Hair Transplant Open House Transcript | Bernstein Medical
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The following are excerpts from Q&A segments of Dr. Bernstein’s Open House Seminars on hair transplant surgery and other medical hair restoration topics.

Hair Transplant Seminar: Part 1

Sutures vs. Staples

Attendee: What’s the difference between using sutures and staples in a hair transplant and why are sutures sometimes used and at other times staples used?

Dr. Bernstein: Our thinking on this has evolved over time. Sutures are the traditional way of closing the donor area in hair transplants. About eight years ago we started using absorbable sutures for the majority of our hair restoration procedures. The reason why we used absorbable stitches was that when you use a regular stitch, the loops strangulate hair follicles. After the hair transplant surgery, there’s some swelling of the scalp. So when you have sutures which are applied in a running, or continuous fashion, the loops actually strangulate the follicles because the tissue within the spiral loops of the suture swells.

Because of this, we began to make the loop smaller and smaller. In other words, closer and closer to the wound edge, so that they would trap less tissue if there was swelling after the hair transplantation. Eventually, we stitched so close to the wound edge that within a few days after the surgical hair restoration they became buried and couldn’t be removed. We thought that if the hair transplant doctor used absorbable sutures, then, after they became buried, they would dissolve and just disappeared on their own. Although that seemed like a great idea, the problem was that sutures are absorbed by the inflammation of the body. As a result, the inflammation from the dissolving sutures was destroying some hair follicles and this negated some of the benefit of stitching close to the wound edge.

Around 1998, Johnson & Johnson developed a new suture called Monocryl which is broken down by water in a process called hydrolysis. This process involves very little inflammation. We started using this material routinely in the hair restoration by placing the sutures very close to the wound edge, so that in three or four days they became buried under the skin. We did a study on a series of hair transplant patients to compare those sutures to staples and it turned out that the sutures actually looked better than the staple closure. And the reason is that the suture line was slightly more smudgy or ill-defined. In other words, you could get the two wound edges flush with one another because you have very good hand control, but the sutures destroyed some follicles and this made the line appear slightly irregular when the surgical hair restoration procedure was completely healed. However, the damage to follicles was minimal, since there was so little inflammation and since so little hair was trapped within the sutures. At the time we judged the cosmetic appearance to be the most important factor in deciding which was the best way for the hair transplant doctor to close the transplant so we began to use mainly sutures.

For about five or six years we continued to use absorbable sutures, called Monocryl. About a year ago we decided to revisit the issue and look simply at the technique that conserves the most hair. It turned out, that even though the Monocryl sutures looked great and were very comfortable, immediately after the hair transplant surgery, they were strangulating a little bit of the hair follicles even though it was a very small amount. This is because they are a running stitch. Staples, on the other hand, are interrupted and they are inert (do not react with the body), so even though staples can be uncomfortable and sometimes leave a more defined line-scar after the hair restoration, they do not waste any hair whatsoever.

We currently use staples for the majority of our hair transplants and reserve sutures for those situations in which the staples don’t give a perfectly flush closure. An example would be when there is scarring in the donor area. It is particularly useful to use staples for the first hair transplantation procedure when the donor area has its full density. If, for some reason, the results with the staples were less than ideal, then sutures could be used for the subsequent hair restoration sessions.

What’s New in Hair Transplantation?

Attendee: I had my surgery seven years ago, what’s new?

Dr. Bernstein: I am often asked that question and the answer is that almost every day something is new. The best hair transplant surgeons are always changing something, tweaking something, improving some aspect of the procedure. We’re always looking at something. The day that we have nothing left to improve in surgical hair restoration, I’ll hand the baton to someone else. Searching to make the procedure better is what my team and I live for… it is what keeps us going. We’re always examining, looking and making changes. There aren’t always dramatic changes, but this is always something to improve, even slightly. A recent example is to apply a massager to the patient’s shoulders when giving the local anesthesia – it is a simple technique, but makes the anesthesia a lot more comfortable. Another is the use of special anesthesia to decrease forehead swelling after the procedure. Other relatively well known changes used by hair transplant doctors in the procedure include; tumescent anesthesia and the use of lateral slits for recipient sites.

Follicular Unit Extraction

Attendee: I heard that you can remove hair without taking out a strip. What do you mean?

Dr. Bernstein: For some people that wish to have a hair transplant, you just can’t remove donor tissue using a strip. Although removing a strip leaves a line scar, and although it is usually a very fine line, if you were to buzz cut the sides and back of your head, you would still see that line. You can cut your hair relatively short, but if you really shaved it or cut it very close, you would see the scar.

So for those people who want to buzz the back and sides, you can do the surgical hair restoration with Follicular Unit Extraction (FUE). Here, the doctor takes out follicular units, one at a time, directly from the back of the scalp – without having a line scar. The problem with this hair transplantation procedure, however, is that there is more transection – destruction of follicles – since it is done directly from the scalp where there is only partial visualization by the doctor of the dissection process and poor stability of the tissue as compared to using a strip. The reason is that a strip can be placed under a microscope were you have complete control of the dissection. This is called dissection “in vitro” or out of the body and is a significant advantage in the hair transplant surgery.

The other problem is that when you remove follicles in FUE, you’re leaving bald skin behind. FUE, does in fact, leave a tiny scar, so it decreases the density each time you go back, but if you take out all the hair, you can be left with a bald area after repeated hair transplants. So what happens is that you really can’t access the best portion of the hair once you start picking away at it with FUE. So it’s not as powerful a procedure as FUT where the strip enables you to use 100% of the best part of the donor are for the hair transplant.

