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International Society of Hair Restoration Surgery (ISHRS)

Innovation and Quality in Hair Restoration Surgery

Synopsis: Hair restoration has advanced dramatically in the past 25 years, most recently with the growing popularity of FUE. The challenge of FUE is that the grafts are more fragile compared to the follicular units generated in traditional FUT/strip procedures. Innovations such as the ARTAS Robot and other devices attempt to address this problem. With the increasing participation of ISHRS members – now 1,200 strong – progression in this field should continue at an accelerating pace.

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Study is the First to Measure Perceived Benefits of Hair Transplant Surgery

A recently published study is the first to measure the perceived benefit of hair transplantation on a patient’s age, attractiveness, successfulness, and approachability – key factors that play an important role in workplace and social success. The pilot study, published in the Journal of the American Medical Association Facial Plastic Surgery, found that hair transplant recipients were perceived by others to be 3.6 years younger following their hair restoration surgery. The data indicate that the person’s attractiveness, successfulness, and approachability also showed statistically significant positive changes as a result of hair restoration surgery.

Follicular Unit Hair Transplantation

Synopsis: Follicular Unit Hair Transplantation in “Surgery of the Skin: Procedural Dermatology,” is Dr. Bernstein’s third update of the chapter in the core surgical textbook for dermatologic training programs. The chapter covers a range of topics including: the basics of hair transplantation, detailed descriptions of both follicular unit transplantation (FUT) and follicular unit extraction (FUE), the importance of patient evaluation in advance of surgery, and aesthetic considerations in hair transplant design. Robotic FUE is included in the chapter for the first time as a hair transplant technique.

Current Status of Surgery In Dermatology: Hair Transplantation

Synopsis: Every few decades, the American Academy of Dermatology publishes a comprehensive survey of the state of dermatology and dermatologic surgery. Dr. Bernstein was asked to contribute to this historical overview. The paper describes important developments in the field of hair restoration surgery over a period of more than twenty years. Dr. Bernstein’s pioneering articles on FUT and FUE are highlighted as key advances in the field, along with contributions by more than a dozen dermatologists. The section on hair transplantation includes a look towards the future with mentions of both robotic graft harvesting and the promise, and challenges, of hair cloning techniques.

Age and the Donor Zone in FU Hair Transplants

Synopsis: When considering Follicular Unit Transplantation (FUT) and Follicular Unit Extraction (FUE) procedures, a person’s age and the ability to assess the permanence of the donor area are important variables in determining surgical candidacy. This FUT case study examines the importance of these variables in the patient evaluation.

Hair Loss & Replacement for Dummies

Synopsis: This is a newly revised edition of the popular Hair Loss & Replacement for Dummies. The 2011 edition presents the latest information on a variety of topics of interest to those suffering from hair loss. The updated edition book discusses the latest in laser light and medical treatments for hair loss, the recent advances in Follicular Unit Hair Transplantation and the new, minimally-invasive hair transplant technique, Follicular Unit Extraction.

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Follicular Unit Hair Transplantation

Synopsis: Dr. Bernstein’s newly revised chapter, Follicular Unit Hair Transplantation, in “Surgery of the Skin: Procedural Dermatology,” a core surgical textbook for dermatologic training programs, covers a wide range of standard topics including; patient evaluation, surgical planning, operating techniques and aesthetic considerations in hair transplant design. New topics include: follicular unit extraction, eyebrow and eyelash transplantation, long-hair transplants, trichophytic closures, automation and hair cloning.

Follicular Unit Hair Multiplication with FUE

Follicular unit extraction is a technique of removing one follicular unit at a time from the donor region. The most important limitation of this hair transplant procedure is a high transection rate during the extraction process. In this clinical study, the authors transplanted different parts of transected hair follicle when harvesting with the Follicular Unit Extraction (FUE) technique. Five male patients participated in the study.

