Q: What is the problem with transplanting the crown too early? — P.L., Newark, NJ
A: If a person’s hair loss continues – which is almost always the case – the crown will expand and leave the transplanted area isolated, i.e. looking like a pony-tail. The surgeon can perform additional hair transplant procedures to re-connect the transplanted area to the fringe, but, as one can see from the photo below, this is a large area that can require a lot of hair. It is often impossible to determine when a person is young if the donor supply will be adequate. If there is not enough donor hair, then the island of hair may remain isolated. Most importantly, it uses up a lot of hair that might be better transplanted to the front and top of the scalp – areas that are far more important cosmetically.
The front and top of the scalp are more important to one’s appearance than the crown, and these areas should be the first priority when planning hair restoration surgery.
As an exception, if a person has a family history of baldness limited to the crown, even at an advanced age, and the person in question is following this pattern, then earlier treatment of the crown may be considered.
Lastly, if you do treat the crown in a younger person, or one with whom the extent of hair loss is uncertain, the crown should be transplanted with light coverage only. That way a limited amount of hair will be used up in this area and there will be enough left over for the more cosmetically significant top and front of the scalp.
In a study ((Shin JW, Kwon SH, Kim SA, Kim JY, Na JI, Chan Park K, Huh CH. Characteristics of robotically harvested hair follicles in Koreans. J Am Acad Dermatol, 2014 Sep 13. pii: S0190-9622(14)01789-7.)) published in the January 2014 issue of the journal ‘Dermatologic Surgery,’ researchers from the Republic of Korea collected and analyzed robotically harvested follicular units in a clinical setting using the ARTAS® Robotic System. This is the first time such data has been collected from Korean patients.
Specifically, they looked at the yield of follicular units, the ratio of successfully extracted follicular units to the total number of attempted extractions, and the rate at which hair follicles were transected, or damaged, during the procedure.
They found that the ARTAS system was able to harvest multiple hairs with high yields and low transection rates.
The Study: Characteristics of Robotically Harvested Hair Follicles in Koreans
The researchers collected data on robotically harvested follicular units from 22 Korean patients in a clinical setting using the ARTAS system. To reduce variation due to differences in patients, they collected follicular units from the same scalp location on each patient.
On average, the researchers found that 95% of extraction attempts were successful in producing a follicular unit, while the remaining 5% of attempts resulted in follicular units either being lost inside the robot’s suction system or becoming attached to the robot’s dissection instrument.
Of the successfully extracted follicular units, the average transection rate was 4.9%. This is 16% to 38% lower than has been reported elsewhere ((Wasserbauer S. Robotic assisted harvest of follicular units: Abstract book of 19th annual scientific meeting of International Society of Hair Restoration Surgery; September 14-18, 2011; Anchorage, AK. pp. 252-6.)), ((Kasai K, Haruyama I, Aikawa Y, Saito K. Advantages and disadvantages of FUE using ARTAS system form Japanese: Abstract book of 21st annual scientific meeting of International Society of Hair Restoration Surgery; October 23-26, 2013; San Francisco (CA). pp. 387-8.)). The researchers hypothesized that this lower transection rate could be due attribute these differences to the variability of a patient’s hair profile (e.g., waviness, thickness, color) and the surgeon’s minute control of the depth of punches.
Finally, they found that the robot was able to harvest follicular units that contained multiple hair follicles, anywhere from 2 to 5 follicles with the average being 2.4; However, they also found that as the number of hair follicles inside a follicular unit increased, the likelihood of transecting one or more follicles also increased.
The researchers concluded that the robot efficiently harvests not only follicular units with single hairs but also follicular units with multiple hairs. A limitation of the study was not comparing the characteristics of robotically harvested follicular units to manually harvested follicular units within the same group of patients.
Dr. Robert M. Bernstein, pioneer of the follicular unit transplantation and follicular unit extraction hair transplant procedures, was selected as one of New York metropolitan area’s top physicians.
New York, NY — Robert M. Bernstein, M.D., F.A.A.D., world-renowned pioneer of the Follicular Unit Transplantation and Follicular Unit Extraction hair transplant techniques and founder of Bernstein Medical – Center for Hair Restoration, was included in New York Magazine’s Best Doctors issue for the twelfth consecutive year.