The way we envision doing Follicular Unit Extraction is to use it in situations where we can’t do a strip, or if in the rare situation where someone had a wide scar from a strip. In this case FUE would allow you to take hair from around the scar and place it into the scar itself, making it less visible.

Attendee: Is the doctor the one who actually makes the cut and takes the strip out?

Dr. Bernstein: Yes. The harvesting of the strip is the part of the hair transplant procedure that requires the most finesse, the most skill – it must be done with precision and be perfect every time. You could argue if I was making 2,000 recipient sites and one site is not deep enough, I could go back and make it deeper. Removing the strip happens quickly – it has to be done with incredible precision so that the maximum number of follicles may be preserved. So yes, of course, that’s something that I always do.

Hair Transplant Seminar: Part 2

Hair Transplants in Women

Attendee: I went to two dermatologists and they told me that I am perfectly healthy, but I was told that I had hormonal hair loss related to aging. What is your experience with hair transplants in women? I see mostly men in the audience!

Dr. Bernstein: Although both men and women have hormonal hair loss, the mechanism in each is different. In the typical pattern of hair loss in men, the follicles in the front and top of the scalp are sensitive to the hormone DHT (produced by the action of the enzyme 5-alpha reductase on testosterone). Over time, DHT causes the affected follicles to become smaller and to eventually disappear. This process is called miniaturization and it occurs in a specific pattern involving the front and top of the scalp. That is why it is called “patterned” hair loss. The back and the sides of the scalp are generally not affected in hereditary “or androgenetic” baldness.

With hair loss in women, the more characteristic pattern is a diffuse type hair loss, which means there is thinning all over. This pattern in women results from the combined effects of two different enzyme systems. One is the DHT pathway that is similar to men. However, women also have an enzyme called aromatase that contributes to their hair loss. Men do not have this enzyme. It is felt that aromatase is at least partly responsible for why a woman’s pattern of baldness is different from a man’s. It is part of the reason that women’s hair will thin all over rather than have thinning just on the front and top of the scalp, with the hair on the back and sides being permanent.

There are a number of implications to this. First, when you thin evenly all over, it usually looks OK until there is a very dramatic amount of hair loss. Usually women complain of decreased hair volume, but they do not actually have bald spots, so people do not notice. Women typically feel much worse about their hair loss than others can appreciate, because changes in volume are often noted by the actual person who is thinning way before it is noticeable to others.

With respect to treatment, what surgical hair restoration does, is to move hair from an area of good density to an area where there is very little. It redistributes hair. Hair transplant surgeons do not actually create new hair (this is cloning) we just move the hair from the back and/or sides of the scalp to the front and top. So, if your hair is thin, but evenly distributed, you really cannot benefit from moving it around.

In this woman, we see that the top is barely thinning, but so are the back and sites, so there is little to gain by moving hair from the back to the top. This difference in the balding pattern is unfortunately the main reason why more men are candidates for hair restoration surgery than are women.

Another reason that women with diffuse hair loss are generally not good candidates for hair transplants is that, in the area of thinning, the hair is undergoing the process of miniaturization. This miniaturized hair can be subject to being shed from the surgery. Now, in a man who is already bald in a specific region of the scalp, we do not really care very much. However, if you have a lot of hair in that area and we are putting just a little bit in, the risk of losing miniaturized hair can outweigh the benefit of what we may be transplanting during the hair transplant.

The third reason, which is the most important, is that in women, the donor area, because it is also thinning, will continue to thin even after you move it. Just because one performs a surgical hair restoration, it does not make that hair permanent if it was not permanent in the donor area. The hair is no better than the area that it comes from.

Therefore, if you have a woman, who is thinning all over and you take hair that may not be permanent over the long term, and put this hair into an area that already has hair; you have risk in both places. You have the risk of shedding because you are putting new hair into an area that already has a lot of hair and you have the risk that the hair you are putting it in may not be permanent. In a man, with patterned hair loss, you have neither of those risks. The donor area is relatively permanent and we are usually putting it into an area that does not have very much hair.

So, when are women candidates for a hair transplant? They are candidates when their hair loss is patterned. When they have a relatively localized area of thinning and a stable donor area.

Hair Transplant Seminar: Part 3

Hair Transplants and Medical Therapy in Women

Attendee: Men can use Propecia, why can’t women take it?

Dr. Bernstein: That is a good question. Propecia blocks DHT and DHT is the cause of androgenetic hair loss in men. As we just said, in women, the mechanism is not only related to DHT, it is also related to aromatase, so Propecia is not as effective in women. And we know in post-menopausal women, it is not effective at all.

It may be effective in a subset of pre-menopausal women, because some women have increased androgens causing the hair loss. However, even if it were effective, pre-menopausal women cannot take Propecia because it causes birth defects.

In other words, if women ingest Finasteride during pregnancy, it can cause birth defects, if there is a male fetus. 5-alpha-reductase, the enzyme that Propecia blocks, allows for the development of the male external genitalia in the late first and early second trimester.

On the other hand, men can take it, impregnate a woman, and continue to take it during the woman’s pregnancy and there is no problem, there is no risk. However, it is not okay for the woman to take it; it is just okay for the man to take it during the pregnancy.

Attendee: And, so you are saying that in post-menopausal women it doesn’t work?

