Hair Transplant History

Surgical hair transplantation has manifested in many forms over the past several decades but one factor has remained constant; hair transplant surgery is still, by far, the most reliable option for achieving quantifiable and consistent results for treating hair loss. This references the ability to grow hair where once there was no hair and is not intended to imply cosmetic outcomes. This greatly depends on the type of hair loss as not all forms of hair loss can justify surgical intervention.

The history of hair transplant surgery is longer than most people may realize. There are references to very crude forms of hair transplant surgery as far back as the 1800’s. Dr. Menahem Hodara of Istanbul, Turkey performed the first documented hair transplant experiment in 1897. The experiment included the transplantation of hair from one part of the patient’s scalp to another area that had developed scarring alopecia due to a fungal condition known as Favus. The hair did not appear to be surgically harvested but rather was cut and refined into smaller strands of 1mm to 4mm in length. Dr. Hodara prepared the recipient zone by cutting into the scar tissue and placing the strands of hair into the incisions. He then covered the recipient area with a type of plaster for a period of four weeks. After the plaster was removed he noted some remaining hair and subsequent growth. Dr. Hodara conducted at least two more hair transplant experiments and the news of his efforts was an exciting development in the media but he never received widespread recognition and credit by his peers.

Hair transplantation continued to have very little progress in the early 20th century and it could even be said to have been moved backward. Dr. J. S. Parsegan developed the first handheld hair transplant machine in 1921. Dr. Parsegan would use his device to pluck long strands of hair from women (18 to 20 inches in length) and transplant them into the scalps of men. The reasoning was that men did not have such long hair so it was more feasible to use hair from women. The hair would then be injected into the patient scalp and cut above the dermis. The operator would then move on to another area to do the same thing. The logic presented at the time stated that the injection of these hairs into the male scalp would stimulate new hair growth as the hairs transplanted were never intended to grow on their own. There are no known reports of the efficacy of this approach.

Eight years later in Japan Dr. Sasagawa created his own custom tools consisting of various needles for what could be considered to be true hair transplant surgery. Previously known efforts involved transplanting only cut hair shafts but Dr. Sasagawa attempted to transplant complete and intact follicles. These attempts are thought to have mostly resulted in failure but in the 1930’s Dr. Shojui Okuda improved on the work of Dr. Sasagawa and successfully transplanted complete hair follicles with documented subsequent growth. Dr. Okuda carried on his work with hundreds of documented cases. Ironically, there isn’t a single documented case of hair transplantation to treat androgenic alopecia but rather Dr. Okuda’s focus was transplanting hair for burn victims and for reconstruction of pubic regions, eyebrows and even eyelashes. Dr. Okuda’s own custom instrumentation consisted of 4mm punches but some of his punches were as small as 1mm in diameter. It would take nearly sixty years for the more refined variation of his method to be reintroduced to the field.

In 1943 another Japanese dermatologist, Dr. Tamura, published a paper in the Japanese Dermatological Journal describing his efforts for transplanting hair. He used 1mm punches more often than Dr. Okuda from several years prior and even went so far as to trim his harvested grafts for additional refinement. Dr. Tamura created an historical mirror of modern follicular unit extraction with his approach which unfortunately was overlooked and forgotten.

In 1952 Dr. Norman Orentreich performed the first hair transplant surgery in North America and is mistakenly credited as being the father of modern hair restoration. He used 4mm punches to core out multiple groupings of hair, much like Dr. Okuda in Japan twenty years prior. After he published his results and findings the field of surgical hair restoration was born and has grown year after year ever since. These punch “plugs” were transplanted, in whole, into similar sized incisions made into the recipient scalp which looked largely unnatural but with this being the only proven alternative to baldness the procedure gained in popularity.

