Bernstein Medical - Center for Hair Restoration - Hair Plugs
About Header Image

Q: I have read a lot on the forums about hair transplant reversal and hair transplant repairs. Are they the same thing, if not, what is the difference? Can you reverse a hair transplant? — K.J. ~ Park Slope, N.Y.

A: A “hair transplant repair” refers to techniques that improve the appearance of a poorly executed procedure or one performed with outdated methods. A “hair transplant reversal” refers to techniques that enable the individual to appear as if no hair restoration surgery had been performed. Although the techniques in attempting to perform a repair or a reversal may be similar, the ultimate goals of each are quite different. It is important to understand that although significant improvement can often be achieved, perfect repairs and/or full reversals are generally not possible.

The main reasons for seeking a repair include; large grafts transplanted to the frontal hairline giving an unnatural, “pluggy” appearance, a frontal hairline placed too far forward, hair placed in the wrong direction, and donor and recipient site scarring. Outdated procedures such as scalp reductions and flaps also need to be repaired.

If the transplanted grafts are large (“hair plugs”), it is possible to surgically excise these grafts, microscopically dissect them into smaller follicular unit grafts, and re-transplant them into the scalp in a more natural-looking, aesthetic way. After these large grafts are removed, the sites are sutured closed and heal with very fine, often imperceptible, white scars. Hair plug removal is often followed by one or more sessions of FUT or FUE in order to harvest additional hair for use in camouflaging any remaining plugs or improving the appearance of the region where the plugs had previously been. These combined repairs can lead to excellent outcomes.

If the grafts at the hairline are not large but are placed too low or too broadly, it is possible to use laser hair removal and/or tweezing to remove these hairs. Repeated treatments may be necessary until the hair ceases to grow back at these locations. Additionally, hair which was placed in a direction different from the way hair naturally grows will usually need to be removed.

Another challenge in hair transplant repair is fixing widened donor scars that had resulted from poorly performed FUT/strip procedures. These scars are permanent and may be visible if the hair is not worn long enough. Scars from FUT procedures can be repaired by harvesting hair from the surrounding donor area (using FUE) and transplanting these follicular unit grafts into the scarred tissue.

Scalp micro-pigmentation (SMP), a permanent micro-tattoo, may be useful to further camouflage these linear scars. SMP can also be used to improve the look of the stippled scars of FUE in patients. This can occur with overharvesting, when patients wear their hair too short, or when the balding is more extensive than anticipated and extends into the harvested area.

A hair transplant reversal, in theory, has the goal of having the person look as though a hair transplant had never been performed. While reversing a hair transplant completely is not possible, the techniques previously discussed can be utilized to achieve a number of important things. The donor site scarring can be minimized and/or camouflaged and the smaller follicular unit grafts in the recipient zone can often be removed without leaving behind any visible scarring of the underlying skin. What is not possible is to restore the person’s density to a pre-procedure level as improperly performed transplants always result in wasted hair.

Posted by

Q: After an old hair transplant using plugs, can you use lasers or electrolysis to remove the transplanted hair? — N.C. ~ Newark, N.J.

A: You can remove the hair in plugs with electrolysis, but it is difficult since the scarring distorts the architecture of the hair shaft and makes it hard to insert the electrolysis needle. Laser hair removal is a far more efficient way of removing the hair but takes multiple treatments. However, the problem with either of these techniques is that the hair is destroyed and the underlying scarred scalp is not improved. In fact, it is made more visible when the hair has been removed.

Our preferred method of repair is to completely remove the plugs, dissect out the individual follicular units from those plugs and then re-implant them in the proper location and direction. In this way, the hair can be reused and the appearance of underlying scarred scalp can be improved, as well as camouflaged with new hair.

Posted by

Q: I was wondering if it was possible to use Follicular Unit Extraction (FUE) on the old plugs instead of graft excision. — N.B. ~ Westport, C.T.

A: Graft excision generally works better than FUE in removing old plugs and mini-grafts. The reason is that, in these grafts, the hair is not aligned due to the scar tissue that tugs on, and bends the hair. Because the hair direction is altered from the scar tissue, there is much more damage when the grafts are removed with the tiny FUE punches. In addition, FUE only removes a very small part of the plug. If the hair in the plug is pointing in the wrong direction or the plug is in the wrong location, the entire graft needs to be removed.