Dr. Bernstein, a Clinical Professor of Dermatology at Columbia University in New York, said that he is honored to be recognized again for the Best Doctors issue. He said, “My inclusion in the Best Doctors issue for the twelfth year in a row is a testament to the hard work and dedication of my staff, our consistently high quality of care, and our passion for treating patients who are struggling with hair loss.”
The New York Magazine Best Doctors issue is an annual compilation of physicians that is based on a peer-review survey conducted by Castle Connolly Medical Ltd., a research company that publishes Top Doctors: New York Metro Area. Each year, medical professionals in the New York metropolitan area nominate their choice of the best doctors in a field. The physicians make their recommendations based on several criteria including: professional qualifications, reputation, skill in diagnosis, and skill in providing treatment for patients.
Dr. Bernstein, a New York native, is a true innovator in the field of hair restoration. His medical publications on follicular unit transplantation (FUT) and follicular unit extraction (FUE) have revolutionized hair transplantation and provide the foundation for techniques in use by hair transplant surgeons across five continents. His medical practice has been solely devoted to the treatment of hair loss since 1995 and he has provided hair loss treatments and hair restoration surgery at his state-of-the-art hair restoration facility in New York City since 2005. The Bernstein Medical – Center for Hair Restoration, located in midtown Manhattan, is dedicated to the diagnosis and treatment of hair loss in men and women and specializes in both restorative and corrective hair transplants.
Dr. Bernstein has appeared on a wide variety of notable media programs and publications. Some of these include: The Oprah Winfrey Show, The Dr. Oz Show, The Today Show, Good Morning America, ABC News, CBS News, Fox News, National Public Radio, New York Times, Men’s Health Magazine, GQ Magazine, Univision, Telemundo, “O” the Oprah Magazine, and more. He is co-author of Hair Loss & Replacement for Dummies and The Patient’s Guide to Hair Restoration.
After trading anecdotes with fellow hair loss physicians about how finasteride can reduce body hair in some patients, Sharon A. Keene, M.D. took the next logical step and asked whether finasteride might have a negative effect on patients who have body hair transplant (BHT) procedures.
In a review of scientific literature on whether finasteride effects body hair growth, Dr. Keene finds that current research is inconclusive.
Finasteride, the drug in the hair loss medication Propecia, works by blocking the 5-alpha-reductase type 2 enzyme (5-AR Type 2) which is needed by the body to covert testosterone to DHT. DHT causes common baldness, by making hair follicles shrink and eventually die.
In looking at DHT’s effect on body hair growth, current research strongly suggests that it does play a key role. Males born with a deficiency of 5-AR Type 2, and thus no DHT, have reduced, or absent, body hair growth (and no loss of scalp hair).
It would seem logical then, that when finasteride is used to re-grow hair on the scalp, it would also inhibit the growth of hair on the body. However, the genetic variation among people is too great to determine exactly how much of an influence it plays.
With this uncertainty of DHT’s effects on body hair, it is impossible to say, without further study, if finasteride would have the same effect on body hairs which are transplanted to the scalp. In Dr. Keene’s conclusion, she suggests:
A patient on finasteride for at least a year who undergoes BHT is probably safe to continue it, as remaining body hairs are apparently not sensitive to the effects of this drug.
You can read the full discussion and review of current research in the January/February 2011 issue of Hair Transplant Forum International, the official newsletter of the International Society of Hair Restoration Surgery (ISHRS).
Q: Heard you were on Oprah with a hair transplant patient of yours. Is this true? — V.B., Chappaqua, N.Y.
A: Yes. Oprah wanted to know if hair transplants really worked, so I was asked to be on The Oprah Winfrey Show to explain the latest in hair restoration techniques.
Q: What’s the best way to camouflage a scar left behind from a scalp reduction that I had in 2001? I am currently wearing DermMatch to cover the area, but the hair parts like the “Red Sea” on top around the scar so the makeup does not look so good. I would like to fill in the area with hair but I am not sure if a hair transplant will grow into scar tissue.
A: Hair will grow in the scar but, as you allude to, the problem is often the abnormal hair direction rather than the scar itself.