Dr. Orentreich also noticed that hair transplanted from the back and sides of the scalp were not affected by traditional hair loss like the hair found on the top of the scalp. This led to Dr. Orentreich publishing a paper describing his “Theory of Donor Dominance” in 1959. This theory stated that hair follicles unaffected by androgenic alopecia would continue to grow in bald or balding areas previously affected by hair loss. It was this discovery that opened to the doors to over sixty years of hair transplant surgery in every developed country in the world. Once the medical world learned that hair transplanted from specific regions of the scalp would continue to grow unaffected by the causes of male patterned hair loss then the popularity of the procedure skyrocketed.

During the history of hair transplant surgery and hair loss treatments up to this point there had never been an official classification system for reference. In 1975 O’tar Norwood of Oklahoma City, Oklahoma realized this and set out to create such a classification system. Dr. Norwood gave us the Norwood Hair Loss Chart. This has become the world standard for evaluating and classifying the multiple stages of hair loss due to androgenic alopecia. The chart starts with documenting the most mild of hair loss stages to the most extreme with multiple stages listed in between. It is understood that this hair loss chart does not describe every level of male pattern hair loss but it does address the most common and has so far withstood the test of time for over forty years.

There were additional methods of surgical hair restoration that were developed in the 1970’s but they cannot be considered true hair transplantation as there is never a complete separation of hair bearing tissue from the scalp. One method of hair restoration is referred to as the “flap” procedure with multiple variations available depending on the doctor performing it. The flap was first introduced in the 1930’s but it wasn’t until 1969 when Dr. Jose Juri of Argentina made the procedure more palatable for patients and other doctors alike. The procedure involves moving a long and narrow strip of hair that is cut away from one side of the scalp. Ninety-five percent of this strip is physically removed from the scalp similar to a modern follicular unit strip surgery but it is left attached on one end. This end is twisted to allow the strip to lay across the frontal scalp inside of a new incision designed to accommodate this new strip of hair. The procedure has been widely discarded and it is not known if any doctor still performs this procedure. It has been noted as being dangerous for the patient due to the excessive amount of bleeding and relatively high chance of scalp necrosis.

The second method introduced in this time frame is the scalp reduction. This procedure was more straightforward than the flap and involved the simple, and logical, removal of bald scalp to address hair loss. Once the bald scalp tissue is surgically removed then both sides of the wound would be pulled together resulting in an immediate cosmetic improvement. This procedure also is no longer performed and is considered to be dangerous due to the high probability of severing larger arteries and the potential for necrosis if incorrectly performed. The result for the patient also made normal hairstyles difficult and it left behind a scar pattern that, if seen, identified that a scalp reduction had been performed.

The punch grafting technique popularized by Dr. Orentreich continued to gain popularity in the 1970’s and was used as an adjunct to the scalp reduction and flap procedures that were also gaining in popularity. In the 1980’s punch plugs and the other alternatives were beginning to wane in popularity as doctors realized they could take more hair from a concentrated region of the posterior donor scalp and then suture the area closed. Up to this point doctors would allow the 4mm donor wounds to heal through secondary intention, or “open donor healing”. This would result in large 4mm wide, round scars that were unappealing cosmetically. When the 4mm punch plugs were removed in a tight, rectangular pattern the final extraction pattern would resemble one larger overall wound which could be pulled together with surgical sutures resulting in more of a linear, single scar. This is how “strip” surgery was born.

Strip surgery is the excision and removal of longer slivers or strips of hair bearing tissue which is a direct result of doctors wishing to reduce the amount of visible scarring in the patient donor area. Early on in the development of this new procedure doctors would use multiple scalpel blades used in tandem to make narrow parallel incisions at once. The incisions would extend across the back of the patient scalp and would be closed into one linear closure using sutures. This was a very fast approach to donor harvesting that matched the speed of punch grafting but would result in high transection rates.

