Synopsis: The traditional order for the steps of a hair transplant sur­ gery has been to first perform donor harvesting then make sites and place grafts. Hair transplant surgery can often be a long procedure, and one goal of many teams is to find ways to decrease the length of the procedure to improve the patient experience, decrease the physical strain on the team, and specifically decrease the out-of-body time of the grafts to improve graft survival.

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Synopsis: With the latest version of the ARTAS platform, 9x, Restoration Robotics has designed a faster and more accurate system for hair transplantation. The improved accuracy of harvesting and shortened procedure time increases graft viability, while smaller needles reduce scarring and allow patients to wear shorter hairstyles. Many of the changes in this upgrade have been made as a response to specific physician feedback.

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Synopsis: Since the publication of “What’s New in Robotic Hair Transplantation” (Hair Transplant Forum Int’l. 2017; 27(3):100-101), there have been important improvements to the robotic system in both its incision and recipient site creation capabilities. These advances fall into four overlapping categories:increased speed, increased accuracy, increased functionality, and improved artificial intelligence (AI). The overlap occurs since improvements in functionality, accuracy, and AI can also increase the overall speed of the procedure. A faster procedure decreases the time grafts are outside the body and allows the physician to perform larger cases without placing additional oxidative stress on the follicles.

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Synopsis:There has been a change in the nomenclature of the FUE procedure. It will not be called Follicular Unit Excision, describing the two main components of an FUE procedure, incision (separatioin of the follicle from the tissue) and extraction (the removal of the follicular unit from the scalp once it is separated). Drs. Robert M. Bernstein and William R. Rassman’s commentary explains the importance of this change in terminology.

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Synopsis: Hair restoration has advanced dramatically in the past 25 years, most recently with the growing popularity of FUE. The challenge of FUE is that the grafts are more fragile compared to the follicular units generated in traditional FUT/strip procedures. Innovations such as the ARTAS Robot and other devices attempt to address this problem. With the increasing participation of ISHRS members – now 1,200 strong – progression in this field should continue at an accelerating pace.

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Synopsis: Since the introduction of robotic FUE technology over five years ago, there have been numerous upgrades to the system. The current paper describes the most recent advances. These include a more user-friendly interface, the ability to select for larger follicular units, greater range-of-motion of the robotic arm, improved methods for stabilizing the scalp and newly designed needles for more accurate harvesting.

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Synopsis: The current robotic system harvests follicular unit grafts in a random manner. A new capability of the ARTAS robot is to select follicular units based on the number of hairs they contain, in order to increase the hair/wound yield. This bilateral controlled study of 24 patients was designed to evaluate this functionality. Results showed that, compared to random follicular unit harvesting, robotic follicular unit graft selection produced more hairs per harvest attempt (2.60 vs. 2.22) and more hairs per graft (2.72 vs. 2.44). The clinical benefit was statistically significant at p<.01.

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Synopsis: Follicular Unit Hair Transplantation in “Surgery of the Skin: Procedural Dermatology,” is Dr. Bernstein’s third update of the chapter in the core surgical textbook for dermatologic training programs. The chapter covers a range of topics including: the basics of hair transplantation, detailed descriptions of both follicular unit transplantation (FUT) and follicular unit extraction (FUE), the importance of patient evaluation in advance of surgery, and aesthetic considerations in hair transplant design. Robotic FUE is included in the chapter for the first time as a hair transplant technique.

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Synopsis: A limitation of FUE procedures is the short-term cosmetic problem of clipping the entire donor area in the back and sides of the scalp. The long-hair robotic technique avoids this problem by harvesting through a broad band of clipped hair that is covered with longer hair combed down over the harvested area. This technique enables the physician to harvest relatively large amounts of donor hair without shaving the patient’s entire scalp.

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Synopsis: In their excellent article, “Robotic Follicular Unit Extraction in Hair Transplantation,” Avram and Watkin give a review of the salient aspects of the newly evolving field of robotic hair transplantation. As the authors state, the appeal of robotic FUE is part of the “inexorable trend” toward minimally invasive surgical procedures. As with any new technology, it is up to the practicing physician to make sure that it is used appropriately and to the maximum benefit of our patients.

