Dr. Bernstein answers frequently asked questions about hair transplantation, hair loss, and medical treatment for hair loss.


Hair Restoration Answers

What Is Your Opinion on Doctors Performing Only FUT or Only FUE?

June 22nd, 2015

Q: It seems that some doctors offer only FUT and others only FUE. What is your opinion on that?

A: Both FUT and FUE are excellent techniques, but have different indications. To deliver the best care for our patients, hair restoration physicians should have expertise in both procedures, and they should offer both in their practices.

The main advantage of FUT is that it typically (but not always) gives the highest yield of hair. Therefore, when the patient’s primary goal is to achieve maximum fullness, FUT should be performed. There are many well described reasons for this, including the precision of stereo-microscopic dissection and the ability to efficiently harvest from a more select area of the donor zone, but these are beyond the scope of this brief commentary.

The main advantage of FUE is no linear scar. Therefore, when the patient’s primary goal is to be able to wear his hair very short, FUE should be performed. FUE is also indicated when there is an increased risk of a widened scar or when scalp laxity does not permit a strip excision. The patient may sometimes chose FUE simply to avoid the stigma of a linear donor scar.

There are situations in which both procedures are useful in the same patient. For example, FUT may first be used to maximize yield, but then, after several sessions, the scalp may become too tight to continue to perform FUT, or the donor scar may become wider than anticipated. In the former case, the physician can switch to FUE to obtain additional grafts; in the latter case FUE may be used to camouflage the scar of the FUT procedure.

It is tempting to see the world in black and white, and it is easiest to learn and train one’s staff in just one hair transplant technique — but medicine is never so simple. Developments over the past twenty years have given us two excellent hair restoration procedures. We should offer our patients both.

Read about FUE Pros and Cons


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Posted by Robert M. Bernstein M.D. on June 22nd, 2015 at 3:08 pm
Hair Restoration Answers

What is Platelet-Rich Plasma (PRP) and How Does It Promote Hair Growth?

June 17th, 2015

Q: I’ve heard a lot about platelet-rich plasma (PRP). What is platelet-rich plasma, and how does it promote hair growth?

A: To begin, first let’s define a few basic terms: blood plasma, platelets and PRP

What Is Blood Plasma?

Blood plasma holds the blood cells in a liquid suspension. Blood plasma makes up about 55% of the body’s total blood volume. There are three basic types of blood cells: red blood cells (that carry oxygen), white blood cells (that have immune functions to help fight infection) and platelets (that facilitate coagulation, wound healing and repair).

What is a Platelet?

A platelet is a type of white blood cell containing approximately 50 to 80 tiny encapsulated structures called alpha-granules. Each alpha-granule contains a high number of growth factors, many playing a fundamental role in healing following tissue damage.1 Many of these platelets are also known to regulate the growth cycle of hair follicles.2

Platelets are formed in the bone marrow and circulate throughout the bloodstream in a concentration of approximately 140,000 to 400,000 platelets/mm3.

What is Platelet-Rich Plasma?

Derived from a patient’s own blood plasma, platelet rich plasma is concentrated blood plasma which contains approximately five times the number of platelets and growth factors normally found in the blood.

How Does Platelet-Rich Plasma Work to Promote New Hair Growth?

Studies that have looked at the therapeutic effects of PRP on hair loss have found that it promotes hair survival and hair growth in both laboratory studies3 and human clinical trials, but exactly how PRP promotes new hair growth isn’t clear. Researchers have suggested a few possible mechanisms.

In a recent pilot study4 that found that PRP injections resulted in noticeable improvement in both males and females with androgenetic alopecia, researchers suggested that PRP may have stimulated hair growth by prolonging the anagen (growth) phase of the hair follicle.

In another study5 that showed PRP promoted hair growth in males with alopecia, researchers suggested that PRP may have protected the hair follicles against one of the possible main mechanisms of pattern hair loss: the death of dermal papilla cells in the hair follicle.6 The death of these cells leads to a gradual shrinking and eventual disappearance of the hair shaft, a process called miniaturization.

