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Robotic Hair Transplants & Hair Restoration
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Dr. Bernstein answers frequently asked questions about hair transplantation, hair loss, and medical treatment for hair loss.

Hair Restoration Answers

Does Propecia (Finasteride) Work Long-Term?

Q: I have been taking finasteride for several years and I seem to be doing well. Does finasteride generally work long-term? — A.C., West University Place, Texas

A: With regard to efficacy, a recent long-term, uncontrolled study by Rossi et al. reported that the beneficial effects of finasteride on hair growth continued as time goes on and that a significant proportion of patients, unchanged after 1 year, improved later on. In addition these patients maintained a positive trend over time -– up to ten years. When comparing different age groups, they found that subjects older than 30 years showed a better hair growth in the long term than those who were younger. Of the 113 patients in the study followed for 10 years, only 14% worsened, whereas the remaining 86% had benefits.

Read more details about the Rossi study


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Hair Restoration Answers

Are Reports of Persistent Side Effects With Finasteride Real?

Q: Dr. Bernstein, I am an attending at Mass General Hospital in Boston and would like to ask you regarding your experiences using finasteride for male androgenetic alopecia. While I have not noticed any side effects in the patients that I have been treating, I increasingly get questions regarding side effects based on the recent media attention to reports of potentially permanent problems regarding libido or erectile dysfunction. I know that in the literature there is a slight increase of reversible sexual dysfunction (~4% vs. ~2% in placebo) with Propecia, and no convincing evidence to date in the medical literature that have used controlled studies regarding permanent problems even after discontinuing Propecia. — S.Z., Boston, Massachusetts

A: That is correct.

Q: I know that you have treated many patients over a long period of time, and I was thus wondering what your take is on potentially permanent sexual dysfunction after taking finasteride. Have you seen any convincing reports/patients or do you have any concerns regarding irreversible side effects?

A: I have seen 5 cases in over 10,000 patients on finasteride that complained of this but, of course, there is no way to know for sure if there is a cause and effect relationship. As you know, real side effects may be followed by psychological ones and if the sexual dysfunction has another cause, then stopping finasteride would have no effect on the symptoms. The incidence of intermittent or persistent sexual dysfunction in the general population of men is about 30%, so one would expect these numbers to be much higher just due to the normal incidence. It is really a difficult situation to understand. The experience that my colleagues and I have in our practices is much different than one would expect after reading the numerous anecdotal reports on the internet.

Q: Would you think it is safe to say that any potential sexual dysfunction is reversible after discontinuing the use of finasteride?

A: I don’t think that anyone knows at this point. The FDA is coming down on the side of caution and saying that it is possible, although it is not based on any new studies. If the phenomenon is real, the possible mechanism is not yet known.

Q: In the relatively few patients that I have treated with Propecia, they did not even report temporary problems regarding libido or erectile dysfunction. Do you think they are real or rather attributed to Propecia simply because the patient is made aware of these potential side effects?

A: I think that psychological effects may account for many cases. At this time, it is still not clear if a physiologic “post-finasteride syndrome” is real. A lot more work needs to be done before we have a definitive answer to this question.


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Hair Restoration Answers

If There is Some Bleeding at the Graft Site, Will it Affect Growth?

Q: I am currently 8 days post op. I started to massage my hair in the shower to get rid of the scabs. When I was done I looked in the mirror and saw two of my transplanted hairs were slightly bleeding but still intact. What does that mean? Did I lose the grafts? — B.G., Stamford, C.T.

A: If they bleed, but were not dislodged (i.e. did not come out), they should grow fine. Just be gentle for the next week. Generally, when follicular unit transplantation is performed with tiny sites (19-21 gauge needles) the grafts are permanent at 10 days. Since I did not perform your procedure and am not familiar with the technique your doctor actually used, I would give it the extra few days.


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Hair Restoration Answers

Should I Start Hair Loss Treatment With Finasteride or Dutasteride?

