Bernstein Medical - Center for Hair Restoration - Scarring
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Q: I was wondering if it was possible to use Follicular Unit Extraction (FUE) on the old plugs instead of graft excision. — N.B. ~ Westport, C.T.

A: Graft excision generally works better than FUE in removing old plugs and mini-grafts. The reason is that, in these grafts, the hair is not aligned due to the scar tissue that tugs on, and bends the hair. Because the hair direction is altered from the scar tissue, there is much more damage when the grafts are removed with the tiny FUE punches. In addition, FUE only removes a very small part of the plug. If the hair in the plug is pointing in the wrong direction or the plug is in the wrong location, the entire graft needs to be removed.

Another benefit of graft excision is that we can remove the underlying scar tissue and improve the appearance of the underlying skin. In FUE, only a tiny bit of the scar tissue is removed and, since FUE holes are left open, FUE actually causes its own scarring. With graft excision, the sites are sutured closed so some scar tissue is removed and the quality of the underlying skin looks more natural.

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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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Q: What is the most common cause of necrosis (death of tissue) in the recipient area? — A.Q., Los Altos Hills, C.A.

A: Recipient site necrosis is one of the worst complications of a hair transplant and results in skin ulceration and scarring. Usually it is caused by a combination of a few or many of the factors listed below. Each by itself should not present a risk.

Pre-existing conditions in the patient such as:

  1. smoking (the big one)
  2. diabetes (juvenile more than adult onset)
  3. photo-damage (alters the collagen and vasculature)
  4. long-standing baldness (less blood supply when there are no follicles)

Poor surgical techniques:

  1. recipient sites that are too large
  2. recipient sites that are placed too closely (too dense)
  3. too many grafts placed at one time
  4. too much epinephrine used in the procedure
  5. multiple procedures in one session — i.e. FUE and FUE in same session, or large FUT and Graft excision, scalp reduction, etc.
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Dr. Eric S. Schweiger - Associate at Bernstein Medical - Center for Hair RestorationDr. Eric S. Schweiger, board-certified dermatologist, is quoted in a few recent articles on the effects of chemotherapy on hair, genetic testing for hair loss, and protecting a balding scalp from the sun.

“Coping with Chemo-Induced Hair Loss” was published in a recent issue of Energy Times, a publication focused on wellness and nutrition. Dr. Schweiger commented on the way hair follicles can react to chemotherapy treatment for cancer patients:

Expect changes like “chemo curl.” Eric Schweiger, MD, explains that chemo shocks rapidly dividing cells like hair follicles in the scalp, causing the hair loss. “When the follicles grow again, the shock sometimes changes how they grow, temporarily resulting in a different hair texture and color, which eventually normalizes,” explains Schweiger.

In the article, “Genetic Testing to Predict Hair Loss,” published on HairLoss.com, Dr. Schweiger and Dr. Bernstein discussed the efficacy of genetic tests for hair loss:

[Dr. Schweiger] explains, “I think the test has probably identified a predictor of hair loss but not the only predictor. There is science behind the test and some published research studies; however, the longitudinal, larger studies have not been done, because this testing procedure is just too new.” Dr. Robert Bernstein, M.D., director at Bernstein Medical Center, agrees and adds, “These tests focus on one particular dominant gene, but what is becoming apparent is that hair loss is a complex genetic condition most likely involving several different genes.” He further notes that age, stress, hormone levels, disease and many other factors also are at play in determining factors for hair loss. “Just because a person has the genes for baldness, it doesn’t mean the trait will manifest itself. The truth is the cause and effect have not been proven and differ from person to person, and the association is not anywhere near 100 percent.”

[…]

“Right now, we predict future hair loss based on follicle miniaturization, using advanced microscopic equipment,” says Dr. Schweiger, “and I advise a man to do this at around age 25. If someone presents with more than 25 percent miniaturization, then it’s time to start a hair loss prevention regimen.”

