Robotic Hair Transplants & Hair Restoration
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Bernstein Medical - Center for Hair Restoration

Dr. Bernstein answers frequently asked questions about hair transplantation, hair loss, and medical treatment for hair loss.

Hair Restoration Answers

Why Is My Hair Dry And Kinky After My Hair Transplant?

Q: I had a hair restoration procedure and the hair grew, but after one year the hair was kinky and dry. It has remained like this ever since.

From what I have read Dr Bernstein says this is uncommon but can happen. I understand there is no definitive explanation for this but I would like Dr Bernstein’s opinion on why this happens. My theory is that DHT is more prominent on the top of the head and is changing the structure of the transplanted hair. The hair is so dry and unmanageable it looks like I am wearing a wig. I await his response. — P.O., Greenwich, CT

A: Some dryness and texture changes can occur after a hair transplant and this usually self-corrects over 1-2 years during which time the transplanted hair gradually regains its original luster and texture. These changes are most likely due to the unavoidable trauma that takes place as follicles are removed from the scalp and placed into recipient sites. Excessive dryness can occur if the sebaceous glands had been stripped away from the graft. In FUT, this can be due to over dissection (i.e., grafts that are trimmed too much). In FUE, this can be due to loss or damage to the sebaceous glands in the extraction process. Persistent kinkiness may represent either damage to grafts from the procedure (improper handling, crush injury) or effects of scarring in the recipient area (usually from older procedures which used larger recipient sites) that distort the growth of follicles.

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Hair Restoration Answers

Can Anyone Tell Me Why Dr. Bernstein Is Still Bald?

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.

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Hair Restoration Answers

What is the Difference Between “Hair Transplant Reversal” and “Hair Transplant Repair”?

Q: I have read a lot on the forums about hair transplant reversal and hair transplant repairs. Are they the same thing, if not, what is the difference? Can you reverse a hair transplant? — K.J. ~ Park Slope, N.Y.

A: A “hair transplant repair” refers to techniques that improve the appearance of a poorly executed procedure or one performed with outdated methods. A “hair transplant reversal” refers to techniques that enable the individual to appear as if no hair restoration surgery had been performed. Although the techniques in attempting to perform a repair or a reversal may be similar, the ultimate goals of each are quite different. It is important to understand that although significant improvement can often be achieved, perfect repairs and/or full reversals are generally not possible.

The main reasons for seeking a repair include; large grafts transplanted to the frontal hairline giving an unnatural, “pluggy” appearance, a frontal hairline placed too far forward, hair placed in the wrong direction, and donor and recipient site scarring. Outdated procedures such as scalp reductions and flaps also need to be repaired.

If the transplanted grafts are large (“hair plugs”), it is possible to surgically excise these grafts, microscopically dissect them into smaller follicular unit grafts, and re-transplant them into the scalp in a more natural-looking, aesthetic way. After these large grafts are removed, the sites are sutured closed and heal with very fine, often imperceptible, white scars. Hair plug removal is often followed by one or more sessions of FUT or FUE in order to harvest additional hair for use in camouflaging any remaining plugs or improving the appearance of the region where the plugs had previously been. These combined repairs can lead to excellent outcomes.

If the grafts at the hairline are not large but are placed too low or too broadly, it is possible to use laser hair removal and/or tweezing to remove these hairs. Repeated treatments may be necessary until the hair ceases to grow back at these locations. Additionally, hair which was placed in a direction different from the way hair naturally grows will usually need to be removed.

Another challenge in hair transplant repair is fixing widened donor scars that had resulted from poorly performed FUT/strip procedures. These scars are permanent and may be visible if the hair is not worn long enough. Scars from FUT procedures can be repaired by harvesting hair from the surrounding donor area (using FUE) and transplanting these follicular unit grafts into the scarred tissue.

Scalp micropigmentation (SMP), a permanent micro-tattoo, may be useful to further camouflage these linear scars. SMP can also be used to improve the look of the stippled scars of FUE in patients. This can occur with overharvesting, when patients wear their hair too short, or when the balding is more extensive than anticipated and extends into the harvested area.

A hair transplant reversal, in theory, has the goal of having the person look as though a hair transplant had never been performed. While reversing a hair transplant completely is not possible, the techniques previously discussed can be utilized to achieve a number of important things. The donor site scarring can be minimized and/or camouflaged and the smaller follicular unit grafts in the recipient zone can often be removed without leaving behind any visible scarring of the underlying skin. What is not possible is to restore the person’s density to a pre-procedure level as improperly performed transplants always result in wasted hair.