Q: I recently visited my dermatologist regarding my hair loss, and after checking my hair he said I am showing signs of Androgenetic Alopecia (common baldness), and said if I don’t treat it, it will progress. From my research on the net, I figured he will put me on Propecia. In fact he put me on Avodart. When I told him it is not FDA-approved for hair loss, and Propecia is, he said Avodart is better and brings DHT down more, and Propecia is nothing next to Avodart. He told me to take it every day for 2 weeks, then every other day from then on as it has a long half life. From researching on the net, many hair restoration doctors rarely prescribe Avodart for hair loss due to some dangers. What is your opinion on this? — T.G., Darien, Connecticut

A: Although dutasteride (Avodart) can be more effective for male pattern hair loss, I would start with finasteride (Propecia) as many patients do great with it and the safety profile is better. The following are things I would consider before starting dutasteride:

  1. As you point out, dutasteride is not FDA-approved for hair loss.
  2. There is no data on its safety when used for hair loss. This is important since dutasteride has been only tested on an older population of patients (with prostate disease) rather than a younger population of patients needing medical treatment for androgenetic alopecia.
  3. These is no natural model for dutasteride’s combined blockage of both type 1 and 2 5-alpha reductase (finasteride blocks only type 2 5-AR and there are families that have this deficiency and have no long-term problems. This, by the way, is how the drug was discovered).
  4. The type 1 enzyme which dutasteride blocks is present in many more tissues of the body (including the brain) compared to type 2 (which is more localized to the skin).
  5. Although so far unproven, there is a concern that finasteride may produce side effects than can be persistent after stopping the medication (post-finasteride syndrome). It this does turn out to be true, the effects from dutasteride would most likely be significantly more persistent.
  6. If you start with finasteride and do have side effects, you will most surely have side effects from dutasteride; therefore, by taking finasteride first you will have avoided the potentially more problematic side effects from dutasteride
  7. You may respond well to finasteride, and so do not need to consider dutasteride

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Hair Restoration Answers

Can Pulling Out Transplanted Hair Effect Growth After Hair Transplant?

Q: At about six days post op, I started to notice hairs on the tips of my fingers as I rubbed off my scabs. Additionally, if I tugged on the hairs lightly, they would immediately come out without any resistance. I did notice the small bulb at the end of the hair. My question is: is it not recommended to remove these hairs that have separated from the follicle? Should I just allow them to fall out on their own, or does it matter at all? Can pulling hairs out at 10 days post op effect growth differently than individuals who allow the hairs to fall out naturally? — T.T., Boston, M.A.

A: At 10 days it should usually not make a difference, but I would still just let the hair fall out naturally when you shampoo. If there are any crusts (scabs) on the hair they are cosmetically bothersome, they can be gently scrubbed off in the shower at 10 days when very tiny recipient sites are used and you should wait slightly longer if larger sites were used. Since I don’t know the technique or site size used in your procedure, I would wait a full two weeks to be certain the grafts are permanent.


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Hair Restoration Answers

Finasteride and Fertility

Q: I have been finasteride for several years. My wife and I are currently trying to conceive our first child and it is unclear to me if it is safe to continue taking finasteride during this period. Unfortunately, I have not been able to get a clear position via the Internet. Most people commenting on it are on blogs and the response goes both ways — some say it’s ok, others say stop. While I know that it’s imperative that a pregnant woman not touch the medicine, can you please let me know if I can continue taking the medicine while trying to conceive? — M.K., Edgeworth, PA

A: It is OK for you to continue finasteride while your wife is trying to conceive. However, there is some data to suggest that it may slightly decrease fertility since, by shrinking the prostate (the prostate produces 25-30% of semen volume) it slightly changes the overall composition of semen. These effects appear to be temporary and finasteride has no direct effect on sperm. If you and your wife were to have difficulty conceiving, at that point is might be reasonable to temporarily discontinue the medication.


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Hair Restoration Answers

A doctor’s comment regarding the paper “Pre-making recipient sites to increase graft survival in manual and robotic FUE procedures.”