Other studies have observed that PRP seems to promote the growth of new blood vessels around treated hair follicles. Because of this, researchers have suggested that the growth of new blood vessels may be helping to stimulate new hair growth.7

In sum, while published studies so far suggest that PRP therapy is a safe and effective treatment option for male and female androgenetic alopecia, there is still a need for more extensive studies to better understand the mechanism by which PRP treatments promote hair growth.

Platelet Rich Plasma (PRP) FAQ

See the PRP Treatment Steps

Read about the latest research into PRP therapy for hair loss

Read more in our section on Platelet Rich Plasma

References:
  1. Eppley BL, Pietrzak WS, and Blanton M. Platelet-Rich Plasma: A Review of Biology and Applications in Plastic Surgery. Plastic and Reconstructive Surgery, 2006. []
  2. Itami S, Kurata S, Takayasu S. Androgen induction of follicular epithelial cell growth is mediated via insulin-like growth factor-I from dermal papilla cells. Biochem Biophys Res Commun. 1995; 212: 988–94. []
  3. Li ZJ, Choi HI, Choi DK et al. Autologous platelet-rich plasma: a potential therapeutic tool for promoting hair growth. Dermatol Surg 2012; 38: 1040–6. []
  4. Schiavone G, Raskovic D, Greco J, Abeni D. Platelet-rich plasma for androgenetic alopecia: a pilot study. Dermatol Surg. 2014; 40(9): 1010-9. []
  5. Cervelli V, Garcovich S, Bielli A, Cervelli G, Curcio BC, Scioli MG, Orlandi A and Gentile P. The effect of autologous activated platelet rich plasma (AA-PRP) injection on pattern hair loss: clinical and histomorphometric evaluation. BioMed Research International 2014; 1-9 []
  6. Whiting DA. Possible mechanisms of miniaturization during androgenetic alopecia or pattern hair loss. J Am Acad Dermatol. 2001 Sep;45(3 Suppl):S81-6. []
  7. L. Mecklenburg, D. J. Tobin, S.Muller-Rover, et al. “Active hair growth, anagen, is associated with angiogenesis.” Journal of Investigative Dermatology 2000, 114:5; 909–916. []

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Posted by Robert M. Bernstein M.D. on June 17th, 2015 at 12:35 pm
Hair Restoration Answers

Which Platelet Rich Plasma (PRP) System Do You Use?

June 11th, 2015

Q: I have seen some talk about different forms of platelet rich plasma (PRP). Which is the best? Which are you using?

A: We use the Emcyte Pure PRP system. It is a double centrifuge system that I think is the best.

Platelet Rich Plasma (PRP) FAQ

See the PRP Treatment Steps


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Posted by Robert M. Bernstein M.D. on June 11th, 2015 at 4:45 pm
Hair Restoration Answers

Could I Have Platelet Rich Plasma Therapy Instead Of A Hair Transplant?

June 11th, 2015

Q: It was recommended by the doctor that I have a hair transplant. Could I do platelet rich plasma (PRP) instead?

A: PRP will generally be inadequate for patients who are candidates for a hair transplant. PRP works to reverse miniaturization (thinning hair) as do other medical treatments (Propecia, Rogaine, LLLT). Unfortunately, medical treatments do not grow hair back once it has been lost.

Platelet Rich Plasma (PRP) FAQ

See the PRP Treatment Steps


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Posted by Robert M. Bernstein M.D. on June 11th, 2015 at 4:31 pm
Hair Restoration Answers

Does Platelet Rich Plasma (PRP) Therapy For Hair Loss Involve Surgery?

June 10th, 2015

Q: How is platelet rich plasma therapy for hair loss performed? Does it involve surgery?

A: Platelet rich plasma (PRP) therapy for hair loss is performed during a simple office visit, takes about 30-45 minutes, and does NOT involve surgery.

The first step in PRP treatment for hair loss involves drawing a patient’s blood into a syringe.

Next we use a double-centrifuge platelet concentration system (the Emcyte Pure PRP system) to separate and then concentrate platelet-rich plasma from the blood.

