Bernstein Medical - Center for Hair Restoration - Dr. O'tar Norwood
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Q: What is the Origin of the Term DUPA? — Z.Z., Darien, CT

A: The terms DPA and DUPA were first described by O’tar Norwood in his seminal 1975 publication: Male Pattern Baldness: Classification and Incidence. ((Norwood OT. Male pattern baldness: classification and incidence. So. Med. J 1975;68:1359-1365. Download)) In the paper, Dr. Norwood defined the two terms as:

Diffuse, Unpatterned Alopecia (DUPA). In this type there is a general decrease in the density of hair without any definite pattern, although it is usually more marked over the top and front. This type is common in women.

Diffuse, Patterned Alopecia (DPA). The patterns in this type of hair loss are essentially the same as in more common male pattern baldness, but the areas involved do not become totally bald; the hair only decreases in density. This also occurs in women.

Dr. Norwood’s realization that all hair loss did NOT follow his own Norwood patterns was a great insight, as well as his observation that DUPA was a common pattern in women and uncommon in men. The terms went relatively unnoticed and were not seen again in the medical literature until Drs. Bernstein and Rassman wrote about them again when they were developing Follicular Unit Transplantation. ((Bernstein RM, Rassman WR: Follicular Transplantation: Patient Evaluation and Surgical Planning. Dermatol Surg 1997; 23: 771-84. Download)) The importance of identifying these conditions is that that DUPA (either in men or women) is a relative contra-indication for hair transplantation and, with densitometry, can be readily detected in individuals at a relatively young age. Patients with DPA can be transplanted as if they were early Norwood Class 6’s.

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Follicular Transplantation - Hair Transplant Forum International - July/August 1997Dr. O’tar Norwood discusses the origin of follicular transplantation, and the influence that Dr. Bernstein’s research and publications have had on the evolution of the hair transplant procedure. Read a segment of the article:

The evolution of “follicular transplantation” can be attributed to three people. Dr. Robert Bernstein coined the phrase and advanced the concept. Dr. Bob Limmer introduced the use of the binocular microscope, providing the technology, and Dr. David Seager showed by direct hair counts, comparing the growth of grafts cut with and without the microscope, how the hair growth was improved when the follicular unit was kept intact.

Read the full article in the Hair Restoration Papers portion of our website.

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by O’Tar T. Norwood, MD, Oklahoma City, Oklahoma, USA

Hair Transplant Forum International (July/August 1997 issue)

NOTES FROM THE EDITOR EMERITUS

Hair Transplant Forum International - July/August 1997The evolution of “follicular transplantation” can be attributed to three people. Dr. Robert Bernstein coined the phrase and advanced the concept. Dr. Bob Limmer ((Limmer B: Forum, Vol. 2, #2, 1991.)), ((Limmer B: J Dermatol Surg Oncol, 1994; 20:789-793.)) introduced the use of the binocular microscope, providing the technology, and Dr. David Seager showed by direct hair counts, comparing the growth of grafts cut with and without the microscope, how the hair growth was improved when the follicular unit was kept intact. ((4th Annual Meeting of the International Society of Hair Restoration Surgery September 19, 1996, “Does the size of the graft matter?”)), ((Seager, DJ: Micrograft size and subsequent survival — accepted for publication — Journal of Dermatologic Surgery.))

“What then is follicular transplantation?” I quote Dr. Robert Bernstein because he states it so completely and succinctly in his 1995 article “Follicular Transplantation:”

“Follicular Transplantation is the logical end point of over thirty years of evolution in hair restoration surgery beginning with the traditional large plugs and culminating in the movement of one, two and three hair units, which mirror the way hair grows in nature. The key to follicular transplantation is to identify the patient’s natural hair groupings, dissect the follicular units from the surrounding skin and place these units in the recipient site in a density and distribution appropriate for a mature individual. The critical elements of follicular transplantation are an accurate estimation of the donor supply of hair, meticulous dissection of the follicular units, and careful design of the recipient area to maximize the cosmetic impact of the transplant, use of large numbers of implants in fewer rather than more sessions, a long-term master plan that accounts for the progression of male pattern alopecia, and realistic expectations on the part of the patient.” ((Bernstein, RM: Follicular Transplantation. Int J of Aesthetic and Restoration Surg. 1994 Vol.3 #2 pp 119-132.))

