Category: Physician training

I met with one of my earliest transplant patients who had surgery in 1992 when I was just in practice for about 6 months. We performed 400 grafts on this patient and he reminded me of the troubles I had in using the glue to hold the grafts in place. At first I had to think about what he was talking about… and then I remembered the painful process of placing a large number of grafts close together.

In those early days, just 80 grafts was considered a big session. 400 grafts was a huge surgery and putting grafts close together caused them to pop out, so I came up with the use of a medical quality methyl methacrylate (a form of super glue) to hold the grafts in place. The problems I encountered was that the glue was stringy and I had to be able to limit the glue to one corner of the graft, holding it to the skin. I had to put the methyl methacrylate into an insulin syringe and then express it through a very tiny needle to produce a micro-drop.

I had to work out just how to do many grafts at one time to stop the popping before this “glue” bonded into the insulin syringe. The glue problem was never solved to my satisfaction, but eventually I developed a very sensitive touch so that when I placed the grafts and kept a steady hand, I did not disturb the adjacent grafts. Eventually I mastered this technique and taught it to my staff. Now the world does it that way.

The patient compared the procedure we did recently to the one I did to him in 1992 and we both has a good laugh. This most recent procedure was his third and the grafts that I placed in 1992 worked very well for him over the past 22 years.

Hi Doctor Rassman,

I’ve been trying to make sense of all the internet literature that states that “Board Certified” by ABHRS is not technically certification by medical standards. What would be the difference if ABMS were to include ABHRS? Would that keep incompetency to a minimum or make me safer?

Other statements made by AHLA such as, “the AHLC uses remarkably outdated information that is dangerous so avoid them etc.” It’s hard for me, to get a real confident feeling, not knowing how to determine whether I’m safe in my decision.

Thank you very much for your time and professional opinion

Hair transplant surgery is NOT technically certified by medical standards. In the United States there are 24 approved medical specialty boards that are overseen by the American Board of Medical Specialties (ABMS), a not-for-profit organization. Certification by an ABMS Member Board has long been considered the gold standard in physician credentialing. To be ABMS board certified means that the physician has undergone formal educational and clinical training at a medical institution after earning their medical degree, and has successfully passed a level of competence via written or practical or oral examinations. I (Dr. Rassman) am ABMS Board Certified in General Surgery and my colleague Dr. Jae Pak is ABMS Board Certified in Emergency Medicine.

Hair transplant surgery is not a part of the ABMS so there can not be any physicians that are board certified as a hair transplant surgeon. This is mainly because there is no formal training or credentialing in hair transplant surgery. There is no standard curriculum. There is no oversight or direct review of the quality of the work being done. Unfortunately, there is no ABMS sanctioned facility to enroll and learn hair transplant surgery. To date, the only way to learn how to perform hair transplant surgery is to read a book, attend a seminar, or become an apprentice to a private practice hair transplant surgeon. Even ABMS board certified plastic surgeons do not receive training in hair transplant surgery as part of their formal training.

In the mid-1990s the American Board of Hair Restoration Surgery (ABHRS) was formed by a group of hair transplant surgeons to create an organization that could independently certify hair transplant surgeons. But the ABHRS does not monitor doctor’s training quality and once the testing process is complete, they do not have any authority to enforce any form of discipline. In states like California, doctors are not allowed to call themselves “Board Certified” if the only certification they have is from the ABHRS or other non-ABMS approved boards. They must qualify which board they are claiming.

I am looking into finding a doctor to discuss my plan of attack for hair loss, and i was wondering what is the ISHRS International society of Hair Restoration Surgery? Is finding a doctor off of that website reliable as finding one from the American hair loss association website?

The International Society of Hair Restoration Surgery (ISHRS) website lists doctors who are members of a learning society. The American Hair Loss Association (AHLA) is a similar site. You must understand that any doctor can be a member of these associations and societies as long as they pay a yearly membership fee. These societies do not have the power to enforce or regulate a doctor’s practice and skills, and the hair restoration/hair transplant field does not fall under the American Board of Medical Specialties (ABMS).

In the United States, there are 24 approved medical specialty boards that are overseen by ABMS, a not-for-profit organization. Certification by an ABMS member board has long been considered the gold standard in physician credentialing. To be ABMS board certified means that the physician has undergone formal educational and clinical training at a medical institution after earning their medical degree, and has successfully passed a level of competence via written or practical or oral examinations.

Since hair transplant surgery is not a part of the ABMS, there can not be any physician that is board certified as a hair transplant surgeon. This is mainly because there is no formal training or credentialing in hair transplant surgery. You read that correctly — there is no board certification in hair transplant surgery! There is no standard curriculum. There is no oversight or direct review of the quality of the work being done. Unfortunately, there is no ABMS sanctioned facility to enroll and learn hair transplant surgery. To date, the only way to learn how to perform hair transplant surgery is to read a book, attend a seminar, or become an apprentice to a private practice hair transplant surgeon. Even ABMS board certified plastic surgeons do not receive training in hair transplant surgery as part of their formal training.

In the mid-1990s the American Board of Hair Restoration Surgery (ABHRS) was formed by a group of hair transplant surgeons to create an organization that could independently certify hair transplant surgeons. But still, the ABHRS does not monitor a doctor’s training quality and once the testing process is complete, they do not have any authority to enforce any form of discipline. In states like California, doctors are not allowed call themselves “board certified” if the only certification they have is from the ABHRS or other non-ABMS approved boards. They must qualify which board they are claiming.

