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The
history of hair transplants
The idea of transplanting hair has been around for a long time.
Animal and bird studies involving the transplantation of hair follicles
or feathers were conducted by several doctors in the early to mid
1800s. However, these studies were not specifically directed at
the development of a treatment for hair loss. The first to make
the connection between hair transplantation and a treatment for
alopecia was one Dom Unger who stated “tunc calvities res
rara erit” or “then baldness will be a rare thing”.
A student of Unger, Johann Friedrich Dieffenbach, published a dissertation
in Wurzburg, Germany in 1822 in which he reported what is probably
the first hair transplant in humans. Using a needle, he made holes
in his own arm and inserted 6 scalp hair follicles. Of these 2
dried up and fell out, 2 were expelled due to an inflammatory reaction,
but 2 became fixed and continued to grow. So follicular unit transplantation
is actually a technique that is over 180 years old! In subsequent
experiments, he improved his transplantation technique and even
started transplanting hair follicles to replace eyelashes. However,
while Dieffenbach, a highly skilled surgeon, was able to conduct
such procedures with the relatively crude surgical instruments
of the day, other surgeons were unable to repeat his success in
hair transplantation. Research on hair transplantation did not
progress and new developments were not seen until 100 years after
Dieffenbach’s work.
The focus for hair transplantation development moved to Japan.
Sasagawa in 1930 reported on a hair shaft insertion to treat hair
loss, probably the first study that intentionally focused on the
development of a surgical procedure to treat scalp alopecia. In
1939, Okuda described the use of small full thickness autografts
of hair bearing skin for the correction of alopecia of the scalp,
eyebrow and mustache areas. In 1943, Tamura, reported the reconstruction
of the female pubic escutcheon by grafting single hairs. However,
because of the Second World War, and the fact that the reports
from Sasagawa, Okuda, and Tamura were published in
Japanese dermatology journals, the reports were not generally read
outside
of Japan. In 1953 Fujita reported the eyebrow reconstruction in
leprosy patients by hair grafting. He also reported punch hair
grafting in which a free skin graft with hairs was divided into
small pieces, each containing two to three or four hairs, using
a scalpel or a pair of scissors. These pieces were inserted separately
into many holes, which were prepared in the recipient site utilizing
a thick injection needle or a slender scalpel. Ths approach is
very similar to the modern method of hair transplantation, but
Fujita's work was not widely recongnised outside of Japan until
many years later when in 1976 Fujita wrote a chapter on his work
and
and other
studies in Japan for a book published in the USA.
It was not until the technique of hair transplantation was
published in the English language that the technique really took
off. In 1950, Barsky reported on the treatment of an individual
with a scarring alopecia by implanting small grafts of hair bearing
skin. In 1959, Norman Orentreich published a key paper describing
the theory of donor dominance in hair follicle transplantation.
Orentreich developed a punch grafting technique of hair transplantation
and conducted an experiment on 52 volunteers with androgenetic
alopecia. He took four full thickness punch grafts of skin form
each volunteer, two were of bald scalp skin, and two were taken
from adjacent, normal hair bearing skin. The grafts were then moved
one hole so that one graft of bald skin was grafted to an area
of bald scalp while the other bald scalp graft was placed in a
hole in a hair bearing area. Similarly with the two hair bearing
punch grafts, one was grafted to a hair bearing area and the other
was grafted into a bald skin area. By observing what happened to
the punch grafts, Orentreich concluded that the hair follicles
in bald skin failed to regrow normal terminal hair even when they
transplanted to a terminal hair bearing area. Equally, normal terminal
hair bearing punch grafts continued to grow even when grafted to
an area of bald skin. This proved the principle of donor dominance,
that hair follicles from a hair bearing region could be transplanted
to a bald region and would continue to grow – the transplanted
follicles kept the characteristics of the hair follicles in the
area from which they were taken, and continued to grow when transplanted
to an area of miniaturized hair follicles in bald skin. This study
finally proved that hair transplants could be used to treat androgenetic
alopecia. Orentreich soon had many disciples in America and Europe
and word quickly spread about this wonderful new technique. By
1970 the technique was being performed by small numbers of dedicated
practitioners in many different countries.
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This
is an old photograph taken of an individual who underwent 4mm
punch biopsy grafting to treat androgenetic aloepcia. The photo
was taken a few weeks after the operation when the new
hair was just beginning to grow. As you can see, the punch
grafting technique resulted in a very unnatural hair line. However,
modern hair transplant techniques have come a long way and now
give a very natural looking result. |
Until about 1975 Orentreich’s 4mm size cut or punch graft
method remained the basic procedure, but the large punch graft
approach resulted in a rather "pluggy" result. Initially, the grafts
were simply placed in holes in the skin and granulated tissue was
allowed to form around the grafts. Gradually
it was learnt that suturing these large grafts
into place
would promote improved wound healing (Carreirao 1978; Pierce 1979).
