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Robotic Hair Transplants & Hair Restoration
Flagship: 110 East 55th Street, New York, NY
212-826-2400 - [email protected]
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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 You Program the FUE Robot To Avoid Scars?

Q: I heard that for someone who has had several strip procedures, the ARTAS robot for FUE does not work because it is programmed to work with “textbook male pattern baldness”, which I no longer have. I thought the scars from previous procedures, as well as the large amount of already transplanted hair, might throw off the robot’s programming (it wouldn’t quite know what to do). But if I am wrong about this then the robot may in fact be the best approach for me. Please advise. — N.C., Paris, France

A: When performing robotic hair transplants on patients with prior surgery, I program the robot to avoid scarred areas – just as we would do visually when performing manual FUE.


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Hair Restoration Answers

Will I Need Multiple FUE Hair Transplants Over Time?

Q: I’ve noticed from the chatter on blogs, that it is not uncommon for men to go through multiple FUE procedures over 10+ year time-frame. It seems to be that after the initial FUE procedure to address moderate hair loss, the patient continues their natural balding to where they must undergo another FUE procedure in order to get back to their desired look. I’m almost 33 and while I take Propecia, my hair loss has been very gradual since I was about 26. I still have what many would consider a full head of hair, although very thin and with noticeable loss at my temples and crown. I’d always thought that a hair transplant would be a “1 and done” procedure, and now I’m concerned that if I do an FUE procedure now to replace what’s been already lost, I’ll just have to revisit a subsequent FUE down the line. Are ongoing FUEs simply part of the hair maintenance that a patient needs to accept about hair restoration process? — A.A., New Hyde Park, N.Y.

A: Your concerns are correct and would apply to any hair transplant procedure; FUT or FUE. That is why it is best not to begin hair restoration surgery too early.


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Hair Restoration Answers

Is Propecia Persistent Side Effects Study Reported in the Media Flawed?

Q: As a Propecia user, I was alarmed when I read headlines last year about a new study indicating very high rates of depression and erectile dysfunction caused by Propecia, with symptoms persisting even after the drug was stopped. However, when I read the articles, this “study” appeared to be survey of 61 men who had taken Propecia and already reported sexual problems who were then asked about symptoms of depression. These rates of depression were compared to a small survey of men who had hair loss but had never taken Propecia.

Anyone with a basic understanding of statistics would know such a survey was deeply flawed. First, it is a textbook example of a bad data sample — to get sound results you have to start with an unbiased and random group of people who took the drug, not a self-selected group of men already suffering symptoms. The study also confuses correlation with causation — because these men are suffering from ED or depression does not necessarily mean it was caused by the drug. Am I missing something here, or did the media just report these “findings” with no scrutiny on what was actually studied? — Jonathan, Brooklyn, NY

A: Jonathan, I think you’re right on the mark. The way the study was conducted raises a lot of concern about the accuracy of the findings. It is really important that additional data is obtained in a controlled way, as this will be most useful for physicians in advising patients. I addressed concern on these reports last year. The issue of persistent sexual dysfunction as a side-effect of finasteride (Post-Finasteride Syndrome) is an on-going issue that we take very seriously. I sit on the International Society of Hair Restoration Surgery (ISHRS) Task Force on Finasteride Adverse Events, so this is an issue that we watch very closely.


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Hair Restoration Answers

Why Recommend FUT Not FUE If I Have No Linear Scar?

Q: If I have no linear scar and I can exercise right away, why would you ever recommend FUT instead of FUE? — H.T., Dover, M.A.

A: I advise FUT because the grafts are of better quality (less transaction and more support tissue surrounding the follicle) and because more hair can be obtained from the mid-portion of the permanent zone –- which is where the hair is the best quality and most permanent. For the majority of patients a linear scar buried in the donor hair is not an issue. Each patient has to weigh the pros and cons of each procedure when making a decision.