Another benefit of graft excision is that we can remove the underlying scar tissue and improve the appearance of the underlying skin. In FUE, only a tiny bit of the scar tissue is removed and, since FUE holes are left open, FUE actually causes its own scarring. With graft excision, the sites are sutured closed so some scar tissue is removed and the quality of the underlying skin looks more natural.

Posted by
New York Post

Dr. Bernstein was quoted in a New York Post article on the growing popularity of surgical hair restoration. In the article, Dr. Bernstein explained how celebrity hair transplants have become a driving factor behind the fading of the decades-long stigma of hair transplants.

“Soccer players, football players — they’re admitting they’ve had the surgery. Patients bring in pictures of [George] Clooney, Brad Pitt. The stigma of the old plugs is fading,” [said Dr. Bernstein.]

While celebs aren’t writing signed confessions, there’s plenty of speculation about which high-profile men may have gotten procedures — such as LeBron James, Kevin Costner, John Travolta and Jeremy Piven.

Advancement in hair transplant technology may also be lending a hand. Follicular Unit Transplant (FUT) surgery and newer techniques, such as Robotic FUE, have all but eliminated the old corn-row style “hair plugs” that were commonplace twenty years ago.

The article discusses how the hair restoration industry saw a 27% increase in hair transplant procedures worldwide since 2012. The newest data released by the International Society of Hair Restoration Surgery (ISHRS) values the global surgical hair restoration market at nearly $2.5 billion.

Posted by

Departures - The State of Plastic Surgery 2012The January/February issue of Departures Magazine contains a feature called “The State of Plastic Surgery 2012”. The magazine covers topics such as how to find the best plastic surgeon, the use of cells in plastic surgery and the best hair loss therapies. The section on hair loss offers a timeline of the major advances in the treatment of hair loss since its inception over 75 years ago.

Here is the list of the milestones presented in the article:

1939: Japanese doctor Shoji Okuda is the first to publish the results of clinical hair-transplant experiments.
1952: Dermatologist Norman Orentreich, M.D., uses four-millimeter punches to perform the first hair transplants, popularizing “hair plugs” to treat male-pattern baldness. Each plug of some 20 hairs is taken from a “donor site” on the scalp (usually toward the back, where there’s adequate growth). They are bulky and, more often than not, the results look like a poorly hoed garden.
1984: Mini-grafting — the use of grafts containing up to six hairs — is introduced.
Late ’80s: Mini-micrografting, the combination of mini-grafts and smaller micro-grafts containing one or two hairs, becomes popular as a more natural alternative.
1995: New York dermatologist Robert M. Bernstein, M.D., and New Hair Institute founder William Rassman, M.D., develop Follicular Unit Transplantation (FUT), which uses a special microscope to identify individual units of one to four hairs, plus nerves, blood vessels and a tiny muscle called the erector pilorum (the same muscle that makes a cat’s hairs stand on end). Transplanting these intact units ensures their maximum survival and a much more natural look.
2002: Dr. Bernstein and Dr. Rassman offer even more refinement with Follicular Unit Extraction (FUE). With FUT, the donor hair is harvested in a single strip, leaving a linear incision; with FUE, the hair is harvested with a tiny punch that leaves lots of tiny circular incisions-a noticeable advantage for patients who want to wear their hair short. The disadvantage is that FUE requires a much larger donor site, and the results may not all be permanent.
2007: The FDA clears low-level lasers, which promise that the absorbed light will stimulate cell metabolism and protein synthesis to regrow hair.
2008: Latisse, a prescription treatment to grow thicker and longer eyelashes, is cleared by the FDA. Now Allergan, the company behind Latisse, is doing a clinical study about a new formulation of bimatoprost (the active ingredient in Latisse) for male-pattern baldness and moderate female-pattern hair loss. The world waits with bated breath.

