The NHI Way
Since its founding in 1992, the New Hair Institute has been a world leader in innovating hair transplantation techniques, in performing clinical research, and in teaching these techniques and innovations to the hair transplantation community. Throughout its history, NHI has trained physicians and educated patients using formal medical presentations, accredited training programs and open house events. NHI has used many vehicles to communicate new ideas, to dispel hair transplantation myths that hold little or no scientific basis, and to answer the many questions of those concerned with hair loss.
Our physicians, surgical team, innovative techniques, experience, ethics, integrity, and open door policy all comprise The NHI way.
It takes years to develop the skills to perfect the technique of Follicular Unit Transplantation. The FUT procedure (a) requires a large number of highly skilled staff (b) demands the team work in an orchestrated fashion and (c) necessitates strict and continuous supervision. These processes must be flawless to maximize both graft yield and survival. Keeping the grafts in a moist environment is central to the process and not as simple as it sounds, as grafts must be dissected, sorted, stored, held and then placed into the recipient sites. In addition, they must be handled gently so that the delicate growth centers are not damaged.
Doctors are trained in medicine and surgery, but are not necessarily trained in team building, understanding process, managing process, or tedious and routine activities. Most doctors have problems with FUT because they are fundamentally poor at creating technician teams that can effectively cut and place grafts. So what do doctors do? Many work with inexperienced teams (that establish their own standards) or hire independent traveling technicians that work per diem and carry with them skills from various doctor's offices. As a result the technicians often dictate the surgery. Unfortunately, stereo-microscopic dissection is not something untrained technicians willingly perform. Doctors who may in fact want to perform FUT or large sessions of small grafts are limited by the skills or whims of the traveling teams (in effect, the tail wags the dog).
At NHI, our surgical team is an essential part of the process. Our staff has as much an interest in seeing a perfect outcome as does the operating surgeon. Each member of our team is thoroughly trained in stereo-microscopic dissection and graft placing. Continual monitoring insures their techniques create a maximum transplant yield. Our extraordinary team effort produces predictable outcomes with the most exacting Follicular Unit Transplantation procedure possible. It is The NHI way.
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The NHI Way is highlighted by constant introspection and change. Part of this process is innovation and, often times, pushing ahead with innovation even when those changes are momentarily unpopular. As NHI has forged forward, the industry has followed.
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In the early 1990's there was a trend in the hair transplant community to create a central island, or tuft of hair, in the front of the scalp often called a "frontal forelock." This was often a necessity with older larger graft methods since the surgeon frequently ran out of hair and had to compromise on hairline design. In 1995, NHI, realizing the power of Follicular Unit Transplantation to conserve donor hair, proposed that the physician not compromise the frontal hairline. We began creating a fully framed face on the very first session, producing a natural look from the outset. Additional density in subsequent sessions was added for those patients who wanted a fuller look. Conventional thinking was challenged and an undetectable hair transplant became the "NHI look".
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From the beginning, NHI has been a leading exponent of reform in hair transplantation ethics. As early as 1992 in the industry newsletter Hair Transplant Forum International, NHI physicians published articles questioning the ethics of using salesmen and their high-pressure sales tactics exploited industry-wide (even today). Many men are desperate for hair and are vulnerable to pressure tactics especially when promises are wrapped in the guise of a doctor's white coat. We have taken considerable flack for our stance. In 1995, an NHI Newsletter titled "For Some Doctors, It's Money above Ethics" outraged many in the hair transplant community (see all our newsletters at newhair.com). However, we continue to speak out against the use of salesman, consultants, scalp reductions, laser hair transplants, automated graft dissectors, transplanting patients with diffuse hair loss or those that are too young, as well as other procedures and decisions that may be harmful to patients. It is The NHI way.
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At NHI, we have had an "open shop" since we started. "Open Houses" and Seminars around the country have been our staple. Anyone could and still can ask questions in an open forum and hold us publicly accountable for our work. Continuous streams of patients continue to show off their results under direct inspection by prospective candidates. We have never employed salesmen to "sell" our procedures. Most importantly, every prospective patient always meets directly with a specially trained NHI physician. It is only the doctor that evaluates the patient and only the doctor who makes recommendations for treatment. It is The NHI Way.
