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Recipient Site Creation at Bernstein MedicalDr. Bernstein creating recipient sites using the ARTAS robot

Hair transplant pioneer Dr. Robert M. Bernstein and his colleague Dr. William R. Rassman have received a patent on a new method that improves the outcome of Follicular Unit Extraction (FUE) — the type of procedure used in half of all hair transplants performed world-wide. The key invention is the addition of a delay between the creation of recipient sites and the insertion of follicular units into those sites. The delay allows the healing process to commence before grafts are inserted, resulting in increased success of the transplant and an improved outcome.

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

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

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

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

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

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

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

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Q: What is the main difference between hair transplants using the robot versus other procedures? — M.P., Flatiron, NY

A: There are two basic types of hair transplant procedures, Follicular Unit Transplantation (FUT or strip surgery) and Follicular Unit Extraction (FUE).

In FUT, donor hair is harvested by removing a long thin strip from the back of the scalp. Individual follicular units are then obtained from this strip using stereo-microscopic dissection. In FUE, individual follicular units are harvested directly from the donor area using a sharp, round cutting instrument.

The ARTAS Robotic System performs the follicular unit isolation step of an FUE procedure and can also create recipient sites according to specifications determined by the hair restoration surgeon. In performing each of these steps, the robot uses its image-guided technology to locate the next target and position the cutting instrument, and it does so with precision and speed that cannot be accomplished using manual FUE techniques or instruments.

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CBS News Report On Robotic FUE Features Dr. BernsteinDr. Bernstein was featured in a CBS News report on robotic hair transplantation. During Dr. Max Gomez’s visit to the Bernstein Medical – Center for Hair Restoration, Dr. Bernstein discusses with Dr. Gomez the difference between FUT and FUE hair transplants, how the robotic system works, and the benefits of extracting hair follicles using robotic FUE rather than by traditional hand-held methods.

Read a transcript of the piece:

CBS 2 News Anchor Chris Wragge: These days we’ve seen robots doing everything from vacuuming our floors to building cars. You may have even had surgery done with the help of a robot. But what about something personal and cosmetic like a hair transplant? Our Dr. Max Gomez tells us about a robot doing just that.

Dr. Max Gomez: Well that’s right Chris. Now first we should make clear that robots in medicine don’t act alone, at least not yet. They’re always under the direction of a doctor. Now, that said, what robots are really good at are tedious, repetitive tasks that need to be done quickly and accurately. Something like a hair transplant.

Dr. Gomez: A full head of hair is called a person’s “crowning glory”. Sure, going bald is a common fashion statement, but most people are like Sam.

Sam, Hair Transplant Patient: I wanted more hair on my head, obviously, and I didn’t want to be bothered with any of the other treatments that are available.

Dr. Gomez: For Sam that meant a hair transplant, where donor hair follicles are taken from the back of the head and transplanted to the thinning areas, usually on top or the former hairline.

Dr. Robert M. Bernstein: The hair on the back and sides of the scalp are not effected by the same genetic process that the hair on the top of the scalp is.

Dr. Gomez: That donor hair is typically taken from a strip of scalp that is cut out and then sutured closed, but that’s not the best choice for everyone.

Dr. Bernstein: Some patients, who want to wear their hair very short, that line can be a problem. Also, there are some people who are at risk of having a wider scar.

Dr. Gomez: The solution is to randomly extract individual follicular units, small groups of one to four hairs.

Dr. Bernstein: The procedure is very labor intensive and you have to do thousands of these in a single session.

Dr. Gomez: Enter the ARTAS robot. It’s a sophisticated hair mapping and extraction system. Once the donor area is identified, the robot maps all of the follicles, and then randomly extracts them with a series of punches. It can even tell the angle the hair is growing at to avoid damaging it.

Dr. Bernstein: It is much more precise than the human hand. It doesn’t tire if you’re doing thousands of grafts. It’s the same every single time.

