- Monday.January 31. 2022
I was introduced to hair transplantation by Dr Roy Easdown in 1978. At this time, only plugs of hair were practised, and personally, I was not impressed with the results.
I did little work in this field over the next decade and usually only on patients who requested it.
Scalp reductions and pre-auricular flaps were practised through the 1980s and, in many cases, gave a superior result in my hands.
In 1990, I attended a workshop at the DHI Institute in Athens, where I met Drs Otar Norwood and Bob Leonard, experimenting with mini grafts of single follicles. This was a quantum leap forward, and in 1991, Dr Bobby Limmer from Texas introduced the concept of a full head of hair being transplanted with single follicles.
“My philosophy is to strive for higher standards of excellence in hair restoration. I continuously research and develop techniques that can improve outcomes in hair transplantation.
Many of my concepts have been taken by other doctors and called their own without acknowledging who alerted them to these ideas in the first place.
This has prompted me to write my story in a timeline sequence so that there can be no misunderstanding by the public and those doctors who have borrowed my ideas from whence they came.”
In 1992 I was the first to offer single follicle grafting in Australia. There was resistance from some patients as they felt they got more hair for their dollar when they had plugs! Also, a surprise note: “if the technique was so good, how come others weren’t offering it”.
I noted that despite using the single follicles, minor problems still arise, such as pitting from the excess epidermis, that the hairs were often quite vertical and often curled the wrong way. These difficulties were overcome by, first of all, trimming the excess epidermis off and leaving some length of hair on the follicle (up till now, the donor hair was totally shaved off. Also, by looking at the integrity of the follicle, it could be seen that the sebaceous gland was always anterior to the hair follicle, so by identifying this structure, hairs would curl and sit better on the scalp.)
By now, I had developed a serious interest in scalp hair (probably a throwback to a childhood full of horseriding and noting how the hair flowed on the horse.)
I took to inspecting close-up photos of scalp hair and hairlines; at this time, I took many photos of flowers and trees to understand the alignment of the petals and foliage to each other and how they accommodated each other to get their share of sunlight.
By 1995, I had worked out that hairlines looked better if there were more irregular and the hairs lay at the more acute angle.
In 1998, I attended a meeting in Los Angeles run by Dr Bill Rassman where the professor of dermatology from Columbia University, Dr Bob Bernstein, was giving a presentation on hairlines. The hairlines that he produced work too bell shaped, and I consulted Dr Barry White from Melbourne, who was in the row in front of me, about whether he had issues with the hairlines; he had no idea what I was talking about.
I took it upon myself to raise my hand so that I could suggest a better outcome; my heart was racing, my hands shaking as I stood up and with far too many people staring at me in amazement as I dared to challenge such a senior person. This was in the days before whiteboards, so Dr Rassman presented me with a pen and led me over to a large sheet of white paper upon which I was to demonstrate my proposed hairline. To say I was terrified of making a fool of myself in this erudite company is understated. At this time, I could only draw an irregular (shaky) line, explaining at the same time that the natural hairline is irregular. I went back to my seat, the lecture was over, and lunch was served.
I was outside sunning myself when Drs Rassman and Bernstein appeared as shadows in front of me. At this stage, I thought I was going to be scolded. Dr Bernstein put out his hand to me to shake and apologised, saying that my concept of an irregular hairline was quite correct! He then went on to ask me what did I call it? I had never thought to call it anything, so the only vision I could rapidly come up with was that of snails tracking all over our cement verandas when I was a child, so I quickly said “snail track hairline“.
In 1999, I wanted to give a paper on the snail track hairline at the ISHRS meeting. As an unknown person with an unknown idea, it was rejected; however, I was allowed to give a poster presentation. Dr Dow Stough, the first President of the ISHRS, came to me so enthusiastic about the concept. He encouraged me to give an oral presentation the following year on the topic.
Sadly, others on the Internet have taken this concept and called it their own; this was the first of many times I have had my work copied and not been given credit for it.
In 1999 and 2000, I undertook a longitudinal study on intact follicles versus one’s that had been transected at the bulge. Twenty patients of mine and two of Dr Bill Parsley, Saratoga Springs, completed the 18 months of observation. We found that on average, 98% of the intact follicles were surviving at 18 months, as were the ones that had been vertically split (that is, the hairs were not damaged, only the surrounding soft tissue was injured). However, the total number of the hairs transected at the bulge that survived was 9%.