Read more about the history, milestones, and innovations in the modern hair transplant techniques that Dr. Bernstein pioneered

Reference
“Personal Best: The State of Plastic Surgery” Departures Magazine, Jan/Feb 2012

Posted by

Q: There is a famous hair transplant out there, Vice President, Joe Biden. How come it looks so unnatural? — W.S., Los Angeles, CA

A: With Joe Biden’s hair transplant a number of errors were made. Some were unavoidable due to the older technology and some were just poor planning. He had a hair transplant consisting mainly of large plugs because that was the way hair transplants were performed many years ago. But many of those plugs have now been fixed.

The persistent (but avoidable) problem is that Vice President Biden has a low, broad hairline. But when you see a low broad hairline one expects to see the rest of head to be covered with hair. But he didn’t have enough donor hair to accomplish this. With better planning, the hairline would have been more receded at the temples, producing a more natural, balanced look.

Posted by

Q: I had a hair transplant in 2004 of mostly plugs. The plugs are in an angle which doesn’t really look natural, far from it. I have lost a lot more hair since I did the hair restoration procedure. I regret ever doing a hair transplant. I prefer to reverse the surgery. I have read a lot about repair work on the net, and I have come to the conclusion that using FUE to take the plugs out, and put them back into the scar might be an option, but it may just make it worse on top. Also I can do electrolysis to remove the plugs, might be better because the possibility of scarring is smaller, and as I already have a lot.

A: If you had plugs, then a graft excision with suturing will generally give a better result than FUE, since a graft excision removes the underling scar tissue as well as the plug. FUE only removes the follicles, but leaves the underlying scar tissue. In addition, the shape of the follicles in scar tissue is often distorted, making extraction difficult and leading to more transaction (damage to follicles).

Electrolysis is very difficult in a scarred scalp and also would not remove scar tissue. Laser hair removal with a diode or Alexandrite laser is generally a better option than electrolysis (it is also faster and less expensive), but like electrolysis and FUE, they do nothing to improve the appearance of underlying scar issue.

For more information on this topic, see our pages on Graft Excision in Hair Transplant Repair and Follicular Unit Extraction (FUE).

Posted by

Howard Stern ShowDr. Bernstein was interviewed on the Howard Stern Show for a Howard 100 News Brief about hair transplantation.

George Takei — originally of Star Trek fame and currently an announcer for the show — had recently described his ‘pluggy’ transplant from 1980s in an interview on the show.

Stream the clip below (2 mins, 19 seconds):

Stream the clip from the Howard Stern Show

Posted by

Q: What’s the story with Joe Biden’s hair? — R.B., Inwood, N.Y.

A: Joe Biden — former Senator from Delaware and now the Vice President of the United States — apparently had a hair transplant many years ago using the older hair restoration techniques. This included not only transplanting hair in large plugs (corn rows), but using them to create a broad frontal hairline; a design that generally does not look natural as a person ages.

Also, the older grafts were transplanted in a vertical orientation giving a sprout-like, unnatural appearance.

The use of large plugs and the inefficiencies of the older procedures waste a considerable amount of donor hair, leaving Senator Biden with a dense rim of hair in the front part of his scalp and little coverage behind that.

The repair strategy would consist of removing the larger plugs, microscopically dividing them into smaller grafts (individual follicular units of 1 to 3 hairs each), and then placing the smaller grafts in a more forward direction and in a more natural distribution. This involves using the 1-hair units to soften the frontal hair line and the 2- and 3-hair units to extend the transplant further back on the scalp.

In addition to the hair transplant repair, Biden received significant cosmetic improvement from the natural graying of his hair over the years, as this tends to make the hair appear fuller and any irregularities less noticeable.

Read about Hair Transplant Repair techniques

View Before and After Hair Transplant Repair photos

Posted by

Q: Can dermabrasion help eliminate the circular edges of raised plug grafts caused by old hair transplants? Is this similar to the suturing and excision look?

A: Although dermabrasion can flatten elevated edges, it will not eliminate the round, white, circular scars that result from old punch graft hair transplants. The scarring in these procedures goes all the way through the dermis to the fat. Dermabrasion can only go down to the upper part of the dermis without causing further scarring.

Graft excision with suturing removes the plug as well as the underlying scar and eliminates the tell-tale circular marks of the older hair restoration procedures.

Posted by

Q: I had several prior hair transplants that left me with a pluggy look, I was hoping to re-utilize the removed hair and re-implant it, perhaps in the front as a new, more recessed hairline. It is possible?

