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DR. HARRIS AT THE FOREFRONT
OF RESEARCH
Dr. Harris is committed to remaining at the forefront of developments related to the field of hair loss and restoration. He is both an active researcher and a teacher at the University of Colorado. Following are summaries of some of Dr. Harris' latest research studies involving hair loss and restoration, all of which have been presented at physician meetings around the country.
Title: The SAFE System: New Instrumentation and Methodology to Improve Follicular Unit Extraction
Introduction: The technique of follicular unit extraction (FUE) as described by Dr.'s Rassman and Bernstein is technically demanding, time consuming, and there is the possibility of high rates of follicle damage. In the study by Rassman, Bernstein, et al, 37.5% of patients were FOX® negative or "not" candidates for FUE due to the high rates of follicle damage. Even for FOX positive patients (candidates for the procedure), the rate of follicle transection may be as high as 20%.
Some of the factors related to the high follicle transection rate are curvature of the follicle below the epidermis and excessive tethering of the follicle to the subdermal tissue by connective tissue components. The author of this report has devised a methodology and surgical instrumentation to address these problems that has resulted in a reduction of the transection rate, an increase in the speed of extraction, and an expansion of patient candidacy.
Objective: To present the surgical methodology and instrumentation, the SAFE System, that, when applied to FUE, will result in minimal transection rates, expand patient candidacy, and significantly increase extraction rates.
Materials/Methods: Cases of FUE with the new methodology and instrumentation are documented with still photography and video. Graft production and transection rates were calculated and recorded. An evaluation of patient candidacy based on transection rates is presented.
Discussion/Results: Over 40 patients have been subjects of this new methodology and instrumentation. The range of grafts extracted in this series has been between 50 and 1400 grafts. Transection rates of hair follicles have ranged from 0% to 8% thus far. All patients so far would be considered FOX positive or candidates for FUE using the SAFE System, as the follicle damage rate is less than 20%. The rate of follicle extraction has been as high as 300 grafts per hour. A test case on the extraction of 20 grafts each on an African American patient and a gray haired patient revealed a 0% transection rate.
Conclusion: The SAFE System for FUE compares favorably to, if not better than, traditional microscopic dissection. Follicle damage rates are comparable to, or less than, microscopic dissection in most patients and the rates are significantly less than traditional FUE. Graft production rates with this new technique are also significantly higher than traditional FUE methodology. The SAFE System has the capability to expand patient candidacy for FUE to virtually 100% of patients, including African Americans and those with gray hair.
Title: Follicular Unit Extraction (FUE) Versus Microscopic Dissection of Follicular Unit Grafts: A Study on Graft Survival and Growth with the Two Methods of Graft Production
Introduction: Follicular unit extraction (FUE) has several theoretical advantages over traditional harvesting techniques. Some of these are a more rapid recovery, minimal or undetectable scarring, more rapid graft growth, and the possible expansion of total available donor grafts. At a minimum, it has been implied that grafts obtained by FUE result in the same growth as those grafts obtained by microscopic dissection. To date, no studies have examined the growth of grafts obtained by FUE as compared to traditional dissection.
Objective: This purpose of this study was to investigate the survival and growth rates of grafts obtained by the FUE method as compared to grafts obtained by traditional microscopic dissection technique. An assessment was made of the growth of grafts planted immediately following extraction versus those grafts planted 3-4 hours following extraction.
Materials/Methods: A male patient undergoing follicular unit transplantation had four 1cm2 squares marked in the crown area, all devoid of visible hair. Each test square had 25 recipient sites created with a 1.2 mm blade; 3-hair follicular unit grafts were placed in each recipient site. As a control, microscopically dissected grafts placed within 4 hours of dissection were located in one of the four squares. FUE grafts placed within 4 hours of extraction are located in two of the squares. Finally one square contained FUE grafts placed within 5 minutes following their extraction.
Donor hair was obtained to measure the average hair shaft diameter to compare to the graft hair shaft diameter at 6 months.
An evaluation at 2, 4, 5, and 6 months included a hair count and macrophotography. At 6 months air samples from the test sites were measured to compare hair shaft diameters from the donor hair to the grafted hair.
