Q: Can anyone tell me why Dr. Bernstein is still bald? — N.H., Brooklyn, NY
When Dr. Bernstein was younger and started to lose his hair, it really didn’t bother him. After medical school, he began his career as a dermatologist and became aware of surgical hair restoration. It was then when he realized that he would not be a good candidate for a hair transplant procedure, even if he wanted one, because his donor area is very thin. In the years since, he has gotten used to being bald. But his not being a candidate made him keenly aware of who is and who is not a good candidate for surgery, and this insight has helped earn him a reputation as an honest and ethical practitioner of hair transplantation.
Q: What is the problem with transplanting the crown too early? — P.L., Newark, NJ
A: If a person’s hair loss continues – which is almost always the case – the crown will expand and leave the transplanted area isolated, i.e. looking like a pony-tail. The surgeon can perform additional hair transplant procedures to re-connect the transplanted area to the fringe, but, as one can see from the photo below, this is a large area that can require a lot of hair. It is often impossible to determine when a person is young if the donor supply will be adequate. If there is not enough donor hair, then the island of hair may remain isolated. Most importantly, it uses up a lot of hair that might be better transplanted to the front and top of the scalp – areas that are far more important cosmetically.
The front and top of the scalp are more important to one’s appearance than the crown, and these areas should be the first priority when planning hair restoration surgery.
As an exception, if a person has a family history of baldness limited to the crown, even at an advanced age, and the person in question is following this pattern, then earlier treatment of the crown may be considered.
Lastly, if you do treat the crown in a younger person, or one with whom the extent of hair loss is uncertain, the crown should be transplanted with light coverage only. That way a limited amount of hair will be used up in this area and there will be enough left over for the more cosmetically significant top and front of the scalp.
Q: I heard FUE is a scarless surgery. Is this true using any of the current FUE methods (ARTAS® robot, Neograft, manual FUE)? — V.S., Weston, C.T.
A: All hair transplant procedures, follicular unit transplantation (FUT) and follicular unit extraction (FUE), leave scars. FUT produces a linear scar at the back of the scalp that may be visible if you keep your hair short. FUE, on the other hand, leaves small dot scars at the back of the scalp that are not visible if you keep your hair short. These tiny scars will happen regardless of which FUE method is used, i.e., ARTAS robot, SAFE system, Neograft, or manual FUE. Some physicians who use the Neograft method advertise that there is no scarring involved when using the Neograft; however, this is not true: however, this is not true: there is some scarring associated with all FUE methods that increases with the total number of grafts harvested.
Q: Is robotic FUE different in the number of follicular unit grafts one can extract compared to manual FUE? — R.V., Stamford, CT
A: We can extract (and transplant) the same number of follicular unit grafts robotically as we can manually?
The goal of a hair transplant is not to simply transplant as many grafts as possible but to achieve the best possible cosmetic result given the number of hair follicles in your donor reserve. Remember, this is always a limited supply.
While there is no difference between robotic and manual FUE in terms of the number of follicular unit grafts that each can extract, robotic FUE does differ from manual FUE in several important ways.
First, there is generally less transection of the hair follicles with robotic FUE, since the method is more precise. This enables us to obtain follicular units with less trauma to the grafts.
Second, while the robot is not necessarily faster than the human surgeon, the robot is much more consistent since, unlike the human surgeon, it never fatigues and the accuracy is maintained throughout the entire procedure.
Q: I received radiation therapy to my scalp two years ago to treat a brain tumor. I lost my hair during treatment and it has not grown back. The doctors said that this treatment might result in permanent hair loss. Is a hair transplant a viable option after radiation treatment? — K.G., Darien, C.T.
A: Unlike chemotherapy which generally causes a reversible shedding of hair (called anagen effluvium), radiation therapy can cause both reversible shedding and the permanent loss of hair follicles (scarring alopecia). Hair can be successfully transplanted into these scarred areas – but there must be enough donor hair to do so. If the radiotherapy was localized, a hair transplant procedure is often quite effective – although several procedures may be required to achieve adequate coverage of the irradiated areas.
Q: At one time, I was told my donor area was not sufficient for an FUT hair transplant procedure. Does this also mean I’m not qualified for a FUE procedure either? — K.K., Houston, T.X.
A: Great question. You are not giving me quite enough information to answer your question specifically, so I will answer in more general terms. If your donor hair supply was not good enough to do FUT (i.e. you have too little donor hair and too much bald area to cover) then most likely you will not be a candidate for FUE either, since both procedures require, and use up, donor hair. That said, if don’t need that much donor hair, but the nature of your donor area is such that a linear FUT scar might be visible then FUE might be useful.
An example would be the case in which a person has limited hair loss in the front of his scalp, has relatively low donor density, and wants to keep his hair on the short sides. In this case, FUT would not be appropriate as you might see the line scar, but we might be able to harvest enough hair through FUE to make the procedure cosmetically worthwhile. Remember, with low density neither procedure will yield that much hair to be used in the recipient area.
Another example is an Asian whose hair emerges perpendicular from the scalp so that a line incision is difficult to hide, i.e. the hair will not lie naturally over it. A third example is where the patient’s scalp is very tight. In this case, the donor density might be adequate, but it would just be hard to access it using a strip FUT procedure. In this case, FUE would also be appropriate.
From these situations, one can see that the decision to perform FUE vs FUT, or even a hair transplant at all, can be quite nuanced and requires a careful evaluation by a hair restoration surgeon with expertise in both procedures.
Q: I am having a facelift next month and also want to have a hair transplant soon after. How long should I wait between procedures? — S.H., Boston, M.A.