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Backed by pioneering work in Follicular Unit Transplantation dating back to 1995, and Megasessions dating back to 1993, NHI has amassed tremendous experience that few medical groups can match. This experience is critical in making important decisions and answering such questions as:
- What are the patient's best non-surgical options?
- At what age should surgical hair restoration be considered?
- When should Megasessions be performed and how large should they be?
- How much donor area should be harvested at one time?
- How close should grafts be placed?
- What are the indications for surgical hair restoration in women?
- How should the transplant be designed and planned for the long-term?
It is The NHI way.
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Dr. Wolf further describes difficulties patients have in discerning truth from fiction:
Concerning follicular unit terminology, there are those that are benefiting from the semantics of FU transplants without really doing them. A local competitor, ISHRS member, advertises that he does "follicular unit minigrafts" that average 5 to 7 hairs per graft. Of course all hair is made up of FUs as all things are made of atoms. To say you drive an "atomic car" would be theoretically correct because it is made of atoms. Semantically and with regard to accepted ideas one would assume that the car was powered using atomic energy. So calling your car "atomic" would be deceptive. In my view it is deceptive to say you use FUs if they are not separated from the FUs around them.
A real FU to be used in hair transplant surgery takes an investment in time, skill, energy, and patience to create and it doesn't exist semantically or for practical purposes unless it is separated from those FUs around it with levels of magnification needed to entirely see all the FUs that exist in a donor strip and sliver. Naming minigrafts by the numbers of FUs in them and implying that one is performing FU hair transplants is deceptive and wrong in my opinion unless every FU is seen and all the dissection is being done with higher powers of magnification. Simply counting how many FUs are in a graft doesn't automatically make it FU surgery any more than my "saying" I drive an "atomic car" because the car is made of atoms.
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The most important means of communicating information has been through peer reviewed medical journals. This medium allows new ideas to be disseminated to physicians throughout the world and, most importantly, be subject to a process where scientific data can be reviewed and scrutinized by experts in the field before it reaches the public domain. Information is truthful and has scientific validity. Our physicians have generated a continuous stream of medical publications documenting their work and accomplishments since NHI's inception. More recently, a body of publications was created, constituting the foundation of a new field in hair restoration surgery, Follicular Unit Transplantation. It is The NHI Way.
With mass marketing, infomercials, the internet, and other forms of communication where the quality and content of the information is literally unchecked, doctors can make claims about anything they choose. It is difficult for patients to discern truth from fiction and nearly impossible to make the best decisions on how their hair loss should be evaluated and treated. To address these concerns, we would like to offer some published comments made by other medical professionals regarding NHI's work while directing you to sources where tried and tested can be accessed.
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Introduced to the field by Dr. Bobby Limmer in the 1980's, the stereo-microscope has proven critical to performing FUT. In particular, it is essential for the efficient dissection of intact follicular unit grafts from the donor area. It allows for the unit to be removed whole and without damage and allows for the natural and maximally full appearance of the final look. The critical use of the microscope was recently summarized quite well by Dr. Brad Wolfe, who like us, uses microscopes as an integral part of the transplant process:
"There is a relative paucity of objective studies in hair transplantation, but I do recall the studies done by Drs. Bob Bernstein and Bill Rassman that showed increased graft numbers when using microscopes. Over the years as I increased the number of microscopes and power of magnification I noticed the number of grafts from a strip increased. A follicular unit cut without any magnification can look as good, identical, or even better than one cut with magnification. But that's not the criteria which should be used, an increase in the number of preserved follicles is. What is being lost isn't being seen because it can't be seen without higher powers of magnification and it's in the garbage.
If one believes these studies and the experience of those who have seen the light, by not using higher powers of magnification one is committing follicular homicide. This is not in the best interest of the patient regardless of cost to the physician and patient in money and/or time. In the past, one could argue that not using magnification didn't really make a difference because we didn't know. That is no longer true so there is no excuse in my opinion. There are ways to magnify without microscopes but I found increased grafts numbers going from loupes to 6X magnification and even more from 6X to 10X magnification. I refer to cutting slivers and the grafts from the slivers with magnification, either/or doesn't count. No assistant has 6X eyes regardless of gender or ethnicity.
