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Dr. Bernstein Interviewed in NY Japion Pt 1

Dr. Bernstein Interviewed in NY Japion Pt 2

Dr. Bernstein was featured in a wide-ranging interview published in the New York City-based, Japanese language magazine NY Japion. Among the topics discussed were the differences between FUT and FUE hair transplants, updates on robotic hair transplant technology, the type of procedure most beneficial for Asian patients, criteria that determine candidacy for a hair transplant, and more. Below are some selections from the interview.

On FUT vs FUE:

FUT is more economical than FUE and also more beneficial for patients who wear their hair longer. However, if your plan is to have the option of wearing your hair short, FUT is not for you. That is because with FUT you will have a fine linear scar after the donor area (the area where strip is removed) is sutured, and this may be seen visible with short hair.

On robotic FUE hair transplantation and the ARTAS Robot:

In the case of ARTAS, an advanced camera system and a computer analyzes images of the scalp and calculates angle and direction of individual hairs, hair density and number of hairs in each follicular unit instantly. Then, based on that calculation, the computer controls the punch so that it goes into the skin at the right angle and depth so that it will not damage hair root and/or surrounding tissues. So far, 135 systems of ARTAS have been installed worldwide. About half of them are in the United States and 11 are in Japan. Currently, 5% of hair transplant treatments are performed with ARTAS worldwide.

On which type of hair transplant is more beneficial for Asian people:

FUE is especially good for Asians, including Japanese. With Asians, scars tend to widen. In addition, Asians usually have coarse hair that grows more perpendicular to the skin than in Caucasian scalps, so a linear scar in the donor area (using FUT) may be more visible — especially if the hair is worn short.

On who is a good candidate for a hair transplant:

Some people are candidates for hair transplantation, but some are not. Since a hair transplant uses a patients’ own hairs and relocates them from the permanent zone in the back of the scalp to areas that are thinning or bald, it is necessary that patients have good and sufficient hairs for that.

On the appropriate age to consider hair transplant surgery:

Hair transplants are not for young people since their future balding is so difficult to predict. Young patients should not consider hair transplant as a technique to prevent hair loss. Prevention is best accomplished by medications. The most effective are Propecia (finasteride) and Rogaine (minoxidil). These medications do have some side effects that need to be considered before starting. In general, hair transplant surgery should not be performed for people under 25. There are exceptions, but I prefer for patients to wait until 30 and over.

Dr. Bernstein’s wife Shizuka Bernstein was born in Tokyo, and the two travel to Japan frequently. Shizuka is a master-aesthetician and owns an award-winning day spa by Rockefeller Center in New York City called Shizuka NY. Shizuka developed her own line of skin-care products based on powerful natural anti-aging ingredients and pure Mt. Fuji spring water. She has been seen on CNN, CNBC, Fox News, The Today Show, The Early Show, CBS’s The Doctors, and E!’s red carpet special leading up to the Primetime Emmy Awards.

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Q: I’m a 42 year old African-American woman and I’m losing hair on the crown of my head. Would I be a good candidate for a hair transplant? — E.E., Philadelphia, P.A.

A: Hair loss in the crown of an African American female can have several different etiologies, so the first thing to do is to make the right diagnosis. The most common causes of hair loss are androgenic alopecia (AGA) and scarring alopecia, also called ‘Central Centrifugal Cicatricial Alopecia,’ or CCCA. A biopsy is often useful to differentiate these two causes of hair loss when the diagnosis is unclear. A biopsy can also identify other, but less common, causes of crown hair loss.

AGA presents with a history of gradual thinning in the front and/or top of the scalp, a relative preservation of the frontal hairline, a positive family history of hair loss and the presence of miniaturization in the thinning areas. Miniaturization, the progressive decrease of the hair shaft’s diameter and length in response to hormones, can be identified using a hand-held device called a densitometer. If the diagnosis is AGA, then a hair transplant can be very successful provided there is enough donor hair.

CCCA presents as a progressive form of scarring alopecia that occurs almost exclusively in African American women. The onset of CCCA is very slow, typically developing over the course of years. CCCA starts near the vertex or top of the scalp and spreads in an outward direction. The involved area is usually smooth and shiny with decreased hair density.