A: Although it would be possible to do a hair transplant as soon as a week after a face or brow lift, ideally one should wait at least three months between procedures for the following reasons: 1) there will be less tension in the donor area and, therefore, it will be possible to harvest more grafts, 2) if there is any shedding from the facelift it will make the planning of the hair transplant more difficult, 3) it will leave the option of adding hair, in or around, any problematic surgical scars, and 4) will provide the ability to add hair to any area of thinning that might result from the facelift.
Q: I have seen through forums that a hair transplant gives severe shock loss in the donor zone (especially behind ears) after the surgery. Doctors say it is temporary and can last about six months or more. Frankly, do you believe in this? Will the donor shocked hair recover? — M.D., Darien, C.T.
A: It depends if you are speaking about follicular unit hair transplantation using strip harvesting (FUT) or Follicular Unit Extraction (FUE). With FUT, it is extremely uncommon to have any shock hair loss in the donor area. This could occur if the hair transplant procedure was done improperly, i.e. the donor area was closed too tightly. In this case, some hair loss may be permanent. This is one of the reasons that very large hair transplant sessions are unwise. Shock hair loss in FUE is more common, but is generally not significant and should eventually recover completely.
That said, some shock hair loss in the recipient area is quite common with either hair restoration procedure (FUT or FUE). This is particularly the case if there is a lot of existing miniaturized hair (hair that is starting to thin) in the transplanted area.
Q: How long are FUT and FUE visible after the procedures? — S.V., Weston, C.T.
A: The recipient area is visible after both procedures for up to 10 days. The donor area in FUT is generally not visible immediately after the procedure. In FUE, the donor area must be shaved, so that will be visible for up to two weeks (the time it takes for the hair to grow in).
Q: What are the chances of the donor scarring being visible long-term in FUT compared to FUE? — M.M., Altherton, C.A.
A: Both FUT and FUE produce donor scarring; FUT, in the form of a line and FUE in the shape of small, round dots. With FUT hair transplantation, the line is placed in the mid-portion of the permanent zone, whereas in FUE the dots are scattered all over the donor area.
If a patient becomes extensively bald (i.e. the donor fringe becomes very narrow), the line of FUT will generally still remain hidden, whereas the dots of FUE will be seen above the fringe of hair. In the less likely scenario of the donor hair actually thinning significantly, both the line (of FUT) and the dots (of FUE) may become visible.
Dr. Bernstein was featured in a CBS News report on robotic hair transplantation. During Dr. Max Gomez’s visit to the Bernstein Medical – Center for Hair Restoration, Dr. Bernstein discusses with Dr. Gomez the difference between FUT and FUE hair transplants, how the robotic system works, and the benefits of extracting hair follicles using robotic FUE rather than by traditional hand-held methods.
Read a transcript of the piece:
CBS 2 News Anchor Chris Wragge: These days we’ve seen robots doing everything from vacuuming our floors to building cars. You may have even had surgery done with the help of a robot. But what about something personal and cosmetic like a hair transplant? Our Dr. Max Gomez tells us about a robot doing just that.
Dr. Max Gomez: Well that’s right Chris. Now first we should make clear that robots in medicine don’t act alone, at least not yet. They’re always under the direction of a doctor. Now, that said, what robots are really good at are tedious, repetitive tasks that need to be done quickly and accurately. Something like a hair transplant.
Dr. Gomez: A full head of hair is called a person’s “crowning glory”. Sure, going bald is a common fashion statement, but most people are like Sam.
Sam, Hair Transplant Patient: I wanted more hair on my head, obviously, and I didn’t want to be bothered with any of the other treatments that are available.
Dr. Gomez: For Sam that meant a hair transplant, where donor hair follicles are taken from the back of the head and transplanted to the thinning areas, usually on top or the former hairline.
Dr. Gomez: That donor hair is typically taken from a strip of scalp that is cut out and then sutured closed, but that’s not the best choice for everyone.
Dr. Bernstein: Some patients, who want to wear their hair very short, that line can be a problem. Also, there are some people who are at risk of having a wider scar.
Dr. Gomez: The solution is to randomly extract individual follicular units, small groups of one to four hairs.
Dr. Bernstein: The procedure is very labor intensive and you have to do thousands of these in a single session.
Dr. Gomez: Enter the ARTAS robot. It’s a sophisticated hair mapping and extraction system. Once the donor area is identified, the robot maps all of the follicles, and then randomly extracts them with a series of punches. It can even tell the angle the hair is growing at to avoid damaging it.
Dr. Bernstein: It is much more precise than the human hand. It doesn’t tire if you’re doing thousands of grafts. It’s the same every single time.
Dr. Gomez: And here’s the result a few weeks later. Even with short hair, the random extraction means it’s virtually impossible to tell where the donor hairs came from.
Now, the rest of the transplant procedure is pretty much the same as without the robot. That’s where the art comes in. Deciding where, how many, how dense, and at what angle the donor hairs are inserted, that’s what makes a hair transplant look natural. And a well-done transplant is amazingly natural.
Q: I am so confused reading about FUT and FUE on all the blogs. Can you please tell me which is better, FUT or FUE? — M.T., East Brunswick, NJ
A:FUT (via strip) will give the best cosmetic results (more volume) since the grafts are of better quality (when using microscopic dissection, there is less transection and more surrounding tissue to protect the grafts) and better graft selection (the grafts can all be harvested from the mid-portion of the permanent zone).
In contrast, in FUE you need approximately 5 times the area. Because of this large donor area requirement, some of the hair must be harvested from fringe areas and thus the hair will be less stable genetically.
