CORE CURRICULUM IN HAIR RESTORATION SURGERY Revised July 22, 2009

Transcription

1 1. BASIC SCIENCE BASIC SCIENCE OF HAIR Scalp Anatomy and Physiology Cyclic Activity of Hair Androgen-dependent Hair Pathophysiology of androgenic alopecia Alopecia: classification and incidence Types of Hair Racial and Individual Variations Hair Loss Etiologies Excess Hair Growth Dermatological Scalp Conditions EPIDEMIOLOGY AND DEMOGRAPHICS OF HAIR LOSS Age and AGA in men Female AGA Ethnic variation in the characteristics of skin, scalp, and hair WOUND HEALING Basic science Factors that influence wound healing Anatomic and skin type considerations Microbiology Biomechanics and histology of normal skin and scars Wound Healing CLINICAL SCIENCE GENERAL SURGICAL PRINCIPLES Sterile technique Instrumentation Instrument preparation Closure materials Wound care PATIENT CONSULTATION, EVALUATION, AND PREPARATION Psychology of Hair Patient evaluation Selection Standardized photography for hair restoration Medicolegal issues in hair replacement Hair Transplantation Hairline design details The Donor Site Graft Preparation Techniques Graft Insertion Techniques Postoperative Care Scalp Reductions and Scalp-Lifting Pedicle rotation flaps in the surgical treatment of alopecia DEVELOPMENT OF TREATMENT PLAN Patient expectations Surgical feasibility Assessments of risks/benefits of treatment plan Informed consent to include alternative therapies ANESTHESIA ASA risk classification Topical

2 Local Regional Nerve block anesthesia of the scalp Special Considerations Complications Pain control and management of the postoperative period EMERGENCY PREPAREDNESS Management of surgical emergencies Basic and Advanced Cardiac Life Support (ACLS Curriculum) Emergency situations in hair transplantation RECONSTRUCTION Surgical techniques Surgical options COMPLICATIONS General theory, management, and prevention of complications: Complications of Flaps in the Treatment of Baldness Complications of Hair Transplantation Scar revision STRATEGIES IN UPDATING OLD TECHNIQUES AND CORRECTING SUBOPTIMAL RESULTS INTERDISCIPLINARY CARE OF PATIENT Interdisciplinary care for complicated cases Interaction with other medical and surgical specialists to provide optimal care Education of other medical, surgical, and lay specialists in HRS Non-surgical Hair Replacement MEDICAL THERAPY Current understanding of AGA and testosterone Minoxidil Finasteride Dutasteride OTC treatments & Hoaxes SPECIAL CONSIDERATIONS Hair Transplantation in Blacks Hair Transplantation in Asians... Error! Bookmark not defined Hair Transplantation in Females Hair transplantation of the eyebrows Hair transplantation of the eyelashes Reconstruction of the Temporal Points Area Moustache Transplantation Hair Transplantation in Skin Grafts, Thin Recipient Skin, and Radiation induced Alopecia Treatment of the genetically male transsexual The treatment of female pattern alopecia Synthetic hair Automation techniques in HRS Scalp Reconstruction Techniques Ethics, Marketing & Patient consent PROFESSIONAL/REGULATORY TOPICS MEDICAL-LEGAL ISSUES Risk assessment in the surgical patient Medical record documentation Quality assurance (QA) and continuous quality improvement (CQI)

3 Informed consent Photographic Reproduction REGULATORY ISSUES OSHA Blood borne pathogens (BBP) PROFESSIONAL ETHICS Professional ethical standards Selection of the most cost-effective treatment plan given patient goals Realistic expectations Professional Marketing

