of how much donor tissue can be safely removed and how many grafts can be relocated into incisions in one session and still grow. Patients on this forum have been at the cutting edge of this debate.

 

But offline it was Dr. Jerry Wong and Dr. Ron Shapiro who formally and cordially debated this hot topic. Dr. Wong made a compelling case for "Ultra Dense Super Mega Sessions" while Dr. Ron Shapiro also made a compelling case for "Traditional Density Mega Sessions" that do not exceed 4,000 grafts except for patients with exceptional characteristics.

 

Both physicians are highly respected members of the Coalition of Independent Hair Restoration Physicians and do highly refined hair transplantation. They both have very large and well trained staffs with the capability to perform super mega sessions at very high densities.

 

Dr. Wong contended that patients want to achieve optimal density and coverage in as few surgical sessions as possible. Thus he argued that super mega sessions are optimal for many patients and that scarring in the donor area did not increase. He also believed based on his experience with hundreds of patients that growth rates in ultra dense super mega sessions are not diminished when performed by highly experienced staff.

 

A study presented by Dr. Thomas Nakatsui supported Dr. Wong's contention. This study showed a 98% growth rate for dense packed grafts placed into ultra refined incisions.

 

On the other hand, Dr. Shapiro contended that he believed that most patients would typically require more than one session, even after dense packing. Thus if a patient ultimately required 6,000 grafts he believed it would be safer and ultimately optimal for the patient to have hypothetically 3,500 grafts in their first session and then 2,500 grafts in their second session rather than attempting to perform four or five thousand grafts in the first session.

 

Given that the average number of hairs per graft used by Dr. Wong is probably a bit lower than those used by Dr. Shapiro the impression of the size difference between these sessions is probably a bit overstated.

 

Dr. Wong and Dr. Shapiro were also chosen to perform surgery on a patient during the live patient showing. Dr. Wong performed surgery on the patient's hairline on one side using lateral (perpendicular) slit incisions, while Dr. Shapiro did surgery on the other side using sagital (parallel incisions). When the hair grows out observers will then be able to evaluate whether there is a significant aesthetic difference between these two techniques.

 

Hair Cloning/Hair Multiplication

 

As follicularly challenged individuals we all dream about the holly Grail of hair transplantation ??“ an endless supply of donor follicles provided compliments of hair follicle multiplication. For the over eight years that I've been online and immersed in hair restoration this has been a hot topic yet as elusive as the hair fairy.

 

But there are two organizations that have been working seriously on developing a commercially viable way of multiplying bald resistant donor follicles. These organizations are Aderans headquartered in Japan and Intercytex based in England. Aderans is the world's largest manufacturer of wigs and acquired the Bosley Medical Group in 2001.

 

The approach currently being tested by both groups involves extracting single hair cells from the bald resistent donor area and attempting to get them to replicate in the laboratory. These "dermal papilla" cells mature into hair follicles in a process known as follicular neogenesis. Theoretically if they can be stimulated to multiply there could be no limit to the number that could be grown in the laboratory and then transplanted (injected) back into the scalp from which they originated.

 

It was 14 years ago that this technique of stimulating hair cells to regenerate was first demonstrated by a British researcher, Colin Jahoda, at the University of Durham in 1990. He took follicle cells from his own head, cultured them in the laboratory and implanted them between the pale hairs on his wife's arm. Out grew a thick, dark hair with male DNA. He carried out a similar experiment with mice and proved that hair cells could be induced to grow anywhere on the body.

 

Since then, researchers around the world have been trying to find ways to make the dermal papilla cells multiply. They will grow strongly when placed in a petri dish in the lab but in doing so they lose the capacity to develop into hair follicles. The researchers ended up with a lot of generic cells that would not grow anything.

 

At Bosley International in the US researchers have experimented with different combinations of growth catalysts and now claim that 80 per cent of their laboratory-grown cells now produce hair when implanted in mice.

 

Intercytex has also had similar success in animal testing. And as Dr. Jerry Cooley joked in presenting these findings the mice also experiences an accompanying increase in self esteem. Just this past summer Intercytex has moved on to limited testing on humans in Manchester England. The Farjo Clinic is heading these clinical trials (Note - they already have all the test participants they need and are not acceptting any more volunteers).

 

However, even if the human trials are successful it is expected that it will be at least five years before the US Food and Drug Administration approves the process, opening the way for it to be marketed to the public.

 

In addition, controling the direction of the new hair growth has been problematic. Thus many believe that such hair cell implantation will probally be used primarily as filler hair in the top and crown area initially, with the critical areas such as the hair line done using conventional grafting. The cost of this laboratory intensive procedure is also expected to exceed conventional hair transplantation when introduced.

 

So for those who have decent donor supply they would be well advised not to wait for hair multiplication. However, if hair cell implantation does arrive in the future it could be used to create even greater levels of density and fullness behind the hairline.

 

Follicular Unit Extraction (FUE)

 

While strip harvesting of donor follicles remains the work horse technique of choice, especially in transplanting large numbers of follicles cost effectively, the FUE procedure has gained acceptance among some patients and physicians as an alternative method of harvesting donor follicles.

