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Q: What are the major obstacles for scientists to cloning hair?

A: The main problem is that the cultured cells may lose their phenotype with multiple passages, i.e. lose their ability to differentiate into hair follicles after they have been multiplied.

Another problem of hair cloning is that the orientation of hair direction must be controlled. With mouse experiments, the hairs grow at all different directions. Scientists need to find a way to align the hair so that it grows in the right direction. Hair, of course, must also be of a quality that is cosmetically acceptable and matches the patient existing hair. And the hair should grow in follicular units. Individual hairs will not give the fullness or natural look of follicular units.

Another problem is the issue of safety. Are we sure that cultured cells may not turn into something else – such as malignancy cells with uncontrolled growth?

Finally, FDA approval would be required and this takes time. It is true that you do not need FDA approval for using your own hair, such as a hair transplant; however, when you take cells from the body and manipulate it in the lab, this requires FDA approval.

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Q: I am considering having an FUE procedure and have heard the phrases topping, capping, and tethering as part of the procedure. What do all these terms mean? — C.C., Hell’s Kitchen, N.Y.

A: These are all terms that refer to the types of injury that can occur to grafts during a follicular unit extraction procedure.

In FUE, a sharp instrument (or sharp instrument followed by a blunt one) is used to separate follicular units from the surrounding donor tissue. Forceps are then used to remove the follicular units from the scalp.

Topping occurs in the first step when the doctor accidentally cuts off the top of the graft so that the remainder of the graft cannot be removed.

Capping occurs when the doctor grabs a graft with forceps and the top of the graft (the epidermis and upper dermis) pulls off, leaving the rest of the graft behind.

Tethering occurs when the bottom of the graft is still attached to the deeper tissues after the first step causing the follicular unit to pull apart during extraction.

There are a few other terms used as well.

Shredding occurs when the follicular unit is not totally separated from the surrounding tissue and pulls apart upon extraction. Shredding can also occur when the follicular unit was partially damaged in the first step.

Transection is like topping, but here the mid or lower portion of the hairs in the unit are cut.

Buried grafts occur when the graft is pushed into the sub-cutaneous space rather than extracted. Buried grafts can usually be removed, but if not removed completely, may turn form small cysts.

Visit the Follicular Unit Extraction page.

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NY Japion - Dr. Robert M. Bernstein

NY Japion — a weekly newspaper in the Japanese language, published in the New York tri-state area, and distributed for free in the Japanese community — has featured Robert M. Bernstein, MD, in their series on hair loss in men and women. In the series, TV producer, Hideo Nakamura, who is bald himself, goes on a mission on behalf of fellow bald men. His column hopes to help others with hair loss to have a more fulfilled, fun life and to raise their self-esteem.

Nakamura interviewed Dr. Bernstein for this weekly series that began in October 2006. In issues No. 1 and 2, Dr. Bernstein explained the basic mechanism of balding for both men and women which are quite different in its causes, balding types, and progression of hair loss. The NY Japion’s readers were all very surprised by the fact that balding for men is actually related to genes on both the mother’s side as well as the father’s side of the family. Dr. Bernstein also shared his unique theory of why Japan’s Samurai had the uniformed bald look.

The column discussed post-op care after hair restoration surgery and explained the drug Propecia, a men’s oral hair growth treatment, minoxidil and some cosmetic hair products.

Reporter Nakamura was also examined by Dr. Bernstein and with the patient’s permission was allowed to observe a hair transplant surgery. Issues No. 3, 4, 5 are about the surgical hair restoration procedure known as Follicular Unit Hair Transplantation (FUT), a method that Dr. Bernstein helped to pioneer. By using the patient’s own hair, FUT can give totally natural looking results. The patient’s own hair starts growing where there was no hair before.

You can download a PDF version of the original series (in Japanese) at the link below:


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The International Society of Hair Restoration Surgery (ISHRS) has named Dr. Bernstein the ‘Pioneer of the Month’ in their official publication, the Hair Transplant Forum International.

Below is the article that appeared in the publication announcing Dr. Bernstein as the recipient of the honor. Dr. Bernstein is also a member of the society.

Hair Transplant Forum International
September-October 2006

Pioneer of the Month – Robert M. Bernstein, MD
by Jerry E. Cooley, MD Charlotte, North Carolina

Pioneer of the Month – Robert M. Bernstein, MDThe term “follicular unit transplantation” (FUT) has become so firmly embedded in our consciousness that we often consider it synonymous with hair transplantation in general. Surgeons new to the field may be unaware of its origin and how the concept evolved. In the 1980s, many separate clinics were developing total micrografting techniques to improve the naturalness of hair transplantation. In 1988, Dr. Bobby Limmer began developing a technique consisting of single strip harvesting with stereomicroscopic dissection of the hair follicles within the strip, which he published in 1994.