In each patient, three boxes of 1 cm2 were marked at both donor and recipient sites. The proximal one-third, one-half, and two-thirds of 15 hair follicles are extracted from each defined box and transplanted in recipient boxes. The density is determined at 12 months after the procedure.

The authors concluded that the survival rate of the transected hair follicles was directly related to the level of transection. The authors demonstrated that even though some of the transected parts of the follicles can survive after being transplanted to the recipient site, the growth rate is not satisfactory and the hair is thinner than the original follicles. As a result of this study, the researchers recommend that the hair transplant surgeon does not transplant the sectioned parts and that they should be careful with the patients whose transection rate is high during Follicular Unit Extraction procedures.

Hair Loss For Dummies

Synopsis: Important information for men and women of virtually all ages anxious to preserve their full head of hair, put the brakes on balding, or explore the safest and most reliable hair replacement techniques currently available. The book offers readers not only the full gamut of modern-day hair-care options, but crucial tips on how to avoid unscrupulous hair transplant doctors and potentially harmful products as well.

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Avoiding Pitfalls in Planning a Hair Transplant

Synopsis: The ability to achieve full cosmetic benefit in follicular unit hair transplantation depends upon a number of factors including proper patient selection, accurately assessing the patient’s donor supply, appropriately designing the hair line and correctly distributing the grafts. This paper reviews the major mistakes that doctors make in these key aspects of the hair restoration process and advises the practitioner on how to avoid them so that the patient will achieve the best possible results.

Staples Revisited: Surgical Staples in Hair Transplantation

Synopsis: Running, continuous sutures and metal staples are the two most common closures used by hair restoration surgeons today. This commentary discusses the pros and cons of various suture and stapling methods and makes an argument that, with new advances in techniques, staples are possibly the best means of closing the donor wound during a hair transplant procedure.

Follicular Unit Plain Speak: Hair Transplant Terminology

Synopsis: In 1998, a group of hair restoration surgeons proposed a classification for follicular unit hair transplantation and mini-micrografting techniques, to improve communication between physicians and their patients. With recent advances in techniques, a number of new terms are being used that do not have clear definitions. This paper expresses the author’s opinions on which of these terms are useful and should be incorporated into the original classification and which are confusing and should be abandoned. The authors also suggest concise definitions for these new terms.

Densitometry and Video-Microscopy

Synopsis: Densitometry and video-microscopy are techniques that analyze the scalp under high-power magnification to give information on hair density, follicular unit composition and degree of miniaturization. They can be used to help evaluate a patient’s candidacy for hair transplantation and help predict future hair loss. The measurements will enable the physician to better estimate the size of the donor strip and anticipate the aesthetic outcome of the hair restoration procedure. This paper describes the value of these techniques in the hair transplant evaluation.

New Methodology and Instrumentation for Follicular Unit Extraction

In this paper, Dr. James Harris presents a blunt tip instrument to be used in a 3-step FUE hair transplant procedure. The instrument is described as a 1-mm dissecting punch that has a tapered blunt edge. After scoring the skin with a sharp punch, the dissecting punch is advanced to a depth of approximately 4-mm.

This instrument is similar to the one recently described by Bernstein and Rassman in New Instrumentation for Three-Step Follicular Unit Extraction, recently published in Hair Transplant forum International New Instrumentation. Dr. Bernstein’s instrument was, in turn, based upon ideas presented in a paper written by Dr. Harris in 2004.

New Instrumentation for 3-step Follicular Unit Extraction

Synopsis: Three-step FUE is a hair transplant technique that uses blunt dissection to prevent damage during the process of separating the follicular unit from the surrounding tissue. The 3 steps are: scoring, blunt dissection, and extraction. Performing Follicular Unit Extraction with a 3-step technique allows the surgeon to minimize damage to follicles and to keep follicular units intact. A disadvantage is the development of buried grafts, but this can be reduced by modifying the technique and using specially designed instrumentation.