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Synopsis: The ARTAS® Robotic System provides a unique, comprehensive suite of tools that physicians can use to minimize donor area scarring and offer the patient greater styling options post-surgery. Factors that influence scarring in the donor area include: dissection punch size, density of harvest sites, distribution of the harvest sites, total number of sites, and the ‘blending in’ of harvest zones with un-harvested areas.

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Synopsis: The initial application of the ARTAS® robotic system (robot), released in the fall of 2011, was the separation of follicular units from the surrounding scalp tissue, the first step in a follicular unit extraction procedure. Subsequent steps in FUE include removal of the follicular unit grafts from the donor scalp, site creation, and graft placement. With its new hardware and software capabilities, the robot can now perform one more step in this process, making recipient sites. Preliminary observations suggest that it can accomplish this function with greater precision and consistency than when performed manually.

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Synopsis: When considering Follicular Unit Transplantation (FUT) and Follicular Unit Extraction (FUE) procedures, a person’s age and the ability to assess the permanence of the donor area are important variables in determining surgical candidacy. This FUT case study examines the importance of these variables in the patient evaluation.

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Synopsis: A major advance in Follicular Unit Extraction is the introduction of a robotically controlled, image guided system to remove intact follicular units directly from the scalp. The robotic device increases the accuracy of graft harvesting, which in turn minimizes damage to hair follicles and reduces harvesting time. Each of these factors potentially contributes to increased graft survival. The technology also enables FUE to be performed on a wider variety of patients. This paper discusses this new robotic technology.

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Synopsis: In addition to acquiring a robotic device, performing FUE hair transplant procedures using a robotic image-guided system requires special surgical facilities, staff training, and modification of the FUE procedure itself. This paper reviews some of the key elements that go into successful implementation of R-FUE into a physician’s practice.

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Synopsis: In FUT procedures, once the donor strip is removed, follicular unit dissection and graft insertion can be performed simultaneously. In FUE procedures, graft extraction must be completed before placement can begin, increasing the time grafts are out of the body and subjecting them to hypoxic injury. Waiting for recipient sites to be made adds to this time. These authors suggest creating recipient sites prior to extraction to decrease the time the grafts are outside the body. Other potential advantages of pre-making recipient sites are discussed.

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Synopsis: Topical bimatoprost was FDA approved in December 2008 for the treatment of eyelash hypotrichosis (thinning eyelashes). Since its approval, there has been interest in its “off label” for hair growth in other areas, such as the scalp or eyebrows, but there has yet to be published scientific evidence to support this use. We report one of the first cases of significant eyebrow hair growth in a patient after use of topical bimatoprost for eyebrow hypotrichosis.

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Synopsis: This is a newly revised edition of the popular Hair Loss & Replacement for Dummies. The 2011 edition presents the latest information on a variety of topics of interest to those suffering from hair loss. The updated edition book discusses the latest in laser light and medical treatments for hair loss, the recent advances in Follicular Unit Hair Transplantation and the new, minimally-invasive hair transplant technique, Follicular Unit Extraction.

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Synopsis: This publication reviews the major advances in the science of hair loss that have occurred over the past decade. These include advances in the diagnosis of androgenetic alopecia, advances in our understanding of the mechanisms behind genetic hair loss, studies in the efficacy of medical treatment of hereditary baldness, the development and FDA-approval of the lasercomb device for hair restoration, and the development of a screening test for hair loss.

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Synopsis: Dr. Bernstein’s newly revised chapter, Follicular Unit Hair Transplantation, in “Surgery of the Skin: Procedural Dermatology,” a core surgical textbook for dermatologic training programs, covers a wide range of standard topics including; patient evaluation, surgical planning, operating techniques and aesthetic considerations in hair transplant design. New topics include: follicular unit extraction, eyebrow and eyelash transplantation, long-hair transplants, trichophytic closures, automation and hair cloning.

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Synopsis: Important information for men and women of virtually all ages anxious to preserve their full head of hair, put the brakes on balding, or explore the safest and most reliable hair replacement techniques currently available. The book offers readers not only the full gamut of modern-day hair-care options, but crucial tips on how to avoid unscrupulous hair transplant doctors and potentially harmful products as well.