After observing histologic sections of scalp biopsies, dermatopathologist Dr. John Headington coined the term “follicular unit” in 1984 to describe the naturally occurring anatomic groupings of hair follicles. In 1995, a surgeon just entering the field of hair transplantation became aware of these natural “follicular units” and came to believe that they should be the building blocks for all hair transplants. His name was Bob Bernstein.

From 1995 to 2000, Bob and his colleague Dr. Bill Rassman articulated the rationale and benefits of FUT in dozens of publications and numerous lectures. Doubtlessly, Bob’s extraordinary effort advocating FUT in public forums during that time was critical to FUT’s rapid evolution and acceptance among surgeons.

Bob was born in New York City and raised on Long Island, New York. For college, Bob headed south to Tulane University in New Orleans. Next, he went to medical school in Newark at the University of Medicine and Dentistry of New Jersey. He then went on to a residency in dermatology at Albert Einstein College of Medicine, where he served as chief resident.

Bob performed some punch grafting procedures in residency and a few more when he started his cosmetically focused dermatology practice in 1982. Not liking the results, he didn’t perform another transplant for 12 years. In the summer of 1994, Bob saw a patient of Dr. Ron Shapiro for a dermatologic problem. Impressed with the results of the surgery, Bob began speaking with Ron about the changes in the field. Ron encouraged him to attend the next ISHRS meeting in Toronto, which he did. While there, he saw several of Dr. Rassman’s patients presented and was greatly impressed.

Soon after, he was in Bill’s office observing micrograft “megasessions.” One of the things that caught Bob’s attention was Bill’s use of the “densitometer” to quantify the patients’ hair density. Bob noticed that the hair surprisingly grew in small groups. Bill half jokingly told Bob that he should give up his dermatology practice and go into hair restoration and invited him back for a second visit. On the 5-hour plane ride to Los Angeles, Bob thought about the potential of only transplanting those small groups he saw with the densitometer, and wrote the outline of a paper entitled, “Follicular Transplantation” (published that same year). The second visit with Bill confirmed his interest in hair transplants and, in particular, developing this idea of FUT. He quickly transferred his dermatology practice to a colleague and joined Bill’s group, the New Hair Institute (NHI).

Over the next 10 years, Bob authored and coauthored over 50 papers on FUT addressing issues such as quantifying various aspects of FUs among patients, racial variations, graft sorting, as well as hairline aesthetics, corrective techniques, the use of special absorbable sutures, and FUE and its instrumentation. One of the concepts he emphasized was the recognition of Diffuse Patterned Alopecia (DPA) and Diffuse Unpatterned Alopecia (DUPA), which were originally described by Dr. O’Tar Norwood. Bob helped raise awareness that patients with DUPA and low donor density are not surgical candidates. For all of his many contributions to the field, Bob was awarded the 2001 Platinum Follicle Award.

Branching out in other directions, Bob decided to go to business school and received his MBA from Columbia University in 2004. He did this to learn how to better streamline the day-long hair transplant sessions and improve general management of his growing staff. In 2005, Bob formed his own practice, Bernstein Medical – Center for Hair Restoration. Looking to the future, Bob says, “I am excited about the accelerated rate of technical changes to the hair transplant procedure. This is due to an increasing number of really clever minds that have entered the field. Almost every aspect of the surgery is being tweaked and improved upon. It goes without saying that cloning will be the next really big thing—but I think it will take longer to develop than some are promising.” On the down side, he notes, “A concern I have is that, as hair transplant practices grow into big franchises with large marketing campaigns, many people are being directed toward surgery rather than being treated as patients with hair loss in need of an accurate diagnosis, medical treatment, emotional support, and surgery only when appropriate.”

Bob met his wife, Shizuka, who was born in Tokyo, when she was opening a dance studio in the East Village section of New York. She now owns a day spa in midtown Manhattan. Bob has three children; two are in college: Michael, 22, is studying mixed martial arts and foreign language; Taijiro, 21, is majoring in theoretical math. His daughter, Nikita, 12, is in 7th grade and plays on the basketball team. In addition to going to Nikita’s games, Bob enjoys skiing, piano, chess, basketball, philosophy, and music history.

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Q: Dr. Bernstein, I was reading about a densitometer on your website. What is it and what is it actually used for? — Z.A., Westchester, NY

A: The hair densitometer was introduced to hair restoration surgeons by Dr. Rassman in 1993. It is a small, portable, instrument that has a magnifying lens and an opening of 10mm2.