Besides adding hair to the scar, if one transplants hair adjacent to the scar in a direction that causes it to lie over the scarred area, the visual affect of the “Red Sea” effect can be lessened.
How much improvement you achieve with the hair restoration will, in part, depend upon the amount of hair available to be transplanted (and the skill of the surgeon).
The Trustees of Columbia University have named Dr. Bernstein, hair transplant pioneer, the Clinical Professor of Dermatology. This promotion was based on Dr. Bernstein’s teaching, lectures, research, original scientific papers, and outstanding patient care.
Robert M. Bernstein, MD, FAAD, is an Attending at the New York Presbyterian Hospital and specializes in surgical hair restoration. Dr. Bernstein is the founder and director of Bernstein Medical – Center for Hair Restoration. His current research focuses on the refinement of Follicular Unit Transplantation, the revolutionary hair restoration procedure that he pioneered.
Dr. Bernstein graduated with honors from Tulane University in 1973, achieving the status of Tulane Scholar. In 1979 he received the degree of Doctor of Medicine at the University of Medicine and Dentistry of N.J. where he was given the Dr. Bleiberg Award for “Excellence in Dermatology”. Dr. Bernstein joined the staff at Columbia in 1982 as an Assistant in Clinical Dermatology, after completing his training as Resident and Chief Resident in Dermatology at the Albert Einstein College of Medicine, New York, N.Y. Dr. Bernstein was promoted to Associate Clinical Professor of Dermatology at Columbia University in 2000. Dr. Bernstein also holds an MBA from Columbia, a degree he received in 2004.
Dr. Bernstein is Board Certified in Dermatology and is a Diplomat of the American Board of Hair Restoration Surgery. He is a fellow of the American Academy of Dermatology. For his for his pioneering hair transplant techniques, Dr. Bernstein received the Platinum Follicle Award, the highest honor bestowed by the International Society of Hair Restoration Surgery.
Columbia University bestows honor upon its physicians in the form of new appointments and promotions within each department. The department of dermatology at the College of Physicians & Surgeons of Columbia University was one of the first academic units established in New York City and is a major center for basic science and clinical research. Its faculty has made numerous contributions to the development of dermatology including pioneering work in the early use of ionizing radiation, advancing the technique of photopheresis for cutaneous T-cell lymphoma and discovering the first human gene associated with hair loss.
Q: What are the major obstacles for scientists to cloning hair?
A: The main problem is that the cultured cells may lose their phenotype with multiple passages, i.e. lose their ability to differentiate into hair follicles after they have been multiplied.
Another problem of hair cloning is that the orientation of hair direction must be controlled. With mouse experiments, the hairs grow at all different directions. Scientists need to find a way to align the hair so that it grows in the right direction. Hair, of course, must also be of a quality that is cosmetically acceptable and matches the patient existing hair. And the hair should grow in follicular units. Individual hairs will not give the fullness or natural look of follicular units.
Another problem is the issue of safety. Are we sure that cultured cells may not turn into something else – such as malignancy cells with uncontrolled growth?
Finally, FDA approval would be required and this takes time. It is true that you do not need FDA approval for using your own hair, such as a hair transplant; however, when you take cells from the body and manipulate it in the lab, this requires FDA approval.
Q: Dr. Bernstein, is a follicular unit hair transplant, the way you perform it, very painful? — M.C., Laguna Niguel, C.A.
A: We perform our hair transplant procedures using long-acting, local anesthesia, so after the initial injections, the patient doesn’t experience any pain or discomfort.
The local anesthesia (a combination of Lidocaine and Marcaine) lasts about 4-5 hours. For long sessions, we give additional anesthesia before the first wears off.
Before we start the local anesthesia, we give most patients IM Versed (also known as midazolam). This medication is a very fast acting sedative that is very relaxing. Some patients even doze off at the beginning of the procedure. This is very different, however from the deep sleep produced by general anesthesia.
Q: Dr. Bernstein, I remember Senator William Proxmire. He was one of the first sort of high-profile people who had a hair transplant probably, what, thirty years ago, and to be honest with you, it wasn’t all that great. It looked kind of funny. Have we made any progress in the last twenty-five, thirty years? — A.E., Fort Lee, N.J.
