INTRODUCTION

PROGRAM

DHI CLINIC

ON THE BOAT

CONFERENCE DAY 1

CONFERENCE DAY 2

PHIDIAS AWARDS

PHOTO ALBUM

1. Ischemia-reperfusion injury and free radicals in hair transplantation
2. Is chilled saline the best holding solution for grafts?
3. How can we make follicular unit grafting even better?

In hair transplantation our common goals are to find methods to improve hair transplantation with naturalness and density. Our goal should be 100% graft growth in 100% of patients with no effluvium. The major factors affecting transplant growth are: Transection, dehydration, crushing, vascular, and biochemical.

When a follicle is removed from the scalp it suffers from ischemia, or a lack of oxygen. When the follicle is planted back into the scalp it is reperfused, or exposed to high levels of oxygen. The trauma to the follicle from a being deprived of oxygen to reperfused with oxygen is called Ischemia-reperfusion Injury or IRI.

Another concern with transplants is exposure to free radicals. Free radicals are unstable, toxic molecules which can damage tissues and cells. Free radicals are caused by diverse triggers including Ischemia-Reperfusion Injury. Since it has been shown that transplanted organs fail due to immune rejection and IRI, could IRI affect the growth of hair grafts? Dr. Cooley's set out to study if Ischemia-reperfusion injury exists in transplanted hair follicles. His conclusions show the answer is most likely yes.

Dr. Cooley described his materials and methods for testing IRI in transplanted grafts versus control grafts.
The results of his study indicate that compared to control samples, ALL transplanted (reperfused) samples showed elevated MDA with the highest readings in the first 2 hours. Dr. Cooley concluded the positive MDA assay suggests that IRI does occur in hair transplants although more patient tests need to be conducted for confirmation.

What is the best method to reduce IRI? Dr. Cooley feels we should determine whether there is less MDA when using existing techniques from tissue/organ transplantation, specifically formulated to support tissues at low temperatures. If so, we should also determine whether these techniques change the clinical outcome of the patient's hair growth. We should also determine the best graft storage solution. Is it saline, cell/tissue culture media, or hypothermic tissue storage media? What is the best temperature? Should the grafts be left on the surface of the solution or fully immersed? To ensure 100% growth in 100% of patients these questions need to be fully researched.

Chilled saline is the most commonly used graft-holding solution today, but is chilled saline really the best holding solution? Dr. Cooley stated that saline lacks metabolic nutrients to prevent apoptosis, buffers to control pH, and antioxidants to prevent IRI. Dr Cooley concluded by describing three new possible graft holding solutions including Moser Machte (wish) Media, a solution being developed by Doctors Rose and Cole, and his personal experience with cell culture and his personal experience with cell culture and Hypothermosol from Biolife Solutions, Inc.

By using new holding solutions we might be able to achieve 100% growth in 100% of patients with no effluvium. In a bold statement, Dr. Cooley predicted in 5 years no hair transplant surgeon will be using saline as a storage solution.

There was a follow up discussion amongst the physicians on methods to reduce IRI by using FIT/FUE techniques and only removing hair follicular units once they were ready to be placed. Some of the doctors suggested the moving a hair follicle directly from the donor site to the recipient site was the best technique to reduce IRI. In such a case each hair follicle is only out of the body for 15 seconds at most and is never placed into a holding solution.

Dr. Minotakis also discussed the probability of poor graft growth when planting over 25 FU/cm2 due to excessive scalp trauma.

As a follow up to Dr. Minotakis' presentation, Dr. Cole asked all of the doctors for their opinion on the maximum density per square centimeter that should be planted in one session. The general consensus was 20-25 FU Grafts/cm2 on the low end and 30-40 FU grafts/cm2 on the higher end. Dr Cole continued the discussion by asking how many of the transplanted grafts were also at risk because physicians may push the donor area higher than the Norwood 7 safe zone. The doctors also discussed the cost vs. cosmetic benefit with higher densities. When a patient can no longer detect significant improvement in dense packing he will feel his return on investment is quite poor.

Dr. Knudsen from Australia commented on the law of diminishing return in a hair transplant. He demonstrated that if an area is completely bald and 25 grafts are placed in the area, the patient notices significant improvement due to the perception of significantly reduced baldness. The patient may perhaps feel he is only half as bald as before or have a 50% improvement. If another 25 grafts are placed in the same area he may only visually detect a 25% improvement in appearance while he was expecting another 50% improvement. Dr. Knudsen further commented that a patient's expectation is what ultimately determines his satisfaction. Even if the patient can be shown under a microscope that he was given another 25 Grafts/cm2 he still may not be satisfied since his expectations were not achieved. The doctors discussed that meeting a patient's expectations is just as important as the technical merit of the surgery.

During the second part of the presentation Dr. Jimenez showed that the medical textbook illustrations of hair follicles and arrector pili muscles are incorrect. The illustrations in our medical textbooks have always shown that each hair follicle has one arrector pili muscle attached to it. However, Dr. Jimenez's research has shown that there is arrector pili muscle for the entire follicular unit, which divides into sub-parts for each hair follicle, similar to branches of a tree. It is thus the arrector pili that defines the follicular unit or follicular group as we know it. Underneath the skin hair follicles may splay out in many directions. The tight grouping of follicles above the skin is due to the arrector pili's attachment to these follicles. Dr. Jimenez created a new medical illustration of how he believes the arrector pili muscle grows around the follicular unit and he will be presenting his research to medical textbook publishers to recommend a change to current skin anatomy publications.

One of his slide headlines: "Now is time to change our anatomic view of the AP muscle" effectively summarized his presentation.

• Dr. Cole commended Dr. Jiminez for redefining the follicular unit as we know it.
• Dr. Minotakis discussed Dr. Beehner's article on problems in the industry
• Russel Knudsen discussed the problem of hair dressers in the industry where hair dressers give advice to patients. 98% of men are told to avoid hair transplants.
• Discussion of making 90%-100% of donor scars undetectable
• Discussion of the need for training other doctors and competition amongst physicians rather than working together.
• Also a discussion of how it's getting harder and harder to get patients.
• Discussion of pitting: Cole commented doctors must thoroughly supervise techs and are responsible for technician mistakes
• Dr. Cole discussed strip vs. FIT on young patients and the benefits of minimal trauma from FIT.
• Scalp reductions were discussed in detail and how they've fallen out of patient favor even some good results have been achieved through scalp lifts.
• FUE vs. Strip scarring: are some patients more prone to scarring, whether it's FUE or strip? We discussed the pros and cons of the dimpled golf ball look of FUE/FIT vs. linear scar of strip.
• Internet forums: There was a discussion of entrepreneur owend forums vs. doctor controlled. I got to chime in here and mention that a little negativity breeds credibility. If a forum is owned by a doctor and it is nothing more than an infomercial for a doctor it has no credibility. I expressed that I feel an objective, independent forum is better for the doctors in the long run.

I joined the revelers aboard Mr. Giotis' sailboat where Stelio continued to perform late into the night. I wasn't sure when the singing and dancing would end. We spent the night docked at Hydra, but one quickly learns not to expect much sleep in Greece.