To use it, the doctor clips the hair short (~ 1-mm) and the instrument is then placed on the scalp. The doctor counts the total number of hairs in the field, looks at the number of hairs per follicular unit and assesses the diameter of the hair, looking in particular for abnormal levels of miniaturization (decreased hair shaft diameter caused by the effects of DHT).

The densitometer can increase the accuracy of the diagnosis of genetic hair loss by picking up early miniaturization.

It can also better assess a person’s donor hair supply, thus helping to determine which patients are candidates for a hair transplant.

Densitometry has helped us define the conditions of diffuse patterned and unpatterned hair loss (DPA and DUPA) and help to refine the diagnosis of hair loss in women.

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Q: Dr. Bernstein, I remember Senator William Proxmire. He was one of the first sort of high-profile people who had a hair transplant probably, what, thirty years ago, and to be honest with you, it wasn’t all that great. It looked kind of funny. Have we made any progress in the last twenty-five, thirty years? — A.E., Fort Lee, N.J.

A: When hair transplant surgery was first developed in the late 1950s, early 1960s, everybody was so ecstatic that it grew – that one could actually move hair from the back of the head to the top, and it would grow – that no one really considered either the long-term implications or the aesthetic aspects of the procedure. And the fact that the hair grew is actually a problem because it never went away when it was transplanted poorly.

Over the years the grafts have gotten smaller and smaller. So where in the ’60s and ’70s they were the size of pencil erasers, they gradually decreased in size until doctors were performing hair transplants using just a few hairs at a time. The major breakthrough came in the mid 1990s when we realized that hair doesn’t grow individually but grows in little tiny groups and these groups are called follicular units.

In modern hair transplant surgery (which began in 1995) hair is taken from the back of the scalp and moved to the front and top of the scalp in these individual groups of one to four hairs.

In this way the results can completely mimic the way hair grows in nature.

See the Follicular Unit Transplant (FUT) section for more information.

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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: Why are strips used so much in a hair transplant when there is now Follicular Unit Extraction (FUE)? — E.N., Long Island, N.Y.

A: Strip harvesting is used in the majority of hair transplant procedures because it allows the surgeon the ability to perform hair transplant sessions using large numbers of grafts while minimizing injury to the patient’s hair follicles.

This is possible because once a strip is removed from the back of the scalp, the tissue can be placed under a stereomicroscope where dissection is accomplished using direct visualization of the follicular units. This allows the grafts to be dissected with minimal trauma.

This degree of accuracy is not possible with other hair restoration techniques, such as FUE, where the separation of follicular unit grafts from the surrounding tissue is accomplished “in vivo” (directly from the scalp).

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Hair Transplant Blog - Bernstein Medical - Center for Hair RestorationDr. Bernstein’s Hair Transplant Blog is a new medical web log (aka “blog”) that is helping the online community handle the challenges of going bald.

Selected as one of New York Magazine’s “Best Doctors” for the ninth year in a row, Dr. Bernstein answers questions at the following website URL:

www.BernsteinMedical.com/hairtransplantblog/

His replies cover over 30 categories ranging from commonly asked questions on “male pattern hair loss” and “when to have a hair transplant” to more scientific issues on specific surgical techniques.

The Hair Transplant Blog serves as a clearinghouse for important concerns of both men and women suffering from hair loss. “I consult with many patients each week in our New York and New Jersey facilities who are so distraught about the state of their hair loss that some can barely function. There is so much information available about baldness and its treatment on the internet that it is difficult to tell exactly what is true. I spend a lot of time just clarifying false, or partially correct, ideas. This misinformation just serves to exacerbate the problem.” Dr. Bernstein says “This Blog is an outgrowth of these consultations. In the Blog, I post answers to the questions that patients bring to my office or submit via our web site.”

Question are answered by Dr. Bernstein in a concise, but easy to understand way. He covers a wide variety of subjects; including new hair replacement techniques, hair transplant repair, medical therapies and interesting diagnostic problems.

The expert medical perspective in the Blog has received the attention of editors for many popular blog directories such as GetBlogs, and Answers.com. Being a featured blog has allowed people from around the world to have a better understanding of hair loss and the process of surgical hair restoration.

Dr. Bernstein has been recognized worldwide for his pioneering work in surgical hair transplantation. His landmark publications on Follicular Unit Hair Transplants, which give results that mimic nature, and Follicular Unit Extraction, a non-invasive hair replacement technique, have earned him international recognition and make him one of the foremost authorities on hair restoration in the world. Known to audiences from his appearances on NBC’s Today Show with Matt Lauer, CBS’s The Early Show, ABC’s Good Morning America, NPR’s The People’s Pharmacy, The Discovery Channel and other nationally syndicated programs, Dr. Bernstein has been providing answers and solutions for hair loss from his Manhattan facility for over 20 years.

