Modern day Hair Transplant: History and Evolution

Hair transplant in modern times was probably first described by a Japanese plastic surgeon Akuda as a reconstructive procedure in his burn patients. He used to harvest hair plugs from permanent donor area which were then implanted in scarred areas of scalp. It was not used for male pattern baldness.
However, due to censorship applied during WW II, these reports and techniques were not available to the rest of the world.

 Dr. Norman Orentreich in New York City was the first to use this technique for male pattern baldness in 1950s. He laid the foundation of modern hair transplants and defined the basic principles of hair transplant. He noted that the hair coming from the permanent zone maintained the characteristics and growth pattern of the area from where it came rather than changing to the implanted area characteristics. He called it the 'principle of donor dominance' which is the fundamental feature of hair restoration surgeries.

This image is from Dr. O'Tar Norwood's textbook 'Hair Transplant Surgery' published in 1973.

During the initial period of hair transplant surgery, large punches were used to cut out hair bearing skin from permanent donor zone which were then placed in holes created by a similar punch in the front. The surgeries were usually small and 25-30 grafts were placed during one session. As the long term results started coming in the flaws in this approach became evident.

First and foremost, the look in the transplanted area was unnatural. The hair came out in tufts at an abnormal angle in the scalp and were likened to "rows of corns" and "doll's hair". Many a times the hair in the central portion of the plug did not grow due to poor oxygenation and were lost forever. There was extensive damage to the donor area. Sometimes the results were so bad that the patient was forced to cover his head, not due to baldness but, due to transplant.

Then came the era of mini and micro transplants where hair was removed as a strip and then cut to small grafts called;

1.Large Mini-grafts – Grafts containing 4-5 hairs
2. Small mini-grafts -- Grafts containing 2-3 hairs

3.Micro-grafts – tiny grafts containing 1-2 hairs. 

Although the results improved but they could not stand to close scrutiny. Since the natural follicular unit architecture of the hair was not respected the hair growth was poor and wastage high.

Modern day "Follicular Unit" grafts compared to common ball point pen.

As interest and research in procedure grew, the importance of follicular unit architecture was realised. And, today "Follicular Unit Transplant" is considered the 'gold standard' hair replacement procedure through out the world.

What is "Donor Zone" ?

In simple words donor zone is the area from where the tissue is being borrowed for placement in another location. In hair transplant this is a ribbon shaped area centered over a bony prominence in the skull called occipital protuberance. This area described as "Universal Safe Zone" forms the basis of hair restoration surgeries. It extends from the area around ear going back towards temples over to the occipital protuberance and is best seen in Norwood VII patients.

Norwood VII is the "Universal Safe Zone" for scalp hair.

The height of donor area is around 5-6 cm in midline and it is approximately 30-35 cm long. If we were to utilise all of it there would be no hair left in the donor zone of a class VII patient. However, it is possible to utilise around 50% of this hair without a visible reduction in hair density on the back. This means a total usable area of around 90-100 square cms. 


Assuming an average density of 100 FUs /cm square in caucasians and 80 FUs / cm square in east asians, this gives us a total of 10,000 FUs to 8000 FUs of movable follicular units having approximately 15 to 20, 000 permanent, DHT resistant scalp hair. Of course, if you have a higher density you will get more hair and vice versa.


Having 10,000 movable follicular units does not mean that all of them can be harvested at the same time. The number of units that can be taken out in one session depends upon your scalp laxity. Harvesting too narrow a strip will give smaller number of follicular units and harvesting too broad a strip may result in wide unsightly scar. So, it's a compromise between the two. A patient with high donor density and good scalp laxity will have significantly higher yield than one with low donor density and poor scalp laxity.


Remember, donor zone is the single most important factor in any hair restoration surgery. As a plastic surgeon I have learned to give utmost respect to donor zone but many a times under-qualified doctors do not give adequate attention donor zone.  If you look at the stage VII of Norwood class you will realise that hairline recedes not only from the front and top but also creeps up from the neck and temples. That is why follicular harvest from areas above or below this zone may result in visible scarring.Over harvesting from the donor zone may result in wide unsightly scars and thinned out see through look in the donor area. This is so unnatural that the whole exercise of hair transplant becomes futile. Although I am a strong proponent of large sessions, for the aforementioned reasons, larger sessions are not always better for you.

Example of  a bad strip scar.
This patient underwent follicular unit transplant by strip method
at a  clinic in New Delhi.  500 FUs were grafted.

 Every one is different and every hair restoration needs to be individualised. Do not rush to the doctor who is offering highest number of grafts for same area. You may end up losing precious donor hair in the bargain. Think, deliberate, consult and research before taking your decision for money can not bring these hair back.

Cheap Hair Transplants : What is the real cost?

Recently, there has been a flood of hair transplant clinics who are willing to do transplants at  ridiculously low prices. As a consumer, you think this is because of growing competition in the field. And like other commodities prices had to fall one day. You are happy that now the procedure is within your 'budget' and you quickly get a transplant before you lose this golden opportunity.