The hair follicles grew in the grafted clumps and this gave a look
similar
to a doll's
head with tufts of hair sprouting out from bald skin. Large
graft plugs can be quite effective when filling in bald areas behind
the hair
line,
but
large graft
plugs
in the
hair
line are very obvious when you see them. The desirability of
using
smaller
punch
grafts
was
clear
to most surgeons
using the punch graft technique and some surgeons did attmept to use smaller
grafts. But, although studies were conducted in an
effort to improve the technique and make a more natural looking
transplantation, it took 30 years before a refinined technique
with minigrafts was developed.
In the years after Orentreich's study several improvements were
made that enabled the minigrafting technique to be developed. The
punch
graft
tools
used in the 1960s were not as sharp as the ones used today. The
first improvement in punch graft tools was a mechanised punch that
rotated like a drill and could be used to quickly make punch grafts
and holes and made for nice clean edges to the graft and less damage
to the hair follicles (Tezel 1969). The problem however, was that
the rotating drill-like punch produced aspirates of airborne blood
particles as it cut the grafts. This was soon recognised as a potential
infectious hazard for the surgeon and nurses. The mechanized
punch graft tool gradually disappeared from the hair transplant
clinic with three new developments, though a few were still using
it well into the mid 1980s (Alt 1984). In the mid 1970s Dr Richard
Shiell introduced
hand punch graft tools with hardened carbonized steel blades that
were sharper and
stayed sharper for longer reducing the need for mechanized punches.
At about the same time, injection of saline into the donor area
was found to increase turgidity and enhanced the ability
to cut the donor skin
quickly
and easily with less damage to the donor graft skin (Frankel
1975). Also, there was a gradual move away from using punches to
harvest the donor grafts towards using scalpels to cut strips of
skin.
Vallis introduced the now very popular method of donor graft harvesting
using a multibladed knife. He used a scalpel with two blades
a fixed distance apart to cut the donor strip of skin from the
back
of the scalp (Vallis 1964). Today, around 70% of hair transplant
surgeons use a scalpel with 2, 3 and even up to 9 blades to cut
the donor skin. Vallis actually grafted the strips of donor skin
in their entirity along with smaller punch grafts as his preferred
method of transplantation (Vallis 1982). However, this form of strip
grafting did not become popular and most surgeons moved to cutting
square donor grafts from the long donor strips prepared with
multi-blade scalpels (eg Coiffman 1987).
Smaller grafts were introduced by
dissecting the traditional 4 mm plugs and squares into halves or
quarters using a scalpel. The idea was first introduced in the
1970s but it took another 10 years for the approach to become widely
used (Orentreich 1970; Stough 1986; Lucas 1988). Mini and micrografts
were introduced by Emanuel Marritt and and Rolf Nordström
with Marrit using minigrafts for eyelash transplantation (Marritt
1980;
Nordström 1981). This produced a much less tufted appearance
in the finished result.
These grafts
still had up to 8 hairs however and could still appear quite
tufted when working with coarse black donor hair. Further subdivision
of the grafts into smaller pieces containing 2-4 hairs was made
popular by Uebel, Bradshaw, Stough and Brandy (Bradshaw 1988;
Stough 1991; Uebel 1991). While these refined techniques gave a
much more
natural
look hair transplant result, the techniques were much more labor
intensive. A grater number of smaller grafts had to be implanted
to transfer the same number of hair follicles as with the old,
large punch graft approach. At this time the cost of transplantion
rose significantly as more people were required to process and
implant the grafts. By 1990 the typical hair transplant procedure
involved about 12 work hours for hair transplant team and
on average 1000 small grafts were transplanted.
The number of work hours per hair transplant procedure increased
to 40 in the 1990s as further refined techniques
increased
the average number of grafts implanted per session to 3000. In
1994 Bob Limmer introduced the method of dissecting the grafts
under stereoscopic dissecting microscopes (Limmer 1994). Limmer
recognized that normal scalp terminal hair follicles grow in groupings
of 1-4, referred to by hair transplant surgeons as "follicular
units". Limmer
developed the methodology of follicular unit transplantation
where
the donor
strip of hair
follicles was microdissected by a team of technicians into
natural follicular units. Implanting hair folliciles
in their natural clusters gave a much more natural looking result.
