According to an article published in the journal of Facial Plastic Surgery Clinics, ((Rassman W, Pak J, Kim J. Scalp micro-pigmentation: a useful treatment for hair loss. Facial Plast Surg Clin North Am. 2013;21(3):497–503.)) scalp micro-pigmentation (SMP) has been found to be a useful cosmetic treatment for hair loss and scalp scars.
SMP is a scalp tattooing technique that uses fine dots – like a stippled painting – to mimic the appearance of extremely short hairs on an otherwise bald scalp.
SMP can create the appearance of a fuller head of hair on a scalp that is losing hair by softening the contrast between the hair that remains and the color of the scalp. It can also effectively camouflage a scalp scar, like the donor scar from a strip hair transplant procedure, the scar from a scalp reduction or scars from trauma to the scalp.
While one might think the placement of the dots need only follow, in a straightforward fashion, the natural distribution and density of hair that occurs on a normal scalp, the application of SMP is in fact more art than science.
The effective application of SMP requires a strategy and technique custom tailored to each patient that takes into account the particular aesthetic needs of the patient and the particular characteristics of their hair and scalp.
To correctly design and execute such a tailored approach, a physician needs to have considerable expertise regarding where to place the dots, the proper needle size, the best angle of application, the depth and duration of penetration, and the best type of dye to use for a particular person’s scalp.
In addition to SMP being an art form, the article stresses that in the case of concealing pattern hair loss, a physician also needs to have a thorough medical understanding of the progressive nature of the genetic balding process.
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.
Q: I heard that for someone who has had several strip procedures, the ARTAS robot for FUE does not work because it is programmed to work with “textbook male pattern baldness”, which I no longer have. I thought the scars from previous procedures, as well as the large amount of already transplanted hair, might throw off the robot’s programming (it wouldn’t quite know what to do). But if I am wrong about this then the robot may in fact be the best approach for me. Please advise. — N.C., Paris, France
A: When performing robotic hair transplants on patients with prior surgery, I program the robot to avoid scarred areas – just as we would do visually when performing manual FUE.
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.
Q: I am considering having a hair transplant. Does my hair need to be cut? — I.S., New York, NY
A: In all hair transplant procedures, we are able to transplant into areas of existing hair without it having to be cut. The question of whether hair needs to be cut in the donor area depends upon the way the donor hair is obtained (harvested).
With a Follicular Unit Hair Transplant procedure using single strip harvesting method (FUT), only the strip of hair that is removed needs to be cut. When the procedure is finished, the hair above the incision lays down over the sutured area and it becomes undetectable.
In Follicular Unit Extraction (FUE), particularly in sessions over 600 grafts, large areas of the donor area must be clipped short (to about 1-2mm in length) in order to obtain enough donor hair.
Q: I have been reading about hair transplantation and I have a question concerning FUT (strip-harvesting). I understand, in this method, a strip is excised from the back of the scalp, the wound then closed. I wonder, then, is not the overall surface of the scalp reduced in this procedure? After two or three procedures, especially, (or even after one large session) will not a patient’s hairline also be shifted? That is, the front hairline would move back by the amount of scalp excised, or, more likely, the “rear hairline” (which ends at the back of the neck) must certainly be “moved upward.” At least, this is how I imagine it would be. Is my logic flawed? I’ve been trying to understand this in researching the procedure, but the point still evades me. — M.M., Great Falls, V.A.
A: The hair bearing area is much more distensible (stretchable) than the bald area and just stretches out after the procedure. As a result, the density of the hair in the donor area will decrease with each hair transplant session, but the position of the upper and lower margins of the donor area don’t move much – if at all. As a result, the major limitation of how much donor hair can be removed is the decreasing hair density, rather than a decrease in the size of the donor area.
With very low donor hair density the strip will yield so little hair that further sessions eventually become impractical. To say it another way, since a hair transplant decreases the donor density, in each succeeding hair transplant session, you need an increasingly larger donor strip to remove the same number of grafts.
This effect also explains why, in most instances, FUE will not allow the doctor to obtain any significant amount of additional hair, since the donor area is already too thin, and FUE would thin it further.
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.
The International Society of Hair Restoration Surgery (ISHRS) has named Dr. Bernstein the ‘Pioneer of the Month’ in their official publication, the Hair Transplant Forum International.
Below is the article that appeared in the publication announcing Dr. Bernstein as the recipient of the honor. Dr. Bernstein is also a member of the society.