With subsequent FUT procedures we remove the first scar, so the patient only has one scar (albeit long). With subsequent FUE sessions we are adding additional scars, so over the long-term the cumulative scarring over large areas can present its own problems of visibility.
The main advantage of FUE is to have the option of wearing your hair very short (but not shaved). FUE is also appropriate for patients who are at risk for a widened donor scar (i.e., very athletic and muscular or with thin, tight scalps, etc.).
In my experience, Robotic Hair Transplantation is superior to other FUE methods in that it is much more accurate and more consistent. It enables the doctor to extract grafts with less damage than with hand-held instruments or other automated devices.
Q: I wanted to find out about the difference between what Dr. Bernstein does with his robotic system versus NeoGraft. — G.M., Newark, NJ
A: The ARTAS robotic system, used at Bernstein Medical, has robotic control, video imaging and uses a blunt dissection technique. This allows for very precise extraction of follicular units from the donor area with minimal transection. The Neograft machine for FUE is a manually operated machine which uses sharp edge dissection. Because it relies on manual controls rather than robotics, it is less accurate and the cutting tip causes more graft injury. The precision of the robot allows the grafts to be harvested with less trauma and will thus result in better growth. In my opinion, these differences are very significant.
Q: I am 24 years old and just starting to thin. I was told by another doctor that it was too early to have a hair transplant, but the hair on the back and sides of my scalp seems really thick. Shouldn’t I have a hair transplant now, just in case I am not a candidate in the future? — A.S., Cherry Hill, NJ
A: The most important criteria in determining who will be a candidate for a hair transplant is the presence of sufficient permanent donor hair. When hair loss is early, it is often hard for the doctor to determine this, since early on the donor area can appear very stable. It is not until the front and/or top of the scalp has significant thinning that the donor area may also show thinning. Therefore, it is only at this time that the stability of the donor area can adequately be assessed.
It has been argued, that one should have a hair transplant early, before the donor area can thin. This is not a reasonable argument, since doing a hair transplant early, does not make the donor hair more permanent. If the donor area is not stable, the transplanted hair will continue to thin after it has been moved to the new location. This will cause the hair transplant to gradually disappear and also risk the donor scar from becoming visible as the hair covering it continues to thin. This problem can affect patients undergoing both FUT and FUE procedures.
Age itself is another factor to consider. The donor area in young people almost always appears adequate. However, the older a person is, the more likely he/she will show donor changes. Therefore, the older a person is, the more confident we are of donor area measurements being accurate. In very general terms, it is very difficult to assess the permanency of one’s donor area in patients under 25 year of age.
Q: Can I tell before I start to bald if I will be a candidate for a hair transplant. — T.E., New York, NY
A: Usually not. The main reason one is either a candidate or not is the stability (permanency) of the hair in the back and sides of ones scalp – the donor area. Since the top of the scalp usually thins first, if the top has not started to thin, the donor area will always appear to be OK. It is only when you have significant thinning on the front or top of your scalp can we actually begin to assess the stability of the donor area with any degree of accuracy.
Q: With the ARTAS™robotic system for FUE hair transplantation, by Restoration Robotics, what part of the FUE hair transplant procedure can actually be done by the robot? — A.M., Los Angeles, CA
A: The ARTAS System is a computer-guided method of harvesting follicular units in the donor area during Follicular Unit Extraction (FUE). The initial phase of FUE, where the follicles are selected, scored and separated from the surrounding scalp is done by the ARTAS System. All other phases of the procedure including; actual follicular unit graft removal from the scalp, hairline design, recipient site creation and placement of the grafts into the balding scalp are done by the surgical team.
In the near future, improvements in the ARTAS System should allow it to be able to actually extract the separated grafts from the scalp. Eventually, the engineers hope to be able to increase the capability of the system so that it can create recipient sites and implant the extracted grafts into them.
A: The ARTAS System for Follicular Unit Extraction (FUE) combines several features including an interactive, image-guided robotic arm, special imaging technologies, small skin punches of two different sizes, and a computer monitor. After the system is positioned over the patient’s donor area of the scalp, ARTAS is capable of identifying and isolating follicular units from the surrounding scalp.
After the robotic arm is aligned with the follicular unit, a sharp 1-mm punch is used to cut through the upper part of the skin (the epidermis and upper dermis).
Immediately following this, a duller, 1.3mm punch is used to separate the deeper part of the follicular unit from the remainder of the dermis and subcutaneous fat. Once separated by the robot, the follicular units are manually removed from the scalp and stored until they are implanted into the patient’s recipient area.
Q: I hear you leave staples in sometimes up to three weeks after a hair transplant. Why do you leave staples in that long? – M.C., Boca Raton, FL
A: My reason for leaving some staples in longer is that the tensile strength of the wound continues to increase (significantly) during the first three week period after surgery — actually, it will continue to gain strength for up to one year post-op. To give the wound the best chance to heal, on average, I take out alternating staples at 10 days and the remaining staples at 20 days.
Although patients do complain that they are uncomfortable, removing half at 10 days offers enough relief for those who are bothered by them. The advantage of leaving the staples in longer is that the wound heals with a finer scar. And for patients who are very active, it allows them to resume activities more quickly. For each patient, I modify the time left in by surgery, length of incision, tension, and also the patient’s needs and ability to have them removed.
In contrast to sutures, staples do not leave any track marks and do not need to be removed as quickly. Sutures can also damage the surrounding hair by strangulating the follicles. Staples are interrupted (placed individually), so they don’t cause damage to the follicles adjacent to the wound edge.
