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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

Can a Hair Transplant Grow Hair Over a Scar From an Injury?

Q: I have a scar on the top of my head the size of a quarter from an old injury. I would like hair to grow back on the bald spot. Can a hair transplant re-grow hair on the spot and not have any scar on my head at all? – E.D., Oceanside, N.Y.

A: Traumatic scars are readily treated with follicular unit hair transplantation. The hair generally grows quite well in scar tissue as long as the scar is not thickened (hypertrophic). Several sessions are usually required. Although the hair restoration can make the bald area undetectable, the underlying scar tissue will still be there.


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Hair Restoration Answers

What is "Shock Fall Out" After a Hair Transplant?

Q: What is “shock fall out”? – D.B., Chappaqua, N.Y.

A: Shedding after a hair transplant is also referred to by the very ominous sounding term “shock fall out.” The correct medical term is “effluvium” which literally means shedding. It is usually the miniaturized hair (i.e. the hair that is at the end of its lifespan due to genetic balding) that is most likely to be shed. Less likely, some healthy hair will be shed, but this should re-grow.

Interestingly, if transplants are spaced less than one year apart, one often notices some shedding of the hair from the first transplant, but this hair grows back completely. For most patients, effluvium is not a major issue and should not be a cause for concern.

Typically, when shedding occurs, a patient looks a little thinner during the several month period following the transplant, before the transplanted hair has started to grow. The thinning is often more noticeable to the patient than to others. Shedding is generally noted as a thinning, rather than of “masses of hair falling out,” as the term “shock fall out” erroneously suggests.

In general, the more miniaturization one has and the more rapid the hair loss, the more likely shedding will be from the hair restoration surgery. Young, actively balding patients would be at the greatest risk. Older patients with stable hair loss would have the least risk. In either situation, since miniaturized hair is eventually going to be lost, the effluvium has no long-term effect on the outcome of the procedure.

It is important to differentiate the phenomena described above from shedding of the hair in the graft. This shedding is an almost universal characteristic of a hair transplant and occurs because during a hair transplant a graft is temporarily stripped of its blood supply. As a response to this insult, the graft sheds its hair. This shedding is generally noted beginning a week following the procedure and can continue for up to six weeks. A very small percentage of patients do not shed and the transplanted hair continues to grow. In others, the transplanted hair remains on the scalp for months until a new hair pushes it out. Whether a patient sheds or not has no bearing on the outcome of the hair restoration.

There are a number of ways to minimize the effects of post-operative shedding: the first is using medication, the second is timing the transplant properly, and the third is performing a procedure using a sufficient number of grafts.

• Medication

Finasteride 1mg reverses or halts the miniaturization process in many individuals and is thus the logical way to decrease the risk of shedding following a transplant. Although many physicians have had the clinical impression that this assumption is correct, there has been no controlled studies to date that prove this.

• Timing and the size of the transplant

It is important to wait until a patient is ready to have a transplant, and then to perform one of sufficient size so that if there is some shedding, the procedure will more than compensate for it – and thus be worthwhile. A problem that patients often run into is that they present to their doctor with early hair loss but with a significant amount of miniaturization. The doctor performs a small procedure and it does not even compensate either for potential shedding or for progression of the hair loss. The result is that the patient is thinner (or more bald) than he was before the procedure. The doctor rarely blames the problem on the fact that the procedure was too small or that the miniaturization was not taken into account, but only that the patient continued to bald. The better solution is to treat early hair loss with medication, but once you make a decision to begin surgery, have a procedure large enough to make a significant cosmetic improvement.

• Performing the procedure using a sufficient number of grafts

As a final point, it is a fallacy that some doctors’ techniques are so impeccable that they can avoid effluvium or those “small” procedures will avoid shedding. Of course, bad techniques and rough handling will maximize effluvium, but effluvium is what hair naturally does when the scalp is stressed and it is stressed during a transplant from the anesthetic mixture and the recipient site creation. It is important to note that it cannot be totally prevented. Despite claims to the contrary, Follicular Unit Extraction has no bearing on this process as it is a harvesting rather than a placing technique.

In sum, the best way to deal with effluvium is:

  • Treat with Finasteride — the active chemical in the hair loss drug Propecia — when hair loss is early
  • Perform a hair transplant only when indicated
  • Perform a hair transplant with skill and using a sufficient number of grafts

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Hair Restoration Answers

How Much Hair Can be Removed From the Donor Area?

Q: When harvesting donor hair, how does the surgeon know when to stop? – D.D., Pleasantville, N.Y.

A: The patient must first decide the shortest length he/she is comfortable wearing his/her hair.