A: When hair transplant surgery was first developed in the late 1950s, early 1960s, everybody was so ecstatic that it grew – that one could actually move hair from the back of the head to the top, and it would grow – that no one really considered either the long-term implications or the aesthetic aspects of the procedure. And the fact that the hair grew is actually a problem because it never went away when it was transplanted poorly.
Over the years the grafts have gotten smaller and smaller. So where in the ’60s and ’70s they were the size of pencil erasers, they gradually decreased in size until doctors were performing hair transplants using just a few hairs at a time. The major breakthrough came in the mid 1990s when we realized that hair doesn’t grow individually but grows in little tiny groups and these groups are called follicular units.
In modern hair transplant surgery (which began in 1995) hair is taken from the back of the scalp and moved to the front and top of the scalp in these individual groups of one to four hairs.
In this way the results can completely mimic the way hair grows in nature.
Q: I am interested in an FUT hair transplant. How do you figure out how large a strip to use for the hair restoration when transplanting all follicular units? — P.K., New York City, N.Y.
A: The length of the donor strip incision is determined by the number of follicular unit grafts required for the hair restoration. There are slightly less than 100 follicular units/cm2, so if a 1cm wide strip is used, a hair restoration procedure requiring 1800 grafts would need a strip that measured slightly more than 18cm in length.
A 2800 graft procedure would measure slightly more that 24cm if the strip were 1.2cm wide.
The width of the strip is determined by scalp looseness or laxity. For more information, please see the page on the Donor Area.
Q: I am 28 years old and was told that I have early Norwood Class 3 hair loss. I want to have a hair transplant but my doctor told me to use Propecia for 6 months and then come back to discuss surgery. I don’t want to wait that long, what should I do? — L.B., Oyster Bay Cove, NY
A: Actually, you should wait a full year. If you are an Early Norwood Class 3, the Propecia can work so well (in actually growing hair back) that you may not even need a hair transplant. The important point is that Propecia only starts working at 3-6 months and during this time there may actually be some shedding as the new growing hair literally pushes out the old.
A hair transplant performed at 6 months may not only be unnecessary, but growth from the medication may be attributed to the hair restoration surgery. I suggest to wait and see what the medication can do before going for hair restoration surgery.
A: The first paper on Follicular Unit Hair Transplantation was published by Dr. Bernstein and Rassman in 1995 in the International Journal of Aesthetic and Restorative Surgery. The title of the paper used the abbreviated name Follicular Transplantation. The longer name “Follicular Unit Transplantation” was formalized by Bernstein et. al. in the paper “Standardizing the classification and description of follicular unit transplantation and mini-micrografting techniques.” This paper appeared in Dermatologic Surgery in 1998.
The Platinum Follicle Award is given by the International Society of Hair Restoration Surgery (ISHRS) for “Outstanding achievement in basic scientific or clinically-related research in hair pathophysiology or anatomy as it relates to hair restoration.” It was presented to Dr. Bernstein at the 9th Annual Meeting of the ISHRS, October 18-22, 2001; in Puerta Vallarta, Mexico.
The award is the highest honor given by the International Society of Hair Restoration Surgery. At the ceremony, Dr. Marcelo Gandelman, the President of the ISHRS, stated:
“I proudly present the 2001 Platinum Follicle Award to Robert M. Bernstein, MD. Dr. Bernstein has contributed to the field of hair transplantation in dramatic and substantial ways, revolutionizing the advancement of Follicular Unit Hair Transplantation. His published articles have become ‘Bibles’ for this methodology. Dr. Bernstein’s contributions extend beyond the application of Follicular Unit Transplantation, such as studies in examining the power of sorting grafts for density, yield by method of graft production, local anesthetic use, and suture materials. These studies have added to the specialty’s depth and breadth of knowledge applicable to traditional mini-micrografting techniques as well as Follicular Unit Transplantation.”
Dr. Bernstein was interviewed by Skin & Allergy News in their article, “Microscopic Dissection Offers Superior Yield” The complete article is below:
Skin & Allergy News
February 1999
Microscopic Dissection Offers Superior Yield
Articles by Anna Nidecker
Senior Writer
Washington — The dissecting microscope takes some getting used to, but using it makes more efficient use of donor hair during follicular unit transplantation than magnifying loupes with transillumination, reported Dr. Robert Bernstein of Columbia University College of Physicians and Surgeons, New York.