Read more details about our use of surgical staples on the Donor Area page.
Q: If a person is graying on the top and sides and you do a hair transplant from the back, will the top look darker after the hair restoration? — W.C., Houston, TX
A: The hair is taken from the back and sides of the scalp and the follicular units, once dissected from the donor strip, are randomly inserted into the recipient area. That way, the color of the harvested hair will be mixed and will match perfectly.
Usually, people’s hair is lighter on the top because of the sun, so when you move the hair from the back and sides to the top, it will actually lighten to match the surrounding hair, if it didn’t match already.
Q: I am considering having a hair transplant. Does my hair need to be cut? — I.S., New York, NY
A: In all hair transplant procedures, we are able to transplant into areas of existing hair without it having to be cut. The question of whether hair needs to be cut in the donor area depends upon the way the donor hair is obtained (harvested).
With a Follicular Unit Hair Transplant procedure using single strip harvesting method (FUT), only the strip of hair that is removed needs to be cut. When the procedure is finished, the hair above the incision lays down over the sutured area and it becomes undetectable.
In Follicular Unit Extraction (FUE), particularly in sessions over 600 grafts, large areas of the donor area must be clipped short (to about 1-2mm in length) in order to obtain enough donor hair.
Q: I am a 34 year old male and my dermatologist prescribed Propecia for me today. Most of my hair loss is at the hairline, but there is some loss on top as well. It’s not bad, I just want to stay ahead of it. If I get a transplant I want to get it at your clinic, but I will give the Propecia a try first. I am going to be overseas for a couple of months starting this Sunday and I was wondering about the necessity or desirability of having someone measure my hair density prior to starting the Propecia. Would you advise waiting to start the Propecia until I come back in two months and having my density examined at your clinic? — M.R., Great Falls, Virginia
A: I would start Propecia as soon as possible. What is important for a hair transplant is the density in the donor area and this is not affected by Propecia (or minoxidil). Your donor density can be measured anytime at an evaluation prior to surgery. If you want to wait to see the effects of Propecia prior to the hair transplant, you really should wait a year; since growth, if any, can take this long. If you just want to have Propecia on board for the hair restoration procedure, or to make sure you don’t have side effects, then generally a month will do. If you would like to do a photo consult through our website to get some preliminary information about how many grafts you might need, you can do that at your leisure, but start Propecia now since the longer you wait the less effective it will be at regrowing hair.
Q: Is it recommended to wait for 1 year after starting Propecia, when the effect of the medication kicks in and improves density of donor area, and then perform the surgery? — Z.B., Bergen County, New Jersey
A: Propecia will not affect the donor area, as this area is generally not impacted by the miniaturizing (thinning) effects of DHT –- the hormone that Propecia blocks. The purpose of waiting the year is to possibly regrow hair in the recipient area. If regrowth is significant, a hair transplant may not be necessary. If a person’s hair loss is extensive and there is little chance that Propecia will grow a significant amount of hair back to give a satisfactory improvement, then waiting the year is unnecessary.
Q: You said I was not a good candidate for a hair transplant because my donor area was too thin. Since finasteride and minoxidil can increase the thickness of the hair, could it make a hair transplant possible?
A: Unfortunately, the medication will not affect the donor area and, therefore, not make a person with low donor density a candidate for a hair transplant.
Q: I have been reading about hair transplantation and I have a question concerning FUT (strip-harvesting). I understand, in this method, a strip is excised from the back of the scalp, the wound then closed. I wonder, then, is not the overall surface of the scalp reduced in this procedure? After two or three procedures, especially, (or even after one large session) will not a patient’s hairline also be shifted? That is, the front hairline would move back by the amount of scalp excised, or, more likely, the “rear hairline” (which ends at the back of the neck) must certainly be “moved upward.” At least, this is how I imagine it would be. Is my logic flawed? I’ve been trying to understand this in researching the procedure, but the point still evades me. — M.M., Great Falls, V.A.
A: The hair bearing area is much more distensible (stretchable) than the bald area and just stretches out after the procedure. As a result, the density of the hair in the donor area will decrease with each hair transplant session, but the position of the upper and lower margins of the donor area don’t move much – if at all. As a result, the major limitation of how much donor hair can be removed is the decreasing hair density, rather than a decrease in the size of the donor area.
With very low donor hair density the strip will yield so little hair that further sessions eventually become impractical. To say it another way, since a hair transplant decreases the donor density, in each succeeding hair transplant session, you need an increasingly larger donor strip to remove the same number of grafts.
This effect also explains why, in most instances, FUE will not allow the doctor to obtain any significant amount of additional hair, since the donor area is already too thin, and FUE would thin it further.
Q: I would like to have the donor area from an old hair transplant repaired so it does not show the scar when I cut my hair shorter. What are my options?
A: Widened scars can be improved in two ways: they can be re-excised to make the scar finer, or hair can be placed into the scar to make it less visible.
Excising a scar works best when the original incision was closed with poor surgical techniques. In this case, using better closure methods can improve the scar. When the scar is the result of a person being a naturally “poor healer,” a wide scar will be the result – regardless of how the incision was closed.
I often approach the problem by excising a small area first, to see if I can decrease the width of the scar. If so, I would then proceed to excise the rest of the scar. If not, I would obtain hair using follicular unit extraction (FUE) — extracting hair in follicular units directly form the scalp — and place this hair into the scar. The hair placed in the scar can also be obtained from the edges of a partially excised scar.