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Hair transplant surgeon Robert M. Bernstein M.D. was recently interviewed on the National Public Radio program The People’s Pharmacy. Invited to speak about hair loss, Dr. Bernstein offered insights about the causes of hereditary baldness and it’s solutions, including hair transplantation.

The show was entitled “Dealing with Hair Loss” and addressed issues such as the importance of hair to our sense of well being.

The full hour radio interview was filled with informative facts about male pattern baldness, cultural attitudes toward hair loss and surgical hair restoration. For example, Dr. Bernstein was asked about his pioneering work in follicular unit hair transplantation and host of other questions ranging from the causes of hair loss to the psychological effects of balding. Here is one exchange from the interview:

Moderator: How one can tell the difference between hair loss from hormonal imbalances and common baldness?

Dr. Bernstein: Measuring hormone levels alone, although important for medical management, does not necessarily reveal whether the cause of the hair loss is actually hormone related or is genetic. The diagnosis is made by examining the scalp and looking at the hair under close magnification using an instrument called a “Densitometer.” If the hair shafts are of different calibers, this is relatively diagnostic of female patterned genetic hair loss and in this case hormone levels are often normal. Hormonal changes or imbalances, on the other hand, may cause alterations in hair texture (such as in thyroid disease) or a generalized shedding that can occur after childbirth (called telogen effluvium). In telogen effluvium, the hair can l actually fall out in clumps – you can literally get handfuls of hair, but the hair often returns over time. In genetic hair loss, however, it is not a question of the hair falling out any faster, but the hair being replaced with thinner, finer hair in each hair cycle, until the hair gradually disappears.

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Q: What exactly is compression in a hair transplant? — D.O., Short Hills, N.J.

A: Compression refers to the visible tufting of grafts due to the contraction of the grafts from the normal elasticity of skin around it, after it has been inserted into the recipient site. Compression is most commonly seen when minigrafts are used in the hair restoration (minigrafts contain more than four hairs each). Follicular units don’t show visible compression, since they are already naturally compact. However, if more than one follicular unit is placed into the same site, it can exhibit this phenomenon.

Compressed grafts will become less visible as more hair is transplanted to the area, but if they are close to the hairline or in areas where a lot of density may not be planned (such as in the crown) they may have to be removed. In this case, they can be placed under a microscope, divided up into smaller grafts and re-implanted.

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Follicular Unit Forum - Bernstein Medical - Center for Hair RestorationFollicular Unit Forum is unique in that it affords visitors an opportunity to anonymously ask questions about the “ins and outs” of hair transplant surgery, of those who actually have had the state-of-the-art Follicular Unit Hair Transplant procedures.

Questions are posted to people who have actually undergone hair restoration procedures. Individuals who are considering a surgical solution to their hereditary baldness are able to search through “threads” or conversations that will answer their most pressing concerns such as; what to expect before, during and after a hair transplant, and what kind of procedure one should have.

The focus of this new online health resource is Follicular Unit Transplantation and Follicular Unit Extraction, two procedures that are universally considered to be the most up-to-date approach to surgical hair restoration. Follicular Unit Transplantation is a surgical technique that transplants hair in naturally occurring groups of 1-4 hairs. These groups (called follicular units) are taken from a single donor strip of skin and dissected using a microscope. Follicular Unit Extraction is a method that obtains the tiny follicular unit grafts from the donor area by using an instrument which removes them one-by-one directly from the scalp.

Patients who have received hair transplants with undesirable results (such as the typical pluggy “dolls hair” look) can also benefit from monitoring the site. FollicularUnitForum.com has posts from patients who have had unnatural looking grafts removed and re-implanted in a more natural way – as follicular units – to produce the most best results.

“We wanted to create a consumer-to-consumer forum that exclusively addressed the topic of Follicular Unit Hair Transplantation – the procedure that is now considered to be the gold standard in surgical hair restoration” said Robert M. Bernstein M.D., founder of Bernstein Medical – Center for Hair Restoration and sponsor of the site. “There are some great forums for hair loss out there but we felt that there was room for one that was created specifically for people who had done their preliminary research but now wanted to hear more first hand experience with FUT or FUE”.

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PRESS RELEASE

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

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

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

The purpose of the annual event is to bring together the world’s best minds in hair restoration surgery for an interchange of ideas, knowledge and experience. The meeting is aimed at enhancing, to the highest possible level, the skills and artistry of the members.