Dr. Bernstein: No it does not, which leads us to the third type of hair loss, which we did not mention yet. We have the DHT- dependent hair loss that produces the pattern in men, the more diffuse hair loss that we see more commonly in women, and the hair loss of aging. Hair loss associated with normal aging is not discussed much, but what happens over time is your hair gets gradually thinner all over and this happens in both men and women.

Patients often ask, “Is my hair transplant permanent?” The answer is, yes. The hair restoration, if done properly, i.e. is taken from the permanent zone, will be permanent. However, the texture of one’s hair changes over time and so the texture of hair transplants will change over time too. That is not necessarily a bad thing because you do not want to have hair in one part of the scalp that does not match the hair in another.

Attendee: If a particular woman is not a good candidate for a hair transplant and she cannot take Propecia, is there anything else that she can do?

Dr. Bernstein: There are actually a lot of things that she can do.

The most common thing to do to camouflage baldness is to lighten your hair. Often women that are thinning darken their hair as they think that this will make them look younger. Although this may be the case, darkening the hair also makes it appear thinner. If you lighten it, it actually reflects more light and it looks fuller. Streaking your hair, coloring your hair, highlighting your hair, all will actually make the hair look full. Waving, curling or perming one’s hair will give the hair more body and make it appear fuller.

The next thing one can do is to part the hair off to the side. Usually people do not bald completely symmetrical, so usually one side is slightly thicker. People usually part their hair on the thin side, because that is where the hair falls. If one parts their hair on the other side then it often will look fuller. So lightening your hair, changing the part, perming it, or adding a wave are all things that you can do if surgical hair restoration is not appropriate.

Another useful technique is cosmetic camouflage. There are a number of products that one can add to the scalp to make it appear more full. They come in powders, creams, lotions, and gels that add both thickness to the hair and leave a residue on the scalp – making the hair look much thicker. They are extremely effective in women. In men that are shinny bald, it can look strange or unnatural. However, in women who have some hair coverage, it can look great. You don’t need that much hair for it to be effective.

The other thing that you can do is use a hairpiece, but his should be reserved for the most extensive hair loss.

There is a drug called Spironolactone, which is a diuretic used for blood pressure control, that blocks androgens that can sometimes benefit women with hair loss, but I generally do not think the risk benefit for this medication is worthwhile.

Rogaine does not really help that much and I think most people find it is a nuisance to use and it is a little bit sticky; it mats your hair down so you lose the fluffiness. You might gain a little bit of hair back from the Rogaine but cosmetically it does not look as good because of its stickiness, so it is kind of a wash.

Hair Transplant Seminar: Part 4

Post-op Care After Hair Transplant Surgery

Attendee: A man is getting a procedure done now. He said he is going back to work tonight.

Dr. Bernstein: That would be a record. We have had people work the next day, however. We transplanted the superintendent of our New York office. In fact, he is the first person on the website, the man with blond hair, and he was doing construction the next day. However, we actually do not – we do not encourage it. I prefer to have people rest the day after their hair restoration procedure. We also want people to take three or four showers the day after their hair transplant surgery and this is easiest to do if you are at home. After that, you can do normal activities such as deskwork and light work after that.

You can go to the gym a couple days after the hair transplantation as long as you are not doing things to stretch the scalp. No headstands, no crunches and no squats with a bar placed behind your neck. The thing you do not want to do is you do not want to do a lot of flexing of the neck soon after the surgical hair restoration. Most other activities are okay.

The important thing to do after hair transplants is to take frequent showers. The recipient sites, where we place the grafts, are made with a 19 or 20g hypodermic needle or its equivalent– they are extremely tiny. Blood is drawn with a 16 or 18-gauge needle. In addition, as you go up in numbers, the diameter gets smaller and smaller. Therefore, at 19- or 20- it is quite small. With eyebrows, we will go as small as 22g. Consequently, the wounds are so small that in 24 hours they are sealed up, so there is no more oozing. Therefore, if you take frequent showers right after the surgery, you can get all that oozing off and then in a few days you can be squeaky clean.

Invariably people baby their scalps too much after the procedure and don’t wash the crusts off and so the crusts will linger, but if you do wash according to the instructions we give you, you can really be crust free in just a few days.

Attendee: It won’t endanger the hair transplant? You cannot rinse them out?

Dr. Bernstein: You cannot rinse the hair follicles out. However, you can dislodge them if you scrub hard the first couple of days following the hair restoration.

We did a study a couple years ago that is going to be published this January in Dermatologic Surgery, where we showed exactly how long it takes for the grafts to be completely secure in the scalp – so that they can’t be physically removed. It is a period after the hair transplant surgery that everyone always talks about, but no one ever knew for certain.

Several years ago we said, why don’t we just do a study and know once and for all. We had consenting hair transplantation patients come in and we used a pair of forceps and to tug on their grafts after their surgical hair restoration procedure. We found that about three or four days after the procedure, the hair was dissociated from the graft. After three or four days, with five days as the outer limit, if you pulled on the hair, the graft would not come out.

However, you could pull a graft out up until nine days after the hair transplant if you grabbed the scab, rather than the hair. The graft often has a little scab that sits on top of the graft and is attached to the skin. Therefore, nine days post-op, if you really yank, one out of every five times you would pull out a graft. After ten days, it was part of the body. You could not even yank them out. So at ten days you can really shampoo as aggressively as you like and if there is any residual crusting, you can literally scrub the crusts off without harming the grafts.

