“Hair Transplantation” is a part of a series of medical textbooks — Procedures in Cosmetic Dermatology, published by Elsevier Saunders — which offers step-by-step, practical guides to performing cutaneous surgical procedures.
In “Hair Transplantation,” Dr. Bernstein co-authored the chapters on Follicular Unit Transplantation and Follicular Unit Extraction, covering the philosophy, basic science, and techniques in a practical clinical format.
The book’s editors selected Robert M. Bernstein as a major contributor, as Dr. Bernstein was uniquely qualified to provide medical professionals with insight and training on the state-of-the-art in hair transplant surgery.
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.
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.
Q: If someone doesn’t have enough donor hair, do you ever perform a hair transplant using FUE, using donor hair from outside the permanent hair zone? — M.V., Nashville, TN
A: No. If hair was taken from outside the permanent zone as the surrounding hair continued to bald, the scars from FUE, although small, would become visible.
In addition, the transplanted hair would not be permanent, and over time would eventually fall out.
Q: Does dense packing hurt grafts? — P.L., Rye, NY
A: There is no absolute answer to this question. In a hair transplant, dense packing has a risk of decreasing yield if there is a significant amount of photo damage to the scalp (which alters the blood supply) and if there is a tendency for the grafts to pop (this is difficult to predict pre-operatively). Very closely spaced grafts exacerbates the popping and exposes the grafts to desiccation (drying), hypoxia (lack of oxygen) and mechanical trauma from the necessary re-insertion.
That said, the skill of the hair transplant surgeon and placing team, the size of the recipient sites, and the way the grafts are dissected and trimmed all play important roles in determining graft survival in dense packing.
This study also demonstrated that the Hedgehog agonist is active in human scalp in vitro as measured by Hedgehog pathway gene expression. The results suggest that topical application of a Hedgehog agonist could be effective in treating hair loss conditions, including male and female pattern genetic hair loss.
Q: I was wondering why you chose two years as the amount of time one should wait to judge the effectiveness of Propecia. Have you had patients who only saw results after that long? Why does Merck say 3-6 months and Dr. Rassman at New Hair say 6-8 months? I know these numbers aren’t arbitrary, but I’m just wondering what the logic is behind this and how does this relate to planning a hair transplant? — I.P., Hempstead, Long Island, NY
A: The Merck data showed that over 90% of patients had peak response at 1 year and this has been my experience as well.
Most patients show the most dramatic response between 6 to 12 months with some getting additional benefit up to two years. Prior to 6 months, the results are quite variable and there may even be a net loss due to shedding during this period, as the Propecia stimulates a new anagen cycle…
Q: Can you perform a hair transplant into scar tissue? A.H. – Rockland County, New York
A: Yes, hair grows in scar tissue, but not quite as well as in normal tissue. The scar is not as elastic as normal tissue so the grafts are at slightly higher risk of being dislodged; therefore, more care must be taken to protect the grafted area after the hair transplant.
In addition, the blood supply in scar tissue is less than in normal tissue, so that area should not be transplanted as densely and the hair replacement should be performed over multiple sessions.
Q: If a second hair transplant is performed before the first had a chance to grow could the second procedure destroy the follicles from the first? — B.M., Upper East Side, NYC
A: Hair from the second hair transplant session would not damage the follicles transplanted in the first session, even if follicular unit grafts were transplanted in exactly the same spot as in the first session.
The reason to wait until the hair grows in, however, is so that you can better plan the subsequent hair restoration procedure. If two follicular units are placed on top of each other or very close together, you will essentially be creating a mini-graft and the results will not look natural.
“Hair Transplantation” is a part of a series of medical textbooks — Procedures in Cosmetic Dermatology, published by Elsevier Saunders — which offers step-by-step, practical guides to performing cutaneous surgical procedures. 