If a wide scar that is thickened (called a hypertrophic scar) is also excised, it will usually reoccur and may result in an even worse scar. Because of this, thick scars should be flattened with injections of cortisone prior to removing. This will decrease the chance of a recurrence.
Flattening the scar is also important to permit the growth of newly transplanted follicular unit grafts.
For more on this topic, please see the page on Fixing Scars.
Q: It’s a question that greatly concerns me because I’m investigating getting a transplant sometime next year. I’m 28 and thought I started balding at 26, but photographic evidence suggests it had started somewhere around age 24. I’m roughly a Class 2 now, and thanks to finasteride, I’ve stayed almost exactly where I was at 26 with some improvement (not really cosmetically significant though). However, I am convinced I have some crown and top of the scalp thinning too, but not to a visible degree.
These people getting these miraculous jobs from Canada – it is a trick, right? They can’t honestly expect to be able to get away with what they’ve done over the course of their entire lives, can they? — L.M., Great Falls, V.A.
A: I think you have better insights into hair loss than many hair transplant surgeons. Patient ABI was the “rare” patient who seems to be a stable Class 3. I made that judgment due to: almost no miniaturization at the border of his Class 3 recession, no crown miniaturization, and his unusual family history. He had several older family members who stayed at Class 3 their whole lives.
Since we only have about 6,000 movable follicular units on average in our donor area, placing 3,000 at the hairline is obviously a joke and/or the doctor is playing “Russian Roulette” with the patient’s future.
As you point out, in most patients the hair loss will progress and the person will be out of luck. It is similar to the way flap patients were stuck without additional donor hair as their hair loss progressed. An additional problem was that the flaps were low on the forehead and very dense. The situation is analogous to placing 100 grafts per sq cm2 to create a low, broad hairline in a young person.
If you do the math you can see how ridiculous this tactic is. A person’s original density is only 90-100 follicular units cm2. Patient with Class 6 hair loss lose hair over an area of about 300 cm2.
This consists of:
50cm2 in the front (including a 15cm2 hairline)
150 cm2 for the mid-scalp
100 cm2 for the crown
Therefore, 6000 FUs transplanted to this area = 6000/300 = 20 FU per cm2. This is the number we often work with. We put up to 50cm2 at the very most in the mid-frontal forelock area and then proportionately less in other areas.
However, if you put 3,000 FUs at the hairline, in a density of 100/cm2, then you have covered only 30cm. This leaves only 3,000 FUs for the remaining 270cm2 of balding scalp for a density of a little over 11 FU/cm2.
Now, transplanting 11FU cm2 over the back part of the scalp is not a disaster EXCEPT if the front was transplanted at 100 per cm2. In this situation (as you have accurately pointed out) the patient will look very, very front heavy, with an aggressively placed, dense, broad, hairline and little hair to support it towards the back.
The gamble is that the patient’s baldness doesn’t progress, that finasteride or dutasteride can halt the process if it does progress, or that hair cloning methods will be available to save the day.
In my opinion, elective surgery should not be performed when its success depends upon these uncertainties – and particularly since a cosmetically disfiguring hair transplant can be so debilitating (and avoidable).
The reality is that doctors who claim to perform these procedures may not even be performing follicular unit transplantation. In FUT, the surgeon transplants naturally occurring intact FUs of 1-4 hairs. The extreme dense packing techniques preclude the use of 4- and sometimes even 3-hair grafts. What happens is that the larger FU are spit up. This doubles the graft counts (and the cost to the patient) without giving the patient any more hair. It also increases the risk of follicular damage and poor growth.
Patients in whom 10,000 follicular units are available to transplant are very rare and when they are shown on the internet, should be viewed as the exception rather than the rule.
Q: I wanted you to determine if I would be a candidate for FUE (to camouflage a scar). After reading through your vastly informative website, I had become aware that the Fox test is necessary to determine patient viability for FUE. When I mentioned the test, I believe I heard you say it was unnecessary. Unfortunately, I can’t help but think there was miscommunication between us, as your letter states that I should schedule a Fox test if I am considering FUE. Please confirm if a Fox test is, in fact, necessary. — N.S., Garden City, N.Y.
A: I perform FOX tests on all patients when I am considering a FUE hair transplant. I do not routinely perform FOX tests before repairs (or on eyebrow transplants) where the number of grafts is relatively small.
The purpose of FUE is to identify those patients in whom FUE is inefficient — i.e. there is a greater than average risk of damage during the harvest. If this is the case, I would not perform the hair transplant since even slight inefficiencies create a significant problem when thousands of grafts are transplanted.
Remember, compared to Follicular Unit Transplant (FUT), FUE is a relatively inefficient procedure. Even when a small FUE hair transplant is performed (i.e., in a Norwood Class 3) we have to anticipate that eventually the person will need a large amount of grafts, so a FOX test is still important.
However, when the total number of grafts is small, such as in scar revisions or eyebrow restoration, small inefficiencies are not as important.
In addition, with repairs, the donor area is altered so that extraction in different areas may be very be different, rendering a FOX test in scar revisions far less useful.
Finally, if a FUE hair transplant is started, but then aborted due to extraction difficulties, the patient must either be reverted to a strip (which was not the preferred means of harvesting or a FUT would have been planned to begin with) or the patient will be left with a partial procedure – both less than ideal situations. However, if a FUE repair has to be aborted due to the inability to efficiently harvest hair, no harm was done; we just won’t be able to achieve our goal.
Q: I have been told a number of different ways to massage my scalp. What do you suggest? — H.H., Pidemont, C.A.
