On Wednesday morning we started our day on the cosmopolitan island of Hydra. The scientific program had more fascinating speeches from the world's leading hair transplant physicians. The program was as follows:

Dr. Russel Knudsen: What exactly is state of the art?

Summary: The thesis of Dr. Knudsen's discussion was that most hair transplant surgeons aim to practice at "Start of the Art," but the reality is that "State of the Art" means different things to different surgeons.

Many surgeons feel a state of the art hair transplant needs microscopes to dissect strip generated FU grafts while others feel abandoning strip all together and only offering FUE/FIT is state of the art. There is also not a clear standard on defining State of the Art for graft density. Most can generally agree that smaller grafts, better tools, and technical precision are a basis for defining state of the art in hair transplantation.

Since an exact standard of "State of the Art" in hair transplantation cannot be universally defined, Dr. Knudsen feels we should define the minimum requirements of "State of the Art" that all surgeons can agree on.

The minimum requirement categories to achieve technical expertise include grafting standards, level of training and experience of both the staff and surgeon, frequency of surgery, surgery magnification, and minimum standards for alopecia reduction.

Following the technical portion, Dr. Knudsen addressed the artistic component of "State of the Art" surgery. He identified patient selection as the single most important component of successful artistic practice. Patient selection is influenced by degree of balding, donor hair characteristics, and a patient's expectation.

Once a good candidate has been the selected the surgeon must focus the artistic elements of correct hairline design, blending of graft size at the hairline, angulation of the grafts, minimization of scarring, pitting & compression, management of crown balding, and possible integration of alopecia reduction surgery into overall surgical planning.

The final component he discussed was combined medical and surgical therapy. Dr. Knudsen identified the ethical need to discuss with most patients the potential benefits of medical therapy such as Propecia & Rogaine, delaying surgery to assess the benefit of medical therapy, and proper management of younger patients, primarily those under 25 years old.

Dr. Knudsen concluded that there is no exact, binding definition of “state-of-the-art” and surgeons should aim to adhere to widely accepted, modern definitions of minimum standards of practice

Summary: Mr. Giotis is the Chairman of the DHI Medical Group. His presentation focused on the future of hair restoration and marketing in the hair transplant industry with the following topics:

Mega Sessions Versus Mini Sessions:

DHI is noticing a patient trend towards smaller graft sessions of 100-400 grafts. DHI seeks to bring an end to hair transplant mega-sessions with a "less is more" concept.

Fewer grafts per transplant procedure is usually less traumatic, are within everyone's financial reach, give patients more control, minimizes fear of surgery, and might give a better result due to less scalp trauma and possible higher growth yields. For a good number of patients a small number of grafts may be all they need to achieve a satisfactory outcome.

Mr. Giotis noted it's much easier for patients to afford 500 graft sessions than 3000 graft sessions. A patient is much more likely to get started on the road to surgical recovery if he only has to come up with $2,500 as compared to $15,000 for the transplant procedure.

With only a slight exaggeration, Mr. Giotis commented that patients can stop by their nearest DHI clinic "every week" for the number of grafts they can afford or need. Realistically every few months the patient can return for more surgery as finances permit. FIT offers this advantage more than strip as excessive strip harvesting can produce larger donor scars while small FIT sessions can be done as often as needed without the risk of excessive strip scarring.

Strip Vs. FUE/FIT

Following the discussion of mega sessions vs. mini sessions, Mr. Giotis presented six reasons that FUE/FIT is a dream procedure from a marketing perspective.

1. No Donor Scars: With FUE/FIT there is no risk of donor scars that need to be removed later or have hair follicles planted into them
2. Less Patient Apprehension: FUE/FIT quells patient fears about trauma of surgery
3. No Dishonesty: FUE/FIT has been thoroughly documented over the Internet eliminating eliminating any chance for clinics to misrepresent the procedure.
4. Undetectable result: FUE/FIT donor sites are virtually undetectable once healed
5. More options: FUE/FIT gives patients another option. Patients like to have a choice even if they decide to go with the strip procedure.
6. Simplicity: Fit is much simpler procedure and in the hands of marketing experts it can produce wonders

A DHI study of 25 questions proves that patients focused on 3 or 4 surgical points of interest and very few are interested for in-depth research. Mr. Giotis presented the results of the study which can be viewed in the attached Powerpoint.

DHI Marketing Strategy:

The future is now for DHI. DHI has established the first global network of hair surgeons and clinics that will be committed to quality results. DHI clinics offer training, marketing, advertising, several web sites, and global recognition

DHI feels the future belongs to large medical groups with more than one doctor and one office, with commitment to quality results. Through a well organized network hair restoration will be offered in every large and small city of the globe by well trained hair surgeons affiliated with large medical groups such as the DHI GLOBAL NETWORK

Brad Wolf: Coronal Incisions (Lateral Slits)

Summary: Dr. Brad Wolf presented a video of his placement technique with Coronal incisions and he expressed his satisfaction the quality results of coronal incisions versus other placement methods. Dr. Cole quickly countered that he's debated Dr. Victor Hasson many times over the use of lateral slits as not being the best method. He discussed his belief in following the scalp's natural logarithmic spirals. Despite Cole's adamant belief in his logarithmic spiral concept, Dr. Wolf feels he obtains excellent aesthetic results from coronal incisions and feels they are best placement technique available today.

Dr. John Cole: Follicular Isolation Technique (F.I.T.)

Summary: Dr Cole opened his presentation with controversy when he stated his belief that surgeons performing strip excision procedure may not be offering the best medical option for the patient. After a lot of heated and spirited debate with the other physicians he then agreed that may have been premature in stating that as the data for FIT is not yet in.

Dr. Cole went on to present his FIT technique and discuss the variations of it such as Woods/FUE/FOX.

This was the first time that results from FUE/FIT and a detailed discussion of this technique have been presented in an international medical forum. Dr. Cole briefly discussed the FOX test offered by NHI that most patients fail. He feels this is because it can take up to a couple hundred grafts for the physician to become adept at removing the follicular groups of hair for each patient. If a biopsy is limited to only 10 FUE/FIT grafts, many patients will fail the test when they are likely good candidates for the procedure.

Dr. Cole presented some slides on how follicular units grow in logarithmic spirals around a center point. He feels surgeons should copy these natural logarithmic spirals during the placement of grafts. I asked how he could determine the spiral pattern in a completely bald area. He responded that the doctor can see the miniaturized hair growth under a microscope and still be able to copy the original logarithmic spiral pattern. Dr. Cole also presented some slides on how a strip procedure destroys the structural anatomy of the scalp because the natural spiral patterns of the donor site weren't sutured together properly after the strip section was removed. Dr. Cooley countered that the surgeon could align the growth patterns with a properly closed suture to preserve the structural anatomy of the scalp. Dr. Cole agreed it was possible to preserve the structural anatomy of the scalp, although most surgeons weren't careful enough to do so. With a FIT procedure, the surgeon wouldn't risk destroying the structural anatomy of the scalp.

Dr. Paul Rose: Difficulties in F.I.T.

Summary: Dr. Paul Rose played devil's advocate to Dr Cole's unabashed support of FIT by discussing the difficulties of the Follicular Isolation technique. FIT is more expensive, more time consuming, and patients must be advised of the pros and cons of strip and FIT. Dr. Rose demonstrated the instruments he's developed for FIT and also suggested practicing FIT in a dissected strip before attempting the procedure on the scalp.