Donor hair can be removed — whether through Follicular Unit Transplantation (FUT) or Follicular Unit Extraction (FUE) — as long as, at this length, the back and sides do not look too thin (i.e. do not have a transparent look) and the donor scars are not visible. The surgeon needs to use his judgment when harvesting, so that this endpoint is not crossed.

Additionally, the surgeon must anticipate that the caliber of hair in the donor area will decrease slightly over time as a normal course of events. The actual number of grafts that can be harvested varies greatly from person to person. It depends on the patient’s donor density, scalp laxity, hair characteristics and size of the donor area.


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Hair Restoration Answers

Can a Hair Transplant Correct Balding from Discoid Lupus Erythematosus (DLE)?

Q: I have a bald patch on my scalp diagnosed as DLE, can this be corrected with a hair transplant? – V.Q., Scarsdale, N.Y.

A: DLE or discoid lupus erythematosus is a type of autoimmune disease where the body produces an inflammatory reaction to components of the skin, causing it to scar and lose hair.

The skin in the area of hair loss generally has a smooth appearance with tiny empty hair follicles, redness, and altered pigmentation. These skin changes help to differentiate it from the more common condition alopecia areata where the underlying skin appears normal.

The diagnosis of DLE can be confirmed by biopsy. Because DLE may exhibit a property called Koebnerization, where direct trauma can make the lesions enlarge, surgical hair restoration risks making the condition worse and is, therefore, not indicated.


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Hair Restoration Answers

Does Hair Grow More Slowly After a Second or After a First Hair Transplant?

Q: This is my second hair transplant and is seems like it is growing more slowly than my first. Is this normal? – J.D., Port Washington, N.Y.

A: It is common for a second hair transplant to take a bit longer to grow than the first, so this should be expected. It is also possible that there is some shedding from the procedure, or a continuation of your genetic hair loss.

Propecia may be helpful in this regard. It is important to wait at least a year for the transplant to grow in fully and to give a chance for any hair that was shed to regrow.


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Hair Restoration Answers

What is Graft Compression After a Hair Transplant and Why Does it Occur?

Q: What is graft compression? — E.Z. Wayne, N.J.

A: Graft compression refers to a tufted look resulting from the contraction of grafts caused by the normally elastic skin that contracts around the graft as the hair transplant heals. This was a common occurrence with mini-micrografting where 5 or more hairs from two or more follicular units were placed into one recipient site.

With follicular unit hair transplantation, follicular units won’t show visible compression since they are already naturally compact.

One reason why FU’s are valuable in a transplant is that they are compact enough to fit into a very small site. It is important, however to “customize” the site size to the size of the graft so the fit is just perfect. This speeds up healing, enables the patient to shampoo the day after surgery, and enhances graft growth.


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Hair Restoration Answers

How Many Grafts are in the Typical Donor Strip in an FUT Hair Transplant?

Q: If I had a hair transplant using Follicular Unit Transplantation, how many grafts would be in a 15cm by 1cm donor strip, on average? — J.A. Point Pleasant, N.J.

A: In a person with average donor density there are approximately 100 follicular units per square centimeter. A 15cm long strip would have slightly less than 1500 grafts due to the tapering of the strip ends.

Therefore, in a hair transplant of 1500 follicular unit grafts, one should take out a 17 cm x 1cm strip (that includes the tapered ends). This is 15cm2.

Read about the number of grafts in a hair transplant


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Hair Restoration Answers

Does an FUE Hair Transplant Leave a Scar?

Q: Can you shave your scalp after a hair transplant with FUE without noticing scarring in the donor area? — A.A. Bronxville, N.Y.

A: Although there is no line scar in follicular unit extraction, there are tiny round ones. You can clip your hair very short after FUE, however, shaving your head will make the very fine white scarring visible.


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Hair Restoration Answers

There is a Lump Beneath My Donor Area After My Hair Transplant. What Is It?

Q: I have developed a rather large, hard lump beneath the skin at the base of my scalp in the donor area that I first noticed this about two or three weeks after my hair transplant. What is this? — A.R. Bronx, N.Y.

A: You are describing an enlarged lymph node, a condition commonly seen as a normal part of the post-op course following hair transplants.

This is a normal part of healing in response to the surgery. It will resolve on its own in about 3-6 months. It doesn’t require any treatment and it should not be a cause for concern.


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Hair Restoration Answers

Hair Transplant for Thinning Hair on a Crown?

Q: Should you perform a hair transplant on a crown that is just starting to thin? — R.R. Philadelphia, Pennsylvania

A: A “thin” crown should first be treated with Propecia, as it may thicken the hair to a cosmetically acceptable degree without the need for surgery. If Propecia is ineffective in restoring enough hair, then surgical hair restoration can be considered.