By combining the concept of follicular transplantation with the use of the binocular microscope, hair transplant surgery has reached a new level of excellence.

This photo from Dr. Seager has appeared in the Forum before, illustrating better growth with follicular transplantation. Right side cut with microscope into intact follicular units of 1-2 hairs, whereas the left side was planted as 1-2 haired micrografts split away from larger intact follicular clumps.

Note, however, the grafts at the top of photo done several years earlier. They contain 4-5 hairs but more importantly they don’t look nearly as natural as the ones where follicular units were specifically kept intact.

Follicular units cut with 3 microscope containing 2-4 hairs. NOTE: They contain shafts, follicles, sebaceous gland and perifolliculum.

Follow-Up
I am beginning to see my first patients back since I began follicular transplantation using the binocular microscope. Growth is better, particularly in single hair grafts which is exactly what I was told would happen. I have seen about ten patients, and every one of them is growing earlier and better.

X-factor
I refer to Dr. Jose Greco’s article in the last Forum about X-factor. I have had patients similar to his that grew only about 10% of the hair and I had repeated it usually at no charge and was very careful and still got poor growth. I have one of those patients now that wants some more grafts and I am going to do follicular transplantation and maybe in another four months we will know the answer.

Postoperative Ointment
Also in the last Forum, an article by Dr. Bernstein on ointment following hair transplants. Over the years I have gotten to where I did not use any ointment but there is a lot of evidence in the dermatology literature encouraging the use of post-op ointment. Ointments appear to speed up the healing process. I asked Dr, Blaine Lehr, my associate, to comment on this and he gave me the following statement “Postoperative ointment maintains moist wounds and increased surface humidity, which greatly increases the rate of re-epithelization. By decreasing crust formation, migrating epithelial cells do not face a barrier to their movement. With improved healing there is less potential for scarring and residual pigmentary abnormalities.”

Since I have been using ointment, patients look much better sooner. Sometimes there are hardly any crusts.

Why does it take so long?
Also in the last issue, Dr. Shiell commented on how it is interesting to read old Forums and specifically mentioned Bob Limmer’s use of the dissection microscope. Since I had not read the last issue of the Forum, I called Bob Limmer to get the first reference on the binocular microscope, and he said it was probably the one mentioned in the last Forum by Richard Shiell in his Editor’s Notes. What a coincidence!

I wonder why it took us so long to recognize how important that work was. I also wonder why it took us so long to recognize follicular bundles as the most logical unit for hair transplanting.

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by O’Tar T. Norwood, MD, Oklahoma City, Oklahoma, USA
Hair Transplant Forum International (May/June 1997 issue)

Hair Transplant Forum International - May/June 1997I just returned from visiting Dr. Bob Bernstein in New York, and was impressed with his operation and even more impressed with his thoughts, observations, and insights into hair transplant surgery. He applies scientific methods to his work, is academically honest, and has an almost eerie instinctive knowledge of hair transplant surgery. Of course he has Dr. Bill Rassman to work with, but it is still remarkable. Dr. Bernstein is best known for introducing follicular transplantation ((R. Bernstein and W. Rassman Follicular Transplantation, International Journal of Aesthetic and Restoration Surgery. Vol. 3: No 2,1995, 119-132.)) to hair transplant surgery, an idea Bob Limmer has been pushing for ten years with the use of the binocular microscope, but no one would listen to him. Dr. Limmer, however, never used the term follicular transplantation. Using the microscope, you automatically dissect the follicular units. It can’t be avoided if done properly.

