Q: I am preparing for FUT surgery and read about scalp laxity exercises. Will they better prepare me for my hair transplant? – O.U. A: For the majority of patients, there is enough scalp laxity so that exercises are unnecessary. If a patient’s scalp becomes too tight for FUT, we would switch to FUE. On […]
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.
International Society of Hair Restoration Surgery (ISHRS)
On March 6th, 2018 the International Society of Hair Restoration Surgery announced an update to the terminology of the FUE hair transplant technique. FUE historically stood for Follicular Unit Extraction but has now been changed to Follicular Unit Excision. The change in terminology is intended to emphasize the surgical nature of the procedure.
There has been a change in the terminology of the FUE procedure, it will now be called Follicular Unit Excision. This 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). It is important to note that this is just a change in terminology, not in the technique itself. Click to read more!
Q: I have heard that shock loss is somewhat common after a hair transplant. Do women experience less shock loss than men? — N.R. ~ Mineola, N.Y.
A: The risk of shock hair loss is generally greater in women than in men since women usually have a more diffuse pattern of thinning. This is because females generally have more miniaturized hair, the hair that is most subject to post-op shedding.
Hair transplant pioneer Dr. Robert M. Bernstein and his colleague Dr. William R. Rassman have received a patent on a new method that improves the outcome of Follicular Unit Extraction (FUE) – the type of procedure used in half of all hair transplants performed world-wide. The key invention is the addition of a delay between the creation of recipient sites and the insertion of follicular units into those sites. The delay allows the healing process to commence before grafts are inserted, resulting in increased success of the transplant and an improved outcome.
The 2015 hair restoration practice census, published by the International Society of Hair Restoration Surgery (ISHRS), showed that hair transplantation is an increasingly popular treatment for hair loss.
The biennial survey found that 397,048 procedures were performed in 2014, an estimated increase of 28% over the previous survey, published in 2012. Three prior surveys found increases of up to 12%, so the rate of surgical hair restoration seems to be accelerating.
On being chosen for his sixteenth consecutive ‘Best Doctors’ issue, Dr. Bernstein said: “I am honored to be considered among the best doctors in New York and it is a credit to the hardworking staff at Bernstein Medical that, after two decades of incredible progress, we are still making significant advances in the surgical treatment of hair loss.”
Recognition of Dr. Bernstein and his contributions to the field of surgical hair restoration comes as he continues to push the envelope with advances in Robotic FUE hair transplants, improving more traditional hair restoration techniques and exploring adjuvant treatments such as Platelet Rich Plasma (PRP).
While there have been significant advances in new stem and cell-based hair loss therapies, surgical hair restoration remains today the only effective treatment option for restoring lost hair.
Q: How Many Hair Transplants Will I Need? — E.E., New York, N.Y.
A: The first session of a hair transplant should be designed as a stand-alone procedure with the following three goals:
Establishing a permanent frame to the face by creating, or reinforcing, the frontal hairline.
Providing coverage to the thinning, or bald, areas of the scalp with the hair transplant extending at least to the vertex transition point.
Adding sufficient density so that the result will look natural.
Achieving all of these goals will allow the first procedure to stand on its own.
Because of this, many people feel one hair transplant is sufficient.
Reasons for Second Hair Transplant
While the first session of a hair transplant is designed to stand on its own, there are several reasons why one would want a second hair transplant, such as increasing the density in a previously transplanted area; refining the hairline created in the first transplant; focusing on increased crown coverage, when appropriate; or addressing further hair loss that’s occurred after the first transplant.
After years of jokes about his continually receding hair line, LeBron James, winner of two NBA championships and four NBA Most Valuable Player Awards, stunned the sports world on September 16th, 2014 when he revealed a newly restored hairline while promoting his new LeBron 12 shoe at Nike World Headquarters.
Folks are now asking – what the heck happened all of a sudden? Where, when and how did LeBron get that great new hair line?
