Strategies for Follicular Cell Implantation

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Strategies for Follicular Cell Implantation

by Jeff Teumer, PhD
Hair Transplant International Forum, Volume 18, Number 3, May/June 2008

Follicular cell implantation (FCI) is based on the ability of the dermal papilla (DP) cells, found at the bottom of hair follicles, to stimulate new hairs to form. DP cells can be grown and multiplied in a culture so that a very small number of cells can produce enough follicles to cover an entire bald scalp.

In order to produce new follicles, two types of cells must be present. The first is Keratinocytes, the major cell type in the hair follicle, and the second are dermal papillae cells (DP) which lie in the upper part of the dermis, just below the hair follicle. It appears that the DP cells can induce the overlying keratinocytes to form hair follicles. There are a number of proposed techniques for hair regeneration that use combinations of cells that are implanted in the skin. The two major techniques involve either transplanting dermal papillae cells by themselves into the skin or implanting them with keratinocytes. These techniques can be used with or without an associated matrix used to help orient the newly forming follicles.

Implanting Dermal Papillae Cells Alone

Implanting DP cells by themselves into the dermis, with the hope that they will cause the overlying skin cells (keratinocytes) to be transformed from normal skin cells into hair follicles. This method is called “follicular neo-genesis” since new hair is formed where none previously existed.
Cells of the dermal papillae are placed alongside miniaturized follicles. The transplanted cells would induce the keratinocytes of the miniaturized follicles to grow into a terminal hair. A potential advantage of this technique is that the existing miniaturized follicles already have the proper structure and orientation to produce a natural look growth.

Implanting Dermal Papillae with Keratinocytes

A mixed suspension of cultured keratinocytes and DP cells are implanted into the skin.
Keratinocytes and DP cells are cultured together such that full or partial hair formation takes place in a culture dish. These culture-grown hairs, or “proto-hairs,” are then implanted into the patient. The advantage of using a proto-hair is that there would be better control over the direction of hair growth because of the structural orientation of the proto-hair.

Cell Implantation using a Matrix

A variation of the above techniques is to use a matrix to help orient the implanted cells. This could be either an artificial matrix composed of materials such Dacron or it could be a biological matrix composed of collagen or other tissue components. The matrix would act like a scaffold to help cells organize to form a follicle. If the matrix were filamentous (like a hair) it could help direct the growth of the growing follicle. A matrix could be used with dermal papillae cells alone or in combination with cultured keratinocytes.

With all of the varied approaches for FCI, the aim is to combine keratinocytes and DP cells to efficiently and reproducibly generate thousands of follicles for hair restoration. In some cases, cells are combined in vivo and all of the hair formation must take place in the body after implantation, while in others, some hair formation takes place in culture before implantation.

Posted by Robert M. Bernstein M.D.

New Methodology and Instrumentation for Follicular Unit Extraction

In this paper, Dr. James Harris presents a blunt tip instrument to be used in a 3-step FUE hair transplant procedure. The instrument is described as a 1-mm dissecting punch that has a tapered blunt edge. After scoring the skin with a sharp punch, the dissecting punch is advanced to a depth of approximately 4-mm.

This instrument is similar to the one recently described by Bernstein and Rassman in New Instrumentation for Three-Step Follicular Unit Extraction, recently published in Hair Transplant forum International New Instrumentation. Dr. Bernstein’s instrument was, in turn, based upon ideas presented in a paper written by Dr. Harris in 2004.

Although Follicular Unit Extraction (FUE) has potential advantages, such as faster surgical recovery, less postoperative discomfort, less noticeable scarring, and possible expansion of the hair transplant patient’s donor area, the acceptance of the technique is limited because it is technically demanding, has limited patient candidacy, and can potentially result in high rates of follicle transection. There are also problems of buried grafts, the inability to transplant large sessions at one time and inefficient use of the mid-portion of the donor area. The proposed methodology and instrumentation may allow more widespread use of the technique.

In the current study, using the SAFE System for surgical hair restoration, the average follicle transection rate was 6.14%, with a range of 1.7 to 15%. The only adverse reaction was the occurrence of two buried grafts, resulting in inflammatory subcutaneous cysts requiring excision.