The last step involves transferring the platelet-rich plasma into a syringe and then injecting the plasma directly into the patient’s scalp.

After the treatment, some patients may experience very temporary soreness and/or swelling, but many patients will experience nothing.

After the initial treatment, patients will typically receive two more treatments at 6 week intervals. After that, they will receive additional treatments every 3 months over the course of the first year. After the first year, patients will receive treatments approximately every 6 months.

Platelet Rich Plasma (PRP) FAQ

See the PRP Treatment Steps

Read about the latest research into PRP therapy for hair loss

Read more in our section on Platelet Rich Plasma


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Posted by Robert M. Bernstein M.D. on June 10th, 2015 at 3:33 pm
Hair Restoration Answers

Are There Any Side Effects or Safety Concerns in Using PRP to Treat Hair Loss?

April 20th, 2015

Q: I’ve heard about using platelet rich plasma (PRP) therapy to treat hair loss. Are there any potential serious side effects that I should be aware of?

A: PRP is a therapy that has been used since 1987 to help promote the healing of hard tissue (bone, joints) and soft tissue (skin). To date, there have been no reported major side effects.1

Only a handful of published studies have tested PRP’s effectiveness and safety in treating hair loss; however, none of those studies have reported serious side effects.2,3,4,5,6,7

This lack of any reported major side effects coupled with the fact that PRP is obtained from a patient’s own blood makes doctors relatively confident that PRP treatments are safe for hair loss.8

All this said, researchers are continuing to evaluate both the efficacy and the safety of PRP therapy for the treatment of male and female pattern baldness.

Read about the latest research into PRP therapy for hair loss

Read more in our section on Platelet Rich Plasma

References:
  1. Hall MP, et al “Platelet-rich Plasma: Current Concepts and Application in Sports Medicine” J Am Acad Orthop Surg, Vol 17, No 10, October 2009, 602-608. []
  2. Kang JS1, Zheng Z, Choi MJ, Lee SH, Kim DY, Cho SB. The effect of CD34+ cell-containing autologous platelet-rich plasma injection on pattern hair loss: a preliminary study. J Eur Acad Dermatol Venereol. 2012 Jan;28(1):72-9 []
  3. V. Cervelli, S. Garcovich, A. Bielli, G. Cervelli, B. C. Curcio, M. G. Scioli, A. Orlandi, P. Gentile. “The effect of autologous activated platelet rich plasma (AA-PRP) injection on pattern hair loss: clinical and histomorphometric evaluation,” BioMed Research International Volume 2014 []
  4. Khatu S.S, More Y.E, Gokhale N.R, Chavhan D.C, Bendsure N. Platelet-rich plasma in androgenic alopecia: myth or an effective tool. J Cutan Aesthet Surg. 2014 Apr;7(2):107-10. []
  5. Schiavone G, Raskovic D, Greco J, Abeni D. Platelet-rich plasma for androgenetic alopecia: a pilot study. Dermatol Surg. 2014 Sep; 40(9):1010-9. []
  6. Takikawa M, Nakamura S, Nakamura S, Ishirara M, Kishimoto S, Sasaki K, Yanagibayashi S, Azuma R, Yamamoto N, Kiyosawa T. Enhanced effect of platelet-rich plasma containing a new carrier on hair growth.Dermatol Surg. 2011 Dec;37(12):1721-9 []
  7. Trink A, Sorbellini E, Bezzola P, Rodella L, Rezzani R, Ramot Y, Rinaldi F. A randomized, double-blind, placebo- and active-controlled, half-head study to evaluate the effects of platelet-rich plasma on alopecia areata. Br J Dermatol. 2013 Sep;169(3):690-4. []
  8. Platelet-rich plasma: Clarifying the issues. The American Academy of Orthopaedic Surgeons website, www.aaos.org, September 2010. []

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Posted by Robert M. Bernstein M.D. on April 20th, 2015 at 9:21 am
Hair Restoration Answers

Does Finasteride Need to be Taken Every Day?

April 13th, 2015

Q: Does finasteride need to be taken every day?

