Updated: Aug 9, 2020
One of the most important technical achievements in hair science in the last century
was the development of hair transplant. This revolutionary discovery
allows both people suffering from various types of head injury and sufferers from alopecia
to enjoy their life again.
Before the introduction of the hair transplantation method, people could only try to stop
the process of hair loss by pharmacological therapy. Therefore, aroused great interest in
various ointments and other preparations sold as effective products to get rid of baldness
and regain lush hair. The effectiveness of such products was, however, none.
In addition, various kinds of wigs and hairpieces were very popular due to their ease of use
and maintenance. The problem with the hairpieces was that they must be periodically
adjusted, requiring repeated visits to the salon and significant expense. Because they can’t
be removed at night, they cause traction hair loss, making the user even more dependent
on the hair piece. After all, to this day many people still use this solution.
However, the desire to restore a human's natural appearance contributed greatly to the
development of hair restoration.
The technique of hair transplantation was first introduced by Dr Shoji Okuda in Japan in
1939. The surgeon used small micro-grafts to replace damaged areas of eyebrows or lashes,
for burn victims but not to treat baldness.
Okuda used personally designed trephines (punches) to remove those skin plugs containing hair. After local anesthesia, the punch was rotated deeply to the level of the
subcutaneous fat layer, taking particular care with hair direction and depth of the hair
bulbs. The incised plug was pulled up with tweezers, and the subcutaneous attachment was
then cut with fine scissors and plugs were implanted into smaller round holes. These holes
were prepared in the scarred or burned areas of his patients. After the skin grafts
healed, they continue to produce hair in the previous bald area of the scalp. Okuda
described how almost all transplanted hair were shed 20-30 days after transplantation and
grown back again around 90 days after the transplant. He has also described in detail
the cases of 200 patients for whom carried out the hair transplantation and eyebrows and
claimed 100% growth success in all of his cases.
Due to war and isolation of Japan, Okuda's achievements and publications were not known
in the western world, until the 50's of XX century.This technique has been newly developed and widely popularized in the 1950's in the United States.
The first transplant carried out by Dr Norman Orentreich utilizing punch grafts with a
diameter of 4mm. Dr Orentreich inserted the hair grafts into the bald area with a small
punch, placing them about 1-graft size away from each other. This distance was to
preserve the blood supply surrounding the newly placed grafts. Dr Orentreich showed that
the success of hair transplants for androgenetic alopecia is dependent on donor dominance.
Donor dominant transplants continue to show the hair-growing characteristics of hair from
the donor site after transplantation to the recipient site.
This technique ensured the possibility of an effective transfer of hair, but leaving an
unnatural aesthetic effect, referred to as "Doll look" (growing in individual clumps). The
only way to resolve the doll head appearance was to do multiple procedures in the attempt
to fill in the gaps between the plugs. Many patients disappointed with the initial results did
not finish the process.
Modifications introduced in subsequent years by many specialists were to reduce
dimensional transplants, partly thanks to the applied new specially designed tools and
As a result in the 1980's, Dr Bob Limmer in San Antonio, Texas introduced the use of the
stereo-microscope to dissect a single strip into small micro-grafts. Microscopic dissection
averaged only about 150-200 grafts per hour and greatly increased the number of staff
members for each procedure.
Dissection teams of 10 or more assistants became common and additional 2-3 assistants
were required for graft implantation.
There was a downside to this development too. It was no longer possible for a cosmetic
surgeon with a casual interest in hair restoration to perform these new procedures at a
high standard. Unless he had a regular flow of hair patients, it was not feasible for the
surgeon to assemble, train and keep a large team of surgical assistants together and
therefore technique became restricted to few dedicated teams.Almost at the same time, Finnish surgeon, Rolf Nordstrom applied as the first,micro-grafts (usually one to three hairs each) to reconstruct the hairline, the most visible landmark, which was extremely important and the most complicated part of the transplant.
Micro-grafts improved considerably the aesthetic effect of the treatment. Several years
later others also found that these small grafts gave a very natural and good result,
wherefore many surgeons all over the world use those micro-grafts to reconstruct naturally
In the later years, Walter Unger a disciple of Dr Norman Orentreich, based on 328
examined patients and classified in terms of age and degree of male pattern baldness
defined the parameters of the "Safe Donor Zone" from which the most permanent hair
follicles could be extracted for hair transplantation. As the transplanted hairs will only
last in its new site for as long as it would have in the original one.
Another important person who contributed to the further development of hair transplant
is a Polish doctor Jerzy Kolasinski.
As the world's first published algorithm reconstructive treatment of hair loss in children.
Dr. Kolasinski has studied children in the age group of 4 to 17 years over a period of 18
years. The most common causes of hair loss in this group of 57 children were burns, x-ray
irradiation and mechanical trauma. In most of these patients, the hair was transplanted
using the four hands stick and place technique. In this technique, hair follicles are
harvested as strips [1 cm wide and 7-12 cm long] from the back of the head. The strip is
then sectioned to obtain micro-grafts [1-2 hairs/graft] and mini-grafts [3-4 hairs/graft].
Using a scalpel an incision is made in the scalp, the wall of the incision held under slight
pressure to keep it open and the graft is placed immediately with the help of a forceps.