Attendee: I was just wondering what the major complication would be in a hair transplant for men specifically.

Dr. Bernstein: The most significant medical risk during hair transplants is really the anesthesia – and that is extremely rare. We dramatically minimize this by using local anesthesia. Hair transplant surgery is safe because we do not use general anesthesia – we do not put people to sleep. A hair restoration is about a seven or eight-hour procedure and if someone would have general anesthesia it obviously would be significant risk. With a local, there is really none.

You want to make sure that a potential hair transplant patient does not have cardiac arrhythmias, in other words an irregular heart beat, because we use a little bit of epinephrine (adrenaline) in the anesthesia and this can sometimes make arrhythmias worse. You also need to be careful that someone does not have significant underlying medical conditions. For example, patients with diabetes may have a slightly greater chance of having an infection. In a healthy patient, hair transplantation is an extremely safe procedure.

Hair Transplant Seminar: Part 5

When to Use Propecia and When to Have a Hair Transplant

Attendee: I know Propecia is good at keeping hair, but once you start it how do you know if it is working?

Dr. Bernstein: That’s a great question! There is a dilemma in going on Propecia, because once you go on Finasteride, there is no way to judge if it’s working unless you stop using it. And if you stop the medication, you’ll lose the hair that you gained or at least the hair that you held onto with the medication. If you stop the medication and lose this hair, when you restart Propecia the hair will usually not return to the level of fullness you had before you stopped. You will be at a new, lower baseline. So you really don’t want to stop the medication once you start. What you have to do is make sure you have a doctor make a correct diagnosis of androgenetic hair loss and then just continue to take it – as long as you want to have its benefits.

Attendee: So when should you have the hair transplant surgery?

Dr. Bernstein: When I used to do general dermatology, I used to give collagen injections. And women used to come in and say when should I schedule my next appointment? They wanted to be in the book for their next visit, before they even needed more collagen. I used to say “just call me when the wrinkles are beginning to come back – don’t’ worry about it until then.”

And it’s kind of the same thing with hair transplantation. The idea is not to come back every year hoping that you will have more hair loss just so that you can have the hair restoration surgery. When you go on Propecia you should just forget about it. You’ll know when you need a hair transplant. You’ll look in the mirror at some point and say I am just not happy with the way my hair looks anymore. And really the indication for a procedure for surgery is when you don’t like the way you look now, not because you’re concerned about future hair loss. Medication is the best treatment for future hair loss.

How Propecia Works

Attendee: What does Propecia do as far as preventing hair loss via growing hair back and what part of the scalp does it work on?

Dr. Bernstein: One of the problems with Propecia is that when the studies were first done, they were done on the crown. It was the same with Rogaine. And the reason why the studies were done on the crown is because it’s the easiest area to show results. And the reason is both Propecia and Rogaine work by increasing the diameter of thinning hair. They reverse the process of miniaturization.

DHT, a byproduct of Testosterone, acts on the hair follicle to cause it to shrivel up, miniaturize and eventually disappear. While the hair is undergoing this process, the process can be reversed. Once the hair is totally gone, neither Propecia nor Rogaine are going to work.

Propecia works much better than Rogaine, but they both work on the miniaturized follicle – on reversing the process so the hair becomes thicker again. Propecia is more effective in doing this.

In the crown, there’s a very long period where hair is miniaturized, so there’s a big window for medication to work. In the front, the area usually goes from being hairy to being bald very quickly – so there is little opportunity for finasteride to work. But in the crown, there’s that long period where it’s miniaturized.

So that’s the reason why it seems like the medicines are working better on the crown. However, it’s just common sense that if the medicines didn’t work in the front at all, eventually the front will become the back and they would be useless. They have to work in the front to some degree – at least in prevention.

If you take a young hair loss patient who’s really just starting to miniaturize in the front – where they are just first showing thinning at the hairline – the Propecia can work dramatically.

I did a study a number of years ago that showed that the diameter of the hair shaft contributes over two and a half times as much to the volume of a person’s hair as the absolute number of hairs on ones head. This is why reversing miniaturization can be so effective in some people in giving a fuller look even if it does not actually grow any new hair.

We have seen patients with early hair loss pushing for hair restoration surgery and we tell them to go on Propecia for a year, and then we’ll schedule a surgery. And we have them come back for their follow-up and they don’t need a hair transplant at all. So it can really work dramatically in front, too, on a younger person if there’s early balding and a lot of miniaturization.

Statistically 83 percent of people on Propecia will maintain the hair for a period of about five years and then it becomes less effective. It actually grows a visible amount of hair back in a much smaller number of patients. It’s probably about 40 percent in younger patients. In older patients, it’s much less than that.

When Does Propecia Start to Work?

Attendee: I had seen you about a year ago and we talked about Propecia. And I started taking it. According to the guy who cuts my hair, it’s working really well and it has grown some hair in back of my head. I’ve just been on it for about ten months and every time I go to the barber to get my hair cut, he says, oh, you know, it’s coming in thicker. How long can I expect this to go on?

Dr. Bernstein: So the question is “how long does it take to get the full benefit of Propecia?” You get most of the benefit in the first year. And you may get some additional benefit with respect to improvement of hair volume up to two years. After two years, there’s no additional benefit. It continues to work, but you’ll no longer get more fullness. So the majority of visible benefit is in the first year with some additional benefit in the second.