The surgeon must also factor whether or not the patient has enough donor reserves to transplant the front and top part of the scalp if the patient becomes very bald. This is hard to predict in patients who are still in their twenties.

See the paper Follicular Transplantation: Patient Evaluation and Surgical Planning for a more complete discussion.


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Hair Restoration Answers

How Long After Hair Transplant Can Grafts Fall Out?

Q: How do you know if you have lost any grafts after a hair transplant and how long after the hair transplant can you still lose them? — T.R. Easton, Pennsylvania

A: Each day following the hair restoration, the transplanted grafts become more fixed in the scalp and the hairs in the grafts become more dissociated (loose). At nine days post-op, the grafts are fixed firmly in the scalp – it has essentially become part of the scalp in the new area and can’t be dislodged.

The hair, however, has totally separated from the follicle by this time, so that it can easily be pulled out without dislodging the remainder of the follicle that contains the growth center. When this hair is pulled out (or is naturally shed) one often sees a tiny bulb at the end. This is the root sheath of the hair and not the growth center. This is normal and is not a lost graft.

If a graft is lost, an event that may occur within the first 3-4 days following surgery, it is almost invariably associated with a small amount of bleeding.

Visit the page for Instructions After FUT Hair Transplant Surgery


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Hair Restoration Answers

In an FUT Hair Transplant, What Percentage of Telogen Phase Follicles in Donor Strip are Wasted?

Q: When a donor strip is taken out during a hair transplant and separated under the microscope, you can read on the internet that there is a wastage of grafts (about 15%), because of those unseen telogen hairs. What do you think about that and how does it affect the hair restoration? — T.B. Baldwin, New York

A: The Telogen phase of the hair cycle is about 3 months long and about 12% of follicles are in this phase at any one time. It is speculated that the follicles may be empty for perhaps 1/2 that time (this number may vary significantly between people). Therefore, approximately 6% of the hair follicles may be in telogen at any one time.

On average about 15% of the follicular units are 1-hair units (but this also may very greatly between patients). If 6% of all follicles are “empty” telogen follicles, then there should be .15 x .06 = .009 or about 1% of the patient’s 1-hair follicular units in the empty telogen phase that can’t be identified and will be missed on dissection.

The 1% isn’t very large. However, also consider that the remaining 5% of the empty follicles are associated with larger follicular units (i.e. those with 2-4 hairs). If these follicular unit grafts are closely trimmed, as is the practice with very dense packing, a much more significant number of follicles are at risk of being lost. With chubby follicular unit grafts (i.e., where the microscopic dissection leaves a protective sheath of tissue around the follicles) the risk should be closer to the 1%.

The lesson for hair transplantation is that over-trimming of grafts, for the sake of very dense packing, may waste telogen hairs as well as place the grafts at an unnecessary risk of mechanical trauma, drying and warming.


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Hair Restoration Answers

Can a Hair Transplant Restore Original Hair Fullness?

Q: Can you get your original density back with a hair transplant? — C.C. Scarsdale, New York

A: Although the cosmetic benefit can be dramatic, a hair transplant only “moves” rather than creates new hair. In surgical hair restoration, a limited amount of hair from the donor area is transplanted to a much larger area in the front and top of the scalp, so that we can never reach the original density.

Achieving a cosmetically appropriate density in the front part of the scalp (which is around 1/3 to 1/2 of the original) generally takes two sessions and is the goal of most hair restoration surgery. Lower densities are used towards the back of the scalp.

View before and after hair transplant photos of some of our patients.


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Hair Restoration Answers

How Do You Recommend Treating Early Hair Loss?

Q: I am 27 years old and have a Class 3 degree of hair loss. Should I do a hair transplant or consider non-surgical methods of hair restoration? — Y.B., Lake Forest Illinois

A: At age 27 with early hair loss, you should consider non-surgical options first.

Propecia is the most important medication, but you need to be on it for one year at the full dose of 1mg a day to assess its benefits.

If you have done this and other parameters are OK for a hair transplant, such as adequate donor hair density and scalp laxity and you have little evidence that you will become extensively bald (i.e. no donor miniaturization and no family history of extensive baldness), then hair transplantation can be considered.


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Hair Restoration Answers

After FUT Hair Transplant Surgery, Can I Travel on an Airplane with Surgical Staples?

Q: I’ll be traveling from New York to Cincinnati the week after my hair transplant. Will I be able to get through airport security if I have staples? — D.B. Fort Lauderdale, Florida

A: Yes. Although the staples that we use to close the donor area after hair transplant or restoration procedures are made of stainless steel, they are too small to be picked up by metal detectors.

I generally prefer staples, as they are superior to sutures in preserving donor hair.


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


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