Eyebrow Transplants: From Scalp to Brow

Synopsis: The partial or complete loss of one’s eyebrows is a relatively common problem and can be caused by disease, accidents, the normal aging process, or can be been self-induced. This paper discusses the importance of eyebrows to one’s appearance and explains the special techniques and surgical skills required for eyebrow restoration.

Graft Anchoring in Hair Transplantation

Synopsis: This study determined exactly how long it takes after a hair transplant for the grafts to be securely anchored in the recipient area, so that they cannot be dislodged. This information is important in guiding the patient’s post-op care after a hair restoration procedure. The study also showed that preventing the formation of crusts following a hair transplant would shorten the time patients are at risk of dislodging grafts. It would also allow them to return to their normal hair care routines more rapidly.

Follicular Unit Extraction

Synopsis: This paper discusses the state-of-the-art in follicular unit extraction. It focuses on the new Three-Step Technique in which a sharp punch is used to cut the epidermis and then a dull punch is used to dissect the follicular unit from the surrounding tissue. The third step being the extraction itself. The “blunt” step significantly reduces follicular transaction, but creates a potential new problem, that of buried grafts. The Three-Step technique increases the number of patients in whom FUE is possible; however, other limitations of the procedure – particularly the lower total yield compared to strip harvesting – remain.

Follicular Unit Transplantation

Synopsis: This writing discusses the current status of Follicular Unit Transplantation and some controversial issues regarding this procedure. These issues include: strip harvesting vs. follicular unit extraction, lateral vs. vertical slit recipient sites, which holding solution is best for grafts, the ideal density and the optimal number of grafts that should be performed in one hair transplant session.

Instrumentation for Three-Step Follicular Unit Extraction

Robert M. Bernstein, M.D. Associate Clinical Professor of Dermatology at the College of Physicians and Surgeons of Columbia University in New York Abstract of Dr. Bernstein’s presentation at the International Society of Hair Restoration Surgery, 2005 – Sidney, Australia Biography Robert M. Bernstein, M.D. is Associate Clinical Professor of Dermatology at the College of Physicians …

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Comparison of Different Instruments to Make Recipient Sites: Needles vs. Blades

SUMMARY of Dr. Perez-Meza’s Abstract from his presentation at the International Society of Hair Restoration Surgery, 2005 – Sidney, Australia

There have been great advances in hair restoration surgery over the past decade. New surgical techniques, instruments and medications have been developed to treat patients with hair loss. Some surgeons use needles to create the recipient sites and others use blades – both groups obtaining great results. There is some controversy, however, about the “ideal” instrument to make the recipient sites.

The objective of this study was to evaluate three different blades and three different needles used to make sites in the recipient area and to compare the wound healing and hair growth after the hair transplan

Follicular Unit Growth at Four Different Hair Transplant Densities

SUMMARY of Dr. Beehner’s Abstract from his presentation at the International Society of Hair Restoration Surgery, 2005 – Sidney, Australia

There is a need to find the “threshold” density at which follicular unit (FU) graft recipient sites may be placed and yield excellent survival following a hair transplant. It also needs to be determined whether or not a smaller recipient site makes a difference in graft survival. This study looks at hair survival in two patients 18 months after they were each transplanted with four different densities.

The objective of the study was to determine the optimal density for “dense packing” FU grafts without causing loss of hair from vascular compromise or other factors that can affect graft growth during hair restoration surgery.

Solution to Decrease Swelling after a Hair Transplant

SUMMARY of Dr. Abbasi’s Abstract from his presentation at the International Society of Hair Restoration Surgery, 2005 – Sidney, Australia

Edema of forehead and peri-orbital area is observed frequently after a hair transplant. To prevent this edema the authors introduced a new method (Abassi’s solution) at the 12th Scientific Meeting of ISHRS in Vancouver, Canada. The present study tries to determine if Abbasi’s solution can have a negative effect on the growth of transplanted grafts following hair restoration surgery.

