Bernstein Medical - Center for Hair Restoration - FUT Hair Transplant
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Q: I have read that some doctors perform something called a trichophytic closure. What is this? — M.S. ~ Thornwood, N.Y.

A: Trichophytic closure is a way to minimize the appearance of the donor scar in a hair transplant using a strip incision. The technique provides improved camouflage of a linear donor scar in Follicular Unit Transplantation (FUT). Normally, in FUT, the surrounding hair easily covers the scar. For some patients with very short hairstyles, the resulting donor scar may be visible. With the trichophytic closure technique, Dr. Bernstein trims one of the wound edges (upper or lower), allowing the edges to overlap each other and the hair to grow directly through the donor scar. This can improve the appearance of the donor area in patients who wear their hair very short.

The trichophytic donor closure can be used on patients who have had previous hair transplant procedures and are looking for improvement in the camouflage of their donor scar. It is particularly useful in hair transplant repair or corrective work. Trichophytic closures work best with sutured incisions. Stapled closures have their own advantages. The doctor will recommend which type is best in your case.

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Dr. Robert M. Bernstein, a Clinical Professor of Dermatology at Columbia University and one of the leading pioneers in modern hair transplant surgery, is recognized for his leadership in the field of hair restoration with inclusion in his 18th consecutive edition of New York Magazine’s ‘Best Doctors of New York.’

Best Doctors 2017 - New York Magazine

New York, NY — Robert M. Bernstein, MD, MBA, FAAD, FISHRS, has been recognized by his peers with inclusion in his eighteenth consecutive edition of New York Magazine’s annual ‘Best Doctors in New York’ issue. Dr. Bernstein, a Clinical Professor of Dermatology at Columbia University and founder of Bernstein Medical – Center for Hair Restoration, helped re-invent hair transplant surgery by pioneering the Follicular Unit Transplantation (FUT) procedure and by becoming an early proponent of robotic hair transplant surgery (Robotic FUE). He is the only hair restoration surgeon named to the prestigious “Best Doctors” list for so many consecutive years.

Dr. Bernstein said:

“New York has some of the finest doctors in the world, so to be considered among the best by my peers is quite an honor. It is equally satisfying when a patient tells us that we helped change their life.”

The ‘Best Doctors of New York‘ issue is an annual edition of New York Magazine that contains a more select version of the Top Doctors: New York Metro Area list published each year by Castle Connolly Medical, Ltd. New York Magazine’s list of 1,341 doctors represents about the top 2% of doctors in the region. In each list, the area’s top physicians are organized by specialty. Dr. Bernstein is listed under dermatology with expertise in robotic hair transplantation, surgical hair restoration, and hair loss treatment. To be included, doctors in New York, New Jersey, and Connecticut are nominated by their peers then subjected to a physician-led review of their skill in diagnosis and treating patients, qualifications, and reputation. Castle Connolly Medical also publishes the America’s Top Doctors directory, which has included Dr. Bernstein in all sixteen annual editions.

Dr. Bernstein has earned top accolades from the hair restoration industry, including the International Society of Hair Restoration Surgery’s Platinum Follicle Award, for his medical contributions to the field. Renowned for developing FUT hair transplants and introducing follicular unit extraction (FUE) procedures, Dr. Bernstein became one of the first in the world to incorporate the ARTAS Robotic Hair Transplant System into his practice in 2011. He has continued innovating through his collaboration with Restoration Robotics, Inc.; the company that developed the image-guided, physician-assisted robot. Recently, he announced a major upgrade to the robot with the release of ARTAS 9x. This latest version of the robot provides improved accuracy, quicker donor healing, and a faster overall procedure.

Dr. Bernstein’s hair restoration facility, Bernstein Medical – Center for Hair Restoration, is dedicated to the treatment of hair loss in men and women using the most advanced treatments and technologies. The state-of-the-art facility is located in midtown Manhattan, New York City and treats patients who visit from 58 countries and all 50 states. The board-certified physicians and highly-trained clinical assistants at Bernstein Medical take pride in providing the highest level of treatment and care for all patients.