A: Finasteride (Propecia) is a competitive inhibitor of Type II, 5 alpha-reductase (5AR is the enzyme that converts Testosterone to DHT which then causes hair to miniaturize and eventually be lost). Finasteride is 100x times more selective in inhibiting the Type II enzyme (present in hair follicles) than the Type I enzyme (present in other body tissues). The turnover (T1/2) of the finasteride/5AR Type II complex is 30 days and the finasteride/5AR Type I complex is 15 days. This explains why finasteride does not need to be taken every day and why, after stopping finasteride, the effects may take a month or longer to begin to dissappear.

Read about the first comprehensive study to investigate Propecia’s long term efficacy

Read more about Propecia (finasteride)


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Posted by Robert M. Bernstein M.D. on April 13th, 2015 at 3:29 pm
Hair Restoration Answers

How Does Platelet Rich Plasma (PRP) Treat Androgenic Alopecia?

April 13th, 2015

Q: How does PRP therapy for hair loss work?

A: In theory, platelet rich plasma (PRP) stimulates the growth of hair follicles by reversing the hair miniaturization (thinning hair) process seen in androgenic alopecia (common baldness).

While it is not exactly known how PRP reverses miniaturization, researchers do have a few ideas. First, PRP may counteract miniaturization by prolonging the growth (anagen) phase of hair follicle.1 Second, PRP has been observed to increase the number of stem cells in hair follicles. This is known to help protect a hair follicle from apoptosis, a natural process of programmed cell death. Researchers think that this anti-apoptotic effect could stimulate new hair growth.2 Finally, PRP treatment has been observed to promote growth of new blood vessels around treated hair follicles. Researchers have suggested that this could also stimulate new hair growth.3

In sum, a number of factors may come into play to effect new hair growth during treatment with platelet rich plasma. Research is ongoing to further clarify the specific mechanisms involved.

Read about the latest research into PRP therapy for hair loss

Read more in our section on Platelet Rich Plasma

References:
  1. Z. J. Li, H.-I. Choi, D.-K. Choi et al., “Autologous platelet-rich plasma: a potential therapeutic tool for promoting hair growth.” Dermatologic Surgery, vol. 38, no. 7, part 11, pp. 1040–1046, 2012. []
  2. Takikawa M, Nakamura S, Nakamura S, et al. “Enhanced effect of platelet-rich plasma containing a new carrier on hair growth.” Dermatol Surg. 2011 Dec;37(12):1721-9. []
  3. L. Mecklenburg, D. J. Tobin, S.Muller-Rover, et al. “Active hair growth (anagen) is associated with angiogenesis.” Journal of Investigative Dermatology, vol. 114, no. 5, pp. 909–916, 2000. []

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Posted by Robert M. Bernstein M.D. on April 13th, 2015 at 8:31 am
Hair Restoration Answers

Why is Robotic Recipient Site Creation an Advantage?

April 9th, 2015

Q: Why is using the robot to create recipient sites useful in a hair transplant?

A: The ARTAS Robotic Hair Transplant system eliminates the inconsistencies inherent in creating large numbers of recipient sites by hand. The robot can create sites at a rate of up to 2,000 per hour. Although there is more set-up time compared to sites made manually, once the physician specifies the parameters such as punch depth, punch angle, and site direction, recipient site creation is precise and rapid.

One of the benefits of robotic site creation is that the distribution of grafts over a fixed area of the scalp can be exact. For example, if one wants to transplant 1,000 grafts evenly over 50cm2 of area, this can be done with great precision and with uniform site spacing. In addition, the physician can vary the densities in select regions of the scalp and the robot will adjust the densities in other areas so that the total number of sites remains the same.

Another benefit of the new technology is that the robot can be programmed to avoid existing hair and select which specific hair diameters to avoid. The robot is programmed to keep a specified distance from the existing hair to ensure that the resident follicles will not be damaged and that the distribution of new hair is even and natural. This computerized mechanism appears to be more accurate than what can be done by hand and, importantly, does not sacrifice speed in the process.

