Carl, a 60-year-old widow, decides that a hair transplant would allow him to feel more youthful. He chooses one of the doctors recommended in an inflight ad for a hair transplant device. Dr. PS is a highly credentialed doctor based in Southern California. He trained in otolaryngology and plastic surgery, has a solid reputation, and has been in practice for 20-plus years. Carl naturally assumes that Dr. PS is also an expert in hair restoration when he books his transplant. This is in 2015.
Today, Carl is in litigation with Dr. PS and has submitted a complaint to the Medical Board of California. Carl's dissatisfaction is due, in part, to poor aesthetics and low hair regrowth after surgery but also because he was unaware that Dr. PS does not perform the critical-to-quality steps of hair transplant surgery, a fact that Dr. PS does not dispute. In his deposition, Dr. PS admits that Carl's hair transplant was performed by his nurse and a per diem technician. He argues that delegation to an unlicensed technician and nurse meets the standard of care in California, as hair restoration surgery is no different than creating a tattoo.
The “expert” witness for the defense, another plastic surgeon who performs hair transplants with the same device, states under oath that hair transplant surgery can be delegated to a non-licensed worker and that such delegation is, “within the standard of care in the professional community.” Dr. PS's nurse has been reported to the California Board of Registered Nursing. The technician, having no state license, falls outside of any regulatory or professional oversight body.
This case has important legal implications. Performing surgery is regulated in most, if not all, of the 50 states in the US to be performed only by a physician or licensed nurse practitioner or physicians' assistant with physician oversight. The court and physician and administrative members of the Medical Board will debate the legal and regulatory issues. As aesthetic surgeons, however, we are in the best position to critically evaluate the non-legal aspects of the “turn-key” model of hair restoration surgery—namely the ethics, the appropriateness of patient care, and the growing role of non-medical/paramedical practitioners within aesthetic surgery.
First, we must agree that hair restoration meets the criteria of surgery. By definition, surgery is the “treatment of injuries or disorders of the body by incision or manipulation.” Hair transplant procedures have utilized trained technicians for 40-plus years, but this utilization in the traditional “strip” or FUT (follicular unit transplantation) procedures was limited to microscopic dissection then planting of grafts. The surgeon will perform the consultation and make a diagnosis and treatment plan, design the hairline, supervise or personally provide anesthesia, excise the donor strip, suture it closed and almost always make all the recipient sites.
FUE (follicular unit excision) was developed in the early 2000s and has become the most popular technique in hair restoration. It is conducive to the development of a different practice approach. Among our plastic surgery, facial plastic surgery, dermatology, and other cosmetic medicine colleagues, FUE has come to be considered a “delegable” procedure. Such a designation came about by one major and several minor copy-cat companies that manufacture the FUE graft excision devices. These companies appear to have a goal to benefit financially through the sale of devices and the “renting out” of technicians. There was no input nor direction from any specialty board, committee of experts in hair restoration, the International Society of Hair Restoration Surgery (ISHRS), or any other aesthetic surgery academy or society in making the “delegable” designation.
The “turn-key” model is apparently attractive to physicians seeking to increase revenues and extremely profitable to the device manufacturers, thus explaining their penetration to the public through direct advertising and to physicians through sponsorships of cosmetic surgery meetings. It is not unusual to see physicians with limited expertise in hair restoration present lunchtime lectures on how easy it is to add hair restoration to one's practice. This model involves the physician purchasing the heavily marketed device and hiring the company's affiliated technicians per diem to perform the procedure.
Technicians do most of if not the entire surgery, including determining the numbers of grafts to be transplanted on the patient, designing the hairline, injecting anesthesia, excising then extracting the grafts, making the recipient site incisions, planting the grafts, and presenting post-op instructions. Unlike all physicians who take an oath to place patient interests before all others, technicians take no such oath, nor do they have the medical training to properly evaluate a patient's medical and surgical candidacy. In this model, all the surgeon needs to do is meet with patients and (sometimes) and explain how the procedure will be performed by “expert” technicians. That's it.
Confronting the Problem
Hair restoration is a surgical procedure with permanent results. It is performed on patients who, like facelift or rhinoplasty patients, seek the best possible outcome with the lowest chance of complications.
The ISHRS, the world's largest organization of doctors devoted to treating hair loss, does not approve of this turn-key approach. The great majority of its 1,100-plus members worldwide and its entire leadership has been clear that the turn-key model is not in patients' best interests. They should know: ISHRS members have witnessed and treated many of the complications created by such turn-key practices.
Based on the facts presented, my recommendations are that:
• Our leading aesthetic societies establish guidelines for hair restoration surgery that require physicians or licensed physician extenders be the only providers who can perform the surgical aspects of hair transplants. This is protecting patients and preserving the domain of all types of cosmetic surgery to physicians in anticipation of the growth of automation that will enable non-physicians to perform an increasing number of surgical procedures.
• Practitioners not utilize minimally supervised unlicensed technicians or nurses for performing graft excisions or recipient site formations or any other part of this procedure that violates states' laws or, more importantly, their own ethos of how surgery should be properly performed.
• The surgeon performing hair restoration acquire a sufficient understanding of medical and surgical therapies of hair loss disorders as well as be knowledgeable of the different etiologies of hair loss, the full scope of therapies, and the proper diagnosis and determination of patient candidacy.
• Physicians interested in adding hair restoration become actively involved in the surgical aspects of the procedure, particularly graft excision and recipient site formation. These skills are best acquired by attending one or more hair courses.
It's Up to Us
In conclusion, we must recognize that the performing of surgery by para-medical personnel will extend beyond hair restoration surgery. As we see more and more devices able to perform a greater amount of surgical steps, we must resist the short-term infusion of money from device manufacturers. It is up to us to maintain the dignity and expertise of our work.