About Robert M. Bernstein, M.D.

Dr. Robert M. Bernstein is a Clinical Professor of Dermatology at Columbia University in New York and is the founder and lead surgeon at Bernstein Medical – Center for Hair Restoration. He was the first to describe Follicular Unit Transplantation and Follicular Unit Extraction in the medical literature, and his more than 70 medical publications have fundamentally transformed the field of hair restoration surgery. Dr. Bernstein has appeared as a hair restoration expert on many notable television programs and in many news and lifestyle publications over the years. Examples include The Oprah Winfrey Show, The Dr. Oz Show, The Today Show, Good Morning America, ABC News, CBS News, GQ Magazine, Men’s Health, Vogue, Interview Magazine, Columbia Business, The Columbia Journalist, The Wall Street Journal, and The New York Times. He is a co-author of Hair Loss & Replacement for Dummies. Dr. Bernstein graduated with honors from Tulane University, received the degree of Doctor of Medicine at the University of Medicine and Dentistry of NJ, and did his training in Dermatology at the Albert Einstein College of Medicine. Dr. Bernstein also holds an M.B.A. from Columbia University.

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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 Magazine Best Doctors 2016New 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.

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Dr. Bernstein, a renowned teacher, lecturer, and surgeon, is bringing his state-of-the-art hair restoration techniques directly to patients. His lecture on Follicular Unit Transplantation (FUT) includes a historical review of hair transplant techniques, from the out-dated “hair plugs” and “cornrows” to refined FUT procedures. Watch the lecture below to see images of surgical tools, illustrations of surgical techniques, and before and after patient photos. Running commentary by one of the eminent authorities on the subject makes it easy to grasp, even for newbies.

Dr. Bernstein has conducted presentations on his innovative hair transplant techniques at medical conferences around the world including Barcelona, Spain; Vancouver, Canada; Sydney, Australia; and Washington D.C. Many have learned about the nuances of hair transplant surgery from one of the pioneers of surgical hair restoration.

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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.

Read our page on FUE vs. FUT

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Robert S. Haber, M.D.
CASE School of Medicine, Cleveland, Ohio, USA

SUMMARY of Dr. Haber’s Abstract from his presentation at the International Society of Hair Restoration Surgery, 2005 – Sidney, Australia

Harvesting high quality donor strips with minimal transaction remains an elusive goal for many hair transplant surgeons, particularly beginners. Hair restoration techniques that involve the use of scalpel blades demand the greatest skill and may cause significant transection. The Sandoval Score and Spread technique showed that non-traumatic dissection during hair transplantation is possible using a blunt instrument, but this technique is limited by poor ergonomics and the potential to cause tissue damage.

A new instrument for blunt dissection had been developed that is easy to use and is able to separate tissue along the natural planes of cleavage that causes minimal damage to hair follicles. This device has four sharp, staggered prongs aligned centrally and long handles developed for hair transplant procedures. This design utilizes the strong forearm muscles, as opposed to the weaker hand muscles, and distributes the spreading force over a larger area, minimizing trauma. A minimum depth scoring incision is made with a double-bladed scalpel to a depth of 1.5 mm. The device is inserted and expanded at intervals along the incision.

Fifty consecutive patients whose donor strip was harvested utilizing the device for the hair transplant were studied. It was found that the device works well for hair transplantation, producing virtually transaction free strips in approximately 90% of cases. The instrument was ineffective when the patient has very rigid tissue that did not yield to the force of the device. Standard scalpel blade excision was used in these cases.

When performing a hair transplant, there exists a natural dissection plane within the donor scalp that can be used to obtain high-quality strips with blunt dissection. This newly developed instrument is ergonomic and easily used by both experienced and beginner hair restoration surgeons.

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

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

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


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

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

Position: YES

Dr. Walter Unger

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

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

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

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

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

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

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

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

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

Position: NO

Dr. Robert M. Bernstein

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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