Read more about Robotic Recipient Site Creation

Read about Robotic Hair Transplantation


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Posted by Robert M. Bernstein M.D. on April 9th, 2015 at 1:15 pm
Hair Restoration Answers

How Does the ARTAS Robotic System Make Recipient Sites in a Hair Transplant?

April 6th, 2015

Q: How do recipient sites get made in Robotic FUE? And how does the robot know where to create the sites?

A: In performing recipient site creation, the ARTAS Robotic Hair Transplant system automates another part of the hair transplant process that is repetitive and prone to human error. In robotic site creation, the physician first designs the hair restoration and then specifies the angle of hair elevation, hair direction, site depth, average density, and total number of the recipient site incisions. The robot then creates the sites according to these specifications.

During site creation, the robot automatically uses its image-guided technology to avoid hairs of a certain diameter (specified by the doctor). The robot creates sites at a minimum distance from hairs of the specified diameter (the distance is also specified by the physician) and will do so randomly throughout the areas where the hair is finer or the scalp is bald. With this important feature, the new distribution of sites can be made to complement the distribution of existing hair. Observation of the ARTAS System suggests that it performs recipient site creation with greater precision and consistency than can be accomplished manually.

Read details on our Robotic Recipient Site Creation page

Read our Robotic Hair Transplant FAQ


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Posted by Robert M. Bernstein M.D. on April 6th, 2015 at 8:35 am
Hair Restoration Answers

How Does Robotic FUE Differ from Other Hair Transplant Procedures?

April 3rd, 2015

Q: What is the main difference between hair transplants using the robot versus other procedures?

A: There are two basic types of hair transplant procedures, Follicular Unit Transplantation (FUT or strip surgery) and Follicular Unit Extraction (FUE). In FUT, donor hair is harvested by removing a long thin strip from the back of the scalp. Individual follicular units are then obtained from this strip using stereo-microscopic dissection. In FUE, individual follicular units are harvested directly from the donor area using a sharp, round cutting instrument. The ARTAS Robotic System performs the follicular unit isolation step of an FUE procedure and can also create recipient sites according to specifications determined by the hair restoration surgeon. In performing each of these steps, the robot uses its image-guided technology to locate the next target and position the cutting instrument, and it does so with precision and speed that cannot be accomplished using manual FUE techniques or instruments.

Read more about the ARTAS Robotic System

Read the Robotic Hair Transplant FAQ


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Posted by Robert M. Bernstein M.D. on April 3rd, 2015 at 12:56 pm
Hair Restoration Answers

Does Propecia Work for Life or Does it Stop Working Over Time?

April 2nd, 2015

Q: Can Propecia (finasteride) completely halt androgenic alopecia for the duration of your lifetime, or does it just slow down the progression of androgenic alopecia?

A: In many patients we have found finasteride to hold on to a patient’s hair for at least 15 years. We don’t have much longer data than that since it was approved for hair loss in 1998. Although finasteride will usually continue to work as long as you take it, it may lose some of its efficacy over time. Generally after about 5 years we may notice that the patient’s hair is starting to thin again and we will increase the dose slightly. It is important to understand that even if someone thins on finasteride it doesn’t mean the medicine is not working, because they might have thinned much more without it. To my knowledge, there are no studies that have looked at the effects of finasteride for such an extended period of time.

Read about the first comprehensive study to investigate Propecia’s long term efficacy

Read more about Propecia (finasteride)


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Posted on April 2nd, 2015 at 4:59 pm
Hair Restoration Answers

Is There Any Research on Platelet Rich Plasma (PRP) As A Hair Loss Treatment?

April 1st, 2015

Q: I have read conflicting reports on the use of PRP to treat hair loss. What is your assessment? Are there any research publications that suggest it does work?

A: Two recent studies published in 2014 have presented preliminary evidence that platelet rich plasma (PRP) therapy may stop or reverse genetic hair loss (androgenetic alopecia) in both males and females.

The first study, published in the medical journal Dermatologic Surgery, found at least some improvement in male and female patients with androgenetic alopecia. This study concluded that 47% of those patients experienced at least moderate to very good improvement,1 a level that the researchers defined as “clinically important.” Because this was just a pilot study without a control group, the authors could not reliably claim that PRP was effective in treating hair loss.