Lastly, Dr. Schweiger contributed featured commentary to an article on HairLoss.com on a topic of importance to those suffering from hair loss, namely, protecting your scalp from the dangerous radiation given off by the sun. In “When You Lose Your Hair, Protect Your Scalp,” Dr. Schweiger encourages bald or balding individuals to take important steps to protect their scalps:

…if you notice your hair thinning or you have baldness of any kind for any reason, it’s important to protect your scalp from sun damage, precancer and skin cancer,” says Dr. Eric Schweiger, M.D., a board-certified dermatologist and hair transplant surgeon at Bernstein Medical — Center for Hair Restoration in New York City. That’s because 100 percent of the surface area on top of your head directly faces the sun’s burning rays when the sun is strongest, between 10 a.m. and 2 p.m. “In general, a mild sunburn on your scalp won’t harm your hair follicles. But any exposure that causes blistering can cause scarring and pre-cancer cells, which will harm hair follicles permanently, so you need to take special care of your scalp when exposed to the sun, even for only a few minutes,” explains Schweiger.

Set up a hair loss consultation with one of our board certified physicians.

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Q: I heard that it is possible to transplant body hair to the scalp. Does it leave any scarring? — V.P., Cherry Hill, NJ

A: Unfortunately, it does leave scarring. And since the hair is generally of poor quality, it is usually not worth the trade-off. Below is the typical scarring seen in a BHT procedure. Click the image for a larger version:

Body Hair Transplant - Scarring

Scarring with body hair transplant
(note circular white scars on the person’s chest)

Read more about Body Hair Transplants

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Q: I had a hair transplant in 2004 of mostly plugs. The plugs are in an angle which doesn’t really look natural, far from it. I have lost a lot more hair since I did the hair restoration procedure. I regret ever doing a hair transplant. I prefer to reverse the surgery. I have read a lot about repair work on the net, and I have come to the conclusion that using FUE to take the plugs out, and put them back into the scar might be an option, but it may just make it worse on top. Also I can do electrolysis to remove the plugs, might be better because the possibility of scarring is smaller, and as I already have a lot.

A: If you had plugs, then a graft excision with suturing will generally give a better result than FUE, since a graft excision removes the underling scar tissue as well as the plug. FUE only removes the follicles, but leaves the underlying scar tissue. In addition, the shape of the follicles in scar tissue is often distorted, making extraction difficult and leading to more transaction (damage to follicles).

Electrolysis is very difficult in a scarred scalp and also would not remove scar tissue. Laser hair removal with a diode or Alexandrite laser is generally a better option than electrolysis (it is also faster and less expensive), but like electrolysis and FUE, they do nothing to improve the appearance of underlying scar issue.

For more information on this topic, see our pages on Graft Excision in Hair Transplant Repair and Follicular Unit Extraction (FUE).

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Q: I recently saw an episode of the Rachel Ray Show where her guest, Dr. Anthony Youn, said that the Neograft machine for Follicular Unit Extraction is painless and uses a vacuum rather than surgery to remove the grafts. Can this be true? — A.B., Old Greenwich, C.T.

A: Follicular Unit Extraction (FUE) using the Neograft machine is not painless and, while it does not produce a linear scar, it is surgery and there is significant scarring in the form of thousands of tiny holes that heal with round white marks.

In the video, Dr. Anthony Youn asks: “Do you wanna take a feel? It’s just a vacuum.” Rachel Ray states: “You don’t feel a thing.” Youn replies: “No [you don’t].”

This is very deceptive on the part of the doctor, since the instrument is basically a cutting instrument with the suction being used to remove and insert the grafts. Although the suction part would not be painful, the cutting part certainly is and requires the same anesthesia as a traditional hair transplant.

Our main concern is that the machine produces grafts that are sub-optimal with respect to quality and potential growth, as the Neograft’s suction apparatus tends to strip follicles away from their surrounding protective tissue and tends to dry the grafts out.

For in-depth information on this topic, read our pages on Follicular Unit Extraction (FUE) and the Neograft Machine for FUE.

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Q: If you have already had a hair transplant, once cloning becomes available, will you be able to transplant the cloned hair into the first transplant’s scar on the back of the head? I like to wear my hair short, especially in the summer, and also would feel more comfortable knowing there is no scar in my head. — H.I., Rockville Centre, N.Y.

