The evolution of hair restoration surgery
The origins of hair restoration surgery lie far further back than one might expect, but the methods used over half a century ago closely resemble many of those used today. Dr Greg Williams explores the history of this fascinating field
Hair restoration surgery, simply put, is the replacement of hair where it has been lost for whatever reason. Causes may be genetic, as in male pattern hair loss and female pattern hair loss; accidental from trauma, burns or surgery; dermatological from scarring and non-scarring alopecias; or self-inflicted from eyebrow plucking, traction alopecia, or compulsive hair-pulling. The search for a solution sparked the evolution of flap and graft surgery, scalp reduction surgery, strip follicular unit transplant surgery (strip FUT) and follicular unit extraction surgery (FUE).
Flap and skin graft surgery
We know that the Indians were doing nasal reconstruction using forehead flaps from 700 BC and that in Europe nasal reconstruction was done with forearm flaps in the 1700s. These early pedicled flap procedures were the ancestors of the Juri (temporo-parietal) flap, which was once commonly used for hairline restoration in burn scars and receding hairlines but which had devastating long term aesthetic consequences if male pattern balding occurred behind the flap.
Similarly, a long full thickness hair-bearing skin graft strip, if it survived, might have produced a temporarily acceptable hairline for the above indications but would be unlikely to have a long standing aesthetic benefit if hair loss progressed behind the graft.
With the advent of tissue expansion technology, large post traumatic and post-surgical hair defects can now be reconstructed successfully using a variety of local flaps but attention still needs to be paid to the potential for future genetically determined patterned hair loss.
Scalp reduction surgery
Scalp-reduction surgery may have seemed like an intuitively sensible thing to do at the time it was popularised for treating advanced male pattern hair loss, and was quite easy to perform surgically. However, although the bald area was reduced, the anatomical result was often unnatural in appearance. Common complications from excessive tension of the wound closure included tissue necrosis and widened scars. Many novel and innovated techniques were introduced to avoid stretching of scars but there was usually a stretch-back tendency causing the remaining bald scalp to expand again and scalp reduction surgery for male pattern hair loss is now relegated to the history books.
Strip FUT surgery
The Japanese dermatologist Sasagawa, in 1930, reported his experiments on the implantation of hair shafts into the skin, and then, in 1943, Tamura implanted grafts of only one to three hairs that he harvested from spindle-shaped strips of scalp skin. This was all published in the Japanese medical literature at the time, but remained unknown in the Western world until the early 1950s, due to the outbreak of the war.
In the 1980s, Carlos Uebel in Brasil and others in the USA began using smaller and smaller micrografts, with fewer and fewer hairs for strip FUT procedures. However, it was not until 1988 when Bob Limmer described that hairs grow in follicular units (groups of 1-4 hairs), and that these grafts gave more natural results than the ones resulting from the coarser mini and micrografts, that the era of the modern strip FUT procedure began
The origins of FUE are also in Japan, starting in 1939, when Akuda described a method using islets of skin measuring 2mm to 4mm to reconstruct eyebrows and moustaches in burn victims. In the West, the father of hair transplant surgery is often named as Norman Orentreich, who worked in New York and in 1959 published almost a decade’s worth of work. He used a 4mm metal cylindrical punch to take out grafts from the occipital scalp region and then used the same cylinder to create recipient sites, into which he transplanted the grafts.
Surgeons used this technique to try and thicken thinning hair. What we have learned now is that those results were not long-lived, and we still see today patients who come in with the results of surgery that they had using this archaic plug technique where the ‘pluggy’ transplanted grafts remain isolated after the natural hair has completed disappeared due to male pattern hair loss .Thankfully, we now have modern hair transplant surgical techniques to reconstruct these aesthetic disasters.
Japan returns to the history of FUE again in 1988, when dermatologist Inaba described using a 1mm needle to extract follicular units. This was then successfully done in the West, first in Australia, by Ray Woods in the late 1980s, and then formally described in the medical literature by Bill Rassman and Bob Bernstein in 2002. However modern FUE grafts are just very refined small plugs.
Modern hair restoration surgery
Today, hair restoration surgery for male and female pattern hair loss is almost exclusively hair transplant based. Entirely natural looking and almost undetectable results can be achieved if patients are selected carefully and designs incorporate the possibility of future hair loss progression.
There is a great deal of mis-information in the public domain regarding the pros and cons of the strip FUT versus FUE methods. Both have advantages and disadvantages that should be explained to prospective patients so they can make informed decisions.
In summary, the evolution of hair restoration surgery for male and female pattern hair loss has involved a progression from open flap based procedures to less invasive hair transplant based techniques. The hair transplants have also become more refined using smaller grafts from the 1960s and 70s when plug grafts were used (10 to 25 hairs per graft) to the 1980s and 90s when mini and micro grafts were used (3-8 hairs per graft) and finally to the modern era of follicular unit grafts (1-4 hairs per graft) by either the strip FUT or FUE methods that give patients the stunningly natural results that are now the expected norm.
Dr Greg Williams is a Plastic Surgeon and the lead Hair Transplant Surgeon at the Farjo Hair Institute’s London clinic W: farjo.com