Dr. Bernstein was interviewed by Spencer Kobren on The Bald Truth, the critically acclaimed broadcast on hair loss and hair restoration. They discussed the latest in robotic hair transplant surgery, the ARTAS Robotic System, FUE and FUT hair transplant procedures, and the future of hair restoration.
Q: I’ve heard it takes the artistry of the surgeon to create a natural looking hair transplant. How do you do this with a robot? — S.S., Shanghai, China
A: I currently create the recipient sites by hand using different size needles. They determine the angle, direction and distribution of the grafts, and these three variables determine the aesthetic aspects of the hair transplant.
In this new robotic-assisted process, the surgeon designs the hairline and delineates the area to be transplanted directly on the patient’s scalp. The surgeon then photographs the patient’s scalp and feeds the photograph into the robot’s computer to create a digital 3-D image. The doctor, in order to have the robot mimic what he would do by hand, can then manipulate various parameters, such as hair angle, direction and density.
Q: At one time, I was told my donor area was not sufficient for an FUT hair transplant procedure. Does this also mean I’m not qualified for a FUE procedure either? — K.K., Houston, T.X.
A: Great question. You are not giving me quite enough information to answer your question specifically, so I will answer in more general terms. If your donor hair supply was not good enough to do FUT (i.e. you have too little donor hair and too much bald area to cover) then most likely you will not be a candidate for FUE either, since both procedures require, and use up, donor hair. That said, if don’t need that much donor hair, but the nature of your donor area is such that a linear FUT scar might be visible then FUE might be useful.
An example would be the case in which a person has limited hair loss in the front of his scalp, has relatively low donor density, and wants to keep his hair on the short sides. In this case, FUT would not be appropriate as you might see the line scar, but we might be able to harvest enough hair through FUE to make the procedure cosmetically worthwhile. Remember, with low density neither procedure will yield that much hair to be used in the recipient area.
Another example is an Asian whose hair emerges perpendicular from the scalp so that a line incision is difficult to hide, i.e. the hair will not lie naturally over it. A third example is where the patient’s scalp is very tight. In this case, the donor density might be adequate, but it would just be hard to access it using a strip FUT procedure. In this case, FUE would also be appropriate.
From these situations, one can see that the decision to perform FUE vs FUT, or even a hair transplant at all, can be quite nuanced and requires a careful evaluation by a hair restoration surgeon with expertise in both procedures.
Dr. Bernstein introduced new technology that allows the ARTAS Robotic System to accomplish a critical step in hair transplant surgery, the creation of recipient sites. Presenting at the 2nd ARTAS User Group Meeting on February 7th and 8th, 2014, Dr. Bernstein previewed the recipient site creation technology that brings the robotic system one step closer to performing critical aspects of the labor-intensive, hair transplant procedure.
Q: Is it true that hair transplants can now be done totally by a robot? — M.S., Los Angeles, California
A: The ARTAS Robotic System, developed by Restoration Robotics, is the most advanced technology for extracting grafts (the first and most difficult step in a Follicular Unit Extraction procedure), but it cannot yet do the entire hair transplant procedure, nor can it work without the supervision of the hair restoration surgeon.
Currently, the ARTAS System assists the surgeon in performing the first part of an FUE hair transplant (i.e., the extraction phase) with greater precision and consistency than can be done by hand. Engineers and researchers are currently developing the ARTAS to do the remainder of the procedure as well, i.e., making recipient sites in parts of the scalp that have lost hair and then implanting the harvested grafts into these sites.
The next step, recipient site creation, will be available in the latter half of 2014. Dr. Bernstein is already testing a beta version of this new technology. We anticipate that within two years, under the supervision of the surgeon, the ARTAS robot will be performing most of the FUE hair transplant procedure.
Dr. Bernstein is credited with introducing the “follicular unit” to surgical hair restoration, the innovation that allowed for a “completely natural-looking hair transplant” to be achieved. The commentary on Dr. Bernstein’s contributions to the field of hair transplantation are outlined in an historical review of dermatologic surgery that appeared in the Journal of the American Academy of Dermatology.