Single hair follicular units could be used to make the hair line
while
larger follicular units of 3-4 hair follicles could be used to
fill in behind the hair line.
Follicular unit transplantation (FUT) was soon taken up by
several big names in the hair transplant world
including Rassmann, Bernstein, Seager, Norwood,
and several others (Berstein 1997; Berstein 1998; Stough 1999;
Unger 2000; Epstein 2003). When properly performed, follicular
unit transplantation consistently and predictably
produces
the
most
natural-appearing
hair restorations. Unfortunately, while the develpoment
of follicular unit transplantion gives a superior result, the
technical skills required, the large numbers of people involved
in the procedure,
and the subsequent expense to the hair transplant surgeon in training
and
paying
the salary for such a large staff, has meant that follicular unit
transplantion
is still not used in many clinics.
The
history of hair transplants timeline references
Notable historical events in hair transplantation:-
- 1800 BC - Egyptians attempt to restore hair and is mentioned
in records such as the Ebers papyrus.
- 1822 – Dieffenbach
described surgical restoration of hair using animal models.
- 1893 – Use
of auto grafts. Pieces of skin from hair bearing regions were
used as grafts for covering bald regions.
- 1919 – Passot
described the use of short hair bearing flaps to cover scars.
- 1930 – Sasagawa,
a Japanese surgeon, reported conducting hair follicle transplantation.
- 1939 – Okuda,
a Japanese dermatologist described techniques to correct alopecia
of the scalp, eyebrows and moustache areas
using cylindrical punches of hair from a donor site.
- 1943 – Tamura
transplanted single hairs in the pubic region.
- 1953 – Fujita
uses single hair transplants to correct a variety of defects.
- 1957 – Lamont
described the use of flaps to hide scars.
- 1959 – Norman
Orentreich, a Dermatologist from New York transplanted punch
biopsies of hair bearing skin and put forth the “theory
of donor dominance” dismissing the hypothesis that
baldness is caused due to poor blood
supply in the
scalp.
- Mid 1970s – alopecia reduction surgery introduced first
in Canada and later other countries.
- 1975 – Jose Juri,
an Argentinean surgeon, proposed the Juri flap technique that
uses 2 long flaps of scalp bearing
hair brought
forward to cover the bald regions.
- 1980 and 1980s – Kitaro
Ohmori introduced microsurgically anastomosed free flaps.
Shorter flaps and variants were introduced
the following years by Stough, Bouhanna, Nordstrom, Frechet
and others.
- 1983 – Dr. Carlos Uebel of Brazil performed
a large session transplanting up to 1000 grafts. This was the
beginning of the “megasession”.
- 1987 – Dr. Bob
Limmer and Dr. Robert Limmer used stereoscopic dissecting microscopes
to dissect grafts. This reduced
the damage done to the hair follicles in the dissection
stage of
hair transplantation.
- 1992 – Moser group from Austria
demonstrated a large transplant session using videotapes.
- 1994 – Dr.
William Rassman of California introduced single session
transplants of over 3600 grafts.
- 1998 – Gandelman
showed desiccation as the main cause for graft damage
and failure of transplanted hair follicles
to grow.
- Late 1990s – Follicular unit transplantation used by
a variety of hair restoration surgeons.
The
history of hair transplants references
- Dieffenbach JF. Nonnulla de regeneratione et
transplantatione. Dissertation inauguralis.
Herbipoli, Typis Richterianis, 1822, p56
- Sasagawa M: Hair Transplantation.
Jpn. J. Dermatol. 30:493, 1930.
- Okuda S. Klinische un experimentelle
untersuchungen uber die Transplantation Von Lebenden Haaren.
Jpn J Dermatol 1939;40: 537.
- Okuda S. Clinical and experimental
studies of transplantation of living hairs. Jpn J Dermatol 1939;46:135–8.
- Tamura H: Pubic hair transplantation. Jpn J Dermatol 1943;
53: 76.
- Barsky AJ. The scalp. The eyebrow. In; Principles and practice
of plastic surgery. Williams and Wilkins, Baltimore, 1950, 137-140.
- Fujita K. Reconstrustion
of eyebrows, La Lepro 1953; 22 : 364.
- Orentreich N. Autografts in alopecia and other selected dermatological
conditions. Ann N Y Acad Sci 1959;83:463.
- Vallis CP. Surgical treatment of the receding hairline. Report
of a case. Plast Reconstr
Surg.
1964
Mar;33:247-52. PMID: 14131619
- Tezel J. Miniature drill expedites hair transplantation. Cutis
1969; 5:461.