The bottom line is that transection is seriously bad for hair follicle survival. That brings me to the topic of FUE, where many follicles are injured in the harvesting process.
Largely because of the important information derived from this, I was awarded the Platinum Follicle Award in New York in 2003 in recognition.
In 2001 Porto Vallarta in Mexico, I used a foam head and covered it in pins to mimic hair growth. Much to my surprise, the audience was enthralled as they got to understand that hair follicles are offset from each other and have different directions and heights of angulation depending on where they are on the head; I never fail to be surprised how much the medical attendees enjoy these simple visual displays.
In 2003, I followed this up with a presentation called A0D, short for angle, orientation, direction. Suffice it to say that a senior colleague came up to me after the presentation asking me which hallucinogen I was using when I wrote that paper!
Fortunately, within a year, the medical fraternity had adopted the need for variable angles and variable direction of hair as it spiralled on the head.
Orientation of the hairs is an extremely difficult concept to explain and took another decade before it was adopted.
Around this time, I had a patient come to me for a second procedure. Dr Richard Shiell carried out the first. As I looked at the previous grafts on his head where three or four hairs were lined up behind each other, I combed the hairs sideways towards his ear and was surprised to find out how much more aesthetic it looked.
I quickly sent an e-mail to Dr Marcelo Gandleman in South America to ask him why hair follicles will be put in rows (sagittally). He said he had absolutely no idea why the medical fraternity had adopted this. On closely examining the follicles on the head, it is seen that the large hair follicles with three and four hairs exit the scalp at right angles to the direction of growth, also known as coronal placement or rights angled placement.
To prove this concept, I had ten patients who allowed me to place one side of the grafts the traditional sagittal placement and the other side the new concept of coronal angled grafting.
I presented a paper at the ISHRS Vancouver meeting in 2004. I met much resistance from many of my colleagues as two of the patients shown had a shadow over their left shoulder, which they thought would interfere with showing that CAG placement was better than SAG. Jinxed! I had had some problems with my overhead flashlights where one went off slightly ahead of the other. I was told to go back to the drawing board!
Meanwhile, in Canada, Drs Hasson and Wong came up with a similar concept calling it lateral slits.
Dr Wong and I ran a workshop at the Sydney ISHRS meeting in 2005 on this topic, which helped propel the idea out to the other surgeons. It probably took till after 2010 before a significant number of surgeons would incorporate CAG/lateral slits into their surgery.
Too much time in our industry has been taken up on the topic of which is the best harvesting technique, FUT or FUE. To my way of thinking, the best harvesting technique is the one that gives you the most intact undamaged follicles that have the best chance of long-term growth.
But patients long-term happiness is more affected by the artistic work undertaken to make recipient sites. In other words, it is not about the “bricks” delivered; it is about the builder’s expertise and professionalism in putting them together to create a mansion rather than something out of a third world country.
I was horrified that our own ISHRS society went to two years without discussing the putting together of the follicles in the recipient sites, so attendees may have left the meeting with maybe knowing how to extract the follicle but with no idea of a grand plan for placement. The issue became even worse when the doctors would leave their technicians to make the holes and implant the hairs! This was and is a big problem, especially internationally.
In 2006, I introduced the concept of minimal trauma by training staff well so that the recipient sites could be made as small as possible with as little depth as necessary. It meant that the follicles could be put closer together, and with less injury to the skin, the likelihood of necrosis of the skin or poor growth could be minimised. I also suggested that trauma be minimised by using tumescence (puffing up the skin) with saline before making the sites.
These are all concepts that the leaders have adopted in our field.
As a result of my work comparing CAG & SAG, by accident, I found out that follicles take up space, which the medical profession didn’t believe until this time. Previously there was a raging disagreement between Dr David Seager and Dr Walter Unger in Toronto. Dr Seager planted 50 follicles per square centimetre, and then Dr Unger would follow the patient up a year later; he only got a count of 40 follicles per square centimetre, suggesting that 20% had died.
My premise was that I believed that follicles actually took up space. So I tattooed an area 10 mm x 10 mm square and transplanted 50 follicles into that area. A year later, when studying this area, I noted that the square was now 11.5 mm x 11.5 mm, now over 121 mm² where previously it had been 100 mm². The area had grown as a result of the follicles being transplanted! I have now solved the issue between Dr Seager and Unger, and they were both right.
