Hair transplants have been used to treat hair loss for nearly 200 years. One of the first hair transplants recorded took place in Germany in 18221. Diffenbach, a medical student, along with his professor, Dr. Unger, successfully transplanted hair from one area of the scalp to another1. They were able to effectively perform hair transplants on both animals and humans. Despite their success, hair transplants were only used sporadically in the following years1. In the late 19th century, hair transplant techniques improved to include hair-containing skin flaps and grafts to treat traumatic injuries and burns1.
In the 1930s, Dr. Okuda, a Japanese physician, became the first to use hair baring skin to correct hair loss found on the scalp, eyebrow region and upper lip2. It wasn’t until many decades later, when his work was translated into English by Yoshihiro Imagawa, that his methods became available to English speaking hair transplant surgeons2.
In 1959, Dr. Orentreich, who is nicknamed the father of modern-day hair transplantation, made a number of important contributions to the hair transplantation field3. Dr. Orentreich discovered and defined “donor dominance” and “recipient dominance”, key concepts used today3. Grafts with recipient dominance have the ability to take on the characteristics of their surroundings3. Donor dominance, on the other hand, are grafts that remain the same and don’t conform to their surroundings3. Using these concepts, Dr. Orentreich determined that for successful hair transplantation, grafts with donor dominance should be used.
Dr. Walter Unger, who was mentored by Dr. Orentreich, took this idea even further by defining the safe donor zone. The safe donor zone contains “permanent hair”, usually located in the lower part of the scalp. The term “permanent” did not necessary mean that these hairs would remain after being transplanted4,5. Instead, these hairs were considered to have the best chance of survival, making them great candidates for transplant.
Years following these new hair transplant concepts and pioneered procedures, additional techniques started to emerge such as mini-grafting and mini-micro grafting. Mini-grafting involved removing small grafts from a strip of hair bearing skin from the back of the scalp6. Mini-micro grafting was a similar method and was used to achieve a more natural look by surrounding a larger graft with smaller grafts6. With these two techniques, less donor tissue was used as compared to grafts made in previous years. Having less donor tissue in the grafts enabled surgeons to either create light coverage over large balding areas or increase hair density in specific balding regions6.
Building upon the mini-graft technique, follicular unit transplantation (FUT, also known as the strip method) was developed. During FUT, a large number of clustered scalp hair (known as follicular units) are removed at the same time through the removal of a hair bearing skin section7. This removed skin strip is then cut into grafts and implanted into balding or thinning areas. The strip method is a popular harvesting technique used today, creating a large amount of high quality, viable grafts8,9.
In the early 2000s, follicular unit extraction (FUE) was developed. Instead of removing a strip of hair bearing skin, this harvesting method removes individual follicular units9. These follicular units are then implanted into desired areas. Through FUE, a linear scar can be avoided10.
Due to the amount of time and skill needed to perform FUE, movement away from manual procedures and towards robotic techniques has occurred. Powered devices, such as those developed by Dr. True and Dr. Cole, help decrease the amount of time required to harvest13–16. Additionally, the ARTAS robotic system, developed by Restoration Robotics Inc., can overcome limitations like physician fatigue as well as decrease the amount of harvesting time required17.
The use of the ‘stick and place ‘ technique applies to both strip and FUE harvesting and this was popularized by Dr. David Seager of the Seager Medical Centre. In this technique the holes for the graft in the recipient area are made and the graft is placed in position as the hole is made. Conversely, in the recipient area, the holes for the grafts would be created and then the grafts would be placed into the pre-made holes. There are several advantages of the ‘stick and place’ technique: only the required number of holes are created in the recipient area; secondly, the amount of bleeding in the recipient area is better controlled since each time the hole is made it is filled immediately with a graft; thirdly, with pre-made holes sometimes it is difficult to find that pre-made hole because it has a tendency to close with time. In the ‘stick and place’ technique this is not an issue. At the Seager-Sure Hair centre we use the ‘stick and place’ technique. Although it takes longer to plant the recipient area with this technique we prefer it for the above-mentioned reasons.
With the use of technology, there have been wide strides made in the field of hair transplantations over the last 200 years. Through continual study of hair loss conditions and contributions made by hair surgeons and researchers, the techniques used in hair transplants will continue to evolve into more successful and effective treatments.
Article by: Sarah Versteeg MSc, Mediprobe Research Inc.
- Historical Overview: 181 Years of Hair Restoration Surgery [Internet]. ISHRS International Society of Hair Restoration Surgery. [cited 2016 Dec 6]. Available from: https://www.ishrs.org/mediacenter/media-history.htm
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- Orentreich N. Autografts in alopecias and other selected dermatological conditions. Ann N Y Acad Sci. 1959 Nov 20;83:463–79.
- Cole J, Devroye J, Lorenzo J, True R. Standardization of the terminology used in FUE: Part II. Hair Transpl Forum Int. 2013;23(6):210–2.
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- Headington JT. Transverse microscopic anatomy of the human scalp. A basis for a morphometric approach to disorders of the hair follicle. Arch Dermatol. 1984 Apr 1;120(4):449–56.
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- Harris JA. New methodology and instrumentation for follicular unit extraction: lower follicle transection rates and expanded patient candidacy. Dermatol Surg Off Publ Am Soc Dermatol Surg Al. 2006 Jan;32(1):56–61; discussion 61–2.
- Devroye J. Powered FU Extraction with the Short-Arc-Oscillation Flat Punch FUE System (SFFS). Hair Transpl Forum Int. 2016;26(4):129, 134–6.
- Harris J. Powered blunt dissection with SAFE System for FUE Part II: the extraction process. Hair Transpl Forum Int. 2011;22(1):16–7.
- Ng B. Powered blunt dissection with the SAFE system for FUE (Part 1). Hair Transpl Forum Int. 2010;20(6):188–9.
- Bicknell L, Kash N, Kavouspour C, Rashid R. Follicular unit extraction hair transplant harvest: a review of current recommendations and future considerations. Dermatol Online J. 2014;20(3).
- Gupta AK, Lyons DCA, Daigle D, Harris JA. Surgical hair restoration and the advent of a robotic-assisted extraction device. Skinmed. 2014 Aug;12(4):213–6.
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