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Smaller recipient sites are always optimal for the transplant. Sites should match the size of the graft so that a snug fit occurs. Small recipient sites limit blood flow issues, a critical concern when dense packing. Some surgeons use nails to stretch undersized sites while others make sites too large. Both approaches reflect what is best (or easiest) for the surgeon and staff rather than what is best for the patient. The smaller the wound size, the faster and more complete the healing. A snug fit reduces the oozing of blood and serum from around the wound and is the only way to ensure that recipient site scarring is eliminated. On the other hand, when sites are too small, the staff must force the graft in the site. The result is a damaged graft or, as discussed above, improperly dissected units. Training is arduous, but the results are vastly better for the patient. Again, some Doctors do not take the time and care to properly create small recipient sites.
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The FOX™ procedure, where individual follicular units are extracted directly from the donor area without a traditional linear incision, was published by us in the journal Dermatologic Surgery in 2002 in the paper titled Follicular Unit Extraction: Minimally invasive surgery for hair transplantation. The procedure has been adapted by some doctors yet resisted by many. The controversy of this procedure was reinforced at the 2003 ISHRS meeting in New York (our annual convention for hair doctors), where many doctors from around the world openly discussed their experience and frustration with this exacting procedure. The difficulty in performing the procedure (which is tedious and stressful for both doctor and staff) was battered about by most physicians in a series of 'talks' on the subject after Dr. Rassman presented his paper. One attempt at a clinical demonstration of the procedure was scheduled at a local New York hair restoration facility, however, the surgeon that was scheduled to perform the procedure mysteriously left town the morning of the surgery. Many of the attendees left wondering if this was 'telling' of an unpredictable surgery.
The FOX™ procedure remains an exciting advance and the promise of an almost scar-less surgery is enticing to both patient and surgeon. An important limitation of the procedure is that the total yield will always be lower than with traditional Follicular Unit Transplantation and for this reason we reserve the procedure for specific indications.
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We published the first paper on Follicular Unit Transplantation in the International Journal of Aesthetic and Restorative Surgery in 1995. The concept of FUT was initially rejected by many in the hair transplant community claiming it to be technically difficult, not significantly different from mini-micrografting, and overall just not worth the effort. We disagreed and pushed onward. We followed the 1995 paper with an extraordinarily detailed pair of articles published in Dermatologic Surgery in 1997; "Follicular Transplantation: Patient Evaluation and Surgical Planning" and "The Aesthetics of Follicular Unit Transplantation".
By the time of the second publication, hair transplant surgeons began to see the value of this new procedure. This sentiment is reflected in the editorial commentary by Dr. Richard Shiell that accompanied the 1997 publications in Dermatologic Surgery:
This is a very important paper on hair transplantation, well written, and covering every important aspect of the subject. A recent advance like stereoscopic microscopy is simply an aid to obtain more accurately cut pilosebaceous units. Cloning, if it ever becomes a practical reality, will simply provide us with more raw materials. Whatever happens, we will still be using something close to the Bernstein-Rassman technique in decades to come, as it provides convincing results with nature's own building blocks, the compound pilosebaceous units.
The authors Bernstein and Rassman are well known for their contributions to this field in the past 5 years and this paper is virtually a mini-textbook on hair restoration practice. There is no doubt that their techniques are revolutionizing hair restoration surgery and almost every practitioner in this field has already been influenced by their past writings and very convincing case presentations at meetings.
In this paper there is much sound advice for the beginner about case selection and donor hair availability. Experienced surgeons have learned much of this in the past by trial and error but the authors provide objective measurements of donor site size and hair density, which makes the "learning curve" far less arduous for the newcomer to this field. Four pages are devoted to the vitally important task of assessing the degree of present and future hair loss. The authors emphasize the importance of measuring the degree of hair shaft miniaturization in both the donor and recipient areas. This is an advance indicator of future trends and is often ignored by those looking only for gross hair loss.
