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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 Unit Transplantation (FUT) was first introduced to the medical community by Dr. Robert Bernstein in his 1995 publication “Follicular Transplantation.” Dr. Bernstein presented this paper at the Annual Meeting of the International Society of Hair Restoration Surgeons the following year. However, the procedure initially met with great resistance by hair transplant community and for the next three years, only a handful of physicians were actually using this new technique. That all changed in 1998.

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

Follicular Unit Hair Transplantation clearly won the day… and the rest is history. Within three years of this debate, there were hardly any doctors left in the United States still performing large-graft hair transplant techniques. A review of their discourse appeared in Dermatology Times.


Excerpts from the debate with Drs. Unger and Bernstein taken from presentations at the annual meeting of the International Society of Hair Restoration Surgery held in Washington, D.C., 1998.

Is There Still a Place for Standard Grafts in Hair Restoration Surgery?

Position: YES

Dr. Walter Unger

You have to use the hair transplant technique that will give you consistently good results. I can consistently produce very natural-looking results regardless of the type of grafts that I use. I have many patients come back who report that even their hairstylists can’t tell that they have had transplants.

It’s not that I don’t like follicular units or have a thing about big grafts; I know that all of these techniques can yield good results. I object to the “absolute” rules presented by speakers at hair restoration meetings, on the Internet, or in advertisements in order to promote one particular concept.

Of course, you can produce 80 hairs per square centimeter with Follicular Unit Transplantation, and you get good results. However, you shouldn’t remove any of the other graft options, including standard grafts, from your armamentarium.

This is what is wrong with our profession right now: there is too much “irrational exuberance.” If you can find something that works well in your hands, then use it, but do not tell other people that it is the only way they can do things.

There are costs to follicular unit-only hair transplantation that must be recognized. I get less density with follicular units than I can get with a session using several different graft sizes. Given, thin is often appropriate; you don’t want to use up all of your donor hair frontally if you have a limited or poor donor-recipient area ratio. You also don’t want to use it up in a young man.

However, there are some people who can well afford the donor hair and want great density. In these individuals, mixed grafts are the best option in my hands.

Furthermore, there is more tissue handling with follicular unit transplantation during both preparation and insertion of the grafts. A larger number of grafts have to be transplanted, and they have to be densely packed if you want a dense enough result per session, compared with standard grafting.

Follicular unit grafting also risks the loss of hairless follicles. You can lose up to 13% of follicles that are in the resting telogen phase. Even if you can see these hairless follicles, and I’m not sure that you can, technicians are not looking for them when they are slicing up donor tissue into follicular units.

Admittedly, you have to be an extraordinary surgeon to get good results with large grafts at the hairline. However, when I use larger grafts, I use them in a limited area posterior to the hairline zone, which is always created with micrografts and minigrafts anteriorly as well as posteriorly; on either side of the larger grafts; and in areas of existing hair that is likely to be lost with the progression of male pattern baldness.

Position: NO

Dr. Robert M. Bernstein

Finally, after 40 years, standard grafts are on the defensive.

Standard grafts exhibit a callous indifference to human tissue. Standard grafting causes significant damage to the donor area through the larger recipient wounds. They always require a “cover-up” using smaller, more appropriately sized grafts.

Proponents of standard grafting claim that large grafts are needed for density and that large grafts avoid the loss of telogen follicles.

They also lament the psychological toll of long hair transplant sessions using small grafts but ignore the effects of a protracted course of small multiple surgeries.

These hair restoration surgeons attempt to impress you with fancy terms like “maximum density” and dazzle you with hair counts approaching 200 hairs per square centimeter.

But traditional grafts often cause the scalp to feel unnatural and have an unnatural look when wet, when the hair is seen at different angles, or when the hair is not perfectly groomed. Other dangers include decreased perfusion after healing, an unnecessarily large number of procedures, and long-term problems with hair distribution.

All of us can achieve high density, but the final density is determined by the amount of hair moved, rather than the size of the grafts. Density is a somewhat misleading term since a transplanted density that approximates 50% of the original hair density is indistinguishable from one’s original hair.

Regardless, you can achieve as much density as you want with follicular transplantation while maintaining a totally natural look.

Moreover, telogen hairs are not necessarily lost when properly dissected during follicular unit harvesting because they often are part of a follicular unit that has visible hairs.

The risk therefore of any of them being lost is negligible, particularly if the dissection is performed with care.

The future of hair transplantation lies in the ability to preserve the blood supply and minimize scarring in the recipient area.

When standard large grafts are used centrally, multiple hair transplant sessions are required and there is a possibility that the blood supply can be compromised, resulting in poor growth and “doughnuting,” a condition where the hair in the center of large grafts does not survive.

Hair survival in larger grafts is highly exaggerated; doughnuting and other evidence of poor graft survival are evident regardless of technique.

Large grafts are very inefficient, seldom grow at 100%, and require a “screening” population of micrografts and minigrafts to look natural. As a result, they rapidly deplete donor supply.

Regardless, the primary reason for the decline of standard graft use is that even the best of 4-session standard graft cases appear pluggy upon close inspection. The rationale for using standard round grafts has been to achieve maximum density. However, appropriate density can now be achieved with a hair restoration procedure that looks totally natural and avoids the problem of these larger grafts. If doctors had the insight to use small grafts when hair transplantation first began in the 1950’s would we even be discussing the use of the larger standard graft procedures today?

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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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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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