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.