Please note: Blog content represents the views of the author and not necessarily the BAHRS
The COVID frontline: My own experience and lessons learnt for hair restoration clinics
Author: Ted Miln, BAHRS FMM Member
Hair restoration is a niche industry. During the COVID-19 global pandemic, there has been limited information from professional organisations, public health bodies and governments that is specifically relevant to our service. As such, hair transplant surgeons have been left to review the evidence, debate the issues and interpret national and international guidelines in order to serve our patients and protect the public.
Most hair transplant clinics in the UK temporarily closed their doors in March as the UK entered lockdown. Many BAHRS members returned to the National Health Service (NHS) frontline in a variety of roles including COVID-19 triage hubs, Nightingale Hospitals, Emergency Departments, Intensive Care Units, General Practices and many more. Along with many of my colleagues, I returned to service in the NHS. Prior to doing so, I ensured my clinic was able to maintain standards of aftercare for existing patients, whilst my business partner continued doing video consultations for prospective patients.
Back in the NHS, my personal experience was of conducting telephone triage within general practice and I received training in our local field hospital. The COVID-19 training I received contained much that is pertinent to a hair restoration practice including managing personalities within clinical teams, correct use of personal protective equipment (PPE) and risk assessment. There was a particularly fascinating talk from a doctor who ran an Ebola field hospital in Africa during that pandemic. He told a story of how staff members’ perception and attitude towards risk changed from situation to situation as well as from person to person. One nurse would fastidiously peel away multiple sheets of toilet paper using gloves before using the toilet roll for fear of coming into contact with the virus, but then would cuddle an infected child which was one of the riskiest causes of transmission. This made me reflect upon the numerous factors that come into play when individuals, including myself are assessing risk.
When we decided to reopen our clinic a few months later, I adapted guidelines from the International Society of Hair Restoration Surgery (ISHRS) to include local public health guidance and UK law. Our risk assessment was primarily focussed on universal principles – in other words, assuming everyone is a carrier of coronavirus. Footfall through the clinic was limited, strict social distancing measures put in place and where this was not possible, full PPE worn. My personal opinion based upon evidence presented from ISHRS and my experience of COVID-19 testing within the NHS, is that COVID-19 testing in the clinic may detract from universal principles and increase the risk of transmission.
The correct use and availability of PPE has been a recurring issue throughout the entire pandemic. In our sector there has been much debate about whether hair transplant surgery is aerosol generating. Dr Dilan Fernando reviewed the evidence presented by Public Health England as part of their PPE guidance. The document highlights that for respiratory infection, there is no evidence of appropriate quality or strength, showing surgical procedures in the head and neck to have increased transmission risk, particularly where the respiratory tract, paranasal sinuses or oral cavity are not involved (1). The document identifies weak evidence showing an increased risk of pathogen transmission in surgeries which use high speed cutting devices (1). Some clinicians may argue this is relevant to motorised follicular unit excision (FUE) devices. On closer inspection of the evidence, these studies are based on dental and lumbar surgical cutting devices with rotation and oscillation speeds 10-fold faster than most FUE devices. More research is required to ascertain whether motorised FUE devices should be considered “high speed” and risk assess the degree of aerosol or droplet production. Another key question is whether the viral load of COVID-19 in blood is sufficient to cause infection by splashing in the eyes? Again, there is little evidence for a key factor influencing choice of PPE.
The inconsistency in the evidence is reflected in the variability of PPE being chosen by individual clinics. In our clinic we use IIR3 facemasks both for staff and patients. Other clinics have opted for fitted N95 or FFP3 facemask which provide a higher degree of protection for the wearer. In hospitals, these are used for confirmed cases of COVID-19. Adapting this to the clinic setting, consideration should be given to how long these masks should be worn for, the level of discomfort and the possible risk from repeatedly taking them on and off. Some clinics have opted to add another level of protection in the form of face visors. There are practical barriers to the use of visors including the difficulty fitting loupes under them and the risk of them fogging up with the use of facemasks. There have been some inventive solutions to this problem including cutting a hole in the visor for the loupes. Some companies now offer visors that fit far away from the face specifically to fit loupes underneath them. Personally, I do not use a visor because I have loupes which already have eye protection.
A major challenge facing most clinics has been the availability of PPE with many suppliers only providing to the NHS. Supplies from China have been unreliable and various opportunistic scammers producing inadequate PPE or none whatsoever. There has been collaboration amongst BAHRS members to source appropriate PPE and buy in bulk to make it more affordable.
During the pandemic, I gained a practical understanding of the limitations and inconsistencies of COVID-19 testing. There were numerous stories of people repeatedly testing negative until they became profoundly unwell and eventually testing positive. Pathologists reporting how death certificates could include COVID-19 ‘on the balance of probabilities’ despite an absent or negative test. This experience seemed to support the work presented by Dr Nilofer Farjo at the ISHRS Zoom meeting, which explained the limitations of the different types of COVID-19 testing including poor sensitivity and sometimes poor specificity.
The situation is far from over and as public health guidance changes, we will need to adapt our practices and risk assessments to allow for this. Evidence is lacking in many areas of day to day practice and these gaps should be filled where possible by quality research, but it is likely that new challenges will emerge as quickly as old ones are addressed.
The pandemic has brought out the finest qualities of BAHRS members – rekindling old skills to serve humanity at a time of need; fostering new inventive ways to protect patients; putting aside commercial interests for the betterment of our speciality; Zoom meetings and WhatsApp exchanges have engendered a true sense of collegiality which mirrors the noble principles of the ISHRS. As a group of professionals, we have been nimble to adapt to changing circumstances, supportive of each other, our communities, and our NHS. I am more proud than ever to be a part of this organisation of individuals, diverse in background, but united as ever through one common interest – hair!