Bernstein Medical - Center for Hair Restoration - Graft Placement
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Recipient Site Creation at Bernstein MedicalDr. Bernstein creating recipient sites using the ARTAS robot

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.

Dr. Bernstein introduced the concept of “pre-making recipient sites” into medical literature in a 2012 publication in Hair Transplant Forum International, has discussed the idea extensively, and presented findings at the 2015 ISHRS Annual Scientific Meeting. However, this is the first time he has patented a hair restoration technique.

The first 24 hours after any wound to the skin is a critical period of time in the healing process. Dr. Bernstein describes this initial period in his 2012 publication:

During the first 24 hours following recipient wound creation, a flurry of biologic activities take place that facilitate healing. These include: the migration of platelets with subsequent release of cytokines, growth factors and pro-inflammatory proteins (histamine, serotonin, kinins, prostaglandins, etc.) that increase blood vessel permeability and stimulate cell migration. Allowing these processes to begin before implantation of the grafts should be beneficial to their healing and subsequent growth. ((Bernstein RM, Rassman WR. Pre-making recipient sites to increase graft survival in manual and robotic FUE procedures. Hair Transplant Forum Intl. 2012; 22(4): 128-130.))

By making recipient sites in advance of harvesting the grafts, three important things are achieved by the surgeon:

  1. The time in which follicular unit grafts are outside the body is decreased
  2. The placement of grafts is facilitated, making it less likely that they are injured in the insertion process
  3. The early phases of the healing process (e.g., blood clot formation, creation of new blood vessels) naturally complete, resulting in a more stable, “fertile” site supplied with oxygen and nutrients essential for graft survival.

Dr. Bernstein proposed “pre-making” recipient sites in 2012 as a way to improve the Follicular Unit Extraction (FUE) procedure, and robotic-assisted FUE (Robotic FUE) in particular. This is due to the fact that the positioning of the patient makes it problematic to create recipient sites and place grafts while follicular units are being extracted from the donor area. This is not the case in Follicular Unit Transplant (FUT) procedures, in which a donor strip is removed from the patient then dissected on a dissecting table. In FUT, recipient sites can be created and grafts can be placed concurrently with the dissection process.

“Pre-making” recipient sites is a protocol that should be followed during all FUE hair transplant procedures. It is also applicable in hair multiplication and hair regeneration techniques that are being studied as a way to provide an unlimited amount of donor hair for hair restoration purposes.

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Q: I understand that in robotic hair transplantation, a robot performs the extraction part of the FUE procedure. What’s the outlook on the robot doing more of the hair transplant procedure? — B.B., Greenwich, CT

A: Currently, the ARTAS® Robotic System is a technology for extracting grafts. This is the most difficult part of a follicular unit extraction procedure, but it is only one part.

There are two other major parts to the FUE procedure: one part is the creation of recipient sites (in our practice, we create the recipient sites first, so that once we harvest the grafts, we can immediately place them into the scalp), and the other part is graft placement.

Recipient site creation involves more than merely making holes in the recipient area. It involves making decisions on hairline design, graft distribution, hair direction, recipient site size and depth. When done manually, the surgeon first designs the new hairline so that the hair transplant will look as natural as possible, particularly as the person ages. Next, the surgeon will demarcate the extent of the area to be transplanted and decide on the graft distribution (i.e., how much hair will be placed in each part of the scalp) and will then prepare a “recipient site” in the part of the scalp that has lost hair. The surgeon will then manually create incisions in the recipient site into which the follicular units will be placed.

On February 8, 2014, Dr. Bernstein unveiled “recipient site” creation capabilities of the hair transplant robot. These new capabilities allow the doctor to import a hairline design and other markings that have been made on the patient’s scalp directly into the robot. The robot then maps the design onto a precise 3-D model of the patient’s head. The physician can then program the proper distribution, direction and depth of the future recipient sites and the robot then creates the sites according to the physician’s specifications.

Graft placement, the last step, is perhaps the most challenging to automate. Engineers are currently working to design and build the capacity to automate the placement of extracted follicular units into recipient site incisions. Done manually, it requires significant hand-eye coordination and a very slow learning curve. For the hair transplant robot, it will be a significant challenge with development taking several years or more.

Read more about Robotic Hair Transplant

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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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