The International Society of Hair Restoration Surgery, ISHRS, USA, is well known for its endeavours to promote education in Hair Transplant. Continuing with the same, the ISHRS recently organised a hair transplant workshop in Manchester, UK from 10-12^th June 2016. The workshop was hosted by the stalwart in the Hair Transplant field, Dr. Bessam Farjo. It was well attended by over 50 delegates and 12 faculties.

The 3 day workshopheld in Midlands Hotel, Manchester,started with a lecture on fair consultationin Hair Transplant which highlighted when to say “YES” and when to say “No” to the patients of baldness for Hair Transplant. He suggested that the patients with very high expectations and the ones with very poor donor areas should not be taken up for the surgery. He also said that the patents should be shown and explained the realistic results of the hair transplant for better satisfaction.

This was followed by an elaborate discussion on various types of motors and punches available for Hair Transplant by Dr. Robert True. He shared his experience of having used a large variety of machines and the compared the blunt v/s flat v/s sharp punches. He also shared that after having used all machines, he now finds that the flat punches are the best for him. Then Dr. Jean Devroye discussed the various parameters of FUEquality index including the measurement and role of follicular transection rates in FUE hair transplant. The artistic section of hairline designing was then discussed by Dr. Arthur Tykocinski from Brazil in which he highlighted the various nitty gritties of designing the hairline. Moving next, recipients and sites & Graft planting discussed by Dr. Brad Wolf and Anaesthesia by Dr. Alex Ginzburg.

Dr. Bessam Farjo then presented the latest Robotic FUE Advances in which he showed how the Artas Robot has made advances over the past couple of years including the increased speed of extraction and the introduction of the new slit making by Robot and efforts to start implantation with machine only.
This was followed by a faculty panel discussion on how to achieve the best results in Hair Transplantation; Safe Donor Area in FUE and FUE ergonomics. The whole faculty participated actively in it and the delegates got a lot of value from the same. It was discussed in detail about how to select the right kind of punch for different types of patients. The author highlighted that he prefers the dull punch for the scalp which helps him to keep the total transections to less than 1% in FUE. However, he shared that he chooses sharp punches when it comes to the body hair extractions (beard and chest) which makes it easier for him to extract the grafts in this area as compared to the dull punch. Apart from this, the different panelists shared how to select the different diameter and the length of shaft of the punch. The common mistakes made during extraction were also discussed. The role of trauma to the grafts & dehydration during the implanation were also discussed. In the Safe Donor Area discussion, the author highlighted that how over harvesting in FUE has led to permanent scarring and hair depletion in the donor area leading to a see through appearance. In the FUE ergonomics discussion, the role of higher magnification,role of proper lighting,proper posture of the patient and the doctor was discussed in detail which increasing the productivity of the FUE surgery.

The action then shifted to Dr. Farjo’s clinic where the faculty demonstrated live surgeries on 3 patients in 3 operating rooms. The delegates were divided into 4 groups. Three groups were in the OR and the 4th one was made to sit in the Video room where a live feed of the surgery was shown. In OR1, Dr. Arthor Tykocinski and Dr. Brad Wolf demonstrated the FUT in a female patient with traction alopecia. They harvested the strip very neatly which was practically bloodless. In OR 2, Dr. Jean Devroye and Dr. Robert True demonstrated FUE on a 32 year old young male with NH grd III. Dr. Devroye demonstrated the use of his machine in which he has made the use of the foot pedal like that of sewing machine. In the OR 3, Dr. Bessam Farjo, demonstrated the surgery on a male patient by the Artas Robot.He showed in detail the different parts of the machine like the mapping of the donor area by the robot, the double punch technique used for extraction, the tensioner, the role of the remote control, and how the variables can be altered. While the delegates were seing live surgery in the Operating rooms, the questions of the delgates in the Vidoe room were taken up in turns by Dr. Jerry Cooley, Dr. Marcio Cristostomo & the author. All the three worked hard to clear the different aspects of the hair transplant. The live surgeries continued till evening when the delegates remained glued to the operating rooms and the video room. This was followed by a warm welcome reception in a nearby pub, Sakana.