4 1. Basic Science 1.1. Basic Science of Hair Scalp Anatomy and Physiology Classic anatomy with emphasis on the scalp and hair Topographical features and underlying bony cranium, musculature and neurovascular anatomy Blood supply of the head and neck Sensory innervation of the head and neck Motor innervation of the head and neck Lymphatic drainage of the head and neck Relaxed skin tension lines of the head and neck Histology/Microscopic anatomy of the skin, scalp, subcutaneous tissues, with specific emphasis on the hair follicle Physiology of the skin and soft tissues Cyclic Activity of Hair Androgen-dependent Hair Pathophysiology of androgenic alopecia Alopecia: classification and incidence Male Female Age and Degree of Male Pattern Baldness Types of Hair Racial and Individual Variations Hair Loss Etiologies Androgenetic Alopecia and Its Treatment Overview - 4 -

5 Male vs. Female History Biochemistry and Pathogenesis Medical Treatment of Androgenetic Alopecia Hair Examination and Investigation Length of the Hair Cycle Examination of Hair Roots Hair Shaft Length and Diameter Measurements Hair Shaft Morphology Vellus Hair Index Hair and Hair Follicle Microscopy Cicatricial Alopecias Morphea LPP Scleroderma Alopecia Areata Etiology Diffuse pattern Alopecia Areata Dermatopathology Clinical Features Progression Associated Clinical Changes Treatment Prognosis - 5 -

6 Congenital Alopecia Circumscribed Alopecia Total Alopecia Hypotrichosis Abnormalities of Hair Shaft Traumatic Alopecia Disturbances of Hair Cycle: Telogen Effluvium Diffuse Alopecia of Endocrine Origin Alopecia of Chemical Origin Alopecia of nutritional and metabolic Origin Chronic Diffuse Alopecia Alopecia in Central Nervous System Disorders Excess Hair Growth Hypertrichosis Hirsutism Dermatological Scalp Conditions Pityriasis Capitis Pityriasis Amiantacea Seborrhea Seborrheic Dermatitis Seborrheic Dermatitis of Infancy Psoriasis of the Scalp Tinea Capitis Pruritic Syndromes Lichenification and lichen Simplex Contact Dermatitis Acne Necrotica Follicular Keloidalis Nuchae (Acne Cheloidalis) - 6 -

7 Folliculitis Decalvans - 7 -

8 1.2. Epidemiology and Demographics of hair loss Age and AGA in men Female AGA Ethnic variation in the characteristics of skin, scalp, and hair 1.3. Wound Healing Basic science Phases of wound healing Tensile strength Theories of epidermal and dermal wound healing Factors that influence wound healing Environmental Local Systemic Genetic Anatomic and skin type considerations Microbiology Normal skin flora Pathogenic organisms Biomechanics and histology of normal skin and scars Wound Healing Wound healing in hair restoration surgery Postoperative dressings 2. Clinical Science 2.1. General Surgical Principles Sterile technique Surgical site preparation Choice of antiseptic solution - 8 -

9 Skin prep technique Staff preparation Hand washing/surgical scrubbing Gowning and gloving Surgical site draping Instrumentation Instrument preparation Instrument handling and sterility Theory of sterilization Methods of sterilization Resources necessary for sterilization Closure materials Wound care 2.2. Patient Consultation, Evaluation, and Preparation Psychology of Hair Body Image Self Esteem Beards Moustaches Eyebrows Eyelashes Patient evaluation Appropriate surgical preoperative physical examination Allergies Medications Anticoagulants Drug interactions - 9 -

10 Past medical history/review of systems Diabetes Heart disease Bleeding disorders Immunosuppression Need for antibiotic prophylaxis Alcohol and tobacco use Social history Hair loss etiologies Anatomic considerations Appropriate diagnostic studies Selection Realistic expectations Motivation for HRS Classification and treatment options Hair characteristics Special considerations in the younger patient Risk Benefit ratios General Patient Specific Standardized photography for hair restoration Medicolegal issues in hair replacement Physician Responsibilities Patient education The Process of informed consent Hair Transplantation History Hair transplant