- Shiell RC. Hair grafting: a practical
possibility. Med J Aust. 1969 Nov 8;2(19):983. PMID: 5359702
- Orentreich N. Hair transplants. In: Current dermatologic management.
S Maddin (ed). Mosby, St Louis, 1970, 13-20.
- Frankel EB. Hair transplantation: Additional observations.
Cutis 1975; 15:545.
- Carreirao S, Lessa S. New technique
for closing punch graft donor sites. Plast Reconstr Surg. 1978
Mar;61(3):455-6. PMID: 343132
- Pierce HE. An improved method of closure
of donor sites in hair transplantation. J Dermatol Surg Oncol.
1979 Jun;5(6):475-6.
PMID: 458015
- Fujita K. Hair transplantation
in Japan. In: Kobori T, Montagna W, (eds). Biology and disease
of hair, Baltimore, 1976, Univ
Park Press.
- Marritt E. Transplantation of single
hairs from the scalp as eyelashes. Review of the literature and
a case report. J Dermatol Surg Oncol. 1980 Apr;6(4):271-3. PMID:
7365092
- Nordström REA: "Micrografts" for
improvement of the frontal hairline after transplantation. Aesthetic
Plast
Surg
1981; 5:97-101.
- Vallis CP. The strip scalp graft. Clin
Plast Surg. 1982 Apr;9(2):229-40.
PMID: 7128015
- Marritt E. Single-hair transplantation
for hairline refinement: a practical solution. J Dermatol Surg
Oncol 1984;10:962–3.
- Alt TH Sr. Evaluation of donor harvesting
techniques in hair transplantation. J Dermatol Surg Oncol.
1984 Oct;10(10):799-806.
PMID: 6491019
- Stough DB 3rd, Mendoza F, Freilich IW. Surgical procedures
for the treatment of baldness. Cutis. 1986 May;37(5):362-5. PMID:
3709227
- Coiffman F. Advancement in scalp grafts.
Ann Plast Surg. 1987 May;18(5):421-8.
PMID: 3592521
- Lucas MW. The use of minigrafts in
hair transplantation surgery. J Dermatol Surg Oncol. 1988 Dec;14(12):1389-92.
PMID: 3057031
- Bradshaw W, Quarter-grafts: a
technique for minigrafts. In: Hair Transplantation. 2nd ed. Unger
WP, Nordstrom REA (eds) Marcel Dekker, New York, 1988: 333-51.
- Stough DB 4th, Nelson BR, Stough DB 3rd. Incisional slit grafting.
J Dermatol Surg Oncol. 1991 Jan;17(1):53-60. PMID: 1991881
- Uebel CO. Micrografts and minigrafts:
a new approach for baldness surgery. Ann Plast Surg. 1991 Nov;27(5):476-87.
PMID: 1746866
- Brandy DA. A three-step systematic
incisional-slit minigrafting approach. J Dermatol Surg Oncol.
1993 May;19(5):421-6.
PMID: 8496485
- Limmer BL. Elliptical donor stereoscopically
assisted micrografting as an approach to further refinement in
hair transplantation. J Dermatol Surg Oncol. 1994 Dec;20(12):789-93.
PMID: 7798409
- Bernstein RM, Rassman WR. Follicular transplantation. Patient
evaluation and surgical planning. Dermatol Surg. 1997 Sep;23(9):771-84;
discussion 801-5. PMID: 9311372
- Bernstein RM, Rassman WR. The
aesthetics of follicular transplantation. Dermatol Surg. 1997
Sep;23(9):785-99. PMID: 9311373
- Bernstein RM, Rassman WR, Seager
D, Shapiro R, Cooley JE, Norwood OT, Stough DB, Beehner M,
Arnold J, Limmer BL, Avram
MR, McClellan RE, Rose PT, Blugerman G, Gandelman M, Cotterill
PC, Haber R, Jones R, Vogel JE, Moy RL, Unger WP. Standardizing
the classification and description of follicular unit transplantation
and mini-micrografting techniques. The American Society
for Dermatologic Surgery, Inc. Dermatol Surg. 1998 Sep;24(9):957-63.
PMID: 9754083
- Stough D, Whitworth JM. Methodology of follicular
unit hair transplantation. Dermatol Clin. 1999 Apr;17(2):297-306,
viii.
Review. PMID: 10327299
- Unger WP. Follicular unit hair transplanting--end
of the evolution or a good thing taken too far? Dermatol Surg.
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- Epstein JS. Follicular-unit
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PMID: 12975146
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