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Hair Restoration Answers

What is your Opinion of Nutrafol?

Q: What’s your honest take on Nutrafol? It is a product my dermatologist has recommended for my hair loss. — N.S. ~ New York, N.Y.

A: The traditional thinking is that that male pattern alopecia (androgenetic alopecia) is due to follicular sensitivity to DHT causing miniaturization and eventual loss of hair. The premise of Nutrafol is that hair loss is multi-factorial with an important inflammatory component and that it is important to address the inflammation as well as the DHT sensitivity.

This is a relatively new and important concept (I would like to stress this point!). However, the big leap is their conclusion: Since hair loss is multi-factorial, then broad, rather than targeted treatments would be most beneficial, and since naturally occurring “phytochemicals” are broader in action than targeted, FDA approved drugs (like finasteride and minoxidil), they should offer benefit in the treatment of hair loss and Nutrafol is the elixir that can accomplish this.

Although this makes sense in concept, there is no scientific evidence that Nutrafol can actually reverse or/mitigate androgenetic alopecia or any other type of hair loss. We need independent, blinded, controlled studies to show that Nutrafol actually works. Until then, it is very difficult to recommend this product and, more importantly, to recommend it over other treatments known to be effective.

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Hair Restoration Answers

When is it Best to Feather in Robotic FUE?

Q: I thought that FUE extraction is performed in a way that it cannot be detected. Therefore, it is best to distribute the pattern evenly starting from the safe zone and fading out on the sides. The ARTAS results often show a smaller extraction area and harder edges (no transition from extraction to non-extraction area). Does this lead to a higher risk to detect the surgery? — H.K. ~ Chicago, I.L.

A: Feathering of the extraction zone in FUE is a technique where the distance between the extractions gradually increases as one reaches the border of the extracted zone. When this technique should be used depends upon the short- and long-term goals of the patient. If the patient’s main goal of the FUE procedure is to wear their hair very short, then the technique of feathering and rounding the edges to have a less distinct border is appropriate, as this will decrease the visibility of the harvested area.

However, if a person does not wear his hair very short (nor plans to) and maximizing the donor supply is paramount, then a more organized pattern, with less feathering, will give a greater long-term yield and a more even distribution. The reason is that the healing of FUE wounds distorts adjacent follicular units making subsequent extraction in the same regions more difficult and increases the risk of transection. For this reason, in subsequent procedures we generally prefer to harvest in new areas. If we need to harvest more hair from the same area, we rarely go back more than once.

When one feathers extensively in the donor area, this utilizes a larger surface area of the scalp with less graft yield, so it may become necessary to go back over the same area to obtain additional grafts, often multiple times. This risks increased transection and an uneven, mottled appearance to the donor area.

If a person wears his hair very short, then feathering is critical (even though it makes subsequent extraction more problematic). It is very easy to feather and round edges with the ARTAS robot, but we make the decision to do so based upon the specific needs and goals of the patient.

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Hair Restoration Answers

What is a Double Centrifuge System for PRP and What are the Benefits?

Q: What is a double centrifuge system for PRP and what are the benefits? — S.B. ~ Manhattan, N.Y.

A: The double centrifuge system is a process used in preparing Platelet-Rich Plasma (PRP) where the whole blood is spun two times to optimize the concentration of the platelets. In the first spin, the red blood cells are separated from the plasma, which contains the platelets. In the second spin, the cellular components in the plasma are further concentrated. The platelets and growth factors that are recovered from the plasma are then injected into the scalp. Additional growth factors are released from the platelets after the injections and it is these proteins that provide the benefit of helping to maintain the hair and to stimulate growth. By using a double centrifuge technique, the ideal concentration of platelets and growth factors are achieved.

  • Read more about Platelet-Rich Plasma (PRP) for Hair Loss
  • View a slideshow of how PRP is prepared

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Hair Restoration Answers

Are Topical DHT Blockers as Effective as Oral Finasteride?

Q: What is more important against baldness, decreasing DHT in serum with oral finasteride or decreasing DHT in the scalp with topical finasteride? — A.G. ~ Brooklyn, N.Y.

A: Decreasing serum DHT with oral finasteride is more effective in combating hair loss, as the decreased blood levels also lowers the DHT in follicles and seem to do it better than finasteride applied topically.

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Hair Restoration Answers

Would A Hair Transplant In Turkey Be Performed Just By Technicians?

Q: I was thinking of having an FUE hair transplant procedure done in Turkey, but I am concerned that it will be done with just technicians. Any thoughts? — E.E. ~ Mount Vernon, N.Y.