The 21st Annual Scientific Meeting of the International Society of Hair Restoration Surgery was held in San Francisco from October 13 through 26, 2013. The meeting covers the most important scientific and clinical advances in surgical hair restoration.
Dr. Bernstein was included in the ‘Best Doctors’ issue of New York Magazine for the fourteenth consecutive year. The annual special issue of the magazine contains a directory of the New York area’s best physicians. The directory is based on the results of a peer-reviewed survey that is conducted by Castle Connolly, Ltd.
Q: I have seen through forums that a hair transplant gives severe shock loss in the donor zone (especially behind ears) after the surgery. Doctors say it is temporary and can last about six months or more. Frankly, do you believe in this? Will the donor shocked hair recover? — M.D., Darien, C.T.
A: It depends if you are speaking about follicular unit hair transplantation using strip harvesting (FUT) or Follicular Unit Extraction (FUE). With FUT, it is extremely uncommon to have any shock hair loss in the donor area. This could occur if the hair transplant procedure was done improperly, i.e. the donor area was closed too tightly. In this case, some hair loss may be permanent. This is one of the reasons that very large hair transplant sessions are unwise. Shock hair loss in FUE is more common, but is generally not significant and should eventually recover completely.
That said, some shock hair loss in the recipient area is quite common with either hair restoration procedure (FUT or FUE). This is particularly the case if there is a lot of existing miniaturized hair (hair that is starting to thin) in the transplanted area.
Q: I heard that for someone who has had several strip procedures, the ARTAS robot for FUE does not work because it is programmed to work with “textbook male pattern baldness”, which I no longer have. I thought the scars from previous procedures, as well as the large amount of already transplanted hair, might throw off the robot’s programming (it wouldn’t quite know what to do). But if I am wrong about this then the robot may in fact be the best approach for me. Please advise. — N.C., Paris, France
A: When performing robotic hair transplants on patients with prior surgery, I program the robot to avoid scarred areas – just as we would do visually when performing manual FUE.
Q: I’ve noticed from the chatter on blogs, that it is not uncommon for men to go through multiple FUE procedures over 10+ year time-frame. It seems to be that after the initial FUE procedure to address moderate hair loss, the patient continues their natural balding to where they must undergo another FUE procedure in order to get back to their desired look. I’m almost 33 and while I take Propecia, my hair loss has been very gradual since I was about 26. I still have what many would consider a full head of hair, although very thin and with noticeable loss at my temples and crown. I’d always thought that a hair transplant would be a “1 and done” procedure, and now I’m concerned that if I do an FUE procedure now to replace what’s been already lost, I’ll just have to revisit a subsequent FUE down the line. Are ongoing FUEs simply part of the hair maintenance that a patient needs to accept about hair restoration process? — A.A., New Hyde Park, N.Y.
A: Your concerns are correct and would apply to any hair transplant procedure; FUT or FUE. That is why it is best not to begin hair restoration surgery too early.
Q: If I have no linear scar and I can exercise right away, why would you ever recommend FUT instead of FUE? — H.T., Dover, M.A.
A: I advise FUT because the grafts are of better quality (less transaction and more support tissue surrounding the follicle) and because more hair can be obtained from the mid-portion of the permanent zone –- which is where the hair is the best quality and most permanent. For the majority of patients a linear scar buried in the donor hair is not an issue. Each patient has to weigh the pros and cons of each procedure when making a decision.
Q: A while ago I saw you and you recommended FUT hair transplantation, but my friend came in and you recommended FUE. How come? — C.T., Hackensack, N.J.
A: I think that both procedures are excellent, which is why I do them both. My recommendations are determined by the individual patient. His or her age, desire to wear hair cut very short, athletic activities, donor density and miniaturization, extent of hair loss, and potential future balding are all important aspects in the decision process.
Q: Is the recovery time a lot longer with FUT compared to FUE? — C.W., Chicago, I.L.