A: The hair from the excised grafts is always re-implanted.

The grafts that are removed are dissected into individual follicular units and then placed back in the recipient area in a more natural distribution and angle. See Patient LKE’s before and after photos in the Hair Transplant Repair Photo Gallery.

Posted by

Q: I had an old hair transplant and I’m hoping to remove these plugs and of course am concerned how much additional scarring would result. I’m wondering if removal of the total hair plugs (which are perhaps 2 or 3 mm in diameter) by coring them out would result in a lot of additional scarring.

A: It will significantly reduce the scarring.

The reason is that the round disc of scar tissue at the bottom of the graft from prior plug hair transplants will be removed and the normal skin edges will be brought together resulting in a barely perceptible fine line scar.

See the Graft Excision in Hair Transplants page.

Posted by

Gotham Magazine - November 2006The November 2006 issue of Gotham Magazine featured Dr. Bernstein in their article on cosmetic surgery and hair transplantation. Read below for a selection from the article, titled “A Cut Above,” which includes the portion about Dr. Bernstein.

Gotham Magazine / November 2006 Issue
A CUT ABOVE

by Beth Landman • Illustration by Barbara McGregor

Once the province of wealthy older women, cosmetic surgery has gone mainstream, with everyone from teenage girls to investment bankers and politicians going under the knife, needle, or laser in the name of aesthetic self-improvement.

WHATEVER HAPPENED TO AGING GRACEFULLY?
Some of us do value natural beauty at any age, of course, and bemoan the prevalence of what can be considered extreme vanity. However, an increasing number of us see nips, tucks, and injections as reasonable measures to take in order to stay “fresh and competitive in a youth-oriented society,” as one of the converted put it. According to the American Society for Aesthetic Plastic Surgery, the number of surgical cosmetic procedures performed has more than doubled in the past 10 years; and, due to the rising popularity of Botox and a wide range of injectibles, the incidence of non-surgical treatments has increased by 726 percent.

Many of New York’s leading physicians have been at the forefront of the beauty battle, developing new techniques and technology while defining the field’s cutting edge. Here’s a rundown of who to see before you snip, suck, fill, or implant.

Dr. Bernstein
The shameless plug: We all know that bad hair plugs can be spotted from across a room, so this job should not be left to chance. Bernstein, who founded the Bernstein Center for Hair Restoration, has made great headway with what’s called “follicular unit transplantation.” Instead of using single plugs, he works with clusters of hair that continue to grow in natural patterns. The results appear more natural, and his patients need fewer sessions than with the traditional method of hair transplant surgery. Dr. Bernstein is researching the possibility of cloning hair so that individuals will have an unlimited supply of donor follicles. “The idea is to clone them and inject them into the scalp,” he explains.

Posted by

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.

Posted by

PRESS RELEASE

World renown hair transplant surgeon introduces a new surgical tool that improves the way hair transplantation can be performed.

New York, NY March 21, 2006

Follicular Unit Extraction (FUE) InstrumentIn a new article appearing on the cover of Hair Transplant Forum International, the official publication of The International Society of Hair Transplant Surgeons (ISHRS), pioneering hair transplant surgeon Robert M. Bernstein MD, along with his colleague Dr. William R. Rassman, recently revealed details about a “New Instrumentation for Three-Step Follicular Unit Extraction.”

Dr. Bernstein is known throughout the world of medicine as author of the landmark publication; “Follicular Transplantation” which described a new hair replacement transplant technique in which he was able to transplant hair exactly as it grows – in naturally occurring groups called follicular units. That paper, together with two dozen other major publications, has revolutionized the way hair transplants are now performed – moving away from “doll’s hair” like plugs and into the realm of natural, undetectable hair patterns.

Follicular Unit Extraction (FUE) is a further refinement of this technique where follicular units are literally removed, one-by-one, directly from the scalp. In the traditional procedure, a strip of tissue is removed from the back of the head and placed under a microscope in order to remove the follicles.