Hair Transplant Forum International
September-October 2006
Pioneer of the Month – Robert M. Bernstein, MD
by Jerry E. Cooley, MD Charlotte, North Carolina
The term “follicular unit transplantation” (FUT) has become so firmly embedded in our consciousness that we often consider it synonymous with hair transplantation in general. Surgeons new to the field may be unaware of its origin and how the concept evolved. In the 1980s, many separate clinics were developing total micrografting techniques to improve the naturalness of hair transplantation. In 1988, Dr. Bobby Limmer began developing a technique consisting of single strip harvesting with stereomicroscopic dissection of the hair follicles within the strip, which he published in 1994.
After observing histologic sections of scalp biopsies, dermatopathologist Dr. John Headington coined the term “follicular unit” in 1984 to describe the naturally occurring anatomic groupings of hair follicles. In 1995, a surgeon just entering the field of hair transplantation became aware of these natural “follicular units” and came to believe that they should be the building blocks for all hair transplants. His name was Bob Bernstein.
From 1995 to 2000, Bob and his colleague Dr. Bill Rassman articulated the rationale and benefits of FUT in dozens of publications and numerous lectures. Doubtlessly, Bob’s extraordinary effort advocating FUT in public forums during that time was critical to FUT’s rapid evolution and acceptance among surgeons.
Bob was born in New York City and raised on Long Island, New York. For college, Bob headed south to Tulane University in New Orleans. Next, he went to medical school in Newark at the University of Medicine and Dentistry of New Jersey. He then went on to a residency in dermatology at Albert Einstein College of Medicine, where he served as chief resident.
Bob performed some punch grafting procedures in residency and a few more when he started his cosmetically focused dermatology practice in 1982. Not liking the results, he didn’t perform another transplant for 12 years. In the summer of 1994, Bob saw a patient of Dr. Ron Shapiro for a dermatologic problem. Impressed with the results of the surgery, Bob began speaking with Ron about the changes in the field. Ron encouraged him to attend the next ISHRS meeting in Toronto, which he did. While there, he saw several of Dr. Rassman’s patients presented and was greatly impressed.
Soon after, he was in Bill’s office observing micrograft “megasessions.” One of the things that caught Bob’s attention was Bill’s use of the “densitometer” to quantify the patients’ hair density. Bob noticed that the hair surprisingly grew in small groups. Bill half jokingly told Bob that he should give up his dermatology practice and go into hair restoration and invited him back for a second visit. On the 5-hour plane ride to Los Angeles, Bob thought about the potential of only transplanting those small groups he saw with the densitometer, and wrote the outline of a paper entitled, “Follicular Transplantation” (published that same year). The second visit with Bill confirmed his interest in hair transplants and, in particular, developing this idea of FUT. He quickly transferred his dermatology practice to a colleague and joined Bill’s group, the New Hair Institute (NHI).
Over the next 10 years, Bob authored and coauthored over 50 papers on FUT addressing issues such as quantifying various aspects of FUs among patients, racial variations, graft sorting, as well as hairline aesthetics, corrective techniques, the use of special absorbable sutures, and FUE and its instrumentation. One of the concepts he emphasized was the recognition of Diffuse Patterned Alopecia (DPA) and Diffuse Unpatterned Alopecia (DUPA), which were originally described by Dr. O’Tar Norwood. Bob helped raise awareness that patients with DUPA and low donor density are not surgical candidates. For all of his many contributions to the field, Bob was awarded the 2001 Platinum Follicle Award.
Branching out in other directions, Bob decided to go to business school and received his MBA from Columbia University in 2004. He did this to learn how to better streamline the day-long hair transplant sessions and improve general management of his growing staff. In 2005, Bob formed his own practice, Bernstein Medical – Center for Hair Restoration. Looking to the future, Bob says, “I am excited about the accelerated rate of technical changes to the hair transplant procedure. This is due to an increasing number of really clever minds that have entered the field. Almost every aspect of the surgery is being tweaked and improved upon. It goes without saying that cloning will be the next really big thing—but I think it will take longer to develop than some are promising.” On the down side, he notes, “A concern I have is that, as hair transplant practices grow into big franchises with large marketing campaigns, many people are being directed toward surgery rather than being treated as patients with hair loss in need of an accurate diagnosis, medical treatment, emotional support, and surgery only when appropriate.”
