Bernstein Medical - Center for Hair Restoration - Hair Transplant Aesthetics
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A recently published study ((Bater KL, Ishii M, Joseph A, Su P, Nellis J, Ishii LE. Perception of Hair Transplant for Androgenetic Alopecia. JAMA Facial Plast Surg. 2016 Aug 25. doi: 10.1001/jamafacial.2016.0546.)) is the first to measure the perceived benefit of hair transplantation on a patient’s age, attractiveness, successfulness, and approachability – key factors that play an important role in workplace and social success. The pilot study, published in the Journal of the American Medical Association Facial Plastic Surgery, found that hair transplant recipients were perceived by others to be 3.6 years younger following their hair restoration surgery. The data indicate that the person’s attractiveness, successfulness, and approachability also showed statistically significant positive changes as a result of hair restoration surgery.

Background

Half of men over 40 experience hair loss. This may be associated with significant adverse psychological effects including reduced self-esteem and self-confidence, plus the social consequences that follow. Prior studies have shown that men who are balding are rated poorly when it comes to attractiveness, likability, and personal and career success. ((Wells PA, Willmoth T, Russell RJ. Does fortune favor the bald? psychological correlates of hair loss in males. Br J Psychol. 1995; 86(pt3):337-344.)), ((Cash TF. Losing hair, losing points? the effects of male pattern baldness on social impression formation. J Appl Soc Psychol. 1990;20(2):154-167.)) This perception motivates men to seek hair restoration in order to improve how they are viewed by others. The new study attempted to quantify, for both patients and their surgeons, the actual benefit of hair transplant surgery on these key perceptions.

Methods

The randomized, controlled study involved 122 participants — 47.5% men, 51.6% women — each of whom were shown a series of 13 sets of before and after hair transplant photos. Of the photo sets, seven showed men before and then after a hair transplant of approximately 1,200 follicular unit grafts. The control group were of men who did not have a hair transplant or any facial cosmetic surgery. Each participant was asked to rate how much younger the “after” photograph appeared, on a scale of 1-10 years. For the other metrics — attractiveness, successfulness, and approachability — the participants used a slider bar to indicate a positive or negative change.

Results

On age, the data showed a range of about one year younger to about six years younger for the “after” photos, for an average of 3.6 years younger in people who had a transplant. The “after” photos for the control group were perceived to be an average of 1.1 years younger, confirming that the post-transplant group appeared younger than the control group. On attractiveness, successfulness, and approachability, study participants rated the “after” photos with scores of 58.5, 57.1, and 59.2, respectively. This amounts to a 17% improvement in attractiveness, 14.2% improvement in successfulness, and an 18.4% improvement in approachability.

Summary

Since the first hair transplants in the 1950s we have observed that surgical hair restoration can significantly improve one’s appearance. Now, for the first time, we have concrete data that shows the extent of the change of perception in the person’s age, attractiveness, successfulness, and approachability that is caused by the hair restoration procedure. This pilot study should be encouraging for prospective patients, as the purpose of hair restoration is not only to improve one’s own self-image, but to improve appearance, attractiveness, and successfulness to other people as well. This study shows that this effect exists in a way that is both measurable and statistically significant.

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Q: For patients who intend to keep their hair parted on the left side, do you follow any rule of making the left side more dense then the right or is it distributed evenly? — M.S., Simi Valley, C.A.

A: On a first hair transplant procedure, I generally place the sites/grafts symmetrically, even if a patient combs his hair to one side. The reason is that the person may change his styling after the procedure and I like to have the first hair transplant symmetrical for maximum flexibility. An exception would be a person with limited donor reserves. In this case, weighting on the part side is appropriate in the first procedure. Once the first hair transplant grows in and the person decides how he wants to wear his hair long-term a second transplant can be weighted to accommodate this. Weighting can be done in one, or both, of two ways: 1) by placing the sites closer together on the part side or 2) by placing slightly larger follicular units on the part side.

If a person decides to comb his hair back, then forward weighting is used. For greater details on this, please see some of my publications where I address the aesthetics of hair transplantation:

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Q: I notice that some patients end up with hair that seems to stand straight up while others have hair that flows to one side or the other. Does the angle at which you place the follicles in the scalp ultimately determine how the hair will lie? Is there some artistic talent needed when placing these follicles so that patients end up with hair that lies flat or sticks straight up? What determines this? Do we have control over it? — H.B., Fort Lauderdale, F.L.

A: Great question. You are correct, the angle of the recipient sites largely determines the hair direction. Hair should be planted the way it grows (i.e., in a forward and horizontal direction at the frontal hairline.) It is extremely important that it is transplanted that way to look natural. The body will alter the angle a bit as it heals, usually elevating it slightly and re-creating any prior wave (yes, waves are determined by the scalp, rather than by the hair follicles per se). In a properly performed hair transplant, a straight-up appearance should be due to grooming, it should not have been a result of the actual procedure. Hair should never be transplanted perpendicular to the scalp. I discussed these important concepts way back in my 1997 paper “The Aesthetics of Follicular Transplantation“.

