Finding and Training Assistants

101 Finding and Training Assistants

Tina Lardner

Summary

Current techniques in hair transplantation often require the preparation and implantation of large numbers of grafts. The increased labor associated with current techniques makes the role of surgical assistants critical. As a group, they substantially affect the patient experience and outcome of every operation. They become an extension of the physician with whom they work, who in turn becomes a manager for the entire surgical team. This chapter addresses those aspects of hair transplantation that relate to surgical assistants.Hair restoration surgery is heavily dependent on well-trained assistants, and physicians entering this field are finding it difficult to get their practice established without the necessary staff. Surgical assistants must know important components of grafts and how to handle tissue correctly, have the dexterity to cut and place grafts, and be able to critically think and handle difficulties in surgery. Even if physicians decide to exclusively perform follicular unit extraction (FUE), assistants must be able to skillfully extract and place grafts. This chapter is intended to instruct physicians on how to find assistants and train them effectively.

Keywords: training technician assistant graft dissection slivering graft placement graft removal graft extraction training staff retaining staff

Key Points

•New assistants should learn basic skills before learning skills that require critical thinking.

•There are two levels of learning: first on inanimate models and second on live patient.

•Quality control should always be monitored for new and seasoned assistants and performed by the lead assistant and the physician.

•It can take a week to learn a new skill, but it takes 6 months to 1 year for an assistant to build speed and competency.

•Retaining staff is more important than training them.

101.1 Introduction

It can be difficult to find or train assistants. Surgical assistants must know how to handle tissue correctly and have the dexterity to cut and place grafts. Training assistants can take many months. If a clinic loses an assistant it can affect the clinics ability to perform surgery. This chapter is intended to instruct physicians on how to find assistants and train them eﬀectively.

101.2 Finding Assistants and Qualifications

Ideal candidates must have the manual dexterity to perform microscopic dissection, perform tedious work for long periods of time, work with the existing team, communicate effectively with the patient and coworkers, and have attention to detail. Ideal candidates do not necessarily need to be medically trained, but should be able to work well with their hands.

If an assistant meets the above-mentioned criteria, it is prudent to let them view a surgery to determine if the prospect is capable and truly interested in this type of procedure. Sometimes a dexterity test, like the O’Connor Tweezer Dexterity Test (Model 32022), by Lafayette Instrument Company, is given to the prospective candidate to see if the individual is capable of following instructions and demonstrates fine motor skills (Fig. 101.1).

Fig. 101.1 Prospective candidate testing fine motor skills.

101.3 New Hire Training

Once the ideal candidate is found, a comprehensive training program should be performed. A simple introduction to the evolution of hair restoration should be covered. The bulk of the didactic training should cover the anatomy of the hair follicle and important components responsible for hair growth. A brief overview of the differences between a terminal and telogen follicle, hair growth cycles, and the progression of hair loss should also be included. Topics that are important for their job function are the human factors that influence growth; desiccation; and transection or crush injury. They should also be knowledgeable in other hair loss treatments such as finasteride, minoxidil, platelet-rich plasma (PRP), low-level laser therapy (LLLT), and the different methods of graft production.

101.4 Methods of Training

To fully understand the process involved in hair restoration surgery, technicians should view the entire procedure from preoperative procedures and the roles of technicians during surgery to postoperative care and follow-up. For physicians starting out, viewing a surgery may not be possible, so obtaining a video on the process of the procedure may be necessary. The important topics are the flow of the surgery, graft dissection, FUE graft removal, and graft placement.

Training can be divided into two categories: “training with inanimate models and training on a live patient.”1 Both methods have their pros and cons, but the use of both methods is necessary to teach assistants.

101.5 Training with Inanimate Models

The use of inanimate models teaches assistants how to hold instruments, establish proper body positioning and hand movements, cutting and placing techniques, and develop critical thinking skills. The benefits of using inanimate models are that it eliminates the fear of damaging follicles, corrections can be made immediately, and assistants can try different instruments to see what feels comfortable to them. Some skills take more time to develop proper techniques and stamina, while others are quicker to learn.