11 Scalp reduction Scalp flaps Scalp expanders Scalp extenders Instrumentation Operating Room Setup Staffing Donor site evaluation Terminology of graft sizes Round punch graft Mini graft Micro-graft Single hair graft Follicular unit graft Multi-follicular unit graft FUs Non FUs Graft Dissection techniques Punch grafting Single ellipse Microscope Loupes Slivering Multibladed knife Follicular unit extraction Hairline design Recipient site considerations Angle of incision

12 Orientation of incision Graft placement Postoperative Care Complications Repairs Hairline design details Density gradient Principles of hairline placement Facial Balance & structural Ethnic considerations Gender considerations Realistic expectations

13 Planning for future hair loss The Donor Site Evaluation Density Tissue Turgidity Scar Management Donor Closure Trichophytic donor closure Accurate estimation of graft requirements when using multibladed knives Elliptical donor harvesting Graft survival Graft Preparation Techniques Graft classification (Micro, mini, FU) Ellipse harvest Multibladed knife Punch grafts Impulse force Use of microscopes Cooling Grafts Storage Solutions Graft Insertion Techniques: Manual/Implanter Devices Parallel Slits Perpendicular slits Manual insertion techniques Implanter devices Postoperative Care Scalp Reductions and Scalp-Lifting

14 Basic Principals of Flap Anatomy and Physiology Axial vs. Random Flaps Delays Advancement vs. Pedicle Flaps Suturing limitations Tip management Planning and Dynamics Anesthesia Scalp Reductions Multiple patterns of scalp reductions Scalp extenders to facilitate reduction procedures Slot formation, prevention and management Slot Correction by a Three-Hair-Bearing Flaps Transposition Procedure in Combination with Scalp Reduction Intraoperative tissue expansion Tension clamps PATE (prolonged acute tissue expansion) Scalp Lifting for Major Reductions Tissue Expansion biological considerations Biological Creep in Tissue Expansion Mechanical Creep in Tissue Expansion Expanded Scalp Flap Techniques

15 Rotation Scalp Flaps Managing Complications of Scalp Reductions and Scalp Lifts Pedicle rotation flaps in the surgical treatment of alopecia Temporoparieto-Occipital Flaps Flap delay Physiology Technique

16 2.3. Development of treatment plan Patient expectations Surgical feasibility Extent of baldness Donor tissue available Scalp reduction, lift, expansion, extension Assessments of risks/benefits of treatment plan Informed consent to include alternative therapies 2.4. Anesthesia ASA risk classification Topical Local Regional Nerve block anesthesia of the scalp Special Considerations Monitoring Preoperative anxietolytics Conscious sedation General anesthesia Complications Pain control and management of the postoperative period 2.5. Emergency Preparedness Management of surgical emergencies Office emergency equipment Staff/physician preparedness Management of office and surgical emergencies including but not limited to: Syncope

17 Convulsions Hemorrhage Anesthetic toxicity Allergic reactions Anaphylaxis Myocardial infarction Cardiac arrest Basic and Advanced Cardiac Life Support (ACLS Curriculum) Emergency situations in hair transplantation ACLS Drug toxicity Drug Interactions Non Selective Beta Blocker Viagra Anaphylaxis Distributive Hypovolemia Treatment Volume expansion Steroids Antihistamines Support Drug overdose Monitoring Resuscitation equipment AED Airway management LMA s

18 Oral airway Endotracheal intubation IV Access techniques Bleeding complications Von Willebrand s disease Aspirin Coumadin Clopidogrel

19 2.6. Reconstruction Surgical techniques A traumatic tissue handling Hemostasis Suture technique Dressing Wound management Surgical options Hair transplant Scalp reduction Scalp flaps Scalp extension Scalp lifting Second intention healing Split thickness skin grafts Full thickness skin grafts Artificial skin and allograft, xenograft 2.7. Complications General theory, management, and prevention of complications: Tissue necrosis Bleeding, hematoma Infection Wound dehiscence Postoperative patient education regarding possible complications, wound care, activity level and need for surgical revision Management of chronic or non-healing wounds Deep Vein Thrombosis