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Hair Restoration Answers

Can I Switch To Rogaine 2% After Good Results With Rogaine 5%?

Q: After achieving results with 5% Minoxidil is it possible to the switch to the 2% version to maintain those results without any adverse hair loss? — I.I., Winnetka, Illinois

A: It will be less effective. The dosing should not be decreased.


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Hair Restoration Answers

Do You Recommend Azelaic Acid With Rogaine (Minoxidil) 2% Or 5%?

Q: Have you any experience with Azelaic Acid as a hair loss treatment — is this something you would recommend using with Rogaine (minoxidil) 2% or 5% solutions? — S.V., Short Hills, N.J.

A: Azeleic acid has no direct benefit in promoting hair growth. Azelaic acid (like retinoic acid) increases the absorption of minoxidil, but also the side effects, so I would especially not recommend it in your case.

Read more about Rogaine (minoxidil)


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Hair Restoration Answers

Will Side Effects of Minoxidil 5% Lotion Reduce Over Time?

Q: Is it possible that side effects attributed to the use of Minoxidil 5% lotion can reduce over time or disappear altogether? Specifically I experienced a heightened sense of heart activity (palpitations). — D.D., Bronxville, NY

A: Yes, the side effects may diminish over time.


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Hair Restoration Answers

Why FUT Hair Transplant For One Person, FUE For Another?

Q: A while ago I saw you and you recommended FUT hair transplantation, but my friend came in and you recommended FUE. How come? — C.T., Hackensack, N.J.

A: I think that both procedures are excellent, which is why I do them both. My recommendations are determined by the individual patient. His or her age, desire to wear hair cut very short, athletic activities, donor density and miniaturization, extent of hair loss, and potential future balding are all important aspects in the decision process.


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Hair Restoration Answers

After Hair Transplant, is Recovery Faster with FUT or FUE?

Q: Is the recovery time a lot longer with FUT compared to FUE? — C.W., Chicago, I.L.

A: Cosmetically, the recovery for FUT is actually shorter, since the back and sides do not need to be shaved and the longer hair can completely cover the donor incision immediately after the Follicular Unit Transplant procedure. In large Follicular Unit Extraction procedures, the entire back and sides of the scalp need to be clipped very close to the scalp. It can take up to 2 or 3 weeks for the hair to grow long enough to completely camouflage the harvested area. Once the healing is complete and any redness has subsided, the hair can be cut shorter.

For strenuous physical activity, however, the recovery is longer with FUT due to the linear incision. This is a major reason why professional athletes or very physically active people prefer FUE. However, many business professionals prefer FUT hair transplantation as there is significantly less down time from work (for the cosmetic reasons discussed above).


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Hair Restoration Answers

Does ARTAS FUE Robot Work with African-American (Very Curly) Hair?

Q: I am an African-American man with tight curly hair. Will the FUE robot be able to work on curly hair? — E.O., Manhattan, N.Y.

A: Yes, the ARTAS robot for FUE can be adapted for African-American hair when performing follicular unit extraction. We use a punch that is 0.1mm wider in diameter than the instrument used for Caucasians. It allows us to incorporate the slightly larger volume of tissue that results from the curved hair and enables us to accomplish the hair transplant with less in jury to follicles than if a smaller instrument were used.

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

Read about Robotic Hair Transplantation


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Hair Restoration Answers

Does the ARTAS FUE Robot Work with Dark Hair?

Q: I read your post that the ARTAS robot doesn’t work well in patients who want FUE but have blond hair. I have dark skin and hair, does that present a problem for the machine? — J.S., London, England, U.K.

A: The ARTAS Robot performs follicular unit extraction just as well with blond hair as dark hair, but not white hair. It is simple to just to dye the white donor hair prior to the hair transplant procedure. This donor hair will be clipped very short the morning of surgery removed anyway, so it will not present too much of a cosmetic issue.

See before & after hair transplant photos organized by hair character


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Hair Restoration Answers

What is Lichen planopilaris?