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Synopsis: The ability to achieve full cosmetic benefit in follicular unit hair transplantation depends upon a number of factors including proper patient selection, accurately assessing the patient’s donor supply, appropriately designing the hair line and correctly distributing the grafts. This paper reviews the major mistakes that doctors make in these key aspects of the hair restoration process and advises the practitioner on how to avoid them so that the patient will achieve the best possible results.

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Synopsis: Running, continuous sutures and metal staples are the two most common closures used by hair restoration surgeons today. This commentary discusses the pros and cons of various suture and stapling methods and makes an argument that, with new advances in techniques, staples are possibly the best means of closing the donor wound during a hair transplant procedure.

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Synopsis: In 1998, a group of hair restoration surgeons proposed a classification for follicular unit hair transplantation and mini-micrografting techniques, to improve communication between physicians and their patients. With recent advances in techniques, a number of new terms are being used that do not have clear definitions. This paper expresses the author’s opinions on which of these terms are useful and should be incorporated into the original classification and which are confusing and should be abandoned. The authors also suggest concise definitions for these new terms.

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Synopsis: Densitometry and video-microscopy are techniques that analyze the scalp under high-power magnification to give information on hair density, follicular unit composition and degree of miniaturization. They can be used to help evaluate a patient’s candidacy for hair transplantation and help predict future hair loss. The measurements will enable the physician to better estimate the size of the donor strip and anticipate the aesthetic outcome of the hair restoration procedure. This paper describes the value of these techniques in the hair transplant evaluation.

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Synopsis: Three-step FUE is a hair transplant technique that uses blunt dissection to prevent damage during the process of separating the follicular unit from the surrounding tissue. The 3 steps are: scoring, blunt dissection, and extraction. Performing Follicular Unit Extraction with a 3-step technique allows the surgeon to minimize damage to follicles and to keep follicular units intact. A disadvantage is the development of buried grafts, but this can be reduced by modifying the technique and using specially designed instrumentation.

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Synopsis: The partial or complete loss of one’s eyebrows is a relatively common problem and can be caused by disease, accidents, the normal aging process, or can be been self-induced. This paper discusses the importance of eyebrows to one’s appearance and explains the special techniques and surgical skills required for eyebrow restoration.

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Synopsis: This study determined exactly how long it takes after a hair transplant for the grafts to be securely anchored in the recipient area, so that they cannot be dislodged. This information is important in guiding the patient’s post-op care after a hair restoration procedure. The study also showed that preventing the formation of crusts following a hair transplant would shorten the time patients are at risk of dislodging grafts. It would also allow them to return to their normal hair care routines more rapidly.

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Synopsis: This paper discusses the state-of-the-art in follicular unit extraction. It focuses on the new Three-Step Technique in which a sharp punch is used to cut the epidermis and then a dull punch is used to dissect the follicular unit from the surrounding tissue. The third step being the extraction itself. The “blunt” step significantly reduces follicular transaction, but creates a potential new problem, that of buried grafts. The Three-Step technique increases the number of patients in whom FUE is possible; however, other limitations of the procedure – particularly the lower total yield compared to strip harvesting – remain.

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Synopsis: This writing discusses the current status of Follicular Unit Transplantation and some controversial issues regarding this procedure. These issues include: strip harvesting vs. follicular unit extraction, lateral vs. vertical slit recipient sites, which holding solution is best for grafts, the ideal density and the optimal number of grafts that should be performed in one hair transplant session.

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Robert M. Bernstein, M.D. Associate Clinical Professor of Dermatology at the College of Physicians and Surgeons of Columbia University in New York Abstract of Dr. Bernstein’s presentation at the International Society of Hair Restoration Surgery, 2005 – Sidney, Australia Biography Robert M. Bernstein, M.D. is Associate Clinical Professor of Dermatology at the College of Physicians …

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Synopsis: This paper reviews the core concepts of Follicular Unit Transplantation, including basing the surgical planning on the follicular unit constant, using only individual, naturally occurring units in the transplant and accomplishing the restoration in a few number of large sessions. The section then describes the techniques of follicular unit hair transplantation as the procedure enters its second decade.

