Hair Transplant Surgery Yesterday, Today and Tomorrow

The hair on your head has been important throughout history, with deep sociological meaning. In men, hair on the head is a symbol of youth and virility; with women it carries connotations of youth. Hair loss on the head is seen as a sign of aging and death. Thus, for centuries, men and women alike have tried to reverse hair loss, using all sorts of measures and currently hair transplant surgery has become one of the most sort after cosmetic surgery procedures in the united States and indeed the world..

Hair transplantation is a surgical procedure that involves removing viable hair (grafts) from where they naturally grow (donor area) and replacing them where the patient lacks hair (the recipient area). Traditionally hair is removed from the back and sides of the head and moved to the top and front.

Donor area immediately following FUE hair transplant.

Hair transplant surgery has gone through a number of major evolutions, beginning in the early 1900s in Japan and progressing to today, with research continuing. Hair transplantation has evolved into a more and more cosmetically acceptable procedure, moving through the early punch grafts and mini and micrografts to the current “gold standard” of follicular unit extraction of “FUE.” This procedure does not leave any of the lineal scarring associated with traditional strip graft surgery. Rather, the FUE method leaves very small wounds that heal with no significant scarring. Advanced FUE can be used in extracting hair follicles from areas of the body other than the head, such as the chest or beard. This is known as body hair transplant or BHT. Dr. Umar is a pioneer in this field and has successfully performed mega-sessions that capitalize upon an expanded donor pull from BHT to give hair to extremely bald patients previously considered poor candidates for the procedure.

Hair Transplant - Before

Hair Transplant - After

Earlier Hair Transplant Methods

The first hair transplant was based on the punch graft. This was originally attributed to the American Dr. Norman Orentriech, however it is now generally accepted that this technique was used earlier by Japanese dermatologists. Dr. Shoji Okuda first used the punch micrograft in 1939 on the scalp, mustache and eyebrows. In 1943, a paper by Dr. Hajime Tamura detailed the use of elliptical excision, akin to the modern strip excision procedure and foreshadowing the trend toward smaller and smaller grafts. In 1952, Dr. Orentreich popularized the punch graft using 4mm punch grafts. This was the standard until the mid ‘70s, but gave an unpleasant “doll’s head” appearance. When hair was lost around the graft “plugs” became visible. Unfortunately, for decades that followed, the general populace equated hair transplant results with the doll’s head look. Dr. Orentreich also originated the theory of donor dominance, where hair taken from the back of the hair and transplanted to the front continued to grow, thus exhibiting the behavior of the donor hair. “Donor dominance” is a theory currently undergoing modification due to experiments in the field that show donor area might not be the determining factor. Dr. Umar believes that some characteristics such as graft survival is innate in the hair itself and that the place it is pulled from plays only a secondary role.

Hair Transplant Methods Today

1. Strip excision also known as follicular unit hair transplant – FUHT or follicular unit transplant FUT is the most commonly practiced method of hair transplantation today, with an elliptical strip donated from the back of the head and split into smaller grafts. The best donor area is right above the occipital bump or below an imaginary line that runs 1cm above the top of the ears. This invariably leaves a lineal scar with a chance of stretching. If the width of the incision is less than 1cm, it would reduce the chances of strip scar complications. Tricophytic closure is a recent innovation that gets hair to grow through the scar. In this procedure, a 1mm ledge of the outer layer of skin is cut off as well as an edge on the donor site before the wound is closed. This results in a smaller and less apparent scar.


Linear scar resulting from strip surgery.

2. FUE is the latest innovation in hair transplantation that has gained in popularity. It entails the extraction of individual follicular units one at a time. The harvesting is done using 0.8 – 1.2mm punches. Unlike follicular unit hair transplant method, there is no linear scars created in this technique, making it ideal for those who prefer to have short hair. The procedure is skill dependent, however, meaning that only an experienced and qualified surgeon should perform the technique. It is a longer and more labor-intensive procedure. Because of this, many surgeons don’t wish to perform it. However, it is becoming more popular because it leaves less scarring and patients are demanding to have it done instead of the strip excision method.

Manual, handheld FUE extraction tool.

Powered, handheld FUE extraction tool.

The idea that FUE is only suitable for small procedures has been shown to be a myth by FUE pioneers like Dr Umar:

Here is a video illustrating the difference between follicular unit extraction – FUE vs FUT also called follicular unit strip surgery:

Hair Transplant Tomorrow

Many physicians have proposed different methods of automating hair transplantation procedures.

1. Automated implanters. Examples include the choi implanter and the neograft implanter. These devices are touted as hands free implanters. However, this is misleading as:
   1. The use of these automated implanters such as choi, actually entails more handling as the grafts are being loaded into the implanter! Less handling occurs traditionally in the hands of experienced personnel simply sliding each graft carefully into a recipient slit.
   2. The neograft implanter uses an air vacuum which in the opinion of this author can desiccate the grafts thereby compromising their survival.
   3. All implanters would limit the ability to dense pack follicles into an area (needed in most hairline designs) as the implanters are simply too robust to allow for the tightly packed grafting. Traditional slit preparation and implantation does not carry these limitations.
   4. The lack of human control on implantation depth could result in a higher incidence of buried grafts resulting in formation of cysts and pitting complications. To avoid these complications of hair transplant surgery, automatic implanters are to be avoided.
2. Automatic extractors eg neograft and Artas robotics. In the opinion of this author, these tools may not measure up to a physician controlled process for the following reasons:
   1. The neograft machine:
      1. It is a vacuum based machine that subjects the grafts to the drying effects of air as they are extracted and transported through a tube. This would compromise the survival of the grafts
      2. Also the tissue protection of the grafts is peels off again reducing chaces of graft survival
      3. The transportation of grafts from extraction point to receiving area may add to graft trauma as well
   2. Artas is a 1st generation of robotics in FUE. At this point, the device:
      1. Has a high transection rate which is cited at 15% (For Artas) in some quarters compared to the traditional 2-5% in most experienced physician controlled techniques. But there are efforts to improve on this
      2. It is thus far approved for use in brown – black  haired (typically caucasoid) individuals with straight hair.
      3. Many hair transplant patients may have trouble with the idea of a robot drilling thousands of holes into the heads.
      4. With hand held devices, every transection becomes immediately apparent alllowing for necessary adjustment in real time or the ability to abort the procedure. With robots, several more grafts may be damaged before this is corrected.
      5. The use of a 1.65 mm punch by the artas robot would create far larger wounds risking larger scars and healing complication. This would increase the chance of donor damage
      6. The use of a 1.65mm punch would increase the risk of damaging adjacent follicles resulting in what is known as the “halo” phenomenon in the parlance of FUE hair transplant. With halos developing, a patient would end up with the look of a “moth eaten”  donor area.

For physicians seriously considering adding FUE to their menu and services, even with the aid of the aforementioned machines, Dr umar advises spending some time tin training with Experienced FUE practitioners.

Hair Cloning and Hair Transplantation

One of the most exciting developments in the world of hair transplantation is the idea of cloning hair. The hope with hair cloning is to remove the limits placed by the donor area. A single biopsy punch could restore hair to the entire head, removing the fears of running out of donor hair.

Current Issues in Hair Transplantation

A hair transplant procedure today is quite different from their invention in turn of the century Japan. Grafts are smaller, techniques are more precise and problems such as unnatural appearance have been resolved. New technologies present new issues, however, such as automation and genetic developments.