In the entire history of cosmetic surgery, it is difficult to think of another procedure with a more interesting and transformative journey than hair transplantation. From humble beginnings in Japan, to the “punch-line” plug results of the 1970s, to the undetectable transformations of today’s refined follicular unit “mega-session” procedures, hair transplants have undergone quite the evolution.
Japan, 1939: Hair Transplant Beginnings
Believe it or not, the first hair transplant procedures were actually carried out in Japan in the 1930s. A physician named Dr. Shoji Okuda first described his hair transplant experiments in a seminal paper published in 1939. In the article, Dr. Okuda explained how he used small dermal punches (similar to what is used in FUE procedures today) to remove hair-bearing skin from the sides and back of participant’s scalp, and then grafted these segments on to bald scalp, eyebrow, and even other regions on the body. Unfortunately, World War II broke out shortly after and Dr. Okuda’s findings were mostly forgotten for decades to come.
New York, 1950s: The Birth of the “Plug”
In New York in the early 1950s a famed dermatologist named Dr. Norman Orentreich began his own experiments with moving hair. Unaware of Okuda’s work at the time, Dr. Orentreich began using much larger punches to move groupings consisting of dozens of follicles from the backs of patient’s scalps to balding regions. Dr. Orentreich’s research initially began as a way to study the effect of scalp grafts on other dermatological conditions, but he quickly made an important discovery: despite being moved from the back of the scalp to the bald regions in the front, these scalp grafts retained their characteristics. In other words, the healthy hair follicles continued to grow and thrive even when implanted into unhealthy scalp. Dr. Orentreich described his findings as “the principle of donor dominance;” and with this declaration, and industry was born. Dr. Orentreich realized that if these grafts would continue growing hair permanently, they could be used for cosmetic hair restoration. He slowly began performing the first hair transplant procedures in his New York office. His theory proved true and by the late 1960s, he had performed an estimated 10,000 hair transplant procedures.
While Dr. Orentreich’s findings were groundbreaking and built the foundation of hair transplant surgery, there was one problem: the results. Dr. Orentreich, and those he trained, used large “punch” tools to harvest the donor grafts. These tools were anywhere between 5mm to 8mm in diameter (for comparison, modern FUE tools range between 0.7mm to 1.3mm in diameter) and removed groupings of sometimes 20-30 grafts in one piece. After removing these pieces, the doctor would remove a similar sized piece of skin in the bald scalp and literally “plug” the graft into the large defect created in the bald area. These “plugs” were so large that only a small number of them could be moved at a time and they had to be placed far apart. While multiple passes could create a better cosmetic result, most patients who underwent these early plug procedures ended up with little “islands” of stalky hairs spread far apart. The results were unnatural – often described as a “doll’s hair” appearance – and became the butt of jokes for many years. The plug procedure was also quite detrimental to the patient’s donor area. The 5-8mm holes created by the plug removal were simply left open to “heal,” and created big scarring throughout the back that resembled a “checkerboard” pattern. Hair transplantation as a medical procedure had arrived, but improvement was needed.
1980s: Divide and Conquer
Clever doctors began using smaller and smaller punches to remove the plugs. But even at sizes as small as 4mm, the unnatural “pluggy” appearance of the grafts still remained. In the 1980s, however, a few doctors had a novel idea: instead of removing one big plug from the back and reinserting it as one large unit, why don’t we divide the plug into smaller pieces and insert these? A greater number of smaller grafts put closer together should look better, right? These doctors were absolutely right, and the idea of cutting plugs down into smaller pieces and implanting these smaller pieces took off. The smaller segments were referred to as “micro grafts” or “mini grafts,” and the results of these procedures were significantly better than the plug results of yesterday. Dedicated clinics soon began using magnification to cut even smaller and more refined pieces, which allowed for larger sessions (still in the “hundreds” of mini/micro graft range) and better results. Another crucial discover occurred during this period: doctors were still using punch tools to remove the grafts from the back; and the scarring from this was still unacceptable; so, a few inventive and bold physicians began to float the idea of taking out a single “strip” from the donor region, stitching the area closed, and then cutting this up into mini and micro grafts. This resulted in a much better appearance in the back (one small incision linear scar) and more grafts. With strip harvesting and micro/mini grafting, modern hair transplantation really began to take off. But the biggest innovation was right around the corner: microscopic dissection and the follicular unit graft.
Microscopes, Follicular Units, and Mega Sessions
The idea of dividing “segments” taken from the donor into smaller and smaller pieces reached its logical conclusion when a few innovative physicians (namely Dr. Bobby Limmer in Texas) began – in the late 1980s and early 1990s — using microscopes to dissect strips. With a microscopic view, it was possible to see the natural follicular groupings, also known as “follicular units,” in the donor tissue and divide the strip down to this level. Once true follicular units could be produced, protocols for safely moving these delicate grafts into the recipient region were quickly established. This procedure became known as Follicular Unit Transplantation or FUT. From here, clinics began performing larger strip harvests and moving more of these follicular units in single sittings until we reached the level of moving 2,500 or more grafts in one surgery. Procedures of this size became known as “mega sessions,” and they became – and remain – the industry “gold standard.” The minimal damage to the donor with FUT/strip harvest, the ability to produce refined follicular units with minimal trauma, and the act of placing these tiny grafts very close together in the bald regions (“dense packing”) created excellent results and allowed hair transplantation to finally be accepted as an effective, natural treatment for hair loss. But what about patients who couldn’t undergo a strip harvest due to naturally tight skin or trauma from outdated hair transplant harvesting? What about patients who had multiple strip procedures and could no longer undergo another, but still wanted more hair? Could anything be done for them?
Follicular Unit Excision or “FUE” (Previously known as Follicular Unit Extraction)
In 1989 a physician in Australia began re-investigating the harvest method originally used by Dr. Okuda in the 1930s. Using a series of needles and small dermal punches, he attempted to remove follicular units “one-by-one” from the donor region. By the mid-90s he had publicly discussed his technique. However, the technique was still shrouded in mystery and not well understood or accepted by the main stream. By 2001, several physicians in North America began investigated the technique themselves. By 2002, a paper on Follicular Unit Extraction (FUE) was published by Drs. Rassman and Bernstein in the ISHRS journal, and several physicians began offering the procedure in very small sittings. However, results were unpredictable and most agreed that it simply was not reliable when compared with FUT.
Innovative physicians continued to work on new extraction devices and techniques, and improvements were made. And with this increased visibility, interest and demand for the procedure grew. Particularly in those who could not undergo or did not want strip surgery. With this increased visibility, however, came the inevitable “over hyping” of FUE from those looking to financially benefit from offering the procedure.
There is a lot of content online coming from both these ardent supporters and dissenters alike, but the general consensus on FUE is as follows: Both FUT and FUE are modern, refined techniques with their own set of “pros and cons,” and both have their indications and contraindications for certain patients; most physicians who can offer both FUT and FUE believe that doing FUT first provides a greater number of lifetime grafts and maximizes the potential of the donor area; FUT is typically better suited for large procedures whereas FUE is better – in most instances – for smaller approaches; FUE leaves small “dot” scarring in the donor area which typically allows patients to “buzz” shorter before the scarring is visible when compared to a linear FUT scar; however, both methods DO create scarring and there is no such thing as “scar-less” or “scar free” surgery; both also produce very minimal scarring in the donor which is very easily concealed in general; the jury is still out on the growth rates of FUE, but published literature demonstrates that it does not grow as consistent or well as FUT on average.
With both FUE and FUT we have now “evolved” to a point in the history of hair transplant surgery where patients have great options to utilize the full potential of their donor and receive excellent results.
