The following are excerpts from Q&A segments of Dr. Bernstein’s Open House Seminars on hair transplant surgery and other medical hair restoration topics.


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Hair Transplant Seminar: Part 1

Sutures vs. Staples

Attendee: What’s the difference between using sutures and staples in a hair transplant and why are sutures sometimes used and at other times staples used?

Dr. Bernstein: Our thinking on this has evolved over time. Sutures are the traditional way of closing the donor area in hair transplants. About eight years ago we started using absorbable sutures for the majority of our hair restoration procedures. The reason why we used absorbable stitches was that when you use a regular stitch, the loops strangulate hair follicles. After the hair transplant surgery, there’s some swelling of the scalp. So when you have sutures which are applied in a running, or continuous fashion, the loops actually strangulate the follicles because the tissue within the spiral loops of the suture swells.

Because of this, we began to make the loop smaller and smaller. In other words, closer and closer to the wound edge, so that they would trap less tissue if there was swelling after the hair transplantation. Eventually, we stitched so close to the wound edge that within a few days after the surgical hair restoration they became buried and couldn’t be removed. We thought that if the hair transplant doctor used absorbable sutures, then, after they became buried, they would dissolve and just disappeared on their own. Although that seemed like a great idea, the problem was that sutures are absorbed by the inflammation of the body. As a result, the inflammation from the dissolving sutures was destroying some hair follicles and this negated some of the benefit of stitching close to the wound edge.

Around 1998, Johnson & Johnson developed a new suture called Monocryl which is broken down by water in a process called hydrolysis. This process involves very little inflammation. We started using this material routinely in the hair restoration by placing the sutures very close to the wound edge, so that in three or four days they became buried under the skin. We did a study on a series of hair transplant patients to compare those sutures to staples and it turned out that the sutures actually looked better than the staple closure. And the reason is that the suture line was slightly more smudgy or ill-defined. In other words, you could get the two wound edges flush with one another because you have very good hand control, but the sutures destroyed some follicles and this made the line appear slightly irregular when the surgical hair restoration procedure was completely healed. However, the damage to follicles was minimal, since there was so little inflammation and since so little hair was trapped within the sutures. At the time we judged the cosmetic appearance to be the most important factor in deciding which was the best way for the hair transplant doctor to close the transplant so we began to use mainly sutures.

For about five or six years we continued to use absorbable sutures, called Monocryl. About a year ago we decided to revisit the issue and look simply at the technique that conserves the most hair. It turned out, that even though the Monocryl sutures looked great and were very comfortable, immediately after the hair transplant surgery, they were strangulating a little bit of the hair follicles even though it was a very small amount. This is because they are a running stitch. Staples, on the other hand, are interrupted and they are inert (do not react with the body), so even though staples can be uncomfortable and sometimes leave a more defined line-scar after the hair restoration, they do not waste any hair whatsoever.

We currently use staples for the majority of our hair transplants and reserve sutures for those situations in which the staples don’t give a perfectly flush closure. An example would be when there is scarring in the donor area. It is particularly useful to use staples for the first hair transplantation procedure when the donor area has its full density. If, for some reason, the results with the staples were less than ideal, then sutures could be used for the subsequent hair restoration sessions.

What’s New in Hair Transplantation?

Attendee: I had my surgery seven years ago, what’s new?

Dr. Bernstein: I am often asked that question and the answer is that almost every day something is new. The best hair transplant surgeons are always changing something, tweaking something, improving some aspect of the procedure. We’re always looking at something. The day that we have nothing left to improve in surgical hair restoration, I’ll hand the baton to someone else. Searching to make the procedure better is what my team and I live for… it is what keeps us going. We’re always examining, looking and making changes. There aren’t always dramatic changes, but this is always something to improve, even slightly. A recent example is to apply a massager to the patient’s shoulders when giving the local anesthesia – it is a simple technique, but makes the anesthesia a lot more comfortable. Another is the use of special anesthesia to decrease forehead swelling after the procedure. Other relatively well known changes used by hair transplant doctors in the procedure include; tumescent anesthesia and the use of lateral slits for recipient sites.

Follicular Unit Extraction

Attendee: I heard that you can remove hair without taking out a strip. What do you mean?

Dr. Bernstein: For some people that wish to have a hair transplant, you just can’t remove donor tissue using a strip. Although removing a strip leaves a line scar, and although it is usually a very fine line, if you were to buzz cut the sides and back of your head, you would still see that line. You can cut your hair relatively short, but if you really shaved it or cut it very close, you would see the scar.

So for those people who want to buzz the back and sides, you can do the surgical hair restoration with Follicular Unit Extraction (FUE). Here, the doctor takes out follicular units, one at a time, directly from the back of the scalp – without having a line scar. The problem with this hair transplantation procedure, however, is that there is more transection – destruction of follicles – since it is done directly from the scalp where there is only partial visualization by the doctor of the dissection process and poor stability of the tissue as compared to using a strip. The reason is that a strip can be placed under a microscope were you have complete control of the dissection. This is called dissection “in vitro” or out of the body and is a significant advantage in the hair transplant surgery.

The other problem is that when you remove follicles in FUE, you’re leaving bald skin behind. FUE, does in fact, leave a tiny scar, so it decreases the density each time you go back, but if you take out all the hair, you can be left with a bald area after repeated hair transplants. So what happens is that you really can’t access the best portion of the hair once you start picking away at it with FUE. So it’s not as powerful a procedure as FUT where the strip enables you to use 100% of the best part of the donor are for the hair transplant.

The way we envision doing Follicular Unit Extraction is to use it in situations where we can’t do a strip, or if in the rare situation where someone had a wide scar from a strip. In this case FUE would allow you to take hair from around the scar and place it into the scar itself, making it less visible.

Attendee: Is the doctor the one who actually makes the cut and takes the strip out?

Dr. Bernstein: Yes. The harvesting of the strip is the part of the hair transplant procedure that requires the most finesse, the most skill – it must be done with precision and be perfect every time. You could argue if I was making 2,000 recipient sites and one site is not deep enough, I could go back and make it deeper. Removing the strip happens quickly – it has to be done with incredible precision so that the maximum number of follicles may be preserved. So yes, of course, that’s something that I always do.


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