A: Cosmetically, the recovery for FUT is actually shorter, since the back and sides do not need to be shaved and the longer hair can completely cover the donor incision immediately after the Follicular Unit Transplant procedure. In large Follicular Unit Extraction procedures, the entire back and sides of the scalp need to be clipped very close to the scalp. It can take up to 2 or 3 weeks for the hair to grow long enough to completely camouflage the harvested area. Once the healing is complete and any redness has subsided, the hair can be cut shorter.
New York, NY (PRWEB) — Robert M. Bernstein, M.D., F.A.A.D., A.B.H.R.S., a world-renowned hair transplant surgeon, presented a series of improvements to hair transplant procedures which use the ARTAS Robotic System for Follicular Unit Extraction (FUE). These updates include revisions to the FUE surgical protocol and technical adjustments to the robotic extraction system. He presented his refinements at the first user meeting held by the developers of the system; Restoration Robotics, Inc.; on September 14 – 16 in Denver, Colorado.
Q: While I was lying awake last night your approach of making sites the day before implantation came to mind. It takes guts to have spearheaded that! I am not aware that that precedent has been set in hair transplant surgery. I would have been timid about infection; it’s a lot like closing a wound with a foreign body in it the next day. As with most things, I am a little slow to jump on board something new so I’m glad you’ve paved the way. Do you have any hesitance about this or do you have enough experience that you no longer hesitate? I would be concerned that variations of the local flora might make a difference and that, accordingly, a large sample size would be necessary to get comfortable. Glad for all of us that you are still blazing trails. — S.S., Shanghai, China
A: Thanks for your kind words. No hesitancy whatsoever. We find no increased risk. Think of it as if you did a hair transplant and ran out of grafts. The remaining sites don’t get infected, they just close up. In the process, all those chemotactic factors involved in the healing process move toward the wounds, so if a graft is placed into them, they would be less likely to get infected than a graft placed into a fresh (non-primed) wound, not more. It is like applying the surgical dressing Duoderm to a wound that helps it auto-sterilize. Putting the speculative science aside, we have not seen one single issue with it. Give it a try with an FUE or FUT procedure. Make the sites, have the patient takes his normal shower that night and you will be pleasantly surprised how little bleeding there is the next day and how easy it is to place the grafts.
In the latest in a long line of improvements made to hair restoration procedures, Dr. Bernstein has published an article in Hair Transplant Forum International which improves the FUE procedure even further, whether performing follicular unit extraction with the FUE robot or by hand.
In his article, Dr. Bernstein suggests two techniques to enhance the FUE procedure. First, he recommends that surgeons create recipient sites prior to extraction, in order to decrease the time grafts are in their holding solution outside the body. Second, he suggests adding time between site creation and graft harvesting and placement, to allow recipient site healing to progress.
Q: I was told that I have low hair density in the donor area. Would multiple hair transplant procedures improve the results of my hair restoration? — J.G., Hoboken, NJ
A: Yes, but subsequent procedures would be smaller and there is a point of diminishing returns where additional procedures would yield so little hair that they would not be practical. There is a finite donor supply and once this is tapped, no more hair transplants are possible, regardless when one uses FUT or FUE.
Q: What are the chances of the donor scarring being visible long-term in FUT compared to FUE? — M.M., Altherton, C.A.
A: Both FUT and FUE produce donor scarring; FUT, in the form of a line and FUE in the shape of small, round dots. With FUT hair transplantation, the line is placed in the mid-portion of the permanent zone, whereas in FUE the dots are scattered all over the donor area.
If a patient becomes extensively bald (i.e. the donor fringe becomes very narrow), the line of FUT will generally still remain hidden, whereas the dots of FUE will be seen above the fringe of hair. In the less likely scenario of the donor hair actually thinning significantly, both the line (of FUT) and the dots (of FUE) may become visible.