Few months pass by and you see some hair growing. You are overjoyed by this new growth and give yourself a pat on the back for a wise decision. Few more months pass by, and you don't really see the results you expected. You talk to your hair transplant physician ( who you now realise is just a general surgeon or not even that) and he reassures you of great results in few months time.

This patient received ' state of the art'  'No stitch No scar' transplant at a leading clinic in New Delhi.
Two years later his whole scalp is scarred, hairline is low and straight and donor area is depleted.

You wait with growing impatience and are then told to go for another procedure to increase the density. You pay again and get a second transplant. This time you see some improvement, but you are still looking 'kind of weird'. And you certainly cant afford a third session that was advised to you.

As time passes you lose some more hair and now the reality of your 'cost effective' transplant is there for all to see. And it is not a pleasant sight. Now you are really concerned  so you start looking for a good hair restoration surgeon. You do your homework, look at doctor's credentials and degrees, look at his results and then get an appointment. It is only now that you understand the full impact of damage done. Most of your donor zone is depleted and even the best plastic and hair transplant surgeon can not do much.

This is a story I hear at least once every day. The real tragedy is not the loss of money but the loss of hair for you and loss of repute for hair transplant procedure. Hair restoration procedure is delicate and highly skilled procedure. And once done, it can not be undone. Take your decision wisely the first time. You may never get a chance again.  Do not be blinded by the discounts and cheap pricing that many clinics are now offering online. Search and research about your surgeon for the success of transplant depends on the surgical team alone.

What is Follicular Unit Extraction and Transplant??

For contemporary hair transplants, there are two basic methods of harvesing donor hair. The conventional strip technique and follicular unit extraction. In Follicular Unit Extraction (FUE) technique donor hair are harvested one by one and is therefore more labour intensive. During this technique a small micropunch usually sized 1mm or smaller is used to isolate a group of hair from its skin attachments. These groups having one to four hair, called follicular units, are then gathered (pulled out) from the head. This leaves a pin point wound from the area of harvest.

In this way the hair are taken out one after another, until adequate number of hair required for that session have been harvested. This surgery is done at a "micro" level and requires 8X magnification and expert hand control. Since FUE procedure requires careful and delicate handling, it is possible to harvest only 1200-1500 follicular units per session. An average session may last 8 hours and may need to be repeated, if balding area or graft requirement is extensive. The donor wounds heal over the next of seven to ten days with barely visible scars. Stiches are not required

In contrast, in FUT (strip) technique all the required hair are removed in one long strip of hair bearing skin. These hair are then isolated from the strip and implanted. To close the gap after strip harvest, stiching is required.

After the grafts are harvested, micro slits are created in the bald area where these follicular units are implanted with help of fine instruments. Once they develop their blood supply they will grow into healthy growing hair. The angulation of hair, density in key areas and hair design remais different from surgeon to surgeon and depends upon his experience and expertise.

At the end of the day the difference is only in harvesting technique, but what a big difference is that.

I will try to post a video of FUE soon and may be a pictorial comparison of two techniques.

Follicular Dissection and Implantation : Video

Follicular unit Harvest as a Strip : Video

Hair Transplant Donor Harvesting & Graft Preparation Techniques Physicia...

Growth after Hair Transplant : What to Expect

What to Expect

Knowledge can prevent unnecessary distress, so it is a good idea to be familiar with natural post operative course of transplanted hair. I have given it in a table form for quick reference, followed by explanation of important points. Remember, everybody is unique and this timeline is just and indicator of average progress. If your experience is a little behind (or ahead) of this timeline, it is still alright.

POST OP DAY	TRANSPLANT AREA	SUTURED AREA (FUHT)	DONOR AREA (FUE)
DAY 1	Stubble like hair, blood and crusting. Decreased sensation	Pain and stretching sensation. Crusting.	Some discomfort. Crusting.
DAY 10	Scabs should be gone. Stubble like hair. Itching.	Some discomfort. Reduced sensation/ Numbness.	Near normal
DAY 15	No scabs. Effluvium begins. Area may feel hard to touch.	Suture removal. Area is hard to touch. May have reduced sensation and/or pain.	Near normal. May be hard to touch.
WEEK 8	All transplanted hair fall. Some redness may persist.	May have reduced sensation. Hard to touch.	Normal. Planning for second session may begin.
MONTH 2-4	Some hair fall from normal non transplant area. (Shock loss)	Near normal
MONTH 3-5	New hair growth begins. They are thin and fine at first.	Near Normal
MONTH 5-9	New hair keep coming out roughly 10-15% per month. Already sprouted hair begin to grow longer.	Near Normal
MONTH 9-10	80% of appearance. Transplant appears thin due to small caliber of new hair. Planning for second session may begin.	Planning for second session may begin. Scalp massage and scalp stretching exercises may commence.
YEAR 1	90% of appearence. Hair shaft continues to grow longer and thicker.
YEAR 2	Final appearence of transplant.

FAQs about Hair Transplant

What is Hair Transplant?

Word "Transplant" can be seen as  made of two  words, Transfer and Implant. So, hair transplant is simply transfer of living hair. These hair can be transplanted in any hairless area such as balding scalp or area of stable scar, eyebrow, moustache etc. Currently, this is the only technique that can give natural, permanent, growing hair in bald area.