Dr. Harris calls the procedure using this instrument, the SAFE (Surgically Advanced Follicular Extraction) System. Interestingly, in an editorial commentary by Dr. Walter Unger that follows this article, Dr. Unger suggests that the SAFE system should be more appropriately called the “SAFER technique,” since it is better than traditional 2-step FUE, but it has not eliminated the issue of follicular transection or some of the other problems of follicular extraction.

Harris JA. New Methodology and Instrumentation for Follicular Unit Extraction: Lower Follicle Transection Rates and Expanded Patient Candidacy. Dermatol Surg 2006; 32: 56-62

Posted by Robert M. Bernstein M.D.

Instrumentation for Three-Step Follicular Unit Extraction

Robert M. Bernstein, M.D.
Associate Clinical Professor of Dermatology at the College of Physicians and Surgeons of Columbia University in New York

Abstract of Dr. Bernstein’s presentation at the International Society of Hair Restoration Surgery, 2005 – Sidney, Australia

Biography

Robert M. Bernstein, M.D. is Associate Clinical Professor of Dermatology at the College of Physicians and Surgeons of Columbia University in New York. His private practice in Manhattan and Fort Lee, NJ is devoted solely to hair restoration. Dr. Bernstein is the recipient of the 2001 Platinum Follicle Award for his pioneering work in Follicular Unit Hair Transplantation. Other contributions include studies in examining the power of graft sorting for density in hair transplant surgery, graft yield by method of production, local anesthetic use, suture materials and Follicular Unit Extraction.

Introduction

The addition of a blunt dissection step in the Follicular Unit Extraction (FUE) procedure by Dr. Jim Harris has been a significant advance over the two-step technique proposed by Rassman and Bernstein. In this new three-step procedure, a sharp punch is used to score the epidermis and papillary dermis, and then a dull punch is used (through a twisting motion) to bluntly dissect the follicular unit graft from the surrounding reticular dermis. The third step, the extraction, is the same as in the two-step technique. One of the problems of FUE had been the relatively high follicular transaction in certain patients undergoing this hair restoration technique.

Rassman and Bernstein developed a simple test, the FOX test, to identify these patients in advance of the procedure, but this limited the number of patient who could undergo FUE. In addition, a significant amount of follicular transection occurred in some of those who were treated. The main advantage of the three-step technique is that it minimizes follicular transection – using the appropriate blunt instrument. The main disadvantages for this hair transplant technique are the logistics of the extra-step and the increased incidence of buried grafts.

Objective

The purpose of this study is to describe a simple instrument that can be used in the blunt dissection phase (second step) of the three-step Follicular Unit Extraction technique and to measure its effectiveness in a controlled study.

Materials and Methods

In patients undergoing hair transplantation, the hair in a 2×4 cm patch in the mid-portion of the donor area was clipped to approximately 1-mm in length and anesthetized. Ten follicular units were extracted from one half of the patch using two-step FUE and ten follicular units were extracted from the other half of the patch using the three-step technique. The two step technique was performed using a 1-mm Miltex punch and fine rat-tooth forceps. In the three step technique, a 1-mm Miltex punch was used to score the skin, a thin cylindrical stainless steel tube was used for the blunt dissection and then fine rat-tooth forceps were used for the extraction. The sides were alternated on different patients. After extraction, each graft was examined under a stereo-microscope and the following information was recorded: 1) hair characteristics; color, wave, and thickness, 2) anticipated yield – the number of hairs visible with the stereo-microscope on the surface of the extracted graft, 3) actual yield – the number of intact follicles in the follicular unit visible under the stereo-microscope. Intact hair yields and graft yields were calculated for the two techniques and compared.

Discussion and Results

In the two-step follicular unit extraction technique, proposed by Rassman and Bernstein, there was an attempt to “separate follicular units from the surrounding tissue down to the level of the mid dermis.” The rational was that because of the anatomic divergence of individual follicles as the follicular unit entered the fat, a punch that neatly encompassed a follicular unit on the surface would amputate the splayed bulbs as it cut through the deeper tissues and result in unacceptable rates of transection.

