The History of Hair Transplantation

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The History of Hair Transplantation
Jae P. Pak, M.D., Paulo Gazoni, M.D., Alvaro Zeballos, M.D., William Rassman, M.D.
March 2008

Introduction

Throughout history man has searched for the cause of hair loss. It is only in recent years, with greater knowledge of genetics and the chemistry of sexual hormones, that we have begun to understand the causes. The most common type of hair loss is Androgenic Alopecia which afflicts more than 50% of the male population to some degree. The allusive cure for Androgenic Alopecia can be traced back thousands of years to the ancient Egyptians or the Romans who applied variety of ointments and salves to their balding head. In the modern era, hair restoration surgery has gained popularity as a permanent means of addressing alopecia.


Origin of Hair Transplantation

The origin of hair transplantation was first documented in 1822 as a doctoral thesis by J. Dieffenbach in Wurzburg, Germany. He investigated the concept of auto transplantation of hair, feathers and skin in animals. Although there were sporadic reports of hair transplantation in European and Japanese literature during the mid to late 19th century, the modern era of hair transplantation began in 1939 with the Japanese dermatologist, Dr Okuda. He started using small full-thickness auto-grafts to correct various alopecias of the scalp, eyebrows, and mustache. At the time, Dr. Okuda was transplanting round grafts of skin containing multiple hair follicles from permanent hair bearing areas into smaller, scarred recipient sites. Dr Okuda noticed better cosmetic results with slightly smaller punches in the recipient area. He noted that single hair grafts appeared most natural.

In 1943, Dr Tamura treated 137 patients with non androgenic alopecia of various etiologies to restore female pubic hair. He noted that single hair grafts produced results almost indistinguishable from the natural growing hairs. He also noted that larger grafts produce a very unnatural appearance, however, due to World War II events that unfolded; these findings remained unknown to the western world.

In 1952, Dr. Orentreich performed the first hair transplant for male pattern alopecia. Seven years later (1959), he coined the term “Donor Dominance”, which is the science from which hair transplantation as we understand it today is practiced. This furthered our understanding that hair grafts continue to show the characteristics of its donor site origin throughout life when they are transplanted to a new recipient site.

In 1975, a dermatologist and hair transplant surgeon, Dr. O'Tar Norwood, building upon the earlier work of Hamilton, developed a classification of male pattern hair loss that is widely used today.



Type A Variant Norwood Classes • Frontal recession keeps advancing backwards
• Single area of balding
• Eventual extent of balding tends to be more limited than in Regular classes Type IIa

• Entire frontal hairline recedes Type IIIa
• Entire frontal hairline recedes Type IVa

• Hair loss moves past this "mid-coronal" line Type Va

• Hair loss extends towards the vertex
• Back part of bald area is narrower than in the regular Norwood VI

Regular Norwood Classes Type I

• No recession
• "Adolescent" or "Juvenile" hairline Type II

• Temporal recession < 1"
• Mild recession along frontal hairline
• "Mature" hairline Type III

• Further frontal recession
• Deeper recession at corners
• Earliest stage of balding Type III vertex

• Hairloss predominantly in vertex (crown)
• Frontal hairline recession may be present Type IV

• Further frontal hair loss and temporal recession
• Enlargement of vertex (crown)
• Solid band of hair across top separating front from vertex Type V

• Frontal and temporal areas enlage further
• Band separating the two areas becomes narrower and sparser Type VI

• Frontal and vertex balding areas merge into one and increase in size Type VII

• Narrow horseshoe band of hair
• Low hairline in the back
• Hair in permanent zone may be sparse
The Evolution of Hair Loss Treatment Options

