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Bernstein Medical - Center for Hair Restoration
Hair Restoration Answers

What Problems Can Arise from Transplanting the Crown Too Early?

Q: What is the problem with transplanting the crown too early? — P.L., Newark, NJ

A: If a person’s hair loss continues –- which is almost always the case -– the crown will expand and leave the transplanted area isolated, i.e. looking like a pony-tail. The surgeon can perform additional hair transplant procedures to re-connect the transplanted area to the fringe, but this is a large area that can require a lot of hair, and it is often impossible to determine when a person is young if the donor supply will be adequate. View the full post to see a photo of a patient who had an early hair transplant to his crown.

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Hair Restoration Answers

Why Does Vice President Joe Biden’s Hair Transplant Look Unnatural?

Q: There is a famous hair transplant out there, Vice President, Joe Biden. How come it looks so unnatural? — W.S., Los Angeles, CA

A: With Joe Biden’s hair transplant a number of errors were made. Some were unavoidable due to the older technology and some were just poor planning. He had a hair transplant consisting mainly of large plugs because that was the way hair transplants were performed many years ago. But many of those plugs have now been fixed.

The persistent (but avoidable) problem is that Vice President Biden has a low, broad hairline. But when you see a low broad hairline one expects to see the rest of head to be covered with hair. But he didn’t have enough donor hair to accomplish this. With better planning, the hairline would have been more receded at the temples, producing a more natural, balanced look.

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Bernstein Medical In The News

Press Release: Hair Transplant Pioneer Studies Hair Cloning, Hair Restoration Procedures Using ACell’s Extracellular Matrix

Hair Cloning with ACell MatriStemRobert M. Bernstein, M.D., F.A.A.D., the renowned hair transplant surgeon and founder of Bernstein Medical – Center for Hair Restoration in New York, is studying four different applications of ACell MatriStem™ extracellular matrix in a type of hair cloning, called hair multiplication, as well as current hair restoration procedures. Click the link to read the whole press release.

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Hair Restoration Answers

How Will Hair Transplant Look If Donor Area Hair Is Dark And Recipient Area Hair Is Gray?

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.

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Hair Restoration Answers

Do I Need a Hair Cut Before My Hair Transplant?

Q: I am considering having a hair transplant. Does my hair need to be cut? — I.S., New York, NY

A: In all hair transplant procedures, we are able to transplant into areas of existing hair without it having to be cut. The question of whether hair needs to be cut in the donor area depends upon the way the donor hair is obtained (harvested).

With a Follicular Unit Hair Transplant procedure using single strip harvesting method (FUT), only the strip of hair that is removed needs to be cut. When the procedure is finished, the hair above the incision lays down over the sutured area and it becomes undetectable.

In Follicular Unit Extraction (FUE), particularly in sessions over 600 grafts, large areas of the donor area must be clipped short (to about 1-2mm in length) in order to obtain enough donor hair.

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Hair Restoration Answers

Does Strip Harvesting In Hair Transplant Make Donor Area Smaller?

Q: I have been reading about hair transplantation and I have a question concerning FUT (strip-harvesting). I understand, in this method, a strip is excised from the back of the scalp, the wound then closed. I wonder, then, is not the overall surface of the scalp reduced in this procedure? After two or three procedures, especially, (or even after one large session) will not a patient’s hairline also be shifted? That is, the front hairline would move back by the amount of scalp excised, or, more likely, the “rear hairline” (which ends at the back of the neck) must certainly be “moved upward.” At least, this is how I imagine it would be. Is my logic flawed? I’ve been trying to understand this in researching the procedure, but the point still evades me. — M.M., Great Falls, V.A.

A: The hair bearing area is much more distensible (stretchable) than the bald area and just stretches out after the procedure. As a result, the density of the hair in the donor area will decrease with each hair transplant session, but the position of the upper and lower margins of the donor area don’t move much – if at all. As a result, the major limitation of how much donor hair can be removed is the decreasing hair density, rather than a decrease in the size of the donor area.

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Hair Restoration Answers

When Should Hair Transplant Be Considered For Thinning Area?

Q: At what level of thinning should the hair transplant be done? — V.K., London, UK

A: A hair transplant should be considered in an area of thinning when:

  • The area has not responded to medical therapy (finasteride 1mg a day orally and minoxidil 5% topically for one year).
  • The thinning is significant enough that it can’t be disguised with simple grooming (i.e. is a cosmetic problem even when the hair is combed well).

Other factors that are important include:

  • the age of the patient
  • the donor supply
  • whether the thinning is in the front of the scalp or in the crown
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Hair Restoration Answers

After Hair Transplant, What Is Recommended Hair Length To Hide Scar?