One of this years exciting presentations was given by Robert M. Bernstein M.D., Associate Clinical Professor of Dermatology at the College of Physicians and Surgeons of Columbia University in New York. Dr. Bernstein is recognized world wide for his pioneering work in Follicular Unit Extraction (FUE) and Follicular Unit Transplantation (FUT), considered to be the state-of-the-art in surgical hair restoration techniques.

Dr. Bernstein introduced a new instrument for FUE that enables hair to be removed directly from the back of the scalp without the need for a linear incision. The instrument increases ones ability to remove the hair in its naturally occurring groups with minimal damage. According to Dr. Bernstein, “FUE has been most useful for camouflaging the scars produced by hair transplants performed with older techniques.”

The International Society of Hair Restoration Surgery brought together a lively collection of panels led by doctors who were well-known and highly-respected professionals from the surgical hair restoration industry. Doctors such as Robert M. Bernstein M.D. shared their expertise in order to cover the issues and advances in medical and surgical hair restoration and the latest research developments in the field. The intention being better treatment and treatment options for patients.

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

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

On average about 15% of the follicular units are 1-hair units (but this also may very greatly between patients). If 6% of all follicles are “empty” telogen follicles, then there should be .15 x .06 = .009 or about 1% of the patient’s 1-hair follicular units in the empty telogen phase that can’t be identified and will be missed on dissection.

The 1% isn’t very large. However, also consider that the remaining 5% of the empty follicles are associated with larger follicular units (i.e. those with 2-4 hairs). If these follicular unit grafts are closely trimmed, as is the practice with very dense packing, a much more significant number of follicles are at risk of being lost. With chubby follicular unit grafts (i.e., where the microscopic dissection leaves a protective sheath of tissue around the follicles) the risk should be closer to the 1%.

The lesson for hair transplantation is that over-trimming of grafts, for the sake of very dense packing, may waste telogen hairs as well as place the grafts at an unnecessary risk of mechanical trauma, drying and warming.

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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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Dr. Bernstein was featured in an article in GQ Magazine on hair transplantation. The article, written by Peter Rubin is entitled, “Grow Your Own.”

Here is a brief synopsis of the article:

GQ: After fifty years of bad plug jobs, we’ve come to regard “hair restoration” as synonymous with “Astroturf head.” Today’s hair transplant procedures are worlds away from the butcherings of old. So forget what you thought you knew.

Two methods of hair restoration are in wide usage: mini-micrografting and follicular unit transplantation. The methods are similar, to an extent, but FUT; co-developed by New York hair transplant surgeon, Robert M. Bernstein, M.D.; is the more advanced of the two procedures, producing cosmetically superior results.

Dr. Bernstein: Anatomically, follicular unit transplantation is the end of the line. The next step would be hair cloning, which is still quite a way off. The way you get the most amount of hair into the smallest wound — and ensure that it’s going to look natural — is by using a follicular unit transplant. We can create swirls, add sideburns… The beauty of follicular transplantation is that the hair will take on the old wave that the original hair had.

GQ: The best part is that FUT regularly achieves an extraordinarily high success rate, meaning nearly every single transplanted graft takes root and grows properly – unheard of fifteen years ago.

Pierce Mattie, a 28-year-old publicist in New York City, had an FUT procedure in May and couldn’t be happier. “I’ve had dental fillings that were more painful,” he says. “I was back in the office two days later, and my hair looks like it did when I was in high school. Everyone keeps saying, ‘You look so great!’—but they have no idea what I had done.”

About GQ Magazine: For nearly half a century, with 854,000 subscribers and 4 million readers, GQ has been a leading voice in men’s magazines, covering men’s style and culture from fashion and politics to travel, entertainment, sports, technology and relationships. GQ has been nominated for 27 National Magazine Awards.

Reference
“Grow Your Own,” GQ Magazine, November 2003, p173-4.

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Follicular Unit Transplant - Surgery of the Skin - Dr. BernsteinSurgery of the Skin: Procedural Dermatology; published in 2005 by Elsevier-Mosby and Edited by Robinson, Hanke, Sengelmann and Siegel; is monumental work that covers the entire spectrum of dermatologic surgical procedures. In the editor’s words, the goal of this 872 page textbook is:

“To capture the art and practice of dermatologic surgery at the beginning of this century.”

It is to be used as the core surgical textbook for dermatologic training programs. The book is divided into four parts: Part I – Basic Surgical Concepts, Part II – Essential Surgical Skills, III – Aesthetic Surgical Procedures, and IV – Special Procedures.

The text covers a wide range of subjects on aesthetic surgery, including liposuction, chemical peels, Botox, soft tissue augmentation, laser hair removal, laser skin resurfacing, leg vein treatment, blepharoplasty, face lifts and, of course, hair transplantation.