The evolution of hair loss treatment options can be subdivided into two types of surgeries: 1) Scalp surgeries, and 2) Hair transplantation surgeries. With respect to genetic androgenic alopecia, many of the scalp surgeries have been abandoned for the more the minimally invasive hair transplant surgeries. There are also medical treatments for androgenic alopecia but the medications are limited to oral finasteride (Propecia) and topical minoxidil (Rogaine).
Scalp Surgeries
Often used for the treatment of patients with severe burns and scars, scalp flap surgeries date back to the 1930's, however, they did not become a routine option for the treatment of hair loss until 1975 when Dr. Jose Juri, considered the father of modern scalp surgery, developed scalp flap techniques which now serve as the template for all scalp flap techniques. In the Juri flap, also known as the temporo-parieto-occipital (TPO) flap, the entire frontal hairline can be reconstructed. The flap is based on the distribution of the superficial temporal artery and consists of a 2.0-2.5 cm pedicle with a width of 4-6 cm and a length of 23-25 cm. This surgery is often done is several stages, typically two smaller procedures where the flaps were incrementally lifted and repositioned, followed by one larger, scalp transfer stage. The first two stages are done to re-route blood supply to the uncut front of the flap and the larger stage involves removal of the bald, frontal scalp, and insertion of the flap over the resected area. This became the basis for a pedicle flap. Despite being able to provide immediate coverage to a bald frontal area, there were considerable risks associated with it. Pedicle flaps can often cause serious complications, the primary one being failure of the blood supply in the pedicle, resulting in the partial or complete loss of the flap. The development of micro-vascular free scalp flaps were published in 1974 by Harii and Ohmori. The basis of the "free" flap is that there is no attached pedicle to the flap. The important aspect of this procedure is that the flap must contain arteries and veins that can be reattached to the blood vessels present at the recipient site. It is extremely important to note that the free flap procedure is an advanced technique that requires great skill, training, and experience and like the Juri flap, there were considerable failures in the hands of many surgeons.

Original credit for the development of scalp reduction for the treatment of male pattern baldness is difficult to determine, but suffice it to say, many hair restoration surgeons during the later part of the 1970's have been associated with the procedure. Dr. Constantine Sparkuhl may have preceded the Blanchard brothers who published the first article on scalp reduction, in the J. Natl. Med Assoc in 1977 and were followed by the Unger brothers in the September 1978 issue of the Journal of Dermatological Surgery. In that same year, Sparkuhl presented his findings at the International Hair Transplant Symposium. In 1979, Dr Bosley published the first large series of scalp reductions and termed them male pattern reductions. Scalp reductions are indicated for treating the bald crown in patient with Class VI or VII alopecia. During the later part of the 1970's and early 1980's, several reduction techniques had been developed, but all modalities have three things in common, incision/excision, mobilization, and finally wound closure. Although theoretically attractive solutions to male pattern baldness at the time, these surgical alternatives have fallen out of favor due to high complication rates and poor aesthetic results. There are, however, still some surgeons who use them in combination with hair transplantation techniques.

As mentioned above, the development of alopecia reduction techniques came about because of the desire to treat hair loss in the vertex and other areas with extensive loss. Alopecia reduction (AR) techniques, as noted, have several shortcomings. Limited excision averaging about 1” of scalp width were achieved in each surgical session and as the width of a typical Class 6 balding pattern was in the 5-6 inch range, multiple surgeries were required. The math however, did not really work out as more and more surgeries induced more and more stretch-back and more scarring. The worst of the ‘successful’ reduction surgeries produced a "slot" deformity, an area of bald scalp that develops secondary to the cooptation of hair pointing away from the excised areas. In 1992, Patrick Frechet first described the concept of "scalp extension" where a spring loaded device was put into the scalp, pulling on the sides to stretch the sides of the scalp and allow for a larger excision of the balding area. Dr. Frachet also developed a correction technique for the slot deformity through the use of the ‘Frechet’ triple hair bearing flap transposition procedure. Today, Dr. Frechet is still at the forefront of this technique and is considered one of a few doctors worldwide that can repair the slot deformity with minimal complications and excellent results.

