Bernstein Medical Center for Hair Restoration - Follicular Unit Grafts

Follicular Unit Grafts

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Q: I am an MMA fighter and I want to get a hair transplant. How long do I have to be out of commission and which type of procedure should I have, FUE or FUT? — J.A., Columbus, OH

A: With any type of hair transplant it takes 10 days for the transplanted grafts to be permanently fixed in place. The difference between FUE and FUT is in the limitations of activity due to the donor area. With FUE one would need to abstain from MMA for the same 10 days it takes the recipient area to heal (the grappling component of Mixed Martial Arts is the most stressful on the scalp). With FUT, however, one would need at least three months for the linear donor scar to heal before one could resume contact sports like MMA.

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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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Q: Can I play a contact sport, like football, right after having a FUE procedure? — C.N., Easton, P.A.

A: I performed a study (“Graft Anchoring in Hair Transplantation,” Dermatologic Surgery 2006; 32: 198-204) to answer a simple question, one that patients ask all the time: at what point are transplanted grafts so securely anchored in the scalp that they cannot be dislodged?

In the study, it was found that after 10 days the transplanted grafts become a permanent part of the body such that no amount of scrubbing or combing can dislodge them. So, while there are generally no limitations on strenuous exercise after a FUE procedure, we recommend waiting at least 10 days before playing any contact sport, like football, as the grafts could be dislodged if vigorously rubbed.

To learn more, see After Your Hair Transplant Surgery

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Q: Is robotic FUE different in the number of follicular unit grafts one can extract compared to manual FUE? — R.V., Stamford, CT

A: We can extract (and transplant) the same number of follicular unit grafts robotically as we can manually?

The goal of a hair transplant is not to simply transplant as many grafts as possible but to achieve the best possible cosmetic result given the number of hair follicles in your donor reserve. Remember, this is always a limited supply.

While there is no difference between robotic and manual FUE in terms of the number of follicular unit grafts that each can extract, robotic FUE does differ from manual FUE in several important ways.

First, there is generally less transection of the hair follicles with robotic FUE, since the method is more precise. This enables us to obtain follicular units with less trauma to the grafts.

Second, while the robot is not necessarily faster than the human surgeon, the robot is much more consistent since, unlike the human surgeon, it never fatigues and the accuracy is maintained throughout the entire procedure.

Read more about Robotic Hair Transplant

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ARTAS Robotic System display monitor showing parameters for the creation of recipient sitesARTAS Robotic System display monitor showing parameters for the creation of recipient sites

New York, NY (PRWEB) — Robert M. Bernstein, M.D., F.A.A.D., A.B.H.R.S., founder of Bernstein Medical – Center for Hair Restoration, introduced new technology that allows the ARTAS Robotic System to accomplish a critical step in hair transplant surgery, the creation of recipient sites. Presenting at the 2nd ARTAS User Group Meeting, Dr. Bernstein previewed the recipient site creation technology that brings the robotic system one step closer to performing critical aspects of the labor-intensive, hair transplant procedure.

The ARTAS System is currently able to harvest intact follicular unit grafts from the permanent area in back of one’s scalp using precise robotic technology. This is the most difficult aspect of a follicular unit extraction hair transplant – the newer type of hair restoration procedure that avoids a linear scar in the back of the scalp. Now that site creation can also be done robotically, only one step remains – graft placement.

The ARTAS Robotic System maps the surgeon's hairline design onto a 3-D model of the patient's headThe ARTAS Robotic System maps the surgeon’s hairline design onto a 3-D model of the patient’s head

For the recipient site creation, the doctor first draws a hairline and other markings directly onto the patient’s scalp to delineate the surgical plan. Next, multiple photographs are taken and fed into software, called the ARTAS™ Hair Studio, which converts the images into a 3-D model of the actual patient. This computer model can be manipulated and saved for the patient’s procedure. Using the ARTAS™ Hair Studio software, the physician then specifies the angle, direction, density, and randomness of the recipient site incisions to create the most natural look. During the procedure, the robot uses image-guided technology to avoid existing hairs while it creates up to 1,500 recipient sites per hour. In performing recipient site creation, the robot automates a process that can be physically demanding and prone to human error.

On the advancement, Dr. Bernstein said:

“This development is a crucial step towards a robotic system that can perform every aspect of a hair transplant. A great deal of credit goes to the engineers of Restoration Robotics who have worked to make automated recipient site creation a reality. I am proud that this work not only improves hair transplants for patients, but adds to the increasingly important trend of using robotic technology in medicine.”

The site creation technology that Dr. Bernstein debuted at the ARTAS User Group Meeting; which was held in California (Laguna Niguel, CA) on February 7th and 8th, 2014; will be available to hair restoration physicians in the fall of 2014. Gabe Zingeratti Ph.D, head of R&D at Restoration Robotics, Inc., presented details of the technology, which was beta-tested at Bernstein Medical – Center for Hair Restoration. With the next generation ARTAS® Robotic System rolling out in the coming months, the focus of research will then be on the final phase of robotic hair transplantation, the robotic insertion of follicular unit grafts into recipient sites. This last step will take several more years to develop.

The ARTAS Robotic System, developed by Restoration Robotics, is currently in use by hair restoration physicians around the world to automate the extraction of grafts of skin and hair called follicular units.. Follicular units, which are natural groupings of one to four hair follicles, form the biological basis of the modern hair transplant procedure. Once extracted from the back of the patient’s scalp, the follicular unit grafts are then inserted into recipient sites in the balding area of the scalp where they grow hairs that are immune to the effects of common hair loss.

No stranger to innovative advances in hair transplant surgery, Dr. Bernstein introduced Follicular Unit Transplantation (FUT) to medical literature in a 1995 publication. FUT transformed hair transplants from the use of large grafts of skin and hair, known colloquially as “hair plugs,” to a more medically-oriented procedure that produces completely natural-appearing results. Dr. Bernstein with his colleague Dr. Bill Rassman again broke new ground with his 2002 publication that introduced the concept of Follicular Unit Extraction (FUE) to scientific literature. Dr. Bernstein was the first physician on the East Coast of the United Sates, and one of the first in the world, to use the ARTAS System to perform FUE using the new robotic technology.

About Robert M. Bernstein, M.D., F.A.A.D.

Dr. Robert M. Bernstein is a Clinical Professor of Dermatology at Columbia University and founder of Bernstein Medical – Center for Hair Restoration. His landmark scientific papers are considered seminal works in the field of hair transplant surgery. Other publications include textbook chapters on dermatologic surgery and books, like Hair Loss and Replacement for Dummies, aimed at the consumer audience. He has been selected as one of New York Magazine’s “Best Doctors” for fourteen consecutive years and has appeared as a hair loss and hair transplantation expert on The Oprah Winfrey Show, The Dr. Oz Show, Good Morning America, The Today Show, CBS News, Fox News, and The Discovery Channel. Dr. Bernstein has been interviewed or featured in articles in the New York Times, GQ Magazine, Men’s Health, Interview Magazine, Vogue, and others.

