A: Staples, because they conserve more hair.

A: I have been using staples in almost all of our follicular unit hair transplants since the beginning of 2006. When we published the Sutures vs. Staples study in 2001, some doctors were still not convinced. Because of this I continued to look at the issue, not in a bilaterally controlled experiment, but just looking at my cases done with the 5-0 Monocryl and those with staples that I continued to use from time to time. After doing hundreds of additional cases, I was still convinced that the overall the suture line looked better with the 5-0 Monocryl sutures than with the staples.

However, it occurred to me that perhaps we were looking at the wrong thing. I began to think that perhaps we should be looking a hair preservation, rather than cosmesis alone.

The problem with the appearance of stapled closures is that it results in a very well demarcated, geometric line. Monocryl sutures, on the other hand, results in a much softer, more smudgy line – the characteristic that made it look better in the study.

This effect is produced by two things. The first is that the very fine 5-0 Monocryl sutures placed very close to the wound edges allow perfect wound edge approximation. However, the running suture actually destroys some hair as it makes its spiral course through the skin, destroying some hair and producing this smudgy appearance. We had felt that suturing very close to the would edge, using fine suture caliber 5-0 Monocryl, advancing the running stitch on the surface rather than in the SC space, and the mechanism of action of Monocryl absorption (via hydrolysis rather than by an inflammatory reaction) would all mitigate against any hair loss – but there was still some. It seemed that although the overall look was better with sutures, it might be at the expense of some hair loss.

To test this, I began to look at the hair yields in the donor strips of second hair transplant procedures where the new harvest completely encompassed the old scar. It seemed, at least anecdotally, that the strip containing an old incision that had been sutured closed contained slightly less hair than that from one that was stapled closed, even if the former looked better. Although I did not do a rigorous study, this was my “sense.”

In addition, I realized that staples could be left in the scalp for 3 weeks after a hair transplant without causing excessive inflammation (patient discomfort not withstanding) and this gave me more flexibility in using staples in patients with slightly tight scalps without having to rely on subcutaneous sutures. I began to take out alternate staples at 7 to 10 days and the remaining staples at 18-21 days post-op.

With the issue of hair preservation, rather than just the cosmetic benefit, as the main goal and with the added flexibility of being able to leave in alternate staples for up to 3 weeks, I started using staples routinely in almost all of our hair transplants.

A: Sutures are great on non-hair bearing skin and allow perfect approximation of the wound edges, but on the scalp they can cause damage to hair follicles below the skin’s surface. The reason is that a running (continuous) suture traps hair follicles and when the skin swells (as it normally does after hair transplants) the trapped follicles can strangulate and die.

Since staples are placed individually – about ½ cm apart – they don’t strangle the tissue. This allows the blood supply to flow freely to the wound edge permitting the blood’s oxygen to reach the follicles in the stapled area and minimizing the risk of any hair loss. The unimpeded blood flow also facilitates wound healing and can sometimes result in a finer scar, particularly in a tight scalp.

For these reasons, we now use staples in most of our hair transplants.

A: There is not much you can do at this time. Depending upon the doctor’s suturing techniques; you may or may not have permanent hair loss from the trauma and subsequent suturing.

The problem is that if the sutures are placed too far from the wound edge they can strangulate hair follicles, particularly if there is any swelling. Hair loss may be temporary, but if it is permanent, it should be minimal.

Additional grafts can be added at your next hair restoration procedure to cover any area of hair loss and the scar from the injury, if it is visible.

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.