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PUBLISHERS NOTE: Single copies of this article can be downloaded and printed only for the reader’s personal research and study.

Synopsis: “Surgery of the Skin: Procedural Dermatology,” covers the entire range of dermatologic surgical procedures. It was conceived to be used as the core surgical textbook for dermatologic training programs. Dr. Bernstein’s chapter on follicular unit hair transplantation covers a wide range of subjects including the history of follicular unit hair transplantation, evaluating the patient, planning the surgery, setting-up the operating room, and maximizing the cosmetic outcome of the hair restoration. Specific topics include the techniques of Follicular Unit Transplantation including density assessment, single-strip harvesting, follicular unit extraction, anesthetic use, aesthetic design and many other important topics.

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Synopsis: This writing is the textbook version of the paper; “Limiting Epinephrine in Hair Transplant Sessions.”

Synopsis: This is the textbook version of the important 1999 paper; “The Logic of Follicular Unit Transplantation” that was instrumental in making follicular unit transplantation a mainstream hair restoration procedure.

Synopsis: This paper describes the technical and organizational skills needed for performing Follicular Unit Extraction Megasessions. It also points out some of the important long-term implications of FUE, especially regarding its inefficient use of donor area which potentially limits the ultimate donor supply.

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Synopsis: This paper proposes that the old punch-graft technique may have a place in modern hair transplant surgery, particularly in patients with significant donor scarring and when further linear incisions are not possible. In these cases, punch harvesting (with subsequent microscopic division of the punch grafts) may be better than FUE, since extracting individual follicular units can be difficult in areas of scarring.

Synopsis: This paper introduced Follicular Unit Extraction into the hair transplant literature. The article describes a procedure in which individual follicular units are removed directly from the donor region through very small round incisions. It identifies significant patient variability and describes a test to determine which patients are potential candidates for this procedure. It also explores the nuances, limitations and practical aspects of Follicular Unit Extraction.

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Synopsis: Together with Part I, Basic Repair Strategies, these paired articles define the state-of-the-art in correcting the cosmetic problems that resulted from outdated hair restoration techniques and/or poor surgical planning. This section emphasizes the importance of graft excision and re-implantation prior to camouflage in order to achieve the best outcome. It details the specific techniques needed for the graft excision and explains the aesthetic nuances of the camouflage.

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Synopsis: The first of two paired articles, this paper focuses on the strategic planning that is necessary to optimize hair transplant repair procedures. The paper identifies the underlying problems that lead to poor cosmetic results and the limitations of the donor supply that limit its correction. It explains how to establish priorities to get the best results in the face of the constraints caused by outdated hair replacement techniques.

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Synopsis: In 1959, Orentreich stated that, in a hair transplant, the transplanted grafts maintained the characteristics of the donor area and were independent of the recipient site. However, new evidence suggests that that the recipient site can influence the rate of hair growth, graying, and the formation of wavy hair. The editor points out that, although these observed effects may violate the principle of donor dominance, they will have positive implications for the success of cloning.

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Synopsis: Patients with tight scalps and snug donor closures often heal with fine scars, whereas patients with loose scalps occasionally heal with wide scars. A patient with the rare condition Ehlers-Danlos Syndrome shed light on this phenomenon. After studying his case, the authors conclude that the integrity of the scalp’s connective tissue was more important than scalp laxity in determining who would heal with a fine donor scar.

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Synopsis: This paper reviews the current status and future of automated devices in surgical hair restoration. Specifically, it discusses the Hair Implanter Pen, the Rapid Fire Hair Inserter, the Calvitron, and the Choi Hair Transplanter.

Synopsis: This study compares the hair replacement techniques of mini-micrografting, vertical sectioning and single-strip harvesting with stereo-microscopic dissection for the generation of follicular unit grafts. It validated the superiority of the latter technique and supported the idea that if one wants to perform Follicular Unit Transplantation properly, single strip harvesting and microscopic dissection should be required.

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Synopsis: This popular guide on hair restoration is revised to include the latest advances in medical and surgical treatments for hair loss and an expanded section of before and after photos.