The follicular transplantation concept is based on the observation that hair naturally grows in follicular units of one to four hairs, so probably the best way to transplant them is to keep them in this natural anatomical and physiological state. Dr. David Seager ((DJ Seager, Micrograft Size and Subsequent Survival, accepted for publication, Dermatologic Surgery.)) has recently shown that when the integrity of the follicular unit is maintained up to 20%, better growth occurs, making this concept of truly major importance.

We discussed many other topics, and it is interesting how he has a fresh, new look at the fundamentals of hair transplant surgery, hair growth, and anatomy and physiology of the hair follicle. Many of these ideas and concepts will appear in the upcoming special issue of Dermatologic Surgery. ((R. Bernstein and W. Rassman, The Art of Follicular Transplantation, accepted for publication, Dermatologic Surgery.))

His views on the following special subjects I find interesting:

1. Donor density: He emphasizes the importance of density, describes how to measure it, and explains how precious donor hair is. He shows that in the average patient, we can safely transplant about 50% of the available “permanent” donor hair. He does this mathematically. Dr. Bernstein and Dr. Rassman have brought measurement of density to a scientific level by using the densitometer and counting numbers of hairs in each square centimeter. I have started using this and it really works. I believe the importance of density cannot be over-emphasized. It is actually as important as the classification in patient selection and design.

2. Caliber of hair: Coarse vs. fine diameter. He believes coarse hair covers much better than fine hair. He considers not only the number of hairs but the total value of hair mass that is available for transfer. He believes that coarse hair creates the illusion of fuller coverage than fine hair can achieve.

3. Scalp – thin vs. thick: He emphasizes the importance of thickness of scalp. I have preferred thick scalps to thin scalps for years, but never was quite sure why.

4. Delayed growth: His analysis of the natural hair cycle and its relation to hair transplant surgery, I think, is brilliant. It explains what we see on a daily basis. ((R. Bernstein and W. Rassman, Delayed Hair Growth, Hair Transplant Forum International. Vol. 7: No 3, 1997.))

5. Diffuse patterned alopecia (DPA) and diffused unpatterned alopecia (DUPA):
Although I first described these years ago, I failed to recognize their importance. They are quite common in men and women. Although they have received some recognition in women, their study in men has been completely ignored. It is important to distinguish DUPA and DPA because hair transplants should probably never be done on a patient with DUPA.

6. Aging alopecia: This occurs in everyone and occasionally occurs extremely early in life, so that is important to recognize. I have watched my own hair thin over the years, and I have watched my patients’ donor hair and their transplanted hair thin over the years. Sometimes you can see through the remaining donor fringe. Dr. Bernstein describes the differences of senile alopecia, androgenic alopecia, and diffuse alopecia and their importance.

I really haven’t had time to “digest” all the new ideas I obtained from Dr. Bernstein. I haven’t had time to try all of the techniques I saw, but I am sure his influence on hair transplant surgery is going to be considerable.

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An Idea Whose Time Has Come - O'tar NorwoodThe following is a portion of “An Idea Whose Time Has Come,” an editorial written by O’Tar T. Norwood, MD — founder of the Norwood Classification System for Hair Loss — and published in the May/June 1997 issue of “Hair Transplant Forum International”:

I just returned from visiting Dr. Bob Bernstein in New York, and was impressed with his operation and even more impressed with his thoughts, observations, and insights into hair transplant surgery. He applies scientific methods to his work, is academically honest, and has an almost eerie instinctive knowledge of hair transplant surgery. Of course he has Dr. Bill Rassman to work with, but it is still remarkable. Dr. Bernstein is best known for introducing follicular transplantation to hair transplant surgery, an idea Bob Limmer has been pushing for ten years with the use of the binocular microscope, but no one would listen to him. Dr. Limmer, however, never used the term follicular transplantation. Using the microscope, you automatically dissect the follicular units. It can’t be avoided if done properly.

To read the full article, visit “An Idea Whose Time Has Come” in the Hair Restoration Papers section of our website.

Reference
Norwood O. “An Idea Whose Time Has Come,” Hair Transplant Forum International 1997; 7(3): 10-11.

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