Views Article
Hair Transplant Forum International 2002; Volume 12, No. 2, p49.
Follicular Unit Extraction: Open Harvesting and Closed-Mindedness
William R. Rassman, MD Los Angeles, New York
In the last issue, Dr. Mark Pomerantz's attack on the "discarded and obsolete" term "follicular unit extraction" was of great interest to me. It seems that the subject has made me (and my colleagues) a target of competitive persecution. For me it was de je vu. Rather than make this a personal attack on him in return, I would prefer to address the subject of change in medicine. Thus, I challenge each of you: How do I keep my mind open to change? The focus upon follicular unit extraction is far less important for this editorial, as time will tell if this new technique will secure a place in the future of hair transplantation.
The new procedure which my colleagues and I have recently introduced into our practice is termed Follicular Unit Extraction (FUE) and the technique to see which patients are candidates is called the FOX™ Test (FOllicular unit eXtraction Test). This procedure extracts the hair follicle directly out of the donor area without the classic donor incision. It is worth noting, just what our responsibilities are as surgeons with regard to new technologies, clinical research, and change in the practice of medicine. The AMA has printed guidelines for clinical research (Issued in 1984 and updated in 1994 ) and the way in which we manage a new technology that might benefit our patients.
In the ethical tradition expressed by Hippocrates and continuously affirmed thereafter, the role of the physician has been that of a healer who serves patients, a teacher who imparts knowledge of skills and techniques to colleagues, and a student who constantly seeks to keep abreast of new medical knowledge.
Physicians have an obligation to share their knowledge and skills and to report the results of clinical and laboratory research. Both positive and negative studies should be included even though they may not support the author's hypothesis. This tradition enhances patient care, leads to the early evaluation of new technologies, and permits the rapid dissemination of improved techniques.
The intentional withholding of new medical knowledge, skills, and techniques from colleagues for reasons of personal gain is detrimental to the medical profession and to society and is to be condemned.
Prompt presentation before scientific organizations and timely publication of clinical and laboratory research in scientific journals are essential elements in the foundation of good medical care.
I would like to begin by way of reference to a personal friend and mentor who died several years ago. Dr. C.W. Lillehei was the first person to perform modern open heart surgery (on a child with an ASD in 1954). He did not have a heart-lung machine (it was in development at that time), so instead of saying 'it can't be done' he attacked the problem by connecting one of the parent's femoral arteries to an afflicted child's femoral artery. Dr. Lillehei was a medical pioneer, ignorant that it could not be done, and driven by faith that the congenital heart disease was reparable. The rest is history, and open heart surgery was born. Fifty cases followed (note that the second child died on the table). Dr. Lillehei commented many times to me, how history might have been altered had the fate of the first two children been switched. Advances in medicine require a strong belief that the impossible is possible, and in the face of failure or what appears to be insurmountable challenge, the pioneer sees opportunities and possibilities that others are blind to. Working with this great man, who never knew the word 'impossible' taught me that there was always a better way to approach a problem. This concept was ingrained into the foundation of my surgical education. The key lesson here is that against many odds, Dr. Lillehei overcame what others believed were insurmountable hurdles. Progress was in the hands of a visionary who had the tenacity to say 'it can be done' while others said 'it can't'. He had more breakthroughs in open heart surgery than any man in the 20th century.
I have been fortunate, over the years, to be at the cutting edge in the new technologies in hair transplantation that have become standards all over the world. I was motivated by many people, particularly Dr. Robert Bernstein, who challenged my ideas and repeatedly brought new insights to my personal productive processes. At the 1995 Las Vegas ISHRS meeting I used the following quote which Dr. Shiell dubbed the "Quote of the Meeting": "Those who say it can't be done should not stand in the way of those who are doing it every day". What I was referring to was not the 23 patients I brought to Las Vegas with results worthy of close inspection, but a new and 'untested' procedure that had brought much consternation within our ranks (the megasession of which these patients were examples). I was only the most recent contributor to the work in megasessions. Each of my predecessors had taken their knocks from the 'establishment' of traditionalists for using techniques that were not standard for their time. I am sure that it was not an easy road for any of them. To some of us who were not in their shoes, we see their success and their fame today (e.g. Drs. Ubel and Lucus on larger sessions of small grafts, and Dr. Limmer on the importance of microscopic graft dissection, along with others). We have no sense of their pain during the early pioneering days when they took their vision into the clinical settings and squared off against competitors with what they felt was a better mouse trap, a better surgical procedure. Many of their critics were doctors who saw these new procedures as a threat to their practice rather than as an opportunity to improve what they could offer their own patients.