About Bernstein Medical – Center for Hair Restoration

Bernstein Medical – Center for Hair Restoration, founded in 2005, is a state-of-the-art facility and international referral center for the treatment of hair loss that is located in midtown Manhattan, New York City. Hair transplant surgery, hair repair surgery, and eyebrow restoration are performed using Dr. Bernstein’s pioneering techniques of Follicular Unit Transplantation (FUT) and Follicular Unit Extraction (FUE).

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New York, NY (PRWEB) — Robert M. Bernstein, M.D., F.A.A.D., A.B.H.R.S., a world-renowned hair transplant surgeon, presented a series of improvements to hair transplant procedures which use the ARTAS Robotic System for Follicular Unit Extraction (FUE). These updates include revisions to the FUE surgical protocol and technical adjustments to the robotic extraction system. He presented his refinements at the first user meeting held by the developers of the system; Restoration Robotics, Inc.; on September 14 – 16 in Denver, Colorado.

Dr. Bernstein receives recognition from Restoration RoboticsDr. Bernstein receives recognition from Restoration Robotics

Dr. Bernstein described his series of improvements in a lecture to an elite group of physicians who are among the first adopters in the industry of the image-guided, robotic-assisted system. The updates are designed to improve the results of FUE hair transplantation by enhancing both the surgical protocols of the procedure as well as the functionality of the robotic system. In FUE, small groups of one to four hairs, called follicular units, are extracted individually from the back and sides of the scalp and are then implanted into recipient sites, which are tiny holes that the surgeon creates in a balding area of the scalp.

Dr. Bernstein discussing robotic-assisted FUE at Restoration Robotics' first user meetingDr. Bernstein discussing robotic-assisted FUE at Restoration Robotics’ first user meeting

The most important update to the FUE procedure that Dr. Bernstein proposed is for surgeons to create recipient sites before they extract the grafts, rather than create the sites after grafts are extracted. Drawing on his decades of experience in hair transplantation, Dr. Bernstein developed this technique of “pre-making” recipient sites in order to maximize survival of the grafts during the hair transplant. Using this technique, extracted grafts are outside the body for a shorter duration of time. It also minimizes instances of “popping,” in which grafts are exposed to desiccation (drying) and hypoxia (low oxygen) before they are inserted back into the scalp. By “pre-making” the recipient sites, these harmful factors are mitigated and a greater number of the grafts grow into viable, hair-producing follicular units. Dr. Bernstein encourages surgeons to use this technique on all FUE procedures, whether using manual methods or robotic instrumentation.

When asked to comment on his improvements to the robotic FUE procedure, Dr. Bernstein said:

“It was fortuitous timing that the ARTAS Robot became available just as I was developing my refinements to the FUE procedure. The combination of the automated robot for graft extraction with the technique of pre-making recipient sites has led to a significant improvement in hair transplant surgery.”

Dr. Bernstein is the founder of Bernstein Medical – Center for Hair Restoration, and he is recognized world-wide for his innovative work in the treatment of hair loss. He is among the first hair transplant surgeons in North America to utilize the ARTAS Robot for FUE in his practice.

Being an early adopter of the advanced follicular unit extraction system has enabled him to work with Restoration Robotics to refine it to his exacting standards. Dr. Bernstein has, again, put his fingerprints on a revolutionary upgrade to the hair transplantation industry. He was the first to describe FUT and FUE procedures in the medical literature, in 1995 and 2002 respectively. In contrast to FUE, where follicular units are extracted individually, in FUT procedures a strip of skin is removed from the back of the scalp, it is then dissected into follicular units, and those follicular unit grafts are then implanted into recipient sites in the patient’s scalp.

About Dr. Bernstein

Robert M. Bernstein, M.D., F.A.A.D., A.B.H.R.S. is a Clinical Professor of Dermatology at Columbia University and a pioneer in the field of hair restoration. His landmark scientific papers are considered seminal works in the field of hair transplant surgery, and he is the most widely published author on the topic having published more than sixty articles, editorial reviews, books, and textbook chapters.

Dr. Bernstein has been selected as one of New York Magazine’s “Best Doctor’s” for thirteen consecutive years and he has appeared as a hair loss and hair transplantation expert on The Oprah Winfrey Show, The Dr. Oz Show, Good Morning America, The Today Show, The Discovery Channel, CBS News, Fox News, and National Public Radio. Dr. Bernstein has been interviewed or featured in articles in GQ Magazine, Men’s Health, Interview Magazine, Vogue, the New York Times, and others.

About Bernstein Medical – Center for Hair Restoration

Bernstein Medical – Center for Hair Restoration is a state-of-the-art hair restoration facility and international referral center, located in midtown Manhattan, New York City. The center is dedicated to the diagnosis and treatment of hair loss in men and women. Hair transplant surgery, hair repair surgery, and eyebrow restoration are performed using Dr. Bernstein’s pioneering techniques of Follicular Unit Transplantation (FUT) and robotic Follicular Unit Extraction (R-FUE).

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Press Release

Dr. Robert M. Bernstein – pioneer of the follicular unit transplantation (FUT) and follicular unit extraction (FUE) hair transplant procedures – will become the first hair restoration physician on the East Coast to employ the robotic ARTAS™ System for FUE hair transplantation.

New York, NY — Robert M. Bernstein, M.D., F.A.A.D., world-renowned pioneer of the Follicular Unit Transplantation (FUT) and Follicular Unit Extraction (FUE) hair transplant techniques and founder of Bernstein Medical – Center for Hair Restoration, will become the first hair transplant surgeon on the East Coast to use the robotic ARTAS System for Hair Restoration. Procedures using the computer-driven, automated system will begin in November 2011 in his state-of-the-art New York City facility.

ARTAS Robotic System for FUE at Bernstein Medical
ARTAS Robotic System for FUE
at Bernstein Medical

Dr. Bernstein, a Clinical Professor of Dermatology at Columbia University in New York, said that he is excited to incorporate the image-guided robotic system into his FUE procedures. “The ARTAS System is a ground-breaking technology for hair transplantation that will provide significant benefits to our patients,” said Dr. Bernstein. “From the accuracy of follicular unit graft extraction to the automation of what is normally a labor and skill intensive procedure, the outcome is better hair restoration results and faster, more comfortable procedures.”

The ARTAS System for Hair Restoration, developed by Restoration Robotics, Inc., overcomes some of the human limitations in performing FUE hair transplant procedures. Greater accuracy in extracting follicular unit grafts, combined with the sharp/blunt extraction technique, allows for graft removal with less damage to the graft and greater preservation of its protective tissues. A lower rate of damage increases the probability that the grafts will survive the transplant process, leading to better hair restoration results. The automation of what is a technically challenging and physically demanding process for the physician when performed manually, contributes to a shorter procedure and a decreased need for local anesthetic.

By utilizing the latest and most effective advancements in hair transplantation technology, Dr. Bernstein, a New York native, is extending his record as a true pioneer in the field of hair restoration. His landmark medical publications on follicular unit transplantation and follicular unit extraction revolutionized the field and provide the foundation for techniques in use by hair transplant surgeons across five continents. His medical practice has been devoted exclusively to the treatment of hair loss since 1995 and he now performs both restorative and corrective hair transplant procedures at his state-of-the-art hair restoration facility in mid-town Manhattan.