“A limiting factor in all hair restoration surgery is the patient’s finite donor supply. […] Meticulous stereomicroscopic dissection should help preserve the supply and ultimately provide the patient with the most transplantable hair,” he said at the annual meeting of the International Society of Hair Restoration Surgery.
Dr. Bernstein compared the follicular unit graft yields of dissections performed with stereoscopic microscopes and with loupes and backlighting. Initial sectioning of the intact strip was done with loupes, as the staff had not yet mastered the skill of slivering that is needed to section the intact strip under microscopic guidance.
“This method may be useful for a team in transition, a model for staffs in transition to using the microscope,” the hair transplant surgeon suggested.
Tips on Transition to Microscopes
The microscope offers a better yield with follicular transplantation, but some doctors feel that abruptly switching from loupe magnification may send an office into turmoil.
Microscopes will be well received by staff if they clearly understand the benefits and are eased into the transition, Dr. Bernstein said.
Dr. David Seager advised physicians planning the transition to the use of microscopes to let staff observe microscopic dissection at another clinic with an established program, and to send them somewhere to be trained before they start. The Toronto hair transplant surgeon also advised buying a couple of microscopes and letting the staff “play” with them for a while, cutting at their own leisurely rate before entering into a high-pressure transplant session.
Dr. Bernstein also recommended easing slowly into the transition by first training a small portion of staff, which will not affect the overall time of surgery.
Another option is to hire a couple of new technicians and train them from the beginning with microscopic dissection, Dr. Seager suggested.
“You’ll be amazed at the beautiful grafts they will be cutting in a couple of weeks. […] It may be only 40 grafts an hour, but these newcomers will be cutting better grafts than even your 8-year veterans,” he said. “Old staff will look at these new technicians and their grafts, and, if they take pride in their work, they will be quite jealous and will be really eager to catch up.”
Dr. Bernstein agreed: “The value of the microscope may be more significant in the hands of less experienced dissectors. […] There’s some advantage even at the outset.”
Continued resistance from staff should be met with a deadline: ‘Anyone who can’t or won’t fit in, tell them they can do something else in the office, but they won’t be doing transplanting,” Dr. Seager said.
In 41 patients, the donor strip was harvested with a double-bladed knife from the midportion of the permanent zone in the back of the scalp.
The strip was divided into two equal parts along the midline; these were further divided into 2- to 3-mm wide vertical sections using loupes and a straight razor. Sections from one of these donor strip halves were further dissected into follicular units using a 10x power microscope; sections from the other donor strip half were dissected using magnifying loupes.
Follicular units cut using the microscope contained an average of 2.41 hairs; those cut using loupe magnification yielded 2.28 hairs. Use of the microscope also yielded 10% more follicular units and 17% more hair overall, compared with use of loupes.
The grafts were dissected and sorted into follicular units containing one to four hairs, and all hair and hair fragments judged to be potentially viable were counted towards the yield (Dermatol. Surg. 24[8]:875-80, 1998).
Microscopic dissection took from two to four times as long as loupe magnified dissection when technicians first began using the microscopes. After 3 months, the procedure still took twice as long with the microscopes. But by the end of the study 1 year later, it took only 10% longer, a rate they currently maintain, Dr. Bernstein said.
Hand-eye coordination was a factor which automatically improved, and the inefficient movement of grafts in and out of the microscopic field was solved with better organization, he said. Technicians with a tendency to obsessively sculpt grafts under the microscope can be educated to limit this sculpting, which does not affect the quality of the transplant.
Use of the microscope also led to fewer reports of back and neck strain by assistants. They also reported easier dissection when there was donor scarring, and with blond or light-colored hair.
Besides the benefit at the stage of dissecting the sections—as shown in this study—microscopes can improve yield by 5%-10% at the “slivering” stage. Yield can be improved an additional 15%-20% by avoiding use of the multibladed knife at the donor harvesting stage.
