Letters to the Editors

The topic of non-physician owned practices is particularly of interest to the field of hair restoration surgery. I found the discussions on lay counselors and non-physician owned practices very interesting. Bottom line, the physician is responsible for what the counselor says. It’s his responsibility, not that of the clinic owner, to train the counselor and verify that the data being delivered to the potential patient is accurate. Because this is the practice of medicine, part of that training has to include how to identify the exception, that being the patient who may not have androgenic alopecia. If the physician is not willing to spend the time training their consultants, or he is prohibited from doing so, then he should not practice in that environment, as it is unsafe for the patient. My philosophy has always been that an appropriately managed practice is dependent upon continuing education of the entire staff… from the physicians to the receptionists.

Censorship by the professional Society will accomplish nothing. When I was the President of the American Hair Loss Council, I realized that censorship results in the offending party leaving the organization and continuing the inappropriate behavior. The Society’s primary focus is education to raise the standard of care. If these marginal members become outcasts, it is impossible to communicate with them concerning their misguided actions, and hence no hope at improving their behavior.

I believe the most effective approach is for the ISHRS Ethics Committee to set clear guidelines for the use of lay counselors, focusing on patient safety and the integrity of the information provided. These guidelines should also clearly define the physician’s responsibilities for the primary training, continuing education, and supervision of the counselors. These definitions will help both the physicians and the lay owners better understand what is expected of them and encourage the correct behavior.

I don’t think anyone wants to harm another person, and wise businessmen know that business growth is dependent upon the quality of service provided. I believe that guidelines as outlined above would help marginal operations to better understand their responsibilities and encourage appropriate behavior.

Reflections of a Convert: How Follicular Unit Grafting Has Made Me a Believer

This December will mark the one-year anniversary of my conversion to follicular unit grafting (FUG). Next to making the decision to going out in my own practice four years ago, the commitment to performing FUG has been the best move I have made. My experiences, I believe, are of importance to the majority of the ISHRS members who, like myself, do not perform exclusively hair transplantation in their cosmetics practice, yet wish to increase the number of transplants they perform.

There is one simple reason for performing FUG: improved outcome. The advantages have been discussed/debated ad nauseum in the Forum, with unfortunately some economic and chauvinistic overtones, and will not be repeated. There are some patients who are best treated with more traditional micro-/minigrafting, namely those patients with light or salt-and-pepper hair colors, and those undergoing reparative procedures. However, for the overwhelming majority of patients, FUG provides the surgeon with the materials for achieving virtually undetectable results.

Once the decision was made to offer what I felt was the best procedure, the challenge was in the investment I faced. In order to perform FUG, a team of at least four trained assistants, working with microscopes, is necessary to perform a procedure that once took less than four hours and now takes 30% to 50% longer. Ironic that at last year’s meeting in San Francisco, I made a video presentation entitled “1,500 Grafts Transplanted by One Surgeon and Two Assistants in Three Hours,” which detailed my technique of performing non–microscope dissected grafts.

When performing two, maybe three transplant cases a week, in my facial plastic surgery practice last December, I had to initially train and hire several part-time assistants to work with my other two full-time experienced assistants. I also discovered that my insurance person must have been a sushi chef in a prior life, for she has developed into a marvelous addition to my team that now numbers eight persons. The investment I made to the hair transplant portion of my practice, and continue to make (I am always looking to add motivated graft cutters), has resulted in a two to three times increase in the number of hair cases I am performing, to where I am now performing one or two cases a day. A marketing miracle? No. Merely obtaining what I feel are the best results I can, and being able to compete with the finest and busiest hair transplant surgeons (which include those employed by national chains) on the level that is most important—infomercials (NO!!). Quality and a commitment to patient care.

Last June of 2000, the 3^rd Annual Congress of the European Society of Hair Restoration Surgery was held in Istanbul, successfully lead by Dr. Melike Kulahci (Turkey) and her active and gentle husband Reiner, who helped her in organizing a good congress.

The ESHRS has grown up thanks to prestigious Dr. Patrick Frechet (France), who has just left the Presidency. From these lines, I want to congratulate him, as well as to tell him that I’m grateful for all the positive efforts he has made for the ESHRS.