The authors make many very valuable points throughout this paper. Some concepts are difficult for the beginner but make excellent revision reading for the experienced surgeon. These are not necessarily new concepts but on the other hand they are points that are rarely discussed and have been seldom, if ever, written in the past.
The authors point out the importance of counseling the patient and educating him about his condition so that his expectations can be realistic. The patient who is complaining of a recent acceleration of his hair loss is probably very anxious and keen to proceed with surgery. This is the very patient who is at the greatest risk of being unhappy with the outcome of surgery, due to difficulty in keeping up with the continuing hair loss or because of accelerated hair loss as a result of surgical intervention.
In 1999, NHI published another controversial paper, The Logic of Follicular Unit Transplantation, this time in Dermatologic Clinics. The editor, Dr. Stough, wrote:
"Everything you wanted to know about follicular unit transplantation, and then some. This monograph presented by Bernstein and Rassman can be thought of as a thesis on the subject of the follicular unit. This may be perhaps the most comprehensive accumulation of thoughts on the matter recorded thus far… Therefore, I believe the follicular unit is here to stay. After all, hair does emerge in follicular groupings and not as a single follicular unit."
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The New Hair Institute is in the unique position of being the only hair restoration practice that works exclusively in its own nationally certified surgi-centers. That distinction insures the patient that he/she will receive the highest safety standards. Certification is achieved through third party audits of the operating facilities, the clinical process, charts, records, patient outcomes, and quality assurance protocols. It is The NHI way.
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The ideal way to perform a hair transplant is to understand its nuances, so that potential problems can be avoided. Unfortunately, this is not the way hair restoration has traditionally been performed. Repair of older type procedures has become a major part of our practice. Initially, a majority of surgeons used camouflage - placing smaller grafts in front of the larger plugs. This was a quick and simple method but was largely ineffective. As our experience with repairs grew, it became apparent that excision of larger grafts previously camouflaged was the missing critical step.
Fortunately, the hair from these larger plugs was not wasted. Under a stereo-microscope they can be dissected into individual follicular units and be immediately re-implanted into the scalp. Many patients later, we published a comprehensive review of our work in the summer of 2002 in the journal Dermatologic Surgery. Like all of our published works before, we laid out the logic of the repair process and believe that our documentation will become the standard for the repair process.
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Achieving as much density as possible in a single session has been the desire of most patients. Prior to 1993, it was thought that density could only be achieved with larger grafts, a falsity that resulted in an unnatural look and often a scarred scalp. In 1993, The New Hair Institute began performing dense packing using very small grafts to achieve significant density while creating a natural result. At the first meeting of the ISHRS, Dr. Rassman came under personal attack for demonstrating dense packing. Doctors claimed that placing grafts so close together would compromise the skin of the recipient area or the graft's ability to survive. In spite of these protests, NHI continued to perform and enhance the technique.
Recently, the field has shifted focus to a literal obsession over dense packing. Doctors have forgotten however, the caution NHI discussed when we first introduced dense packing. Doctors can risk poor graft growth due to graft mishandling and some compromise of the blood supply. Inexperienced hair restoration surgeons now market and push the technique, but often lack the skills to carry it out. Some are even breaking up follicular units to make grafts smaller, making dense packing technically easier and artificially increasing the graft count. However, this shortcut technique actually produces a thinner look, the opposite of what the patient wanted to achieve.
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The concept of Megasessions, where a thousand or more very small grafts are placed in a single session, was first proposed by Dr. Uebel in Brazil in the late 1980's. However, this technique gained little attention in the United States until the New Hair Institute presented live patient Megasession results before physician audiences in 1993 and 1994. As a perspective, when NHI was performing up to 2,000 grafts in a single session, the hair transplant community rarely went above 200-300 large grafts in a single session.
Achieving a patient's goals in the shortest timeframe with the fewest surgeries required a paradigm shift for the doctor's practice. Multiple sessions of large grafts were easier and more profitable than the Megasession. Doctors were reluctant to abandon their old ways.