A: I do not have first-hand information on the clinics in Turkey, but there is a recent “Letter to the Editor” in Hair Transplant Forum International, the official publication of the “International Society of Hair Restoration Surgery” that you might find informative. From the article:

“In Turkey, there are 300 FUE clinics in Istanbul alone but, unfortunately, at only 20 of them are operations are done by doctors. We do not exactly know how many of those 300 clinics have legal permissions, but we know very well that an average of 500-1,000 FUE operations are done per day.”

If you would like to read the entire article, the reference is: A Report from Turkey – the situation in a top FUE destination. Hair Transplant Forum International July/August 2017 p 162.

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Hair Restoration Answers

Do Women Have Less Shock Loss Than Men?

Q: I have heard that shock loss can occur after a hair transplant. Do women experience less shock loss than men? — N.R. ~ Mineola, N.Y.

A: Actually, the risk of shock hair loss is usually greater in women than in men since women generally have a more diffuse pattern of thinning. This is because females often have more miniaturized hair, the hair that is most subject to post-op shedding.

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Hair Restoration Answers

Is Manual FUE Better Than Robotic FUE Because The Physician Can “Feel” The Follicle During Extraction?

Q: Is it true that manual FUE hair transplant procedures are better than robotic hair transplants because the physician can adjust and feel the follicle when extracting? — M.H. ~ Great Neck, N.Y.

A: The ARTAS robot is a physician controlled, computerized device that uses a three-dimensional optical system to isolate follicular units from the back of the scalp in a hair transplant. The robotic system assists the physician in the extraction of grafts with precision and speed. Although there is some advantage to having “human feel” for the tissue, this is far outweighed by the fact that repetitive procedures performed manually thousands of times lead to operator fatigue and result in increased transection and damage to grafts. With the ARTAS robotic system, the quality of the first and the last graft harvested will be the same.

Read about advantages of the ARTAS Robot over manual FUE procedures

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What is Trichophytic Closure After An FUT Hair Transplant?

Q: I have read that some doctors perform something called a trichophytic closure. What is this? — M.S. ~ Thornwood, N.Y.

A: Trichophytic closure is a way to minimize the appearance of the donor scar in a hair transplant using a strip incision. The technique provides improved camouflage of a linear donor scar in Follicular Unit Transplantation (FUT). Normally, in FUT, the surrounding hair easily covers the scar. For some patients with very short hairstyles, the resulting donor scar may be visible. With the trichophytic closure technique, Dr. Bernstein trims one of the wound edges (upper or lower), allowing the edges to overlap each other and the hair to grow directly through the donor scar. This can improve the appearance of the donor area in patients who wear their hair very short.

The trichophytic donor closure can be used on patients who have had previous hair transplant procedures and are looking for improvement in the camouflage of their donor scar. It is particularly useful in hair transplant repair or corrective work. Trichophytic closures work best with sutured incisions. Stapled closures have their own advantages. The doctor will recommend which type is best in your case.

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Hair Restoration Answers

What Is The Difference Between The ARTAS 9x And The Earlier Versions Of The Robot?

Q: What is the difference between the ARTAS 9x and the earlier versions of the robot? — T.J. ~ Washington, D.C.

A: The differences can be grouped into four broad categories:

1. Speed: The 9x is 20% faster than the 8x. This is achieved through the ARTAS robot’s ability to more quickly and accurately align with the follicles, faster movement from follicular unit to follicular unit while harvesting, and a shortened dissection cycle (less than 2 seconds). In addition, the 9x uses white LED lights instead of red, which permits an increased work flow from the ability to simultaneously incise and extractions grafts. The decreased strain on the eyes from the white lights (compared to red) makes this possible.

2. Accuracy: The 9x uses smaller needles that minimize wounding and donor scarring. It is especially useful for patients with fine hair or those who want to keep their hair short.

3. Functionality: The robotic arm on the 9x has a 1-inch base extender that gives the machine a longer reach and decreases the need for the patient to be repositioned. The ARTS 9x also has a smaller robotic head allowing the robot to harvest the grafts at a more acute angle. The ARTAS 9x also allows for more site making options due to the universal blade holder and the ability to program a change in the orientation of the incision in different regions of the scalp. The ARTAS 9x also uses a new harvesting halo to secure the tensioner (the grid-like device that indicates where the robot should harvest) which is faster to apply and more comfortable for the patient.