Transplantation Surgeries

The most significant advance in hair transplantation and the current method of harvesting and placement of hair, the Follicular Unit Transplantation, is based on Dr Headington’s histologic definition (1984) of a follicular unit, a naturally occurring grouping of 1-4 terminal hairs. A histological view of the corresponding Follicular Units seen in cross-section within the dermis (Fig. 1). Perfectly intact 1-, 2-, 3-, and 4-hair Follicular Units removed from the donor strip using a dissecting stereo-microscope is shown in Fig 2.

Fig.1 Fig. 2 Through the years there has been a progression and refinement in harvesting donor grafts. Five methods have been used and developed, however, only the last two methods (Single strip harvesting and Follicular Unit Extraction –FUE) are used today. The original method, devised by Dr. Orentreich in the 1950's, used a hand punch to cut single grafts 3- 5mm in size that could contain up to 30 or more hairs. After experimenting with a number of different size grafts, Dr. Orentreich chose to use 4mm punches (which are about the size of pencil erasers) as his "workhorse". (Fig. 3)
Fig. 3
Each punch hole was separated by small islands of skin which was measured to be the same radius as the recipient grafts. The plan was to remove the skin bridges in a series of 4 such procedures until all of the bald skin was replaced by hair baring skin grafts. Unfortunately, grafts greater than 2mm in width could not receive the needed oxygen (by diffusion) because the distance between the center of the graft exceeded 1mm from its periphery. This produced considerable hair wastage around the center of the graft from cell death caused by anoxemia. These larger grafts had hair around the periphery and a donut of bald skin in the center. Add to this a high transection rate from improper alignment of the punch with the hair follicles and the amount of damage caused by the surgery increased even further. These large punch methods are now rarely used. The donor grafts were often taken with a mechanical punch held in a small hand engine to core out a number of round grafts of known size. The punch turned or oscillated at high speed causing more damage. To solve many of these problems, the doctors bisected or quartered the grafts making minigrafts, which oxygenated better than the large grafts. The circular wounds from these drills were originally left open but over time many surgeons started to close the wounds because the weeping open donor area was not acceptable to many patients. If the donor sites are closed, they develop significant less scaring. Most doctors have abandoned all of these techniques.

The next method for harvesting grafts uses multiple, parallel scalpels attached together on a handle, called a multi-bladed knife. (Fig.4) Multiple thin strips of hair-bearing donor skin are removed simultaneously and then grafts of the desired size are cut from the thin strips of tissue produced by the multi-bladed knife. Using a scalpel does not produce any torque or heat energy; therefore, no heat or torque damage to the grafts can occur. This method is quick and simple and still quite popular. Unfortunately, this method can cause extensive damage to the donor tissue, as it is impossible to line up the multiple blades parallel to the hair follicles. The more
Fig. 4 the blades and the closer they were to each other, the greater was the damage to the hair in the excised donor strip. Because of this there is unacceptable cutting of individual follicles (transection) and breaking up of naturally occurring follicular units.

The single strip harvesting method became the standard today. Here the donor tissue is removed as a single strip. In single strip harvesting, the donor strip is removed either with two parallel blades forming a single long, thin strip or with a single blade producing a long, thin oval: termed an ellipse. The strip is then further divided into smaller sections using a dissecting stereo-microscope, introduced into the field of hair transplantation by Dr. Bobby Limmer, who recognized the logic of using microscopes as a tool as early as 1987. The use of the microscope allows for total visual control over the harvesting and avoids the unnecessary transection (cutting) of hair follicles. The great advantage of this method is that the tissue is removed from the scalp with the minimal amount of "blind" cutting. The only blind cutting is in the single incision around the periphery of the donor strip as it is removed. All further dissection can be then performed by direct visualization using a dissecting stereomicroscope. This keeps potential damage to follicles at an absolute minimum and allows preservation of intact naturally occurring follicular units. In order to perform Follicular Unit Transplantation, single strip harvesting and stereo-microscopic dissection must be used.

Drs. Rassman showed that a large number of grafts (megasession) could be removed in a single session (J Aest and Rest Surg, 1995). Drs. Bernstein and Rassman (Dermatologic Surgery, 1997) developed, introduced, and described in detail the advantages of The Follicular Unit Transplantation, whereby the entire transplant is accomplished by moving these naturally occurring follicular units from the donor area to a recipient area. Since, follicular unit transplantation has evolved, it has become more refined, with superior aesthetic results and is now the gold standard for hair transplantation surgery. In addition to this new developing procedure, Rassman presented 23 live patients who had undergone FUT with high numbers of follicular units (at the 1995 ISHRS conference in Las Vegas), popularizing the "megasession", a technique, first introduced in 1982 by Dr. Carlos Uebel, whereby large number of grafts are moved in a single session.

Lastly, a technique of minimally invasive hair transplantation, known as Follicular Unit Extraction (FUE) was developed and published by Rassman, et. al in 2002 in the Journal of Dermatologic Surgery. This can be thought of as the ultimate refinement of Dr. Orentreich's old punch graft method from the 1950's but based upon the fundamental anatomical unit. The current procedure entails removing individual follicular units with one millimeter punch excisions, aligning the punch with the hair shafts, obviating the need for strip harvesting and the horizontal surgical scar from the strip harvest.



Medical Treatment

Topical Minoxidil (Rogaine)

Minoxidil, developed in the early 1980's for the treatment of high blood pressure, was discovered to have the side effect of hair re-growth. This prompted the formulation of topical minoxidil in the late 1980's for the treatment of hair loss. The exact mechanism of minoxidil in promoting hair growth is not known. It most effective in those with early hair loss and only affecting small areas. For patients with large and extensive amounts of hair loss, it is thought that minoxidil has decreased effectiveness. In addition, it is better for promoting hair growth in the central, vertex, of the scalp than in the front. Potential side effects are generally related to skin irritation or itching.

Finasteride (Propecia)

Finasteride, initially approved in 1992 (as Proscar) for the treatment of benign prostatic hypertrophy, is now also used as treatment for androgenic alopecia. In 1997, the Food and Drug Administration (FDA), approved finasteride (as Propecia) in a 1mg dose, for the treatment male pattern hair loss. Finasteride works by blocking the action of 5-alpha reductase, thus preventing the conversion of testosterone to dihydrotestosterone (DHT), the cause of male pattern hair loss. Known side effects include breast tenderness, and decreased libido.


The Future

Even in the future when Cloning of hair becomes a reality, the Follicular Unit Transplantation techniques will still be utilized to transplant the hair in its naturally occurring pattern and groups.
At present, there is no cure for balding. While modern hair transplant surgery has evolved to a point of undetectable and natural looking results, there is always a supply and demand limitation. In other words, there will never enough of a donor hair supply to meet the demand of the balding area in individuals with advanced balding.

The thought of being able to culture hair follicles and have an unlimited donor supply has been a long-time dream of doctors and patients alike. The obstacles, however, is enormous since the hair follicle is a very complex structure of skin cells, blood vessels, nerves, muscles, and glands. (As an analogy, culturing a hair follicle would be more like culturing an entire eyeball rather than just the cells of the cornea.)


Conclusion

Genetic hair loss does not discriminate race, ethnicity, or socio-economic class as it afflicts 50 percent of men world wide at some point in their lives. We have classified it and even arrived at some insight in to the bio-chemical mechanisms responsible, but the definitive cure for balding still remains elusive. The treatment for hair loss has been refined both medically and surgically. While lotions, potions and “secret” herbal treatments abound, Propecia and Rogaine remain the only medically proven treatment for hair loss. After scalp flaps and scalp reductions and “pluggy” transplants of generations past, hair transplantation surgery has come full circle back to the original work of Dr. Okuda. Follicular Unit Extraction and Transplantation is the ultimate refinement of Dr. Okuda’s technique by harvesting and transplanting the single follicular units one anatomic unit at a time.
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Los Angeles Hair Restoration Surgeon