International Society of Hair Restoration Surgery Annual Scientific Meeting – 2013

November 12th, 2013

The 21st Annual Scientific Meeting of the International Society of Hair Restoration Surgery was held in San Francisco from October 13 through 26, 2013. The meeting covers the most important scientific and clinical advances in the field of surgical hair restoration.

As a member of the panel on “Difficult Cases,” that explored challenging and atypical medical conditions and their treatment, Dr. Bernstein presented the “Management of Frontal Fibrosing Alopecia.” This condition is a form of primary scarring hair loss. Dr. Bernstein chose to discuss this disease because it can be mistaken for common baldness; however, since the transplanted hair will be destroyed by the disease process, it is a contra-indication for hair transplantation. Since missing this diagnosis can lead to unnecessary and ineffectual surgery, an awareness of its signs and symptoms are important for every physician managing patients with hair loss.

On the panel on “Post Finasteride Syndrome,” Dr. Bernstein was part of a group that reviewed the latest studies on the efficacy and safety of finasteride in the treatment of androgenetic alopecia. They discussed possible adverse events including claims of persistent sexual dysfunction (Post Finasteride Syndrome) and concerns relating to prostate cancer. They also discussed the challenges that arise in caring for patients when scientific research and the mass media give conflicting information.

In the Symposium “Question the Expert,” Dr. Bernstein presented a case of Diffuse Un-patterned alopeica (DUPA). This condition was first detailed by Dr. Bernstein in his landmark paper “Follicular Transplantation: Patient Evaluation and Surgical Planning,” that was published in Dermatologic Surgery in 1997. DUPA is a form of androgenetic alopecia that presents as rapid generalized hair loss in young adults. Besides being a significant psychological burden for young men and women, its identification is extremely important since medical intervention can have a significant positive impact when instituted early. On the other hand, a misdiagnosis that leads to surgery can result in a failed hair transplant and donor scarring that may become visible over time.

Dr. Bernstein was also the Keynote Speaker for the ARTAS International Users Forum. His presentation, titled “Follicular Unit Extraction: Then and Now,” discussed the evolution of FUT, FUE and Robotic-FUE and how it relates to today’s hair restoration practice. Of particular significance was the natural progression of FUE instrumentation from hand-held manual tools to robotic assisted hair transplantation. Dr. Bernstein explained that in the future, robotic capabilities will not be limited to graft extraction, but eventually will perform each aspect of the transplant including recipient site creation, and graft placement. See “Dr. Bernstein Gives Keynote Presentation On Robotic Hair Transplantation” for more details on the presentation and some photographs of the event.


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Posted on November 12th, 2013 at 6:09 pm

Dr. Bernstein Gives Keynote Presentation On Robotic Hair Transplantation

November 12th, 2013
Dr. Bernstein Presenting ‘Follicular Unit Extraction: Then and Now’

Dr. Bernstein was honored to deliver the keynote address at the ARTAS International Users Forum in San Francisco, California. Dr. Bernstein’s presentation, “Follicular Unit Extraction: Then and Now,” was a review of the evolution of surgical hair restoration from Follicular Unit Transplantation (FUT) through Follicular Unit Extraction (FUE) to the cutting edge technique of Robotic-FUE.

The presentation described the steps that resulted in the use, and growth in popularity, of the state-of-the-art ARTAS Robotic System for FUE. Dr. Bernstein pointed out that with the introduction of each procedure — FUT, FUE, and Robotic-FUE — there was initially a rocky reception with physicians. In each instance, however, the surgeons’ concerns were overcome first by strong, patient interest and then by clinical studies that confirmed the procedures’ usefulness.

Dr. Bernstein discussed how FUE procedures progressed from the use of hand-held instruments to the computer-assisted, image-guided ARTAS Robot. One of the initial hurdles of FUE procedures using hand-held devices was a high rate of follicular unit transection (cutting of the follicles). Restoration Robotics, Inc., the company that developed the ARTAS system, used a “sharp/blunt” punch technique that was introduced by Jim Harris in his 2004 publication on the SAFE System for FUE. The sharp/blunt technique, that was validated in 2006 by Dr. Bernstein’s research publication, “New Instrumentation for Three-Step Follicular Unit Extraction,” reduced transection of follicles when compared to older instrumentation. Dr. Bernstein then detailed modifications to the system that he proposed in order to improve the ARTAS robot. These improvements include: a smaller tip for the sharp/blunt punch, selection of larger over smaller follicular units, tensioner placement, ‘feathering’ the ends of the tensioner, and pre-making recipient sites before extracting the follicular unit grafts.

Looking to the future, Dr. Bernstein mapped out the further evolution of the Robotic FUE procedure and the tasks it will be required to perform. In future procedures, the physician will not only guide the robot on extracting follicular units, but also in creating recipient sites and, further down the road, placing grafts into the recipient sites. Graft placement will represent the most significant challenge to the robotic system as this step is the most sensitive to patient to patient variability. Once this last step is accomplished, a fully automated hair transplant should be possible, eliminating much of the human error in the mechanical aspects of the hair restoration process.

More photos from the event:


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Posted on November 12th, 2013 at 5:38 pm

How Do You Make Recipient Sites in a Hair Transplant?

January 20th, 2011

Q: How do you make the recipient sites in a hair transplant? — N.P., New Delhi, India

A: I make the recipient sites using 19-, 20-, 21- and 22-gauge needles. The higher the number, the finer the needle. The hairline is done with a 21-gauge, which is really very tiny. Eyebrow sites are created with a 22-. When one draws blood in a routine blood test, an 18-g needle is used and, of course, there are no residual marks. The instruments we use are significantly finer than this.