A: We have found that the most successful technique is to perform the exercises: once a day, for at least 15 minutes, and using three different hand positions.
The main limitation is to avoid putting direct pressure on the donor area and to avoid stretching the back of the scalp (neck flexion) as this will increase the chance of stretching the donor scar after a strip procedure.
There is no such limitation with follicular unit extraction (FUE). However, in general, contact sports should be avoided for at least 10 days with FUE and a month after a strip procedure.
Q: I’ve been losing my hair just around the front of my scalp for years, but now it’s bad enough that I need to wear a wig to hide the top and back. Do you transplant women?
A: If you have thinning in such a broad area, most likely your donor area is also thin and you would not be a good candidate for surgery.
An examination can determine this and also determine if there is some other cause of your hair loss other than genetics.
Q: I have heard of body hair transplants as an option being considered by some patients. Do you think that could be an option for me as my donor area isn’t able to provide the hair that I need? — N.S., Winnetka, I.L.
A: With body hair transplants, the hair quality is poor and there can be a significant amount of scarring where the hair is harvested, so we are not recommending it at this time.
Q: I am scheduled to have a hair transplant next month and wonder if I should do scalp exercises before the procedure? — G.F., Providence, R.I.
A: For the majority of patients, scalp exercises are not necessary.
The scalp in the donor area has a fair amount of redundancy. With a properly planned hair transplant, the donor area will close relatively easily.
If a patient’s scalp is particularly tight, or if a very large session is planned (even in the face of an average scalp), vigorous scalp exercises are useful in increasing laxity.
The advantage of stretching one’s scalp prior to surgery is that it allows the doctor to remove a slightly wider strip and it decreases tension on the closure so the person will heal with a potentially finer scar.
Q: I would be so grateful if you could give me some idea on how the quality of the hair that is transplanted is affected by its new ‘home’ and the native neighboring hair. — D.C., Flatiron, N.Y.
Is it likely all the hair that is going to be able to come back to life with Propecia will also mature fully eventually? At the moment there is a big visual difference between the front section and rest of hair. (I understand hair count per cm2 may differ more drastically- I’m thinking here just of the hair shaft thickness.) Also, when I have hair transplants – as I intend to when Propecia has done all it can – will the hairs from the back of my head (thick) stay that thick regardless or will they take on the properties of the new surrounding hair?
A: Hair that responds to Propecia doesn’t always regain the full character of the original hair, so the area may still look thin.
The transplanted hair, however, will look like the original hair and maintain, over time, the same character as the hair in the donor area (where it came from).
Q: I am 26 years old, have had two successful hair transplants, but am still losing hair in the crown area. The doctor I have worked with told me that he does not do crown work on anyone until they are at least 40 (due to lack of donor area). I have very thick hair and the transplanted area looks as if nothing was lost. Would you do work on someone my age in their crown area if they have enough donor hair? — A.W., Brooklyn, N.Y.
A: Although I am hesitant to start with the crown when transplanting a younger person, if you have good coverage on the front and top of your scalp from the first two sessions then extending the hair transplant into your crown may be reasonable. It depends upon your remaining donor supply and an assessment of how bald you will become. I would need to examine you.
If it is likely that you will progress only to a Norwood Class 6, then transplanting your crown can be considered. If you will progress to a Class 7 then you should not since, in the long term, hair that was placed in the crown might be better used for other purposes, such as connecting the transplanted top to receding sides.
Q: I heard that a smaller per cent of women are candidates for hair transplants compared to men. Is this true?
A: Yes, that is true. Women more commonly have diffuse hair loss where the thinning is all over the scalp. This means that the donor area (the back and sides of the scalp) are thinning as well.
If the donor area is not stable, then there is no point in doing a hair transplant, since the transplanted hair will continue to fall out. Remember, the transplanted hair is no better than the area where is comes from.
On the other hand, women with stable donor areas can be great candidates for surgical hair restoration. The stability of the donor area can be assessed using a procedure called densitometry and should be part of the hair loss evaluation when you see your physician.
Q: I am a 33 year old women and am just starting to thin on the top of my scalp behind my frontal hairline. What should I do? Should I have a hair transplant?
A: There are a number of things that you should consider that can be effective in early hair loss. These include minoxidil (Rogaine), laser therapy, and using cosmetics specifically made to make the hair appear fuller. Lightening or streaking the hair, as well as parting the hair off to the side, will also make the hair appear fuller.
If a surgical hair restoration is performed too early and there is still a lot of existing hair in the area, the hair transplant may actually accelerate hair loss. Surgery should not be performed prematurely.
Also, it is important that the doctor check the stability of the donor area, using densitometry, to make sure that the procedure is even possible. For those women who are good candidates, and if it is done at the appropriate time, a follicular unit hair transplant is a great procedure that can produce really natural results.
Dr. Bernstein took part in a PRWeb podcast about hair transplantation in June 2007. Stream the discussion below or read the transcript:
Announcer: PRWebPodcast.com, visiting with newsmakers and industry experts.
Mario: This is Mario from PRWeb, and today it is a real pleasure to have with us Robert M. Bernstein, M.D. Dr. Bernstein is Associate Clinical Professor of Dermatology at Columbia University, and founder of New York City‑based Bernstein Medical – Center for Hair Restoration. Dr. Bernstein, it’s a pleasure to have you here on PRWeb.
Dr. Bernstein: Nice to be speaking with you.
Mario: Give us some understanding, sir, of your practice, the Bernstein Medical – Center for Hair Restoration. How long have you been around, where you guys are located, what is it you do there, please?