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ARTAS at Bernstein Medical - Center for Hair Restoration
Dr. Bernstein and Staff with ARTAS System

We are pleased to announce that robotic FUE is now available at Bernstein Medical – Center for Hair Restoration. This is a major advance in FUE technology.

The ARTAS system for hair restoration allows us to more effectively isolate follicular unit grafts from the donor area of the scalp without causing damage to individual follicles, a problem that has been a limitation of manual FUE techniques. Many other important parts of the FUE procedure will still be performed by the physician and team, including actual removal of the follicular units from the scalp, recipient site creation, and graft placement. The aesthetic elements that give a hair transplant a natural-looking result will still be in the hands of the physician. Read more about the benefits of robotic hair transplantation.

We are proud of the cutting-edge work we do in our state-of-the-art medical facility and are excited as we take FUE hair transplantation to the next level.

View our press release about the ARTAS system at Bernstein Medical.

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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.

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Q: How are grafts distributed in a hair transplant? Are they distributed evenly? — B.V., Jersey City, NJ

A: Actually, we don’t make the transplanted hair evenly distributed. It is usually front weighted, so that the hair restoration will look most full when looking at the person head on.

Framing the face is the most important part of the restoration. Covering the top is the next most important region and, if the patient has enough donor supply, then hair can be added to the crown.

For a more detailed discussion of this topic, view our page on recipient sites in a follicular unit hair transplant. Also, read the publication written by Dr. Bernstein in 1997 which became the industry benchmark for aesthetics in hair transplant surgery, “Aesthetics of Follicular Transplantation.”

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Our friends at the Hair Transplant Network have posted a 3-part video interview with Dr. Bernstein on YouTube for your viewing pleasure.

Watch the videos below (all three will play in order):

You can also view the videos individually on YouTube by visiting these links:

If you like the videos, visit the YouTube pages above and share them via email or a social media website like twitter or facebook. Or, log in to YouTube and add a comment.

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Q: Dear Dr. Bernstein, a full head of hair averages ~100 FU/cm2. To achieve the appearance of fullness with a hair transplant 50% is required. In one of your articles you say that you recommend 25 FU / cm2 to your patients. Is that the density per one session or the final one? If that is final density, then it is far below the 50%. Please explain as I am profoundly confused. — W.N., Easton, C.T.

A: If a person is to become a Norwood Class 6, the hair that we have available for us to transplant is only about 12% of what was there originally. This, of course, will vary from patient to patient depending upon one’s donor density and scalp laxity and a host of other factors.

We make the hair restoration look good by restoring 25-50% in the front, and proportionately less in the back. Logically one cannot restore 1/2 of ones original density to an entire bald scalp with only a thin strip of donor hair – there is just not enough hair, even with multiple sessions.

I transplant 25-35 FU/mm2 in one session, but this is the density created in the front, not overall.

Due to follicular unit graft sorting (placing the larger follicular units in the forelock area) this provides even more density than the actual numbers suggest. If someone is relatively certain to have more limited hair loss, then the numbers can be increased, but it is risky if you underestimate the degree of eventual hair loss.

Please carefully read the article on Hair Transplant Aesthetics.

It will answer your excellent question in greater detail. The article is a bit old, but the principles are the same.

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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.

See the Follicular Unit Transplant (FUT) section for more information.

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Mohammad H. Mohmand, M.D.
International Laser Hair Transplant Surgery Center, Islamabad, Pakistan.

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

The objective of this presentation is to share our experience and observations regarding the importance of the angle of curvature of the hair shaft during the hair transplant for producing a natural looking hairline.

Four important factors were kept in mind while performing the hair transplant regarding the natural looking hairline: 1) Avoidance of a straight line, 2) Keeping a transition zone between the bare forehead and the dense packing, 3) Density, 4) The acute angle of exit from the skin, 5) The angle of curvature of the hair shaft.

In our experience, since incorporating the angle of curvature of the hair shaft, the naturalness of the hairline has improved significantly. This is especially true for the frontal hair rows and the temporal peaks.

Almost all the patients were satisfied with the technique and the naturalness of the surgery. The main difference was noticed in the patients who underwent a second or third session. They could really appreciate the difference. This technique allows the hair to fall on the forehead, giving softness to the hair transplant.

From our initial limited experience, we believe by taking into account the natural curvature of the hair shaft, one can bring more naturalness to the already existing techniques. We are all in pursuit of mimicking nature as closely as possible. This is just another small little point that can help.

Dr. Bernstein’s Comment – Dr. Mohmand’s attention to hair curvature at the frontal hairline adds another interesting refinement to follicular unit hair transplantation. Considering the curvature of the hair is particularly important in eyebrow restoration where even the slightest misalignment of hair has a significant impact on the aesthetics of the restoration.

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