Q: While I was lying awake last night your approach of making sites the day before implantation came to mind. It takes guts to have spearheaded that! I am not aware that that precedent has been set in hair transplant surgery. I would have been timid about infection; it’s a lot like closing a wound with a foreign body in it the next day. As with most things, I am a little slow to jump on board something new so I’m glad you’ve paved the way. Do you have any hesitance about this or do you have enough experience that you no longer hesitate? I would be concerned that variations of the local flora might make a difference and that, accordingly, a large sample size would be necessary to get comfortable. Glad for all of us that you are still blazing trails. — S.S., Shanghai, China

A: Thanks for your kind words. No hesitancy whatsoever. We find no increased risk. Think of it as if you did a hair transplant and ran out of grafts. The remaining sites don’t get infected, they just close up. In the process, all those chemotactic factors involved in the healing process move toward the wounds, so if a graft is placed into them, they would be less likely to get infected than a graft placed into a fresh (non-primed) wound, not more. It is like applying the surgical dressing Duoderm to a wound that helps it auto-sterilize. Putting the speculative science aside, we have not seen one single issue with it. Give it a try with an FUE or FUT procedure. Make the sites, have the patient takes his normal shower that night and you will be pleasantly surprised how little bleeding there is the next day and how easy it is to place the grafts.

Read a summary of the article on pre-making recipient sites

Read the full article as it was published in the Hair Transplant Forum International


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Hair Restoration Answers

Are Patients in Photos of Medical Treatment Using Concealers, or are Results Genuine?

Q: Doctor Bernstein, I was looking at your website and saw the photos of medical hair loss treatments only, with Rogaine and Propecia. Doctor, are all those pictures just with medical treatments or is there concealers as well? I don’t mean to sound rude or disrespectful, but are the pics all real and genuine? Those are some impressive responses to medical treatment. — A.D., Scarsdale, NY

A: The photos are un-retouched and without concealers. These are responses to medical treatment alone. Yes, medications (finasteride and minoxidil) can work really well in select patients. Patients with early stages of thinning usually respond the best. Contrary to popular belief, the medications can work in the front part of the scalp, as long as the area is not shiny bald.

Perhaps about 1/3 of patients respond well enough to be put on the site. Most others have a good response, but not necessarily improvement significant enough to be easily noticeable in photos.


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Hair Restoration Answers

Before and After Photos of Medical Therapy Look Too Good To Be True!

Q: Are the “result” photos from taking Propecia and using Rogaine legitimate? Some of the after photos look too good to be real and a few patients looked like they combed their hair to look like they had more coverage. — T.Y., Darien, Connecticut

A: The before and after photos of patients using Propecia and Rogaine are my patients. All photos on our website are un-retouched. When patients have a good response to medical therapy, they often have more flexibility in how they can groom and style their hair. This is reflected in the photos.


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Hair Restoration Answers

What Is The Latest On ACell Extracellular Matrix For Hair Cloning?

Q: I haven’t seen much new with ACell. Have you been making progress with your research?

A: Thus far, we have not been able to multiply transplanted hairs with ACell, nor have been able minimize the width of the donor scars following FUT. At present, we are not recommending ACell to our patients, but are continuing to explore different ways of using it.

Visit the Hair Cloning News section to read about the latest research on cloning and multiplication
Read about Hair Cloning Methods


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Hair Restoration Answers

Will Multiple Hair Transplant Procedures Improve Hair Density?

Q: I was told that I have low hair density in the donor area. Will multiple hair transplant procedures improve the results of my hair restoration? — J.G., Hoboken, NJ

A: Yes, but subsequent procedures would be smaller and there is a point of diminishing returns where additional procedures would yield so little hair that they would not be practical. There is a finite donor supply and once this is tapped, no more hair transplants are possible, regardless if one uses FUT or FUE.


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Hair Restoration Answers

Persistent Side Effects From Propecia

Q: You prescribed Propecia for my hair loss. I was wondering if the news report on Propecia side effects has altered your opinion regarding the safety of this drug? — N.D., Belle Meade, Tennessee

A: It has not changed. I believe you are referring to Dr. Michael Irwig’s study at George Washington University published in the Journal of Sexual Medicine. I was already aware of the study when I prescribed the medication for you and we discussed the risk of persistent side effects at your consult.