Dr. Gomez: And here’s the result a few weeks later. Even with short hair, the random extraction means it’s virtually impossible to tell where the donor hairs came from.

Now, the rest of the transplant procedure is pretty much the same as without the robot. That’s where the art comes in. Deciding where, how many, how dense, and at what angle the donor hairs are inserted, that’s what makes a hair transplant look natural. And a well-done transplant is amazingly natural.

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Q: I am so confused reading about FUT and FUE on all the blogs. Can you please tell me which is better, FUT or FUE? — M.T., East Brunswick, NJ

A: FUT (via strip) will give the best cosmetic results (more volume) since the grafts are of better quality (when using microscopic dissection, there is less transection and more surrounding tissue to protect the grafts) and better graft selection (the grafts can all be harvested from the mid-portion of the permanent zone).

In contrast, in FUE you need approximately 5 times the area. Because of this large donor area requirement, some of the hair must be harvested from fringe areas and thus the hair will be less stable genetically.

With subsequent FUT procedures we remove the first scar, so the patient only has one scar (albeit long). With subsequent FUE sessions we are adding additional scars, so over the long-term the cumulative scarring over large areas can present its own problems of visibility.

The main advantage of FUE is to have the option of wearing your hair very short (but not shaved). FUE is also appropriate for patients who are at risk for a widened donor scar (i.e., very athletic and muscular or with thin, tight scalps, etc.).

In my experience, Robotic Hair Transplantation is superior to other FUE methods in that it is much more accurate and more consistent. It enables the doctor to extract grafts with less damage than with hand-held instruments or other automated devices.

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Q: What does the hair transplantation process do to your existing hair? — R.V., London, UK

A: When we perform hair transplant surgery, we transplant into an area that is either bald or has some existing hair. The hair that is existing is undergoing a process called miniaturization. What this means is that the hairs are continuing to decrease in size – both in diameter and in length. When we perform a hair transplant, we don’t transplant around the existing miniaturized hair on your scalp, we transplant through it. And the reason why we do that is because the miniaturized hair, the fine hair that is being affected by DHT, is eventually going to disappear, so you don’t want there to be any gaps.

So the question is, does the hair transplant actually destroy the existing hair? The answer is that it doesn’t destroy, but it can “shock” it. In other words, creating recipient sites (that the grafts are placed into) will temporarily alter the local circulation of the scalp and this can cause some of the hair in the area to be shed. The reason why hair may be shed is that hair is naturally cyclical. In other words, hair is normally growing, shedding, and then regrowing again. When you stress the scalp, the growing hair may be shed prematurely, but then it regrows.

If you think about the process of electrolysis, it makes sense that you don’t damage follicles from making recipient sites during a hair transplant procedure. In electrolysis used to treat unwanted hair, you stick a needle in the follicle, and you turn on an electric current. And you burn it. And then what happens to the hair? It usually comes back and you need to do it a few more times, even though we are applying an electric current via a needle placed directly in the follicle. So it makes sense that by just inserting a fine needle – the tool commonly used to make a hair transplant site – into the skin, one would not destroy hair follicles. However, the cumulative effect of making hundreds or thousands of recipient sites does shock the follicles and, as a result, some may shed their hair.

It can occur with general anesthesia – when the scalp is not even touched – and it can occur with oral medications, from pregnancy, or after psychological stress. So if you have hair restoration surgery and there is shedding, and it takes six months to a year for the transplanted hair to grow in, during this time hair transplant patient will experience some thinning. Since miniaturized hair is going to eventually disappear anyway, some of the miniaturized hair that is shed may not return. But if it is healthy hair, and it is shed, it will grow back. And, of course, the transplanted hair will be growing in as well during this time.

I am often asked to describe how much can be expected to be shed. The answer is that it is an amount that is often noticeable by the patient, but not noticeable by anyone else.

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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.

NY Magazine - Best Doctors - 2011

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.

