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Robotic Hair Transplants & Hair Restoration
Flagship: 110 East 55th Street, New York, NY
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Dr. Bernstein answers frequently asked questions about hair transplantation, hair loss, and medical treatment for hair loss.

Hair Restoration Answers

What is a "Bar Code Hair Style"?

Q: I was at a party the other day and some women were talking about their boyfriend’s hair. I heard one refer to her ex-boyfriend as having a “bar code.” What is that? — B.A., New Albany, Ohio

A: A “bar code” is slang term used in Japan for a comb over.


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Why Should Hair Transplant Doctor Measure Miniaturization in Donor Area Before Transplant?

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).


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Hair Restoration Answers

What are Obstacles to Hair Cloning Techniques?

Q: What are the major obstacles for scientists to cloning hair?

A: The main problem is that the cultured cells may lose their phenotype with multiple passages, i.e. lose their ability to differentiate into hair follicles after they have been multiplied.

Another problem of hair cloning is that the orientation of hair direction must be controlled. With mouse experiments, the hairs grow at all different directions. Scientists need to find a way to align the hair so that it grows in the right direction. Hair, of course, must also be of a quality that is cosmetically acceptable and matches the patient existing hair. And the hair should grow in follicular units. Individual hairs will not give the fullness or natural look of follicular units.

Another problem is the issue of safety. Are we sure that cultured cells may not turn into something else – such as malignancy cells with uncontrolled growth?

Finally, FDA approval would be required and this takes time. It is true that you do not need FDA approval for using your own hair, such as a hair transplant; however, when you take cells from the body and manipulate it in the lab, this requires FDA approval.


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Hair Restoration Answers

How Are Hair Cloning, Hair Multiplication, and Follicular Neogeneis Different?

Q: What is the difference between hair cloning, hair multiplication, and follicular neogeneis? I have read about these terms on the internet and am completely confused.

A: Cloning generally refers to the multiplication of fetal stem cells or embryonic tissues. “Hair cloning”, as the term is generally used, involves the multiplication of adult tissue cells that are used to induce the formation of new hair, so the term is not exactly accurate.

“Hair multiplication” refers to the multiplication of adult hair structures. This model is not actively being pursued since the hair follicle is too complex to be simply cultured in a tube. Instead individual cells called fibroblasts are removed from the scalp multiplied in tissue culture and then these are injected back into the scalp in the hope that they will induce intact follicles to form.

“Follicular neogeneis” is probably the best of these terms, as it describes the formation of new follicles derived from inducer cells that are cultured and then injected into the scalp. It is the preferred term of Ken Washenik at Aderans. Interctyex uses the term “follicular cell regeneration” for its technology.


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Hair Restoration Answers

What is Difference in Hair Cloning Techniques Studied by Aderans and Intercytex?

Q: I know that both Aderans and Intercytex are doing research with cloning hair. Is there any difference in their approaches?

A: Aderans is using the “two-cell” approach. They feel that the best way to produce viable hair follicles is to use a combination of inducer cells and responder cells. Each would be multiplied separately and then injected together into the skin. The inducer cells are follicular fibroblasts and lie at the base of the hair follicle. The responder cells are keratinocytes. They feel that the combination of cells will have the best chance of producing clinically useful hair.

Intercytex prefers a one-cell approach. Their researchers feel that when the cultured inducer fibroblasts are injected into the skin there will be enough existing cells in the skin to produce a cosmetically viable hair. In their experimentation, Intercytex uses a new animal model, termed the “flap graft” model, that involves the implantation of cultured dermal papilla cells with keratinocytes placed under a flap on the back of hairless mice. Later the flap is exteriorized (turned over), allowing the hair to grow normally. Exactly how this will be applied to clinical use in humans is not clear.

A completely different view is held Dr. Ralf Paus at the University of Luebeck in Germany. He feels that there are already enough stem cells in the bald scalp and that the key to hair re-growth is to target key elements in the hair cycle. He feels that topically applied inhibitors of catagen (the resting phase of the hair cycle), exogen (the formation of an empty hair follicle), or inhibitors of the terminal-to-vellus transformation (the process of a hair shrinking in size under the influence of DHT and referred to as miniaturization) will the most effective way to go.

Finasteride and dutasteride are drugs that work in this way, but are clearly not very effective in stimulating new growth. He also feels that an anagen inducer, along the lines of a minoxidil-type medication has a better chance of success then the stem cell targeting strategies described above. In these cases one would, in a sense, rejuvenate dormant hair follicles rather than induce new ones to grow.

Read about Hair Cloning Methods


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Hair Restoration Answers

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

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? — C.C., Hell’s Kitchen, N.Y.

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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Hair Restoration Answers

Instead of Hair Transplant, Can You Treat Early Hair Loss with Once a Day Minoxidil?

Q: I have some early thinning in my crown and the doctor said I am too early for a hair transplant. I don’t want to take Propecia, but using Rogaine twice a day is a big nuisance. Can I use Rogaine once a day? — L.B., Cleveland, Ohio

A: The tissue half-life of minoxidil is 22 hours.