The types of inanimate models can vary. Over the years, different materials have been used and some types work better than others. For the sake of teaching how to sliver, Emina K. Vance from Dr. Sam Lam’s office uses grapefruit skin cut into 1-cm-wide strips. The yellow skin represents the epidermis and the white part represents the dermis and fatty layers. Using a microscope even with the inanimate models allows assistants to get used to working under the microscope. The teaching philosophy is to have the assistant visualize the pores of the grapefruit as follicular units and to sliver the grapefruit skin one pore wide. The instructor first demonstrates the cutting technique, talking through every step. They are instructed how and where to grasp the top part of the skin, the gliding motion of the blade, the peeling motion of separating the tissue, and cutting the sliver one pore wide (Fig. 101.2). Once the assistant grasps the concept, they can begin practicing.

Fig. 101.2 Slivering grapefruit skin.

The grapefruit skin can also be used to cut grafts. Lines are drawn in representing follicular groupings so that assistants can position their blade so that it is parallel with the follicles. Points to be emphasized are where and how to grasp the tissue and positioning the blade so that cuts are made down and not a sawing motion.

For FUE after physician dissection, the author has found 5-mm-thick craft foam that could be dissected with a 1- or 2-mm biopsy punch or motorized FUE machine and used to teach assistants to remove dissected FUE “grafts.” The dissected foam pad is taped to a table to keep it in place and two curved, serrated Foerster forceps are used to remove the “grafts.” When using the two-handed, hand-over-hand approach to remove grafts, this technique gives assistants the “feel” of grasping tissue and removal from the scalp. Special attention is made to where the graft is grasped and how much force is applied with the forceps.

To teach graft placement, a larger piece of grapefruit skin is cut out and pinned to a Styrofoam head representing the recipient area. Recipient sites are created with 19- and 18-gauge needles and since they are often hard to see, methylene blue or liquid ink could be used to highlight the sites. Craft foam mentioned earlier (5-mm thickness is ideal) can be dissected into small 1-mm pieces representing grafts. Different colored foam grafts can be used to differentiate 1-, 2-, 3-, and 4-hair grafts. This is important as it allows the assistant to develop critical thinking skills needed to place grafts in areas of importance, as directed by the physician’s plan, to give the patient the most natural-looking appearance. Practicing on a Styrofoam head allows the assistant to visually see what area they are responsible for and how to work with other placers.

Assistants working on inanimate models should be able to practice daily. Stamina should be developed so it is recommended for assistants to practice initially at 30-minute intervals twice a day; working up to 1 to 2 hours. This is a great time to evaluate movements, discuss why things are done a certain way, and to correct poor habits.

Some companies like Science Care provide cadaver scalps for teaching purposes. Ideal cadaver scalps have naturally dark hair, a thick fatty layer, and are flushed in formalin. Female scalps work best if the scalp has a good amount of hair. An assistant can familiarize themselves with follicle components.

101.6 Training on Real Patients

When assistants have practiced with inanimate models and have demonstrated proper technique for each skill, the assistant is slowly introduced to live tissue. Once they begin working on a patient with constant supervision, limit the time of their practice to 30 to 45 minutes at a time. Working with real tissue can be overwhelming, especially when working with white hair during graft preparation or dealing with bleeding, popping, and patient movement during graft placement. Each day add an additional 15 minutes until they have the endurance to place for longer periods. During this time if corrections are needed or if you notice ways to make them more efficient, the assistant should be pulled from the patient so that the patient does not hear the instructions given to the assistant. The patient should never know a new assistant is working on him or her. If the assistant still does not make the necessary adjustments, it is prudent to schedule the assistant for additional practice on the inanimate models until they understand the proper technique. If the assistant can dissect or place grafts with no intervention, you can spot-check their performance. Even the assistants who have been practicing for a while need to be spot-checked as they can sometimes develop poor habits.

101.7 Learning Objectives

Considering that assisting in hair restoration requires several important skills, this section will address teaching points as pertinent to each individual skill. Understanding and clearly communicating learning objectives sets realistic expectations and helps both the trainer and the trainee.

101.7.1 Slivering

The objectives of teaching an assistant how to sliver should cover several topics. Body positioning is necessary to understand how important it is to position the tissue and hold the instruments so that it is comfortable for the assistant to effectively cut the tissue over a long period of time. There are several teaching points to cover. The tissue must be anchored to a silicone, slivering board to stabilize the strip. The tissue is held with the nondominant hand using forceps with teeth to grasp the epidermis and gently pulling (like opening the pages of a book) to separate the tissue so that the follicles are visible underneath. The blade angle must match the angle of the follicles while gliding the blade between follicular groupings (Fig. 101.3). During this time, emphasis on hydration of the “tissue” should be maintained. Once the assistant can cut uniform pieces and demonstrates proper technique, they may learn how to further cut tissue and create grafts.