Discussion/Results: There was no statistical difference in hair counts between the FUE grafts and the grafts obtained by microscopic dissection. The average hair shaft diameter of the FUE grafts was the same as the diameters of the donor area hair. FUE grafts placed immediately after extraction did not show more rapid growth than grafts placed after several hours in the holding solution.
Conclusion: FUE grafts appear to grow at the same rate and with the same success as grafts obtained by microscopic dissection. FUE, if performed properly, will result in the same results as traditional follicular unit transplantation. Immediate implantation of grafts will not result in more rapid growth.
Title: Application of the Hair Volume Index (HVI) in Obtaining a Target Hair Density
Introduction: The HVI is directly proportional to both hair volume and hair density and it correlates with the subjective visual density of an individual's hair. This may be useful for pre-operative consultations, as it may help to determine an accurate estimate of the number of hairs needed in the transplanted area, determining a target hair density.
Objective: To present a methodology utilizing the HVI for pre-operative assessments.
Materials and Methods: Obtain 25 hairs from the mid-portion of a proposed donor site on a transplant candidate. A Starrett micrometer is used to obtain mean hair shaft diameter.
Discussion/Results: The patient selects the desired final visual density (thin, moderate, dense), which correlates to a pre-determined HVI. The object is then to determine the number of hairs, given the average hair shaft diameter, that need to be placed in 1 cm2 to achieve the desired hair volume index (HVId). The HVI equation can be re-written to find the target hair density (HDt) in hairs/cm2 resulting equation is:
HDt = (HVId / HSD2) x 104
HDt = target hair density in hairs/cm2
HVId = desiredHVI correlating with visual density
HSD = average hair shaft diameter in microns
Conclusion: The HDt gives the surgeon an actual target for hair density given the patient's requirements for visual density. The ability to calculate this number is a function of the HVI and its relationship to visual density. Based upon the physician or clinic's capabilities regarding graft placement densities and the patient's hairs/follicular unit, an accurate estimate of the number of grafts and the number of sessions to meet the patient's expectations may be offered.
Title: Biodiversity of Hair Shaft Diameters
Introduction: Hair shaft diameter (HSD) has been shown by several authors to be a significant characteristic of hair relating to visual density. However, there has been no easy way to apply hair shaft diameter in a useful way to assist surgeons in pre-operative planning and patient education. This study will be the first step in determining how to apply the hair shaft diameter in this regard.
Objective: The purpose of this study is to measure hair shaft diameters using an inexpensive, readily available micrometer, in a sample group of patients to ascertain descriptive statistics. These statistics can be used to determine the correct sample size, the number of hairs which need to be sampled in any individual to obtain an estimate of the patient's average hair shaft diameter.
Materials and Methods: A Starrett digital micrometer was used to evaluate the hair shaft diameter from 50 consecutive transplant patients. The hair samples were taken from the mid-portion of the applicable donor strip and the diameters were recorded on the first one hundred hairs counted
Discussion/Results: A total of 5000 hairs in 50 subjects were sampled. Although the method of the instrument utilized and the inability to measure imperfect cylinder-like structures accurately, the device is readily available to any physician, relatively inexpensive, easy to use, and the results can be generally applied.
Conclusion: To obtain an average hair shaft diameter in most individuals, with a probability of 95% and a precision of +/- 3 microns, one must sample approximately 25 hairs. This information can then be utilized in subsequent patient evaluations to assess hair volume or a related index, such as the Hair Volume Index.
Title: Introduction of the Hair Volume Index (HVI) and its Correlation to Subjective Visual Hair Density
Introduction: It has been well documented that the visual density of hair is not only dependent on the absolute number of hairs in a given area but also on the hair volume, a function of the hair shaft diameter and length. The proposed HVI is an index that varies proportionately to a change in calculated volume of an individual hair and accounts for the number of hairs/cm2. A previous presentation postulates that an appropriate sample size to calculate the average hair shaft diameter is approximately 25 hairs. The equation for the HVI is:
HVI = (HSD / 100) x (#hairs/cm2)
HSD = average hair shaft diameter in microns
Objective: To obtain HVI ranges for patients with subjective evaluations of thin, medium, and dense hair.