Dr. Bernstein has appeared on a wide variety of notable media programs and publications. Some of these include: The Oprah Winfrey Show, The Dr. Oz Show, The Today Show, Good Morning America, ABC News, CBS News, Fox News, National Public Radio, New York Times, Men’s Health Magazine, GQ Magazine, Univision, Telemundo, “O” the Oprah Magazine, and more. He is co-author of Hair Loss & Replacement for Dummies and The Patient’s Guide to Hair Restoration. He has been selected as one of NY Magazine’s “Best Doctors in New York” for 12 consecutive years.

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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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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.

View our page on the Pros & Cons of FUE hair transplantation

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Q: I am a 34 year old male and my dermatologist prescribed Propecia for me today. Most of my hair loss is at the hairline, but there is some loss on top as well. It’s not bad, I just want to stay ahead of it. If I get a transplant I want to get it at your clinic, but I will give the Propecia a try first. I am going to be overseas for a couple of months starting this Sunday and I was wondering about the necessity or desirability of having someone measure my hair density prior to starting the Propecia. Would you advise waiting to start the Propecia until I come back in two months and having my density examined at your clinic? — M.R., Great Falls, Virginia

A: I would start Propecia as soon as possible. What is important for a hair transplant is the density in the donor area and this is not affected by Propecia (or minoxidil). Your donor density can be measured anytime at an evaluation prior to surgery. If you want to wait to see the effects of Propecia prior to the hair transplant, you really should wait a year; since growth, if any, can take this long. If you just want to have Propecia on board for the hair restoration procedure, or to make sure you don’t have side effects, then generally a month will do. If you would like to do a photo consult through our website to get some preliminary information about how many grafts you might need, you can do that at your leisure, but start Propecia now since the longer you wait the less effective it will be at regrowing hair.

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Q: I recently saw an episode of the Rachel Ray Show where her guest, Dr. Anthony Youn, said that the Neograft machine for Follicular Unit Extraction is painless and uses a vacuum rather than surgery to remove the grafts. Can this be true? — A.B., Old Greenwich, C.T.

A: Follicular Unit Extraction (FUE) using the Neograft machine is not painless and, while it does not produce a linear scar, it is surgery and there is significant scarring in the form of thousands of tiny holes that heal with round white marks.

In the video, Dr. Anthony Youn asks: “Do you wanna take a feel? It’s just a vacuum.” Rachel Ray states: “You don’t feel a thing.” Youn replies: “No [you don’t].”

This is very deceptive on the part of the doctor, since the instrument is basically a cutting instrument with the suction being used to remove and insert the grafts. Although the suction part would not be painful, the cutting part certainly is and requires the same anesthesia as a traditional hair transplant.

Our main concern is that the machine produces grafts that are sub-optimal with respect to quality and potential growth, as the Neograft’s suction apparatus tends to strip follicles away from their surrounding protective tissue and tends to dry the grafts out.

For in-depth information on this topic, read our pages on Follicular Unit Extraction (FUE) and the Neograft Machine for FUE.

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Q: I had a hair transplant about a month ago and I had scabs and some dead skin until day 16 or 17. Will that endanger the growth of the hair restoration procedure? — S.P., Hoboken, N.J.

A: No, it will not. If follicular units were used for the hair transplant, the grafts should be permanent at 10 days. After this time, you can scrub as much as you need to get the scabs off.

Read more about caring for your hair transplant after your surgery.

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Q: I had a hair transplant 10 days ago and I lost some hair that looks like the hair fell out at the root. — R.A., Bronxville, N.Y.

A: When there is shedding after a hair transplant, it is the hair that is lost, not the follicle that contains the growth center (the follicle eventually produces the new hair).

Since the “hair” usually consists of a hair shaft and the inner and outer root sheaths, which creates a little bulb at the end of the hair, it looks like the hair is “falling out at the root.” Do not be concerned as this is not the growth center.

The growth center remains in the scalp and is what produces the new hair. If some grafts were to become dislodged and fall out -– which can happen the first few days after the hair transplant — there would be some localized bleeding. At 10 days the grafts cannot be dislodged, even with vigorous scrubbing.

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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.

With very low donor hair density the strip will yield so little hair that further sessions eventually become impractical. To say it another way, since a hair transplant decreases the donor density, in each succeeding hair transplant session, you need an increasingly larger donor strip to remove the same number of grafts.

This effect also explains why, in most instances, FUE will not allow the doctor to obtain any significant amount of additional hair, since the donor area is already too thin, and FUE would thin it further.

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Q: If you transplant grafts in between the thinned out areas, is there a risk of cutting previously normal roots, even if one is cautious? — J.S., Upper Saddle River, N.J.

A: Healthy hair can be temporarily shocked from a hair transplant and then shed (the process is called telogen effluvium) but it will not be permanently damaged.

Any healthy hair that is lost in this shedding process should re-grow.

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Bizymoms.com, the premier work-at-home community on the Internet with more than 5 million visitors per year, has interviewed Dr. Robert M. Bernstein in order to answer readers’ common questions about hair restoration and hair loss.

Below is a sample of the interview:

Q: Who would be a good candidate for hair transplant surgery?

In general, men and women age 30 and older can be candidates, but there are a host of factors that determine if a person is a good candidate…

Q: How does hair transplantation work?

Hair removed from the permanent zone in the back and sides of the scalp continues to grow when transplanted to the balding area in the front or top of one’s head…

Q: What can be done for people dissatisfied with previous mini/micrograft procedures?

If the grafts are too large they can be removed, divided into smaller units under a microscope, and re-implanted back into the scalp (the same day)…

Q: What are the possible harmful effects of Propecia and Rogaine?

The main side effect of Propecia (finasteride 1%) is sexual dysfunction, which occurs in about 2-4% of men taking the drug. Fortunately, these side effects are completely reversible when the medication is stopped. […] The main side effect of Rogaine (minoxidil) is scalp irritation. […] Both Propecia and Minoxidil can produce some hair shedding at the beginning of treatment, but this means that the medications are working…

Q: How many grafts/hairs are needed for hair transplant surgery?

An eyebrow restoration can require as few as 200 grafts, a hairline 800 and a scalp, with significant hair loss, 2,500 or more grafts. An equally important consideration is the donor supply…

Q: What are the advanced hair transplant techniques?

Follicular Unit Transplantation (FUT), where hair is transplanted exclusively in naturally occurring follicular units, is the state-of-the art. […] A more recent means of obtaining the donor hair, the follicular units are extracted individually from the back of the scalp. This procedure, called Follicular Unit Extraction (FUE) eliminates the need for a line-scar, but is a less efficient procedure for obtaining grafts…

Q: What are the new hair restoration treatments available for men and women?

Low-Level Laser Therapy (LLLT) utilizes cool lasers to stimulate hair growth and reduce shedding of hair. […] Latisse (Bimatoprost) is an FDA approved topical medication for eyelash growth.

Go to Bizymoms.com to read the full interview.

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Q: Do patients need to wear a bandage after the surgery and for how long? — L.H., West University Place, T.X.

A: In a properly performed follicular unit hair transplant, the patient can remove any bandages the day after the procedure and gently shower/shampoo the transplanted area. The bandages do not need to be reapplied. The reason the dressing can be removed so soon is that follicular unit grafts fit into tiny needle-size incisions that heal in just one day.