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Synopsis: This paper introduces a new synthetic suture for surgical hair restoration called Poliglecaprone 25 or Monocryl. It is a strong, absorbable, suture with low tissue reactivity that can be used in hair transplantation to close the donor wound with a single, running stitch. This suture can provide a donor closure that ensures hemostasis, has little risk of infection and is comfortable for the patient, and generally results in a fine surgical scar.

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Synopsis: This editorial emphasizes that an accurate representation of a hair transplant technique is important, even if it is with respect to how it is named, so that the public may make informed decisions about the procedures they choose.

Synopsis: This editorial discusses the important observation of Gandelman that the drying of grafts during a hair transplant is a common denominator for other forms of injury, as it makes the grafts more subject to damage due to crushing and warming during the procedure.

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Synopsis: The risks of using too much adrenaline in a hair transplant are discussed and a number of alternative methods of establishing hemostasis are offered including; body positioning, florescent lighting, ring-block anesthesia, tumescence, pre-making recipient sites, applying bi-manual traction, and creating a snug fit between the recipient site and graft.

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Synopsis: When follicular unit transplantation was still in its infancy, there were many detractors in the hair transplant community. This paper defended the procedure and explained its superiority over other hair replacement techniques in producing the best short and long-term cosmetic results.

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Synopsis: This section, published in a textbook for professional estheticians, explains basic concepts of follicular unit hair transplantation in easy-to-understand terms.

Synopsis: This article uncovers an attempt by the proponents of slot grafting to rename this technique (which produces poor cosmetic results) and call it “follicular unit coupling,” so that unwary patients will think that it is actually a variation of follicular unit transplantation.

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Synopsis: This short paper summarizes the article that advises to physicians to limit the use of adrenaline when performing large hair transplant sessions and it explains various practical ways to accomplish this.

Synopsis: This paper argues for standardization in the classification of various hair transplant techniques in order to facilitate communication between hair restoration surgeons and their patients and to aid in scientific research.

Synopsis: This paper discusses the evolution and rationale for follicular unit hair transplantation, as well as the logic for the various techniques used in its implementation. The central role of the follicular unit constant in the surgical planning is discussed, as well as the importance of keeping recipient sites small, using microscopic dissection and performing large hair transplant sessions.

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Synopsis: As the twentieth century drew to a close, this paper looked into the future to try to discern the direction that hair transplantation was headed in the next millennium. Particular areas of interest were; the follicular unit/mini-micrograft controversy, graft storage mediums, how to maximize the donor supply, methods to enhance wound healing, automated devices, lasers, new medications, cloning and genetic engineering.

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Synopsis: This editorial cautions that new instruments made to cut the donor strip rapidly, by placing the strip on a grid of knives, cause unacceptable levels of graft damage. The author advises that these devices should not be used in surgical hair restoration.

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Synopsis: The “Carousel” is an automated device used for hair transplantation that simultaneously makes recipient sites and inserts grafts. The instrument can hold up to 100 grafts at time. In theory, the instrument could decrease the total operative time and eliminate some human factors that contribute to graft injury during the hair restoration process. The Carousel, however, was limited in that very close graft placement was not possible and it could not account for the great variability in the human scalp that sometimes rendered the device ineffective.

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Synopsis: Dr. Bernstein heads a group of twenty-one hair restoration surgeons in an attempt to standardize the classification of follicular unit transplantation and other small graft procedures, including various technical aspects of graft harvesting, graft dissection, and placement. The goal is to standardize the nomenclature, and formally describe other factors in the surgery, so that communication between physicians and patients may be enhanced and different hair replacement procedures may be examined and compared.

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Synopsis: A satire on the perceived resistance of hair transplant surgeons to accept new ideas and adapt new technologies.

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Synopsis: This book explains, in layman’s terms, the causes of hair loss, the way it is diagnosed and how androgenetic alopecia is treated – using medical therapy or surgical hair restoration. The book focuses on Follicular Unit Transplantation, but covers a wide range of topics from the emotional aspects of hair loss to steps one should take when considering hair transplant surgery.

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Synopsis: This article acknowledges the wide variability in the anatomy of follicular units, but challenges the notion that using grafts larger than naturally occurring follicular unit is advantageous, if it necessitates using larger recipient wounds.