Q: I never kept my hair really long, what length can I wear my hair after a hair transplant to hide that I had a procedure? — D.F., Chappaqua, N.Y.

A: Hair transplants, whether using the strip method to harvest the donor hair or by extracting individual follicular units one-by-one directly from the scalp, will leave some scarring. If the hair is long enough so that the underlying scalp is not visible, these scars will not be seen.

The quality and density of a person’s donor hair will affect this coverage and determine how short a person may keep his hair. In some cases the back and sides can be cut to a few millimeters, in others it would need to be kept longer. Since there is no scarring in the recipient area (the front and top of the scalp where the grafts are placed) the hair in these areas may be kept at any length.

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Hair Restoration Answers

Can You Have a Hair Transplant to the Crown Before the Front or Top of Scalp?

Q: Can the crown be transplanted first instead of frontal area? Why is the crown the last choice? Any reasons behind it? — H.H., Ladue, M.I.

A: The crown can be transplanted first in patients who have very good donor reserves (i.e., high density and good scalp laxity). Otherwise, after a hair restoration procedure to the crown you may not be left with enough hair to complete the front and top if those areas were to bald.

Cosmetically, the front and top are much more important to restore than the back. A careful examination by a trained hair restoration surgeon can tell how much donor hair there is available for a hair transplant.

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Hair Restoration Answers

Areas of Unethical Behavior Practiced Today

Note from Dr. Bernstein: This article, by my colleague Dr. Rassman, is such important reading for anyone considering a hair transplant, that I felt it should be posted here in its entirety.

Areas of Unethical Behavior Practiced Today
William Rassman, MD, Los Angeles, California

I am disturbed that there is a rise in unethical practices in the hair transplant community. Although many of these practices have been around amongst a small handful of physicians, the recent recession has clearly increased their numbers. Each of us can see evidence of these practices as patients come into our offices and tell us about their experiences. When a patient comes to me and is clearly the victim of unethical behavior I can only react by telling the patient the truth about what my fellow physician has done to them. We have no obligation to protect those doctors in our ranks who practice unethically, so maybe the way we respond is to become a patient advocate, one on one, for each patient so victimized.

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Hair Restoration Answers

After a Hair Transplant What are the Effects of DHT on Donor Hair?

Q: Hi! I wanted to ask if after a hair restoration surgery the transplanted hair will eventually fall out? Because the surgery is to restore hair mainly for people with genetic hair loss which results from DHT, won’t the DHT make the new follicles implanted fall out as well? — B.C., Stamford, C.T.

A: Hair loss is due to the action of DHT (a byproduct of testosterone) on hair follicles that cause them to shrink and eventually disappear (the process is called miniaturization). The follicles on the back and sides of the scalp are not sensitive to DHT and therefore don’t bald (miniaturize).

When you transplant hair from the back and sides to the bald area on the front or top of the scalp the hair follicles maintain their original characteristics (their resistance to DHT) and therefore they will continue to grow.

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Hair Restoration Answers

What Happened with Joe Biden’s “Pluggy” Hair Transplant and What Repair Strategy Do You Suggest?

Q: What’s the story with Joe Biden’s hair? — R.B., Inwood, N.Y.

A: Joe Biden — former Senator from Delaware and now the Vice President of the United States — apparently had a hair transplant many years ago using the older hair restoration techniques. This included not only transplanting hair in large plugs (corn rows), but using them to create a broad frontal hairline; a design that generally does not look natural as a person ages.

Also, the older grafts were transplanted in a vertical orientation giving a sprout-like, unnatural appearance.

The use of large plugs and the inefficiencies of the older procedures waste a considerable amount of donor hair, leaving Senator Biden with a dense rim of hair in the front part of his scalp and little coverage behind that.

The repair strategy would consist of removing the larger plugs, microscopically dividing them into smaller grafts (individual follicular units of 1 to 3 hairs each), and then placing the smaller grafts in a more forward direction and in a more natural distribution. This involves using the 1-hair units to soften the frontal hair line and the 2- and 3-hair units to extend the transplant further back on the scalp.

In addition to the hair transplant repair, Biden received significant cosmetic improvement from the natural graying of his hair over the years, as this tends to make the hair appear fuller and any irregularities less noticeable.

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Hair Restoration Answers

What Makes Eyebrow Transplant Different From Other Hair Transplants?

Q: I have had thinning eyebrows since my early twenties (I am now 32) and they have gotten to the point that I can’t make them look good with mascara anymore. I am considering an eyebrow hair transplant, how is it different from other hair transplants? — C.C., Williamsburg, N.Y.