In Istanbul, proposed by the Board Governors of the ESHRS, (Dr. Sikos, Hungary; Dr. Kolasinski, Poland; Dr. Clamp, United Kingdom; Dr. Habbema, The Netherlands; Dr. Kulahci, Turkey; Dr. NeideI, Germany; Dr. Nordstrom, Finland; Dr. Nyberg, Switzerland; Dr. Rosati, Italy; Dr. Frechet, France), I’ve been elected the new ESHRS President by the General Assembly and I hope I’ll help the ESHRS to improve, to expand, and to acquire an international acknowledgment in all referring to restoration, all over Europe.

Finally, I’d like to announce the IV ESHRS Annual Congress will be held in Barcelona (Sitges) May 30–June 3, 2001. Prestigious professionals from Europe and all over the world will participate in organizing: scientific sessions, medical surgical assistants program, and live surgery, during the Congress.

Note: For further information on the IV Annual Congress of the European Society of Hair Restoration Surgery, you can address to the Secretary: Paseo Bonanova, 9. 08022 Barcelona. Spain

Fax 34.93.212.21.15

E-mail: dr{at}vilarovira.com

Dr. Robert Yoho’s letter to the Forum warning on the potential dangers of intravenous midazolam (Versed, Hypnovel) inadvertently appeared in TWO editions of Forum this year (April and October).

Two doses of his gloomy and frightening predictions caused me to rethink my position on this matter as I believe that I was one of the first to use this drug for Hair Transplantation when it first became available in Australia in 1986. I have used it in some 7,000 cases since that time without any serious problem, although I concede that minor degrees of respiratory depression as gauged by my pulse oximeter are very common.

No, Dr. Yoho, I have NEVER had to use my emergency oxygen supply, as 5-10 deep breaths by the always conscious patient is perfectly adequate to restore full oxygenation.

I have ALWAYS accepted that midazolam (along with diazepam, lidocaine, epinephrine, prednisolone, antibiotics, analgesics, and numerous other substances used by the practicing physician) are potential “health hazards” when used inappropriately. I wondered if midazolam might be any worse than the others?

To settle my mind on this matter, I first discussed it with 30 prominent HT surgeons. on the Internet. Not one knew of any serious problems resulting from the use of midazolam and most wondered where Dr. Yoho was obtaining his information to the contrary.

Then I asked an Australian colleague, Dr. Bruce Fox, now a cosmetic surgeon but once the practicing anaesthiologist who wrote the chapter on Anaesthetics for the book Hair Transplant Surgery in 1984 (Editors Norwood & Shiell). He too was puzzled, but promised to speak with a busy, currently practicing anaestheologist, Dr. John Bemelen, F.A.N.C.A. John also had no knowledge of any deaths that could be attributed solely to midazolam.

Dr. Fox and Dr. Bemelen made several important points, however:

• ⋅ Anaesthetic deaths have occurred in busy hospitals and private clinics in patients receiving a “cocktail” of medication (including midazolam). This also occurs with other sedative agents of course and is more likely in patients with a pre-existing respiratory disability.

• ⋅ All patients receiving sedative medication by any route should be monitored during operation (pulse oximetry at the very least).

• ⋅ Midazolam is a relatively safe drug when used alone but when used in high doses or in a “cocktail” with other drugs, its effects may be magnified.

• ⋅ Sedatives administered by the intravenous route could reasonably be considered safer than when given intramuscularly. The intravenous route enables one to titrate the patient’s requirements immediately and accurately.

• ⋅ Surgeons using sedatives intramuscularly or orally on their patients for minor surgery may be lulled into a sense of false security. Thinking it is safer, they may allow their patients to be unmonitored or even unattended for short periods of time.

• ⋅ Anexate is a very effective drug for reversing an inadvertent overdose or more commonly a hypersensitivity to the effects of midazolam and should be kept at hand.

Midazolam has an excellent safely record when used alone with healthy young patients without pre-existing respiratory disease. Surgeons should not be afraid of it as the benefits are considerable and the risks small. However, as with any potent medication, there are side effects. One should be aware of these and capable of dealing with them promptly if they arise.