A: Hair transplants, whether using the strip method to harvest the donor hair or by extracting individual follicular units one-by-one directly from the scalp, will leave some scarring. If the hair is long enough so that the underlying scalp is not visible, these scars will not be seen.

The quality and density of a person’s donor hair will affect this coverage and determine how short a person may keep his hair. In some cases the back and sides can be cut to a few millimeters, in others it would need to be kept longer. Since there is no scarring in the recipient area (the front and top of the scalp where the grafts are placed) the hair in these areas may be kept at any length.

Below is the article that appeared in the publication announcing Dr. Bernstein as the recipient of the honor. Dr. Bernstein is also a member of the society.

Hair Transplant Forum International
September-October 2006

Pioneer of the Month – Robert M. Bernstein, MD
by Jerry E. Cooley, MD Charlotte, North Carolina

The term “follicular unit transplantation” (FUT) has become so firmly embedded in our consciousness that we often consider it synonymous with hair transplantation in general. Surgeons new to the field may be unaware of its origin and how the concept evolved. In the 1980s, many separate clinics were developing total micrografting techniques to improve the naturalness of hair transplantation. In 1988, Dr. Bobby Limmer began developing a technique consisting of single strip harvesting with stereomicroscopic dissection of the hair follicles within the strip, which he published in 1994.

After observing histologic sections of scalp biopsies, dermatopathologist Dr. John Headington coined the term “follicular unit” in 1984 to describe the naturally occurring anatomic groupings of hair follicles. In 1995, a surgeon just entering the field of hair transplantation became aware of these natural “follicular units” and came to believe that they should be the building blocks for all hair transplants. His name was Bob Bernstein.

From 1995 to 2000, Bob and his colleague Dr. Bill Rassman articulated the rationale and benefits of FUT in dozens of publications and numerous lectures. Doubtlessly, Bob’s extraordinary effort advocating FUT in public forums during that time was critical to FUT’s rapid evolution and acceptance among surgeons.

Bob was born in New York City and raised on Long Island, New York. For college, Bob headed south to Tulane University in New Orleans. Next, he went to medical school in Newark at the University of Medicine and Dentistry of New Jersey. He then went on to a residency in dermatology at Albert Einstein College of Medicine, where he served as chief resident.

Bob performed some punch grafting procedures in residency and a few more when he started his cosmetically focused dermatology practice in 1982. Not liking the results, he didn’t perform another transplant for 12 years. In the summer of 1994, Bob saw a patient of Dr. Ron Shapiro for a dermatologic problem. Impressed with the results of the surgery, Bob began speaking with Ron about the changes in the field. Ron encouraged him to attend the next ISHRS meeting in Toronto, which he did. While there, he saw several of Dr. Rassman’s patients presented and was greatly impressed.

Soon after, he was in Bill’s office observing micrograft “megasessions.” One of the things that caught Bob’s attention was Bill’s use of the “densitometer” to quantify the patients’ hair density. Bob noticed that the hair surprisingly grew in small groups. Bill half jokingly told Bob that he should give up his dermatology practice and go into hair restoration and invited him back for a second visit. On the 5-hour plane ride to Los Angeles, Bob thought about the potential of only transplanting those small groups he saw with the densitometer, and wrote the outline of a paper entitled, “Follicular Transplantation” (published that same year). The second visit with Bill confirmed his interest in hair transplants and, in particular, developing this idea of FUT. He quickly transferred his dermatology practice to a colleague and joined Bill’s group, the New Hair Institute (NHI).

Over the next 10 years, Bob authored and coauthored over 50 papers on FUT addressing issues such as quantifying various aspects of FUs among patients, racial variations, graft sorting, as well as hairline aesthetics, corrective techniques, the use of special absorbable sutures, and FUE and its instrumentation. One of the concepts he emphasized was the recognition of Diffuse Patterned Alopecia (DPA) and Diffuse Unpatterned Alopecia (DUPA), which were originally described by Dr. O’Tar Norwood. Bob helped raise awareness that patients with DUPA and low donor density are not surgical candidates. For all of his many contributions to the field, Bob was awarded the 2001 Platinum Follicle Award.