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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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Q: Dr. Bernstein, I think that you have established a great monument in the history of hair transplantation. Especially, your historical works about Follicular Unit Transplantation, which you published about 15 years ago, have contributed greatly to the spread of modern hair transplant technique in the whole world.

In the past days, there might have been many physicians who did not care much about the importance of the follicular unit and they have only cut the grafts to size. Now, every hair transplant physician believes the importance of follicular unit, and there is no one who cut the grafts to size ignoring each follicular unit.

However, there are some physicians who shout that a hair transplant procedure can be called FUT only when people use all single FU exclusively, and the procedure cannot be called FUT, if mixture of single FU and double FU are used in a session.

I would like to ask you, if you could accept the usage of combination of single FU and double FU under the name of FUT, as long as the grafts were cut according to each FU and intact FU are used throughout the procedure. Could you accept easing of the very strict definition of FUT, which you published about 15 years ago? Could you agree to use mixture of single FU and double FU under the name of FUT? — N.W., Huntington, N.Y.

A: Thank you for the kind words. In thinking about hair transplantation in general, it is important to consider that a hair restoration procedure spreads hair around and, as a result, the transplanted hair will be less dense than the person’s original hair. Therefore, one would never want grafts larger than the largest original follicular units or the results will not look natural. The artificially large grafts will stand out in relatively thin surroundings. If one were to try to fix this by transplanting the doubled FUs very close together (over one or more sessions) one risks running out of grafts for other areas of the scalp. In other words, you can’t fool mother nature.

For example, if a person has thin hair and has only 1-, 2- and 3-hair units occurring naturally in his scalp, then creating 4-hair grafts (by combining two 2’s or 1’s and 3’s) can result in an unnatural, tufted look. Doubling larger follicular units also necessitates larger wounds to receive the grafts which defeats one of the main advantages of FUT, namely to minimize recipient wounding.

That said, it is not unreasonable to place two 1-hair FUs in a single site (if there are extra 1s from the FU dissection) in order to increase density in an area and to eliminate an extra wound.) We do this for crown hair transplants when we are not doing a hairline and there is no need for 1-hair grafts. However, this is the exception.

Technically speaking, anything other than transplanting individual, naturally occurring follicular units is not FUT. However, a physician should make modifications to the procedure for the specific needs at hand. This is the art of medicine. By understanding and applying the underlying principles of Follicular Unit Transplantation, rather than being limited by its nomenclature, the physician will serve his patient best.

In addition to exploring Hair Restoration Answers to learn more about this topic, visit the Follicular Unit Transplant (FUT) section of our website and read detailed information about the hair transplant evaluation, the hair restoration procedure, follicular unit grafts, the donor area, and more.

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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. The following reflects a list of the practices I find so abhorrent:

1. Selling hair transplants to patients who do not need it, just to make money. I have met with an increasing number of very young patients getting hair transplants for changes in the frontal hairline that reflect a maturing hairline, not balding. Also, performing surgery on very young men (18-22) with early miniaturization is in my opinion outside the “Standard of Care”. Treating these young men with a course of approved medications for a full year should be the Standard of Care for all of us.

2. Selling and delivering more grafts than the patient needs. Doctors are tapping the well of the patient’s graft account by adding hundreds or thousands of grafts into areas of the scalp where the miniaturization is minimal and balding is not grossly evident. I have even seen patients that had grafts placed into areas of the scalp where there was no clinically significant miniaturization present. Can you imagine 3,000-4,000 grafts in an early Class 3 balding pattern? Unwise depletion of a patient’s finite donor hair goes on far more frequently than I can say.

3. Putting grafts into areas of normal hair under the guise of preventing hair loss. There are many patients who have balding in the family and watch their own “hair fall” thinking that most of their hair will eventually fall out. A few doctors prey on these patients and actually offer hair transplantation on a preventive basis. This is far more common in women who may not be as familiar with what causes baldness and do not have targeted support systems like this forum. They become more and more desperate over time and are willing to do “anything” to get hair. They are a set-up for physicians with predatory practice styles.

4. Pushing the number of grafts that are not within the skill set of surgeon and/or staff. The push to large megasessions and gigasessions are driven by a limited number of doctors who can safely perform these large sessions. Competitive forces in the marketplace make doctors feel that they must offer the large sessions, even if they can not do them effectively. A small set of doctors promote large sessions of hair transplants, but really do not deliver them, fraudulently collecting fees for services not received by the patient. Fraud is a criminal offense and when we see these patients in consultation, I ask you to consider your obligation under our oaths and our respective state medical board license agencies to report these doctors.

5. Some doctors are coloring the truth with regard to their results, using inflated graft counts, misleading photos, or inaccurate balding classifications. False representation occurs not only to patients while the doctor is selling his skills, but also to professionals in the field when the doctor presents his results. Rigging patient results and testimonials are not uncommon. Lifestyle Lift, a cosmetic surgery company settled a claim by the State of New York over its attempts to produce positive consumer reviews publishing statements on Web sites faking the voices of satisfied customers. Employee of this company reportedly produced substantial content for the web.

The hair transplant physician community has developed wonderful technology that could never have been imagined 20 years ago. The results of modern hair transplantation have produced many satisfied patients and the connection between what we represent to our patient and what we can realistically do is impressive today. Unfortunately, a small handful of physicians have developed predatory behavior that is negatively impacting all of us and each of us sees this almost daily in our practices. Writing an opinion piece like this is not a pleasant process, but what I have said here needs to be said. According to the American Medical Association Opinion 9.031- “Physicians have an ethical obligation to report impaired, incompetent, and/or unethical colleagues in accordance with the legal requirements in each state……”

Rassman, WR: Areas of unethical behavior practiced today. Hair Transplant Forum Intl. Sep/Oct 2009; 19(5) 1,153.

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Q: I would like to have the donor area from an old hair transplant repaired so it does not show the scar when I cut my hair shorter. What are my options?

A: Widened scars can be improved in two ways: they can be re-excised to make the scar finer, or hair can be placed into the scar to make it less visible.

Excising a scar works best when the original incision was closed with poor surgical techniques. In this case, using better closure methods can improve the scar. When the scar is the result of a person being a naturally “poor healer,” a wide scar will be the result – regardless of how the incision was closed.

I often approach the problem by excising a small area first, to see if I can decrease the width of the scar. If so, I would then proceed to excise the rest of the scar. If not, I would obtain hair using follicular unit extraction (FUE) — extracting hair in follicular units directly form the scalp — and place this hair into the scar. The hair placed in the scar can also be obtained from the edges of a partially excised scar.

If a wide scar that is thickened (called a hypertrophic scar) is also excised, it will usually reoccur and may result in an even worse scar. Because of this, thick scars should be flattened with injections of cortisone prior to removing. This will decrease the chance of a recurrence.

Flattening the scar is also important to permit the growth of newly transplanted follicular unit grafts.

For more on this topic, please see the page on Fixing Scars.

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Q: I have had a hair transplant done in the hairline of 1,000 or so FUE grafts. However, as the hair sheds, under natural light the recipient skin seems bumpy with incisions and holes that are noticeable. Do these tend to go away with time once they have healed? — S.S., Glencoe, I.L.