Central Centrifugal Cicatricial Alopecia is diagnosed with a scalp biopsy performed in the area of hair loss. Those patients with CCCA are generally not candidates for a hair transplant procedure since the body may reject the transplanted hair. This condition is better treated with oral and injectable anti-inflammatory medications. Surgical treatment for cosmetic benefit may be an option in some cases after the disease has been inactive for many years.

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Q: I am 26 years old and have been suffering from hair loss for 8 years. I have been on Propecia (finasteride) and Rogaine (minoxidil) during those years. Unfortunately my hair loss has continued to progress aggressively. I am of half African and Caucasian descent, and my hair is curly. I understand that there are certain limitations on having hair transplants before you are 35, however I do not mind having another transplant in a few years, if necessary. — A.L., Rye, N.Y.

A: Although it is possible to have a hair transplant to the crown using robotic FUE in African American patients, given your young age and that you state your hair loss is progressing aggressively while on Propecia and Minoxidil, it is likely not a good decision to have surgery at this time.

The reason is that as your hair loss surrounding the crown expands over time, it may look unnatural to have hair transplanted solely to the crown region.

At your age, it is best to take Propecia (finasteride) and Rogaine (minoxidil), and if a transplant is indicated, to start at your frontal hairline and top of your scalp, the areas that will be most important cosmetically long-term.

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Given the large number of people who are affected by common genetic balding and for whom traditional treatments, like surgical hair restoration or hair loss medications, may not be indicated, could low-level laser therapy (LLLT) be a viable and effective treatment option?

New research published this year (2014) in the American Journal of Clinical Dermatology says yes. ((Jimenez J.J, Wikramanayake T.C, Bergfeld W, Hordinsky M, Hickman J.G, Hamblin M.R, Schachner L.A. Efficacy and safety of a low-level laser device in the treatment of male and female pattern hair loss: a multicenter, randomized, sham device-controlled, double-blind study. Am J Clin Dermatol. 2014 Apr;15(2):115-27.))

Androgenetic Alopecia, The Most Common Hair Loss

Androgenetic alopecia will affect half of all men over the age of 50 and half of all women over the age of 80, and its severity increases with age. ((Olsen E.A, Messenger A.G, Shapiro J, Bergfeld W.F, Hordinsky M.K, Roberts J.L, et al. Evaluation and treatment of male and female pattern hair loss. J Am Acad Dermatol. 2005;52(2):301–11.)) It is characterized by a gradual miniaturization of the terminal (adult) hair into vellus (short, fine, almost invisible) hair.

While this miniaturization has no cure, this type of hair loss can be effectively addressed by surgical hair restoration techniques (FUT or FUE) and it can be treated with the medications finasteride (Proscar®) and dutasteride (Avodart®) in men or with anti-androgens (spironolactone) and estrogens (OCAs) in women.

However, as effective as these surgical techniques and medications are, some men, and most women, are not qualified candidates for a hair transplant, and the medication treatment options available for women are sometimes not as effective as the medication treatment options available for men.

How Laser Therapy Treats Male and Female Pattern Hair Loss

Laser therapy, also referred to as photobiomodulation or photobiostimulation, works in androgenetic alopecia in both men and women by both stopping miniaturization and stimulating hair growth. Specifically, past studies have suggested that LLLT increases terminal hair density by reversing the miniaturization process and causing follicles in a telogen (resting) phase to shift into an anagen (growth) phase.

The exact mechanism by which low-level laser therapy might protect and promote hair growth isn’t clear, but various researchers ((Lubart R, Eichler M, Lavi R, Friedman H, Shainberg A. Low energy laser irradiation promotes cellular redox activity. Photomed Laser Surg. 2005;23(1):3–9.)) have proposed that LLLT may accelerate mitosis (new cell growth), reduce the inflammation associated with androgenetic alopecia, stimulate follicular stem cells, and/or alter follicular cell metabolism for greater ATP production.

Based on anecdotal experience, practitioners report that LLLT in the range of 650–900nm wavelengths at 5mW appears to both promote new hair growth and protect existing hair against the effects of androgenetic alopecia.

