What Dermatologists Will Lose

We have to claim back what we started

That was the message that was echoed in a luxury hotel conference room this weekend at the American Academy of Dermatology’s annual meeting.

Dr. Paul Rose, a tenured dermatologist, and an avid robotic hair restoration surgeon opened with a story to a packed room of dermatologists.

Many, if not all, had never done hair restoration in their practice.

Dr. Rose urged his peers that although hair restoration has many non-dermatologists practicing the art with fantastic results, he felt that dermatologists were the physicians best suited to take this procedure on.

This was because of their extensive training and deep understanding of underlying pathologies that cause hair loss.

However, the story goes deeper than that.

That's because the conception of hair restoration is deeply rooted in the history of dermatology.

The First Strand

The first successful hair transplants were carried out by Professor Dom Unger in Germany in 1822.

A medical student named Diffenbach detailed how procedures were carried out on humans and animals, and that Professor Unger believed hair transplantations would make baldness “a rarity in the future”.

The only problem was that it received most of its attention in the 19th century from “medicine men”, who are best known as “snake-oil salesman”.

They traveled from town to town in painted wagons and also happened to be great at marketing (by 19th century standards, that is).

Newspapers carried advertisements for remedies that claimed to do everything from cure cancer to putting hair back on the bald scalp.

Treating baldness received no real attention until one faithful year the technique took a big, innovative step.

To appreciate the history of hair and dermatology, we start where it all first took off; Japan.

Domo Arigato

The year was 1939 and a Japanese dermatologist named Dr. Okuda first described punch technique.

Dr. Okuda developed a breakthrough process to restore hair loss used by a punch technique in a post burn patient.

In transplanting skin grafts, he was not intending on observing hair growth.

Then, in 1943, another Japanese surgeon named Tamura had treated 137 cases of non-androgenetic alopecia of various etiologies using techniques very similar to modern-day hair transplantation.

Dr. Tamura transplanted micro-implants of 1 - 3 hairs to restore female pubic hair.

Making an elliptical incision that was later sutured closed, Tamura harvested donor micrografts and prepared recipient sites using a thick needle.

Dr. Tamura found that single-hair grafting resulted in growth practically indistinguishable from naturally grown hair.

This translated to a more natural look than hair transplants using larger punch grafts.

Nevertheless, it would take several decades for Western surgeons to embrace the wisdom of Tamura’s insights as World War II effectively halted the flow of these findings out of Japan.

What’s amazing was that the reports Okuda created on treating traumatic alopecia were in Japanese and were not seen outside Japan for many years.

Somehow a magical thing happened; his technique was almost identical to the first reported hair transplant in the United States in 1959.

For an added twist, the first reported case in the U.S. was also used to treat androgenetic alopecia (vs traumatic alopecia in Japan).

Different pathologies, no communication, yet the techniques were mysteriously the same.

Coming to America

1959 gave birth to the modern wave of hair transplantation for treating androgenetic alopecia.  

That year, dermatologist Dr. Norman Orentreich, MD, published a paper on that transplantation technique.

Again, it was a dermatologist that elevated the innovation of hair transplantation techniques.

The significance of this paper in pushing the techniques adoption was that it presented a physiologic basis for successful hair transplantation - the concept of "donor dominance" and "recipient dominance".

The donor dominance concept explained the contradictory results of many previous hair transplantation studies.

Showing that the success of hair transplants for androgenetic alopecia is dependent on donor dominance, Dr. Orentreich blazed a trail in the U.S. and added momentum to Japanese dermatologists Dr. Okuda and Dr. Tamura’s original work.  

Dermatology driven research published in the 1950s and 1960s also confirmed that so-called "male-pattern baldness" is an inherited condition, treatable by hair transplantation.

These findings put to rest other hypotheses regarding the cause of male-pattern baldness-among them, the theory that movement of the scalp muscles would, over a long period of time, incapacitate hair follicles, and cause hair loss.

Dr. Orentreich's 1959 paper marked the beginning of a new and modern era of hair transplantation.

The science and art of hair transplantation then progressed together, with the science developing techniques for harvesting and transplanting even a single hair follicle.

However, the work carried out by pioneers such as Orentreich, Stough, Ayres and Rabineau mirrored the 4mm, “punch” technique of Okuda, rather than the “micrograft” technique of Tamura.

Doll Hair

In the 1960s and 70s, Physicians first began performing hair transplants for cosmetic improvement.