The day 2 started off with discussion on the best practices in FUT. He shared his pearls of wisdom which have made it possible to give an imperceptible scars in FUT. The role of holding solutions, role of trauma, dehydration and ischemia and reperfusion injury were discussed in detailed by Dr. Jerry Cooley in his topic on Maximizing Graft Survival. ThenDr. Marcio Crisostomo from Brazil discussed how combination of FUE and FUT surgery has helped him to give more than 4000- 5000 grafts for covering the advance grades of baldness. He usually leaves an area of donor area untouched equal to the size of strip above or below the strip which can be used in the second surgery. Then Dr. Patrick Mwamba discussed his technique for black patients in which he highlighted the he uses usually a wide diameter punch and tries to remain superficial at the time of removing the grafts.
Then the author discussed the role of body hair as a FUE donor area. He highlighted that the beard,the chest, the abdomen, the arms and the legs can be used as an alternative source for harvesting grafts by FUE technique.Out of these, beard is the best source after the scalp as the percentage of hair in the anagen ( growing phase) are maximum for the beard ( 70%) as compared to the other body parts.Apart from this, the anagen phase of chest hair is more ( 1-2 years) as a result of which that is also a very good source of body hair. Then the modifications in the technique of harvesting of FUE grafts which include the use of sharp punches, lesser diameter of the punch, superficial scoring and lesser length of the shaft of the punches was discussed in detail. The art of giving anaesthesia in the beard and the chest area was also discussed in detail. Then the results of different patients who had undergone anywhere from 2000 to 4000 body hair grafts were shown and discussed which was highly applauded by the people.This was followed by Dr. Jerry Cooley’s talk on PRP and the role of Adjuvant Therapies in improving the hair growth.
This was followed by panel discussion on FUE vs FUT and how to minimize the white dots in FUE; beard transplant and complications in FUE. It was pointed out that although FUE is becoming very popular nowdays but still there is a scope for FUT in today’s world especially when you have a patient with thin donor hair who want to undergo the surgery and in combination hair transplant surgeries. In how to minimize white dots it was pointed out that there is a racialdifference in people from different areas like the white dots are less prominent in caucasians as compared to that of the people from Indian subcontinent. So it was discussed that the number of grafts which are taken out in one go should be limited to around 15-20% and to remove the rest in successive surgeries ( again 15-20% each time to a total of 50%) to decrease the white dots appearance. Apart from that some surgeons also suggested that you can go in for scalp micro pigmentation to decrease the effect of white dots in the donor area. In the beard transplant, the author shared that for smaller area in the beard, the beard itself can be used as a source for the graft harvesting, however for larger areas the grafts are usually obtained from scalp only which can be done primarily by FUE and sometime by strip as well. The main challenge is at the time of slit making as the skin is very lax and tends to get closed at the time of implantation so again stretching of skin is required at that time to facilitate the entry of the grafts in the slit. Another challenge is at the time of administring local anaesthesia when the patient feels a lot of pain. So, the authors prefer to give nerve blocks in this area to decrease the pain sensation of the patients. Then the complications of FUE were discussed in which over harvesting, scarring and loss of hair in donor area because of overaggresive FUE was highligthed. All the beginners were advised not to go for a mega sessions of FUE and to increase slowly the number of grafts to give good results.
Then second part of the Day 2 was again in Dr. Farjo’s clinic where the focus shifted on to the live surgery demonstration. In OR1, Dr. Jerry Cooley demonstrated FUT in the female patient. In OR2, the author operated upon the same male patient ( the other half of donor area) by FUE technique which had been operated upon by Dr. Devroye the day before. He highlighted the 7 steps of the surgery with his customised dull punches which included how to give local anaesthesiain donor area, 2nd , the infiltration of donor area (around 0.5 ml/ cm2) and not tumescense; 3rd, traction counter traction; 4th ,alignment of the punches along the exit angle of the hair, 5th, engagement of the punch, 6th, the advancement of the punch and the 7th,simultaneous removal of grafts. He highlighted how the simultaneous removal of grafts has led to increase in the speed of the grafts. His partial transection rates were 2.97% as shown in the picture below and his total transections were very less than 1% which was highlyapplauded by the delegates and the rest of the faculty. Then there was also a demonstration of FUE by Dr. Marcio in which he demonstrated FUE in a very good way. Apart from that Dr. Alex Ginzburg demonstrated FUE on another patient. In OR3, Dr. TK Shia demonstrated his latest machine of extarcting grafts which is very useful for the new entrants in the field of hair restoration. His machine uses a mechanism by which the punch goes into the skin to a limited depth only guided by the sensors. The limited depth penetration gives the beginners the confidence to go ahead with extraction without much fear of transections. Then, there was also demonstration of PRP injection using the angel system by Dr. Jerry Cooley. The surgeries concluded in the evning which was followed by the by the lavish Gala Dinner.

It was held in the Science and & Industry museum. The food was excellent. The faculty were given awards by the host. The ISHRS ambassador, Dr. Arthur Tycosinki applauded the overall effort, planning and execution of the event by Dr. Bessam Farjo and his team. This was followed by a very good music and dance by the deleagtes and the hosts.

The day 3 was a half day event which started with a live patient hairline design workshop in which all the faculty participated. All the important points for hairline designing including the mid frontal point, the frontotemporal angle and temporal pointswere discussed; and when to do and when not to do was clearly highlighted. It was conveyed to the delegates that they should try to avoid creating the temporal points in the young patients as later on with the persistent hair loss, only island of hair separate from the rest of the hairs might be left over there. Then the role of giving the conservative hairline and the importance of giving proper frontotemporal angles was also discussed. After this another panel discussion on pre op, post op, staffing, FUE automation and micro pigmentation was done in which some people said that they do not do any pre-operative tests but the author highlighted that in India it is imperative to do the viral tests. They always do the viral test of HIV, HepatitisB and Hepatitis C before taking the patient for the surgery. In the post op care, the role of spraying of normal saline and the different protocols to decrease the scab formation was also highlighted. Some doctors advise their to patients do it after every 15 mins whereas others do it after half an hour and some every hourly. Then Dr. Jerry Cooley pointed out that he is using a post-operative spray containing copper peptide and Dr. Mwamba said that he is using solution with diluted silver nitrate solution for post op spraying. The micro pigmentation and the role and use of pigmentation was discussed by all the faculty.The workshop was declared closed at 11.00 am with the closing remarks by Dr. Bessam Farjo. It was a wonderful learning experience for the delegates as well as the faculty who had learnt a lot by interacting with their experienced colleagues.