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Robert M. Bernstein, M.D., F.A.A.D., Renowned Hair Transplant Surgeon and Founder of Bernstein Medical – Center for Hair Restoration in New York, is Studying Four Applications of ACell MatriStem™ Extracellular Matrix in a Type of Hair Cloning, Called Hair Multiplication, as well as in Current Hair Restoration Procedures.

New York, NY (PRWEB) March 15, 2011 – Robert M. Bernstein, M.D., F.A.A.D., Clinical Professor of Dermatology at Columbia University in New York and founder of Bernstein Medical – Center for Hair Restoration, has been granted approval by the Western Institutional Review Board (WIRB) to study four different applications of the ACell MatriStem extracellular matrix (ECM) in hair restoration.

Hair Cloning with ACell MatriStemHair Cloningwith ACell MatriStem

Two of the studies include its use in a type of hair cloning, called hair multiplication, where plucked hairs and transected follicular units are induced to generate new hair-producing follicles. The other two areas of study include evaluating the use of the ECM in current hair transplant procedures to enhance hair growth and facilitate wound healing.

Approval by the WIRB allows the researchers to conduct double-blinded, bilateral controlled studies. Controlled studies are the best way to increase the objectivity of the research and insure the validity of the results.

“The medical research we are performing is important because it may lead to hair multiplication as a way to increase a person’s supply of donor hair. In this way, patients would no longer be limited in the amount of hair which can be used in a hair restoration procedure,” said Dr. Bernstein. “Additionally, in the near-term, the extracellular matrix may be able to improve the cosmetic benefit of current hair transplant procedures. We are simultaneously pushing the boundaries of hair cloning methods and follicular unit transplantation.”

Hair multiplication, a variation of what is popularly known as hair cloning, is a procedure where partial hair follicles are stimulated to form whole follicles. These parts can either be from hairs derived from plucking or from follicles which have been purposely cut into sections. Generally, damaged follicular units will stop growing hairs. However, there is anecdotal evidence that an extracellular matrix applied to partial follicles may stimulate whole follicles to grow and, when applied to wounds, may stimulate the body’s cells to heal the damaged tissue.

This new medical research also attempts to show that ACell can improve the healing of wounds created when follicular units are harvested for hair transplant surgery. Currently, in follicular unit hair transplant procedures, a linear scar results when a surgeon incises the patient’s scalp to harvest follicular units. Occasionally, this scar can be stretched, resulting in a less-than favorable cosmetic result. If ECM can induce the wound to heal more completely, the linear scar may be improved. The extracellular matrix may also benefit general hair growth in hair transplantation in that the sites where hair is transplanted, called recipient sites, can be primed with ECM to encourage healthy growth of the hair follicle.

Dr. Bernstein is known world-wide for pioneering the hair restoration procedures of follicular unit transplantation (FUT) and follicular unit extraction (FUE). Follicular units are the naturally-occurring groups of one to four hair follicles which make up scalp hair. These tiny structures are the components which are transplanted in follicular unit hair transplants.

While hair cloning has been of great interest to hair restoration physicians and sufferers of common genetic hair loss, the method by which this can be achieved has yet to be determined. The use of ACell’s extracellular matrix to generate follicles is a promising development in achieving this elusive goal. In addition to the longer term implications of using ECM in hair multiplication, its impact on hair restoration will be more immediate if it can be proven effective when used in current FUT procedures.

About Dr. Robert M. Bernstein:

Dr. Bernstein is a certified dermatologist and pioneer in the field of hair transplant surgery. His landmark medical publications have revolutionized hair transplantation and provide the foundation for techniques used by hair transplant surgeons across five continents. He is respected for his honest and ethical assessment of a patient’s treatment options, exceptional surgical skills, and keen aesthetic sense in hair transplantation. In addition to his many medical publications, Dr. Bernstein has appeared as a hair loss or hair transplantation expert on The Oprah Winfrey Show, The Dr. Oz Show, Good Morning America, The Today Show, The Discovery Channel, CBS News, Fox News, and National Public Radio; and he has been interviewed for articles in GQ Magazine, Men’s Health, Vogue, the New York Times, and others.

