The future for the surgical treatment of hair loss
Dr Nilofer Farjo and Dr Greg Williams address the issues surrounding new legislation, training and staffing requirements for hair loss treatment
Anybody who is interested in setting up a hair transplant service, and those who currently are offering hair transplants, will have concerns about what effects legislation might have on them in the future.
At the moment there is very little legislation regarding hair transplant surgery except that, as with any form of surgery, it needs to be done in a Care Quality Commission registered and regulated environment.
One of the big questions currently being debated around the world is ‘who can perform hair transplants’?
The Royal College of Surgeons has no definition of what ‘surgery’ actually is. This is understandable, since it is a very difficult thing to define. At a very basic level, if one tries to define ‘surgery’ as ‘any procedure involving an incision in the skin’ then something as simple as taking blood, or giving an immunisation, would be considered surgery. One of the reasons why this is relevant to hair transplant surgery is to determine whether follicular unit extraction (FUE) is actually surgery at all. Some might argue that FUE harvesting is really no different to a dermatological punch biopsy—it is just being done many times. Likewise, the incision that is made to implant hairs with a hypodermic needle is not really any different to the incision made for taking blood, it is just done many times. Most clinicians would agree that hair transplants involving removing a strip of skin and then stitching or stapling constitutes ‘surgery’ but there is less agreement as to whether FUE is ‘surgery’.
In January 2013, the Royal College of Surgeons published its Professional Standards for Cosmetic Practice and within this guidance cosmetic or aesthetic surgery was defined as: “operations and all other invasive medical procedures where the primary aim is the change, the restoration, normalisation, or improvement of the appearance, the function, and wellbeing at the request of an individual.” By this definition, all forms of hair restoration surgery, even the FUE technique, can be considered cosmetic or aesthetic surgery.
Having agreed that all hair transplant procedures constitute surgery, should they therefore only be done by a doctor who is registered and in good standing with the General Medical Council (GMC)? The legality involved with creating FUE incisions, in other words doing surgery, without a medical license is unclear in the UK. In many countries around the world it is considered a criminal offence to operate without a medical license. The GMC does not comment on the legality of this in the UK as they only regulate offences by doctors. However, if a complaint or an allegation was made to them regarding an individual performing surgery who was not a doctor, then they would investigate and report the matter to the police.
In July 2013 the British Association of Hair Restoration Surgery (BAHRS) agreed, and published, Professional Standards both for Hair Transplant Surgeons and for Hair Transplant Surgical Assistants. All members, both surgeons and assistants sign a Code of Conduct agreeing to abide by the relevant Professional Standards which both include a clause that FUE incisions (in other words, surgery) will only be performed by doctors. In this area, the UK is well ahead of most of the rest of the world. The International Society for Hair Restoration Surgery (ISHRS) has professional standards, but there is nothing that requires members to follow them.
In April 2013 the Keogh Review of the Regulation of Cosmetic Interventions was published and there were three key areas of suggested change that were needed: high quality care with safe products, skilled practitioners, and responsible providers was the first. An informed and empowered public to ensure that people get accurate advice and that the vulnerable are protected was the second and accessible redress and resolution in case things go wrong was the third.
The Department of Health official response to the Keogh review was published in February 2014 and one of the outcomes has been to look at the training required for persons delivering cosmetic interventions. The Royal College of Surgeons has been mandated with overseeing the requirements for surgical cosmetic procedures and Health Education England (HEE) for overseeing the requirements for non-surgical cosmetic procedures. As hair restoration surgery is carried out mostly by doctors without a formal surgical qualification, it was decided it was better placed with HEE rather than the Royal College of Surgeons.
So what is the implication of the Keogh review for hair transplant surgical assistants, who for the most part will not be registered with a regulatory body (the exception being those assistants who are nurses)? There is a strong suggestion from the government that all cosmetic practitioners who are not registered with a regulatory body should be part of a voluntary register. This is available through the BAHRS for hair transplant surgical assistants. As part of being on the voluntary register they would be obliged to sign up to professional standards and codes of conduct thus giving the public a degree of assurance that they are acting in a responsible and professional manner.