A: Yes, as long as the scar is not thickened, cloned hair should grow just as normally transplanted hair would and would be a great way to address any residual scarring from the procedure.

Although hair can be transplanted into widened scars, hair does not grow well in thick scars – this would apply to hair restoration procedures performed via traditional means as well as those using cloned hair.

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Q: I never kept my hair really long, what length can I wear my hair after a hair transplant to hide that I had a procedure? — D.F., Chappaqua, N.Y.

A: Hair transplants, whether using the strip method to harvest the donor hair or by extracting individual follicular units one-by-one directly from the scalp, will leave some scarring. If the hair is long enough so that the underlying scalp is not visible, these scars will not be seen.

The quality and density of a person’s donor hair will affect this coverage and determine how short a person may keep his hair. In some cases the back and sides can be cut to a few millimeters, in others it would need to be kept longer. Since there is no scarring in the recipient area (the front and top of the scalp where the grafts are placed) the hair in these areas may be kept at any length.

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Q: Is using Minoxidil combined with Retin-A better than regular Minoxidil for Hair Loss? — L.W., Gowanus, New York

A: Minoxidil has been prescribed (off-label) in combination with other medications, such as topical retinoic acid (Retin-A), to enhance its penetration into the skin and thus increase its effectiveness. This combination of medications can increase the absorption of minoxidil into the bloodstream and may increase the risk of potential side effects, including changes in blood pressure and scalp irritation. It is important to use combination therapy under the supervision of a physician.

If person wants to add Retin-A to the minoxidil regime, the Retin-A should be applied only once a day, since the Retin-A will bind to the skin and will last for at least 24 hours.

Applying Retin-A more frequently will not increase its effectiveness (in facilitating the absorption of minoxidil); it will only increase the incidence of side effects. Retin-A can be applied to the scalp at the same time as Minoxidil, or by itself.

Explore the pro’s and con’s of Minoxidil — also known by its over-the-counter product Rogaine — at the Rogaine/Minoxidil page or by viewing posts tagged with Rogaine (minoxidil).

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Q: Hi Dr. Bernstein. My question is: if you have a surgical scar or incision on your head that is relatively large, is it possible to do a hair transplant into this scar?

A: Hair can grow well in a scar. Since scar tissue generally has a somewhat lower blood supply than normal tissue, we have to make some adjustments in the technique.

When we perform a hair transplant into a large scar, we place the grafts into the perimeter first i.e. the outer edge of the scar. This allows new blood vessels to develop and permits additional hair to be added more centrally at a later date until the whole area is filled in.

If the scar is small or thin it can be transplanted as with normal tissue.

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Q: What can be done if I want to have a hair transplant and my scalp is very tight from prior surgeries? — R.R., Long Island, N.Y.

A: Follicular Unit Extraction is ideal in very tight scalps, provided that there is enough hair to extract without leaving the donor area too thin and provided that the follicles are not too distorted from the scarring.

With strip harvesting, undermining techniques may be helpful to close the wound edges once the strip is removed.

In undermining, the surgeon uses either a sharp instrument (scalpel) or blunt instrument (the dull edge of scissors) to separate the upper layers of the scalp (dermis and epidermis) from the lower part of the scalp (fascia). The hair transplant surgeon accomplishes this by spreading apart the fat layer of the skin or by cutting through scar tissue.

Undermining allows the upper layers of skin to literally slide over the lower layers and can significantly increase the ability to close a tight wound. However, if not done carefully, it may increase the risk of bleeding and injury to nerves and occasionally may damage hair follicles.

Undermining is usually used with a layered closure where the deeper tissues are brought together first with a layer of absorbable sutures before the surface of the skin is sutured closed with sutures that are removed.

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Q: I understand that even if you have multiple hair transplants you will only be left with one scar in the donor area. — T.J., Yonkers, N.Y.

A: If the closure is performed without tension, each procedure should result in the same fine scar.

The best-placed incision is in the mid-portion of the permanent donor area. Since there is only one mid-point, there is one best position for the scar. All incisions should lie on this plane leaving one scar.

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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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