Donor Hair Harvesting - Bernstein Medical - Center for Hair Restoration
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Q: In hair transplant repairs do you always harvest additional hairs to give the hair restoration a better result? Which is better for repair procedures, FUT or FUE? — E.Z. ~ Fairfield, C.T.

A: We do not always harvest additional hair in repair procedures, but we do if possible because it can improve the aesthetic outcome by adding additional density and camouflage. This is called Combined Repair. As for whether we use FUT or FUE in repair procedures, the answer depends on the clinical situation. For example, a loose scalp favors FUT. If the person wants to wear their hair short, that favors FUE. If donor scars from the plugs need to be removed, that favors FUT. If scarring in the donor area needs to be camouflaged rather than removed, that favors FUE.

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Q: I have read that the ARTAS System works best on straight black hair. Is this an option for gray hair? How about wavy or curly hair? – P.W., Fort Lee, NJ

A: The ARTAS robotic system can be used in patients with any hair color although in order for the robot to visualize white hair (or very light blond hair) the hair must be dyed. Curly hair is also not a problem as the donor hair in a robotic procedure is shaved to approximately 1 mm in length so a wave or curl is eliminated. In patients of African descent, where the hair below the surface of the skin may be curved, a slightly larger punch can be used. we have patients dye their hair the evening before or the day of the procedure. For convenience, only the hair in the donor area (back and sides) where the robot will be doing the harvesting needs to be dyed.

In patients who prefer not to shave or dye the entire back and sides of the scalp, we can perform the ARTAS robotic FUE using the long-hair technique. With this technique, you will grow your hair on the back and sides of the scalp a bit longer so it can cover the harvested area. On the day of the procedure, we will lift up the hair, clip a long thin band of donor hair and then extract follicular units from this limited region of the scalp. After the procedure, you can simply comb down your hair to cover the donor zone. The area that has been harvested (and possibly dyed depending on your hair color) will not be visible.

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Q: I have been reading about Robotic FUE and have seen some photos on your website of you operating the ARTAS robot using what looks like a remote control. What is that thing and how does it control the robot? — C.B., Greenwich, CT

Dr. Bernstein Operating the ARTAS FUE Robot
Dr. Bernstein Operating the ARTAS FUE Robot

A: The ARTAS robot uses a dual operating system when performing follicular unit extraction. One station consists of a desktop computer adjacent to the robot. This station is used to establish the basic parameters of the transplant such as the spacing of grafts, the angle and depth of the harvest, which size follicular units will be targeted, and a host of other important variables.

The hand-held pendant is used by the operator situated next to the patient. The remote has more limited options – the main ones being depth adjustment and to immediately suspend the action of the robot. Many of the parameters are determined automatically by the robot’s computer to maximize the accuracy of the harvesting. The robot also makes real-time adjustments to these variables during the hair restoration procedure.

The physician sets the parameters at the computer monitor and, once the settings are determined, he/she sets the tensioner grid on the patient’s scalp. The tensioner determines where the grafts will be harvested. The grid is moved approximately every 130 harvests. The robot can be operated at the computer terminal and through a mobile pendant. The physician often alternates with a trained assistant between that station and using the pendant.

Besides the involvement in the operation of the robot, there are many other important physician-dependent steps to the hair transplant including the planning and design of the procedure, and recipient site creation. Other steps, such as the microscopic sorting and trimming of harvested follicular unit grafts and graft placement, are often performed by trained staff, but require the physician’s close supervision.

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Dr. Bernstein Presenting at ARTAS® User Group Meeting 2015Dr. Bernstein Presenting at ARTAS User Group Meeting 2015

Dr. Robert M. Bernstein introduced a new capability of the ARTAS® robotic system, “Follicular Unit Graft Selection,” at the ARTAS User Group Meeting on February 7th, 2015 in Newport Coast, CA. He presented the new technology and the preliminary results of a bilateral pilot study of the technique conducted at Bernstein Medical.

In robotic graft selection, the hair restoration surgeon programs the ARTAS robot to harvest follicular units based on the number of hairs in each unit. The robot first selects and then isolates larger follicular units of 2-hairs or more. If too few 1-hair units are extracted, the surgeon can program a second pass at extracting only the smallest grafts. As an alternative, the larger units can be divided into smaller ones using stereo-microscopic dissection. The goal is to both minimize wounding and harvest an adequate distribution of varying size follicular units to satisfy the surgeon’s, and ultimately the patient’s, aesthetic hair restoration needs. The new robotic graft selection system enables the robot to intelligently and efficiently harvest follicular units.

Results of the bilateral pilot study showed that the robot’s new graft selection capability was superior to random graft selection, the robot’s default setting, in the amount of hairs extracted per harvest attempt. Dr. Bernstein described how he was able to generate more transplantable grafts with fewer attempts at harvesting. By splitting larger follicular units into smaller grafts under stereo-microscopic dissection, he was able to produce additional grafts for use in the transplant without causing further wounding.