The important thing for patients to remember is that Propecia doesn’t start to work until about three to six months. So over the first three to six months you should expect no improvement. In fact, some people can actually thin in the first few months as Propecia starts a new hair growth cycle and the old hair is pushed out, so people can sometimes experience shedding during this time. That indicates that the medicine is working if you’re losing hair with the medicine. Propecia is not known to cause hair loss, but it can cause some initial shedding.

The problem is that, for some reason, people’s attention spans are about six months, so unless we really emphasize that they have to wait a full year, after six months they throw up their hands and stop the drug. They come in for their one-year follow-up and they complain that the medication didn’t work. Well, I tell them that we just have to start again.
So the bottom line is that, barring the uncommon situation that you have side effects, you’re going to wait the year for the Propecia to work.

The thing that really makes me upset is when a patient goes to a doctor that specializes in hair transplantation and the doctor says, let’s see if Propecia will work. Come back in six months and if doesn’t work we’ll do a hair transplant.

So what happens is obviously it’s not going to work in six months. And they come back, they do the hair transplant and then they get the benefit of the Propecia and they think it’s the transplant, they think it’s the surgery, because the Propecia then kicks in at the same time as the hair transplantation, which is kind of dirty pool. So if your hair transplant surgeon says come back in six months to be evaluated for surgery, I suggest that you run.

Hair Transplant Seminar: Part 6

Hair Loss Treatments and Products

Attendee: In terms of lightening hair, as opposed to dying it, is it that the difference in color between the scalp and the hair is less so the hair doesn’t look as thin or does lightening it actually make the hair thicker than dying it?

Dr. Bernstein: Lightening the hair does two things. It decreases the contrast between the skin and hair for those with light skin. And it acts as filler, filling in the spaces between the hairs.
The other thing that it does is it reflects more light so that it looks fuller.

Did everyone understand that? Okay, then I am going to ask the group a question. In a black person, does lightening their hair give the appearance of more hair or less hair? Any ideas?

Attendee: Less?

Dr. Bernstein: It makes it look like less hair, because it increases the contrast with the dark skin. However, the light hair would also reflect more light! So then the question is, which is more important, the contrast or the fact that it reflects more light? Actually both of these factors are important so it would depend upon the individual situation.

Attendee: Doesn’t lightening your hair cause you to lose more hair?

Why should lightening your hair cause you to lose more hair? Hair grows from the root, from the follicle that sits below the surface of the skin. Although, lightening the hair may damage the hair shaft and make it appear more brittle, it does not effect the root – it will not effect the growth of new hair. That is of course unless the scalp itself is burned from overzealous treatments.

On the other side of the coin, many people use hair conditioners, hair treatments, all those things and they think will help you grow more hair. Actually, they don’t. Hair is dead, so treating the hair doesn’t affect growth. Treatments may make the hair silky and keep it from breaking, but it won’t affect growth.

It’s the same thing with hair treatments, whether you use a conditioner to keep your hair from breaking, it can make your hair look more full, but actually the growth center below the follicle – you know, below the surface of the skin in the follicle is not affected by things you do to your hair. Otherwise, cutting the hair would be bad for it. And certainly cutting is more traumatic than bleaching it or dying it.

So as long as you’re not burning the roots, as long as you’re just doing it to the hair, then it will be no problem.

Attendee: Could you tell me some products that you can put on your head to make the hair appear thicker?

Dr. Bernstein: Yes. Go to our website and look under Medical Treatments, which is on the left navigation. When you click on Medical Treatments, there’s going to be a number of buttons on top of the page. One says Camouflage Agents. When you click on that, there is a list of products with their descriptions, the companies that make them and telephone numbers where you can get them. There are five main product types and they’re all very different – there are powders, creams, and sprays and they come in a wide variety of colors to match your hair or scalp. You have to get a few and see which ones you like.

Hats and Hair Loss

Attendee: Does wearing a hat cause hair loss?

Dr. Bernstein: I find it fascinating that this is such a frequently asked question. The answer is “obviously not.” Think about it for a moment. A hat generally touches the sides of the head, not the top where you lose the hair – so it can’t be from pressure. And it certainly doesn’t cause hair loss by depriving the head of oxygen. Hair, like everything in the body, gets its oxygen through the blood stream, not by the surrounding air. Does wearing shoes and socks prevent ones toenails from growing?

Diagnosing Androgenetic Alopecia

Attendee: “My son has started to – I think he may be thinning and we’re concerned about putting him on Propecia for life.” So the question is how can you tell, when someone is young, whether they’re actually balding or not? How do you tell if an eighteen-year-old kid is balding?

Dr. Bernstein: There are actually a number of things that we can look at that can make the hair loss diagnosis pretty clear-cut. Some things are soft findings and some things are hard – more reliable. The first soft thing is family history. If someone has a family history where people are bald, then obviously it increases their chances of becoming bald. Particularly, if someone has a family history where some in the family says, “oh, when I was eighteen I started losing my hair and then I became bald over the next five years”. If another family member started to thin at 18, then this is obviously not a good sign. So the family history is important particularly if there is a family member that is older but had a similar pattern of loss as the person in question.

The second thing is the person’s own sense of his hair loss. Although this is a soft finding, I think that this is extremely important. If an eighteen-year-old – I’m saying eighteen just as an example – an eighteen-year-old comes into my office and says, “I put my comb through my hair and it seems like it is getting thinner. I used to go to the barber and they used to use these thinning shears. They don’t have to do that anymore.” That’s very, very important to me. Even though he looks like he has a full head of hair to me, it doesn’t matter. If the person is complaining of decreased hair volume, that’s a sign that he may be losing his hair. So that’s another soft finding, but very important.