However, their first attempts were unsuccessful as the hair results came out as a “bristle brush-baby doll” appearance.

Why was this happening? The grafts contained an astounding 15 to 25 hairs!

Although it is easy to look back critically on these procedures, they did provide important findings that are still valuable today.

Minimally Invasive for Maximum Results

In 1984, Dr. Wayne Bradshaw introduced the idea of making small incisions into the recipient area, then filling those incisions with what he called mini-grafts.

These grafts contained only six to eight hairs, but still resembled the “plug” effect of the previous decades.

Surgery is an art rooted in science, and the art soon followed in the steps of science and took flight by refining these grafts.

Micrografts, Minigrafts, and Hair Plugs

Micrografts and minigrafts were the next logical progression from hair plugs, which used a large 4 millimeter or 5 millimeter punch device to scoop out the donor hairs for transplantation.

Micrografts, and even the larger minigrafts, were much smaller than hair plugs, which often left unsightly scars and other noticeable complications. 

Minigrafts and micrografts evolved into follicular units when the stereoscopic microscope was introduced into the field of hair restoration by Dr. Bobby Limmer from Austin, Texas. 

And yes, he was also a dermatologist.

A 1997 study compares both mini-and-micro-grafts after observing ninety grafting sessions.

Even though 10% of the patients experienced cysts, the study shows that the patients enjoyed a 97% satisfaction rate.

This was nearly twenty years ago, however, and techniques have evolved considerably since then.

The minigrafts (3 to 5 hairs) evolved into micrografts (1 to 3 hairs) to create an entirely natural look on the transplanted scalp.

The Modern Era

The techniques continued to progress in the 1990s with significant improvements in the number of hairs per graft fell below six and the number of graft transplants per session simultaneously increased between 1600 and 3000.

This was the mark of a liberated future of surgery, where incisions were becoming smaller and efficacy was being optimized to a new level of patient care.

History rarely repeats itself, but it definitely rhymes.

Hair’s Rhyming History

Follicular unit extraction (FUE) was first described by Masumi Inaba in Japan in 1988 who introduced the use of a 1-mm needle for extracting follicular units.

FUE was then successfully conducted on public patients by Dr. Ray Woods in Australia in 1989 and was filmed for the 'Good Medicine' program for the first time in 1996.

As dermatology history uttered a lyrical rhyme, the U.S. helped in popularizing another hair transplant technique that we owe the Japanese credit for finding.

A Liberated Step into the Future

In 2002, a groundbreaking publication by Dr. William R. Rassman and Dr. Robert M. Bernstein described the technique in their publication “Follicular Unit Extraction: Minimally Invasive Surgery for Hair Transplantation.”

For me, this was an exciting moment in hair restoration history as it involved a profound collaboration between a non-dermatologist (cardiovascular surgeon Dr. Rassman) and a heavily trained dermatologist (Dr. Bernstein).

Personally, I feel that this was a tipping point for modern hair restoration.

Between Dr. Rassman's training as a war surgeon and mentorship under one of the fathers of modern heart surgery (Dr. C.W. Lillehei) and Dr. Bernstein's heavy aesthetic and restorative surgical training, it was a big step into a liberated future of hair.

This is when things got really interesting.

Smaller Cuts, Better Grafts

Photo Courtesy of Medivia Clinic

In the past decade, FUE has grown in popularity, offering state-of-the-art combinations of different size grafts (e.g., from one to six hairs) to make endless variations of placing the hair to create a natural look.

While the surgical technique is still important, sound aesthetic judgment is also a must if surgeons are to deliver virtually undetectable hair restorations.

The emergence of Follicular Unit Extraction (FUE) for hair transplant surgery created a paradigm shift for the hair transplant world.

Hair transplantation began to evolve from primitive beginnings into the more sophisticated and advanced form of hair restoration.

This also pushed the industry to new technological heights, changing both the public’s demand for what has been promoted as a minimally invasive surgery and the need for service providers’ to fulfill the demands of this process.

Two catalysts account for this: Patients and Physicians.

Patients were unwilling to undergo a hair transplant when it appeared to be an invasive surgery producing a visible linear donor scar and varying degrees of post-operative pain.

Stylish young men also wanted to wear their hair short without a visible linear scar.

Physicians wanting to enter the business could not put together the complex infrastructure to deliver a quality strip-harvesting procedure requiring teams of highly skilled nurses and/or technicians to dissect the grafts.