In the past, most doctors trained their surgical staff to perform a series of two-hour surgeries. Other cosmetic procedures were performed in the same two-hour timeframe so Doctor's squeezed in these small transplant sessions to fit their current schedules. Few doctors were willing to take the time, make the effort, or bear the expense of revamping their office procedures. Aggressively defending their status quo was an easier solution.
When Dr. Rassman entered the transplant field, a well known hair transplant surgeon welcomed him with the following greeting:
"This is a wonderful business and the money is good, just don't make waves and you will succeed and make a very comfortable living."
Dr. Rassman clearly did not follow his advice. Instead, Dr. Rassman forced the paradigm shift to encompass a lower per graft price and longer, tedious, and more stressful surgeries for both the surgeon and his staff. But the NHI staff quickly adapted to the demands of the new procedure. It was to become the NHI Way.
As pioneers, we had to give special attention to (a) developing safe anesthesia techniques to span the longer surgical procedure, (b) the size and number of recipient wounds to reduce and control bleeding, (c) the donor strip which had to be wider and longer to yield a large number of grafts, and (d) special graft handling so that delicate follicular unit grafts would not be harmed. We developed special techniques to address each of these critical issues. In the beginning, there were days when the surgery went well into the night as we perfected the process. A step up of 500 grafts from a 500 to a 1,000 graft procedure created an exponential increase in complexity and required a new set of skills.
We initially published our articles in the industry newsletter, Hair Transplant Forum. Worldwide dissention arrived as other doctors failed to replicate our results and were only met with complications. It was clear that the paradigm we developed required special skills. The Megasession was so labor intensive that it was virtually impossible for an experienced surgeon to make the without major structural changes in his office. Instead of making these changes, many turned their failures into points of 'attack' against NHI during various medical meetings.
As NHI patients were presented at hair transplant conventions, the enthusiasm for this approach slowly began to take hold. In 1995 we presented 23 completed patients before an audience of over 500 doctors. The initial protests began to wane as doctors were able to see first-hand results of the technique.
It was immediately clear that using individual follicular units, instead of micrografts, was the ideal way to perform Megasessions, an idea we soon published. In this article, we merged Megasessions and FUT into one procedure and recommended sessions as large as 3,500 grafts for Norwood Class 6 and 7 patients.
The key to our success was to train a new group of technicians to complete a surgery in less than 10 hours, the generally accepted time frame that hair grafts would survive and the maximum time frame for the type of local anesthesia used. Patients would no longer need 4-8 surgical procedures. We called the remarkable results of these Megasessions the Fast-track™ Approach.
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- Rassman WR. One of our greatest Problems…Lowballing! Hair Transplant Forum Intl. 1992; 2(6): 5
- Rassman WR. Pomerantz, MA The Importance of Measuring Hair Density in the Diagnosis and Treatment of Hair Loss. Hair Transplant Forum Intl. 1993; 3(2): 8-9
- Rassman WR, Pomerantz, MA. The art and science of minigrafting. Int J Aesthet Rest Surg 1993; 1:27-36.
- Rassman WR. Megatransplants in Transition - A Pictorial Review. Hair Transp Forum Intl. 1993; 3(4): 11
- Rassman WR. Megasessions: Dense Packing. Hair Transplant Forum Intl. 1994; 4(3): 5
- Norwood, OT. William Rassman, M.D - Gearing Up for Two Thousand Grafts per Session and Dense Packing. Hair Transplant Forum Intl. 1994; 4(4): 1-4
- Rassman WR. Concern about Quality. Hair Transplant Forum Intl. 1994; 4(4): 8-9
- Rassman WR. Trouble with Megasessions and Dense Packing. Hair Transplant Forum Intl. 1995; 5(6): 4-5
- Rassman WR, Carson S. Micrografting in extensive quantities; The ideal hair restoration procedure. Dermatol Surg 1995; 21:306-311.
- Bernstein RM, Rassman WR, Szaniawski W, Halperin A: Follicular Transplantation. Intl J Aesthetic Restorative Surgery 1995; 3: 119-32.