Two additional developments transformed strip surgery into the gold standard of the mid-to late nineties and well into the twenty tens. The first was the addition of high powered stereoscopic microscopes as introduced by Dr. Bobby Limmer of San Antonio, Texas. Dr. Limmer has been using microscopes for a number of years and was being recognized for his natural results that were well beyond that of his peers. His use of microscopes allowed his technicians to separate the natural hair groupings, termed “follicular units” as they grow naturally in the scalp. Dr. Limmer argued that by transplanting these “units” that the naturalness will be far superior to other techniques. His observations and methods caught on and became the industry standard approach to hair restoration for many years. The second development was the elimination of the multi-blade handle and the move to a single scalpel for donor strip harvesting. Some studies noted that the addition of stereoscopic microscopes helped to improve hair transplant yield by up to 30%. The addition of the single blade scalpel also helped to raise the final yield percentages due to the greatly reduced donor zone transection.

Follicular unit extraction, or “FUE”, can trace it’s roots all the way back to Dr. Okuda in Japan in the late 1920’s and early 1930’s with his use of 1mm punches for surgical hair transplantation. It was in the late 1980’s that Dr. Ray Woods of Sydney Australia continued this development and became known as the father of modern FUE. Dr. Woods, and his sister Dr. Angela Campbell, wished to enter the field of surgical hair restoration but did not want to contribute to the potential negative scarring side effects seen on many patients of the era. They sought to find a minimally invasive alternative and that eventually ushered in the current era of FUE. It is not known if Dr. Woods gained access to the “Okuda papers” or had some other method of learning of Dr. Okuda’s work. Dr. Woods campaigned to have his procedure accepted in the industry but it was met with a negative response from the industry for several years.

In 1999, after being frustrated with the negative response to his new technique, Dr. Woods reached out to consumer advocate and author of the international best selling book, The Bald Truth, Spencer Kobren. Dr. Woods invited Spencer Kobren to New York City to meet him and some of his patients, some of which had been repaired with Dr. Wood’s FUE technique after having failed hair transplant surgeries from other methods. Spencer Kobren immediately saw the benefits of FUE and set out to inform the then leaders of the hair transplant establishment that FUE was a legitimate development that should be learned and understood. In 2002 several North American doctors decided to try and develop their own method of FUE. Among the North American pioneers of follicular unit extraction were Dr. Jones of Toronto Canada, Dr. Alan Feller of New York, Dr. Alan Bauman of Boca Raton, Florida and Dr. John Cole of Atlanta, Georgia. Each of these doctors had their own versions of FUE that were largely the same. These methods consisted of using a small punch in the 1.0mm to 1.2mm diameter range in order to harvest individual follicular units in order to treat androgenic alopecia.

Since 2002 the field of FUE has been extremely controversial but it has gained steady support. In 2008 the world’s first surgical hair transplant robot was introduced by Restoration Robotics, Inc. The robotic system is known as “ARTAS”. After the system gained FDA clearance units were being tested by various hair restoration surgeons working with Restoration Robotics, Inc. The goal was to gauge efficacy and reliability while delivering a consistency to rival that of its human counterparts. Through updated telemetry data transmitted by each robot in the market the engineers at Restoration Robotics improve every system built through regular firmware and algorithm updates. RR has also been working with medical professionals to improve the mechanics of the system with improved dexterity as well as smaller punch sizes for donor harvesting that currently match the punch sizes used by hair transplant surgeons that utilize handheld manual punch systems as well as hand held micro-motor punch systems. The continued development of the ARTAS system now allows for recipient site creation utilizing the lateral slit technique which includes recipient sites created by flat blades custom cut to match the size of the harvested follicular units. The system performs hairline design and maps out the area to be addressed, all with the latest algorithms and supervised by a qualified hair restoration physician.

In 2014 the International Society of Hair Restoration Surgeons (ISHRS) polled the nearly 1200 member doctors world wide regarding various aspects of their respective surgical practices. One result from this poll revealed that the number of FUE surgeries performed worldwide had gained parity with the number of FUSS procedures performed worldwide. This was a watershed moment as until then the legitimacy of FUE had continued to be questioned with regards to it’s effectiveness when compared to the gold standard of the past twenty years, FUSS.

FUE continues to gain ground in the overall marketplace and it now can be considered to be the dominant form of surgical hair restoration worldwide.