The next thing is if the hairline is changing. I often hear “my hairline used to be flat, straight across, and now it’s kind of going up in the corners.” This may also indicate that someone is thinning. Some people’s corners go up, but they actually never go bald. They go from an adolescent hairline to an adult hairline, which is normal. It doesn’t mean you’re balding. However, a changing hairline can indicate that someone is actually going bald. So it’s a soft sign.

If someone is receding in the temples but also their crown is starting to thin, then that is definitely a sign that they are going to eventually lose their hair and go bald, especially in a young person. So temple recession plus crown thinning is a clear sign of genetic hair loss.

The next thing is if one thins beyond the hairline. And the way you can tell is to look at their scalp and you see miniaturization. This is accomplished with an instrument called the densitometer. It has a strong light with magnification and this magnifies the scalp thirty times, so that you can clearly see the different populations of hair – hair with different shaft diameters. If you see thick terminal hair interspersed with very fine hair, that means that the hair is not stable, is becoming miniaturized, and that person is balding. This is a hard finding.

So when you put soft findings of family history and the sense of decreased hair volume and changing hair line, together with the hard findings of patterned hair loss and the presence of miniaturization, then the diagnosis of hair loss, of androgenetic hair loss, is pretty secure. And those are the people that we put on Propecia. And you want to put the hair loss patients on earlier rather than later. If a patient only has soft findings, it is more of a judgment call, but with several soft findings, I will place younger patients on the medication as well.

The most important thing when evaluating a young person with hair loss is to look at their donor area. Because if the hair in ones donor area, the back and sides of the scalp, are also miniaturizing, this is a condition called diffuse unpatterned hair loss. In these men the hair is thinning diffusely all over and these people are not candidates for a hair transplant surgery. And they are also at risk of balding very, very rapidly very early.

Hair Transplant Seminar: Part 7

Designing a Hairline

Attendee: How do you know where to put the hairline, there must be an infinite number of possibilities?

Dr. Bernstein: I think that there is really one best place to place the hairline in hair transplantation. When I draw a hairline at the consult, I photograph it and then when the patient comes the day of surgery, I draw a hairline again. I don’t look – even though we photographed the hairline and put it in the chart, I generally don’t look at it before I draw the line. I draw the hairline at the time of the hair restoration and then I look at the photo in the chart and they’re almost always the same.

So there really is one correct way. There are some rules that govern this position. You should place the hairline a centimeter and a half above the upper brow crease, above the upper wrinkle. The frontalis muscles cause the forehead to wrinkle and in a teenager, the hair starts right above the muscle. If the hair grew over the muscle and you smiled, the hair would move. So we know it starts above the muscle as a teenage and in an adult, it moves further up about a centimeter and a half.

I just happen to have a finger that’s a centimeter and a half wide, so if I put my finger above the upper muscle; it usually sits just below the correct hairline for an adult. So raise your eyebrows all the way up so everyone can see the muscle wrinkle the skin. See, this is the ridge and this is where the hair in the mid-portion of the hairline should start – exactly a centimeter and a half above the upper brow crease.

My colleague Dr. Bill Rassman, a hair transplant surgeon in California, fist came up with this idea. In the old days, people used the rule of thirds, you know, from the proportions in Michelangelo’s sculptures. Basically there’s a third distance from the chin to the tip of the nose, a third from the tip of the nose to the eyebrows, and a third from the eyebrows to the hairline. But that’s in the perfect proportions of someone that’s not undergoing hair loss. That’s a David. It’s not in a mature adult male. So the rule of thirds is not a good one in designing an adult hairline for a hair transplant.

The way he got this was that he was thinking, “How can I come up with some kind of rule that works for everyone?” And he said, “Well, you know, since I’m doing hair transplants, I’m going to make hairlines of my own image.” So he went to the mirror, he wrinkled his eyebrows, he put his finger up on top of the wrinkle to measure the position of his hairline and he said, “Ah, it’s a centimeter and a half. I am going to make everybody a centimeter and a half.” And that’s how that rule came in being. It’s a funny story, but the rule is extraordinarily helpful.

Attendee: But everybody has different size and shaped foreheads.

Dr. Bernstein: That’s exactly right. And so the mid part of the hairline is going to start a centimeter and a half above the muscle. And people with different sized foreheads have different lengths of the frontalis muscle, so the positions will vary widely and that is precisely the point. It changes with each person. But that is not the whole story. There is a lot more to a hairline than just where it starts. It has to be properly shaped or tapered as is goes towards the temples, it must be feathered to look soft and natural and it can not be too symmetrical or it will look strange.

Hair Systems

Attendee: I heard that some companies attach hair. Is this OK?

Dr. Bernstein: Hair extensions are generally bad for your hair particularly if they are worn for extended periods of time because they accelerate hair loss. Anything that is permanently attached to the scalp – something that you must sleep with – can cause hair loss. Wigs sit on your head and you can remove them at night, so they are generally OK. But, any attachment that you sleep in, that constantly tugs on the hair, decreases the blood supply and eventually accelerates hair loss. And the hair loss can be permanent.

Attendee: I heard that if you wear wigs a lot, then that will cause hair loss.