This procedure involves two people, the surgeon and his assistant who use their hands
deftly in a highly coordinated manner
He is currently an active member of the International Society of Hair Restoration
Surgery.This evolution has led to a final reduction in the size of hair transplant to one follicular unit (graft). A follicular unit contains a single hair or multiple hairs grouped together, and also contain sebaceous (oil) glands, nerves, a small muscle, and occasional vellus hair, which are finer than the normal scalp hair.
They are all distinct anatomic entities, so keeping them intact during the harvesting
process from the donor area maximizes the chances of successful regrowth once they are
implanted into the recipient area of the scalp.
A major advantage of using follicular units in hair transplantation is to be able to keep the
recipient sites as small as possible. The smaller the recipient sites, the closer together
they can safely be placed in the scalp. Transplanting follicular units allows the most hair to
be placed into the smallest possible recipient sites, giving maximum fullness to the hair
transplantation procedure. This guarantees that these grafts will not appear pluggy,
because follicular units represent the way hair grow in nature.
Although using follicular units prevents a pluggy look, they must be placed in the
proper direction and distribution to ensure a totally natural appearance to the hair
Nowadays, there are two primary methods of hair transplantation, both have their special
indications and can be combined.
FUT (follicular Unit Transplantation) - a section of scalp containing healthy hair is removed
from the donor areas on the back and sides of the head in a long narrow strip. This donor
area is then closed with sutures (stitches), leaving a linear scar at the back of the
patient's head. The harvested strip is immediately immersed in chilled normal saline.
Proper hydration of the donor grafts with cold saline is very important throughout the
surgery as it influences survival rate of the grafts.
Technicians, with the aid of a microscope, make the smallest grafts possible by separating
the naturally occurring groupings of follicular units from surrounding bald skin. Those grafts are then transplanted to the balding areas.
Although the resulting scar on the back of the head is very easy to hide by the remaining
donor hair, however, it results in a certain group of patients a discomfort. Therefore, the increasingly popular is the FUE method (Follicular Unit Extraction), which is characterized by a different way of raising the hair follicles for transplantation and leaves no linear scar at the back.
The individual grafts are extracted from donor area with micro punches and replaced in
areas where the hair loss and thinning are more prominent. FUE harvesting of grafts causes “pit” scarring, small, round, and white scars in the patient’s donor area where the grafts have been removed. Those small scars are often hard to detect when the hair in the donor area is at normal length and the extraction is performed by a skilled surgeon. However, with FUE, the follicles are harvested from a much bigger area of the donor zone compare to FUT. Maximum follicular unit graft yield is lower than with FUT and may result in greater follicular transection.
The FUE method is suitable for people who are going to wear very short hair as well as
corrections of linear scars. Follicular unit transplantation has made eyebrow, beard and mustache reconstruction viable. Men with naturally small or light beards who desire better coverage, or those whose beards have been damaged by accident or disease, can have follicular unit grafts placed in the area. Bald area of the eyebrows can result from excessive tweezing, hypothyroidism, trichotillomania, and naturally poor density. If medical treatment is indicated, it should always precede any cosmetic surgical procedure. Treating hypothyroidism with the appropriate medication may cause the regrowth of some hair. Therefore, the area shouldn’t be evaluated for surgical treatment until the medical therapy has been completed.
Proper eyebrow reconstruction requires great attention to detail. Single hair follicular
units should be used to achieve the most natural-looking eyebrows.
And since the transplanted hair came from the head, it will continue to grow in the
eyebrow area, requiring occasional trimming.
In the past few years, the development of tools that automates the process of extracting
individual hair follicles has made impressive progress.
NeoGraft is a revolutionary device, which automates the hair transplant, shortens the
treatment time and provides greater precision. NeoGraft extracts follicular units
according to specifications programmed by the physician.
NeoGraft uses a controlled pneumatic pressure to slide out the graft smoothly, so there is
no pulling or twisting which can risk damaging the graft. In a manual FUE procedure, the
surgeon selects the grafts to be extracted, estimates the angle the hair grow out of the
scalp, centers the extraction instrument over the graft and then manually removes it from
the surrounding tissue. The smallest deviation with a hand-held tool can transect (damage)
the follicular unit. NeoGraft helps to minimize transection caused by human error.
Along with greater accuracy, reduces the percentage of damage to the grafts, which is
very important for the final results.Better results, shorter recovery period, no scars, and less surgical intervention contributed to the large popularity of this alternative method.
Scalp micropigmentation (SMP) is a new technique that offers an alternative for patients
who are not candidates for hair transplant surgery (with limited donor hair or are too
young). It also helps to camouflage the appearance of thinning hair and scalp scarring due
to a variety of causes.
Scalp micropigmentation is a permanent tattoo (tiny microdots) that mimics the very short
hair. The pigment is used on the scalp to create the appearance of real hair follicles
recreating hairline and adding the appearance of density to the thinning areas. These dots
are created using specifically formulated pigments and are skillfully implanted into the
scalp in a very detailed patterned sequence. SMP doesn’t penetrate the skin as deeply as
normal tattooing avoiding the blueing effect of aged tattoos and the ink colour can be
matched to the previous hair colour and skin tone for the most realistic look achievable.
The result is the immediate and permanent look of the very stylish, popular and widely
accepted buzz cut. Because of the non-invasive procedure of SMP, healing time is limited
to only a few days. SMP procedure for an average full head can take a cumulative 12-20
hours in two or more sessions. Half the head for the treatment of scars takes usually 8-12