In this study, the authors examined the effects of Abbasi’s solution on hair growth one year after a hair restoration procedure.

Hair Curvature: An Important Factor for a Natural Looking Hairline

SUMMARY of Dr. Mohmand’s Abstract from his presentation at the International Society of Hair Restoration Surgery, 2005 – Sidney, Australia

The objective of this presentation is to share our experience and observations regarding the importance of the angle of curvature of the hair shaft during the hair transplant for producing a natural looking hairline.

Four important factors were kept in mind while performing the hair transplant regarding the natural looking hairline: 1) Avoidance of a straight line, 2) Keeping a transition zone between the bare forehead and the dense packing, 3) Density, 4) The acute angle of exit from the skin, 5) The angle of curvature of the hair shaft.

In our experience, since incorporating the angle of curvature of the hair shaft, the naturalness of the hairline has improved significantly. This is especially true for the frontal hair rows and the temporal peaks.

Trichophytic Closure: A New Way to Camouflage a Hair Transplant Incision

Summary of “Trichophytic Closure of the Donor Area” which appeared in Hair Transplant Forum International July/August 2005 by Mario Marzola, MBBS Norwood Australia

When hair transplant surgeons meticulously close the edges of a donor wound, they generally end up with a fine, linear scar that is approximately 1-2mm in width. Sometimes, the scar can be a bit wider and every once in a while, when the person’s connective tissue is weak, or the edges of the scar are closed too roughly or have too much tension, the scar can be a cosmetic problem. The educated patient, who has expectations of a thin scar, or the patient who is likely to wear his hair very short, hopes that their hair transplant doctor can produce scars that are practically invisible.

A Trichophytic closure is a way of improving the linear donor scars of hair transplant patients. A Trichophytic incision in hair transplantation involves trimming off the upper edge of the incision and then closing the wound in such a way the hair near the edge can grow through the scar. This has the potential to produce a scar that is virtually undetectable.

To perform a comparison study, Dr. Marzola conducted a trial using 26 consecutive patients. Each hair transplant patient had one side of their scar closed trichophytically (i.e., with the top edge removed) and the other side closed with the edge left as is.

Enhancement of Follicular Unit Extraction

SUMMARY of Dr. Harris’ Abstract from his presentation at the International Society of Hair Restoration Surgery, 2005 – Sidney, Australia

The SAFE System for FUE provided a novel methodology and new hair transplant instrumentation to increase graft production rates, decrease follicle transection rate, and expand patient candidacy for surgical hair restoration. However, the mechanism of the interaction of the blunt dissecting punch and the dermis produced follicular unit graft burial (approximately 7.2% of attempted extractions) that slowed the extraction process during the hair transplantation and resulted in inflammatory cysts requiring surgical excision in .02% of attempted graft extractions.

The purpose of this study was to assess the efficacy of a new dissecting tip that could potentially decrease the graft burial rate and increase the graft production rate in the hair restoration. In the study, three patients received a total of 422 grafts. The protocol utilized limited sharp dissection of the epidermis (using a 1-mm punch to a depth of approximately 1.3 mm) followed by the insertion of the specially modified dull dissecting tip to its full depth of 5 mm. The follicular units were then grasped with fine forceps and removed.

A New Device for Efficient Strip Harvesting

SUMMARY of Dr. Haber’s Abstract from his presentation at the International Society of Hair Restoration Surgery, 2005 – Sidney, Australia

Harvesting high quality donor strips with minimal transaction remains an elusive goal for many hair transplant surgeons, particularly beginners. Hair restoration techniques that involve the use of scalpel blades demand the greatest skill and may cause significant transection. The Sandoval Score and Spread technique showed that non-traumatic dissection during hair transplantation is possible using a blunt instrument, but this technique is limited by poor ergonomics and the potential to cause tissue damage.