But Is Laser Therapy Effective For Both Male and Female Pattern Hair Loss?

So far, only a few peer-reviewed studies ((Rangwala S, Rashid R.M. Alopecia: a review of laser and light therapies. Dermatol Online J. 2012;18(2):3.)) have produced data about the efficacy of LLLT for male pattern hair loss and only one published study ((Satino J.L, Markou M. Hair regrowth and increased hair tensile strength using the HairMax LaserComb for low-level laser therapy. Int J Cosmetic Surg Aesthetic Dermatol. 2003;5(2):113–7.)) has demonstrated, with limitations, LLLT efficacy for female pattern hair loss.

In other words, past research has demonstrated the efficacy of LLLT in men, but evidence that low-level laser therapy works for women has been comparatively weaker.

In order to convincingly address the efficacy of low-level laser therapy for both men and women, researchers conducted one of the most comprehensive, randomized, sham device-controlled, double-blind clinical studies to date.1

They found that LLLT, using the FDA-cleared HairMax Lasercomb, significantly increased hair density in both men and women diagnosed with androgenetic alopecia.

Efficacy of Low-Level Laser Therapy For Androgenetic Alopecia

The researchers included 128 men and 141 women, all diagnosed with androgenetic alopecia. Half the men and women used a real HairMax lasercomb and the other half used a sham, or fake, HairMax lasercomb device that appeared to emit laser light but in fact only emitted colored white light. However, none of the study participants knew if the lasercomb they were using was real or a sham.

After 26 weeks, men using the real lasercomb gained an average of 21.6 new terminal hairs/cm2 compared to an average 5.2 hairs/cm2 for men using the sham device; women using the real lasercomb gained an average of 20.4 new terminal hairs/cm2 compared to 2.9 new hairs/cm2 for women using the sham device. As a reference, the average non-balding person has approximately 220 terminal hairs/cm2.

In other words, men and women in the real lasercomb groups gained significantly more new hair than men and women who received no treatment, and men and women benefited, on average, equally from using the HairMax lasercomb.

Not only were these gains in terminal hair density for the real lasercomb groups significant, these gains were comparable to significant gains in terminal hair density seen in short-term trials of 5% minoxidil topical solution and 1 mg/day finasteride; however, the gains in this study were less than the gains seen in long-term trials of minoxidil and finasteride.

In sum, the benefit of LLLT for men and women appears equal to the benefit of hair loss medications, at least over the short term. This comparison between LLLT and hair loss medications should be of particular interest to women for whom drug treatment options are limited compared to men.

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Q: My hair is thinning, but I’ve been told I have too much existing hair to warrant a hair transplant. I heard that transplanting new hair into my thinned areas will lead to a loss of existing hair follicles. I was told to delay a hair transplant procedure until my density has further decreased. Is this true? — M.S., Maple Glen, P.A.

A: A hair transplant does not cause loss of hair follicles in the recipient area. The procedure may cause a temporary “shock” loss of the hair. Shock hair loss is a physiologic response to the trauma to the scalp which is caused by a hair transplant. Hair that is healthy is going to come back after some period of time – generally 6 months. Hair that may be near the end of its lifespan may not return. When a hair transplant is performed at the proper time, in the proper candidate, shock hair loss should just be an incidental issue.

It is possible that you simply don’t need a hair transplant at this time. If you have early thinning, it may be best treated with medication, or not at all. As you age, we will have a better idea of your thinning pattern and, at that time, a hair transplant may be more appropriate.

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Dr. Bernstein Touts Benefits Of Robotic FUE On Bloomberg TV
Dr. Bernstein discusses the ARTAS Robot for FUE

Dr. Bernstein spoke with Bloomberg’s Matt Miller about the future of hair transplantation in a segment called, “The Bald Economy: Surgical Solutions to Hair Loss.”

Here is an excerpt from the segment:

Bloomberg’s Matt Miller: Riding the wave into the future happens to be one of the pioneers of FUE, Dr. Robert Bernstein.

Dr. Bernstein: “The robot now allows a mechanized system to do [follicular unit extraction] very, very quickly and very consistently, so that the human error in this part of the procedure is now gone.”