To circumvent the problem of “follicular unit splay,” they considered Inaba’s technique of removing hair from the donor area with a punch that was used to cut only part of the way down the follicle. The depth of the traditional punch (used in older hair transplant techniques) was difficult to control, however, and transection resulted in many cases. The FOX test was able to screen out the patients who were most likely to be subject to excessive transection and thus improve patient selection, but it did not improve the quality of the grafts.

The three-step FUE technique of Harris overcomes the limitation of the original technique, as the blunt tipped instrument is advanced into the dermis, splayed follicles are gathered together avoiding transection. In effect, Harris’ dull-punch technique allows a full realization of the “extraction concept.” One untoward result of the three-step technique is a possible higher incidence of buried grafts. It also adds an additional step to an already tedious hair restoration process.

There are many possible permutations of blunt instrument design. Possibly the most straightforward is to use a cylindrical instrument whose walls are thin enough to dissect though dermal connective tissue with a simple rotating movement, yet thick enough so that the advancing edge avoids follicular transection. The instrument design used in the current study will be presented. The current study confirms the advantage of the three-step procedure over the standard method of follicular unit extraction.

Conclusion

The three-step FUE technique proposed by Harris offers significant improvement over the two-step technique. The main advantage of the three-step technique for hair transplantation is that it minimizes follicular transection. The main disadvantages are the logistics of the extra-step and the increased incidence of buried grafts. A new type of blunt instrumentation is described in this study. The ideal tool design that will minimize both transection and the possibility of buried grafts still needs to be determined.

Posted by Robert M. Bernstein M.D.

Comparison of Different Instruments to Make Recipient Sites: Needles vs. Blades

David Perez-Meza, MD, Melvin Mayer, MD

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

There have been great advances in hair restoration surgery over the past decade. New surgical techniques, instruments and medications have been developed to treat patients with hair loss. Some surgeons use needles to create the recipient sites and others use blades – both groups obtaining great results. There is some controversy, however, about the “ideal” instrument to make the recipient sites.

The objective of this study was to evaluate three different blades and three different needles used to make sites in the recipient area and to compare the wound healing and hair growth after the hair transplant.

Recipient sites were made using the following instruments: 18-, 19- and, 20-gauge needles, Sharpoint 22.5º, Minde 1.3 mm and Custom blades. Each instrument was used to make sites at a depth of 4 mm and at an angle of 30-45º. Two-hair follicular units were placed in pre-made incisions.

We evaluated intra-operative bleeding from the recipient sites (bleeding makes it more difficult to place the grafts). We also examined the patient at 10 days post-op for redness, swelling and scabbing, and at 6 and 12 months for terminal hair counts.

The results showed that there were no differences between the two groups with respect to intra-operative bleeding and, at 10 days, there was similar healing for each of the instruments. In addition, at 6 and 12 months, the hair counts were similar.

Our conclusions were that all of the instruments produced similar hair growth and survival. None of the instruments produced cysts, ingrown hairs, pitting or cobblestoning. There was similar naturalness, quality of hair and cosmesis. In sum, if one uses very small instruments in the hair transplant, similar results will be observed regardless of the specific type of instrument used.

Posted by Robert M. Bernstein M.D.

Follicular Unit Growth at Four Different Hair Transplant Densities

Michael L. Beehner, M.D.
Saratoga Hair Transplant Center, Saratoga Springs, NY, USA.

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

There is a need to find the “threshold” density at which follicular unit (FU) graft recipient sites may be placed and yield excellent survival following a hair transplant. It also needs to be determined whether or not a smaller recipient site makes a difference in graft survival. This study looks at hair survival in two patients 18 months after they were each transplanted with four different densities.

The objective of the study was to determine the optimal density for “dense packing” FU grafts without causing loss of hair from vascular compromise or other factors that can affect graft growth during hair restoration surgery.

In the study, two male patients, both with Norwood Class VI patterns of hair loss, were examined. Two-hair FUs were planted respectively at densities of 20, 30, 40, and 50 FUs per cm². 19g needles were used for the boxes with 20 and 30 grafts per box, and 20g needles were used for the boxes with 40 and 50 grafts/cm². The grafts were placed using a “stick-and-place” method.

