For several years, Arturo Sandoval-Camarena, MD, has invited prominent hair replacement surgeons to a special live-surgery workshop at his clinic in Guadalajara, Mexico. The number of participants is purposely limited to 10-12 surgeons. While the conference appears small, it is more than compensated by the vast experience each participant brings.
This year Sheldon Kabaker, John Cole, Ron Shapiro, Charles Curtis, and James Arnold attended from the United States. More distant travelers were Walter Unger (Canada), Patrick Frechet (France), Piero Rosati (Italy), Jung Chul Kim (Korea), and Marcelo Gandelman (Brazil). The participants were selected for both their knowledge and reputation for teaching, and represented 225 years of surgical experience! Dr. Sandoval describes his conference as a “teacher to teacher exchange of ideas.”
Dr. Sandoval's clinic is very modern and well equipped, reflecting his position as the most eminent transplant surgeon in Mexico. A full-time anesthesiologist and two dozen well-trained, professional assistants are constantly busy assisting in five operating rooms. The technique favored by Dr. Sandoval utilizes follicular units with assistants inserting the grafts via the stick and place method. The equipment and staff trained to perform other methods of hair replacement surgery were available to the attending surgeons, as well as an eager pool of patients with various degrees of hair loss. Each attendee was encouraged to perform surgery, demonstrating the various details of his particular technique while the others observed.
Naturally, there was never a consensus on the “best” approach to each patient. The philosophy and experience of the participants varied greatly, and yet there was widespread acceptance and respect for each person's difference of opinion. The case discussions were of immense value, as the pros and cons of various treatment plans were entertained. These debates were lively at times, but always friendly with much laughter. In one instance, Dr. Marzola was preparing to operate on a patient with posterior hair loss while Dr. Frechet continued to support an alternative plan. Finally, in a good natured way, Dr. Marzola removed his surgical gown, offered it to Dr. Frechet, and said “Patrick, I would like to see what you're suggesting!” Dr. Frechet accepted the gown and proceeded to demonstrate his remarkable skill, as the friendly bantor continued. The surgery Dr. Frechet performed was a modified midline scalp reduction leaving a round area at the posterior end for later transplantation. “This technique eliminates the need for slot correction,” Dr. Frechet explained. “But I don't have a name for it, and scalp reduction has such a bad connotation.” Dr. Kabaker quickly added “Why not call it the French Correction?”
Several surgeries were of particular interest. Tissue expanders were used in two pediatric patients who presented with very large scars on the scalp. Dr. Kabaker had flown to Guadalajara several weeks earlier to insert the expanders. Partial scar excision and reinsertion of the expanders was of interest to all. Dr. Kim demonstrated two new implanting devices of his own design, including one capable of planting three grafts simultaneously. Dr. Marzola showed how he fashions hypodermic needles to control depth. During surgery, the depth-controlled needles also act as “shoehorns” to facilitate graft insertion. Walter Unger performed a hair transplant utilizing a large variety of graft sizes: one and two hair grafts for the hairline, blending back to three and four hair grafts, mini grafts of two sizes and 3.5mm grafts centrally. Dr. Unger is very familiar with the use of all forms of grafts, and includes graft variety in all his patients. The focus of his work and the meticulous attention he gives to detail are also remarkable. John Cole stimulated our minds with a plethora of intriguing questions, and Dr. Gandleman, as always, had a wealth of sagacious comments to contribute in every situation.
Our host, Dr. Sandoval, had much information to share. With each patient, he draws a grid of 1cm squares over the recipient area, instructing his assistants on the number of follicular units to be placed in each square. Accurate patient records have afforded Dr. Sandoval the opportunity to make long-term, follow-up evaluations of graft survival in many patients. He has learned that “dense packing” of grafts in the range of 45 grafts/cm2 can result in lower hair counts than in patients grafted with 30-35 grafts/cm2. Other surgeons confided similar suspicions with some of their own patients. The possible detriment of excessive graft manipulation or added trauma to the recipient site was discussed at length. Dr. Sandoval currently has a scientific study underway to shed more light on this subject. He plans to share the results of his investigation at the ISHRS meeting in Hawaii in the fall.
During a roundtable discussion, the subject of hair survival was broached. The number of possible factors and the mix of opinions from the group made it difficult to distill practical information. To bring order to this chaos, the suggested factors were listed on a large sheet of paper. During the afternoon, each surgeon went over the list, numbering the factors according to their perceived significance. The results were somewhat surprising. Transection of follicles came in fourth! Greater importance was given to 1) dehydration of grafts, 2) trauma from unnecessary handling or forced insertion, and 3) discarded hair (i.e., transected hair within discarded tissue, or as Ron Shapiro described, “hair left on the table as opposed to planting everything.”)
Many surgeries were performed and observed, and, needless to say, all were of great educational value. And, as is often the case when all the participants of a particular workshop are exceedingly knowledgeable on the subject, the subsequent transfer of information between individuals was fast, stimulating, and to a greater depth than usual. Dr. Sandoval's concept of a private, advanced seminar for experienced, dedicated surgeons has been successful. Innovative ideas arising from these sessions are like ideas from any scientific think tank, evolving into changes benefiting everyone in the field.
Of special note was the gracious hospitality extended to the attendees by Dr. Sandoval and his lovely wife, Christine. We were dined and serenaded by music nightly, and even attended Guadalajara's acclaimed Dance Folklorico. On our final evening, the Sandoval's hosted a sumptuous garden party at their home, complete with a lively Mariachi band playing music of Mexico as well as our International requests. And then, for the grand finale, a fireworks display (cleverly arranged by Dr. Sandoval) burst into showers of sparkling color, filling the clear night sky with splendor. Wow! This meeting was indeed a scintillating experience to remember. Thank you, Arturo.
- Copyright © 2000 by the International Society of Hair Restoration Surgery