Branching out in other directions, Bob decided to go to business school and received his MBA from Columbia University in 2004. He did this to learn how to better streamline the day-long hair transplant sessions and improve general management of his growing staff. In 2005, Bob formed his own practice, Bernstein Medical – Center for Hair Restoration. Looking to the future, Bob says, “I am excited about the accelerated rate of technical changes to the hair transplant procedure. This is due to an increasing number of really clever minds that have entered the field. Almost every aspect of the surgery is being tweaked and improved upon. It goes without saying that cloning will be the next really big thing—but I think it will take longer to develop than some are promising.” On the down side, he notes, “A concern I have is that, as hair transplant practices grow into big franchises with large marketing campaigns, many people are being directed toward surgery rather than being treated as patients with hair loss in need of an accurate diagnosis, medical treatment, emotional support, and surgery only when appropriate.”

Bob met his wife, Shizuka, who was born in Tokyo, when she was opening a dance studio in the East Village section of New York. She now owns a day spa in midtown Manhattan. Bob has three children; two are in college: Michael, 22, is studying mixed martial arts and foreign language; Taijiro, 21, is majoring in theoretical math. His daughter, Nikita, 12, is in 7th grade and plays on the basketball team. In addition to going to Nikita’s games, Bob enjoys skiing, piano, chess, basketball, philosophy, and music history.

A: One of the causes of having pimples and redness following Follicular Unit Extraction may be buried hair fragments and there are significantly more hair fragments generated with the two-step FUE technique than with the three-step method.

In the three-step procedure, we use blunt dissection which minimizes transection (cutting of hair follicles) and thus reduces the incidence of hair fragments. See the Instrumentation for Three-Step FUE page at the Bernstein Medical – Center for Hair Restoration website.

In our practice, we also place every extracted graft under the microscope. This serves a number of purposes:

1. It gives me immediate feedback on transection rates, so that I can adjust my technique in real-time (using a stereo-microscope is much better than visual inspection for this purpose)
2. It enables us to trim away excess tissue and hair fragments (we use the same judgment as we do with strip harvesting, so that a “viable looking” fragment would be left attached
3. It allows us to accurately count the number of hairs in each follicular unit graft, as it is particularly important to have pure 1-hair grafts for the frontal hairline. This also allows us to better anticipate the end cosmetic result.
4. It allows us to dissect larger follicular units into smaller ones for specific cosmetic purposes, i.e. eyebrows, hairlines, temples etc.

One of the ironies of FUE is that it is more efficient to extract the larger FUEs, since this gives us a greater hairs/hole ratio, but this often leaves us with an inadequate number of 1-hair units, which must be obtained though traditional stereo-microscopic dissection of the larger extracted grafts.

Other causes of folliculitis (manifested by pimples and redness) can result from placing the grafts too deep in the recipient site (where they may get buried) and secondary infection. A mild, transient folliculitis is often seen after a hair transplant without any precipitation factors.

A: Follicular Unit Extraction is ideal in very tight scalps, provided that there is enough hair to extract without leaving the donor area too thin and provided that the follicles are not too distorted from the scarring.

With strip harvesting, undermining techniques may be helpful to close the wound edges once the strip is removed.

In undermining, the surgeon uses either a sharp instrument (scalpel) or blunt instrument (the dull edge of scissors) to separate the upper layers of the scalp (dermis and epidermis) from the lower part of the scalp (fascia). The hair transplant surgeon accomplishes this by spreading apart the fat layer of the skin or by cutting through scar tissue.

Undermining allows the upper layers of skin to literally slide over the lower layers and can significantly increase the ability to close a tight wound. However, if not done carefully, it may increase the risk of bleeding and injury to nerves and occasionally may damage hair follicles.

Undermining is usually used with a layered closure where the deeper tissues are brought together first with a layer of absorbable sutures before the surface of the skin is sutured closed with sutures that are removed.

A: Strip harvesting is used in the majority of hair transplant procedures because it allows the surgeon the ability to perform hair transplant sessions using large numbers of grafts while minimizing injury to the patient’s hair follicles.

This is possible because once a strip is removed from the back of the scalp, the tissue can be placed under a stereomicroscope where dissection is accomplished using direct visualization of the follicular units. This allows the grafts to be dissected with minimal trauma.

This degree of accuracy is not possible with other hair restoration techniques, such as FUE, where the separation of follicular unit grafts from the surrounding tissue is accomplished “in vivo” (directly from the scalp).