Robotic Hair Transplants & Hair Restoration
110 East 55th Street, New York, NY
Contact Us: 212-826-2400
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

Is it Safe to Implant 6,000 Grafts in 2 Days Using FUE?

Q: Is it safe to implant 6,000 grafts in 2 days with an FUE procedure? — L.P. ~ Port Washington, N.Y.

A: A 6,000-graft procedure would be a very large hair transplant. Transplanting this many grafts at once would necessitate grafts being placed very close together. In this situation, the blood supply may not be adequate to support the growth of the newly transplanted grafts.

Another reason for concern is that when harvesting, FUE yields about 20 grafts/cm2. A 6,000-graft procedure would require 300 cm2. Since the donor area is about 30 cm long, this would require a donor height of 10 cm, clearly extending beyond the permanent zone of the scalp of most patients.

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Can Women That Are Breastfeeding Have A Hair Transplant?

Q: Can a woman who is breastfeeding have a hair transplant? — M.R. ~ Long Beach, N.Y.

A: Since surgical hair restoration is an elective procedure, I would wait until 1 year after delivery and once breastfeeding has completed before considering a hair transplant. Often after pregnancy, there is a post-partum shedding that occurs as the hormones fluctuate and then return back to their normal levels. This active period of shedding can cause a few issues. The first issue is that active shedding can make it difficult for the surgeon to determine where best to place the grafts for the optimal long-term cosmetic result. Additionally, medications may be used during and after the procedure that can potentially appear in breast milk.

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Hair Restoration Answers

What is your Opinion of the Companies that Advertise Hair Loss Solutions like Hims and Keeps?

Q: What is your opinion of the companies that advertise hair loss solutions like Hims and Keeps?

In searching the web and riding the subway I’ve seen many ads for a company called Hims that offers hair loss medicine and other medical solutions for men’s problems. What are the medications used for hair loss and how do they compare to Propecia and Rogaine? — V.T., Long Island, NY

A: Hims and Keeps are digital wellness companies that are geared toward men. They prescribe the same hair loss products that you can receive from a doctor or from online stores like Amazon, such as minoxidil, finasteride, biotin, salicylic acid shampoos and other topical and oral medications. The patents on the most commonly used prescription medications have expired within the last few years, opening the door for companies to distribute their own generic versions. The online system that Hims uses allows people to get prescriptions without seeing a doctor. Although this might be convenient, receiving an in-person evaluation from an experienced physician is important to ensure that you receive the proper treatment. Medical treatments for hair loss are most effective when started early. Therefore, making sure the diagnosis is correct and that the medications are optimized, will give you the best chance of re-growing your hair and preventing future thinning.

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Hair Restoration Answers

Can Rogaine Cause Miniaturization?

Q: Can Rogaine Cause Miniaturization?

When I am on Rogaine it seems – to my untrained eye – that I am having hair miniaturization and when I stopped briefly, I had shedding. Does this seem accurate based on what you have seen? Can Rogaine cause miniaturization? Is there a point you would recommend I stop Rogaine or is it something that likely can’t cause a negative impact on hair? — B.T., Brooklyn, NY

A: Minoxidil reverses miniaturization. It does not cause it. Shedding can occur after starting use of Rogaine but this means the medication is working should resolve with continued use. New miniaturized hairs are either from the progression of your genetic male pattern hair loss or newly forming hair that was stimulated by the minoxidil which can mimic miniaturized hair.

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In What Cases Do You Think Scalp Micro-Pigmentation (SMP) Is Most Useful?

Q: In what cases do you think Scalp Micro-Pigmentation (SMP) is most useful?

When do you think Scalp Micro-Pigmentation (SMP) — M.O., Greenwich, CT

A: Scalp Micro-Pigmentation (SMP) is used in patients who want to make their thinning hair look fuller and want to avoid the nuisance of daily application of cosmetic concealers, powders or fibers. It is for patients who want a permanent solution, but who do not want, or who are not candidates for hair transplant surgery. It can achieve a variety of looks such as a buzz cut by tattooing hundreds of microdots that appear like follicles or it can reduce the contrast between generalized dark hair that is thinning over a pale scalp. It can even give the appearance of hair over a scar that has now become noticeable.

Dr. Shaver performs all Scalp Micro-Pigmentation procedures at Bernstein Medical.

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How is Scalp Micro-Pigmentation (SMP) Performed?

Q: How is Scalp Micro-Pigmentation (SMP) Performed?

How is SMP done? — B.P., Long Island, NY

A: Scalp Micro-Pigmentation (SMP) is applied with tiny microneedles that mimics the appearance of hair in an area of the scalp that looks thin. It requires the use of local anesthesia and is performed in a doctor’s office. SMP is typically performed over a series of three or more sessions spaced at least 2-4 weeks apart. The length of each session varies depending on the area to be tattooed and can last from a few hours to a full day.

To perform successful SMP, the hair length and color must be analyzed in consultation along with a discussion of cosmetic goals and the potential techniques that could be implemented for the patient’s hair type. The procedure is performed under local anesthesia and is generally well tolerated with very few post-op limitations.

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What is Scalp Micro-Pigmentation (SMP)?

Q: What is Scalp Micro-Pigmentation (SMP)?

What is SMP? — M.O., Greenwich, CT

A: Scalp Micro-Pigmentation (SMP) is a medical-grade scalp tattoo. It is a form of permanent cosmetic camouflage that can mimic the appearance of hair in locations such as scars or balding areas. SMP gives the appearance of fullness of hair without actual hairs being present. Although permanent dyes are generally used, semi-permanent materials can be substituted that will purposely fade over time.

Dr. Shaver is our dedicated in-house physician for Scalp Micro-Pigmentation procedures.

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