The History of Hair Transplant Surgery

by Dr. Maurice Collins

Posted on Saturday 5th of September 2009

The origins of hair transplant surgery can be traced back as far back as the early nineteenth century. First performed on animals in the 1800s, hair transplants (or hair-bearing autografts as they were known) have been carried out to treat alopecia with varying degrees of success since 1893.

Early research and studies either failed or produced contradictory results. Further confusion was caused by transplants that had failed to “take” or had been only partially successful. An example of a study carried out in 1959 follows:

“After administration of local anaesthesia and appropriate surgical preparation of the skin, which included washing, trimming, and cleansing with alcohol, four full-thickness punch excisions below the level of the hair papilla were made (with punches of 6, 8 and 12 mm). Each graft was trimmed of excess fat. Of the punch grafts, two were excised from a site of persistent disease, and two were excised from a healthy, normal skin site. The grafts were then transplanted in clockwise rotation in the following manner: (1) a normal graft was transplanted to an affected site; (2) a normal graft was transplanted to an affected site; (3) an affected graft was transplanted to a normal site; and (4) an affected graft was transplanted to an affected site.” (Stough, 1996 p. 60)

Results were as follows:

“Donor dominance was observed in all 52 cases of androgenic alopecia: normal graft to normal site grew hair; normal site to bald site grew hair; affected graft to affected site remained bald; and affected graft to normal site remained bald.”

The study concluded:

“The results...corroborated the statement that “the capacity for development of baldness appears to be controlled by factors resident in localised areas of the scalp”; that is, that the pathogenesis of common baldness is inherent in each individual hair follicle. This phenomenon thus would explain the common clinical finding of isolated, normally growing, terminal hairs in a sea of male pattern baldness.” (Stough, 1996 p. 60)

The first hair transplant in the United States was performed by Dr. Norman Orentreich in the late 1950s. He proposed the concept of “donor dominance” – the idea that grafts continue to show the characteristics of the donor site after they have been transplanted to a new site. This principle provides the basis for all hair transplant surgery. Although “donor dominance” ensured that transplanted hair will continue to grow, it did not ensure that the results would look natural. Punch grafting could successfully transplant hair but could not produce a natural-looking result.

Since the 1960s the field has expanded, resulting in improvements in instrumentation and technique. Physicians from different specialties and backgrounds have entered the field which has resulted in the development of new innovations and alternative techniques of transplantation in addition to punch grafting.

The original concept for Follicular Unit Transplantation was introduced by Drs. Robert M. Bernstein and William Rassman in their 1995 paper "Follicular Transplantation". The procedure was further detailed in articles, “Follicular Transplantation: Patient Evaluation and Surgical Planning” and “The Aesthetics of Follicular Transplantation” (1997). The concept was further elaborated upon in the 1999 publication “The Logic of Follicular Transplantation.”
By the year 2000, Follicular Unit Transplant (also referred to as FUT) was firmly established as the state-of-the-art due to its ability to produce natural-looking results. However, because the procedure was more labour intensive, time consuming and therefore more expensive than mini-micrografting, it was adopted slowly by the medical community.

In the last few years, an elite group of hair restoration physicians have, and continue to, revolutionise standard follicular unit transplantation, called "Ultra Refined follicular unit hair transplantation". Trimming smaller "skinny" grafts and making smaller incisions with ultra refined tools allows a hair transplant surgeon to dense pack follicular unit grafts even closer together, almost twice as much as standard follicular unit transplantation. Benefits therefore of ultra refined follicular unit hair transplantation include:
1.dense packing follicular unit grafts closer together when appropriate for the patient;
2.larger single hair transplant sessions requiring fewer sessions for the patient;
3.minimising scalp trauma and lessening the risk of "shock loss" of existing "native" hair.

In the past, hair transplant patients with minimal hair loss would still need multiple sessions to achieve their desired hair density. But surgeons who trim skinnier follicular unit grafts and make smaller incisions with ultra refined follicular unit hair transplantation gives the surgeon the ability to "dense pack" or place follicular unit grafts closer together. Patients therefore can achieve their desired hair density within a single session. But high levels of dense packing are not always advantageous to the patient. Patients with higher levels of balding must often choose between adequate hair coverage or hair density. One often must be sacrificed to achieve the other. Keeping in mind the potential for future hair loss is also important as a surgeon and patient plan how to make use of the finite donor hair supply.

There are several reasons to transplant large numbers of grafts in each session. Large sessions: 1) allow the hair restoration to be completed quickly so that the patient has minimal interference with his/her lifestyle; 2) can compensate for Telogen effluvium or "shock loss", the shedding that frequently accompanies a hair transplant; 3) preserve the donor supply by reducing the number of times incisions are made in the donor area; 4) provide sufficient 1- and 2 hair grafts to create a soft frontal hairline and enough 3- and hair grafts to give the patient the fullest possible look.

Follicular units are relatively compact structures, but are surrounded by substantial amounts of non-hair bearing skin. In stereo-microscopic dissection using ultra refined follicular unit hair transplantation, this extra tissue can be removed without injuring the follicles, thus making the grafts smaller. Small grafts can then be placed into small incisions; minimising damage to the scalp’s connective tissue and blood supply.

The larger wounds produced by mini-micrografting and plug transplants cause cosmetic problems that include: dimpling and pigment changes in the skin, depression or elevation of the grafts, and a thinned, shiny look on the scalp. The key to a natural appearing hair transplant is to have the hair emerge from perfectly normal skin. The only way to ensure this is to keep the recipient wounds very small.

Another advantage of small wounds is creating a “snug fit.” Unlike the punch and some mini-grafting techniques, which remove a small bit of tissue to make room for the new grafts, the small grafts used in follicular unit transplantation fit into a small, needle-made incision without the need for removing tissue. This preserves the elasticity of the scalp and holds the tiny follicular unit graft snugly in place. After surgery, the snug fit facilitates wound healing and helps to ensure that the graft will get enough oxygen from the surrounding tissue to maximise their survival.

The origins of hair transplant surgery can be traced back as far back as the early nineteenth century. First performed on animals in the 1800s, hair transplants (or hair-bearing autografts as they were known) have been carried out to treat alopecia with varying degrees of success since 1893.

Bernstein, Robert M., Rassman, William R., Szaniawski, W., Halperin, Alan J. Follicular Transplantation, International Journal of Aesthetic and Restorative Surgery 1995; 3(2):119-132.

Bernstein, R.M., Rassman, W.R., Follicular transplantation: patient evaluation and surgical planning, Dermatol Surg 1997; 23:771-784.

Bernstein, R.M., Rassman, W.R., The aesthetics of follicular transplantation, Dermatol Surg 1997; 23:785-799

Bernstein, R.M., Rassman, W.R., The logic of follicular unit transplantation, Dermatologic Clinics 1999; 17(2):277-295

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