Dr. Bernstein was featured in a CBS News report on robotic hair transplantation. During Dr. Max Gomez’s visit to the Bernstein Medical – Center for Hair Restoration, Dr. Bernstein discusses with Dr. Gomez the difference between FUT and FUE hair transplants, how the robotic system works, and the benefits of extracting hair follicles using robotic FUE rather than by traditional hand-held methods.
New York, NY — Robert M. Bernstein, M.D., F.A.A.D., the world-renowned hair transplant physician, pioneer of the Follicular Unit Transplantation (FUT) and Follicular Unit Extraction (FUE) and founder of Bernstein Medical – Center for Hair Restoration, was included in New York Magazine’s ‘Best Doctors‘ issue for the thirteenth consecutive year.
“It is such an honor to be recognized by New York Magazine. Our passion for providing the best hair loss treatments has served as the impetus for pushing the envelope in utilizing new state-of-the-art hair restoration techniques such as Robotic assisted hair transplants.”
Q: I am so confused reading about FUT and FUE on all the blogs. Can you please tell me which is better, FUT or FUE? — M.T., East Brunswick, NJ
A:FUT (via strip) will give the best cosmetic results (more volume) since the grafts are of better quality (when using microscopic dissection, there is less transection and more surrounding tissue to protect the grafts) and better graft selection (the grafts can all be harvested from the mid-portion of the permanent zone).
In contrast, in FUE you need approximately 5 times the area. Because of this large donor area requirement, some of the hair must be harvested from fringe areas and thus the hair will be less stable genetically.
Dr. Bernstein not only pioneers hair transplant procedures, but hair restoration technology as well. The NY1 television station, based in New York City, visited Bernstein Medical to see a demonstration and talk about the newest tool in the hair restoration toolkit, the ARTAS Robot for Hair Restoration.
The NY1 piece shows the robotic FUE system in action at Bernstein Medical, with views of the robotic arm, the image-guided system, the punch tool, and the user interface.
Dr. Bernstein was featured as the cover story of the April 27th edition of 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.
Dr. Bernstein spoke with Bloomberg’s Matt Miller about the future of hair transplantation in a segment called, “The Bald Economy: Surgical Solutions to Hair Loss.” Here is an excerpt from the segment:
Bloomberg’s Matt Miller: Riding the wave into the future happens to be one of the pioneers of FUE, Dr. Robert Bernstein.
Dr. Bernstein: “The robot now allows a mechanized system to do [follicular unit extraction] very, very quickly and very consistently, so that the human error in this part of the procedure is now gone.”
Q: When was ARTAS robot for FUE approved for use in hair transplantation? — J.B., Jersey City, NJ
A: Restoration Robotics’ ARTAS System for robotic follicular unit harvesting, received 510K clearance by the Food and Drug Administration (FDA) on April 14, 2011. The indication is for “harvesting hair follicles from the scalp in men diagnosed with androgenetic alopecia (male pattern hair loss) with black or brown straight hair.”
Q: What is Restoration Robotics? — L.N., East Brunswick, NJ
A: Restoration Robotics is a medical device company, based in Mountain View, California, that has developed a computerized instrument to assist in the graft extraction phase of follicular unit extraction (FUE) hair transplant procedures. Their patented device, called “ARTAS,” is an image-guided system for FUE. Their website is: www.restorationrobotics.com.
Q: I am considering having a hair transplant. Does my hair need to be cut? — I.S., New York, NY
A: In all hair transplant procedures, we are able to transplant into areas of existing hair without it having to be cut. The question of whether hair needs to be cut in the donor area depends upon the way the donor hair is obtained (harvested).
With a Follicular Unit Hair Transplant procedure using single strip harvesting method (FUT), only the strip of hair that is removed needs to be cut. When the procedure is finished, the hair above the incision lays down over the sutured area and it becomes undetectable.
In Follicular Unit Extraction (FUE), particularly in sessions over 600 grafts, large areas of the donor area must be clipped short (to about 1-2mm in length) in order to obtain enough donor hair.