Although all types of data should be considered, it is important to realize that this was not a scientific study, but a survey. It had very significant selection bias. From this type of study, one can’t prove cause and effect relationships or even get a sense of actual incidences. These were patients who were recruited because they already had persistent sexual dysfunction. Since it is not clear if their persistent problems were directly due to the medication or from other factors, and since these patients were selected, rather than randomly assigned, the additional information can be gained from the report is very limited.

That said, the reporting of persistent side effects should not be taken lightly, but should be viewed in the context of all available data. It is extremely important for us to continue to be vigilant, as this is a very significant issue, but it is equally important not to make decisions on data sensationalized in the media. As a result of the finasteride data, some are presenting surgery as a more reasonable alternative than medication. For a young person, that is usually not the case.


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Hair Restoration Answers

Risk of Visible Scar Long-term, FUT or FUE?

Q: What are the chances of the donor scarring being visible long-term in FUT compared to FUE? — M.M., Altherton, C.A.

A: Both FUT and FUE produce donor scarring; FUT, in the form of a line and FUE in the shape of small, round dots. With FUT hair transplantation, the line is placed in the mid-portion of the permanent zone, whereas in FUE the dots are scattered all over the donor area.

If a patient becomes extensively bald (i.e. the donor fringe becomes very narrow), the line of FUT will generally still remain hidden, whereas the dots of FUE will be seen above the fringe of hair. In the less likely scenario of the donor hair actually thinning significantly, both the line (of FUT) and the dots (of FUE) may become visible.


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Hair Restoration Answers

Rare Complication Of A Hair Transplant: Necrosis In The Recipient Area

Q: What is the most common cause of necrosis (death of tissue) in the recipient area? — A.Q., Los Altos Hills, C.A.

A: Recipient site necrosis is one of the worst complications of a hair transplant and results in skin ulceration and scarring. Usually it is caused by a combination of a few or many of the factors listed below. Each by itself should not present a risk.

Pre-existing conditions in the patient such as:

  1. smoking (the big one)
  2. diabetes (juvenile more than adult onset)
  3. photo-damage (alters the collagen and vasculature)
  4. long-standing baldness (less blood supply when there are no follicles)

Poor surgical techniques:

  1. recipient sites that are too large
  2. recipient sites that are placed too closely (too dense)
  3. too many grafts placed at one time
  4. too much epinephrine used in the procedure
  5. multiple procedures in one session — i.e. FUE and FUE in same session, or large FUT and Graft excision, scalp reduction, etc.

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Hair Restoration Answers

Which Is The Better Hair Transplant Technique, FUT or FUE?

Q: I am so confused reading about FUT and FUE on all the blogs. Can you please tell me which is better, FUT or FUE? — M.T., East Brunswick, NJ

A: FUT (via strip) will give the best cosmetic results (more volume) since the grafts are of better quality (when using microscopic dissection, there is less transection and more surrounding tissue to protect the grafts) and better graft selection (the grafts can all be harvested from the mid-portion of the permanent zone).

In contrast, in FUE you need approximately 5 times the area. Because of this large donor area requirement, some of the hair must be harvested from fringe areas and thus the hair will be less stable genetically.

With subsequent FUT procedures we remove the first scar, so the patient only has one scar (albeit long). With subsequent FUE sessions we are adding additional scars, so over the long-term the cumulative scarring over large areas can present its own problems of visibility.

The main advantage of FUE is to have the option of wearing your hair very short (but not shaved). FUE is also appropriate for patients who are at risk for a widened donor scar (i.e., very athletic and muscular or with thin, tight scalps, etc.).

In my experience, Robotic Hair Transplantation is superior to other FUE methods in that it is much more accurate and more consistent. It enables the doctor to extract grafts with less damage than with hand-held instruments or other automated devices.


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


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