About Bernstein Medical – Center for Hair Restoration:

Bernstein Medical – Center for Hair Restoration is a state-of-the-art hair restoration facility and international referral center, located in midtown Manhattan, New York City. The center is dedicated to the diagnosis and treatment of hair loss in men and women. Hair transplant surgery, hair repair surgery, and eyebrow transplant surgery are performed using the follicular unit transplant (FUT) and follicular unit extraction (FUE) surgical hair restoration techniques.

Contact Bernstein Medical – Center for Hair Restoration:

If you are a journalist and would like to discuss this press release, please email us or call us today (212-826-2400) to schedule an appointment to speak with Dr. Bernstein.

View the press release at PRWeb.

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Q: Is it correct that the hair transplant surgery lasts about eight hours or if there is a range, what is that generally? — M.R., Montclair, NJ

A: The range is about 5 to 8 hours. For a completely bald person, it would be in the higher range. Keep in mind that the person is just relaxing, watching TV or dozing off. The time goes by quickly for the patient. Since there is no general anesthesia, there is no medical risk for this relatively long procedure.

To review the procedure in more detail, please visit our Overview of FUT Hair Transplant Procedure section; which includes details for before, during, and after the hair transplant. View the Overview of FUE Hair Transplant Procedure section for details on the follicular unit extraction procedure.

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Q: Dr. Bernstein, I think that you have established a great monument in the history of hair transplantation. Especially, your historical works about Follicular Unit Transplantation, which you published about 15 years ago, have contributed greatly to the spread of modern hair transplant technique in the whole world.

In the past days, there might have been many physicians who did not care much about the importance of the follicular unit and they have only cut the grafts to size. Now, every hair transplant physician believes the importance of follicular unit, and there is no one who cut the grafts to size ignoring each follicular unit.

However, there are some physicians who shout that a hair transplant procedure can be called FUT only when people use all single FU exclusively, and the procedure cannot be called FUT, if mixture of single FU and double FU are used in a session.

I would like to ask you, if you could accept the usage of combination of single FU and double FU under the name of FUT, as long as the grafts were cut according to each FU and intact FU are used throughout the procedure. Could you accept easing of the very strict definition of FUT, which you published about 15 years ago? Could you agree to use mixture of single FU and double FU under the name of FUT? — N.W., Huntington, N.Y.

A: Thank you for the kind words. In thinking about hair transplantation in general, it is important to consider that a hair restoration procedure spreads hair around and, as a result, the transplanted hair will be less dense than the person’s original hair. Therefore, one would never want grafts larger than the largest original follicular units or the results will not look natural. The artificially large grafts will stand out in relatively thin surroundings. If one were to try to fix this by transplanting the doubled FUs very close together (over one or more sessions) one risks running out of grafts for other areas of the scalp. In other words, you can’t fool mother nature.

For example, if a person has thin hair and has only 1-, 2- and 3-hair units occurring naturally in his scalp, then creating 4-hair grafts (by combining two 2’s or 1’s and 3’s) can result in an unnatural, tufted look. Doubling larger follicular units also necessitates larger wounds to receive the grafts which defeats one of the main advantages of FUT, namely to minimize recipient wounding.

That said, it is not unreasonable to place two 1-hair FUs in a single site (if there are extra 1s from the FU dissection) in order to increase density in an area and to eliminate an extra wound.) We do this for crown hair transplants when we are not doing a hairline and there is no need for 1-hair grafts. However, this is the exception.

Technically speaking, anything other than transplanting individual, naturally occurring follicular units is not FUT. However, a physician should make modifications to the procedure for the specific needs at hand. This is the art of medicine. By understanding and applying the underlying principles of Follicular Unit Transplantation, rather than being limited by its nomenclature, the physician will serve his patient best.