Dr. Bernstein was honored to write the section on hair transplantation that covers the historical aspects of the field, patient evaluation and surgical planning, operating room set-up, surgical techniques and how to maximize the cosmetic outcome of the hair transplant.

The focus of Dr. Bernstein’s chapter is on Follicular Unit Transplantation, the technique that has changed the face of surgical hair restoration over the past decade. The chapter discusses strip harvesting, follicular unit extraction, the use of anesthetics, ways to optimize density and ensure the naturalness of the procedure, as well as a host of other important topics. The textbook may be purchased at Amazon.com.

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Robert M. Bernstein M.D. was asked to provide expert medical commentary in two hair transplant videos produced by Healthology. The topics included “Hair Transplantation Techniques” and “Using Cloning Techniques in Hair Transplantation”.

Healthology, the leading producer of broadcast and webcast programming that provides consumers with direct access to top medical experts, produced an important series of videos on hair loss. As Associate Clinical Professor of Dermatology, Columbia University College of Physicians and Surgeons, Dr. Bernstein was a vital part of the interview series.

Hair Transplantation Techniques

The first video that Dr. Bernstein was invited to take part in, focused on the various techniques used in surgical hair restoration. As a pioneer of Follicular Unit Transplantation, the filmmakers were eager to hear Dr. Bernstein’s thoughts on FUT:

“A major breakthrough in hair restoration came via identification that hair didn’t grow individually, but actually in small groups called follicular units. And these follicular units are naturally occurring groups of hair from one to four” Dr. Bernstein explained, “in modern hair transplantation, a procedure we call Follicular Unit Transplantation is used; we transplant the hair the way it actually grows in nature.”

This Healthology segment explored how the Follicular Unit Transplantation technique is also helping patients who want to improve the appearance of old transplants or scars.

“What we can do now is remove the old grafts, sew the holes closed where they’re transplanted, place those grafts under a microscope, divide them into individual follicular units and then place them back in the scalp the same day.” said Dr. Bernstein.

In addition to covering surgical hair restoration, the segment touched on the issue of medications for hair loss. Though some patients think getting a hair transplant means they can stop taking hair loss medications, Dr Bernstein illustrated why most physicians recommend using medicine along with surgery:

“Hair transplantation and medications do essentially different things. The main benefit of a transplant is to restore hair that’s been lost. The main benefit of medication is to prevent further hair loss.”

Using Cloning Techniques in Hair Transplantation

In this second Healthology video segment, on hair cloning, they invited Dr. Bernstein to take part in the discussion along with other distinguished guests; including Angela Christiano, PhD an Associate Professor of Dermatology and Genetics & Development at Columbia University.

This interesting segment explored how researchers are trying to find ways to make more follicles for hair transplant surgeons to work with. Research into cloning techniques shows it may be possible to create a virtually limitless supply of new follicles in the not too distant future. Dr. Bernstein provided some insights as to how hair restoration doctors might approach hair cloning in the future:

“The actual role of cloning in hair transplantation will depend upon how the cloning technology actually evolves. Initially, cloning may be used to supplement a regular hair transplant. We would use Follicular Unit Transplantation to give definition to a hairline and frame the face. Cloning would then be used to give the hair transplant bulk, by placing the cloned hair (which may not look as natural as normal hair) behind the transplanted hair.”

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Q: If a second hair transplant is performed before the first had a chance to grow could the second procedure destroy the follicles from the first? — B.M., Upper East Side, NYC

A: Hair from the second hair transplant session would not damage the follicles transplanted in the first session, even if follicular unit grafts were transplanted in exactly the same spot as in the first session.

The reason to wait until the hair grows in, however, is so that you can better plan the subsequent hair restoration procedure. If two follicular units are placed on top of each other or very close together, you will essentially be creating a mini-graft and the results will not look natural.

We advise waiting at least 8 months between sessions with 10-12 months being ideal so that the grafts of the second session can be evenly distributed among the grafts of the first.

The extra few months not only allow the surgeon to identify all of the previously transplanted grafts, but enables him to get a sense of the “look” of the first session (i.e. the wave, the density, and how the patient will ultimately want to comb his newly transplanted hair). This is very useful in guiding the placement of grafts in the second session to maximize its cosmetic benefit.

Read more about a second transplant
See before after hair transplant photos of patients who had a second procedure

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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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Hair transplantation was introduced in the United States by Dr. Norman Orentreich in 1959. He demonstrated that hair taken from one area of the scalp would continue to grow even if it were transplanted to a balding area of the head.

The problem with this scientific breakthrough was that hair was being transplanted in clumps or “plugs” that did not appear natural. And although patients who had hair transplants were indeed growing hair on what was once a balding pate, the appearance was akin to that of a doll’s head and hardly much of a cosmetic improvement for their baldness.