Q: I heard that there have been some new advances in hair cloning and that it may be available sooner than we thought. I was planning on doing a hair transplant soon. Considering that hair cloning may be available at some point in the future, should I do FUE or FUT, or wait for cloning? — K.R., Fort Lee, NJ
A: Although there has been a major development in hair cloning with the use of ACell, an extracellular matrix to simulate hair growth, the model, at this point, is still in its earliest stages of development. It is hard to know when the technology will reach a state where it can be useful in hair restoration.
With respect to which you should do FUE or FUT if, theoretically, cloning is around the corner, the answer would be FUT, since FUT will give you the fuller look.
If the goal is to eliminate any trace of the traditional hair transplant, again FUT will most likely be the best choice, since the single linear scar would be easy to camouflage with cloned hair. With FUE, this would be much more difficult, since there are literally thousands of tiny scars. However, neither FUE nor FUT will preclude a patient from fully benefiting from cloning if, and when, it becomes available.
In this paper, Dr. James Harris presents a blunt tip instrument to be used in a 3-step FUE hair transplant procedure. The instrument is described as a 1-mm dissecting punch that has a tapered blunt edge. After scoring the skin with a sharp punch, the dissecting punch is advanced to a depth of approximately 4-mm.
This instrument is similar to the one recently described by Bernstein and Rassman in New Instrumentation for Three-Step Follicular Unit Extraction, recently published in Hair Transplant forum International New Instrumentation. Dr. Bernstein’s instrument was, in turn, based upon ideas presented in a paper written by Dr. Harris in 2004.
Robert M. Bernstein, M.D. Associate Clinical Professor of Dermatology at the College of Physicians and Surgeons of Columbia University in New York Abstract of Dr. Bernstein’s presentation at the International Society of Hair Restoration Surgery, 2005 – Sidney, Australia Biography Robert M. Bernstein, M.D. is Associate Clinical Professor of Dermatology at the College of Physicians […]
Q: What is Follicular Unit Transplantation and how is it different from Follicular Unit Extraction? — H.L., White Plains, NY
A: Follicular Unit Hair Transplantation, called FUT for short, is a procedure where hair is transplanted in the naturally occurring groups of one to four hair follicles. These individual groups of hair, or units, are dissected from a single donor strip using a stereo-microscope. The area where the donor strip was removed is sutured closed, generally leaving a thin, fine, line scar.
In Follicular Unit Extraction, or FUE, the individual units are removed directly from the back or sides of the scalp through a small round instrument called a punch. There is no linear scar. There is, however, scarring from the removal of each follicle. Although the scars of FUE are tiny and round, the total amount of scarring is actually more than in FUT.
In addition, since in FUE the bald skin around each follicular unit is not removed, the total amount of hair that can be removed in FUE is substantially less than in FUT. This is because if one were to remove all the hair in an area, it would be bald. In FUT, the intervening bald tissue is removed along with the follicles in the strip.
SUMMARY of Dr. Harris’ Abstract from his presentation at the International Society of Hair Restoration Surgery, 2005 – Sidney, Australia
The SAFE System for FUE provided a novel methodology and new hair transplant instrumentation to increase graft production rates, decrease follicle transection rate, and expand patient candidacy for surgical hair restoration. However, the mechanism of the interaction of the blunt dissecting punch and the dermis produced follicular unit graft burial (approximately 7.2% of attempted extractions) that slowed the extraction process during the hair transplantation and resulted in inflammatory cysts requiring surgical excision in .02% of attempted graft extractions.
The purpose of this study was to assess the efficacy of a new dissecting tip that could potentially decrease the graft burial rate and increase the graft production rate in the hair restoration. In the study, three patients received a total of 422 grafts. The protocol utilized limited sharp dissection of the epidermis (using a 1-mm punch to a depth of approximately 1.3 mm) followed by the insertion of the specially modified dull dissecting tip to its full depth of 5 mm. The follicular units were then grasped with fine forceps and removed.