- Bernstein RM: Are scalp reductions still indicated? Hair Transplant Forum Intl. 1996; 6(3): 12-13. Bernstein RM, Rassman WR: Laser hair transplantation: Is it really state of the art? Lasers in Surgery and Medicine 1996; 19: 233-5.
- Bernstein RM, Rassman WR: Follicular Transplantation: Patient Evaluation and Surgical Planning. Dermatol Surg 1997; 23: 771-84.
- Bernstein RM, Rassman WR: The Aesthetics of Follicular Transplantation. Dermat Surg 1997; 23: 785-99.
- Norwood, OT. Notes from the Editor Emeritus: "An Idea Whose Time Has Come." Hair Transplant Forum Intl. 1997; 7(3): 10-11
- Bernstein RM, Rassman WR: What is delayed growth? Hair Transplant Forum Intl. 1997; 7(2): 22.
- Bernstein RM. Measurements in Hair Restoration. Hair Transplant Forum Intl. 1998; 8(1): 27.
- Bernstein RM, Rassman WR. Dissecting microscope versus magnifying loupes with transillumination in the preparation of follicular unit grafts. A bilateral controlled study. Dermatol Surg 1998; 24: 875-80.
- Bernstein RM, Rassman WR, Seager D, Shapiro R, et al. Standardizing the classification and description of follicular unit transplantation and mini-micrografting techniques. Dermatol Surg 1998; 24: 957-63.
- Bernstein RM: Microscopophobia. Hair Transplant Forum International. 1998; 8(5): 23.
- Rassman WR. Blind Graft Production with Cutting Grates and Multi-bladed Knives. Hair Transplant Forum Intl. 1998; 8(5): 22-23
- Bernstein RM: Blind graft production: Value at what cost? Hair Transplant Forum International 1998; 8(6): 28-29.
- Bernstein RM, Rassman WR: The logic of follicular unit transplantation. Dermatologic Clinics 1999; 17 (2): 277-95.
- Bernstein RM: Unified terminology for hair transplantation. Hair Transplant Forum International 1999; 9(4): 121-3.
- Bernstein RM, Rassman WR: Hemostasis with minimal epinephrine. Hair Transplant Forum International 1999; 9(5): 153.
- Bernstein RM: A slot by any other name. Hair Transplant Forum International 1999; 9(6): 175.
- Bernstein RM, Rassman WR, Seager D, Unger WP, et al. The Future in Hair Transplantation. Journal of Aesthetic Dermatology & Cosmetic Dermatologic Surgery 1999; 1(1): 55-89.
- Bernstein RM, Rassman WR: Limiting epinephrine in large hair transplant sessions. Hair Transplant Forum International 2000; 10(2): 39-42.
- Bernstein RM, Rassman WR, Stough D: In support of follicular unit transplantation. Dermatologic Surgery 2000; 26(2): 160-2.
- Bernstein RM, Rassman WR, Rashid N: A new suture for hair transplantation: Poliglecaprone 25. Dermatol Surg 2001; 27(1): 5-11.
- Bernstein RM, Rassman WR: Follicular unit graft yield using three different techniques. Hair Transplant Forum International 2001; 11(1): 1, 11-13.
- Bernstein RM, Rassman WR: The scalp laxity paradox. Hair Transplant Forum International 2002; 12(1): 9-10.
- Bernstein RM, Rassman WR, Rashid N, Shiell R: The art of repair in surgical hair restoration - Part I: Basic repair strategies. Dermatol Surg 2002; 28(9): 783-94.
- Bernstein RM, Rassman WR, Rashid N, Shiell R: The art of repair in surgical hair restoration - Part II: The tactics of repair. Dermatol Surg 2002; 28(10): 873-93.
- Rassman WR, Bernstein RM. The Automation of Hair Transplantation: Past, Present, and Future. In: Harahap M, ed. Innovative Techniques in Skin Surgery. New York, Marcel Dekker, Inc., 2002: 489-502.
- Rassman WR, Bernstein RM, McClellan R, Jones R, et al. Follicular Unit Extraction: Minimally invasive surgery for hair transplantation. Dermatol Surg 2002; 28(8): 720-7.