A new instrument for blunt dissection had been developed that is easy to use and is able to separate tissue along the natural planes of cleavage that causes minimal damage to hair follicles. This device has four sharp, staggered prongs aligned centrally and long handles developed for hair transplant procedures. This design utilizes the strong forearm muscles, as opposed to the weaker hand muscles, and distributes the spreading force over a larger area, minimizing trauma. A minimum depth scoring incision is made with a double-bladed scalpel to a depth of 1.5 mm. The device is inserted and expanded at intervals along the incision.

Follicular Unit Transplantation

Synopsis: This paper reviews the core concepts of Follicular Unit Transplantation, including basing the surgical planning on the follicular unit constant, using only individual, naturally occurring units in the transplant and accomplishing the restoration in a few number of large sessions. The section then describes the techniques of follicular unit hair transplantation as the procedure enters its second decade.

Follicular Unit Hair Transplantation

PUBLISHERS NOTE: Single copies of this article can be downloaded and printed only for the reader’s personal research and study.

Synopsis: “Surgery of the Skin: Procedural Dermatology,” covers the entire range of dermatologic surgical procedures. It was conceived to be used as the core surgical textbook for dermatologic training programs. Dr. Bernstein’s chapter on follicular unit hair transplantation covers a wide range of subjects including the history of follicular unit hair transplantation, evaluating the patient, planning the surgery, setting-up the operating room, and maximizing the cosmetic outcome of the hair restoration. Specific topics include the techniques of Follicular Unit Transplantation including density assessment, single-strip harvesting, follicular unit extraction, anesthetic use, aesthetic design and many other important topics.

Rationale for Follicular Unit Transplantation

Synopsis: This is the textbook version of the important 1999 paper; “The Logic of Follicular Unit Transplantation” that was instrumental in making follicular unit transplantation a mainstream hair restoration procedure.

Follicular Unit Extraction Megasessions

Synopsis: This paper describes the technical and organizational skills needed for performing Follicular Unit Extraction Megasessions. It also points out some of the important long-term implications of FUE, especially regarding its inefficient use of donor area which potentially limits the ultimate donor supply.

Back to the Future with the “Dissected–Punch” Technique

Synopsis: This paper proposes that the old punch-graft technique may have a place in modern hair transplant surgery, particularly in patients with significant donor scarring and when further linear incisions are not possible. In these cases, punch harvesting (with subsequent microscopic division of the punch grafts) may be better than FUE, since extracting individual follicular units can be difficult in areas of scarring.

Follicular Unit Extraction: Summary

Minimally Invasive Surgery for Hair Transplantation William R. Rassman, MD*, Robert M. Bernstein, MD*,**, Robert McClellan, MD*, Roy Jones, MD*, Eugene Worton, MD*, Hendrik Uyttendaele, MD, PHD** Dermatologic Surgery 2002; 28: 720-728. *New Hair Institute Medical Group, A Professional Corporation, Los Angeles, California and **Department of Dermatology, Columbia University, College of Physicians and Surgeons, New …

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Follicular Unit Extraction: Minimally Invasive Surgery for Hair Transplantation

Synopsis: This paper introduced Follicular Unit Extraction into the hair transplant literature. The article describes a procedure in which individual follicular units are removed directly from the donor region through very small round incisions. It identifies significant patient variability and describes a test to determine which patients are potential candidates for this procedure. It also explores the nuances, limitations and practical aspects of Follicular Unit Extraction.

Art of Repair in Surgical Hair Restoration – Part II: Summary

Robert M. Bernstein, MD,*† William R. Rassman, MD, ‡ Nazia Rashid, and Richard C. Shiell, MBBS Dermatologic Surgery 2002; 28(10): 873-93. © 2002 The American Society for Dermatologic Surgery *College of Physicians and Surgeons, Columbia University, New York, New York †New Hair Institute Medical Group, A Professional Corporation, New York, New York and ‡Los Angeles, …

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Art of Repair in Surgical Hair Restoration – Part II

Synopsis: Together with Part I, Basic Repair Strategies, these paired articles define the state-of-the-art in correcting the cosmetic problems that resulted from outdated hair restoration techniques and/or poor surgical planning. This section emphasizes the importance of graft excision and re-implantation prior to camouflage in order to achieve the best outcome. It details the specific techniques needed for the graft excision and explains the aesthetic nuances of the camouflage.