The latest FUE instrument design is based upon Dr. J. A. Harris’ concept of using a blunt tool to prevent damage to hair follicles during extraction. The new device improves on the old method by re-conceiving the shape of the tool’s edge in order to minimize injury to hair follicles. “Our new instrument is made in the shape of a cylindrical tube with a bull-nosed edge. This allows us to capture the entire follicular unit (naturally groups of 1-4 hairs) without damage to the hair bulbs.” We also found that the incidence of buried grafts decreased significantly with the new instrument from about 9% to 1.8% with this new device” said Dr. Bernstein from his Center for Hair Restoration in New York.

In a recent study conducted by Leever Research Services, it is estimated that over 360,000 patients sought help from doctors for their hair loss last year. With ground-breaking work by surgeons like Robert M. Bernstein M.D., the impressive aesthetic results from new hair transplantation techniques are helping men and women who suffer from baldness to get a renewed outlook on their lives.

Posted by

Q: When performing a repair on an old, pluggy hair transplant, why can’t all the grafts be removed at once?

A: We always try to do this, but it is not always possible.

If the large grafts (plugs) are spaced too close together, suturing one will put tension on an adjacent graft and make it more difficult to close. This may worsen, rather than improve, the underlying scar.

In addition, it is not always possible to remove all the follicles in a graft on one pass, as the root tends to fan outward deeper in the skin. If you use a large enough punch to remove all the follicles at once than you risk leaving a mark from the excision.

For more details, please see the following hair restoration publications:

Posted by

Q: Do you ever see poor growth from a hair transplant? What causes this to happen? — R.L., Edison, NJ

A: The situations where I have encountered poor growth are:

1) When hair is transplanted to areas of skin that has been thickened due to the prior placement of larger grafts or plugs (this is called “hyperfibrotic thickening”). Removal of the larger grafts can somewhat ameliorate this problem.

2) When hair is transplanted into a thickened scar.

3) When a hair transplant is performed into an area of severe chronic sun damage. In this case, a very modest number of grafts should be used in the first session and if these grow well, additional grafts can be added in a subsequent session.

Read answers on the topic of Growth After Hair Transplant

Posted by

The highly-rated CBS television program “The Early Show” interviewed Dr. Bernstein as part of a three-part series on hair loss in women. View a clip of the video here:

Watch the video at YouTube or go to the Bernstein Medical YouTube Channel to see more videos on hair loss in women and other hair restoration topics.

Read the full transcript here:

Julie Chen: There are many treatments available for serious hair loss including surgical options like hair transplants. That may sound scary, but for one woman, it was the answer she’d been waiting for.

Narrator: Marian Malloy is used to being in control. As the duty manager for an international terminal at Newark Airport, it’s her job. But Marian wasn’t always so self-confident. Due to a condition called alopecia areata, Marian began losing her hair back in college.

Marian Malloy: I was on my own for the very first time and I was learning about life and learning about my hair loss. And it just devastated me. So I started out picking out methods to improve my hairline. Initially, I went to a dermatologists who put me on a prescription of injections, actually. I would go over weekly and he injected my head, and I got results, but I also started growing facial hair, which wasn’t something that I wanted. After that, I decided to start with the Rogaine and once again I saw results, but Rogaine was something that I had to do every day for the rest of my life, and I just didn’t want to be that dependent on a medication.

Narrator: Marian continued to search for an acceptable treatment to her condition, even trying hair plugs, until she heard about Dr. Robert Bernstein’s new method of Follicular Unit Transplantation, or in layman’s terms, a hair transplant.

Marian Malloy: I wasn’t scared at all. I was desperate, so that overrode everything.

Julie Chen: Marian Malloy is here along with her hair transplant surgeon, Dr. Robert Bernstein, to help us look at some of the medical options that are available to women suffering from this affliction.

Good morning to both of you.

Dr. Bernstein: Good morning.

Marian Malloy: Good morning.

Julie Chen: Marian, thank you for speaking out about this very private problem. How has your life changed since getting the hair transplant?

Marian Malloy: Well, I just feel better about my appearance, and appearance is very important to me in my line of work. I just feel a lot better and I think I look better. My hairline looks better.

Julie Chen: Boost in the self-confidence department?

Marian Malloy: Actually, yes.

Julie Chen: And your friends and family see a difference in it?