 

For an indepth comparison of strip versus FUE, including video demonstrations, click here.

 

Although the FUE procedure is typically more tedious and expensive than strip harvesting, it is less invasive than strip harvesting and has quicker healing in the donor area. However, it typically requires that the patient's donor area be shaved.

 

Dr. Jim Harris and Dr. Alan Bauman presented their techniques for FUE at the meeting. They have both earned high regard among their colleagues for sharing and demonstrating their FUE techniques.

 

Dr. Harris recently hosted an ISHRS workshop at his clinic in Denver that focused on his three step "SAFE" FUE process and instrumentation, while Dr. Bauman has demonstrated his technique during the ISHRS live surgery workshop in Orlando.

 

Dr. Mwamba who performs FUE in Beligium presented his estimates of the follicle transection rate resulting during the follicular unit extraction process. In short, over time his transection rate declined from 8% down to 2.6%, which he felt was comparable or even better than transection rates generated during strip excision.

 

Body Hair Transplantation (BHT)

 

Dr. Robert True presented his technique for transplanting hairs from the chest, back and torso areas of a patient to the scalp. His procedure is similar to his FUE procedure only he finds that he often needs to make deeper punch incisions to extract follicles from the extremities since the follicles often are deeper. However, he reported that patients donor areas healed rapidly due to the small size of the punch incisions.

 

Despite the fact that a person can have up to 5 million hair follicles on their body, the vast majority are unsuitable for transplantation to the scalp. However, Dr. True presented his methodology/evaluation tool for measuring whether a person is a viable candidate for body hair to scalp transplantation. Basically the closer the person's body hair is in density and characteristics to their scalp hair the better potential candidate they are.

 

For highlights and photos from his full presentation, click here.

 

Donor Closure Techniques to Minimize Donor Scarring

 

Much of the patient interest in the FUE technique is the result of patient concerns about the potential for a noticeable linear donor resulting from strip excision surgery. However, physicians have placed more emphasis in recent years on donor closure techniques to minimize visible scarring in the donor area.

 

One such technique, first introduced to the field of hair transplantation by Dr. Mario Marzola of Australia, is the Trichophytic Closure technique also referred to as the "Ledge Closure" by Dr. Paul Rose. For an excellent presentation on the Trichophytic Closure technique visit Dr. Shapiro's posting on this topic.

 

While the Trichophytic Closure is not a panacea or substitute for closing under minimal tension to avoid excess scarring, it does provide enhanced cosmetic masking of the donor scar due to the hairs growing up and through the linear donor scar.

 

In addition, many physicians who use this technique believe that the hairs growing into and through the scar line act almost like sutures in strengthening the scar line and preventing stretching in the scar.

 

The three principal leading advocates for this closure technique ??“ Dr. Marzola, Dr. Rose and Dr. Frechet ??“ use a fundamentally similar technique with some minor variations that were discussed during the meeting.

 

Dr. Frank Neidel of Germany and Dr. Mohmand H. Mohmand of Pakistan also presented compelling evidence that the Trichophytic Closure technique could make linear donor scars virtually invisible in many patients.

 

Over the past year in particular many leading physicians have embraced the use the Trichophytic Closure technique and use it on a regular basis. They also report increased success in minimizing the visibility of the linear donor scar.

 

Safe Donor Harvesting ??“ the Donor Spreader

 

The donor spreader, invented by Dr. Bob Haber, was introduced at last years ISHRS meeting in Australia. This device is designed to enable a surgeon to separate the donor strip from the donor area with a minimal amount of follicle transaction (severing of the follicles). It has proven to be very effective in producing virtually transaction free donor strips.

 

Dr. Haber presented updates and refinements regarding the Donor Spreader. This devise will make a commendable contribution to preserving limited donor follicles as more and more surgeons adopt its use.

 

Effects of Oral Dutasteride in Identical Twins

 

Dr. Dow Stough presented the results of a study designed to show the effectiveness of dutasteride (marketed as Avodart) in treating hair loss. 17 sets of identical twins were enlisted in this study over a one year period. In this double blind study one twin took a placebo, while the other took 0.5mg per day of dutasteride. One year later it was found that dutasteride significantly improved the hair growth of the twins on the drug as compared to the twins on the placebo.

 

Like finasteride (marketed as Propecia) dutasteride inhibits the formation of hair loss causing DHT in the scalp. However, unlike finasteride, dutasteride has not yet been formally approved by the FDA for the treatment of hair loss. However, some physicians do prescribe dutateride to patients to treat hair loss.

 

Changes within the ISHRS Leadership

 

Coalition member, Dr. Paul Rose of Tampa Florida, served this past year as the President of the ISHRS. Dr. Rose had many accomplishments as President, including championing the probono hair transplant program known as "Operation Restore".

 

This program provides free surgeries to patients who have suffered hair loss due to injury or illness. To learn more about this charitable program, visit the ISHRS web site at http://www.ishrs.org/ishrs-pro-bono.htm

 

Dr. Paul Cotterill of Toronto, Canada will be the new President of the ISHRS in the coming year.

