Bernstein Medical - Center for Hair Restoration - Aesthetics of Follicular Transplantation
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Q: How can I better understand how I will look after my hair transplant before I actually do the procedure? — E.M. ~ Wantagh, N.Y.

A: A key part of a hair loss evaluation is for the doctor to manage the patient’s expectations for possible benefits from both medication and surgery. The way we decide how to plan a hair transplant is through a careful history and examination, demarcating the extent of the hair transplant on the patient’s actual head and photographing it. When showing other photo results to patients, it is important to not only show before and after photos of the recipient area but also of the donor area; how the back of the head looks immediately after the procedure, at post-op intervals, and at different hair lengths. Most importantly, one should point out that every patient is different so that a picture of another person does not necessarily represent what you might achieve.

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Q: For patients who intend to keep their hair parted on the left side, do you follow any rule of making the left side more dense then the right or is it distributed evenly? — M.S., Simi Valley, C.A.

A: On a first hair transplant procedure, I generally place the sites/grafts symmetrically, even if a patient combs his hair to one side. The reason is that the person may change his styling after the procedure and I like to have the first hair transplant symmetrical for maximum flexibility. An exception would be a person with limited donor reserves. In this case, weighting on the part side is appropriate in the first procedure. Once the first hair transplant grows in and the person decides how he wants to wear his hair long-term a second transplant can be weighted to accommodate this. Weighting can be done in one, or both, of two ways: 1) by placing the sites closer together on the part side or 2) by placing slightly larger follicular units on the part side.

If a person decides to comb his hair back, then forward weighting is used. For greater details on this, please see some of my publications where I address the aesthetics of hair transplantation:

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Journal of the American Academy of DermatologyDr. Bernstein is credited with introducing the “follicular unit” to surgical hair restoration, the innovation that allowed for a “completely natural-looking hair transplant” to be achieved. The commentary on Dr. Bernstein’s contributions to the field of hair transplantation are outlined in an historical review of dermatologic surgery that appeared in the Journal of the American Academy of Dermatology.

Dr. Bernstein is noted as being responsible for moving the field of hair restoration surgery away from large graft “plugs” and mini-micrografts to follicular units:

The following year, dermatologists Bernstein et al laid down the conceptual framework for follicular unit transplantation in their 1995 article, “Follicular transplantation.” In 1997, they detailed its clinical application in the paired articles, “Follicular transplantation: patient evaluation and surgical planning” and “The aesthetics of follicular transplantation.”

The 2 advances, the application of the stereomicroscope to follicular dissection and the use of follicular units as the basic element of hair transplantation, arose from a background in dermatology. They moved the field of hair restoration surgery from plugs and mini-micrografting, where this basic anatomical feature of the hair follicle was ignored, to follicular unit transplantation, where the follicular unit became sacrosanct. These 2 ideas, when put to clinical use, allowed the once elusive goal of a completely natural-looking hair transplant to finally be achieved.

Dr. Bernstein’s pioneering of the Follicular Unit Transplant (FUT) procedure still resonates, almost two decades later, as the follicular unit continues to be the anatomical structure that is transplanted in hair transplant surgeries worldwide.

The article then describes how Dr. Bernstein, along with his colleague Dr. Rassman, laid the foundation for the next major developments in hair restoration; first with his description of the Follicular Unit Extraction (FUE) technique and more recently with innovation in robotic hair restoration technology.

With the publication of the article, “Follicular unit extraction,” in 2002, the follicular unit extraction procedure gained popular appeal and was rapidly adopted by doctors worldwide. The authors cautioned on the limitations of this harvesting technique and the risk of follicular damage. Dermatologists Berman, Zering, and Bernstein, along with their colleagues in other specialties, continue to work on the problem of harvesting in follicular unit extraction, with the application of robotic technology showing particular promise.”

Taken together, these passages underscore how Dr. Bernstein’s research and medical publications have fundamentally transformed the field of hair restoration to the benefit of patients and physicians alike. While many other very talented physicians have had a substantial impact on hair restoration procedures ever since the hair transplant concept was first proposed by Dr. Norman Orentreich in the 1950s, Dr. Bernstein has contributed the key innovations that have made modern, natural-looking hair transplant surgery a medical and aesthetic possibility.

The article is titled, “Current status of surgery in dermatology.” The Journal of the American Academy of Dermatology is the official journal of The American Academy of Dermatology (AAD), the largest, most influential and most representative dermatology group in the United States.

Reference

C. William Hanke, Ronald L. Moy, Randall K. Roenigk, Henry H. Roenigk Jr., James M. Spencer, Emily P. Tierney, Cynthia L. Bartus, Robert M. Bernstein, Marc D. Brown, Mariano Busso, Alastair Carruthers, Jean Carruthers, Omar A. Ibrahimi, Arielle N.B. Kauvar, Kathryn M. Kent, Nils Krueger, Marina Landau, Aimee L. Leonard, Stephen H. Mandy, Thomas E. Rohrer, Neil S. Sadick, Luitgard G. Wiest, Current status of surgery in dermatology, Journal of the American Academy of Dermatology, Volume 69, Issue 6, December 2013, Pages 972-1001, ISSN 0190-9622, http://dx.doi.org/10.1016/j.jaad.2013.04.067.

Read more about Dr. Bernstein’s history of innovation in hair transplant surgery

Read Dr. Bernstein’s landmark medical publications

Download and read ‘Current status of surgery in dermatology’ (pdf)

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Q: I notice that some patients end up with hair that seems to stand straight up while others have hair that flows to one side or the other. Does the angle at which you place the follicles in the scalp ultimately determine how the hair will lie? Is there some artistic talent needed when placing these follicles so that patients end up with hair that lies flat or sticks straight up? What determines this? Do we have control over it? — H.B., Fort Lauderdale, F.L.

A: Great question. You are correct, the angle of the recipient sites largely determines the hair direction. Hair should be planted the way it grows (i.e., in a forward and horizontal direction at the frontal hairline.) It is extremely important that it is transplanted that way to look natural. The body will alter the angle a bit as it heals, usually elevating it slightly and re-creating any prior wave (yes, waves are determined by the scalp, rather than by the hair follicles per se). In a properly performed hair transplant, a straight-up appearance should be due to grooming, it should not have been a result of the actual procedure. Hair should never be transplanted perpendicular to the scalp. I discussed these important concepts way back in my 1997 paper “The Aesthetics of Follicular Transplantation“.

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Q: How are grafts distributed in a hair transplant? Are they distributed evenly? — B.V., Jersey City, NJ

A: Actually, we don’t make the transplanted hair evenly distributed. It is usually front weighted, so that the hair restoration will look most full when looking at the person head on.

Framing the face is the most important part of the restoration. Covering the top is the next most important region and, if the patient has enough donor supply, then hair can be added to the crown.

For a more detailed discussion of this topic, view our page on recipient sites in a follicular unit hair transplant. Also, read the publication written by Dr. Bernstein in 1997 which became the industry benchmark for aesthetics in hair transplant surgery, “Aesthetics of Follicular Transplantation.”

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