Marian Malloy: You know, my friends and family really didn’t notice a difference before, and they thought I was crazy for harping on it the way that I did.

Julie Chen: But if you see it, that’s all that —

Marian Malloy: And it was all about me. It’s not about my family and friends. It’s about how I feel.

Julie Chen: Right.

Marian Malloy: Yes.

Julie Chen: Dr. Bernstein, I want to go through all the options that are available for women, but what is the difference between female and male hair loss option-wise. What can we do to treat it?

Dr. Bernstein: The main difference medically is that women have hair loss often from hormonal changes and it’s due to an imbalance between progesterones and estrogens. That equilibrium can be reestablished with medication. Often birth control pills can do that.

Julie Chen: So that’s one option.

Dr. Bernstein: One option. For the most common cause of hair loss, genetic hair loss, Minoxidil can be used for both men and women, but the most effective medication for men, Propecia, can’t be used in women. And the reason –

Julie Chen: Why not?

Dr. Bernstein: The reason is that it causes birth defects if taken during pregnancy and postmenopausally it doesn’t seem to work.

Julie Chen: Oh, okay. So talk to me about Minoxidil, also known as Rogaine .Just as successful for women as in men?

Dr. Bernstein: It seems to be similarly successful, but the success rate is not very good, and one of the problems with its use in women is that you can get hair at the hairline on the forehead. So the usefulness is a little bit limited.

Julie Chen: So is it promoting hair growth if it does work, the Rogaine, or is it just making your existing hair grow in thicker? I’ve heard both.

Dr. Bernstein: It actually stimulates the growth of existing hair.

Julie Chen: Okay so you got to be really careful topically what you touch after you’re rubbing it into your scalp.

Dr. Bernstein: Yes.

Julie Chen: Another option is topical Cortisone and Cortisone injection.

Dr. Bernstein: Yes many people think that Cortisone can be used for genetic hair loss or common hair loss and it really can’t. It’s a good treatment for specific types of diseases, the most common one is alopecia areata. In that condition, the body actually fights off its own hair follicles. And then the Cortisone is used to suppress the immune system and actually allows the body to permit the hair to grow back.

Julie Chen: Now, Marian tried these options that we’re talking about. You weren’t satisfied, so you had a hair transplant.

Marian Malloy: Yes.

Julie Chen: Describe exactly what you did for Marian.

Dr. Bernstein: In the past, hair transplantation was not a good option for women because hair was transplanted in little clumps. With Follicular Unit Transplantation, we can now transplant hair exactly the way it grows, which is in little tiny bundles of one to four hairs. With Marian we took a strip from the back of her head, in other words, right from the back of the scalp where you can’t see it.

Julie Chen: Where there’s more hair?

Dr. Bernstein: Yes, we remove that strip and place it under a microscope and dissect out the individual follicular units – the hair is transplanted exactly the way it grows in nature. And that hair is then put in needle-poke incisions all along the hairline, and because the grafts are so small, you can actually mimic the swirls and the change in hair direction exactly the way the hair grows naturally.

Julie Chen: And it stays?

Dr. Bernstein: Yes, it stays. We make a very snug fit between the graft and the needle-poke incision. And so it really holds on to the grafts well. In fact, the patients can shower the next morning.

Julie Chen: The next morning? Marian, what was your experience like having this hair transplant? No problems since?

Marian Malloy: No problems, absolutely no problems.

Julie Chen: Did insurance cover any of this?

Marian Malloy: No, absolutely not.

Julie Chen: How costly is this?

Dr. Bernstein: The average procedure is about $7,000.

Julie Chen: And it’s one procedure and you’re done?

Dr. Bernstein: Usually one to two procedures.

Julie Chen: $7,000 a pop. Well, you found it was worth your money, is that right, Marian?

Marian Malloy: Absolutely, yes.

Julie Chen: Dr. Bernstein, Marian Malloy, thank you both for coming on the show talking about this.

Posted by

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?

Posted by

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.

Posted by



Browse Hair Restoration Answers by topic:








212-826-2400
Scroll to Top

Learn more about hair restoration

Hair loss has a variety of causes. Diagnosis and treatment is best determined by a board-certified dermatologist. We offer both in-person and online photo consults.

Provide your email to learn more.