Matt Miller: That’s right, a robot. Dr. Bernstein is piloting a high-tech solution called ARTAS.

Dr. Bernstein: “What it is very precise at doing is getting around the follicular unit to separate it from the tissue.”

Matt Miller: The procedure, which costs twice as much as the standard surgery, has one clear advantage.

Dr. Bernstein: “The difference is, in the back, in the area where we take the hair, there will be little tiny dots that just fade into the scalp.”

Read more about the ARTAS Robot for FUE and Robotic Hair Transplantation

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Q: I am 24 years old and just starting to thin. I was told by another doctor that it was too early to have a hair transplant, but the hair on the back and sides of my scalp seems really thick. Shouldn’t I have a hair transplant now, just in case I am not a candidate in the future? — A.S., Cherry Hill, NJ

A: The most important criteria in determining who will be a candidate for a hair transplant is the presence of sufficient permanent donor hair. When hair loss is early, it is often hard for the doctor to determine this, since early on the donor area can appear very stable. It is not until the front and/or top of the scalp has significant thinning that the donor area may also show thinning. Therefore, it is only at this time that the stability of the donor area can adequately be assessed.

It has been argued, that one should have a hair transplant early, before the donor area can thin. This is not a reasonable argument, since doing a hair transplant early, does not make the donor hair more permanent. If the donor area is not stable, the transplanted hair will continue to thin after it has been moved to the new location. This will cause the hair transplant to gradually disappear and also risk the donor scar from becoming visible as the hair covering it continues to thin. This problem can affect patients undergoing both FUT and FUE procedures.

Age itself is another factor to consider. The donor area in young people almost always appears adequate. However, the older a person is, the more likely he/she will show donor changes. Therefore, the older a person is, the more confident we are of donor area measurements being accurate. In very general terms, it is very difficult to assess the permanency of one’s donor area in patients under 25 year of age.

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Q: Can I tell before I start to bald if I will be a candidate for a hair transplant. — T.E., New York, NY

A: Usually not. The main reason one is either a candidate or not is the stability (permanency) of the hair in the back and sides of ones scalp – the donor area. Since the top of the scalp usually thins first, if the top has not started to thin, the donor area will always appear to be OK. It is only when you have significant thinning on the front or top of your scalp can we actually begin to assess the stability of the donor area with any degree of accuracy.

Read more about how a hair transplant physician evaluates a candidate for hair transplant.

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Q: I have read that in the evaluation of a patient for hair restoration surgery some doctors use a densitometer to measure miniaturization – the decrease in size of hair diameters. I read that miniaturization is a sign of genetic hair loss, but when there is miniaturization of greater than 20% in the donor area, a person may not be a good candidate for hair transplants. Is this correct and does 20% miniaturization mean that 20% of the population of terminal hairs have become fine vellus-like hairs or that there is a 20% decrease in the actual diameter of each of the terminal hairs? — B.A., New Albany, Ohio

A: Miniaturization is the decrease in hair shaft length and diameter that results from the action of DHT on healthy, full thickness terminal hairs. The hairs eventually become so small that they resemble the fine, vellus hair normally present in small numbers on the scalp and body. Miniaturized hairs have little cosmetic value. Eventually miniaturized hairs will totally disappear. Twenty percent miniaturization refers to the observation, under densitometry, that 20% of the hairs in an area show some degree of decreased diameter.

In the evaluation of candidates for hair transplantation, we use the 20% as a rough guide to include all hairs that are not full thickness terminal hairs. Of course we are most interested in the presence of intermediate diameter hairs — i.e. those whose diameters are somewhere between terminal and vellus and are clearly the result of DHT. I don’t know if one can tell the difference on densitometry between vellus hairs, fully miniaturized hairs and senile alopecia. The partially miniaturized population is most revealing.

Miniaturization in the recipient scalp (i.e. the balding areas on the front top and crown that we perform hair transplants into) is present in everyone with androgenetic hair loss. Miniaturization in the donor area, however, is less common (in men). It means that the donor area is not stable and will not be permanent. Men with more than 20% of the hair in the donor area showing miniaturization are generally not good candidates for hair transplant surgery.

Read about Miniaturization
Read about Candidacy for Hair Transplant Surgery

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