In addition to exploring Hair Restoration Answers to learn more about this topic, visit the Follicular Unit Transplant (FUT) section of our website and read detailed information about the hair transplant evaluation, the hair restoration procedure, follicular unit grafts, the donor area, and more.

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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.

They showed a film of me performing a follicular unit hair transplant and then brought the actual patient in the video on stage for a look at the results of his procedure.

Watch a video clip of Dr. Bernstein discussing hair restoration with Oprah Winfrey and Dr. Mehmet Oz in our Hair Transplant Video section.

For more information on Dr. Bernstein’s appearance, read the press release, “Pioneering Hair Transplant Doctor Explains Procedure on Oprah Winfrey Show“.

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Q: I am scheduled to have a hair transplant next month and wonder if I should do scalp exercises before the procedure? — G.F., Providence, R.I.

A: For the majority of patients, scalp exercises are not necessary.

The scalp in the donor area has a fair amount of redundancy. With a properly planned hair transplant, the donor area will close relatively easily.

If a patient’s scalp is particularly tight, or if a very large session is planned (even in the face of an average scalp), vigorous scalp exercises are useful in increasing laxity.

The advantage of stretching one’s scalp prior to surgery is that it allows the doctor to remove a slightly wider strip and it decreases tension on the closure so the person will heal with a potentially finer scar.

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Columbia University Medical CenterColumbia University Medical Center has awarded Dr. Bernstein, Clinical Professor of Dermatology, a “Certificate of Appreciation” for sustained contributions to the academic programs of the Department of Dermatology, Columbia University. Please read below for the Bernstein Medical – Center for Hair Restoration press release and a transcript of an interview with Dr. Bernstein on receiving the honor:

Press Release:

New York, NY (PRWEB) October 2, 2008 — Columbia University Medical Center awarded their Certificate of Appreciation to Robert M. Bernstein, MD, founder of Bernstein Medical – Center for Hair Restoration for his sustained contributions to the academic programs of the Department of Dermatology at Columbia University.

Dr. Bernstein specializes in hair loss and hair transplant surgery. He was instrumental in developing the Follicular Unit Hair Transplant procedure, now considered the most advanced technique for surgical hair restoration. This procedure has revolutionized modern hair transplantation, with its unique ability to mimic natural hair growth patterns in the scalp.

In the past, multiple, small procedures were an inefficient way to restore a person’s hair. Using these new techniques, we now have the ability to transplant 3000 or more follicular units safely in one session.

“With respect to medical feasibility, follicular hair transplant surgery is significantly different from traditional grafting,” notes Dr. Bernstein. “In the past, multiple, small procedures were an inefficient way to restore a person’s hair. Using these new techniques, we now have the ability to transplant 3000 or more follicular units safely in one session.”

The complex nature and microscopic scale of the Follicular Unit Hair Transplantation procedure require superior surgical precision. Dr. Bernstein is well known for his surgical skill and talent; he has been named in New York Magazine’s “Best Doctors” list 9 years in a row.

In addition to his world-renowned skill in the field of hair replacement surgery, Dr. Bernstein is also acclaimed for the care that he provides for his patients. Dr. Bernstein and the rest of the staff at the Bernstein Medical Center for Hair Restoration aim to provide their patients with the best possible care and comfort during their hair transplant procedure. Their award winning website www.bernsteinmedical.com is recognized for providing outstanding health information.

Columbia University is one of the world’s most important centers of medical research and distinguished learning environment for undergraduates and graduate students in many scholarly and professional fields. The University recognizes the importance of its location in New York City and seeks to link its research and teaching to the vast resources of a great metropolis. It seeks to attract a diverse and international faculty and student body, to support research and teaching on global issues, and to create academic relationships with many countries. It expects all areas of the university to advance knowledge and learning at the highest level and to convey the products of its efforts to the world.