Q: What is Lichen planopilaris? — G.S., Pleasantville, NY

A: Lichen planopilaris (LPP) is a distinct variant of cicatricial (scarring) alopecia, a group of uncommon disorders which destroy the hair follicles and replace them with scar tissue. LPP is considered to have an autoimmune cause. In this condition, the body’s immune system attacks the hair follicles causing scarring and permanent hair loss. Clinically, LPP is characterized by the increased spacing of full thickness terminal hairs (due to follicular destruction) with associated redness around the follicles, scaling and areas of scarred scalp. In contrast, in androgenetic alopecia (AGA) or common baldness, one sees smaller, finer hairs (miniaturization) and non-inflamed, non-scarred scalp. Complicating the picture is that LPP and AGA can occur at the same time – particularly since the latter condition (common baldness) is so prevalent in the population (see photo). And LPP can involve the frontal area of the scalp, mimicking the pattern of common genetic hair loss. Interestingly, the condition is more common in women than in men.

For those considering a hair transplant, ruling out a diagnosis of LPP is particularly important as transplanted hair will often be rejected in patients with LPP. In common baldness, the disease resides in the follicles (i.e., a genetic sensitivity of the follicles to DHT). Since the donor hair follicles remain healthy, even when transplanted to a new location, we call common baldness donor dominant. It is the reason why hair transplantation works in persons with common baldness. In contrast, LPP is a recipient dominant condition. This means that the problem is in the recipient area skin, so if healthy hair is transplanted into an area affected by LPP the hair may be lost.

Because it is so important to rule out suspected LPP when considering a hair transplant and because it is often hard to make a definitive diagnosis on the physical exam alone, a scalp biopsy is often recommended when the diagnosis of LPP is being considered by your doctor. A scalp biopsy is a simple five minute office procedure, performed under local anesthesia. Generally one suture is used for the biopsy site and it heals with a barely detectable mark. It takes about a week to get the results. The biopsy can usually give the doctor a definitive answer on the presence or absence of LPP and guide further therapy. If the biopsy is negative, a hair transplant may be considered. If the biopsy shows lichen planopilaris, then medical therapy would be indicated.


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Hair Restoration Answers

What is the Origin of the Term DUPA?

Q: What is the Origin of the Term DUPA? — Z.Z., Darien, CT

A: The terms DPA and DUPA were first described by O’tar Norwood in his seminal 1975 publication: Male Pattern Baldness: Classification and Incidence.1 In the paper, Dr. Norwood defined the two terms as:

Diffuse, Unpatterned Alopecia (DUPA). In this type there is a general decrease in the density of hair without any definite pattern, although it is usually more marked over the top and front. This type is common in women.

Diffuse, Patterned Alopecia (DPA). The patterns in this type of hair loss are essentially the same as in more common male pattern baldness, but the areas involved do not become totally bald; the hair only decreases in density. This also occurs in women.

Dr. Norwood’s realization that all hair loss did NOT follow his own Norwood patterns was a great insight, as well as his observation that DUPA was a common pattern in women and uncommon in men. The terms went relatively unnoticed and were not seen again in the medical literature until Drs. Bernstein and Rassman wrote about them again when they were developing Follicular Unit Transplantation.2 The importance of identifying these conditions is that that DUPA (either in men or women) is a relative contra-indication for hair transplantation and, with densitometry, can be readily detected in individuals at a relatively young age. Patients with DPA can be transplanted as if they were early Norwood Class 6’s.

  1. Norwood OT. Male pattern baldness: classification and incidence. So. Med. J 1975;68:1359-1365. Download []
  2. Bernstein RM, Rassman WR: Follicular Transplantation: Patient Evaluation and Surgical Planning. Dermatol Surg 1997; 23: 771-84. Download []

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Hair Restoration Answers

How Long Are FUT and FUE Hair Transplants Visible After Procedure?