This means that 22 hours after it is applied, about 1/2 of the compound is still bound to the skin and exerting some effect. Because of this, once a day dosing is probably OK.

Please note that this is hypothetical and that there have been no controlled studies to confirm this.


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Hair Restoration Answers

Can Hair Transplant Thicken Thinning Hair in Person with Early Hair Loss?

Q: I am 22 and losing my hair all across the top of my head. How can I thicken my hair to its level a few years previously? — I.L., Kentfield, CA

A: If medication, such as finasteride, is successful it can thicken hair by increasing the diameter of the existing hair shafts. Although the cosmetic benefits can be dramatic in a person with significant hair loss, a hair transplant can not restore hair to its original density, since it only moves the existing hair around and does create new hair.

When hair cloning technology is available, this will change as a person’s donor supply will be increased.


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Can Hair Transplant Treat Diffuse Hair Loss in Women?

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.


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After Hair Transplant, What Happens if Transplanted Area is Injured?

Q: I am a patient of yours who had a hair transplantation procedure done mostly in the crown area and in the front about seven months ago. The hair is just starting to come in nicely and is starting to fill in the bald spots. Yesterday I carelessly banged the top of my head against a beam in my attic and cut a nice gash in, you guessed it, a transplanted area. I’d say that the cut is about a good inch. My wife works for a doctor who is certified in facial plastic surgery and I had him suture up the gash. He did not cut any hair, but it took 4 stitches to close the wound. I’m worried about the impact on the transplanted area. Just when it was starting to come in nice I now have a bald spot that I suspect is going to stay as a result of the accident. Please advise. — V.F., Fort Lee, N.J.

A: There is not much you can do at this time. Depending upon the doctor’s suturing techniques; you may or may not have permanent hair loss from the trauma and subsequent suturing. The problem is that if the sutures are placed too far from the wound edge they can strangulate hair follicles, particularly if there is any swelling. Hair loss may be temporary, but if it is permanent, it should be minimal. Additional grafts can be added at your next hair restoration procedure to cover any area of hair loss and the scar from the injury, if it is visible.


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After a Hair Transplant, What is Post-op Wound Dressing and How Soon Can I Shower?

Q I had a friend that had to wear a turban-like bandage on his head for a week after his hair transplant, but his procedure was a number of years ago. What is the post-op dressing like now and how soon can you shower after a hair transplant procedure? — E.B., White Plains, N.Y.

A: Patients leave the office after the surgical hair restoration wearing only a tennis band wrap and a surgeon’s cap (that can be worn under a baseball cap).

The morning following the hair transplantation, the dressing can be removed and no further dressings or bandages need to be used.

The day following hair transplant surgery I suggest patients to take 3 or 4 showers to remove the crusting as it forms. The crusts are removed by gently shampooing with a copper-peptide based product. After the 1st day following the procedure, the crusts no longer form and showering/shampooing can be decreased to twice a day; morning and night.

After the first week, showering once a day is fine.


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How Do You Treat Diffuse Hair Loss in Donor Area?

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.


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Can You Perform Hair Transplant with Curly Hair?

Q: I have curly hair with thinning on top and strong, but less curly hair on the sides and back. My hairline is receding, but it is really the area on top I am concerned about. Does hair replacement work with curly hair and will it match? — E.B., Sanibel, F.L.

A: Yes, curly hair grows as well after a hair transplant surgery as straight hair.

After the hair restoration, the transplanted hair will take on the characteristics of the hair that was originally in the area, so it will match perfectly with respect to curl and wave.

See before and after hair transplant photos of patients with curly hair


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Can Hair Transplant Treat Chronic Telogen Effluvium?

Q: I am a 36 year old female who has been diagnosed with Chronic Telogen Effluvium. Although I do not have any bald spots yet my hair is much thinner on both of my temples as well as in the back of my head. Is a hair transplant an option for me or am I just going to shed the new hair as I am shedding my current hair? — R.K., Providence, R.I.

A: Since Chronic Telogen Effluvium is a generalized condition, it is not amenable to correction by a hair transplant. The reason is that there is no stable area to take donor hair from. Chronic TE is generally self-limited, so try to be patient.


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Which Contributes More to Hair Loss: Stress or Genetics? [Updated]

Q: Can stress accelerate hair loss? I am 25 and there is balding on my dad’s side of the family. I never had any thinning or hair loss till this year. I guess you can say I’ve been under a lot of stress. When I did notice shortly after my 25th birthday I started stressing even more, which led to more hair loss. It is thinner up front and it is thin on top. I have heard of some hair docs mapping your head for miniaturization, do you do this too? — E.W., Miami, FL

A: Yes. The presence of miniaturization (decreased hair diameter) in the areas of thinning allows us to distinguish between hair loss due to heredity (i.e. androgenetic alopecia) — in which hair progressively decreases in diameter under the influence of DHT — and other causes. The degree of miniaturization can be assessed using a hand-held instrument called a densitometer.

The pattern of hair loss and the family history are also important in the diagnosis.

Stress more commonly produces telogen effluvium, a generalized shedding that is not associated with miniaturization and is often reversible without treatment.


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Updated: 2019-11-15 | Published: 2009-07-02


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