About Dr. Bernstein:

Dr. Bernstein is the most widely published author on the subject of Follicular Unit Hair Transplantation, with over fifty articles, editorial reviews, books and textbook chapters. His landmark scientific papers are considered to be seminal works in the field of hair transplant surgery. In addition to a busy surgical practice, Robert M. Bernstein, MD, is Clinical Professor of Dermatology at Columbia University in New York. He lectures both nationally and internationally on the diagnosis and treatment of hair loss and treats patients from all over the globe at his state-of-the-art surgical facility in mid-town Manhattan.

Interview:

Interviewer: I am here today with Dr. Robert M. Bernstein, founder of the Bernstein Medical – Center for Hair Restoration. Dr. Bernstein is the recipient of the “Platinum Follicle Award” the highest honor given by the International Society of Hair Restoration Surgery. He has been chosen as one of New York Magazine’s “Best Doctors in New York” for nine consecutive years. Good morning Dr. Bernstein.

Dr. Bernstein: Good morning.

Interviewer: Dr. Bernstein, I understand you have recently been awarded a Certificate of Appreciation from Columbia University in New York.

Dr. Bernstein: Yes, I have been teaching at Columbia for 25 years. I was very honored to receive it.

Interviewer: Could you tell us about it?

Dr. Bernstein: The certificate is for the contributions that I have made to the academic programs of the Department of Dermatology.

Interviewer: You specialize in hair replacement and hair transplant surgery, and you were instrumental in developing the Follicular Unit Hair Transplantation procedure. Why don’t you tell us a little bit about this procedure and how you came up with the idea?

Dr. Bernstein: Sure. The Follicular Unit Hair Transplantation procedure is based on the discovery that in humans, hair does not grow singly as one commonly thinks, but rather, in tiny bundles of one to four hairs. We call these bundles follicular units. While evaluating patients for surgery using an instrument called a densitometer we could easily visualize these naturally occurring groups. It just made sense to perform the entire transplant using these tiny follicular units, as it would allow us to most closely mimic nature. We found that it also would enable us to safely transplant thousands of grafts in a single session and, for the patient, to complete the hair restoration as quickly as possible.

Interviewer: Interesting. I understand you not only use your knowledge in practice, but you are the most widely published author on this subject.

Dr. Bernstein: It is through publishing in medical and scientific journals that we can best share our ideas with our colleagues and ultimately improve patient care.

Interviewer: Is there a website where listeners can find these papers and learn more about the procedure and other information about hair loss?

Dr. Bernstein: Yes. If they go to the Bernstein Medical – Center for Hair Restoration website they will find links to all of my medical publications. The site has my blog and a lot of other useful information for persons who are experiencing hair loss.

Interviewer: Well, again congratulations, it was good to have you on the program.

Dr. Bernstein: Thank you.

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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.

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Q: Why are strips used so much in a hair transplant when there is now Follicular Unit Extraction (FUE)? — E.N., Long Island, N.Y.

A: Strip harvesting is used in the majority of hair transplant procedures because it allows the surgeon the ability to perform hair transplant sessions using large numbers of grafts while minimizing injury to the patient’s hair follicles.

This is possible because once a strip is removed from the back of the scalp, the tissue can be placed under a stereomicroscope where dissection is accomplished using direct visualization of the follicular units. This allows the grafts to be dissected with minimal trauma.

This degree of accuracy is not possible with other hair restoration techniques, such as FUE, where the separation of follicular unit grafts from the surrounding tissue is accomplished “in vivo” (directly from the scalp).

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Q: I have read about something called “tumescent anesthesia” but didn’t understand what it is. What exactly is it? — S.S., Hoboken, N.J.

A: Tumescent techniques were first popularized in liposuction surgery where large quantities of fluid containing adrenalin were injected into the person’s fat layer to decrease bleeding before the fat was literally sucked out of the body. Bleeding was minimized because the epinephrine (adrenaline) constricted blood vessels and the fluid compressed the blood flow in the smallest blood vessels called capillaries.