A second study, published in the journal BioMed Research International, concluded that treatments of platelet-rich plasma stimulated hair growth in men with pattern hair loss.2 In this clinical study, the researchers found a statistically significant increase in both hair density and terminal hairs.

While more comprehensive testing needs to be done, these studies provide preliminary evidence that platelet rich plasma therapy may stimulate hair growth in patients with male or female pattern baldness.

Read more about Platelet Rich Plasma (PRP)

Read our PRP FAQ for answers to common questions

References:
  1. Schiavone G, Raskovic D, Greco J, Abeni D. Platelet-rich plasma for androgenetic alopecia: a pilot study. Dermatol Surg. 2014 Sep; 40(9):1010-9 []
  2. V. Cervelli, S. Garcovich, A. Bielli, G. Cervelli, B. C. Curcio, M. G. Scioli, A. Orlandi, P. Gentile. “The effect of autologous activated platelet rich plasma (AA-PRP) injection on pattern hair loss: clinical and histomorphometric evaluation,” BioMed Research International Volume 2014. []

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Posted by Robert M. Bernstein M.D. on April 1st, 2015 at 11:37 am
Hair Restoration Answers

How Does a Hair Transplant Surgeon Operate the ARTAS Robot for FUE?

March 11th, 2015

Q: I have been reading about Robotic FUE and have seen some photos on your website of you operating the ARTAS robot using what looks like a remote control. What is that thing and how does it control the robot?

Dr. Bernstein Operating the ARTAS FUE Robot
Dr. Bernstein Operating the ARTAS FUE Robot

A: The ARTAS robot uses a dual operating system when performing follicular unit extraction. One station consists of a desktop computer adjacent to the robot. This station is used to establish the basic parameters of the transplant such as the spacing of grafts, the angle and depth of the harvest, which size follicular units will be targeted, and a host of other important variables.

The hand-held pendant is used by the operator situated next to the patient. The remote has more limited options – the main ones being depth adjustment and to immediately suspend the action of the robot. Many of the parameters are determined automatically by the robot’s computer to maximize the accuracy of the harvesting. The robot also makes real-time adjustments to these variables during the hair restoration procedure.

The physician sets the parameters at the computer monitor and, once the settings are determined, he/she sets the tensioner grid on the patient’s scalp. The tensioner determines where the grafts will be harvested. The grid is moved approximately every 130 harvests. The robot can be operated at the computer terminal and through a mobile pendant. The physician often alternates with a trained assistant between that station and using the pendant.

Besides the involvement in the operation of the robot, there are many other important physician-dependent steps to the hair transplant including the planning and design of the procedure, and recipient site creation. Other steps, such as the microscopic sorting and trimming of harvested follicular unit grafts and graft placement, are often performed by trained staff, but require the physician’s close supervision.

Read about Robotic Hair Transplantation

Read articles about Robotic FUE


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Posted by Robert M. Bernstein M.D. on March 11th, 2015 at 9:41 am
Hair Restoration Answers

How Does the ARTAS System, or the Surgeon, Determine the Depth of the Incision, and Can it be Adjusted During Surgery?

February 13th, 2015

Q: How does the ARTAS robot control the depth of the incision in Robotic FUE?

A: The ARTAS robotic system is equipped with advanced sensors that determine the precise depth of the sharp and blunt needles used both in the graft harvesting step and for recipient site creation. The robot automatically adjusts to the precise depth needed for the non-traumatic extraction of the grafts. The tip of the punching mechanism contains depth markings so that the physician can visually override the punch when he wants to fine-tune its action. While monitoring the procedure in real time, if it is observed that the punches are too superficial or too deep, punch depth can be modified using the robot’s computer system.

The physician can also use the ARTAS system to precisely control the depth of recipient sites. As with harvesting, the robot automatically adjusts the depth based on parameters set by the physician and the doctor can then make further adjustments, in real-time, during the procedure.

Click here to read more about Robotic Hair Transplantation


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Posted by Robert M. Bernstein M.D. on February 13th, 2015 at 4:51 pm


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