For further reading on this topic, please visit our page on recipient sites in a hair transplant.


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Posted by Robert M. Bernstein M.D. on January 20th, 2011 at 12:28 pm

What Are Differences Between Follicular Unit Transplantation, Follicular Unit Extraction, and Ultra-refined FUHT?

March 21st, 2007

Q: What is the difference between the following ways of doing hair transplants: Follicular Unit Transplantation (FUT), Ultra-refined FUHT, and Follicular Unit Extraction (FUE)?

A: Please see the Bernstein Medical – Center for Hair Restoration website as it explains Follicular Unit Transplantation (FUT) and Follicular Unit Extraction (FUE) in detail.

In brief, with FUT, follicular units are obtained from the microscopic dissection of a donor strip that has been removed from the back of the scalp. In FUE, the doctor attempts to remove intact follicular units directly from the scalp via a small round instrument called a punch.

Ultra Refined FUHT (Follicular Unit Hair Transplantation) is term that Pat Hennessey uses on his Hair Transplant Network. It refers to using very tiny recipient sites, carefully dissected follicular unit grafts, and large hair transplant sessions in FUHT procedures.


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Posted by Robert M. Bernstein M.D. on March 21st, 2007 at 1:38 pm

In FUT Hair Transplant, How Important Are Microscopes?

December 7th, 2006

Q: I went to a hair transplant doctor for a consultation for my hair loss and he said that it was not that important to use microscopes for hair transplants. I had heard that it was. What’s the deal?

A: It is extremely important to use microscopes when performing hair transplants. It is the only way that follicular units, the naturally occurring groups of hair follicles, can be isolated from the donor tissue without damaging them.

Other techniques, such as magnifying loops and back-lighting are not as precise. Using microscopically dissected follicular units in hair transplants has been the main advance that has allowed doctors to move away from the older mini-micrografting hair restoration techniques to the current procedure that can produce totally natural results.

See the Graft Dissection page.


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Posted by Robert M. Bernstein M.D. on December 7th, 2006 at 8:54 am

What is Follicular Unit Extraction and What Other Terms are Associated with the Procedure?

November 6th, 2006

Q: I am considering having an FUE procedure and have heard the phrases topping, capping, and tethering as part of the procedure. What do all these terms mean?

A: These are all terms that refer to the types of injury that can occur to grafts during a follicular unit extraction procedure.

In FUE, a sharp instrument (or sharp instrument followed by a blunt one) is used to separate follicular units from the surrounding donor tissue. Forceps are then used to remove the follicular units from the scalp.

Topping occurs in the first step when the doctor accidentally cuts off the top of the graft so that the remainder of the graft cannot be removed.

Capping occurs when the doctor grabs a graft with forceps and the top of the graft (the epidermis and upper dermis) pulls off, leaving the rest of the graft behind.

Tethering occurs when the bottom of the graft is still attached to the deeper tissues after the first step causing the follicular unit to pull apart during extraction.

There are a few other terms used as well.

Shredding occurs when the follicular unit is not totally separated from the surrounding tissue and pulls apart upon extraction. Shredding can also occur when the follicular unit was partially damaged in the first step.

Transection is like topping, but here the mid or lower portion of the hairs in the unit are cut.

Buried grafts occur when the graft is pushed into the sub-cutaneous space rather than extracted. Buried grafts can usually be removed, but if not removed completely, may turn form small cysts.

Visit the Follicular Unit Extraction page.


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Posted by Robert M. Bernstein M.D. on November 6th, 2006 at 9:23 am

How Does Densitometer Help Diagnose Hair Loss?

August 17th, 2006

Q: Dr. Bernstein, I was reading about a densitometer on your website. What is it and what is it actually used for?

A: The hair densitometer was introduced to hair restoration surgeons by Dr. Rassman in 1993. It is a small, portable, instrument that has a magnifying lens and an opening of 10mm2.

To use it, the doctor clips the hair short (~ 1-mm) and the instrument is then placed on the scalp. The doctor counts the total number of hairs in the field, looks at the number of hairs per follicular unit and assesses the diameter of the hair, looking in particular for abnormal levels of miniaturization (decreased hair shaft diameter caused by the effects of DHT).

The densitometer can increase the accuracy of the diagnosis of genetic hair loss by picking up early miniaturization.

It can also better assess a person’s donor hair supply, thus helping to determine which patients are candidates for a hair transplant.

Densitometry has helped us define the conditions of diffuse patterned and unpatterned hair loss (DPA and DUPA) and help to refine the diagnosis of hair loss in women.


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Posted by Robert M. Bernstein M.D. on August 17th, 2006 at 1:18 pm

Can One Have Hair Transplant if Scalp is Tight from Prior Surgery?

July 5th, 2006

Q: What can be done if I want to have a hair transplant and my scalp is very tight from prior surgeries?

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

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

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

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

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


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Posted by Robert M. Bernstein M.D. on July 5th, 2006 at 6:33 am

How are Hair Transplant Recipient Sites Made?

May 27th, 2005

Q: How are recipient sites made?

A: At Bernstein Medical – Center for Hair Restoration we use a series of custom made, ultra-fine blades to create recipient sites. The blades differ in size by only one tenth of a millimeter and range from 0.6mm for one-hair follicular units to 1.2mm for 4-hair follicular units.

At the start of the procedure, the different size follicular units are fitted to specific site sizes to determine exactly the best size instrument to use for each graft. By custom fitting the sites to the grafts, healing is incredibly fast and patients are able to gently shampoo their scalp the day following the procedure.

All recipient sites are made using lateral slits, as these give the most full, natural coverage.


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Posted by Robert M. Bernstein M.D. on May 27th, 2005 at 1:57 pm



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