Dr. Bernstein: Bernstein Medical has evolved over the last ten years. It was set it up to do a specific procedure that I pioneered called “follicular unit hair transplantation.”
In this procedure, we dissect out hair follicles from the back of the scalp, exactly the way they grow in nature, so we are now able to perform hair transplants that essentially mimic nature.
This procedure is used by doctors around the world in hair restoration procedures. Our NY Hair Transplant Center is in midtown Manhattan and has been specifically designed for performing this hair transplantation technique.
Mario: You recently co‑authored an article, Dr. Bernstein, that appeared in the “Medical Journal of the International Society of Hair Restoration Surgery”. Now, you are well read and interviewed all over. This must be a bit exciting, something that was positive for you and your clinic. Tell us about the article, what it touched on, and some of the things that would be important for our listeners.
Dr. Bernstein: It sure was very exciting. The hair transplantation procedure has been around for many years, but a lot of it has been too much of an art and not enough of a science. What we’ve found is that doctors sometimes make these very general judgments about how bald the patient is going to become, how much hair they may need for the hair transplant or for the restoration.
We’ve found that by using a procedure called “densitometry”, where the hair is looked at under high magnification, we are able to get much more specific and useful information, both on the extent of how much someone is going to lose their hair, and also whether they are going to be a good candidate for hair restoration surgery.
One of the things that we’ve found is that when people start to thin, the hair first changes diameter before it’s lost, and this change in diameter may not necessarily be seen by the naked eye or be observed by another person.
But if you clip the hair very short and look at the base of the hair follicles under very high power, 30X magnification, you can actually see these very subtle, early changes, and these changes will anticipate future hair loss.
When we’re trying to decide whether a person should have hair transplant surgery, we can actually look at the donor area in the back and sides of the head, and see how stable these areas are. For example, someone that is becoming very bald, if the back and sides of their head show no change in the hair diameter, or no miniaturization, then we know that they may have very good hair for hair transplants; where a person with a similar degree of hair loss, whose sides and back are not stable, may not be a good hair transplantation candidate.
In a sense, by being able to measure things now, we’re able to have a much better sense of whether people are going to become very bald, possibly the rate of change of their hair loss, and then if they do need surgery, such as a hair transplant, we’re able to give much more specific information about what actually might be done.
Mario: We’re speaking to Dr. Robert M. Bernstein, M.D., an Associate Clinical Professor of Dermatology at Columbia University, and founder of New York‑based Bernstein Center for Hair Restoration.
Dr. Bernstein, give us some contact information where we can learn more about your services, and be able to end up taking advantage of them.
Dr. Bernstein: The best information can be found on our web site. The web address is www.BernsteinMedical.com.
Mario: Dr. Bernstein, it’s been a pleasure having you here on PRWeb podcasting with us. The best of luck to you, and congratulations again for that article in the “Medical Journal of the International Society of Hair Restoration Surgery.”
Dr. Bernstein: Thanks a lot, nice talking to you.
Announcer: Produced by PRWeb, the online visibility company.
Q: I recently had a follicular unit extraction procedure of 320 grafts to fix an old strip scar. The donor area where the FUE’s were taken looks very diffuse – worse than the original scar ever was, it looks horrible. My doctor said this was just shock loss. Have you seen that happen where the donor area gets all diffuse from shock? If not, have you seen it where the FUE’s are taken in an illogical pattern resulting in new scarring that is noticeable? — E.O., Providence, R.I.
A: You can have shedding in the donor area from an FUE procedure, although it is not common. In FUE, the hair must be taken from the permanent zone and if there is too much wastage in the extraction process, too large an area may be needed to obtain the hair. This can leave a thin look even without shock loss (shedding).
Q: I am suffering from Pseudopelade for four years now. I have lost a lot of hair & there are big bald patches on the top of my scalp that are difficult to hide. Is there any hair transplant surgery or follicle transplant surgery possible in my case, or anything else I can do? — T.L., Boston, MA
A: In general, hair transplantation does not work for Pseudopelade (a localized area of scarring hair loss on the top of the scalp) since the condition is recipient dominant rather than donor dominant.
With a donor dominant condition, such as androgenetic hair loss, the tendency to have the condition, or be resistant to it, is located in the hair follicle and moves with the hair follicle when the follicle is transplanted to a new area. Therefore, in androgenetic alopecia, healthy permanent hair taken from the donor area in the back of the scalp will continue to grow in the a new location in the balding part of the scalp.
In a recipient dominant condition, such as Pseudopelade, the problem is in the skin, so if you perform a hair transplant into an affected area of skin, the transplanted hair will become affected by the same process and be lost.
Q: Could you tell me in case there is an infection at the donor area following a hair transplant, will it prevent the hair to grow after healing if the donor area closed by Trichophytic Closure? What are the problems which may the infection cause? — S.S., Park Slope, NY
A: Infection may cause the donor incision to heal more slowly or with a widened scar after a hair transplant. It may affect any closure, Trichophytic or not.
The risk of infection after a hair restoration procedure is made worse by a tight closure, but not necessarily a Trichophytic closure, unless too much skin was removed at the edges leaving the dermis (deeper part of the skin) exposed.
Q: In my first hair transplantation procedure, I wanted to be as conservative as possible and focus on thickening the thinning hair on top of my head and lowering the hairline minimally. Is it still possible to lower the hairline further in a second hair restoration procedure? Is there an “ideal” time period for a second hair transplant after the first? — B.B., Meatpacking, N.Y.
A: It is possible to lower the hairline with a second hair transplant, but the doctor must be certain that you have enough donor hair so that the transplanted pattern will look natural long-term.