% Hair survival

Recipient Site Density	20/cm²	30/cm²	40/cm²	50/cm²
Patient I (18 Months)	95	93	70	67
Patient II (13 Months)	88	92	100	93

The author concluded that both patients had excellent growth of the transplanted hair at densities of 30/cm². However, one patient had decreased density at 40/cm² and 50/cm². Based upon this very limited study, the researcher suggested that there are probably individual factors unique to each patient which affect graft survival of transplanted hairs at high densities.

The author proposes that the patient to patient variation at high densities may be due to variations in 1) scalp thickness, vasculature (atherosclerotic changes or differences in collateral circulation), presence of past transplant work or surgery with resultant “micro-scarring”, amount of epinephrine used in recipient area, or technique and care to grafts by cutters and placers.

Posted by Robert M. Bernstein M.D.

Solution to Decrease Swelling after a Hair Transplant

Gholamali Abbasi, MD, Sepideh Pojhan, MD, Susan Emami, MD. Tehran, Iran

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

Edema of the forehead and the peri-orbital area is observed frequently after a hair transplant. To prevent this edema the authors introduced a new method (Abassi’s solution) at the 12th Scientific Meeting of ISHRS in Vancouver, Canada. The present study tries to determine if Abbasi’s solution can have a negative effect on the growth of transplanted grafts following hair restoration surgery.

In this study, the authors examined the effects of Abbasi’s solution on hair growth one year after a hair restoration procedure.

Abbasi’s Solution
Normal saline, 100cc
Epinephrine 1/1000, 1cc
Triamcinolone acetate, 40 mg

In this study, the authors injected Abbasi’s solution into one side of the bald scalp and tumescent solution in the other side. 30 FU’s (2 hairs) were transplanted to each side. Photos were taken before, immediately after surgery, and 12 months after the hair transplant. In order to evaluate the hair growth, they compared the number of transplanted hairs with the number of hairs that actually grew after 12 months.

Results:

Preventative Methods % Edema Free
Oral Steroid 47.6
I.M. Steroid 65.7
Xylocaine/Steroid Mixture 70.0
Abbasi’s solution 97.4

Results showed that for hair transplant patients who received Abbasi’s solution, 97% had no edema during the period of 2-6 days after surgery. About 95% of the implanted hairs showed regrowth after 12 months.

The conclusion was that Abbasi’s solution not only can prevent post-operative edema following hair restoration procedures but also does not show any negative effect on the growth of the transplanted hairs.

Posted by Robert M. Bernstein M.D.

Hair Curvature: An Important Factor for a Natural Looking Hairline

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.

Posted by Robert M. Bernstein M.D.

Trichophytic Closure: A New Way to Camouflage a Hair Transplant Incision

Summary of “Trichophytic Closure of the Donor Area” which appeared in Hair Transplant Forum International July/August 2005 by Mario Marzola, MBBS Norwood Australia

When hair transplant surgeons meticulously close the edges of a donor wound, they generally end up with a fine, linear scar that is approximately 1-2mm in width. Sometimes, the scar can be a bit wider and every once in a while, when the person’s connective tissue is weak, or the edges of the scar are closed too roughly or have too much tension, the scar can be a cosmetic problem. The educated patient, who has expectations of a thin scar, or the patient who is likely to wear his hair very short, hopes that their hair transplant doctor can produce scars that are practically invisible.

A Trichophytic closure is a way of improving the linear donor scars of hair transplant patients. A Trichophytic incision in hair transplantation involves trimming off the upper edge of the incision and then closing the wound in such a way the hair near the edge can grow through the scar. This has the potential to produce a scar that is virtually undetectable.

To perform a comparison study, Dr. Marzola conducted a trial using 26 consecutive patients. Each hair transplant patient had one side of their scar closed trichophytically (i.e., with the top edge removed) and the other side closed with the edge left as is.

At seven months, the study proved to Dr. Marzola that the trichophytic closure was significantly better than the traditional closure in leaving a hair transplant scar that was better camouflaged and thus less visible.

The principles of good surgical practice apply in hair transplantation as much as in any other area of surgery. Start out small, be careful and conservative, treat the tissues with respect, and above all else, avoid creating too much tension on the wound.

Summarized by Bernstein Medical, P.C.

