Bernstein Medical - Center for Hair Restoration - Recipient Site Healing
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Q: I’ve read some information on your website about donor area scarring from FUT and FUE. Since I wear my hair longer in the back, I am not really concerned about that. But what about the recipient area where my hair is thin? Are any scars visible in the recipient area after a hair transplant? How long after a hair transplant will you be able to see redness, marks, or scars on the top of my scalp? — A.N., Chicago, IL

A: The marks and redness from a hair transplant should fade in about 10 days, although there is significant patient to patient variability. The tiny recipient sites that we use prevent visible scarring, pitting, or other surface irregularities as a result of the procedure.

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Dr. Bernstein at ISHRS 2015 Annual Scientific MeetingDr. Bernstein at the 2015 ISHRS Annual Scientific Meeting

Small, simple modifications in the sequence of the major steps in a Follicular Unit Extraction (FUE) hair transplant procedure will be beneficial to healing and growth following the procedure, says renowned hair restoration surgeon Dr. Robert M. Bernstein. Presenting at the 23rd Annual Scientific Meeting of the International Society of Hair Restoration Surgery (ISHRS) in Chicago, Illinois, Dr. Bernstein detailed how making recipient site incisions before harvesting follicular unit grafts can improve the outcome of an FUE procedure.

For years, it was standard operating procedure in an FUE hair transplant to first harvest follicular units, then create recipient sites in the balding areas and place the extracted units into these sites. This practice persisted despite the fact that hair restoration physicians had known for years that prolonged periods of time outside the body decreased survival of follicular unit grafts. With the widespread adoption of FUE, and the long time needed for the extraction phase of the procedure, Dr. Bernstein looked for ways to streamline the process.

Dr. Bernstein Presenting at ISHRS 2015Dr. Bernstein Presenting at ISHRS 2015

By making the requisite number of recipient sites before harvesting, the grafts can be placed as soon as they are extracted. This reduces the critical period of time that grafts are out of the body. Sites created before harvesting have more time to begin healing, and so they exhibit less bleeding. This results in fewer grafts that “pop” out of the recipient site during placement. Mechanical trauma to grafts that need re-positioning after popping is also reduced. Allowing time for recipient sites to begin healing might also provide a more fertile bed for newly implanted grafts to take root. Additionally, pre-making sites provides time for crusts to form on the surface of the wound. Removing these crusts before placement decreases post-operative inflammation and promotes wound healing.

Dr. Bernstein proposed that in some large FUE sessions, in which large numbers of follicular units are transplanted, the surgeon might deliberately delay extraction to allow pre-made recipient sites additional time to heal by creating recipient sites the day before harvesting.

In sum, Dr. Bernstein provided the audience of hair restoration surgeons with a practical modification of the traditional FUE procedure that could impact the outcome of every hair transplant. Given the growth in the number of FUE hair transplants being performed (now about 50% of all hair transplant procedures) and the international platform provided by the ISHRS Annual Scientific Meeting, this small procedural adjustment could have a significant benefit for thousands of hair restoration patients around the world.

Read these publications by Dr. Bernstein on recipient site creation:

Pre-Making Recipient Sites to Increase Graft Survival in Manual and Robotic FUE Procedures (2012)
Robotic Recipient Site Creation in Hair Transplantation (2014)

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Q: How long are FUT and FUE visible after the procedures? — S.V., Weston, C.T.

A: The recipient area is visible after both procedures for up to 10 days. The donor area in FUT is generally not visible immediately after the procedure. In FUE, the donor area must be shaved, so that will be visible for up to two weeks (the time it takes for the hair to grow in).

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Q: While I was lying awake last night your approach of making sites the day before implantation came to mind. It takes guts to have spearheaded that! I am not aware that that precedent has been set in hair transplant surgery. I would have been timid about infection; it’s a lot like closing a wound with a foreign body in it the next day. As with most things, I am a little slow to jump on board something new so I’m glad you’ve paved the way. Do you have any hesitance about this or do you have enough experience that you no longer hesitate? I would be concerned that variations of the local flora might make a difference and that, accordingly, a large sample size would be necessary to get comfortable. Glad for all of us that you are still blazing trails. — S.S., Shanghai, China

A: Thanks for your kind words. No hesitancy whatsoever. We find no increased risk. Think of it as if you did a hair transplant and ran out of grafts. The remaining sites don’t get infected, they just close up. In the process, all those chemotactic factors involved in the healing process move toward the wounds, so if a graft is placed into them, they would be less likely to get infected than a graft placed into a fresh (non-primed) wound, not more. It is like applying the surgical dressing Duoderm to a wound that helps it auto-sterilize. Putting the speculative science aside, we have not seen one single issue with it. Give it a try with an FUE or FUT procedure. Make the sites, have the patient takes his normal shower that night and you will be pleasantly surprised how little bleeding there is the next day and how easy it is to place the grafts.

Read a summary of the article on pre-making recipient sites

Read the full article as it was published in the Hair Transplant Forum International

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Robotic FUE has improved Follicular Unit Extraction by automating what has been a labor intensive and often inexact manual procedure. It is the latest in a long line of improvements made to hair restoration procedures that lead to better results for hair transplant patients. Dr. Bernstein’s recent publication in Hair Transplant Forum International improves the FUE procedure even further, whether performing follicular unit extraction with the FUE robot or by hand.

In his article, Dr. Bernstein suggests two techniques to enhance the FUE procedure. First, he recommends that surgeons create recipient sites prior to extraction, in order to decrease the time grafts are in their holding solution outside the body. Second, he suggests adding time between site creation and graft harvesting and placement, to allow recipient site healing to progress.

Pre-Making Recipient Sites

As is discussed in the full article (which is available for viewing and download in our Medical Publications section), by making recipient sites first, the time grafts are out of the body will be reduced.FUE procedures lend themselves to easily reversing the normal hair transplant sequence of graft (strip) harvesting followed by dissection and site creation.

These “pre-made” recipient sites will also exhibit less bleeding than newly created sites and will exhibit the stickiness that makes older sites easier to place grafts into with less popping (a common source of graft injury). Besides allowing the placing step to proceed more quickly, pre-making sites will reduce the risk of mechanical injury inherent in repositioning elevated grafts.

After Site Creation, Add Delay between Graft Harvesting and Placement

While Dr. Bernstein acknowledges the expediency for the hair restoration physician, as well as the comfort of the patient in a single-day session, he suggests that, to facilitate growth after a transplant, multiple-day procedures should be considered in large hair transplant sessions that involve the placement of thousands of grafts.

In conclusion, these two modifications -— pre-making recipient sites and adding a delay before graft placement -— to the FUE procedure can potentially contribute to better growth due to easier, less traumatic graft insertion, a shortened time “out of body,” and the creation of a more fertile bed for the implanted grafts.

View the full article to read details about these and other potential advantages of pre-making recipient sites

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