The technique allowed small liposuction procedures to be performed safely as an out-patient procedure. In surgical hair restoration, low concentrations of anesthetic fluid and adrenaline are injected into the fat layer in the back of the scalp.

In a hair transplant, besides decreasing the bleeding, the fluid makes the skin more rigid so that the incision can be more easily made without cutting hair follicles. It also helps the doctor avoid damage to the deeper blood vessels and nerves in the scalp.

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Q: Can hair be transplanted from one person to another? M.Y. – Hoboken, New Jersey

A: A hair transplant between individuals can only be performed on identical twins, since they are genetically the same.

In all other cases, including non-identical siblings, the transplanted hair will be rejected.

We are often asked how it is that one can perform kidney transplants from one person to another, but not hair transplants. The reason is that the skin is more antigenic than a kidney i.e. it is more likely to be rejected. The reason is complex, but this makes sense considering that the skin is the first line of defense against foreign organisms.

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Q: After a strip procedure, will the scalps laxity return to normal and how long after the hair transplant does it take? C.B. – Roanoke, Virginia

A: The scalp regains most of its laxity in the first eight months following the hair transplant, but it will continue to loosen slightly after that.

It is interesting that if the scalp is tight prior to surgery, the scalp is less likely to have its full laxity return than in patients who had loose scalps to begin with. With average or loose scalps, there is usually no difference. However, over time, the patient rarely, if ever, notices any permanent tightness unless aggressive procedures have been performed or procedures such as scalp reductions and lifts.

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Q: Is it possible to tell me roughly how many grafts would be left from donor area if one had a hair transplant of 2,500 grafts and had a density of around 2.0? G.H. – New York, NY

A: How much hair can be harvested in total depends upon a number of factors besides donor density. These include: scalp laxity, hair characteristics (such as hair shaft diameter, color and wave), and the actual dimensions of the permanent zone.

Every person is different, so all of these factors would need to be taken into account to determine the total number of grafts that would be available for the hair restoration.

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Dr. Bernstein was featured in an article in GQ Magazine on hair transplantation. The article, written by Peter Rubin is entitled, “Grow Your Own.”

Here is a brief synopsis of the article:

GQ: After fifty years of bad plug jobs, we’ve come to regard “hair restoration” as synonymous with “Astroturf head.” Today’s hair transplant procedures are worlds away from the butcherings of old. So forget what you thought you knew.

Two methods of hair restoration are in wide usage: mini-micrografting and follicular unit transplantation. The methods are similar, to an extent, but FUT; co-developed by New York hair transplant surgeon, Robert M. Bernstein, M.D.; is the more advanced of the two procedures, producing cosmetically superior results.

Dr. Bernstein: Anatomically, follicular unit transplantation is the end of the line. The next step would be hair cloning, which is still quite a way off. The way you get the most amount of hair into the smallest wound — and ensure that it’s going to look natural — is by using a follicular unit transplant. We can create swirls, add sideburns… The beauty of follicular transplantation is that the hair will take on the old wave that the original hair had.

GQ: The best part is that FUT regularly achieves an extraordinarily high success rate, meaning nearly every single transplanted graft takes root and grows properly – unheard of fifteen years ago.

Pierce Mattie, a 28-year-old publicist in New York City, had an FUT procedure in May and couldn’t be happier. “I’ve had dental fillings that were more painful,” he says. “I was back in the office two days later, and my hair looks like it did when I was in high school. Everyone keeps saying, ‘You look so great!’—but they have no idea what I had done.”

About GQ Magazine: For nearly half a century, with 854,000 subscribers and 4 million readers, GQ has been a leading voice in men’s magazines, covering men’s style and culture from fashion and politics to travel, entertainment, sports, technology and relationships. GQ has been nominated for 27 National Magazine Awards.

Reference
“Grow Your Own,” GQ Magazine, November 2003, p173-4.

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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

Skin & Allergy News - Microscopic Dissection Offers Superior Yield

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 Microscopic Dissection of follicular unitsCollege 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.

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