A: If a follicular unit transplant is performed properly (using either extraction or a strip) there should be no bumps or surface irregularities. When the hair restoration is totally healed, the recipient area should be appear as normal looking skin.

With FUE it is important to sort out the grafts under a microscope, to make sure that all of the grafts placed at the hairline are 1-hair grafts and that the larger grafts are place behind the hairline. They should not be planted without first being sorted under a microscope.

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Q: When can I wash my hair after a hair restoration procedure?

A: If a follicular unit hair transplant is performed so that there is a “snug fit” between the graft and the incision into which it is placed, the grafts are reasonably secure the day after the procedure.

At this time, gently washing your scalp with lightly flowing water and a patting (rather than rubbing) motion is permitted. Vigorous rubbing, however, will dislodge the grafts.

Over the course of the week the grafts become more secure, and at 10 days post-op they are permanent. At this time, normal scrubbing of the scalp is permitted.

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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: I had hair transplant surgery 10 days ago and have since developed what looks like big, dry flakes in the transplant area. How long does it take for the grafts to root, and is it okay that some of the grafts fall out when brushing my hair back carefully at this point? Also, the area that was worked on has not fallen out yet, so should I shave this area before the new hair comes in or should this be a natural process? — N.N., Easton, C.T.

A: Grafts are generally permanent 9 days following a follicular unit hair transplant procedure, so you may shampoo the flakes off at this time. If larger grafts were placed (with correspondingly larger recipient sites), the grafts will be subject to being lost for a slightly longer period of time. After 9 days, you may shave or clip the hair in the transplanted area if you like, but this will not affect the success of the hair restoration one way or the other.

Visit: Graft anchoring following a hair transplant

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Q: I am interested in an FUT hair transplant. How do you figure out how large a strip to use for the hair restoration when transplanting all follicular units? — P.K., New York City, N.Y.

A: The length of the donor strip incision is determined by the number of follicular unit grafts required for the hair restoration. There are slightly less than 100 follicular units/cm2, so if a 1cm wide strip is used, a hair restoration procedure requiring 1800 grafts would need a strip that measured slightly more than 18cm in length.

A 2800 graft procedure would measure slightly more that 24cm if the strip were 1.2cm wide.

The width of the strip is determined by scalp looseness or laxity. For more information, please see the page on the Donor Area.

Read more about FUT hair transplant procedures

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Q: I am 22 and want to go for hair transplantation. I want hair restoration surgery now because I have a concern about my donor area that it might diminish if I postponed my transplantation. Could this be the case? — T.J., Westchester County, N.Y.

A: The logic is not correct. Having a hair transplant at an early age does not protect the donor supply.

If your donor area diminishes over time, then the transplanted grafts will fall out as well. Hair does not become permanent just because it’s moved in a hair transplant. It is never any better than the hair in the area where it came from.

The longer you wait – i.e. the older you are when a hair transplant is performed – the more information we will have about the stability of your donor area and this will allow for optimal planning of the hair restoration.

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Q: Should I cut my hair prior to the hair transplant? — R.R., Poughkeepsie, N.Y.

A: It is easier for the hair transplant surgeon and his team to work when the existing hair in the area to be transplanted is cut short, but a skilled surgeon can work well in either situation. Most experienced surgeons are used to working without cutting the hair in the recipient area, since so few patients want their hair to be cut – particularly in New York.

The main advantage of having a closely clipped scalp is that one has better visibility and therefore the procedure moves along faster. This has little bearing in moderately sized sessions, but becomes very important in sessions over 2,400 grafts, when working through existing hair can make the duration of the procedure excessively long. Of course, the disadvantage of clipping the hair is that it is more difficult to “hide” the procedure.

I prefer for the patient to arrive the morning of the scheduled hair restoration with his/her hair having some length so that I can better see the demarcation of the area of thinning. Once the area is marked, the hair can be clipped to the appropriate length in the operating room. Although the hair transplant will be more visible post-op if the hair is clipped short, it is much easier for the scalp to be kept free of crusts.

It is important to differentiate between a closely clipped scalp, which is an advantage, and a shaved head, which makes performing the hair transplant more difficult. When there is some existing hair, the distribution and angle of the original hair is easy to discern and this allows the new grafts to be placed in a direction that follows the existing hair and in a distribution that complements that hair.

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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.

View Before and After Hair Transplant Photos

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Follicular Unit Transplantation - Dermatologic Clinics“Dermatologic Clinics” is a quarterly review with comprehensive, state-of-the-art information by experts in the field of dermatology. The industries most highly knowledgeable medical professionals provide current, practical information on the diagnosis and treatment of conditions affecting the skin. Each issue of Dermatologic Clinics focuses on a single topic. The July 2005 issue, entitled “Advanced Cosmetic Surgery”, published an article authored by Robert M. Bernstein M.D, and co-authored by William R. Rassman M.D. entitled “Follicular Unit Transplantation: 2005.”

In their article on FUT, the authors helped the dermatologic community to better understand the best practices of surgical hair restoration. Follicular Unit Transplantation (FUT) focuses on recognizing that the follicular unit is a discrete, anatomic and physiologic entity, and that preserving it through stereomicroscopic dissection is the best way to ensure the natural appearance of the hair restoration. Dr. Bernstein explains why this major step has brought hair transplantation into the twenty-first century.

This chapter also points out that the issues yet to be resolved in hair transplantation include determining the maximum density and number of grafts that can be used safely in a single session, deciding whether it is preferable to pre-make recipient sites or immediately place grafts into sites as they are made, and defining the precise role of Follicular Unit Extraction (FUE).

The authors conclude by stressing that the essence of providing the best care for hair transplant patients rests on proper patient selection, establishing realistic expectations, and using non-surgical management for young persons who are just starting to thin. When surgery is indicated, Follicular Unit Hair Transplantation is the ideal hair restoration procedure.

Read the publication Follicular Unit Transplantation: 2005

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Dr. Bernstein — and a Bernstein Medical – Center for Hair Restoration hair transplant patient — were featured on NBC television’s “Today” program with Matt Lauer. The segment, which mostly covered hair transplant repair procedures and hair restoration, was one of a three-part series on hair loss.

Visit NBCNews.com for breaking news, world news, and news about the economy

Read below for a portion of the transcript:

What men will do for a few more strands of hair

Recent changes in transplant surgery have led to more natural-looking results and a boost of self confidence for some balding men

Hair transplants are one of the top five cosmetic procedures for men in the U.S., with more than 19,000 performed last year, according to the American Society for Aesthetic Plastic Surgery. But is it worth it? As part of a three-part series on hair loss, “Today” spoke with two men who underwent the procedure.

Allen Appleblatt has made a big change in his life. He works out, spends time with family and stays busy with work. And when it comes to his appearance, he’s feeling good about his new head of hair.

“I kind of felt like I was an idiot looking at myself in the mirror,” said Appleblatt. “Whenever I took a shower, at the end of the shower I found a clump of hair at the bottom of the drain. And there was no way of stopping it.”

So Appleblatt had two hair transplants. His partner, Shirley Garofano, likes what she sees.

