History of Hair Transplant Surgery
It is hard to imagine a procedure that has had a more fascinating and transformative history than hair transplantation in the history of cosmetic surgery. Hair transplants have seen a lot of evolution, from humble beginnings in Japan to the 1970s “punch-line” plug results to today’s “mega-session”, refined follicular unit procedures.
Japan, 1939: Hair Transplant Beginnings
It is true that the first hair transplants were performed in Japan in 1930s. In a seminal 1939 paper, Dr. Shoji Okuda described his hair transplant experiences. Dr. Okuda described how he removed hair-bearing skin using small dermal punches, similar to FUE procedures. These were then used to graft the segments onto the bald scalp, eyebrows, and other areas of the body. Dr. Okuda’s findings were not only forgotten but also lost in the midst of World War II.
New York, 1950s: The Birth of the “Plug”
Norman Orentreich, a well-known dermatologist in New York, began experiments with moving hair in the 1950s. Unaware that Okuda’s work was being done at the time, Dr. Orentreich used larger punches to move large groups of hair from the backs of patients’ scalps to the balding areas. Although Dr. Orentreich initially started his research to examine the effects of scalp grafts upon other dermatological conditions and conditions, he soon discovered that these scalp grafts still retained their original characteristics, despite being moved from one side of the scalp to another. The healthy hair follicles survived even though they were implanted in an unhealthy scalp. His findings were called “the principle of donor dominance” by Dr. Orentreich. With this declaration, the industry was born. Dr. Orentreich discovered that these grafts could grow hair for cosmetic purposes if they were stable enough. In his New York office, he began to perform the first hair transplant procedures. He proved his theory correct and performed approximately 10,000 hair transplant procedures by the end of 1960.
Although Dr. Orentreich’s groundbreaking findings laid the foundation for hair transplant surgery, one problem was the results. Dr. Orentreich and his colleagues used large “punch tools” to harvest donor grafts. These tools could be between 5mm and 8mm in size (in comparison to modern FUE tools, which can range from 0.7mm to 1.5mm in diameter). They were able to remove groups of grafts up to 20-30 at a time. The doctor would then remove the affected pieces and “plug” the graft in the defect. These “plugs”, which were so large, could only be moved in a limited number and had to be placed far apart. Although multiple passes may have produced a more pleasing cosmetic result, many patients who had these early plugs ended up with small “islands” of hairs that were spread out far apart. These results looked unnatural and were often called “doll hair”. They became a joke for many years. The patient’s donor area suffered from the consequences of the plug procedure. The plugs were removed with a 5-8mm hole. These holes were left open for healing and caused a lot of scarring on the back. It looked like a checkerboard pattern. Although hair transplantation was a medical procedure, there were improvements that needed to be made.
1980s: Divide and Conquer
Clever doctors used smaller and smaller punches in order to remove the plugs. Even at 4mm in size, the grafts looked unnaturally “pluggy”. A few doctors came up with a new idea in the 1980s. Instead of taking out one plug and reinserting it as one unit, how about dividing the plug into smaller pieces that can be inserted? It should look better if there are more grafts. These doctors were right. The idea of cutting down plugs and implanting smaller pieces was a success. These smaller pieces were called “micro grafts” and “mini grafts,” respectively. The results were much better than those of yesterday’s plugs. Magnification was soon used by dedicated clinics to make smaller, more precise pieces. This allowed for longer sessions and improved results (still within the “hundreds of micro/mini graft range). Another important discovery was made during this time: doctors still used punch tools to remove grafts from the back. The scarring from this was unacceptable. So, some brave and inventive physicians started to suggest that one “strip” be taken from the donor area, then stitched closed and then cut into micro and mini grafts. This created a better look in the back with only one small linear scar and many more grafts. Modern hair transplantation was able to flourish with micro/mini grafting and strip harvesting. The biggest breakthrough was microscopic dissection of the hair and the follicular ungraft.
Microscopes, Follicular Units, and Mega Sessions
When a few pioneering doctors (including Dr. Bobby Limmer in Texas), began using microscopes to cut strips, the idea of “segments” being taken from the donor was realized. It was possible to see the natural, or “follicular unit” follicular groups in donor tissue by using a microscope. Then, the strip could be divided down to that level. After follicular units were produced, protocols were established for moving delicate grafts safely into the recipient area. Follicular Unit Transplantation, or FUT, was the name of this procedure. Clinics started to perform larger strip harvests, and move more of these follicular unit in one sitting until they could move 2,500 or more grafts per surgery. These procedures were called “mega sessions” and became the industry standard. What about patients who are unable to undergo a strip harvest because of their naturally tight skin? Or trauma from old hair transplant harvesting techniques? Patients who have had multiple procedures but couldn’t undergo the next one, but still desired more hair. What could be done?
Follicular Unit Excision or “FUE” (Previously known as Follicular Unit Extraction)
A doctor in Australia started re-investigating Dr. Okuda’s 1930s harvest method in 1989. He used a series small dermal punches and needles to try to remove the follicular units from the donor area. He had already discussed his method publicly in the mid-90s. The technique was not widely accepted or understood by the mainstream, and it was still mysterious. In 2001, many North American physicians began to investigate the technique. In 2002, Drs. In 2002, Drs. Bernstein and Rassman published a paper on Follicular Unit Extraction (FUE). Several physicians started offering the procedure in small groups. The results were unpredictable, and many doctors agreed that the procedure was not as reliable as FUT.
Innovations were continued by innovative physicians who worked on new extraction techniques and devices. With this increased awareness, the demand and interest in the procedure grew. This was especially true for those who couldn’t or didn’t want to undergo strip surgery. This increased visibility led to the inevitable “overhyping” FUE by those who wanted to make a profit from the procedure.
While there are many opinions online, not all of them agree with FUE.