The history of the megasession and small graft evolution during my short tenure in this industry (1993-1995) as it directly impacted me provides an excellent example. I want to quote what some of our colleagues had said about what I was doing at that time.
Dr. Shiell (Forum - June 1993) Problems with Minigrafts ' The Transplant Is Not Thick Enough…. "Many patient express disappointment with the lack of density achieved after 3-4 sessions of minigrafts."
Dr. Lucas (Forum - January 1994) "For several months now patients … have been coming to me after megasessions with relatively significant necroses…" He further blamed poor blood supply, stating that only disappointing results can be achieved.
Dr. Norwood (Forum - January 1994) stated: "I have been hearing more and more reports of bad results with megasessions and dense packing… the number of grafts undoubtedly contributed in one way or another."
Dr. Bosley (Forum - January 1994) emphasized the need to use larger grafts if the patient's goal is greater density. He urged: "Scalp reduction, larger grafts (3.5mm grafts for density)" rather than smaller grafts or larger sessions.
Dr. Hitzig (Forum - January 1994): "I'm not suggesting that we go back to the 4.5 mm punch grafting, but 1000-3000 micrograft sessions cannot be the answer. …. Let's be honest, the advent of large micro and minigraft sessions has been pioneered primarily by physicians who have only recently come into this field and who do not have the experience and training to understand that proper artistic graft placement is more critical than large random transplant sessions on the patients head. With the great influx of physicians coming into this field there is a tendency for these physicians to push new concepts so that they can be recognized, do not let ambition be interpreted as experience."
Dr. Pierre Pouteaux (Forum - January 1994) "[megasessions] seem to me to be a Herculean task, full of danger. 'Premum nocere'. It is logical to take so many risks (dehydration, blood loss, etc….) for a cosmetic operation?"
Dr. Limmer (October 1994) stated: "I can assure you that a megasession of 2800 grafts does not make a full head of hair." Despite his strong negative criticism of the megasession, I would give him credit to note that in the same article he stated publicly his intention to explore the world of megasessions himself to get to know what others have learned.
Dr. Shiell (Forum December 1994), stated: "I am certainly glad that you [Dr. Norwood] are on the same wavelength as me on the matter of megaessions [and lasers]. Both may be the 'breakthrough of the decade' or the 'disaster of the decade'…. I can sympathize with the guys that have gone fully commercial with a huge staff and advertising expenses. They cannot afford to sit back and make a leisurely and scholarly decision about these matters. …. I am sure that with dense packing (400 micrografts on the hairline) there would be even more questionable growths. Bill Rassman's article on scalp reductions will throw an interesting 'cat amongst the pigeons' and I look forward to reading the howls of protest from the 'shrinkers' in the next edition."
Dr. Pomerantz (Forum - May 1995) stated: "I limit them [megasessions] to 1000-1200 grafts per session. I can do that many grafts without undue scarring of the donor area and without crowding the grafts. …….. I have seen the following problems in several patients (1) failure of most or all of a super-megasession's grafts to grow…. (2) Loss of a significant number or previously placed grafts." He goes on to discuss the economics of larger sessions being misleading, concluding that smaller sessions are less expensive (suggesting that the "value the patient receives would be greater").