When the new computerized graft selection capability is coupled with dissection of larger units, the result is a substantial improvement over randomized graft selection. Read more about Robotic Graft Selection and the pilot study.

Dr. Bernstein also updated the meeting attendees on the robot’s recipient site creation technique that he introduced the prior year and some best practices in incorporating the ARTAS Hair Studio software into clinical practice.

Click here to read about Robotic Follicular Unit Graft Selection

Click here to read about Robotic Hair Transplants


ARTAS User Group Meeting 2015

Dr. Bernstein Presenting at ARTAS User Group Meeting 2015
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Q: How many follicles can you transplant with robotic FUE compared to manual FUE? — R.V., Upper West Side, N.Y.

A: We can extract the same number of follicles robotically as we can manually.

That said, the goal of any hair transplant procedure is not to transplant as many hair follicles as possible but rather to achieve the best possible cosmetic result given your degree of hair loss and the number of hair follicles available in your donor area.

While there is no difference between robotic and manual FUE in terms of the number of follicles that each procedure can extract, robotic FUE does have the following advantages over manual FUE:

  • During the follicular unit extraction (or harvesting) phase of a hair transplant, there is less chance of damaging follicular units using a robot vs. a hand held device (e.g., Neograft), because the robot is more accurate. This means more grafts survive after transplant.
  • Robotic graft harvesting times are shorter than manual, e.g., while on average if a physician could manually extract 200-300 grafts per hour, the same physician could robotically extract up to 500-1000 grafts per hour ((Chang, H.H. Robotics, artificial intelligence, and the future of hair transplantation. Prime Dermatology, July/August 2014.)). This means a shorter procedure time for the patient.

Read more about the advantages of Robotic FUE.

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Q: I have a significant amount of hair loss. Can a hair transplant make me look exactly the way I did before I lost my hair? — V.S., Fairfield, C.T.

A: In most cases, the answer is no. All surgical hair restoration procedures move hair – they cannot create new hair. Specifically, surgical hair transplantation takes existing hair from the donor area (located in the back and on the sides of the scalp) and moves (transplants) them to the part of the scalp that has lost hair. It is usually the case that there is not enough hair in one’s donor area to replace all lost hair. That said, in persons with extensive hair loss, the restoration can often produce a dramatic improvement in one’s appearance.

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

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

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

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

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

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

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

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

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Q: What is the main difference between NeoGraft and the ARTAS robotic system? — H.T., Staten Island, NY

A: The Neograft device is basically a powered FUE tool. It is still done by hand and therefore risks operator induced errors and damage to hair follicles. The ARTAS System, made by Restoration Robotics, uses electronic image-based tracking capabilities to map the individual follicular units. It does so to determine the optimal approach for automated graft harvesting. The robotic harvesting device produces consistently high quality grafts and low dissection rates.

For more information on these systems, visit the Follicular Unit Extraction (FUE) section or read Dr. Bernstein’s answers to questions on Robotics.

Read about Robotic FUE Hair Transplantation

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Q: When was the ARTAS robot for FUE approved for use in hair transplantation? — J.B., Jersey City, NJ

A: Restoration Robotics’ ARTAS System for robotic follicular unit harvesting, received 510K clearance by the Food and Drug Administration (FDA) on April 14, 2011. The indication is for “harvesting hair follicles from the scalp in men diagnosed with androgenetic alopecia (male pattern hair loss) with black or brown straight hair.”

Read about robotic FUE hair transplantation

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Robert M. Bernstein M.D.

Q: If a person is graying on the top and sides and you do a hair transplant from the back, will the top look darker after the hair restoration? — W.C., Houston, TX

A: The hair is taken from the back and sides of the scalp and the follicular units, once dissected from the donor strip, are randomly inserted into the recipient area. That way, the color of the harvested hair will be mixed and will match perfectly.

Usually, people’s hair is lighter on the top because of the sun, so when you move the hair from the back and sides to the top, it will actually lighten to match the surrounding hair, if it didn’t match already.

For further reading on how your hair performs after a transplant, visit the Growth After Hair Transplant topic.

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Q: I had a follicular unit hair transplant performed by another doctor that was scheduled for 2,500 grafts and I ended up paying for exactly that amount. I was supposed to be paying per graft, so it seems strange that it came out to be exactly 2,500? How do I know what I really got? — J.R., Westport, C.T.

A: This is a question that should be addressed to the doctor that operated on you.

If a doctor is charging by the graft, then you should know exactly how many grafts you are receiving. It is possible that he/she hit the number (2500) exactly on the head, but statistically that is extremely unlikely. In a Follicular Unit Hair Transplant (FUT) procedure, a strip is removed from the donor area and then dissected into individual follicular units, so although an experienced surgeon can remove a strip that contains close to the desired number of follicular units, it would be very rare to hit that number precisely.

