Q: Is it safe to implant 6,000 grafts in 2 days with an FUE procedure? — L.P. ~ Port Washington, N.Y.
A: A 6,000-graft procedure would be a very large hair transplant. Transplanting this many grafts at once would necessitate grafts being placed very close together. In this situation, the blood supply may not be adequate to support the growth of the newly transplanted grafts.
Another reason for concern is that when harvesting, FUE yields about 20 grafts/cm2. A 6,000-graft procedure would require 300 cm2. Since the donor area is about 30 cm long, this would require a donor height of 10 cm, clearly extending beyond the permanent zone of the scalp of most patients.
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By Robert M. Bernstein, MD
When Dr. Rassman and I coined the term Follicular Unit Extraction (FUE) in our 2002 publication “Follicular Unit Extraction: minimally invasive surgery for hair transplantation” we used the term to imply that this new procedure was less invasive than a traditional FUT/strip procedure ((Rassman WR, Bernstein RM, McClellan R, Jones R, et al. Follicular Unit Extraction: Minimally invasive surgery for hair transplantation. Dermatol Surg 2002; 28(8): 720-7.)), ((Bernstein RM, Rassman WR, Szaniawski W, Halperin A. Follicular Transplantation. Intl J Aesthetic Restorative Surgery 1995; 3: 119-32.)) Recently, FUE has been marketed by some practices as being non-surgical and this has given rise to the procedure being performed without physician participation (in some practices even without physician oversight).
The fact is that the FUE procedure is more than just the extraction of follicular unit grafts. The surgeon must first create an incision with a punch tool before the grafts can be extracted. The punch tool can be manually operated, automated or robotic. ((Bernstein RM. Integrating Robotic FUE into a hair transplant practice. Hair Transplant Forum Intl. 2012; 22(6): 228-229.)) The extraction can be performed with forceps or suction. This process of incising and then extracting grafts is a surgical procedure and is, therefore, better described by the word excision.
To avoid giving the erroneous impression that an FUE procedure is non-surgical, the term FUE will now be short-hand for Follicular Unit Excision. This better describes the two main components of an FUE procedure, incision (the separation of the follicular unit from the surrounding tissue) and extraction (the removal of the follicular unit from the scalp once it is separated).
OLD Terminology
FUE = Follicular Unit Extraction = the entire harvesting procedure
NEW Terminology
FUE = Follicular Unit Excision = incision (cutting) + extraction (removal)
It is important to note that this is just a change in terminology, not in the technique itself. The FUE procedure has not changed. The FUT/strip procedure and its nomenclature have also not changed. ((Bernstein RM, Rassman WR, Seager D, Shapiro R, et al. Standardizing the classification and description of follicular unit transplantation and mini-micrografting techniques. Dermatol Surg 1998; 24: 957-63.)) It is also important to understand that both FUE and FUT/strip refer to harvesting techniques and not to implantation of grafts into the recipient areas of the scalp (a process that is basically similar in both procedures).
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Q: I thought that FUE extraction is performed in a way that it cannot be detected. Therefore, it is best to distribute the pattern evenly starting from the safe zone and fading out on the sides. The ARTAS results often show a smaller extraction area and harder edges (no transition from extraction to non-extraction area). Does this lead to a higher risk to detect the surgery? — H.K. ~ Chicago, I.L.
A: Feathering of the extraction zone in FUE is a technique where the distance between the extractions gradually increases as one reaches the border of the extracted zone. When this technique should be used depends upon the short- and long-term goals of the patient. If the patient’s main goal of the FUE procedure is to wear their hair very short, then the technique of feathering and rounding the edges to have a less distinct border is appropriate, as this will decrease the visibility of the harvested area.
However, if a person does not wear his hair very short (nor plans to) and maximizing the donor supply is paramount, then a more organized pattern, with less feathering, will give a greater long-term yield and a more even distribution. The reason is that the healing of FUE wounds distorts adjacent follicular units making subsequent extraction in the same regions more difficult and increases the risk of transection. For this reason, in subsequent procedures we generally prefer to harvest in new areas. If we need to harvest more hair from the same area, we rarely go back more than once.
When one feathers extensively in the donor area, this utilizes a larger surface area of the scalp with less graft yield, so it may become necessary to go back over the same area to obtain additional grafts, often multiple times. This risks increased transection and an uneven, mottled appearance to the donor area.
If a person wears his hair very short, then feathering is critical (even though it makes subsequent extraction more problematic). It is very easy to feather and round edges with the ARTAS robot, but we make the decision to do so based upon the specific needs and goals of the patient.
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Q: I was thinking of having an FUE hair transplant procedure done in Turkey, but I am concerned that it will be done with just technicians. Any thoughts? — E.E. ~ Mount Vernon, N.Y.
A: I do not have first-hand information on the clinics in Turkey, but there is a recent “Letter to the Editor” in Hair Transplant Forum International, the official publication of the “International Society of Hair Restoration Surgery” that you might find informative. From the article:
“In Turkey, there are 300 FUE clinics in Istanbul alone but, unfortunately, at only 20 of them are operations are done by doctors. We do not exactly know how many of those 300 clinics have legal permissions, but we know very well that an average of 500-1,000 FUE operations are done per day.”