Loupe advocates argue that microscopes unduly slow down the procedure and that staff resistance to this new technology may be an insurmountable problem in some practices. They also lament the higher economic cost of purchasing the microscopes, training the staff, and slowing down dissection time with no clear benefits.
Dr. Bernstein said that the benefits of microscopic dissection far outweigh these minor inconveniences and should be incorporated into hair transplant procedures.
Dr. Bernstein receives the Surgeon of the Month award given by the International Society of Hair Restoration Surgery. Read the statement on the award that appeared in the Hair Transplant Forum International, the society’s official publication:
Hair Transplant Forum International 1997; 7(1): 16.
Surgeon of the Month: Robert M. Bernstein, M.D.
It has been my policy, since taking over as Editor of the FORUM, to nominate a Surgeon of the Month in each edition. Rather than give further honors to those illustrious member of our profession who have had frequent mention over past years, I have tried to seek out those who have much to contribute in the future. Recent editions have honored a Mexican, an Australian and two South American surgeons. On this occasion, we return to the USA, to pay homage to a young dermatologist who has contributed a great deal in a few short years since entering the hair transplant field. – RS
Robert M. Bernstein, MD, is Medical Director of the New Hair Institute Medical Group in New York. He is Assistant Clinical Professor of Dermatology at the college of Physician and Surgeons of Columbia University, and an Associate in the Dermatology Service at the Columbia Presbyterian Medical Center, where he teaches dermatologic and laser surgery, and hair transplantation. He is also an attending physician in dermatology at Englewood Hospital and at the Manhattan Eye, Ear and Throat Hospital.
Dr. Bernstein received his MS degree at the University of Medicine and Dentistry of New Jersey in 1978, and was the recipient of the Dr. Jacob Bleiberg Award for Excellence in Dermatology. He received his dermatologic training at the Albert Einstein College of Medicine, where he served as chief resident.
Dr. Bernstein is board certified in dermatology, and in his private practice, has a special interest in cosmetic dermatologic surgery and laser surgery. Dr. Bernstein has served as Chairman of the Quality Assurance and Compliance Committee of the Department of Dermatology at Englewood Hospital, and was Co Director of their annual dermatology seminar for 10 years. Although he trained in hair restoration surgery during his residency, and performed hair transplantation and scalp reductions when he started private practice, he soon abandoned both procedures when he was not satisfied with the results. He observed the evolution of the procedure for many years until, after seeing the work of Dr. William Rassman and others performing large sessions of small grafts, he decided to re enter the field. Dr. Bernstein soon joined Dr. Rassman at the New Hair Institute to devote his time solely to hair transplantation.
Dr. Bernstein introduced the concept of “follicular transplantation” in an article published in 1995 in the International Journal of Aesthetic and Restorative Surgery, which recommended that in all hair transplantation, the implants should consist of only the naturally occurring follicular units. The anatomic follicular units, seen clinically as the patient’s natural hair groupings, are different for each individual, and these differences should be reflected in the transplant plan. He has been a strong advocate of using follicular transplantation for the best possible cosmetic result, and has encouraged his colleagues to use this approach in both his writings and lectures.
Dr. Bernstein was born in New York City in 1952. He is married to Shizuka, who is a medical aesthetician, and they have two sons, Michael (age 12), and Taijiro (age 11), and a daughter, Nikita (age 2 1/2). Dr. Bernstein’s hobbies include skiing, basketball, piano, ballroom dancing, and chess all of which he enjoys with his family.
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.
The Trustees of Columbia University have named Dr. Bernstein, hair transplant pioneer, the Clinical Professor of Dermatology. This promotion was based on Dr. Bernstein’s teaching, lectures, research, original scientific papers, and outstanding patient care.
The 
College of Physicians and Surgeons, New York.
Robert M. Bernstein, MD, is Medical Director of the New Hair Institute Medical Group in New York. He is Assistant Clinical Professor of Dermatology at the college of Physician and Surgeons of Columbia University, and an Associate in the Dermatology Service at the Columbia Presbyterian Medical Center, where he teaches dermatologic and laser surgery, and hair transplantation. He is also an attending physician in dermatology at Englewood Hospital and at the Manhattan Eye, Ear and Throat Hospital.
