History of Hair Transplant

For most of history, a bald man had one option: hide it. Wigs, toupees and caps covered the scalp but did nothing for it, and everyone knew what they were looking at.

The first documented hair transplant was made in 1822 by German physicians, using skin grafts. It proved that hair-bearing skin could be moved from one place to another. It did not yet prove that it could be done well.

Dr. Okuda, a Japanese dermatologist, worked out how to help burn victims by taking small round sections of hair-bearing scalp and placing them in damaged skin. His methods were far ahead of their time. The Second World War buried them, and the West learned of them late.

Dr. Norman Orentreich of New York turned the craft into a treatment for male-pattern baldness. His key finding was donor dominance: hair taken from the back and sides keeps the character of its origin. It lasts longer and keeps growing in its new place instead of falling out like the hair around it.

The tools of the day were crude. Large punch grafts carried 20 to 30 hairs each, and the results had the stiff, tufted look people called doll’s hair.

Plate III · Dr. Norman Orentreich.

Surgeons then tried a different route: lift a band of hair-bearing scalp, keep its blood supply, and swing it across the bald area. The Juri flap is the best known. Flaps could cover a lot of ground at once, but the hair often pointed the wrong way, tissue could die, and the scars were severe.

Big moves, big scars. It took the next generation of surgeons to go the other way: smaller and smaller.

It was not until the 1980s and 1990s that the work of Dr. Rassman and others brought real refinement, and much better results. They realised that scalp hair grows in natural groups of one to four follicles, together with oil glands and blood vessels.

This led to FUT, the “Strip Method”: a strip of skin is taken from the donor area and, under the microscope, dissected into individual follicular units. The results looked far more natural than the older punch grafts.

In the 1990s Dr. Unger defined the safe zone for harvesting, the area where donor hairs hold on over time. It is still used today for both strip and FUE harvesting. By the mid-1990s, follicular units and the safe zone had opened a new era in hair transplantation.

Plate VI · Dr. Kinnar Kapadia with Dr. William Rassman.

Plate VII · Dr. Kinnar Kapadia with Dr. Walter Unger.

In the early 2000s a group of surgeons began intensive research into FUE. The name first stood for Follicular Unit Extraction, but the ISHRS changed it to Follicular Unit Excision to reflect that it is a surgical procedure.

The biggest drawback of the Strip Method was the strip itself: the stitching, and the scar that followed. Patients wanted something less invasive, and the persistent efforts of these early FUE surgeons made it possible.

At first, many grafts were cut through during extraction (transection), which made it hard to collect the number of grafts needed. For a long time, FUT remained the gold standard.

From the late 2000s into the early 2010s, almost every major conference staged a debate on which method was better. Surgeons who performed FUT presented its strengths and the weaknesses of FUE, while the FUE surgeons argued the reverse.

I attended these sessions and watched the debate live. At times it became very heated. By around 2015, the question had settled for me personally: both methods give excellent results, and each has its own advantages.

One advantage of FUE stood out, though. Patients accepted it more readily, because there is no strip to remove and no stitches. Most patients wanted a less invasive option, and FUE sounded far better than going through suturing and a linear scar.

Extraction instruments improved a great deal, and so did implantation. Surgeons now choose from a range of devices, and every clinic builds its own routine around the ones it trusts. NeoGraft, Trivellini, U Graft, WAW,ARTAS
For implantation, sapphire blades, sharp implanters such as the Choi, and blunt implanters such as the KEEP system have all made it possible to place grafts with more control over angle and density.