 

Dr. Bernard Nusbaum was the chair of the meeting's Scientific Committee for 2006. By all accounts he did an excellent job of organizing workshops, presentations and lectures that were very topical and valuable to physicians.

 

Best wishes to all members of this community,

 

Pat

[Bushy]

Wow, Pat, that was a great read. Thanks for sharing all this invaluable information with us.

 

Two questions, if I may: First, were any potential downsides raised by the panel with regard to trichophytic closure? Were any patients (models) shown?

 

Second, in the Wong-Shapiro debate, were any potential downsides presented for the super-large sessions (other than potentially larger scars, which doesn't seem to be a problem for H&W)?

 

Thanks for all you do for the HT community.

[Bill - Seemiller]

Thanks for this additional detailed information Pat...very thorough and informative. I greatly appreciate all the time you take to collect and share this information with us. That answered a lot of my questions.

 

One more though if I may, in addition to Bushy's questions:

 

Was there any downside presented for the case of FUE? If I understood correctly, it appeared that the successful growth rate for FUE is inferior to strip...is this wrong or is there any evidence supporting or invalidating this claim?

 

Bill

[the B spot]

Man, I wish I could been there to listen in on these discussions!!!

 

A few things: Fue transection rates-- I still argue that because every patient is not an "ideal" patient, these transection rates are completely misleading, ESPECIALLY when held against a strip surgery. In addition, what size session sizes, etc... were these statistics compiled?

 

I guess in the Super-mega session debate, both Dr. Wong and Dr. Shapiro made very convincing cases for and against.

I guess that main result was increased risk for complications exist the larger the session.

Another point was why increase potential complications when a 2 very large sessions can accomplish either the same or slightly better result, giving a top surgeon a second chance to improve on an already great design.

 

I know I am going for #2 in the coming months and I plan on speaking to Dr. Shapiro in depth about this subject.

 

I come away with the idea that only a very few doctors will ever be able to perform these larges sessions, preferring to work in sessions of 1500--2500 minimizing potential complications, and not over-taxing themselves or staff.

 

While I have posted that I feel strongly against sessions that require massive tissue removal, I think that the right clinics are completing and risking these sessions in a controlled manner.

I still believe that the pendulum will swing toward the 3000-4000 range which is a significant increase from the 1500-2000 graft sessions that are industry standard.

 

One thing I would like to say is thanks to the doc's who have moved up session sizes, kept pricing very competitive, and keep the best interests of the patient in mind.

 

BIG shout out to Pat whom is continuing to do a GREAT job!!!!!!! Acountability !!!!!!!!

Thanks Again!!!!

[Pat - Community Publisher]

Guys,

 

Thanks for your feedback on my report. Bushy, the main concerns/reservations about the super mega sessions were over taxing the donor area and potential diminished growth rates due to the large number of incisions in the scalp.

 

Personally I think that given the minimally invasive nature of these ultra refined incisions that growth rates are very healthy - in experienced hands.

 

But I do tend to agree with B Spot and Dr. Shapiro that perhaps 3,000 to 4,000 graft cases (of 1, 2, 3 and 4 hair follicular unit grafts) for ideal candidates will in time prove to be both optimal and safe for those who need such sessions. I just don't think it is worth the risk of donor scarring to go past these numbers except in extremely rare cases.

 

B Spot - best wishes for a great second session.

 

Bill, I think the biggest concern with FUE is the potential for transecting and or damaging the follicle when the surgeon is attempting to remove it. Essentially during FUE the physician has to guestimate the angle of the follicle sight unseen beneath the skin. Whereas with strip excision the technicians can isolate and trim the follicles with the benefit of high powered microscopes.

[Bushy]

Originally posted by Pat - Publisher of this Community:

Count Hairs not Grafts

Pat, is this your new bumper sticker?

[Bill - Seemiller]

Bill, I think the biggest concern with FUE is the potential for transecting and or damaging the follicle when the surgeon is attempting to remove it. Essentially during FUE the physician has to guestimate the angle of the follicle sight unseen beneath the skin. Whereas with strip excision the technicians can isolate and trim the follicles with the benefit of high powered microscopes.

 

That makes perfect sense. I know that I haven't researched too many FUE cases, but I have seen a few that seemed to work out real nice...mainly by Dr. Feller since he posts pretty regularly. I'll be curious to see where the future of Hair Transplantation is going. I'm also hoping that successful hair cloning and transplantation will happen in my lifetime

 

Bill

[Robert_]

Originally posted by Bushy:

Originally posted by Pat - Publisher of this Community:

Count Hairs not Grafts

Pat, is this your new bumper sticker?

 

Close, Bushy. But I think Pat is carrying this message a little "closer to heart." Hense the new tattoo:

 

 

 

Pat,

 

Great write up. I'm always super interested in the discussions that go on at these ISHRS meetings. I am ecstatic that physicians continue to actively discuss and debate the finer points in hair restoration surgery. Though the industry is far from perfect, it's great to know that the pioneers and frontrunners such as Dr. Cooley , Dr. Shapiro , and Dr. Wong continue to strive to perfect their craft for the patient's benefit.

 

-Robert