Q: How long are FUT and FUE visible after the procedures? — S.V., Weston, C.T.

A: The recipient area is visible after both procedures for up to 10 days. The donor area in FUT is generally not visible immediately after the procedure. In FUE, the donor area must be shaved, so that will be visible for up to two weeks (the time it takes for the hair to grow in).


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Hair Restoration Answers

What is Latest Information on Persistent Side Effects from Finasteride?

Q: I have heard that side effects from finasteride can persist even after stopping the medication. What is the most current information on this issue? — S.V., Short Hills, N.J.

A: For the past two years I have been on the International Society for Hair Restoration Surgery (ISHRS) Task Force on Finasteride Adverse Events and struggling to make sense of this issue. There seems to be a disconnect between the relatively low incidence of side effects that we, as physicians, see in our practices, what published controlled studies have shown, and what is now being reported on the internet and in some instances in the media. For example, a 2012 study by Sato of 3,177 Japanese men published the Journal of Dermatology, showed a 0.7% incidence of adverse reactions to finasteride 1mg and no persistent side effects after stopping the medication.

That said, there has been a recent increase in anecdotal reports of side effects from finasteride as well as reports of persistent side effects after the medication has been discontinued (referred to as “Post-finasteride Syndrome”).

The FDA

Based on post-marketing reports of sexual dysfunction, in April 2012, the FDA announced changes to Propecia (finasteride 1 mg) labeling to expand the list of sexual adverse events and that some of these events had been reported to continue after the drug is no longer being used. It is important to note that no new clinical studies were reviewed to evaluate these adverse events and that the FDA is not aware of any additional controlled clinical studies conducted to evaluate these adverse events or to determine their cause or duration. (see FDA Label Changes for Finasteride 2012)

The FDA states that despite the fact that clear causal links between finasteride (Propecia and Proscar) and sexual adverse events have NOT been established, the cases suggest a broader range of adverse effects than previously reported in patients taking these drugs. The FDA states that it believes that finasteride remains a safe and effective drug for its approved indications, but also advises that healthcare professionals and patients should consider this new label information when deciding the best treatment option.

The difficulty with interpreting anecdotal information is significant. The following need to be considered; first, sexual dysfunction, both temporary and persistent, is quite common in the general population and patients may have new-onset sexual dysfunction from some other, unrelated, cause and second, patients may have real (physiologic) side effects from the medication and then have psychological after effects. It is so difficult to sort these factors out.

The ISHRS

The Finasteride Symposium at the 2012 ISHRS, of which I was a panelist, explored safety issues with finasteride. Dr. Akio Sato presented his data (quoted above) suggesting that finasteride side effects are uncommon and that persistent side effects were not seen. Dr. Freedland, a urologist and featured guest speaker at the ISHRS symposium, questioned whether long-term effects of a slight elevation in estrogen levels could have adverse effects on the prostate. The panel discussed the paper of Dr. Michael Irwig at George Washington University that appeared in The Journal of Sexual Medicine this year. In his survey of 54 patients of men who had persistent sexual side effects three or more months after the discontinuation of finasteride, he reported that sexual dysfunction continued for many months or years in the majority of the patients.

Difficulties in interpreting this study are that it assumed that the patient’s sexual dysfunction were caused by finasteride when, in fact, there is no way of knowing that finasteride was the actual cause of the side effects (this would need a blinded, placebo-controlled study). A second reason that makes interpretation difficult is that, because there was selection bias in the Irwig survey, there is no way of knowing if these patients are representative of the population of men on finasteride. That said, the data presented by Dr. Irwig stresses the importance of having more clarity on the potential side effects of finasteride, since it is so widely prescribed.

It was clear from the presentations and questions asked, that many issues are still unresolved. All in attendance agreed that further research is urgently needed. In the short term, it is most important that all patients who are having problems can have easy access to doctors with expertise in this area, so that they can be diagnosed properly and treated.


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


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