Depending on a number of critically important factors, hair transplant surgery can either be one of the best decisions you will ever make or among the worst. Today we’re going to discuss the pros and cons of surgical hair restoration, euphemistically called hair plugs or transplantation. In fact, the more accurate description is “autologous hair bearing skin transplantation”. This is because the actual procedure involves harvesting sections of skin from a hairy part of one’s scalp (donor) and moving it to a bald area (recipient) of the same person. Skin transplantation between anyone other than genetically-identical twins does not work.
The technique of moving hair bearing skin tissue grafts from one part of the scalp to another dates back at least 50 years. In the 1950’s a pioneering surgeon by the name of Dr. Norman Orentreich began to experiment with the idea on willing patients. Orentreich’s groundbreaking work demonstrated a concept that became known as donor dependence, or donor identity, that is to say that hair bearing skin grafts harvested from the zone of the scalp outside the pattern of loss continued to produce viable hair even though the grafts had been relocated into areas that had previously gone bald.
During the next two decades hair transplantation Haartransplantation Berlin gradually evolved from a curiosity into a popular cosmetic procedure, primarily among balding men of late middle years. In the 1960’s and 1970’s practitioners including Dr. Emanuel Marritt in Colorado, Dr. Otar Norwood, Dr. Walter Unger showed that hair restoration could be feasible and cost effective. A standard of care was developed that, in experienced hands, allowed for reasonably consistent results.
At the time the most common technique involved the use of relatively large grafts (4mm — 5mm in diameter) that were removed individually from the donor site by round punches. This tended to leave the occipital scalp resembling a field of Swiss cheese and significantly limited the yield that was available for movement to the bald zones on top and in front of the patient’s scalp.
Over the course of multiple surgical sessions, grafts were placed into defects that had been created in the recipient zone (bald area) using slightly smaller punch tools. After healing the patient returned for follow up sessions where grafts were placed in and amongst the previous transplants. Because of the relative crudity of this technique, results were often quite apparent and the patient was left to walk around with a dolls hair like appearance, particularly noticeable at the frontal hair line, and especially on windy days. Such patients were usually quite limited in the manner they could style their hair and, because of the wasteful donor extraction method, many persons ran out of donor hair long before the process could be completed.
In the 1980’s hair restoration surgery gradually began to evolve from the use of larger punch grafts to smaller and smaller mini and micrografts. Minigrafts were used behind the hair line, while one and two hair micrografts were used to approximate a natural transition from forehead to hair. Donor site management also evolved from round punch extraction to strip harvesting — a far more efficient technique. Pioneers in this area were skilled surgical practitioners such as Dr. Dan Didocha, Dr. Martin Tessler, Dr. Robert Bernstein and others. The concept of creating a more natural appearance evolved still further in the 1990’s with the advent of follicular unit extraction (FUE), first proposed by the highly gifted Dr. Robert Bernstein, and described in the 1995 Bernstein and Rassman publication “Follicular Transplantation.”
The 1990’s also brought new tools into the mix, such as the introduction of binocular or ‘stereoscopic’ microdissection. Stereoscopic microdissection allowed the surgeon to clearly see where one hair follicle begins and another ends. As the 1990’s progressed, many transplant surgeons shifted away from the use of larger grafts in favor of one, two and three hair follicular units.