The History and Evolution of Hair Transplantation

1 The History and Evolution of Hair Transplantation

Richard C. Shiell and Ronald Shapiro

Summary

Many lay people still associate hair transplants with unnatural looking “pluggy” grafts from the past. In fact, even many physicians are not aware of the huge progress that has been made in the field over the last 50 to 60 years. Today, hair transplants are so natural they are virtually undetectable. This chapter gives an overview of the major changes that have occurred in the field since Orentreich first introduced the procedure in the 1950s. The progression from standard large grafts to mini-micro grafting followed by follicular unit transplantation and then follicular unit extraction is explored. The forces behind these changes as well as some of the more important changes are emphasized.

Keywords: standard punch grafting minigrafting micrografting mini-micro grafting multibladed knife strip harvesting microscopic graft dissection follicular unit transplantation follicular unit extraction

Key Points

•The original standard “large” punch graft technique grew hair but was unnatural, creating the pluggy dolls head look associated with transplants of the past.

•The search for naturalness led to smaller grafts and mini-micro grafting, which was an improvement but could still look unnatural.

•Follicular unit transplantation using naturally occurring one to three hair follicular unit grafts was a major advancement producing results so natural they were virtually undetectable.

•Follicular unit extraction arose as an alternative method of harvesting follicular unit grafts to prevent linear scars in the donor area.

1.1 Introduction

Although there are those who accept hair loss gracefully, for many it causes significant social and psychological stress. Concern over hair loss has been documented throughout history. A prescription for restoring hair is included in the ancient Ebers Papyrus of ancient Egypt, and we are all familiar with the story of Samson and Delilah, perhaps the most famous “hair equals virility” story of all time. It is not surprising that much effort has been spent trying find a solution to this problem.

The goal of this chapter is to present an overview and give some perspective on the evolution of hair transplantation. Therefore, I refer readers interested in more historical detail to the splendid 29-page section on The Development of Hair Transplantation from 1822 until 1987, written by David and Norman Orentreich for the 2nd edition of Unger’s book.1

1.2 Early History

The roots of modern-day surgical hair restoration were cultivated in Japan. It was in 1939 that Japanese dermatologist Dr. Okuda described his groundbreaking work in burn patients, using a punch to extract hair-bearing skin, which were then implanted into slightly smaller round holes.² In 1943, Dr. Tamura, another Japanese dermatologist, refined Okuda’s technique by using significantly smaller grafts consisting of one to three hairs to replace lost pubic hair in female patients. He used an elliptical incision to extract the donor tissue and then dissected each individual graft. Interestingly, Dr. Tamura’s technique was very similar to the follicular unit transplantation (FUT) techniques developed years later. The work was lost for over a decade. Both addressed traumatic alopecia and not male pattern baldness.

Fig. 1.1 (a) Large 4-mm punch graft used in standard punch grafting. (b) Potential scarring in donor area from standard punch grafting. (c) Potential unnatural “dolls” head pluggy look produced from standard punch grafting.

1.3 Era of Standard Punch Grafts―1957 to Mid-1980s

In 1952, Dr. Norman Orentreich from New York performed the first known hair transplant for a patient suffering from male pattern baldness. In 1959, after much resistance from his peers, Dr. Orentreich published his findings and set forth his theory of “donor dominance.”³ His work demonstrated that, contrary to past beliefs, hair from the back and the sides of a man’s scalp was for the most part resistant to the balding process, paving the way for hair transplants in male pattern baldness (androgenetic alopecia). He generously taught many physicians and is credited with starting modern-day clinical hair transplants.

Orentreich’s standard punch technique using 4-mm punches with 20 to 30 hairs each was the primary technique performed in the 1960s and 1970s. Sessions were limited by blood supply to 50 to 100 grafts. Unfortunately, although the hair grew well, the ability to create naturalness was a problem. Too often, the technique led to an unnatural “dolls head” appearance associated with transplants from this period. In addition, these large punches left the donor area depleted with a scarred checkerboard appearance (Fig. 1.1a–c).