Unless there is some pressing reason that you had to have a second session sooner, I would wait a minimum of 10-12 months between hair restoration procedures so that you can see the full cosmetic impact of the first session.
As a hair transplant matures and thickens, the hairline will look lower as the eye doesn’t see as far into the scalp.
Q: I had hair transplant surgery 10 days ago and have since developed what looks like big, dry flakes in the transplant area. How long does it take for the grafts to root, and is it okay that some of the grafts fall out when brushing my hair back carefully at this point? Also, the area that was worked on has not fallen out yet, so should I shave this area before the new hair comes in or should this be a natural process? — N.N., Easton, C.T.
A: Grafts are generally permanent 9 days following a follicular unit hair transplant procedure, so you may shampoo the flakes off at this time. If larger grafts were placed (with correspondingly larger recipient sites), the grafts will be subject to being lost for a slightly longer period of time. After 9 days, you may shave or clip the hair in the transplanted area if you like, but this will not affect the success of the hair restoration one way or the other.
Q: Why should a doctor measure miniaturization in the donor area before recommending a hair transplant? — E.B., Key West, F.L.
A: Normally, the donor area contains hairs of very uniform diameter (called terminal hairs). In androgenetic hair loss, the action of DHT causes some of these terminal hairs to decrease in diameter and in length until they eventually disappear (a process referred to as “miniaturization“). These changes are seen initially as thinning and eventually lead to complete baldness in the involved areas.
These changes affect the areas that normally bald in genetic hair loss, namely the front and top of the scalp and the crown. However, miniaturization can also affect the donor or permanent regions of the scalp (where the hair is taken from during a hair transplant). If the donor area shows thinning, particularly when a person is young, then a hair transplant will not be successful because the transplanted hair would continue to thin in the new area and eventually disappear. It is important to realize that just because hair is transplanted to another area, that doesn’t make it permanent – it must have been permanent in the area of the scalp it initially came from.
Unfortunately, in its early stages, miniaturization cannot be seen with the naked eye. To detect early miniaturization a doctor must use a densitometer, or an equivalent instrument, that magnifies the surface of the scalp at least 20-30 times. This enables the doctor to see early changes in the diameter of the hairs that are characteristic of miniaturization. If hairs of varying diameter are noted (besides the very fine vellous hairs that normally occur in the scalp), it means that the hair is being affected by DHT and the donor area is not truly permanent.
In this situation, a person should not be scheduled for hair transplantation. If the densitometry reading is not clear, i.e. the changes are subtle and the doctor is not sure, then the decision to have surgery should be postponed. By waiting a few years, it will be easier to tell if the donor area is stable. Having surgery when the donor area is miniaturizing can be a major problem for a patient, since not only will the transplanted hair eventually disappear, but the scar(s) in the donor may eventually become visible. This problem will occur with both follicular unit transplantation (FUT) and follicular unit extraction (FUE).
Q: My hair loss resembles the grade I female hair loss scale, but none of the male hair loss patterns. It has been relatively stable for the past five years and only recently has it begun to progress further. I began both Propecia and Rogaine two months ago, but the hair loss still continues at the same pace. I’m really worried. Does a hair transplant work in such a diffuse hair loss? — D.D., Park Slope, Brooklyn
A: If your hair loss is diffuse only on top, then a hair transplant will be effective. This condition is called Diffuse Patterned Alopecia or DPA.
If the diffuse pattern of hair loss affects the back and sides as well, then surgical hair restoration should be avoided. In this case (called Diffuse Unpatterned Alopecia or DUPA) the donor area is not permanent and the transplanted hair will continue to thin over time.
Q: I underwent hair transplant surgery several years ago and was pleased with the results. However, over the last 2-3 years I’ve lost hair in the donor area with subsequent loss of hair in the transplanted area. Is this type of hair loss especially difficult to treat? What accounts for hair loss from the back of the head that is typically considered “permanent”? — F.D., Laude, Missouri
A: Less than 5% of patients have unstable donor areas, i.e. where the back and sides thin along with the front and top. We call this condition Diffuse Unpatterned Alopecia or DUPA. It is best to identify this condition before hair transplant surgery is contemplated as people with DUPA are not good candidates for hair transplantation. The diagnosis is made using densitometry by noting high degrees of miniaturized hair in the donor area.
At this point, I would use medications such as finasteride. I would not do further hair restoration surgery.
Q: Although I read that women are supposedly protected from hair loss in the frontal hairline by the enzyme aromatase that is exactly where I am losing hair. My hairline has receded and I have developed a widow’s peak. What can be causing this, and how can I fix it? It seems to have been happening gradually for a few years.
Women with this pattern can often be good candidates for hair transplant surgery, particularly if the donor area is stable. View our Women’s Hair Transplant Gallery for some examples of the kind of results we can achieve for women at Bernstein Medical – Center for Hair Restoration.
Q: I have heard that staples are uncomfortable after the hair transplant, why do doctors use them? — B.E., Great Falls, V.A.
A: Staples are used for two main reasons.
The first is that being made of stainless steel; they don’t react with the skin and, therefore, cause little inflammation.
The second is that, unlike sutures which are used with a continuous spiral stitch, each staple is separate and this causes minimal interruption to the blood supply. The combination of little inflammation and minimal interference with the blood flow facilitates healing and minimizes damage to hair follicles.
Although sutures are generally more comfortable after the hair transplant, the doctors who choose to use staples do so because they are the least injurious to the hair in the donor area.
Dr. Bernstein was featured in a CBS News report on 