Bob met his wife, Shizuka, who was born in Tokyo, when she was opening a dance studio in the East Village section of New York. She now owns a day spa in midtown Manhattan. Bob has three children; two are in college: Michael, 22, is studying mixed martial arts and foreign language; Taijiro, 21, is majoring in theoretical math. His daughter, Nikita, 12, is in 7th grade and plays on the basketball team. In addition to going to Nikita’s games, Bob enjoys skiing, piano, chess, basketball, philosophy, and music history.
Q: I had a hair transplant of over 600 grafts using Follicular Unit Extraction (FUE) to my frontal hairline and the frontal part of my scalp. The procedure was done less than a year ago by another doctor. Since then I have had persistent pimples and redness in the area that the grafts were placed. Also, the surface of the skin in the area is irregular. — E.Z., Long Island, N.Y.
A: One of the causes of having pimples and redness following Follicular Unit Extraction may be buried hair fragments and there are significantly more hair fragments generated with the two-step FUE technique than with the three-step method.
In the three-step procedure, we use blunt dissection which minimizes transection (cutting of hair follicles) and thus reduces the incidence of hair fragments. See the Three-Step FUE page at the Bernstein Medical – Center for Hair Restoration website.
In our practice, we also place every extracted graft under the microscope. This serves a number of purposes:
It gives me immediate feedback on transection rates, so that I can adjust my technique in real-time (using a stereo-microscope is much better than visual inspection for this purpose)
It enables us to trim away excess tissue and hair fragments (we use the same judgment as we do with strip harvesting, so that a “viable looking” fragment would be left attached
It allows us to accurately count the number of hairs in each follicular unit graft, as it is particularly important to have pure 1-hair grafts for the frontal hairline. This also allows us to better anticipate the end cosmetic result.
It allows us to dissect larger follicular units into smaller ones for specific cosmetic purposes, i.e. eyebrows, hairlines, temples etc.
One of the ironies of FUE is that it is more efficient to extract the larger FUEs, since this gives us a greater hairs/hole ratio, but this often leaves us with an inadequate number of 1-hair units, which must be obtained though traditional stereo-microscopic dissection of the larger extracted grafts.
Other causes of folliculitis (manifested by pimples and redness) can result from placing the grafts too deep in the recipient site (where they may get buried) and secondary infection. A mild, transient folliculitis is often seen after a hair transplant without any precipitation factors.
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.
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).
Surgery of the Skin: Procedural Dermatology; published in 2005 by Elsevier-Mosby and Edited by Robinson, Hanke, Sengelmann and Siegel; is monumental work that covers the entire spectrum of dermatologic surgical procedures. In the editor’s words, the goal of this 872 page textbook is:
“To capture the art and practice of dermatologic surgery at the beginning of this century.”
It is to be used as the core surgical textbook for dermatologic training programs. The book is divided into four parts: Part I – Basic Surgical Concepts, Part II – Essential Surgical Skills, III – Aesthetic Surgical Procedures, and IV – Special Procedures.
The text covers a wide range of subjects on aesthetic surgery, including liposuction, chemical peels, Botox, soft tissue augmentation, laser hair removal, laser skin resurfacing, leg vein treatment, blepharoplasty, face lifts and, of course, hair transplantation.
Dr. Bernstein was honored to write the section on hair transplantation that covers the historical aspects of the field, patient evaluation and surgical planning, operating room set-up, surgical techniques and how to maximize the cosmetic outcome of the hair transplant.
The focus of Dr. Bernstein’s chapter is on Follicular Unit Transplantation, the technique that has changed the face of surgical hair restoration over the past decade. The chapter discusses strip harvesting, follicular unit extraction, the use of anesthetics, ways to optimize density and ensure the naturalness of the procedure, as well as a host of other important topics. The textbook may be purchased at Amazon.com.
The term “follicular unit transplantation” (FUT) has become so firmly embedded in our consciousness that we often consider it synonymous with hair transplantation in general. Surgeons new to the field may be unaware of its origin and how the concept evolved. In the 1980s, many separate clinics were developing total micrografting techniques to improve the naturalness of hair transplantation. In 1988, Dr. Bobby Limmer began developing a technique consisting of single strip harvesting with stereomicroscopic dissection of the hair follicles within the strip, which he published in 1994.
Surgery of the Skin: Procedural Dermatology; published in 2005 by Elsevier-Mosby and Edited by Robinson, Hanke, Sengelmann and Siegel; is monumental work that covers the entire spectrum of dermatologic surgical procedures. In the editor’s words, the goal of this 872 page textbook is:
