The History of Surgical Hair Restoration
"The truth is the truth and the truth will make people mad. It's true."
- Joe Tillman
There are many stages of hair loss that occupy so many of our scalps worldwide. It has been a problem that men have tried to deal with in many ways for thousands of years. The oldest known prescription for hair loss is from Egypt and is 3500 years old. It consisted of hippopotamus fat, crocodile, cat, and porcupine hair boiled in water. Thankfully, no one tried to invent hair transplant technology back then!
Hippocrates also suffered from hair loss 2500 years ago and he used a mixture of pigeon poo, horseradish, opium and spices. However, Hippocrates also noticed and recorded that eunuchs never seem to lose their hair and suggested castration would be the answer to the problem. Yeah, that’s a bit rough but he was actually correct in his assumption as confirmed by researchers at Duke University in the mid 1990’s.
But it wasn't until the middle of the twentieth century that something started to take shape that could be called real progress, more or less. Dr. Norman Orentreich performed hair transplant surgery in his New York office in 1952 and this was the beginning of what we know today as surgical hair restoration. He published a paper in 1959 where he introduced the "theory of donor and recipient dominance" where he described how the transplantation of androgen insensitive hairs could successfully allow hair to grow in previously bald areas. This laid the foundation for surgical hair restoration as we know it today. THIS is the guy that started it all and he did so by bringing to the world the gift of the hair plug...(crickets).
Early Hair Transplant Technology
But let's back up for a moment. Dr. Orentreich was not the first person to transplant hair. No, this was done in experiments as early as the late 1800's, with some success too. In 1921 there was Dr. J. S. Parsegan who had this crazy idea that if you transplant a woman's hair onto a balding man's scalp it would reactivate dormant follicles. WHY would this make sense? I wrote about this in a blog post and you can see a sketch of the machine used for this procedure to the left. The hair transplant technology in the image is medieval stuff!
Anyway, it was Dr. Orentreich who was the first in North America to successfully transplant hair for the cosmetic benefit of men with male patterned hair loss (the term had not been used yet) and it was his work that opened the gates to hair restoration being a cosmetic procedure to "cure" baldness. Before Dr. Orentreich there was work being performed in other parts of the world, most notably in Japan.
Dr. Shojui Okuda (1886-1962) is the unsung hero of hair restoration. This man performed hundreds of hair transplant procedures and he documented his work in such detail that it is thought that no one has documented as thoroughly since. He wasn't the first in Japan to perform hair transplantation as there was Dr. Sasagawa who actually developed his his own hair transplant technology by making custom needles in 1929 but the paper he published showed he was unsuccessful with heterograft transplantation . Dr. Okuda, however, built upon Sasagawa's work and was transplanting anything and everything he could think of. He transplanted hair from the scalp to the arm for experimentation. He rebuilt eyebrows, pubic regions, and even eyelashes. His tools included surgical punches up to 4mm in diameter (a true punch plug) and as small as 1mm in diameter. He noted that the smaller punches were much more difficult to get viable hair so he usually stuck with 2mm to 2.5mm incisions but the point is that he used 1mm punches on many occasions and noted in his journal how the cosmetic effect was superior to that of the larger punches he used. The "Okuda papers" were published in 1939 and at this point he had already been performing surgeries for ten years. Dr. Okuda never wrote about using his hair transplantation methods for treating male patterned hair loss. However, in 2009, Dr. Okuda's grandsons opened up a room that had been storing their grandfather's equipment and it had previously remained undisturbed for at least 30 years. Among the items in storage were before and after photographs of successful hair transplant procedures that were undocumented in his papers thus indicating that Dr. Shojui Okuda is the true pioneer and father of punch grafting.
About four years after Dr. Okuda's papers were published there was a second Japanese doctor that started to improve on Okuda's hair transplant technology by using smaller punches on a regular basis. Dr. Tamura used smaller punches of roughly 1mm more frequently than Dr. Okuda and even went so far as to refine the grafts that were harvested by trimming and dissecting them before implantation. He published his papers in 1943 in the Japanese Dermatological Journal during the height of the Pacific campaign of WWII. Dr. Tamura's refinement of Dr. Okuda's work is a more direct fore bearer to the modern FUE procedure we have today and in effect it renders any recent claims of being "the first" null and void. The first was Dr. Okuda and subsequently Dr. Tamura. It would be a long time before western medicine would learn of these two true pioneers as the information they documented was inaccessible due to WWII and it's aftermath.(Credit: American Hair Loss Association). It wasn't until 1959 with Dr. Norman Orentreich, mentioned at the top of this page, that western medicine caught on but unfortunately it was not in the form of refinement that one would expect with time.
Fast forward to 1975. Disco was king and so was polyester and crazy hair. Lots of great things came out of the 70's including Dr. O'tar Norwood and his classification system known as...wait for it...the Norwood Hair Loss Chart. Original, I know, but this was fairly important as it helped to standardize how hair loss was measured and this allowed for easier diagnosis and treatment recommendations by hair restoration clinics. It isn't entirely accurate however as there are several patterns found in nature on a regular basis that are not represented on the NW chart but it gets the basics down well enough. Dr. Norwood's classification system also gave the public a way of understanding their own hair loss. They could simply look in the mirror then look at the chart. Boom! Once a balding man knew where he was on the chart it would psychologically give them a solid base to associate themselves so they could take action to actually do something about their problem. Think about it. If a doctor points to a picture and says "This is you." and you don't like the picture then it is easier to point at another picture and say, "But this CAN be you if you pay me to move these 67 plugs for you.”
The 1970’s also introduced a few alternatives to plug hair transplant technology but mainly they were adjuncts to the procedure overall. First you have the scalp flap. The scalp flap was first performed in the 1930’s but it never caught on till Dr. Jose Juri of Argentina introduced the Juri Flap in 1969. A scalp flap is an extremely invasive procedure that requires a high degree general and plastics surgical skill to perform successfully and even then the outcome is questionable. Basically this involves removing a large piece of tissue from one area of the scalp and rotating it to another area in need of hair. When I say that the tissue is “rotated” I mean literally it is rotated like twisting a wet towel. It isn’t fully removed because, get this, you need to keep it attached to the major blood vessels that keep the tissue alive.
Another hair transplant technology alternative is the scalp reduction. Scalp reductions were procedures that literally remove the area of scalp that had hair loss and then pull the edges of the wound together so that the areas of still strong growing hair would be much closer to each other thus you have a reduction of hair loss from this reduction of scalp. It made sense at first glance because you’re just cutting out the problem and throwing it away but the problems emerged when arteries would be cut thereby inducing nearly uncontrollable bleeding or when the final result matured the patient would have difficulty styling their hair. This was due to the natural hair geometry being completely distorted from the procedure. Both scalp flaps and scalp reductions have thankfully had their short time in the history of hair restoration and we have moved on to better methods but I still see the remnants of these procedures to this day.
Punch grafting survived the 1970’s and continued to thrive into the 1980’s. There were some doctors that had tried to use punches significantly smaller than 4mm but none were successful, or at least not enough to warrant creating change, but there was something different that started to push the industry forward. It was the pattern of plug extractions that helped to usher in the next big change. The way that doctors would traditionally remove punch grafts is that they would take their plugs from random areas of the scalp. Sometimes in close knit groupings and other times spread out over the entire safe donor zone and sometimes well outside of the safe donor zone. But some doctors started to see that when the plugs were extracted close enough together, and in a pattern that formed something similar to a rectangle, they would see that they were creating one large wound that forced them to suture the wound closed. EUREKA!!! No more punch scars! Eventually someone got the bright idea that a scalpel might be a better way to get out this new rectangular pattern of hair bearing scalp so that patients wouldn't have the buckshot scarring from surgery any more. It kind of makes sense, right? Well, the problem is that someone still decided that it should be easier, not better, so now we have the multi-blade scalpel.
The multi-blade scalpel is a medieval looking piece of hair transplant technology that takes two to four scalpel blades and puts them in one handle. This means that the doctor can just make one swipe of the scalpel(s) and you've pretty much got up to four narrow strips to dissect hairs from for placement into the recipient scalp. Don't worry about follicular transection because there's plenty of that to go around. Enter the age of the mini-micro graft. This is where the experience of yours truly comes into the picture, as this is the procedure I had performed in the early 90's. But I digress. Mini-micro grafting is not such a bad procedure if performed by someone that gives a damn. No, it can work well but there are several disadvantages to the method. If a multi-blade scalpel is used to harvest the donor hair then many of the grafts in the donor zone, both in the strip removed and the adjacent areas of the donor zone left behind, will be transected and rendered useless. This leads to permanent shock loss in the donor zone and less growth of transplanted hairs for the final result months later. It was a step in the right direction but not quite there. Yay progress! Meanwhile in Australia...
Current Hair Transplant Technology
In 1994 there was a good ole boy in San Antonio, Texas by the name of Limmer, Dr. Bobby Limmer, and we have him to thank for the common sense approach of actually caring about how hair transplants look. What Dr. Limmer did was basically take the industry of hair restoration, shove it down a cannon tube and fire it forward into the age of common sense. Dr. Limmer presented the world with the idea that using stereoscopic dissecting microscopes for the dissection of follicular units would provide for a more natural result and a higher yield (growth rate) of transplanted hair. As it turns out he was right and with that he ushered in the age of the follicular unit transplant. Follicular unit grafting via stereoscopic microscopes allows for 30% higher yield of the transplanted grafts and it allowed for refinement that was much more difficult to detect. Finally, it only took about sixty years after Dr. Tamura for the western world to finally get it.
Follicular unit grafting did not actually take off quickly from the start. As with any new development, when it comes to hair transplantation, it was met with massive resistance but eventually it became the gold standard in the field and this is still the case today (2015) where approximately 67% (as of 2014) of all hair restoration surgeries are carried out via FUT. In the beginning of FUT the biggest procedures were in the range of 800 grafts to 1200 grafts but with time there were improvements to follicular unit grafting and the donor harvesting process as well. Yields continued to climb and harvests of hair continued to grow to the point that today there are many clinics that routinely harvest up to 4000 grafts in a single procedure. There have been many cases of clinics going larger but going beyond the 4000 to 4500 graft range is considered by many to be pushing the envelope just a little too much.
So if FUT is the gold standard in 2015 and dominates approximately 70% of all hair restoration surgeries performed, what kind of surgery makes up the remaining 30%? Remember a few paragraphs ago I said "meanwhile in Australia"? Well, there is this guy name Dr. Ray Woods in Sydney Australia and back in 1989 he didn't quite buy into the notion that we had to cut open our scalps just to get some hair to give us coverage. I'm not sure how he thought of this, whether it was just a common sense thing or maybe he got a hold of Dr. Tamura's papers, but he and his sister, Dr. Angela Campbell, figured that if they could just remove each follicular unit with a tiny punch then that would be better for the patient. No big issues with scarring and the patients are still happy with the improvement. It's similar to the common sense approach of the Japanese when you think about it. Yes, Dr. Ray Woods of Sydney Australia started working with FUE way back in 1989 and he's been a rogue middle finger to the establishment ever since. While the powers that be in North America were setting the stage for how the industry would move forward for the next thirty years Dr. Woods was working to refine his technique and to make the "do no harm" method (my words, not his) the preferred method of hair restoration. Dr. Woods tried to talk to all of the big names of the time and predictably, if not unfortunately, his efforts fell on deaf ears. It wasn't until 1999 when Dr. Woods contacted this crazy cat named Spencer Kobren that things started to turn around.
Spencer Kobren is the author of The Bald Truth, which is basically the first book about hair loss to really get any traction in the book world. It was one of the first bestsellers on Amazon.com and helped to educate a lot of people about the reality of hair loss and hair restoration. Spencer also had a radio show (currently a wildly popular live internet video broadcast) back then and he had a loyal group of listeners. Dr. Woods decided that convincing Spencer Kobren of the superiority of his technique might be the way, if not the last resort, to get anyone to listen to him. After some discussion, Spencer met some of the patients that had travelled to see Dr. Woods and he was convinced that Dr. Woods had built a better mousetrap so he started speaking to doctors on Dr. Wood's behalf to get them to listen about this new method of hair restoration. It took time but eventually there were some doctors that decided it was worth a shot so this is where the seeds were planted for the next big shakeup in the hair transplant world. I’m talking about FUE or Follicular Unit Extraction.
Let’s get something clear. A lot of people call themselves pioneers but the true, original pioneers of FUE were Okuda and Tamura. When you're using 1mm punches for moving hair, you're performing FUE. But, the “modern” pioneer of FUE is Dr. Ray Woods. No one else can make this claim simply because no one else can back up their claims with solid and unquestionable proof. Dr. Woods can and anyone that says otherwise is simply lying. So FUE got its start in North America with Dr. Rob Jones of Toronto and Dr. Alan Feller of New York. Both of these doctors saw the merits of the procedure and Dr. Feller in particular, who is kind of a gadget geek to begin with, started working on his own tools and he was the first in North America to create his own FUE hair transplant technology. You see, Dr. Woods had great foresight and passion to really push the procedure but one thing he didn’t have was business sense. Granted, this is just my opinion, but I think I’m making sense when I say that you don’t normally want to piss off those that you are asking for money. The story goes like this. When Dr. Woods started getting some recognition he decided to offer training to other doctors that wanted to learn what he was up to and take it home for themselves. Well, Dr. Woods wanted to charge a fee for this training, which there is nothing wrong with, but he wanted to charge in the range of 100,000 to 150,000 dollars. Yes, that is a lot of money but in the grand scheme of things it really isn’t a huge investment for hair transplant doctors. However, during this time when Dr. Woods was talking about offering training he was simultaneously insulting those that wished to train with him. He called strip surgeons butchers (more or less) and kept talking about how in his practice he never required patients to sign surgical waivers. He made this appear to be a dishonest practice by North American doctors. What Dr. Woods did not realize is that doctors in North America are required to have patients sign surgical waivers in order to be covered by medical malpractice insurance. If they didn’t require this of their patients they would not get insurance that is required to perform surgery in the first place. Regardless, Dr. Woods was painting North American doctors as butchers and con-men and this isn’t exactly the best way to go about selling your training package. I may be wrong about this but until I hear from Dr. Woods and anyone that spoke to him about his training and they have information to dispute this then this is what I know to be true.
Dr. Feller and Dr. Jones started working with FUE in 2002. Because Dr. Woods was not sharing the details of his procedure and no one knew what tools he was using it was up to these doctors to come up with their own ideas on how to perform this new procedure. News of this new procedure being offered was being spread by very few online resources as most forums were just as resistant to the idea of FUE as most doctors were. Dr. Jones simply used medical biopsy punches or some other readily available punch but Dr. Feller soon patented his own tools, and subsequently other doctors started to take note and also investigate FUE. Dr. Bernstein and Dr. Rassman of NHI (New Hair Institute) wrote the first medical paper on the subject in 2002 and came up with what is known as the “FOX” test. The FOX test was designed to help identify individuals that are good candidates for FUE and those that are not good candidates for FUE. Dr. John Cole of Alpharetta, Georgia also became interested in FUE in 2002 and it is reported that he travelled to Sydney Australia in an attempt to learn from Dr. Woods but for some reason the meeting never progressed beyond the initial introduction and Dr. Cole unfortunately returned to Georgia empty handed. Dr. Cole however is a determined and driven man and he took it upon himself to create his own version of FUE that he calls “FIT”. This stands for Follicular Isolation Technique and it basically introduced depth control to the process of FUE. Dr. Cole transitioned his practice to mainly offer FUE ( and lots of body hair) by the middle of 2003 but he still performed strip surgery for several years. Dr. Cole became North America’s main proponent of FUE albeit in the form of his proprietary hair transplant technology he called FIT until around 2006 when new clinics were emerging that similarly also only offered FUE. FIT eventually was renamed CIT or “Cole Isolation Technique”. To this day no one knows any of the details about how Dr. Woods performs his FUE procedure.
The hair restoration industry has slowly but surely started to transition away from strip toward FUE but the real push began around 2008 with the introduction of Neograft® hair transplant technology. Neograft® is a motorized, hand held FUE device that has a rotating punch that “scores” the follicular unit. This is nothing new as there were other motorized punches being developed and introduced around the same time but the Neograft was different in that it offered extraction AND implantation. It was a novel and unique idea. The way that it works is that once the graft is scored a high powered vacuum attached to the end of the hand held wand would suck the graft out of the donor scalp, through a tube, and into a reservoir filled with chilled saline as a storage medium. Once the grafts were extracted the user would make some adjustments to the machine and then the system would push the grafts back through the tubing to be inserted into the recipient sites made by the wand. This sounds like the perfect system but there was one issue that kept getting in the way of this being the pinnacle of hair restoration. Desiccation. This would occur when the vacuum used to suck the grafts out would dry the grafts out in an instant and once this happens you can’t suddenly rehydrate the graft expecting it to survive. This wasn’t a consistent problem across the board but it is bad enough that you just don’t see solid results like you get from other FUE systems. There are a few FUE doctors that have taken the Neograft and modified it to eliminate the vacuum process. Once such doctor is Dr. Alan Bauman of Florida. He was one of the first users of Neograft in North America but subsequently he was also one of the first and only to modify the machine for his own use and to do that meant to eliminate the only component that separates Neograft form it’s competitors. There are other aspects of Neograft that some find attractive as a piece of the overall system but those are personal choices and preferences. Neograft made an impact on the industry for two reasons.
First, it introduced an opportunity for the industry to gain more mainstream appeal as Neograft created a massive media and advertising push that had one simple but very effective message. There is no strip scar from the procedure. People that took the time to investigate and research hair restoration techniques knew about FUE in general but the lay public had no idea what was involved and they only knew that strip surgery meant a strip scar and the “Neograft technique” as many later referred to it, offered no strip scar. The company focused on this message and completely avoided the issue of quality of growth and let the public assume that all results would be the same. The second reason that Neograft made an impact on the industry is because they introduced what was essentially the first “turn key” hair transplant clinic in the world. For a fairly nominal fee one could purchase a Neograft machine, rent a small office and maybe hire a receptionist and they could start offering surgery after taking a single weekend training course. Neograft has a team of traveling technicians that would also travel to new clinics to help get them up and running but the formula was simple. Sell as many machines as possible for a decent price. It worked and now Neograft is one of the more recognized names to anyone researching hair restoration. Any doctor or clinic that has the slightest interest in offering hair restoration alongside tummy tucks and Botox injections can now do so.
The Future of Hair Transplant Technology
In 2011 the potential future of hair transplant technology received 510K clearance by the United States FDA. The ARTAS® system by Restoration Robotics was introduced shortly thereafter. This is the first and currently the only robotic hair restoration system. It is exactly as it sounds. A robotic arm with a punch tipped apparatus makes incisions and scores grafts for extraction. The system is actually fairly limited in that it does not remove grafts on it’s own and it does not place any grafts. Trials are currently underway however to allow the system to make incisions for placement. The idea behind the ARTAS® system is that it takes the element of fatigue away from the procedure and introduces the use of highly developed algorithms that supposedly offer faster and more reliable scoring of grafts. One unique aspect of the system is that it is constantly being updated based on regular system feedback from each individual machine in use. This means that with every software update that the system goes through it is bringing the lessons learned from the cumulative number of surgeries performed prior to the update. This has the potential of offering exponential improvements for the accuracy and reliability of the system. Currently the system is using punch sizes of .9mm to 1.1mm but in the early days of its use it was using punches as large as 1.6 and 1.7mm respectively. The progress has been steady and currently Restoration Robotics is working on improving the system to allow for .825mm punches. Current limitations of the ARTAS® hair transplant technology include the ability to only work on darker, straighter hair. It has trouble removing grafts from certain areas of the scalp on even the best candidates so supervising doctors must have the ability to compensate by offering alternative means of extraction with either hand held motorized punches or manual punches.
Back to The Basics
Current Methods of Surgical Hair Restoration