1.4 Era of Small Grafts and Mini-micro Grafting―1980s to Mid-1990s

The desire to improve naturalness motivated physicians to search for ways to use smaller grafts.

•Early efforts: Physicians like Dr Pouteaux from Paris used 2-mm grafts with some success in the 1970s but most surgeons found that this resulted in a high graft transection rate and very poor growth. Bradshaw from Australia demonstrated cutting 4-mm plugs into smaller “split” and “quarter-grafts” grew well when inserted into slits made with an 11 blade. However, these grafts still contained 8 to 12 hairs and could look “pluggy.”⁴ Others like Nordström and Marritt cut smaller one to three hair grafts (labeled micrografts), from the outside of a donor plug, and used them to “feather” a harsh hairline.⁵ However, this technique did not become a widespread practice.

•Strip harvesting: A significant advance occurred with strip harvesting using a multibladed knife. With this method, multiple thin strips were harvested from the donor area and subsequently dissected into smaller grafts under direct visualization into a variety of different sizes. The single linear scar left in the donor area was an improvement over the previous multiple large circular scars

The increased ease of small-graft production led to more physicians doing larger sessions of small grafts (400–800 grafts) placed into smaller incisions closer together. Although, collectively called micro-mini grafting, significant variation existed in the number and combination of different-sized grafts used.

1.5 Mega Sessions Using Exclusively One to Four Hair Grafts

The trend toward even greater numbers of smaller grafts continued, and by the 1990s we began to see very large, 1,000-plus sessions using exclusively one to four hair grafts, called “mega sessions.” Uebel from Brazil was probably the first to do this, cutting the small grafts from a donor ellipse with the aid of optical loops.6 The Moser Clinic from Vienna refined Uebel’s technique and published their results of 1,000-plus graft cases in the Hair Transplant Forum in 1992, creating an instant sensation. Rassman upped the ante by performing a session of over 3,000 grafts in 1993, consisting exclusively of one to three hair micrografts.

Around this time in 1993, the International Society of Hair Restoration Surgery (ISHRS) was founded by Dow Stough and O’Tar Norwood with the “ Hair Transplant Forum International” as its newsletter. This was a significant development for the advancement of the field as, almost immediately, the ability to share information and techniques improved.

1.5.1 The Rise and Fall of Flaps and Scalp Reductions

Flaps and scalp reductions were popular adjuncts and alternatives to hair restoration before small grafts became popular. As the ability to consistently produce high degrees of naturalness and coverage with small grafts increased, the use of flaps and reductions fell out of favor. The potential complications were significant, including flap failure, “central slots,” and “white sidewalls.” Today, these procedures have a useful but more limited place in hair restoration surgery, usually for the repair of major scalp defects caused by trauma or congenital abnormalities. An exception is a unique “hairline lowering” flap procedure for women championed by Dr. Sheldon Kabaker, which is still popular and may be the preferred procedure in some women (see Chapter 86, Hairline Lowering Technique, Chapter 87, Scalp Extension and Triple-Flap Techniques to Treat Extensive Baldness, and Chapter 88, Scalp Repair Using Flaps and Tissue Expanders).

1.6 Follicular Unit Transplantation―1995 to Present

The next major advance in hair transplantation came with the shift from using simple micrografts to the use of more refined follicular unit (FU) grafts.

This advance began with the recognition by Headington in 1984 that hair grows in tiny, naturally occurring groupings of one to four hairs called follicular units.⁷ With this observation, some physicians began using microscopic magnification to isolate and dissect grafts that kept these natural groupings intact (Fig. 1.2). Dr. Bobby Limmer from Texas was probably the first to do this in 1988.His results were announced in the FORUM Newsletter as early as November 1991 when he had already been using microscopically dissected grafts from skin flaps for 3 years. However, he did not specifically call the grafts follicular units and did not publish his finding until 1992 until sure of his results.⁸ Dr. David Seeger from Canada, who learned from Limmer, was very active in promoting and teaching this technique.⁹ Drs. Bernstein and Rassman wrote the first actual paper defining FUT in 1995, explaining the characteristics and benefit of this technique.¹⁰