Dr. Bernstein: If the wigs are loosely attached and taken off at night, they don’t cause hair loss. Remember, hair doesn’t breathe through the ambient air. It breathes through the blood supply. So you can’t suffocate your head by wearing a wig.


Determining the Number of Grafts for the Hair Restoration

Attendee: Can you tell me how many grafts you would think that I would need?

Dr. Bernstein: [Examines patient] For this very early Norwood Class 6 patient, I would suggest about 2,300 grafts. So the question is why this number? Why not fifteen hundred, why not three thousand? The reason is that the patient doesn’t have tons of donor supply for the hair transplantation procedure. He has a number of limiting factors. The density of his hair is low, it’s 1.9. The average person’s density is 2.2-2.3. So that limits the amount of hair we have available to us. He has fine hair, medium fine hair. The average person has hair that has a little bit more weight. And then he has less scalp mobility than the average person. His scalp is slightly tight.

Everything here seems to be negative for a hair transplant surgery. Does he have anything that’s good at all? Well, actually he does. There are some things. One thing is that he has hair loss in the front. If we just put hair in the front and left his crown bald, he would still look a lot better. So even if we did modest hair transplantation, we could still improve his appearance.

So he has enough hair loss to warrant surgical hair restoration even though he doesn’t have a lot of donor hair because his density is a little low, his scalp is a little tight, and his hair is a little fine. He’s a good candidate because number one, he needs it; number two, his hair loss is in the right spot for a hair transplant, it’s in the front. What else?

Attendee: Low Contrast?

Dr. Bernstein: Right. He has low color contrast. So a modest amount of hair is going to be filled in with the background color of his scalp, so it will look fuller. What else is good about his hair characteristics?

Attendee: His age?

Dr. Bernstein: Yes, he is older so his hair loss pattern is more predictable and his expectations are more reasonable. When I drew his hairline, he smiled – he was ok with it. He didn’t say, “Uh, Oh, it’s that high up?”

So his expectations, his age, light skin, and hair color contrast all counterbalance the density and scalp laxity and fine hair – things we said were negative. Some of the things that we haven’t spoken about are, first of all, whether the crown is very important to him. If I can convince him that just transplanting the hair in front and top will be adequate to improve his appearance and he buys into that, then we can go ahead. If he says, “what I had in mind is filling in the whole thing and if you can’t do that, I’m not interested,” then he’s not a good candidate for hair transplant surgery.

And then the final thing is Propecia. If he goes on Propecia and it enables him to hold onto what he has, or the finasteride slows down the hair loss, that will also give him some benefit.

Fifteen hundred grafts would not be enough to cover the front and top, three thousand would use too many grafts in the first session and risk a wider scar (since he has a tight scalp). Using too great a percent of a patients total donor reserves in the first hair restoration session, doesn’t allow us to have as much aesthetic flexibility in the second session. For example, say he only had 4,000 total follicular units to move. If after the first hair transplantation procedure, he felt the front was still too thin, we could use the second session to increase the density with another 1,300 grafts and still have 1000 left over for future balding. However, if the first session used 3,000 grafts and extended into the crown, as the crown expanded, it would require even more hair to look natural, so increasing the density in the front might not be possible.

Another advantage of leaving hair for a second hair transplant session, particularly in someone with limited donor supply is to be able to weight the second session. For example, patients with fine hair can increase the appearance of fullness by combing their hair to the side. This look can be enhanced by placing more hair on the part side in the second session. Before the first hair transplantation session, the patient often has no idea about future grooming, so these decisions are more difficult.

Hair Transplant Seminar: Part 9

Follicular Unit Extraction

Attendee: When would you use follicular unit extraction?

Dr. Bernstein: As we discussed before, the strip harvesting technique in follicular unit hair transplantation will give more hair. It is overall a better procedure. We would consider FUE if someone shaves the hair on the back and sides very, very close, if the scalp is too tight for strip harvesting and for repairs of donor scars.

Attendee: Like shaving your head too?

Dr. Bernstein: If you consider shaving your head, you probably should do this before contemplating hair restoration. When one has hair transplant surgery, the purpose is to have the appearance of more hair. If you want to shave it off, I would offer that you are really not ready for the procedure. Remember, follicular unit extraction is also going to leave little dots – tiny white scars.

Attendee: Now, where would you see the dots? Would you take the hair from all over?

Dr. Bernstein: Yes. We take it from all over, as long as it is in the permanent zone. But that is actually the reason why a strip is superior. Because when you take a strip, you’re taking all the hair in the mid-portion of the permanent zone, you are not just picking away at it. So it’s an extremely efficient hair transplantation procedure. There’s a band here that’s dead center of the permanent hair. That is all used in FUT and the area is then sutured closed.

When you extract, you’re not removing bald skin. You’re just taking the hair out. So if you take all the hair away, you’re going to be left with a big bald area. So you can only take a portion of that away which is why you are so limited.

So what you have to do is to start to go lower or higher in the donor area, but that hair is not necessarily permanent at the margins of this zone. So that’s why it’s so much more efficient to do the strip. So we can do extraction, but usually people that are young, really the people that want extraction, are the people that are losing their hair at a young age and therefore are likely to become very bald. And to maximize the transplanted hair one should really use a strip. So the best thing is to delay hair transplant surgery on those people until they decide how they really want to wear their hair.