Who Needs It?

Hair transplantation is used predominantly to treat the hereditary balding condition known as androgenetic alopecia ( Male pattern baldness). Patients with male pattern hair loss tend to loose hair from the front and top of their head. Since baldness is often ridiculed in society, it can undermine one's confidence and performance, especially if it comes at a young age.

Women with diffuse alopecia, selected patients with burn alopecia, eyebrow and facial hair loss patients are other candidates who can benefit from the procedure.

What Causes Hair Loss?

Although there are many causes of hair loss, the commonest cause is male pattern baldness. this is due to a combination of two factors. First, the hormonal byproduct Di Hydro Testosterone (DHT) and second your hair follicle's susceptibility to DHT, which is genetically determined. Both the factors should be present to cause hair loss.

How is Hair Transplant done?

Patients having baldness still have good density of permanent hair on the sides and back of the head. These good quality hair that naturally last a lifetime, are used to fill up the bald region. The hair are taken out from the scalp one by one (as single units called FUE)  and are implanted individually in the bald area. This highly sophisticated procedure replicates the natural hair growing pattern.

Is There Pain?

Hardly if any at all. I customise local anesthesia solution to gently numbs the area of procedure. You will not feel anything at all. even in post operative phase when anaesthesia effect wears off, only mild painkillers may be required. Some people do not require any painkiller after FUE method.

How Long Will It Take?

Hair transplant is a one day  procedure in office setting. No admission is required. An average surgery of 1500-2000 grafts takes 5-6 hours. Megasessions of 3000 or more grafts may take 8-10 hours. You can go home the same day after procedure.

Are Results Permanent?

Yes. Since transplanted hair come from permanent hair zone (the back and side of scalp) that is unaffected by DHT, these hair do not fall after implantation. They will have same texture, colour, growth and quality as your back hair and the results will last you a lifetime.

Why Shouldn't I go for Artificial Hair?

Entirely too many reasons. The biggest reason that my patients tell me is that they feel artificial. There is always that fear of losing face in public if the hair piece comes off. Then, of course, there is price for maintenance, price for replacement and price for touch ups. After some time the cost of maintaining a good hair piece crosses that of transplant and you still have nothing to show. Last but not the least is health reasons. The glue can cause allergy, the clips can cause headache,even wounds if they are too tight, weaving may pull and damage your existing hair

Can I afford it?

The initial cost of a good hair transplant may be high but it does not require any maintenance. It is a kind of investment that will keep you giving good returns for times to come. An average a transplant session costs 5-7,000 US $ for FUT and 15-20,000 US $ for FUE hair transplants, but it is much cheaper in India.

Cause of Hair Loss

There are many myths in the society regarding hair loss. Reasons from diet to dandruff and change of water to  family stress have been cited as the cause for hair loss. There also have been a lot of research on the cause of baldness. In this post I would like to tell you about real cause of hair loss. It is always an advantage to know your enemy if you want to defeat him. I hope, with this working knowledge you would be able to plan your fight against hair loss in a better way.

 On the basis of cause hair loss or alopecia can be divided into three basic groups

1. Male Pattern or Androgenic alopecia, by far the common balding.
2. Diffuse pattern alopecia usually caused by disease
3. Scarring alopecia where injury to scalp causes hair loss.
   
   
   More than 95% of hair loss in men is due to androgenic alopecia. For androgenic alopecia to occur, three conditions must be met,
   
   
   1.Genetic predisposition to balding:This is not as simple as it sounds. You may have a father with full head and brothers with some baldness but you have a clean pate. The inheritance is usually polygenic, meaning multiple genes and their expressions play a role in development of baldness.
   However, if every man in your family loses hair by thirty, there is a stronger possibility that you will follow suit. Genetic factors are non modifiable. You must live with them.

2. Androgens or Male Hormones: All men and all women (YES!) produce male hormones. These hormones are generated in different quantities in men and women and typically the levels are much higher in males. This is also the reason why patterned baldness is much much more common in males than in females.
The male sex hormone, Testosterone is converted to another product called Di Hydro Testosterone (DHT) which is presently considered the main reason for hair fall. The conversion of Testosterone to DHT is mediated by an enzyme called 5 alpha reductase. DHT progressively destroys the hair root in genetically susceptible hair by a process called “miniaturisation” which leads to baldness.

         3.Time: Time or ageing is the third factor that plays arole in balding process. Nobody           loses hair before puberty (because DHT is not present in the body) but after that, everybody loses some hair. The pace of hair fall vary amongst individuals but it takes approximately 10 hair cycles for a strong anagen hair to become velus hair.

          Although much less important let me discuss other causes of baldness as well. Diffuse thinning of hair may be caused by anemia, thyroid or other hormonal disorder, severe physical stress etc. A rare type of diffuse thinning called diffuse unpatterned alopecia may even involve permanent hair zone.

On the other hand scarring alopecia could be due to injury, burn or skin conditions. Alopecia areata is a rare autoimmune disease in which hair are lost in bunches and body hair may also be involved.I hope it is now clear that change of water, tension and helmets are not the cause of your hair loss. And repeated shaving or oiling is not going to save them either.