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Synopsis: This was the first objective study that showed that using stereo-microscopic techniques to dissect follicular unit grafts, was superior to loop magnification in preserving follicular units and reducing the transection of follicles.

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Synopsis: This editorial reviews a study suggesting that ATP can be used to increase the life of grafts while they are being held outside the body during a hair transplant.

Synopsis: This paper traced the beginnings of Follicular Unit Hair Transplantation from Headington’s histologic description of the follicular unit, Limmer’s single strip harvesting and stereo-microscopic dissection and then Bernstein’s idea to use the follicular unit as the sole graft type in the hair restoration process.

Synopsis: This writing stresses the importance of objective scientific measurements in patient evaluation and surgical planning prior to a hair transplant. Specifically, it explains, in mathematical terms, the greater contribution of hair shaft diameter as compared to the number of hairs in the appearance of fullness.

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Synopsis: An editorial that challenges the assumption that insufficient blood supply in a hair transplant is the main contributor to delayed growth.

Synopsis: This editorial challenges those who claim to not have seen delayed growth to look more carefully, since large-graft hair transplants interrupt the blood supply to a greater extent than using large sessions of very small grafts.

Synopsis: This article focuses on various aesthetic aspects of follicular unit hair transplants including hair distribution, density, hairline design, and temple and crown restoration. It also examines racial variations that can affect the hair restoration. Together with the 1995 paper, these paired articles laid the foundation for Follicular Unit Hair Transplantation.

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Synopsis: This landmark paper details how a patient should be evaluated for Follicular Unit Transplantation, stressing densitometry as a means of assessing both miniaturization and donor supply. It also provides guidelines for the planning of the first and subsequent hair transplant sessions and discusses the management of patients with diffuse androgenetic hair loss.

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Synopsis: This short article describes the design for a wall-mounted placing stand that can store, chill and protect grafts while they are waiting to be placed into the scalp during the hair restoration procedure.

Synopsis: Hypothesizes the possible causes of delayed growth following a hair transplant procedure. It differentiates between physiologic factors that cause normal variations in the growth cycle and those due to graft injury that can possibly be prevented by meticulous surgical techniques.

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Synopsis: A short paper that describes the cause and treatment of the occasional itching that follows a hair transplant procedure.

Synopsis: This writing explains the rationale for using large numbers of grafts in surgical hair restoration. It discusses the advantage of megasessions in conserving the donor supply, increasing patient satisfaction, and providing greater flexibility to the surgeon in sorting and distributing small grafts.

Synopsis: This was the first paper to challenge those promoting laser hair transplants and who claimed that lasers would be the future in surgical hair restoration. The publication stressed that lasers caused damage to the recipient area and could result in scarring and poor growth. It explained why lasers were, in fact, inferior to cold steel techniques in making recipient sites.

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Synopsis: This publication, written when scalp reductions were at the height of their popularity, cautioned that scalp reductions caused unnecessary scarring, used up precious donor reserves and caused more cosmetic problems than they solved. It suggested that, with the advent of the more robust follicular unit hair transplantation, scalp reductions should not be used in the treatment of androgenetic hair loss. This publication, along with the 1993 paper of O’Tar Norwood, played a critical role causing the rapid decline in the use of scalp reductions in hair restoration surgery. Fortunately, this once common procedure for male pattern alopecia is now rarely used.

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Synopsis: This was the first paper on Follicular Unit Transplantation. This publication introduced into the medical literature the idea of using individual, naturally occurring follicular units exclusively in the hair transplant procedure and stressed using large sessions to maximize the aesthetic outcome. The paper defined the various components of Follicular Unit Hair Transplantation, explained the anatomic and physiologic advantage of using follicular units in the procedure and described how follicular units could be used safely in large numbers to complete the hair restoration as quickly as possible. This publication was instrumental in having hair restoration surgeons shift from the older mini-micrografting techniques to the cosmetically superior technique of using follicular units.

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Synopsis: This paper describes a case where severe psychological stress caused a patient’s hair shaft to be altered so that it mimicked an infestation of head lice. The correct diagnosis was made by microscopic examination of the deformed hair shafts.