Dr. Shiell (editor's notes October 1995) "Pomerantz, Manfred Lucas, and Tom Rosanelli's [statements] concerning the potential risks of 'dense packing' of micrografts. These warnings were no more than projected fears for they were made without first hand knowledge of what 'Dense Packing' was really about."
Dr. Shiell (addressing minigrafts in Forum December 1995) stated: "I want to point out several "negative" [emphasis added] points against minigrafts…… [they] may result in a substantial loss of income to the surgeon [as a result of the very effectiveness of the minigraft]…... It takes an awful lot of minigrafts to create a good crop of hair. The resulting high cost can be a deterrent [spelling corrected] to the new patients. The patients are often so contended after one session they may be slow to return for further work…… they have little 'advertising' value [emphasis added] [as it is frequently undetectable]." He further states that "unless the patient chooses to tell his friends, few people ever realize how good the modern methods have become."
We, as surgeons, must address the way we think and our responsibility to question everything we do, for the benefit of our patient. Simply stated: Compliancy has no place in medicine. I believe that it is our responsibility to improve not only what we do, but what the profession does for the betterment of all mankind. That responsibility does not mean that when a fellow physician presents something new, that we rush to replicate what he/she has done before it is proven, or at the least, as good as what we can do ourselves. What may be better in the hands of some, may not be better in the hands of others.
I have tried to understand what Dr. Pomerantz must have felt when he heard about the FOX™ Procedure. I would imagine that he said to himself something like, 'Why is this guy Rassman rocking the boat again? What we do now is good stuff, so why mess with a good thing?' I wonder, however, why he decided to write about this new procedure without knowing the details and before the work has been made public through publication (we have just submitted a formal manuscript to a peer reviewed medical journal). We are prisoners of what we write, so, I ask Dr. Pomerantz: Why were you so driven to criticize something with no facts at your fingertips?
I do wish to acknowledge that in writing his recent editorial, Dr. Pomerantz did do us all a service. He voiced what many of the readership may have been thinking and were afraid to say, and even more significantly, he gave me the opportunity to discuss our need to constantly focus on doing things better and keeping an open mind as others try to improve upon the status quo.
What my colleagues and I did in our recently submitted manuscript on the FUE Procedure was to fulfill our responsibilities with a 'prompt presentation before scientific organizations and timely publication of clinical and laboratory research in scientific journals' as suggested by the AMA. As many of you know, each and every time we have introduced an improved clinical approach to the field of hair transplantation, we have published our work in leading medical journals and presented our work at the industry' leading medical gatherings. We have kept no secrets. We have held open discussions and at appropriate times, have opened our offices to visiting doctors who observed and learned what we were doing, first hand and up close. Many of our competitors or would-be competitors have visited our offices, and for the most part, most of the exchanges were courteous, educational and eye-opening.
Of greatest interest was the realization that our strongest supporters were, at times, our strongest critics. What doctors like Shiell, Norwood, Marritt, and Limmer did was to urge caution while they explored the full implications of the new technologies. Manny Marritt told me how painful that sorting process became, for the end result for him was to accept that the larger session of smaller grafts were superior to his 'frontal forelock' solution which he had personally invested so much time to define, explore and promulgate. These men kept their mind open while they sorted through the information as it became available.
In conclusion, we as a community should be open-minded to change and close minded to complacency. We should explore new technologies and techniques with a healthy skepticism, asking appropriate questions after the information is available for review. We should recognize what the AMA has clearly stated: "the intentional withholding of new medical knowledge, skills, and techniques from colleagues for reasons of personal gain is detrimental to the medical profession and to society." That means, simply, that innovation without proper publication and education is no innovation, and has no place in modern, ethical medicine. I invite Dr. Pomerantz to review our upcoming article when it is published and present as many questions and/or concerns as he may have after he has had the opportunity to read it. It is my hope that Dr. Pomerantz and the other surgeons in the hair restoration community can have a healthy and productive discussion regarding any and all changes facing our profession today with a focus on improving medical care. Politics and closed-mindedness have no place here.
© 2008 New Hair Institute. www.newhair.com |
 | 