In 1995, Drs. Bernstein and Rassman presented a paper describing a new procedure surgical hair restoration called Follicular Unit Transplantation or FUT. In this new technique, hair would be transplanted using only naturally occurring, individual units of 1, 2, 3 or 4 follicles. These perfectly intact “follicular units” would be obtained by removing a single, thin strip of skin from the back of the scalp and then using a dissecting stereomicroscope to isolate the tiny naturally occurring groups of hair.

Since the publication of “Follicular Transplantation” hair transplantation has undergone an “extreme makeover” itself, in part due to the incredibly natural results that this powerful procedure can produce. FUT is now considered to be the state-of-the-art in hair transplant surgery and is currently the most widely used surgical hair restoration technique.

Robert M. Bernstein M.D., Clinical Professor of Dermatology at Columbia University in New York City, sat with us for a Q&A on hair transplant surgery and its future.

How are Hair Follicles Removed in Follicular Unit Transplantation?

In order to safely remove and preserve the follicular units without causing any damage to them, the donor tissue is removed in one thin piece. This technique is called Single Strip Harvesting and it is an essential component of follicular unit hair transplants.

How Many Grafts Should be Transplanted at Once?

The average session for a moderately bald person, who has lost most of the hair on the top of his scalp is around 2,500 grafts. Although it is best to complete the hair restoration in as few large sessions as possible, there are limits. When too large a strip is removed, it can cause undue tension in the donor area and cause a stretched scar or loss of hair. Excessively long hair transplants, where the grafts are kept outside the body for an extended period of time, may compromise graft survival.

Another issue with very large sessions is that a hair transplant doctor has less flexibility if problems arise during the surgery. Patient variability is an intrinsic part of hair transplants. In some patients, the grafts tend to pop up above the skin surface as they are inserted into the scalp. Popping also occurs when a graft placed in the skin causes an adjacent one to lift. The closer you put the grafts and the more grafts you transplant at one time, the greater the chance that these problems will occur and the more difficult they will be to manage. The goal is to always maximize what you get from the back and what grows in the front and top. It’s not a race where we have to do 3,000 or 4,000 grafts in every patient. When I hear people say, “Oh, I had 5,000 grafts.” I think “How many of those actually grew?”

Is Hair Transplant Surgery Permanent?

Yes, the hair on the back and sides of the scalp is permanent and it retains this characteristic even when moved to the front and top of the scalp.

Will Transplanted Hair Change Over Time?

The genetic tendency of hair to grow is dependent upon the donor area where the hair comes from. We call this “donor dominance.” However, the character of the hair, the wave, the rate of growth, is affected by the area where it is transplanted into. For example, we discovered that when we take scalp hair and transplant it to the eyebrows, over time, the growth rate actually slows down to match the growth of eyebrows. In this case, the recipient area has an influence on the growth of the eyebrow hair.

Can You Take Hair from Someone Else and Transplant it on Your Own Head?

You cannot perform hair transplants with hair taken from someone else. It has to be your own hair or it will be rejected by the body.

What is the Future of Hair Transplantation?

The next big improvement to the field of surgical hair restoration will be hair multiplication – commonly but erroneously referred to as hair cloning. This technique will dramatically increase a person’s limited donor supply, an issue that frustrates many patients wanting hair restoration.

The mechanism for cloning is based on the multiplication of the cells that surround a hair follicle. These cells, called fibroblasts are readily multiplied outside the body. Once multiplied, the “fibroblasts” could be injected into the skin to induce hairs to form. The problem is that when you multiply these fibroblasts, they lose their ability to stimulate hair to grow – a major roadblock that still needs to be overcome.

Another concern with hair cloning is that if you’re inducing hair to grow, what will it look like? Is it going to be wild and uncontrollably wiry? Will it look like the person’s normal hair? Because the recipient area plays a factor in the way a follicle grows, it’s reasonable to assume that even if you inject these fibroblasts to induce a hair to form, that hair will start to take on the characteristics of a person’s original hair.

It is exciting to think of the possibilities that improvements in the science of hair transplants will afford to those suffering from the effects of hair loss. Perhaps someday any baldness in men and women will be a result of choice and not a genetic constraint, but will unlikely be available for at least 5-10 years.

Watch video Q&A with Dr. Bernstein

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Dr. Bernstein was interviewed by New York Newsday in their article, “It’s a Hairy Decision Picking a Treatment for Baldness.” The complete article is below:

HEALTH MATTERS COLUMN

Even IF they don’t talk much about it, just about all the guys he knows are taking medication for their thinning hair, said Steve, a retail manager in his early 30s from Suffolk County, NY. He would be too, but he had side effects right away. He’s had consultations for hair transplants, but that won’t work either because of the pattern of his balding.