If you would like to read the entire article, the reference is: A Report from Turkey – the situation in a top FUE destination. Hair Transplant Forum International July/August 2017 p 162.
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Q: Why go to a hair restoration practice that specializes in both FUT and FUE? — L.P., Bayside, NY
A: This is a great question, but the answer may be counterintuitive in today’s age of specialization. The answer is that you should always go to the practice that offers both. To deliver the best care, hair restoration physicians should have expertise in both Follicular Unit Transplantation (FUT) and Follicular Unit Extraction (FUE) techniques and should offer both in their practices. There are at least five good reasons why:
1. FUT and FUE are both excellent techniques, but have different indications for their use; therefore, a patient might benefit from one technique over the other. If the doctor offers both procedures, the physician will be able to choose the best one for the specific patient rather than treating everyone with a single type of procedure.
The main advantage of FUT is that it typically gives the highest yield of hair. Therefore, when the patient’s primary goal is to achieve maximum fullness, FUT should be performed. There are many well-described reasons for this, including the precision of stereo-microscopic dissection (which helps preserve follicles and the protective tissues around them) and the ability to harvest efficiently from a more select area of the donor zone.
The main advantage of FUE is no linear scar. Therefore, when the patient’s primary goal is to be able to wear his hair very short, FUE should be performed. FUE is also indicated when there is an increased risk of a widened scar or when scalp laxity does not permit a strip excision. The patient may sometimes choose FUE simply to avoid the stigma of a linear donor scar.
2. The same patient may benefit from both procedures
There are situations in which both procedures are useful in the same patient. For example, FUT may first be used to maximize yield, but then, after several sessions, the scalp may become too tight to continue to perform FUT, or the donor scar may become wider than anticipated. In the former case, the physician can switch to FUE to obtain additional grafts; in the latter case, FUE may be used to camouflage the scar of the FUT procedure.
3. There is a cross-over set of skills from FUT to FUE
To do an FUE procedure well, the follicular unit grafts that are extracted should be examined carefully under a stereomicroscope and, when needed, trimmed and sometimes subdivided into individual hair follicles (such as for hairlines, eyebrows, temples, etc.). Stereo-microscopic dissection is basic to FUT and is a skill that is second-nature to the staff of hair restoration practices that regularly perform FUT procedures, so this critical step will not be hit or miss. A doctor and staff who perform only FUE will often lack this skill.
4. Practices that offer both procedures are usually more experienced
It is easier to learn and train one’s staff in just one hair transplant technique. In particular, FUE procedures require a smaller staff than FUT and, thus, many doctors entering the field of hair restoration surgery will perform FUE, but not master the skill or make the commitment (financial, time, and infrastructure) to hire and train the staff to perform FUT.
5. Better decision making
One could argue that if a doctor performed only one procedure, but the patient needed the other, then he/she would refer the patient to a colleague. Although this sounds nice in theory, it is very rare for a doctor to refer a surgical case to a colleague if it is a condition that he/she actually treats. More likely, the doctor will convince the patient (and probably himself) that the procedure he offers is the appropriate one, even though it may not be the case.
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Dr. Robert M. Bernstein, pioneer of modern hair transplant procedures and a Clinical Professor of Dermatology at Columbia University in New York, was selected for the 17th consecutive time to be included in New York Magazine’s annual ‘Best Doctors’ issue.
New York, NY — Robert M. Bernstein, MD, MBA, FAAD, FISHRS, a Clinical Professor of Dermatology at Columbia University in New York and distinguished pioneer of modern hair transplant surgery, was included for the seventeenth consecutive time in the ‘Best Doctors’ edition of New York Magazine. Dr. Bernstein was selected by his peers as one of New York’s top doctors on account of his prominent work in developing Follicular Unit Transplantation (FUT), Follicular Unit Extraction (FUE), and Robotic Hair Transplantation (Robotic FUE).
Dr. Bernstein said: “It is exciting to be part of the continuing progress made in the treatment of hair loss as technological advances in both robotics and traditional surgery converge to improve the care of our patients.”
Bernstein Medical – Center for Hair Restoration, founded by Dr. Bernstein in 2005, is a center of innovation for the hair restoration industry. So far in 2016, Dr. Bernstein has patented a modified FUE procedure and published research on improvements to the ARTAS® Robotic Hair Transplant System. Each of these advances is designed to enhance surgical outcomes for hair transplant patients. Bernstein Medical is a beta-test site for Restoration Robotics, Inc.; the company that produces the ARTAS robot and Dr. Bernstein is a medical advisor to the company.
The ‘Best Doctors’ issue is a special annual edition of New York Magazine that contains a peer-nominated list of 1,300 of New York City’s top physicians. The list of doctors is cultivated by Castle Connolly, Ltd., through a survey of physicians in the New York Tri-State area, which includes New York, New Jersey, and Connecticut. Doctors who are nominated must pass a rigorous physician-led review of their qualifications, skill in diagnosis and treating patients, and reputation. Castle Connolly also publishes America’s Top Doctors, which has included Dr. Bernstein in all fifteen editions, and Top Doctors: New York Metro Area, which has included Dr. Bernstein in fifteen consecutive editions.