When introduced in 2002 through an oral presentation at the International Society for Hair Restoration Surgeon’s meeting, DVDs were also made available to all physicians in attendance.

This unfortunately inspired a mentality of "see one, do one", and doctors from across the globe who adopted the technique after viewing the DVD without any training.

Medical Macgyver 

Much like the famous MacGyver show, physicians have a talent to innovate on the spot to overcome obstacles.

The problem is that this isn't always the best approach.

For those who don't know, medicine has an effective learning method of "watch one, do one, teach one". However, once in practice with little training available one tends to be self-reliant.

Many doctors’ then immediately started to perform the FUE procedure. Most who tried produced what Rassman described as "Follicular Holocaust".

Inexperienced physicians also embarked on aggressive marketing campaigns with their own inhouse techniques they developed.

Although FUE turned out to be more difficult than most doctors realized, nevertheless, many doctors were motivated to include this technology into their patient offerings.

More and more patients wanted it, thus more and more and more physicians felt compelled to offer it in their practice.

The challenges met along the harsh learning curve in FUE techniques were many.

It was just as simple as implanting new follicular cores and reap the benefits of the initial yield.

Afer a 5-7 month, initial growth period for grafts, failures became apparent once this initial growth cycle slowed down.

Failure for grafts to grow was a rude awakening that the doctor did not control the process.

With the absence of available training at the time and a long learning curve, this stimulated doctors to ‘invent’ technologies on the fly to solve what was perceived to be simply, a mechanical ‘instrument’ problem.

Many patients experienced failures while the doctors learned to adapt their techniques, one step and one patient at a time. 

Coming from the world of spine and neurosurgery, my first initial reaction was "what about the medtech industry"?

Well, unlike other new technologies in medicine and surgery such as surgical staples and endoscopy where large companies became involved in the education and the dissemination of the technology, no such evolution occurred in FUE hair transplantation.

This left doctors figure out solutions to the problems of FUE failures on their own.

So, they did what they could with what they had.

ADVANCEMENTS IN FUE

The last half-decade has given way to a variety of new techniques in FUE.

Handheld devices that were loosely marketed as "automated" were adopted. These devices claimed to give a faster extraction rate of grafts in a limited time. However, there is greater pulling and twisting of grafts which puts the graft at risk of damage, resulting in greater transection.

Still, they were a much better option to what was done prior. FUE pioneer Dr. Bernstein explains the progression of these technologies.

Robots were eventually introduced and seem to have addressed many of the issues that early FUE had, which was being hand held and with a human bias.

The coring process associated with FUE requires that the operator has good eyesight and proper magnification, but proper instrument alignment alone did not solve all of the problems encountered with FUE in the hands of many surgeons.

The ARTAS System developed by Restoration Robotics, according to Rassman, solved many of these problems for the surgeon.

Robots have been found to enhance and extend human capabilities in surgery. One large advantage is providing accuracy and repeatability may reach the sub-millimetre level.

A robot like ARTAS can be optimized to perform tasks demanding a high amount of precision at fast speeds, automatically and tirelessly, thus increasing productivity and efficiency.

An important conclusion from this is that the performance output is consistent and predictable.

These technical strengths may make them suitable for a number of hair transplantation tasks, such as FUE.

Returning Back to Whence They Came

Dermatologists have to heed the warnings of the medical jungle.

It wasn't long ago that general surgeons had pioneered procedures and were doing everything imaginable.

Now, it's sad to see that many are having difficulty surviving as other specialties have poached away procedures that were once theirs.

Dermatologists must recognize that this can happen to them too. Actually, it already is.

With the introduction of robotics and other technologies, the art and science of hair restoration are in the hands of physicians who will usher it into the new digital age.

With machine vision, artificial intelligence, and unparalleled speed and accuracy, it's easy to get through an even smaller learning curve.

Dermatologists owe it to their history and its pioneers to learn this art, continue to push the science, and honor the work that has been done for them to reap.

For if they don't, someone else among their medical peers in the competitive world of modern medicine will.

Omar M. Khateeb is an unorthodox and innovative medical device marketing leader with a background in science and medicine. 

He publishes an article a week on LinkedIn, drawing from various sources.

His interests reside in sales psychology, neuromarketing, and self-development practices. He often reads 2-3 books a week and combines concepts to execute strategies in new ways.

Check out his virtual bookshelf here to find your next great read, and connect with him on LinkedIn, Twitter, or SnapChat.