4. Use of Artificial Intelligence: The technology notifies the physician early-on if the harvesting is not precise, so that action can be taken to ensure most effective results. The ARTAS software can now detect areas with low (or no) hair density and prevent those areas from being over-harvested. This also decreases human error and saves time by automatically blocking these areas with low density. Finally, the ARTAS Hair Studio, can now create a 3-D image of the patient’s head with only one photo (as opposed to the prior requirement of 3 to 5).

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Hair Restoration Answers

Why Visit a Practice That Specializes in Both FUT and FUE?

Q: Why go to a hair restoration practice that specializes in both FUT and FUE? — L.P., Bayside, NY

A: This is a great question, but the answer may be counterintuitive in today’s age of specialization. The answer is that you should always go to the practice that offers both. To deliver the best care, hair restoration physicians should have expertise in both Follicular Unit Transplantation (FUT) and Follicular Unit Extraction (FUE) techniques and should offer both in their practices. There are at least five good reasons why:

1. FUT and FUE are both excellent techniques but have different indications for use

The main advantage of FUT is that it typically (but not always) gives the highest yield of hair. Therefore, when the patient’s primary goal is to achieve maximum fullness, FUT should be performed. There are many well-described reasons for this, including the precision of stereo-microscopic dissection and the ability to harvest efficiently from a more select area of the donor zone, but these are beyond the scope of this brief commentary.

The main advantage of FUE is no linear scar. Therefore, when the patient’s primary goal is to be able to wear his hair very short, FUE should be performed. FUE is also indicated when there is an increased risk of a widened scar or when scalp laxity does not permit a strip excision. The patient may sometimes choose FUE simply to avoid the stigma of a linear donor scar.

2. The same patient may benefit from both procedures

There are situations in which both procedures are useful in the same patient. For example, FUT may first be used to maximize yield, but then, after several sessions, the scalp may become too tight to continue to perform FUT, or the donor scar may become wider than anticipated. In the former case, the physician can switch to FUE to obtain additional grafts; in the latter case, FUE may be used to camouflage the scar of the FUT procedure.

3. There is a cross-over set of skills from FUT to FUE

To do an FUE procedure well, the follicular unit grafts that are extracted should be examined carefully under a stereo-microscope and, when needed, trimmed and sometimes subdivided into individual hair follicles (such as for hairlines, eyebrows, temples, etc.). Stereo-microscopic dissection is basic to FUT and is thus a skill that is second-nature to the staff of practices that regularly perform FUT procedures, so this critical step will not be hit or miss.

4. Practices that offer both procedures are usually more experienced

It is easier to learn and train one’s staff in just one hair transplant technique. In particular, FUE procedures require a smaller staff than FUT and, thus, many doctors entering the field of hair restoration surgery will perform FUE but not master the skill or make the commitment to hire and train the staff to perform FUT.

5. Better decision making

One could argue that if a doctor performed only one procedure but the patient needed the other, then he/she would refer the patient to a colleague. Although this sounds nice in theory, it is very rare for a doctor to refer a surgical case to a colleague if it is a condition that he actually treats. More likely, the doctor will convince the patient (and probably himself) that the procedure he offers is the appropriate one, although, as one can see from the discussion above, this may often not be the case.

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Hair Restoration Answers

Can Hair Transplant “Plugs” be Repaired by Lasers or Electrolysis?

Q: After an old hair transplant using plugs, can you use lasers or electrolysis to remove the transplanted hair? — N.C. ~ Newark, N.J.

A: You can remove the hair in plugs with electrolysis, but it is difficult since the scarring distorts the architecture of the hair shaft and makes it hard to insert the electrolysis needle. Laser hair removal is a far more efficient way of removing the hair but takes multiple treatments. However, the problem with either of these techniques is that the hair is destroyed and the underlying scarred scalp is not improved. In fact, it is made more visible when the hair has been removed.

Our preferred method of repair is to completely remove the plugs, dissect out the individual follicular units from those plugs and then re-implant them in the proper location and direction. In this way, the hair can be reused and the appearance of underlying scarred scalp can be improved, as well as camouflaged with new hair.

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Hair Restoration Answers

Does Frequent Combing Cause Hair Loss?

Q: Is it ill-advised to comb one’s hair more than twice a day, especially hair that has been transplanted? Will frequent combing induce hair loss? — G.K. ~ Paramus, N.J.

A: Combing or brushing one’s hair does not cause hair loss – no matter how many times a day you do it. However, constant traction with braids or hair extensions can cause hair loss and this loss can be permanent.

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Updated: 2017-08-14 | Published: 2009-07-02




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