Posted by Robert M. Bernstein M.D.

Enhancement of Follicular Unit Extraction

James A. Harris, MD.
University of Colorado, Greenwood Village, CO, USA.

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

The SAFE System for FUE provided a novel methodology and new hair transplant instrumentation to increase graft production rates, decrease follicle transection rate, and expand patient candidacy for surgical hair restoration. However, the mechanism of the interaction of the blunt dissecting punch and the dermis produced follicular unit graft burial (approximately 7.2% of attempted extractions) that slowed the extraction process during the hair transplantation and resulted in inflammatory cysts requiring surgical excision in .02% of attempted graft extractions.

The purpose of this study was to assess the efficacy of a new dissecting tip that could potentially decrease the graft burial rate and increase the graft production rate in the hair restoration. In the study, three patients received a total of 422 grafts. The protocol utilized limited sharp dissection of the epidermis (using a 1-mm punch to a depth of approximately 1.3 mm) followed by the insertion of the specially modified dull dissecting tip to its full depth of 5 mm. The follicular units were then grasped with fine forceps and removed.

The grafts represented a possible total of 1207 follicles, with 48 follicles transected. This is a follicle transection rate of 4%. In this series of 422 extracted grafts, there were 4 buried grafts with three retrieved representing a graft burial rate of .9% and a non-retrieval rate of 0.2% of total graft extractions. This is an approximately 8-fold improvement when compared to the 7.2% burial rate and 1.4% non-retrieval rates of the previously described dull dissecting punch. Subjectively, the modified tip allows for a more rapid and smoother insertion process that enhances the dissection phase of the extraction.

The improvements to the dull dissecting tip have decreased the graft burial rate, increased the graft extraction rate by decreasing the need to search for buried grafts, and allowed for a more ergonomic extraction process while producing a nominal transection rate. This will lead to time and cost savings for the physician performing hair transplantation using follicular unit extraction and allow broader acceptance by physicians and increase the availability of this procedure for patients.

Posted by Robert M. Bernstein M.D.

A New Device for Efficient Strip Harvesting

Robert S. Haber, M.D.
CASE School of Medicine, Cleveland, Ohio, USA

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

Harvesting high quality donor strips with minimal transaction remains an elusive goal for many hair transplant surgeons, particularly beginners. Hair restoration techniques that involve the use of scalpel blades demand the greatest skill and may cause significant transection. The Sandoval Score and Spread technique showed that non-traumatic dissection during hair transplantation is possible using a blunt instrument, but this technique is limited by poor ergonomics and the potential to cause tissue damage.

A new instrument for blunt dissection had been developed that is easy to use and is able to separate tissue along the natural planes of cleavage that causes minimal damage to hair follicles. This device has four sharp, staggered prongs aligned centrally and long handles developed for hair transplant procedures. This design utilizes the strong forearm muscles, as opposed to the weaker hand muscles, and distributes the spreading force over a larger area, minimizing trauma. A minimum depth scoring incision is made with a double-bladed scalpel to a depth of 1.5 mm. The device is inserted and expanded at intervals along the incision.

Fifty consecutive patients whose donor strip was harvested utilizing the device for the hair transplant were studied. It was found that the device works well for hair transplantation, producing virtually transaction free strips in approximately 90% of cases. The instrument was ineffective when the patient has very rigid tissue that did not yield to the force of the device. Standard scalpel blade excision was used in these cases.

When performing a hair transplant, there exists a natural dissection plane within the donor scalp that can be used to obtain high-quality strips with blunt dissection. This newly developed instrument is ergonomic and easily used by both experienced and beginner hair restoration surgeons.

Posted by Robert M. Bernstein M.D.