So to answer your question about which site is best, well, I don’t have an answer to that. They’re all pretty good resources for finding doctors in your area, but you need to do your own research to find the doctor that can provide the results you want. The real test for finding a good surgeon is outlined here on our Selecting a Hair Transplant Doctor section.

I’ve been writing about hair transplant failures more and more on this site lately, because it is a growing concern. I have been seeing, on average, 1 patient per week (from outside my office) who had a hair transplant with a significant failure of the grafts to grow (greater than an 80% failure).

I just saw another patient who had received over 2000 grafts a few years ago. He was not a happy camper. There was very little growth and he had a very detectable scar which did not allow him to cut his hair short. He had such high hopes that the new hair from the transplant a few years ago would solve his image problems, but after much consternation and considerable anguish, he found that his situation was worse off than if he never had any procedure at all.

The patient explained that he did not like his doctor’s lack of concern in addressing the failure of his transplants to grow nor the detectable scar that plagued him every day. He was disappointed that his research on this particular doctor left no clue to the quality of this doctor’s work, nor his indifference to his plight. Before the surgery, when the doctor’s team “sold” him on the transplant solution, the environment was welcoming… but after the grafts failed to grow, he did not feel welcome by that particular doctor as he was made to feel that the failure of the transplant was his fault, not the doctor’s problem.

This particular patient had as much focus on his scar as he had with the failure for the transplants to grow, because he had the same look from the front and top view as he had before the surgery. He had no deformities from the surgery and his recipient area healed well with no scars present.

So what could be the possible causes for a failure of transplants to grow?

I should start off saying that I have never seen the cause of the problem stemming from something the patient did or did not do. Many of the patients who come to see me because their transplant did not grow felt that they were responsible for the failure. I think that patients feel that the surgery is a mysterious process and that there must be something wrong with them.

I have seen problems appear with graft growth in some women, as they may have had an undiagnosed condition called diffuse alopecia areata as a cause. Sometimes there may be problems with the recipient area skin (e.g. blood supply or scarring). That being said, most failures reflect surgical factors that are within the scope of what the surgeon and his team control.

Quality control means closely monitoring the activities of each and every staff member in the hair transplant process. Most of the failures reflect a failure of one or more of the following:

• Graft drying: exposure to air for more than 10-20 seconds can kill the graft. The smaller the graft, the greater the risks for graft damage or graft kill. This risk occurs at many times in the procedure: (a) immediately after graft removal, the grafts are not immersed in a bath of a physiologic solution, (b) during graft trimming, when the grafts are optimized with regard to the size, (c), during movement of the graft from one place to another, (d) during placing, when the grafts are held in the air for more than 10-20 seconds.
• Graft storage: The solutions used contribute to the survival of the graft and the longer it is out of the body, the greater the potential damage. This risk reflects upon the skill of the surgical team and the experience of each technician.
• Graft handling: Managing the movement of the grafts from the physiologic bath solution to the recipient area takes time. Some doctor’s assistants who place the grafts will pile them up on the finger or hand, leaving them exposed to air for more than 20 seconds.
• Graft placement: This requires a special skill that often takes more than a year to acquire. Often it reflects a talent. The grafts must be delicately handled, because crush injuries are a potential problem.
• Graft depth: There is such a thing as a graft that is placed too deep or too superficial. Too deep can kill the graft as it turns the graft into a foreign body. It can also produce pimples or folliculitis sometimes weeks after surgery
• Grafts destroyed or never done as claimed: For long cases, I am under the impression that some doctors and/or some of their technicians actually toss the grafts in the garbage because: (a) they were too tired, (b) the placing was too difficult, (c) they never harvested or placed the number of grafts that they actually charged for. All of these things probably happen far more often than anyone cares to admit, but because it is a financial issue, the doctor and/or the team gets greedy. That means that from some surgeons’ points of view the surgery is about money, not grafts… and certainly not results.

When I see claims of FUE or strip surgery in the numbers that some patients from other clinics tell me that they received, I know in my heart that it could be a scam. This, of course, is a felony, but how does anyone know it if it is not reported? I have been told by many technicians that these things happen at other medical offices where they worked. Once, I had a technician toss away some grafts in my own practice and I fired that tech on the spot. This problem is the most alarming of the problems in this industry.

When a surgeon and his/her team finish placing the grafts, violations to any significant degree of any of the above can result in placing grafts that were killed in the surgical process. The surgeon and the patient will not know if the procedure worked until 6+ months after the procedure was done. By that time, the patient’s check has cleared the surgeon’s bank account by the time he finds out if the surgical techniques worked out or if the patient was honestly delivered what they purchased.

Doctor, love the blog, lots of useful information. I was hoping you could give a little career advice. What would you say to the students in medical school interested in getting into the field of hair transplantation? Would this not be a wise decision with companies such as histogen/replicell potentially achieving positive results using non-invasive techniques?

For a medical student thinking of a specialty to choose, I would not recommend hair transplant surgery. Not because it is not a great field, but mainly because there is no formal hair transplant surgery training or residency that would give you the requisite skills you should have. There is no consistency in the field of hair transplantation. I do believe the community of hair transplant doctors is improving and striving for consistency and it has greatly improved in the last decade. In fact, there is a board certification for hair transplant doctors, but it isn’t recognized by the American Board of Medical Specialties (ABMS).

If you still would like to pursue the hair transplant field, I would pursue a ABMS approved residency program of your interest. First get basic training in some official specialty like dermatology, and then get a fellowship under some well recognized expert in the hair transplant field who will take you under his wing.