Shampooing, Shedding, and Androgenetic Alopecia

Attendee: I know when I wash my hair, I’m afraid to touch the top because every time I touch the top it falls out. If you look at your hand every day when you’re washing your head, you start freaking out.

Dr. Bernstein: Washing doesn’t cause hair loss at all. What happens is that when people are afraid to wash, afraid to brush their hair, afraid of combing, afraid to vigorously shampoo or shampoo less often, the hair that would normally be removed, just accumulates on the scalp. When the person finally does shampoo, more appears to fall out because it has been sitting up there for days. The patient, however, says, ah-ha, look, see all the hair. Now they wait ten days. And then they comb their hair after ten days and say, ah-ha, now look there is even more hair….. and it just continues. So the less frequently you do it, the more you see it at any one time. But it doesn’t affect the rate of hair loss.

Now, this is an important concept. In male pattern hair loss, what did we say is the cause of the hair loss? The cause is the progressive shrinking of hair shaft length and diameter – what we call shortening of the cell cycle. The hair doesn’t grow as long. In genetic hair loss, hair is not growing, rather than falling out at a faster rate. To stress this point, let me say it again, “Male pattern hair loss (or androgenetic hair loss) is not caused by hair falling out; it is caused by hair not growing back with the same thickness or length.”

So the fact that you see hair in the tub is a good sign – as long as it is not excessive. It means there is hair to fall out. Remember, it is not the falling out, but the fact that the hair is not growing back that’s the process of hair loss. And it’s not over one cycle. It’s very gradual as normal hair is replaced with the smaller and smaller hair.

With hair loss from pregnancy or from taking birth control pills, there you see actual shedding. Genetic hair loss in men is not a process of your hair falling out. It’s a process of the hair not growing back. So seeing hair on the comb is actually a good sign. It should not be a concern.

Hair Transplant Seminar: Part 10

Scalp Laxity

Attendee: How does a tight scalp affect hair transplants?

Dr. Bernstein: There are two components to having a loose scalp. The first is having elastic or stretchable skin. This is not much benefit for the hair transplant. The other is having more redundant or more mobile skin. This is very helpful in surgical hair restoration. If you have a loose scalp due to redundant tissue, you essentially have more hair.

Now, we used to think that a loose scalp was only important with a strip. Obviously, if you’re taking out a strip and the scalp is loose it is easier to close, but it’s actually more complicated than that. A loose scalp, instead of just being more stretchable, can also be more redundant – you have extra scalp. So you have extra hair to remove.

Now, if you have a very tight scalp because it’s not redundant, because you don’t have extra scalp, then it’s bad both for a strip and for a follicular unit extraction. Remember, the big constraint in FUE is that you often don’t have enough hair. So someone who has a tight scalp just doesn’t have a lot of hair.

Now, another corollary to that is we used to think that people with very loose scalps healed with the finest scars. It kind of makes sense. It turns out that it’s possibly just the opposite. And I wrote a paper on this many years ago called “The Scalp Laxity Paradox.” The reason is, if you think about it, why does someone have a loose scalp? Because it’s really stretchable, it doesn’t hold together well. So after you sew the edges back together, it’s going to re-stretch. So people with loose scalps often have the worse scars.

Now, someone with a tight scalp, why is it tight? It is tight because it doesn’t move, because it stays in place. So people with tight scalps usually heal with the best scars as long as you plan the hair transplant surgery right, plan the surgery so that the strip is narrow enough to easily close.

And so this is an interesting twist on scalp laxity. We had our first insights into this taking care of a hair restoration patient with a disease called Ehlers-Danlos syndrome – a condition where the collagen is not formed well. And the person healed with a wide scar although we thought he would heal beautifully because his scalp was so loose.

Attendee: My scalp tingles a bit, it feels kind of funny. What does this mean?

Dr. Bernstein: In early hair loss sometimes there’s a little bit of a tingling in the scalp, a little bit of a sensation, nobody really knows what causes it. Maybe there’s a touch of inflammation associated with androgenetic alopecia. The people that are having male pattern hair loss and I guess female hair loss, as well experience this kind of sensitivity or tingling on the scalp, not infrequently.

Attendee: Can medications such as Propecia work once a follicle dies?

Dr. Bernstein: Once a follicle is completely miniaturized, only a hair transplantation procedure will get the hair back. At some point there will be cloning, but this technology is still a ways off.

Dr. Bernstein’s Hair Loss

Attendee: How come you didn’t have a hair transplant yourself?

Dr. Bernstein: That’s a fair question. Everybody asks me that. I am actually not a good candidate. My dad is very, very bald. In fact, his sides are extremely thin and my sides are getting there. So I don’t have really stable donor hair. So even if I had a hair transplant, my transplant would be really thin and ratty. My kids kid me when I cut my hair. They say that my hair doesn’t fall on to the floor. It kind of sticks to my clothes – it is so fine and static. So I don’t have enough donor hair to be a good candidate.


Attendee: How thick will my hair be after the hair transplant?

Dr. Bernstein: I like to describe what hair transplants do, by what they don’t do. It doesn’t keep you warm and it doesn’t keep the sun off your head. It doesn’t keep you from getting a sun burn. And I think that that’s a good analogy because it’s not a magical procedure. We’re just moving hair, not creating new hair, but we’re moving it in a way that makes the patient look better – often dramatically better.

So we’re changing the distribution to make it look better without actually adding total hair volume. And that’s why it is more difficult to treat a younger person who’s complaining of decreased hair volume when the hair is actually distributed nicely.

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