Posted by Robert M. Bernstein M.D.
The following are excerpts from a recent interview with Dr. Bernstein. The oral text was modified for readability.
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Part 1
Hair Loss in the Younger Person
Interviewer: I brought a fair number of questions related to aspects of androgenetic alopecia and hair transplantation, but I will also ask you some questions regarding two other types of hair loss, like alopecia areata and cicatricial alopecia. Most of our listeners are fairly educated about the different hair restoration options available to them, so I’ll tailor my questions primarily for this type of audience.
The first question that I want to direct here is the dilemma that many young people face when they’re losing their hair and are considering getting a hair transplant. They typically don’t know the degree to which their hair loss is going to progress. When you’re in your 20s and 30s, you want to have a decently low-running hairline and you want to have a crown that looks full. But given that you don’t know how far your hair loss is going to go, how would you address this scenario for people in that age range?
Dr. Bernstein: That is the main problem with treating younger people. We don’t really know how they’re going to progress. It is so important to wait, usually until the person is 23 to 25 before you can really get a sense of how much hair loss they are going to lose. And even at that age it’s sometimes very difficult to tell. That’s even after considering things such as family history.
A problem with treating a younger person with surgical hair restoration is that they often want things that are unrealistic. A person in their 20s is what we call “backward-looking.” They’re looking to when they were a teenager and they want their flat hairline back and all their old density. But hair transplants are forward-looking. We need to consider what they’re going to be like in ten or twenty years – not how they looked in the past.
A density and a transplanted hairline that would be appropriate for someone older, is obviously not going to be satisfactory for someone that is younger, so it’s really best to wait on hair transplant surgery. Fortunately, there are some other good hair restoration treatments, such as medication, and that’s what the focus should be on in a younger person.
Interviewer: A lot of people are in that situation and are considering hair transplants. I guess the hard thing to do is convey to them your point that they really should be forward-looking instead of backwards-looking and maybe they will have to settle for a somewhat higher one than they originally thought so that it will be good on the long-term.
The Donor Area in a Hair Transplant
With regards to the donor area, it’s sort of been spread as gospel that hair from this area is completely immune to thinning and hair loss. Is this really the case? For instance, there are people in their 50s and beyond who still have relatively thick hair in that area, the donor area still appears thinner than it was when they were younger. I look at my own father, for instance, as an example. His donor area is obviously still relatively thick, but he has less hair in that area. So when you’re young, and you transplant hair from that area, can you expect some of those transplanted hairs to fall out?
Dr. Bernstein: The donor area in hair transplantation, for most people is, in fact, permanent in that the hair that is transplanted will remain. What happens, though, is that in the course of one’s lifetime, that hair will change in quality. So the hair actually thins out over time. It’s not miniaturization in the sense that hair that’s being lost to genetic hair loss is miniaturized, but there’s a change that we call “senile alopecia” where the hair changes in diameter. It is more of a uniform change than we see in typical androgenetic change and so over time the donor area and, therefore, the transplanted area as well, will appear thinner.
That said, it’s still important to identify the fact that some patients will actually lose a significant amount of hair in the donor area. We call those people DUPA or diffuse unpatterned hair loss. What that means is that the androgenetic related process that is occurring on the front and top of the scalp is also affecting the back and the sides. It is really important to identify those patients because those with DUPA are not candidates for hair transplantation, since the hair transplants are only as good as the hair in the donor area. If the hair in the back and sides thins or falls out over time, so will the transplanted hair.
DUPA or diffuse unpatterned hair loss can be identified by Densitometry. Essentially what that is, is clipping a little bit of hair from the donor area and seeing if there are changes in hair shaft diameter at a young age. If the miniaturization (decrease in hair diameter) exceeds about thirty percent, it’s very suggestive of this type of hair loss. It’s also much easier to pick up this condition when someone is a little older, which is another argument for not performing a hair transplant on someone who is too young.
Interviewer: So how long does it take to determine if someone will have extensive hair loss and possibly not be a good candidate for a hair transplant. I mean, when you first take the initial sample, how long do you have to wait before you check again to see if it actually happens?
Dr. Bernstein: Generally, the first thing that a young person will notice is decreased hair volume. They will complain “I feel like I have less hair” or “when I go to the barber, he says I’m thinning,” or “when I run my fingers or comb through my hair, it seems like its thinner”. At this point, it is usually easily confirmable on densitometry. We can find increased miniaturization in the donor area. And this can sometimes occur as early as 14 or 15 years old. So it really can occur very early and, unfortunately, those patients are usually going to become very bald – usually at a young age.
The good thing is that if you have very thin hair all over, it often doesn’t look as bad as having dense hair on the back and sides with a bald top. So even though people with diffuse unpatterned hair loss can lose lots of hair, they actually don’t do so badly since their hair is uniformly thin. And they sometimes respond well to medications, such as Propecia. Although this is not a permanent cure, it may at least get them through the critical years of their teens and early 20s.
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