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Home arrow Hairtransplant in detail arrow Historical development
Historical Development of Hair Transplant Surgery

Historical Development of Hair Transplant Surgery  

The history of hair transplant surgery (HT) goes back to as far as the first half of the  20th century.

Nevertheless, in comparison with the other medical methods of treatment, HT remained at a rather primitive level from the technical and cosmetic point of view for more than fifty years.

It is only during the last ten years, that the biggest strides and refinements in the field have taken place.

The Japanese physician Dr. Sasegawa reports about his experiments on the implantation of hair shafts into the skin.

For the first time, the Japanese dermatologist Dr. Okuda describes a method, which was to be known later on as the punch technique. He transplanted islets of skin measuring 2 to 4 mm in diameter from the hairy scalp to the scarred areas of the eyebrows and moustache of burn victims.  Hereupon, he found out that after some time the transplanted hair normally grew further.

Again another Japanese dermatologist, Dr. Tamura, transplanted to a woman much smaller grafts containing only 1 to 3 hairs using a similar method. He won grafts by cutting out spindle-shaped strips from the hairy scalp.

This method greatly resembles the one still widely carried out up to this day, which is no other than the Strip technique.

Both methods were published before in Japanese medical journals, but they remained unknown to the Western world till 1958 due to the outbreak of World War II. 

The New York physician Dr. Norman Orentreich published the results of his works in this year.

In the beginning of the 1950's, he began carrying out hair transplants with the purpose of curing androgenetic alopecia.

He found out that hair roots taken from the crown spared by hereditary hair loss, retain their characteristic of longevity after being eventually transplanted to bald areas.  

This means that they grow further normally without falling out, just like the hair formerly located at the bald spots.  By using a metal cylinder, he took punch grafts with a thickness of approximately 4 mm from so-called donor sites. Using the same metal cylinder, he took out islets of bald skin with the same diameter from the recipient site. He then transplanted the donor grafts into these holes.
Thus, the era of hair transplant surgery for cosmetic reasons in the treatment of male pattern baldness actually began with Orentreich.

During the following thirty years, the methods developed by Orentreich und Okuda were the standards employed in hair transplant surgery.

Originally, the punch cylinders were bored into the scalp. However, beginning in 1969, punch cylinders were used as head- pieces attached on the top of drilling machines.

The 1980's:
Since the 4 mm punch grafts looked odd in its recipient area (so-called "island effect" or "Barbie doll effect"), smaller grafts were later on developed: (a) the small minigrafts contained a minimum of four hair follicles and (b) the much finer micrografts contained 1 to 4 hair follicles. With these grafts, it was possible to reconstruct naturally-looking hairlines, although they looked somewhat artificial.

Prof. Dr. Carlos Oscar Uebel
In lieu of punch grafts, the Brazilian doctor used a big slice of a spindle-shaped stripe of skin taken from the back of the head with the use of a scalpel.  The stripe was eventually divided into single minigrafts and micrografts. This signalled the era of the strip method.

During the preparation of grafts under the microscope, Dr. Bob Limmer accidentally discovered that, by nature, the hair does not grow individually but in small groups. He designated these small groups as follicular units (FU). These follicular units are composed of 1 to 3 (rarely, 4) hair follicles that stand very close to each other.

The use of follicular units as graft has led to more natural results than the ones resulting from the coarser minigrafts and micrografts. The common abbreviation used for strip hair transplant applying follicular units is "FUSS" (Follicular Unit Strip Surgery).

It should be critically noted in this regard, that these small groups of hair follicles have been already known to dermatologists many decades ago. As early as 1927 (!), Prof. H. Pinkus described this unit and named it as "hair region". Other researchers christened it as "dermaton" or "hair bundle". Finally in 1984, that is, four years before Limmer, it was Prof. T. Headington, who coined the word still used of to this day, "follicular unit". The FUSS method could have been developed much earlier had there been enough literary knowledge about it.

1991- 1992:
In the meantime, most hair transplant institutes have switched to the strip method from the punch method.  