A: Eyebrow hair restoration procedures are similar to hair transplants to the scalp in that the hair, once transplanted, is permanent. They differ both in the techniques used to perform them and in the results.

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Hair Restoration Answers

Do You Use Megasessions or Very Large Graft Sessions In Your Hair Transplant Procedures?

Q: Some surgeons are doing hair transplants using 5,000 to 6,000 grafts in a single surgery. Looking at the cases in your photo gallery, it seems like your hair transplants involve many fewer grafts per surgery. Do you do such large graft numbers in a single hair restoration procedure? — H.P., Cranston, R.I.

A: The goal in surgical hair restoration should be to achieve the best results using the least amount of donor hair (the patient’s permanent reserves) and not simply to transplant the most grafts in one session. In my opinion, although large sessions are very desirable, the recent obsession with extremely large numbers of grafts in one session is misplaced. The focus should be on results.

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Hair Restoration Answers

After Hair Transplant, Can Hairline be Lowered Further with Second Procedure?

Q: In my first hair transplantation procedure, I wanted to be as conservative as possible and focus on thickening the thinning hair on top of my head and lowering the hairline minimally. Is it still possible to lower the hairline further in a second hair restoration procedure? Is there an “ideal” time period for a second hair transplant after the first? — B.B., Meatpacking, N.Y.

A: It is possible to lower the hairline with a second hair transplant, but the doctor must be certain that you have enough donor hair so that the transplanted pattern will look natural long-term.

Unless there is some pressing reason that you had to have a second session sooner, I would wait a minimum of 10-12 months between hair restoration procedures so that you can see the full cosmetic impact of the first session.

As a hair transplant matures and thickens, the hairline will look lower as the eye doesn’t see as far into the scalp.

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Hair Restoration Answers

What are Typical Hair Transplant Results?

Q: I know that I can’t get all of my hair back, but what can I realistically expect from the best hair transplants? — S.A., Santa Monica, C.A.

A: You can expect the follicular unit hair transplant procedure to be perfectly natural, that the hair restoration will be completed in one or two sessions and you should anticipate a quick and easy post-op course.

The amount of coverage and density will depend upon your Norwood (balding) class, your donor reserves and your hair characteristics.

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Hair Restoration Answers

Can Hair Transplant Thicken Thinning Hair in Person with Early Hair Loss?

Q: I am 22 and losing my hair all across the top of my head. How can I thicken my hair to its level a few years previously? — I.L., Kentfield, CA

A: If medication, such as finasteride, is successful it can thicken hair by increasing the diameter of the existing hair shafts. Although the cosmetic benefits can be dramatic in a person with significant hair loss, a hair transplant can not restore hair to its original density, since it only moves the existing hair around and does create new hair.

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Hair Restoration Answers

How Many Hair Transplant Grafts Will Give Best Results and Do Megasessions Yield Best Cosmetic Benefit?

Q: There is such a big deal made on the chats about people getting Megasessions of over 4000 grafts per session. When I look at the pictures on your website, the results look great, but I am surprised that not many grafts were used compared to what is being talked about. — N.R., Poughkeepsie, N.Y.

A: My goal is not to transplant as many grafts as possible, but to get the best results possible without exhausting a person’s donor supply. It is important to keep reserves for future hair loss. Unnecessarily large sessions also risk poor growth and have a greater incidence of donor scarring.

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Bernstein Medical In The News

Dr. Bernstein Presents at ISHRS 13th Annual Scientific Meeting in Sydney, Australia

Dr. Bernstein - Presenting on Hair Transplantation in Sydney, AustraliaSome of the world’s most renown hair transplant surgeons gathered this month to hear about the latest cutting edge methods in surgical hair restoration. Speakers included Robert M. Bernstein. M.D. founder of Bernstein Medical – Center for Hair Restoration , New York, NY

The International Society of Hair Restoration Surgery (ISHRS) recently held their 13th annual scientific meeting. A broad range of topics were explored including; the most recent research in cloning, the latest proven medical therapies to prevent hair loss, and the newest concepts in the harvesting of donor hair follicles used for transplanting. The event was capped off with a live hair transplant surgery workshop.

As the largest non-profit voluntary organization comprised of over 650 hair restoration physicians, the ISHRS is the first international society created to promote continuing quality improvement and education for professionals in the field of surgical hair restoration.

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Hair Restoration Answers

How Much Hair Can be Removed From the Donor Area?

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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Hair Restoration Answers

Hair Transplant for Thinning Hair on a Crown?