20 Complications of Hair Transplantation Scarring and keloid formation Inadequate growth Poor graft preparation Graft dessication Post Op Bleeding Mushy dermis and donor harvest Post-transplant epidermoid cysts/ folliculitis Arteriovenous malformation Dissatisfied Patients Complications of Flaps in the Treatment of Baldness Violations of the axial blood supply leading to necrosis Abnormal hair direction Aesthetic problems with poor execution Long-term problems after hair bearing flap transpositions for male pattern baldness Scar revision Principles of wound healing Scar formation Normal Hypertrophic Keloid Recognition and management of suboptimal scar Hypertrophy Keloid Dyschromia Erythema Wound contracture

21 Other Principles of scar revision Elongation and reorientation Z-plasty W-plasty Geometric Tissue expansion Resurfacing Dermabrasion Shave abrasion Skin graft Laser Non-surgical approaches Intralesional and topical steroids Silicone gel sheeting Massage

22 2.8. Strategies in updating old techniques and correcting suboptimal results 2.9. Interdisciplinary Care of Patient Interdisciplinary care for complicated cases Interaction with other medical and surgical specialists to provide optimal care Education of other medical, surgical, and lay specialists in HRS Non-surgical Hair Replacement Medical Therapy Current understanding of AGA and testosterone Minoxidil Finasteride Dutasteride Low level light therapy OTC & other treatments Special Considerations Hair Transplantation in Blacks Hair Transplantation in Asians Hair Transplantation in Females Hair transplantation of the eyebrows Hair transplantation of the eyelashes Reconstruction of the Temporal Points Area Moustache Transplantation Hair Transplantation in Skin Grafts, Thin Recipient Skin, and Radiation induced Alopecia Treatment of the genetically male transsexual Hair transplantation Scalp expansion

23 Scalp flaps The treatment of female pattern alopecia Synthetic hair Automation techniques in HRS Scalp Reconstruction Techniques Surgical Treatment of the Avulsed Scalp Management of the Tunnel Graft for hair piece retention Ethics, Marketing & Patient consent The relationship between the patient and physician The patient s responsibilities The physician s responsibilities 3. Professional/Regulatory Topics 3.1. Medical-legal Issues Risk assessment in the surgical patient Preoperative Intraoperative Postoperative Medical complications/contraindications for surgery Medical record documentation Written patient questionnaires Preoperative evaluation Operative report Postoperative instruction Documentation of telephone calls for appointments/advice/prescriptions

24 Quality assurance (QA) and continuous quality improvement (CQI) Understanding of concepts of QA and CQI Participation in QA and CQI project Informed consent Concept of informed consent Expressed of implied Written versus verbal Who may provide consent Medical record documentation Elements of informed consent Problem to be treated Proposed test or treatment Indications for test or treatment choice Expected results or goals of test or treatment Disclosure of risks, complications and side effects Reasonable alternative methods of diagnosis or treatment Consequences of no treatment or delayed treatment Documentation of informed consent

25 Medical and surgical standard of care Photographic Reproduction Photographic informed consent Use of images (e.g., medical records/publication/presentation) Patient s right to privacy 3.2. Regulatory Issues U.S. Occupational Safety and Health Administration (OSHA) standards OSHA regulations as they relate to HRS Federal, state and local compliance requirements Hazard determination and safety procedures Hazard chemical inventory including material safety data sheets (MSDS) Monitoring/updating program Log of hazard communication program Inventory update log MSDS update log MSDS request log Special labeling requirements Preparation for inspection Blood borne pathogens (BBP) OSHA regulations regarding BBP Epidemiology, mode of transmission and symptoms of BBP Universal precautions Exposure control plan for HRS Reduction of exposure to BBP

26 Personal protective equipment Post-exposure management plan for BBP 3.3. Professional Ethics Professional ethical standards Doctor/patient relationship Physician interactions Medical ethics Business ethics Other Selection of the most cost-effective treatment plan given patient goals Realistic expectations Professional Marketing Fidelity Patient Autonomy Apply Consultation & Patient Education Ethical Standards