Currently there is no formal training available in the UK for hair restoration surgery. However there are some learning themes in common with the education required for the other modalities that are being overseen by HEE and that were addressed in the Keogh review including botulinum toxins, dermal fillers, chemical peels and lasers.
It is envisioned that any credentialing for hair transplant surgeons would follow the same process as for those surgeons being credentialed for specific surgical cosmetic procedures, or groups of cosmetic procedures, by the Royal College of Surgeons.
It is worth noting that there are a few International Society of Hair Restoration Surgery (ISHRS) fellowships (most in the USA) and there is an American Board of Hair Restoration Surgery (ABHRS) examination available for interested doctors. Recently the ISHRS has extended the fellowship program to make distance learning modules available.
It had been suggested that hair transplant surgical assistants could form part of the HEE training framework which would result in a recognised qualification, as they too would have had learning themes in common with the education required for the other modalities that are being overseen by HEE. However the critical difference between them and other individuals progressing through the HEE training pathway is that they will never function autonomously or have full responsibility for patient care as they would always work under the direct supervision of the hair transplant surgeon.
Whilst there is also no formal training for hair transplant surgical assistants in the UK that results in a recognised qualification, each hair transplant surgeon or hair transplant clinic will have their own method of training assistants.
Training for doctors
Hair transplant training for doctors involves a combination of knowledge and skills.
Knowledge can be gained from textbooks, journals, training modules, conferences and workshops. The ISHRS has published a Core Curriculum and Core Competencies that cover all the educational content required to pass the ABHRS examination.
The ISHRS also has annual scientific meetings where there is always a beginner’s course and an advanced review course for doctors who want to sit the ABHRS examination.
The British Association of Hair Restoration Surgery has one or two meetings a year and one of these at least has educational content.
How does a doctor learn the hands-on skills needed for hair restoration? The ISHRS sponsors surgery workshops and there is one in Orlando every springtime. Internationally there are usually somewhere between one and three sponsored workshops each year and some of these include cadaver workshops, so attendees can actually get some hands-on experience using cadaver tissue.
At the annual ISHRS conference there are also ‘hands-on’ workshops where attendees can learn how to cut grafts and practice placing grafts on simulated tissue. It is not quite the same as learning on a patient, but at least it gets one started.
Setting up a surgical facility
State of the art consultation rooms have computer screens where patients can be shown before and after photographs, as well as magnified views of their scalps using portable video-microscopes. Examination stations ideally have mirrors set up so the patient can be shown the back of their heads from different angles with optimal lighting.
Good clinical photography forms an important part of the medical record and photos are best taken in a designated area that has the standardised lighting and background.
There are two methods of harvesting donor hairs—the strip technique and the FUE technique—and there are differences in the surgical facilities required for the two methods.
The strip technique requires a typical treatment room surgery set-up but there are a number of assistants needed to cut the grafts (typically one assistant per very 400 grafts and up to 5000 grafts may be harvested in one sitting) who need to be accommodated at ergonomically comfortable cutting stations.
Operating time is often six to eight hours, so the dental-type operating chair needs to be well padded. Patients should ideally be provided with some entertainment like a TV and refreshments as required.
The FUE technique may only require the surgeon and one or two staff members so it can be performed in a smaller room with less equipment. The majority of surgeons doing FUE tend to have their patients lying down in the prone position for the graft extraction so an attachment for the operating chair/table similar to that on a massage table is required to allow the patient to have their head face down and still be able to breathe.
Whichever method is used, a hair transplant is a meticulous procedure and the work requires a great deal of concentration from all the team members. If the team, led by the surgeon, lacks the motivation required to pay attention to meticulous detail for several hours at a time then they will not achieve the ultimate goal which is a patient satisfied by a natural hair transplant result.
Dr Nilofer Farjo runs the Farjo Hair Institute with her husband Dr Bessam Farjo and Dr Greg Williams is the lead Hair Transplant Surgeon in their London clinic