Transplanting into scars over the years had resulted in variable outcomes. My approach was based on my daughter Sara’s anatomy textbook talking about wound healing. Any surgical wound is associated with swelling three days post-operatively, so I surmised that if you put a follicle into a slit in a thick scar, it would probably die suffocated by the post-operative swelling. I suggested punching little pieces of the scar to allow for the post-operative swelling, and I was rewarded with excellent graft growth. I first spoke on this in Adelaide in April 2006, but the audience was relatively small, and the talk was probably inappropriate for them.
I followed up with a webinar and 2007 to the ISHRS membership, but the topic was too new and an outrageous idea. Indeed the problem couldn’t be solved so easily.
It was not until 2012 in the Bahamas when I was President of the ISHRS that I put forward the concept again. Fortunately, in the audience was an experimental dermatologist from Germany, Dr Ralf Paus, who recognised with clarity that what I said made sense; that scar tissue, when traumatised, becomes more embryonic and has another chance to become normal tissue given the fact that the hair follicles not only contain hair but stem cells. Another breakthrough for me after years of lecturing to a deaf audience!
Following the theme of artistic hair transplantation, my then sixth year medical student daughter Sara Kotai, in 2004, came up with the concept of ‘curl’ of the hair being essential for a natural look. Sara also has other doctors internationally who have stolen her concept without recognition on the Internet.
In 2006, the ISHRS held an Eyelash Workshop in California where my new concept on transplanting eyelashes using coronal sites and with attention to curl was presented and demonstrated. Since then, even though I introduced the technique, I rarely use it as I wouldn’t say I like the results enough.
In 2007, at the Las Vegas ISHRS meeting, I introduced the concept of Graduated Central Density, which added to the naturalness of the outcome. The results were based on research on young men who are not losing hair, yet with using a dermatoscope, it is possible to show that hair groupings increase in density from the front to the crown.
Over the prior eight years, it had become abundantly clear to me that to achieve the most artistic results in placing hair follicles, all the above “bits” needed to be put together; that is science, time management, staff training, manage resources, surgery, minimal trauma, maths, artistry. It was suggested that because all these ideas had emanated from me, I should consider trademarking the “Martinick Technique” and the “Two Touch Technique “, the latter being a means by which technicians could efficiently and effectively transplant large numbers of grafts. So in 2008, both were duly trademarked.
Always looking to improve on things, “no straight lines in nature” has been added to the technique.
I was honoured by Dr Walter Unger asking me to write chapter 12 on Recipient Sites-Minimising Trauma in his book “Hair Transplantation”.
In 2009, I wrote “The New Hair Restoration” book to educate the public.
In 2010 at the Boston ISHRS meeting, I introduced the concept of a never fail self removing suture, a technique used in many clinics worldwide.
From 2010 to 2013, I was asked to produce a series of videos and power points as teaching tools for technicians, available to new doctors setting out through the ISHRS.
From 2011 to 2012, I served as President of the International Society of Hair Restoration Surgeons, and I set up an FUE committee to investigate the efficacy of FUE; this committee since that time has undertaken some excellent research and is still in the process of trying to find out how to improve outcomes.
In 2017 in Orlando, I was part of the Annual Live Surgeries Workshop. There were 14 surgeries carried out; three were FUT and the rest FUE. Doctors Sharon Keane, Bill Parsley and I were given 20 random grafts from each surgery; we did not know which device or doctor created the grafts. Our job was to assess the quality of the follicles, such as intact, not transected, a little bit of subdermal fat, etcetera. The results were supposed to be published, but this has not happened yet. But I do know that the best quality grafts came from FUT, something that is not so surprising, given the fact that the follicles are cut with microscopic dissection.
This is a paper that needs to be given as it is information that is needed by the public as well as the new doctors as they unwittingly are damaging patients and destroying their reputations in the interim.
Since then, I have continued to lecture internationally on these trailblazing ideas; they are gaining traction over time. But again, many of my concepts have been taken by other doctors and called their own without acknowledging who alerted them to these ideas in the first place.
This has prompted me to write my story in a timeline sequence so that there can be no misunderstanding by the public and those doctors who have borrowed my ideas from whence they came.