Materials and Methods: Several patients with subjective evaluations of thin, medium and dense hair will be evaluated. In each patient an area of 1 cm2 will be identified, marked, and a hair count of non-vellus hairs performed. A sample of 25 hairs will be obtained (see Hair Shaft Diameter study) from the marked area and their diameters obtained with a Starrett micrometer. The average diameter will be calculated and the HVI calculated as per the above equation.
Discussion/Results: Preliminary results indicate that patients with an index less than 20 will have a thin appearance. When the index is in the range of 30 to 40, the hair will have a moderate density. Patients with indices greater than 60 will have a dense appearance. Photos of the various subjective densities will be presented.
Conclusion: The HVI proves to be a valuable correlate to visual hair density. This calculated value is easy to obtain with the use of a micrometer and a densitometer to estimate hair counts. The HVI allows for an objective quantification, in a single value, of hair volume and hair density for any given individual.
Additional topics of research and recent presentations include:
Introduction to Hair Restoration Workshop: Psychology of Hair Loss
This presentation deals initially with the patient's reaction to hair loss. The vulnerability of a patient and the ensuing emotional state of the patient may affect their ability to adequately make a treatment decision. Common reactions include panic, fear, denial, humiliation, desperation, fixation, and jealousy. We reviewed these reactions and their impact on the patient. An understanding of these reactions and their causes will help the physician guide the patient through these difficult times.
Once these reactions and emotions are identified the patient will be served well by evaluating his or her goals, verbalizing fears and thoughts about hair loss, and evaluating realistic treatment options. The role of the physician in this process was addressed.
The Use of Follicular Unit Grafts for Treatment of Scars and for Hair Transplant Repair
Dr. Harris presented a brief review of FUHT and discussed why their use is ideal for repair of scars and old style transplants. In addressing scar repairs, he talked about thermal and chemical burns, traumatic scars, and iatrogenic (caused by a physician performing surgery) scars. Examples of each type of scar case was given and the surgical theory and plan for each patient was presented. Dr. Harris also discussed the technical aspects of each type of repair. Within the presentation on scars, examples of specific repairs were also given, for example, eyelash, eyebrow and sideburns. Reconstruction of conditions such as androgenetic alopecia and triangular alopecia were also presented.
The principles behind the repair of poorly planned or executed transplants were discussed. The main complications of plugy appearance, compression, and abrupt hairlines were illustrated. An explanation of the techniques of thinning, graft removal, and camouflage was given and their use on specific patient cases was illustrated.
Hair Transplant Update - Instrumentation, Methodologies, Medications, and Cellular Technology
A discussion of what is new in hair transplantation was given. The lecture began by discussing instrumentation such as the hair implanter pen (HIP), computer controlled anesthesia delivery system (CCADS), and low level laser therapy (LLLT). The HIP, introduced in the last two years, seems to allow for more rapid implantation of grafts over manual implantation. However, due to the size of the apparatus, larger graft recipient sites are required. This then requires that the grafts cannot be placed as close and therefore will affect the visual density of the result.
The CCADS system is intended to reduce the pain of injecting local anesthesia by controlling the rate of injections. The system works well in most offices, however, in my experience, for some patients, the rate was still too fast causing more pain than our standard injection technique.
LLLT is an unproven laser technology still under investigation in clinical trials. There is no data to suggest that this technique will slow hair loss or cause hair to grow, and at $760 per hour to sit under the laser, I feel more investigation is required before patients spend the money and time in hopes of some success.
Finally, a review of the techniques of dense packing and coronal recipient sites was given and an explanation of how these techniques allow surgeons to give high-density appearances and the most natural results.
Follicular Unit Extraction (FUE) - Dr. Harris discussed advances in FUE, including the logic behind it, reasons to use this technique, and the advantages/disadvantages of the procedure. He also discussed a modification of the procedure that he introduced, allowing patients to have the procedure without having to shave their head, making the post-operative appearance much more natural.
Nizoral 2 percent shampoo and Dutasteride - both were introduced and the possible theraputic results were discussed.
Cell Multiplication, Cloning, Gene Therapy - Dr. Harris presented an update on each of these, including the cell types that may be important in follicle introduction and cloning, along with new research updates in this field. The genetic messengers that affect follicle growth and possibly new follicle growth, sonic hedgehog (SHH), noggin, and beta-catenin were also discussed. These are the potential targets for gene therapy in the treatment of hair loss.
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