At the Beginning of the 1990's:
The Australian physician Dr. Ray Woods and his sister Dr. Angela Campbell developed the technique of FUE (follicular unit extraction)
They were of the opinion that cutting out of big patches of skin was unnecessarily traumatic. Whereas using fine needles is more gentle, leads to less complications and does not leave a lifelong scar typical of the strip method.
By this method, the follicular units are taken one by one directly from the donor area through the use of fine needles, which make the use of scalpels and coarse punch cylinders superfluous. Dr. Woods und Dr. Campbell, therefore, were the pioneers of modern FUE.
However, their work remained relative unknown for the time being.

Yet the number of institutes working with minigrafts and micrografts still dominate.

In the meantime, natural results and high density have been reached through the application of FUs - in contrary to earlier times - that it has become difficult for the normal unaided eye to differentiate them from the original untreated hair areas.

In April, Dr. Coen Gho from the Netherlands offers his self-developed FUE technique. Several months later, Dr. Robert Jones from Canada and Dr. John Cole from the USA followed.

2003- 2005: 
The possibility to transplant body grafts with FUE is taken up by more and more FUE- practitioners.


A Look into the Future 

How does the future of hair transplant surgery look like?

Modifications in the various aspects of the FUE- method surely will lead to further improvements, e.g. in
  • the extraction instruments
  • the graft solution
  • the prae- and postoperative care of the transplanted area.Intensive research is done on these fields worldwide, including ourselves.
Nevertheless, it would be a revolutionary breakthrough if we can solve the problem of the limited number of donor hair follicles. It should be recalled that a hair transplant is merely a skilful distribution of available hair. However, no new hair is produced.

At the present moment, there are two stances on this matter:

One method is designed at using the property of a donor hair follicle to regenerate again, when a certain part of it is retained in the donor area during the extraction process.

The stem cells contained therein are apparently adequate enough to produce a new hair follicle, theoretically, two follicles from one. This means that the number of donor hair is doubled.

Only a few of the internationally leading hair experts report about this form of new hair growth. Some experts express doubt over the quality of both the resulting hair shafts.

We are following up this stance consequently and we are trying our best to exactly analyze the parameters behind this new growth.

Another stance, on which several researchers around the world have been professionally working for many years now, is the so-called "cell therapy", more often known as "hair multiplication". By this is meant that some suitable cells from the hair cells of the genetically resistant donor area are isolated. Special processing of these cells take place and are reproduced several times and afterwards injected into bald areas of the scalp, which are later expected to form new hair follicles.  
Theoretically, an infinite stock of potential donor hair can be reached and the above problem would be solved. We, just like all other persons affected with this problem, hope all the best for cell therapy.

We can well imagine that a great breakthrough will take place in the years to come. This does not mean, however, that hair transplants using the FUE technique will be superfluous. It is possible, that cell therapy will not be effective in all cases, for example, in scar tissues.

It is also conceivable, that there will be more expenses that will be involved or it would be immoderately dear when hair multiplication is performed in small areas of baldness (for example, in the correction of the lateral sides of the hairline or eyebrows).
From today's viewpoint, a precise injection of the processed cells into the scalp is still a problem. A substance injected into the scalp spreads more or less in a diffuse manner. Thus, it could be very difficult to accurately design the otherwise important hairline.

Above all this, there are hundreds of hair transplants still being performed using the strip technique. And just like in the past decades, other old techniques of hair transplant surgery are continuously done all over the world. Hence, the FUE institutes are destined in the future to carry out "repair work" resulting from these methods.

The repair works through the help of FUE are varied:
Non-natural grafts and too big grafts like punch grafts and mini-grafts must be removed and then splitted into follicular units. The latter will be implanted again in a natural distribution. Obviously, big strip scars in the donor region must be filled up again with hair follicles.

Areas of older hair transplants using the strip or punch technique are not usually dense. In this case, it should be aimed that a higher hair density be attained in these areas.