So he’s using a protein product that makes his hair look fuller, changed his diet to include leafy green vegetables, gone to two psychics for help. And, he said, he’s biding his time, waiting for new hair restoration medications or for hair cloning to hit the marketplace.

“In the ’90s, everything’s about looks,” said Steve, who asked that his last name be kept confidential. “No one wants to give up their youth.” All the effort to find a hair restoration solution is worth it, he said, “because losing my hair bothers me a lot.”

Sure, hair loss isn’t crippling or life-threatening. But to hear people’s tales, it’s traumatic, depressing and embarrassing.

Yet, you’re more likely to get a snicker than a hug for your pains, said Spencer Kobren, 34, a Manhattan consumer activist and author of “The Bald Truth,” (Pocket Books, 1998, $6.99.) There may be few open arms to comfort you, he said, but there are plenty of extended hands to take your trust and your money.

Kobren should know. He has spent several years testing out hair loss products and talking to the experts about his own hair loss, which began at 22. Now he serves as a sounding board and clearinghouse for the good news and the bad about hair loss and its treatments on a syndicated radio show, aired locally on WEVD /1050 AM on Sunday nights.

“You feel like you’re losing a part of yourself. You see your appearance deteriorate, often rapidly and drastically,” he said. You become vulnerable to promises and pitches, but don’t be swayed by them, said Kobren, who now has a full head of hair. Instead, do a lot of research. The wrong hair restoration products or treatments may not only fail to grow hair, they can make matters a lot worse. For example, he said he gets thousands of letters and e-mails about botched hair transplants that leave men scarred, poorer and balder.

According to Kobren, about $7 billion is spent by consumers annually on finding solutions to hair loss. There are about 50 million men who are balding, with at least 20 percent starting in their 20s. Most have male-pattern baldness, genetically linked and triggered by the action of a hormone called dihydrotestosterone (DHT).

Hair loss is not just a guy thing, though. Plenty of women — about 20 million — have varying degrees of it too. Hair loss is finally getting recognition as a women’s health problem, said Maggie Greenwood- Robinson, whose book, “Hair Savers for Women” (Three Rivers), is due next spring. Kobren’s “The Truth About Women’s Hair Loss,” (Contemporary) will be out in January. “There are more options than ever before for women with hair loss,” said Greenwood-Robinson, and they shouldn’t give up.

But they do have to be cautious. The diagnosis and treatment for men and women is very different, said Dr. Robert M. Bernstein, assistant professor of dermatology at Columbia College of Physicians arid Surgeons and medical director of the New Hair Institute in Manhattan and Fort Lee, N.J.

“Women usually have a diffuse type of hair loss with thinning all over,” he said, “while men generally lose hair on the front and top and keep a permanent zone on the back and sides.” Female baldness can also be due to DHT, but many women lose hair because of anemia, gynecological issues, thyroid disorders or stress, among other reasons. You don’t want to waste your efforts on hair restoration products when what you need is more iron or different birth control pills. “A medical evaluation is extremely important to rule out underlying medical conditions,” said Bernstein.

The treatment of hair loss is an increasingly complicated decision for both men arid women, but at least there is more information than ever to help you ask the right questions. Web sites include www. thebaldtruth.org and www.regrowth.com. Bernstein’s practice has a Web site at www. newhair.com and a detailed book called “The Patient’s Guide to Hair Restoration.”

Your hair restoration options include:

Medication: Finasteride (brand name Propecia), taken orally by prescription. Available for under two years, Propecia is for men only and causes side effects in about 2 percent of them. It has been shown to stop hair loss in about 87 percent of users and new growth in about half. It’s not for women, because it can cause birth defects if a woman is pregnant, and if she’s past child-bearing age, it doesn’t seem to work.

Minoxidil: (brand name Rogaine), used topically. It can be used by both men and women and appears to slow down the rate of hair loss, but not to prevent balding in the long haul. Any effect from either of these hair restoration medications stops when you no longer use them.

Hair transplant surgery: for men and women. Bernstein has pioneered a state-of-the-art technique called follicular unit transplantation, a precise method using hair-follicle groupings that result in a more natural growth of hair and doesn’t leave scars.

Removing grafts of skin from your head and placing them in balding spots is clearly an art as well as a science. Besides being a good candidate for surgical hair restoration, you need to find a dermatologist with a lot of experience performing hair transplant surgery. Expect to ask many questions, learn the risks, see pictures of other patients and meet them in person.

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

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

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

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

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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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