“I liked him both ways. But I like him better now. He looks great, he’s very positive, he’s happier,” she said.

Happier, but he still wants thicker hair. “Today” followed him while he underwent his third hair transplant, taking advantage of the latest techniques.

“Over the past 10 years we’ve developed a new procedure called follicular unit transplantation, where hair is transplanted exactly the way it grows,” said Dr. Robert Bernstein, an associate clinical professor of dermatology at New York’s Columbia University.

This new technique replaces the plugs — groups of hairs inserted into round holes in the scalp — used in the early days of hair transplant procedures. It is now known that hair grows in groups of one to four hairs.

“So follicular unit transplantation is a transplantation of hair in its naturally occurring groups,” said Bernstein. “We’re really just transplanting the root.”

Appleblatt is given valium and local anesthesia, and then a donor strip is removed from the back of the head where hair is not genetically programmed to fall out.

“We have a team of people dissecting the grafts. They divide it into individual follicular units,” said Bernstein.

The units are then transplanted into the balding area. And 10 to 12 months later, the new hair will be in place.

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“Good Morning America” interviewed Dr. Bernstein in their two-part series on hair transplant surgery. View a clip of the video here:

Read the full transcript:

Charles Gibson: In a two-part series this week, “The Bald Facts,” we are looking at what works and what doesn’t in hair replacement.

And first up, we want you to meet Charles Teacher, a real estate executive who for 30 years has been a guinea pig for every kind of baldness remedy there was. Let’s look at his struggle through the years.

Charles Teacher: It was very restrictive. You’re always patting it down, looking in the mirror to see that it’s not sort of showing. It’s a really difficult way to live.

Charles Gibson: Charles Teacher should know. He’s been studying the latest trends in baldness for three decades. His hair started thinning when he was just 26, and back then he tried that bastion of hope, the comb-over.

Charles Teacher: I still had hair then. You couldn’t see that I was bald, but I could see I was very thin. It really is this fear of being unattractive to women. I suppose it is a certain amount of vanity in terms of how you look, but most of it is this fear of being rejected.

Charles Gibson: So even at an early age, he began wearing a toupee and bemoaning his genetic fate. His father had male pattern baldness. Would he spend the rest of his life worrying which way the wind blew on the golf course? Then came 1977 and the heralding of the hair plug. Charles Teacher was first in line for the surgery, and what a surgery it turned out to be.

Charles Teacher: Most of the plugs didn’t take and the few that did were in the front in a very bad hairline. It looked stupid.

Charles Gibson: This was the hairline of those old plugs, right across his forehead, so he went back to his toupee. He had a curly rug when styles were curly, a grayer one as he grayed, and he wore his hairpiece to bed. Even his wife never saw him without it.

Charles Teacher: She never saw me without the hairpiece for 30 years until I had the consultation with the surgeon who is doing the transplant and I removed it off like that.

Charles Gibson: The consultation was with hair transplant surgeon Robert Bernstein who recommended Teacher go bald, just a better bald, moving hair around to give him more on top. He demonstrated with before and after pictures of former patients. Teacher signed on and had the old plugs removed which would be added on with the rest.

Years ago in transplants like Charles Teacher’s, the surgeon removed small circles of tissue from the back of the head where hair growth is stable, then to transplant those clumps of up to 30 hairs, the surgeon would remove a matching circle of tissue from the top of the head and put in the graft. It worked, but it didn’t look natural.

Dr. Bernstein: That has always been the problem, that grafts that were done 25, 30 years ago are still around. So really the idea is not just to get the hair to grow. That’s the simple part. The challenge is to do it in a way that looks natural.

Charles Gibson: Now Charles Teacher’s best hope, single follicular unit transplants. The surgeon removes a strip of hair-producing tissue from the back of the head and separates it under a microscope into units of one to four hairs, the way hair grows naturally. The surgeon then makes tiny incisions exactly where and at what angle he wants each hair to grow and then implants it.

Teacher decided it was worth a try, even though it would cost thousands of dollars. Now he wants to burn his old toupee for one of the best results of all, to go swimming with his new grandchild, carefree.

Charles Teacher: I really feel that I’ve been given a new lease in life in many ways. It sounds silly, but just to be normal, just to be normal.

Charles Gibson: We’re joined by Charles Teacher, sans toupee, and the man who helped to get rid of it, Dr. Robert Bernstein, Associate Clinical Professor of Dermatology at Columbia University.

Good to have you both here. Why go through all this trouble? Why not just be bald?

Charles Teacher: I think it’s because I started with a hairpiece when I was rather young, 26, and I just didn’t have the guts to take it off. I think I felt a bit like Samson and Delilah, should we say, you know, if I lost my hair, I’d lose my strength or my personality.

Charles Gibson: And you’re pleased with this.

Charles Teacher: It’s just awesome.

Charles Gibson: Dr. Bernstein, is his hair actually growing? I had always heard that you can transplant hair, but you can’t make it grow.

Dr. Bernstein: No, actually, a transplant will continue to grow. He has to get haircuts just like it’s his normal hair.

Charles Gibson: Are there good candidates and bad candidates for this?

Dr. Bernstein: Yes. And actually people that wear hairpieces are sometimes tricky because their baseline is a full head of hair, so one of the important things that we had to discuss in the first consult was what his expectations were and whether he realized that a transplant wouldn’t give him the fullness of a hairpiece, but of course, it would look much more natural.

Charles Gibson: That’s why you lose the line, you’re still bald to some extent, but it’s a better kind of bald.

Dr. Bernstein: Yes.

Charles Gibson: Single follicular unit transplants is such a mouthful, but basically it’s saying you’re just transplanting a hair two or three at a time.

Dr. Bernstein: Right. In the old days, hair was planted in little clumps and then it was divided into small pieces but arbitrarily. Now we transplant hair exactly the way it grows in nature, and hair normally grows in little tiny bundles and they’re called follicular units.

Charles Gibson: I don’t know if it’s dirty trick, but we have a camera behind you because in the back of your head, you’re going to have a second procedure now.

Charles Teacher: Yes, we’ll have a second procedure actually this morning. I think that we’ll leave the back and probably just reinforce the front so that it –- I mean, you don’t really see the back of your head, you’re only worried about how you appear in the mirror.

Charles Gibson: Right. How much does it cost?

Charles Teacher: I haven’t told my wife. Can I give that a miss?

Charles Gibson: Well, I’m sure Dr. Bernstein, he’ll probably say something.

Dr. Bernstein: We charge about $5 a graft.

Charles Gibson: About $5 a graft, which is one, two, three, four, five hairs –-

Dr. Bernstein: That’s right.

Charles Gibson: — per time. So that gets rather expensive. I mean, we’re talking about $10,000, $15,000 for a total procedure?

Dr. Bernstein: Yes.

Charles Gibson: Which insurance does or does not cover?

Dr. Bernstein: It usually does not.

Charles Gibson: But you probably spent that much in toupees over the time.

Charles Teacher: Absolutely. You know, so $2,000 or $3,000 a year with the toupees and the hairdresser worrying every week, you know, yeah.

Charles Gibson: Gotta ask. You’re a little thin on top yourself, yet you haven’t done this.