An Idea Whose Time Has Come

by O’Tar T. Norwood, MD, Oklahoma City, Oklahoma, USA
Hair Transplant Forum International (May/June 1997 issue)

Hair Transplant Forum International - May/June 1997 I just returned from visiting Dr. Bob Bernstein in New York, and was impressed with his operation and even more impressed with his thoughts, observations, and insights into hair transplant surgery. He applies scientific methods to his work, is academically honest, and has an almost eerie instinctive knowledge of hair transplant surgery. Of course he has Dr. Bill Rassman to work with, but it is still remarkable. Dr. Bernstein is best known for introducing follicular transplantation ((R. Bernstein and W. Rassman Follicular Transplantation, International Journal of Aesthetic and Restoration Surgery. Vol. 3: No 2,1995, 119-132.)) to hair transplant surgery, an idea Bob Limmer has been pushing for ten years with the use of the binocular microscope, but no one would listen to him. Dr. Limmer, however, never used the term follicular transplantation. Using the microscope, you automatically dissect the follicular units. It can’t be avoided if done properly.

The follicular transplantation concept is based on the observation that hair naturally grows in follicular units of one to four hairs, so probably the best way to transplant them is to keep them in this natural anatomical and physiological state. Dr. David Seager ((DJ Seager, Micrograft Size and Subsequent Survival, accepted for publication, Dermatologic Surgery.)) has recently shown that when the integrity of the follicular unit is maintained up to 20%, better growth occurs, making this concept of truly major importance.

We discussed many other topics, and it is interesting how he has a fresh, new look at the fundamentals of hair transplant surgery, hair growth, and anatomy and physiology of the hair follicle. Many of these ideas and concepts will appear in the upcoming special issue of Dermatologic Surgery. ((R. Bernstein and W. Rassman, The Art of Follicular Transplantation, accepted for publication, Dermatologic Surgery.))

His views on the following special subjects I find interesting:

1. Donor density: He emphasizes the importance of density, describes how to measure it, and explains how precious donor hair is. He shows that in the average patient, we can safely transplant about 50% of the available “permanent” donor hair. He does this mathematically. Dr. Bernstein and Dr. Rassman have brought measurement of density to a scientific level by using the densitometer and counting numbers of hairs in each square centimeter. I have started using this and it really works. I believe the importance of density cannot be over-emphasized. It is actually as important as the classification in patient selection and design.

2. Caliber of hair: Coarse vs. fine diameter. He believes coarse hair covers much better than fine hair. He considers not only the number of hairs but the total value of hair mass that is available for transfer. He believes that coarse hair creates the illusion of fuller coverage than fine hair can achieve.

3. Scalp – thin vs. thick: He emphasizes the importance of thickness of scalp. I have preferred thick scalps to thin scalps for years, but never was quite sure why.

4. Delayed growth: His analysis of the natural hair cycle and its relation to hair transplant surgery, I think, is brilliant. It explains what we see on a daily basis. ((R. Bernstein and W. Rassman, Delayed Hair Growth, Hair Transplant Forum International. Vol. 7: No 3, 1997.))

5. Diffuse patterned alopecia (DPA) and diffused unpatterned alopecia (DUPA):
Although I first described these years ago, I failed to recognize their importance. They are quite common in men and women. Although they have received some recognition in women, their study in men has been completely ignored. It is important to distinguish DUPA and DPA because hair transplants should probably never be done on a patient with DUPA.

6. Aging alopecia: This occurs in everyone and occasionally occurs extremely early in life, so that is important to recognize. I have watched my own hair thin over the years, and I have watched my patients’ donor hair and their transplanted hair thin over the years. Sometimes you can see through the remaining donor fringe. Dr. Bernstein describes the differences of senile alopecia, androgenic alopecia, and diffuse alopecia and their importance.

I really haven’t had time to “digest” all the new ideas I obtained from Dr. Bernstein. I haven’t had time to try all of the techniques I saw, but I am sure his influence on hair transplant surgery is going to be considerable.

Posted by Robert M. Bernstein M.D.

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Hair Transplant

Strategies for Follicular Cell Implantation

New Methodology and Instrumentation for Follicular Unit Extraction

Instrumentation for Three-Step Follicular Unit Extraction

Comparison of Different Instruments to Make Recipient Sites: Needles vs. Blades

Follicular Unit Growth at Four Different Hair Transplant Densities

Solution to Decrease Swelling after a Hair Transplant

Hair Curvature: An Important Factor for a Natural Looking Hairline

Trichophytic Closure: A New Way to Camouflage a Hair Transplant Incision

Enhancement of Follicular Unit Extraction

A New Device for Efficient Strip Harvesting

An Idea Whose Time Has Come

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