Q: Should you perform a hair transplant on a crown that is just starting to thin? — R.R. Philadelphia, Pennsylvania

A: A “thin” crown should first be treated with Propecia, as it may thicken the hair to a cosmetically acceptable degree without the need for surgery. If Propecia is ineffective in restoring enough hair, then surgical hair restoration can be considered.

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Hair Restoration Answers

In an FUT Hair Transplant, What Percentage of Telogen Phase Follicles in Donor Strip are Wasted?

Q: When a donor strip is taken out during a hair transplant and separated under the microscope, you can read on the internet that there is a wastage of grafts (about 15%), because of those unseen telogen hairs. What do you think about that and how does it affect the hair restoration? — T.B. Baldwin, New York

A: The Telogen phase of the hair cycle is about 3 months long and about 12% of follicles are in this phase at any one time. It is speculated that the follicles may be empty for perhaps 1/2 that time (this number may vary significantly between people). Therefore, approximately 6% of the hair follicles may be in telogen at any one time.

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Hair Restoration Answers

After FUT Hair Transplant Surgery, Can I Travel on an Airplane with Surgical Staples?

Q: I’ll be traveling from New York to Cincinnati the week after my hair transplant. Will I be able to get through airport security if I have staples? — D.B. Fort Lauderdale, Florida

A: Yes. Although the staples that we use to close the donor area after hair transplant or restoration procedures are made of stainless steel, they are too small to be picked up by metal detectors.

I generally prefer staples, as they are superior to sutures in preserving donor hair.

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Hair Restoration Answers

Can I Have a Hair Transplant If I Have Fine Hair?

Q: My hair is fine. Is that a problem for a hair transplant? — N.R., Boston, MA

A: Fine hair will give a thinner look than thicker hair, but will look completely natural. Thin hair doesn’t prevent one from having surgical hair restoration, providing your donor density and scalp laxity are adequate. These would need to be measured.

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Hair Restoration Answers

Can I Have an FUE Hair Transplant Using Beard Hair?

Q: Can you use beard hair for a hair transplant using Follicular Unit Extraction? — A.C., San Francisco, CA

A: It is possible to use beard hair for a hair transplant, but there are three main differences between harvesting from the donor area and harvesting from the beard that should be taken into account. These are: 1) scarring 2) ease of extraction and 3) hair quality. Let’s explore these differences in turn.

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Hair Restoration Answers

Can an FUE Hair Transplant Use Donor Hair from Outside the Permanent Zone?

Q: If someone doesn’t have enough donor hair, do you ever perform a hair transplant using FUE, using donor hair from outside the permanent hair zone? — M.V., Nashville, TN

A: No. If hair was taken from outside the permanent zone as the surrounding hair continued to bald, the scars from FUE, although small, would become visible.

In addition, the transplanted hair would not be permanent, and over time would eventually fall out.

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Bernstein Medical In The News

Dr. Bernstein Debates Large Graft Hair Transplants At 1998 ISHRS Meeting

At the 6th Annual Meeting of the International Society of Hair Restoration Surgeons held in Washington, D.C. in 1998, Dr. Walter Unger (defending the “old guard”) debated Dr. Bernstein (representing the new technique of Follicular Unit Transplantation) in front of an audience of over 450 hair restoration surgeons from around the world. Dr. Unger took the position that large grafts still had a place in surgical hair restoration, particularly for creating density. Dr. Bernstein took the position that the new procedure of Follicular Unit Transplantation could create that density while at the same time achieving a completely natural look — something large graft procedures were incapable of doing. He argued that the versatility and naturalness of Follicular Unit Transplantation rendered the older procedures obsolete.

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Bernstein Medical In The News

Follicular Hair Transplantation Makes Splash After Bernstein Introduces Procedure To American Academy of Dermatology

Cosmetic Surgery Times
Cosmetic Surgery Times - April 1997

Cosmetic Surgery Times features Dr. Bernstein’s presentation to the 55th annual meeting of the American Academy of Dermatology in their April 1997 issue.

The article describes Dr. Bernstein’s introduction of the concept of Follicular Unit Transplantation to the academy as well as the keys to making the technique successful. From the article:

“‘Hair doesn’t grow singly it grows in naturally occurring groups of from one to four hairs. In follicular transplantation, we use these naturally occurring groups as the unit of the transplant,’ he told CST.

Although the procedure is highly labor intensive, it can actually be less expensive than conventional hair replacement surgery, because it can be performed in a single, but lengthy, session.

‘It is also much more efficient and conserves donor hair much better than conventional hair transplants. Every time you make an incision in the person’s scalp you waste some hair and make the remaining hair more difficult to remove. Accessing the donor area just once or twice will increase the total amount of hair that is available for the transplant,’ Dr. Bernstein told CST.”

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