Dr. Bernstein: Everybody asks me that. It just doesn’t bother me. And I think it’s important being a doctor that people, when they come to see me, they don’t feel compelled that they have to have the transplant, that they’re here because they want to. And that being bald is okay.

Charles Gibson: So the title, if somebody’s interested in this, is follicular unit transplant.

Dr. Bernstein: Yes.

Charles Gibson: All right. Dr. Bernstein, thanks very much. Charles Teacher, thank you very much.

Charles Teacher: Thank you.

Charles Gibson: Good to see you. Good luck with the procedure today.

Charles Teacher: Thank you.

Watch more videos on hair transplantation and hair transplant repair in our Hair Restoration Videos section

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The Platinum Follicle Award is given by the International Society of Hair Restoration Surgery (ISHRS) for “Outstanding achievement in basic scientific or clinically-related research in hair pathophysiology or anatomy as it relates to hair restoration.” It was presented to Dr. Bernstein at the 9th Annual Meeting of the ISHRS, October 18-22, 2001; in Puerta Vallarta, Mexico.

The award is the highest honor given by the International Society of Hair Restoration Surgery. At the ceremony, Dr. Marcelo Gandelman, the President of the ISHRS, stated:

“I proudly present the 2001 Platinum Follicle Award to Robert M. Bernstein, MD. Dr. Bernstein has contributed to the field of hair transplantation in dramatic and substantial ways, revolutionizing the advancement of Follicular Unit Hair Transplantation. His published articles have become ‘Bibles’ for this methodology. Dr. Bernstein’s contributions extend beyond the application of Follicular Unit Transplantation, such as studies in examining the power of sorting grafts for density, yield by method of graft production, local anesthetic use, and suture materials. These studies have added to the specialty’s depth and breadth of knowledge applicable to traditional mini-micrografting techniques as well as Follicular Unit Transplantation.”

Read more about the Platinum Follicle Award

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Dr. Bernstein was interviewed by Skin & Allergy News in their article, “Microscopic Dissection Offers Superior Yield” The complete article is below:

Skin & Allergy News
February 1999

Skin & Allergy News - Microscopic Dissection Offers Superior Yield

Microscopic Dissection Offers Superior Yield
Articles by Anna Nidecker
Senior Writer

Washington — The dissecting microscope takes some getting used to, but using it makes more efficient use of donor hair during follicular unit transplantation than magnifying loupes with transillumination, reported Dr. Robert Bernstein of Columbia University Microscopic Dissection of follicular unitsCollege of Physicians and Surgeons, New York.

“A limiting factor in all hair restoration surgery is the patient’s finite donor supply. […] Meticulous stereomicroscopic dissection should help preserve the supply and ultimately provide the patient with the most transplantable hair,” he said at the annual meeting of the International Society of Hair Restoration Surgery.

Dr. Bernstein compared the follicular unit graft yields of dissections performed with stereoscopic microscopes and with loupes and backlighting. Initial sectioning of the intact strip was done with loupes, as the staff had not yet mastered the skill of slivering that is needed to section the intact strip under microscopic guidance.

“This method may be useful for a team in transition, a model for staffs in transition to using the microscope,” the hair transplant surgeon suggested.

Tips on Transition to Microscopes

The microscope offers a better yield with follicular transplantation, but some doctors feel that abruptly switching from loupe magnification may send an office into turmoil.

Microscopes will be well received by staff if they clearly understand the benefits and are eased into the transition, Dr. Bernstein said.

Dr. David Seager advised physicians planning the transition to the use of microscopes to let staff observe microscopic dissection at another clinic with an established program, and to send them somewhere to be trained before they start. The Toronto hair transplant surgeon also advised buying a couple of microscopes and letting the staff “play” with them for a while, cutting at their own leisurely rate before entering into a high-pressure transplant session.

Dr. Bernstein also recommended easing slowly into the transition by first training a small portion of staff, which will not affect the overall time of surgery.

Another option is to hire a couple of new technicians and train them from the beginning with microscopic dissection, Dr. Seager suggested.

“You’ll be amazed at the beautiful grafts they will be cutting in a couple of weeks. […] It may be only 40 grafts an hour, but these newcomers will be cut­ting better grafts than even your 8-year veterans,” he said. “Old staff will look at these new technicians and their grafts, and, if they take pride in their work, they will be quite jealous and will be re­ally eager to catch up.”

Dr. Bernstein agreed: “The value of the microscope may be more significant in the hands of less experienced dissectors. […] There’s some advantage even at the outset.”

Continued resistance from staff should be met with a deadline: ‘Anyone who can’t or won’t fit in, tell them they can do something else in the office, but they won’t be doing transplanting,” Dr. Seager said.

In 41 patients, the donor strip was harvested with a double-bladed knife from the midportion of the permanent zone in the back of the scalp.

The strip was divided into two equal parts along the midline; these were further divided into 2- to 3-mm wide vertical sections using loupes and a straight razor. Sections from one of these donor strip halves were further dissected into follicular units using a 10x power microscope; sections from the other donor strip half were dissected using magnifying loupes.

Follicular units cut using the microscope contained an average of 2.41 hairs; those cut using loupe magnification yielded 2.28 hairs. Use of the microscope also yielded 10% more follicular units and 17% more hair overall, compared with use of loupes.

The grafts were dissected and sorted into follicular units containing one to four hairs, and all hair and hair fragments judged to be potentially viable were counted towards the yield (Dermatol. Surg. 24[8]:875-80, 1998).

Microscopic dissection took from two to four times as long as loupe magnified dissection when technicians first began using the microscopes. After 3 months, the procedure still took twice as long with the microscopes. But by the end of the study 1 year later, it took only 10% longer, a rate they currently maintain, Dr. Bernstein said.

Hand-eye coordination was a factor which automatically improved, and the inefficient movement of grafts in and out of the microscopic field was solved with better organization, he said. Technicians with a tendency to obsessively sculpt grafts under the microscope can be educated to limit this sculpting, which does not affect the quality of the transplant.

Use of the microscope also led to fewer reports of back and neck strain by assistants. They also reported easier dissection when there was donor scarring, and with blond or light-colored hair.

Besides the benefit at the stage of dissecting the sections—as shown in this study—microscopes can improve yield by 5%-10% at the “slivering” stage. Yield can be improved an additional 15%-20% by avoiding use of the multibladed knife at the donor harvesting stage.

Loupe advocates argue that microscopes unduly slow down the procedure and that staff resistance to this new technology may be an insurmountable problem in some practices. They also lament the higher economic cost of purchasing the microscopes, training the staff, and slowing down dissection time with no clear benefits.

Dr. Bernstein said that the benefits of microscopic dissection far outweigh these minor inconveniences and should be incorporated into hair transplant procedures.

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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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Dr. Bernstein receives the Surgeon of the Month award given by the International Society of Hair Restoration Surgery. Read the statement on the award that appeared in the Hair Transplant Forum International, the society’s official publication:

Hair Transplant Forum International 1997; 7(1): 16.

Surgeon of the Month: Robert M. Bernstein, M.D.