Art of Repair in Surgical Hair Restoration – Part I: Summary

Robert M. Bernstein, MD,*† William R. Rassman, MD, ‡ Nazia Rashid, and Richard C. Shiell, MBBS *College of Physicians and Surgeons, Columbia University, New York, New York †New Hair Institute Medical Group, A Professional Corporation, New York, New York and ‡Los Angeles, CA Dermatologic Surgery 2002; 28(9): 783-94. © 2002 The American Society for Dermatologic …

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Art of Repair in Surgical Hair Restoration – Part I

Synopsis: The first of two paired articles, this paper focuses on the strategic planning that is necessary to optimize hair transplant repair procedures. The paper identifies the underlying problems that lead to poor cosmetic results and the limitations of the donor supply that limit its correction. It explains how to establish priorities to get the best results in the face of the constraints caused by outdated hair replacement techniques.

Donor Dominance Revisited: Summary

SUMMARY of Dr. Bernstein’s editorial commentary on Hwang SM et al. Does the Recipient Site Influence Hair Growth Characteristics in Hair Transplantation? The original article appeared in Dermatol Surg 2002; 28(9): 798-99. The field of hair transplantation in the United States began with Dr. Norman Orentreich’s famous 1959 paper on Donor Dominance. In it, he …

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Donor Dominance Revisited

Synopsis: In 1959, Orentreich stated that, in a hair transplant, the transplanted grafts maintained the characteristics of the donor area and were independent of the recipient site. However, new evidence suggests that that the recipient site can influence the rate of hair growth, graying, and the formation of wavy hair. The editor points out that, although these observed effects may violate the principle of donor dominance, they will have positive implications for the success of cloning.

Scalp Laxity Paradox

Synopsis: Patients with tight scalps and snug donor closures often heal with fine scars, whereas patients with loose scalps occasionally heal with wide scars. A patient with the rare condition Ehlers-Danlos Syndrome shed light on this phenomenon. After studying his case, the authors conclude that the integrity of the scalp’s connective tissue was more important than scalp laxity in determining who would heal with a fine donor scar.

Automation of Hair Transplantation

Synopsis: This paper reviews the current status and future of automated devices in surgical hair restoration. Specifically, it discusses the Hair Implanter Pen, the Rapid Fire Hair Inserter, the Calvitron, and the Choi Hair Transplanter.

Follicular Unit Graft Yield Using Three Different Techniques

Synopsis: This study compares the hair replacement techniques of mini-micrografting, vertical sectioning and single-strip harvesting with stereo-microscopic dissection for the generation of follicular unit grafts. It validated the superiority of the latter technique and supported the idea that if one wants to perform Follicular Unit Transplantation properly, single strip harvesting and microscopic dissection should be required.

A New Suture for Hair Transplantation: Poliglecaprone 25: Summary

Robert M. Bernstein, MD, William R. Rassman, MD, and Nazia Rashid Dermatologic Surgery 2001; 27(1): 5-11. College of Physicians and Surgeons, Columbia University, New York, New York Background The most common type of donor closure in hair transplantation is with non-absorbable, running sutures, usually of nylon or polypropylene. This is accomplished with, or without, buried …

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A New Suture for Hair Transplantation: Poliglecaprone 25

Synopsis: This paper introduces a new synthetic suture for surgical hair restoration called Poliglecaprone 25 or Monocryl. It is a strong, absorbable, suture with low tissue reactivity that can be used in hair transplantation to close the donor wound with a single, running stitch. This suture can provide a donor closure that ensures hemostasis, has little risk of infection and is comfortable for the patient, and generally results in a fine surgical scar.

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