More importantly, it is impossible to perform follicular unit transplantation properly without knowing both the exact number of follicular units harvested from the donor area and the exact number of hairs in each unit (i.e. the number of 1-, 2-, 3-, and 4-hair follicular unit grafts). This information is essential in determining both the distribution and density of the hair transplant and in creating transitional zones such as the frontal hairline, where single-hair follicular units are required.

In all hair transplants, the number of grafts harvested should equal the number of recipient sites, so the doctor must know the exact number of grafts so that he can make the appropriate number of recipient sites. An exception to this rule is the stick and place technique, where each graft is inserted as soon as the site is made, but this technique is much less common than first making the recipient sites. The surgeon also needs to know the number of grafts so that he can make the sites in the appropriate distribution. For example, if the number of grafts harvested was less than anticipated, the doctor can space the sites further apart, cover less of an area (for example, not extend the restoration as far back into the crown) or harvest additional donor tissue – each option having advantages and disadvantages.

It is equally important to know the exact composition of follicular units, so that different densities can be created in different areas, producing the most natural appearance. For example, the 3- and 4- hair follicular units should be placed in the central forelock area as this area normally has the most density. On the other hand, if these larger units are placed near the hairline, they will look distinctly unnatural.

So how can the patient really know? Obviously, trust in your doctor is the most important insurance. If you are skeptical about the way the doctor conducted the consult (i.e. used a salesman to encourage a sale), if he or she skipped over important options such as medication, or if you felt pressured or rushed into making a decision to have surgery; you should be skeptical about other aspects of your care as well – such as an accurate graft count.

Although just a very general guide, here are some things you can do at your consult when trying to decide if a doctor can be trusted to give you accurate information regarding the number of grafts you receive.

  1. Ask to see the operating room – see if there are plenty of microscopes (the larger the session, the more are needed).
  2. Ask the doctor how he keeps count of the grafts that are dissected and how does he record how many hairs in each follicular unit graft.
  3. Ask the doctor how he keeps track of the number of recipient sites that are made.
  4. Ask to see how all this information is documented in the patient’s medical record.
  5. Ask the doctor if he refunds money to the patient if he transplants less grafts than scheduled.
  6. Speak with other staff members to confirm the use of dissecting microscopes for the entire surgery and confirm the procedure for tracking grafts.

In sum, knowing the exact number of grafts and their composition is extremely important, not only to ensure that you are being charged fairly, but in maximizing the aesthetic results of your follicular unit transplant procedure.

Be certain that this information will be available to you (and of course your surgeon) before scheduling a procedure.

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Q: Is it possible to tell me roughly how many grafts would be left from donor area if one had a hair transplant of 2,500 grafts and had a density of around 2.0? G.H. – New York, NY

A: How much hair can be harvested in total depends upon a number of factors besides donor density. These include: scalp laxity, hair characteristics (such as hair shaft diameter, color and wave), and the actual dimensions of the permanent zone.

Every person is different, so all of these factors would need to be taken into account to determine the total number of grafts that would be available for the hair restoration.

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Q: I have had 4 hair transplants with strips taken out for a total of 2600 grafts over 15 years. The last one was 1,650 grafts. My doc says my donor site is good for a few more but I think it has been probably stretched to its max. Is it believable that the skin can be stretched to such extremes safely? – Murray Hill, N.Y.

A: The scalp is very resilient to stretching, particularly in those with a loose scalp to begin with. After removing a strip, the laxity often returns to normal or very close to it within 6 months to a year.

The problem with multiple hair transplant procedures is not only that scalp laxity may decrease, but that the donor density decreases as well. If too much hair is harvested, the donor area may eventually appear too thin. This may happen with either Follicular Unit Transplantation (FUT) or Follicular Unit Extraction (FUE).

Therefore, it is important the doctor not only assess the scalp laxity, but the residual donor density.

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Q: When harvesting donor hair, how does the surgeon know when to stop? – D.D., Pleasantville, N.Y.

A: The patient must first decide the shortest length he/she is comfortable wearing his/her hair.

Donor hair can be removed — whether through Follicular Unit Transplantation (FUT) or Follicular Unit Extraction (FUE) — as long as, at this length, the back and sides do not look too thin (i.e. do not have a transparent look) and the donor scars are not visible. The surgeon needs to use his judgment when harvesting, so that this endpoint is not crossed.

Additionally, the surgeon must anticipate that the caliber of hair in the donor area will decrease slightly over time as a normal course of events. The actual number of grafts that can be harvested varies greatly from person to person. It depends on the patient’s donor density, scalp laxity, hair characteristics and size of the donor area.

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