It has been my policy, since taking over as Editor of the FORUM, to nominate a Surgeon of the Month in each edition. Rather than give further honors to those illustrious member of our profession who have had frequent mention over past years, I have tried to seek out those who have much to contribute in the future. Recent editions have honored a Mexican, an Australian and two South American surgeons. On this occasion, we return to the USA, to pay homage to a young dermatologist who has contributed a great deal in a few short years since entering the hair transplant field. – RS

Dr. Robert M. BernsteinRobert M. Bernstein, MD, is Medical Director of the New Hair Institute Medical Group in New York. He is Assistant Clinical Professor of Dermatology at the college of Physician and Surgeons of Columbia University, and an Associate in the Dermatology Service at the Columbia Presbyterian Medical Center, where he teaches dermatologic and laser surgery, and hair transplantation. He is also an attending physician in dermatology at Englewood Hospital and at the Manhattan Eye, Ear and Throat Hospital.

Dr. Bernstein received his MS degree at the University of Medicine and Dentistry of New Jersey in 1978, and was the recipient of the Dr. Jacob Bleiberg Award for Excellence in Dermatology. He received his dermatologic training at the Albert Einstein College of Medicine, where he served as chief resident.

Dr. Bernstein is board certified in dermatology, and in his private practice, has a special interest in cosmetic dermatologic surgery and laser surgery. Dr. Bernstein has served as Chairman of the Quality Assurance and Compliance Committee of the Department of Dermatology at Englewood Hospital, and was Co Director of their annual dermatology seminar for 10 years. Although he trained in hair restoration surgery during his residency, and performed hair transplantation and scalp reductions when he started private practice, he soon abandoned both procedures when he was not satisfied with the results. He observed the evolution of the procedure for many years until, after seeing the work of Dr. William Rassman and others performing large sessions of small grafts, he decided to re enter the field. Dr. Bernstein soon joined Dr. Rassman at the New Hair Institute to devote his time solely to hair transplantation.

Dr. Bernstein introduced the concept of “follicular transplantation” in an article published in 1995 in the International Journal of Aesthetic and Restorative Surgery, which recommended that in all hair transplantation, the implants should consist of only the naturally occurring follicular units. The anatomic follicular units, seen clinically as the patient’s natural hair groupings, are different for each individual, and these differences should be reflected in the transplant plan. He has been a strong advocate of using follicular transplantation for the best possible cosmetic result, and has encouraged his colleagues to use this approach in both his writings and lectures.

Dr. Bernstein was born in New York City in 1952. He is married to Shizuka, who is a medical aesthetician, and they have two sons, Michael (age 12), and Taijiro (age 11), and a daughter, Nikita (age 2 1/2). Dr. Bernstein’s hobbies include skiing, basketball, piano, ballroom dancing, and chess all of which he enjoys with his family.

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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 entitled, “Follicular Transplants Mimic Natural Hair Growth Patterns,” describes Dr. Bernstein’s introduction of his new procedure, Follicular Unit Transplantation, to the academy as well as the keys to making the technique successful. Find the complete article below:

Form Follows Function: Follicular Transplants Mimic Natural Hair Growth Patterns

By Neil Osterweil
Contributing Editor

SAN FRANCISCO – In recent years, many hair replacement surgeons have adopted the modem architecture philosophy that “less is more,” moving from the use of hair plugs, to split grafts, to minigrafts and, finally, micrografts. But at least one hair transplant specialist contends that a more appropriate architectural dictum is “form follows function.”

In other words, the surgeon should let the technique fit the head, and not the other way around, suggested Robert M. Bernstein, MD, at the 55th annual meeting of the American Academy of Dermatology.

Dr. Bernstein is an assistant clinical professor of dermatology at the College of Physicians and Surgeons, Columbia University in New York. He described his “follicular transplantation” technique in a meeting presentation and in an interview with COSMETIC SURGERY TIMES.

Natural Hair Groups Used

Dr. Robert M. Bernstein“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.

The typical follicular unit consists of one to four terminal hairs, one or two vellus hairs, sebaceous glands, subcutaneous fat and a band of collagen which circumscribes and defines the unit. In the follicular transplant technique, the follicular unit is carefully dissected and removed, and then the intervening skin is discarded. This enables the donor site to be small, allowing implantation through a small needle poke. Because trauma to the recipient sites is minimal, the entire procedure can be performed at one time. Dr. Bernstein and colleagues have implanted as many as 3,900 follicular units in a single, 1 day session.

Keys to the follicular transplant technique are:

Identify the patient’s natural hair groupings and isolate the individual follicular units – Hair groupings are assessed with an instrument called a densitometer, and the average size of a person’s groups can be easily calculated. This information is critical in the planning of the transplant. The density of hairs in an individual measured as the number of hairs per square millimeter of skin is quite variable, but the density of follicular units is relatively constant within individual races.

Most people of Caucasian ancestry have a density of approximately one group per millimeter; people of Asian and African descent tend to have slightly less dense growth patterns, although the characteristics of the person’s hair (such as wavy or wiry hair), can give a full appearance even with low density.

If a patient has an average hair density of two, he will receive mostly two hair implants, with some one-hair and three hair implants mixed in. “If you try to make the groups larger than they occur naturally, they will look pluggy. If you try to make them smaller than they naturally occur, they’re not going to grow as well, because each group is actually a little biologic machine that makes the hair — it’s an anatomic unit. If you break it up it just doesn’t grow as well,” Dr. Bernstein observed.

Form Follows Function: Follicular Transplants Mimic Natural Hair Growth Patterns
A 38-year old man with a Norwood Class 5A/6 hair loss pattern undergoes a single procedure of 2,500 follicular implants. The result 11 months later. (Photos courtesy of Robert M. Bernstein, MD)

Harvest meticulously – The acquisition and preparation of grafts must be carefully performed to ensure success for this demanding technique. Highly trained, skilled assistants are essential to the success of the procedure. Dr. Bernstein noted that he uses a highly trained team of up to 10 assistants to produce the implants for a single case. “The assistants, who range from medical technicians to registered nurses, are such an integral part of the procedure that they must become expert in their specific tasks for the surgery to be successful.” The physician must be able to skillfully harvest the donor strip and must be able to make accurate judgments about the size of grafts intra-operatively and adjust the technique accordingly. Dissection and placing of the follicular units is the most labor intensive part of the procedure.

Design the recipient area well – The recipient sites are carefully distributed so that a natural looking pattern is maintained throughout the recipient area. An important consideration for this stage of the procedure is to “frame the face and spare the crown” so those facial features are kept in correct proportion. A common mistake in hair replacement, said Dr. Bernstein, is to create a hairline that is too high thereby elongating the forehead and accentuating, rather than minimizing, the patient’s baldness. It is also important to avoid or eliminate contrast between the implants and surrounding skin by creating a soft transition zone of single hairs and to have the hair emerge from the scalp at natural angles.

Procedure Lowers Cost

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.

“In the very near future, the procedure will be improved and made more affordable with automated instruments that will enable the surgeon to make sites and implant the hair in a single motion. This will also decrease the possibility of injury to the implants by reducing handling and keeping the grafts uniformly cool and moist. It is possible that someday hair follicles may be cloned to provide a virtually unlimited supply of custom follicular units, but until then the finite nature of a person’s donor supply must be respected,” concluded the doctor.

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