History of Hair Transplant Surgery
As early as the 1930’s, Japanese physicians were successfully harvesting
and grafting multiple and single hairs into other areas of the body, including
the scalp, face, and pubic region. The reports of these procedures were
written in Japanese; this, together with the onset of World War Two, insured
that the Western world remained in the dark until the late 1950’s.
In 1959, New York dermatologist Norman Orentreich reported hair-bearing
scalp autografts (from the same person) that were successfully transplanted
from the back of the head to the balding front and top. Thus the concept
of "donor dominance" was introduced, and the discipline of hair
restoration surgery in the West was born.
Donor dominance is the central functional principle of hair transplant
surgery. What this means is this: if one harvests hair follicles from the "permanent
zone" of the scalp, and transplants it to the balding areas, the donor
hair characteristics will predominate. In other words, since this donor
hair is genetically programmed not to respond to the male hormone DHT by
becoming miniaturized, it will continue to grow and thrive even though its
location is now in a balding "zone".
Evolving Aesthetics of Hair Transplantation
For the first 20 to 25 years of hair transplantation, 3-4mm (millimeter)
round, "plug" grafts were the standard units generally placed
in balding areas. These were felt to be the optimal size grafts in terms
of density (hairs per square mm) and in terms of blood flow (nourishment)
to the tissues of the graft. In other words, these grafts, with 12 to 20
hairs each, could achieve high density in the recipient (balding) area;
also, bigger grafts would be easier to move, but re-establishing their blood
flow, especially toward the center of the grafts, would be tricky. Later,
this was found to be a problem even with these standard grafts, and sometimes
the hairs in the very center of the graft would die, leading to the appearance
of a hole in the middle, hence the term "donutting".
Other cosmetic problems were soon recognized. Often, a raised area
at the base of the graft led to the aptly named "cobblestoning" effect.
Probably the most widely recognized negative effect is the so-called "doll’s
hair" "toothbrush" or "cornrow" appearance. This
results from a dense, round graft set in the midst of bald scalp; the effect
is worsened by the fact that, as the graft heals in place, scarring causes
it to contract. This increases the density (compresses the hairs into a
bundle) even more, to a level not found anywhere on the head, therefore
appearing unnatural. When these round grafts were placed at the frontal
hairline, they often appeared as an inhumanly straight, regular row, which
is not the way hairs grow in nature. Furthermore, if the patient’s
balding progressed, these grafts stood out even more, to the point of becoming
a cosmetic nightmare. Also, if the hair behind the grafts was lost, there
developed an unnatural look further back in the scalp; this appears as a
posterior, or "rear" hairline.
In addition, the normal, natural direction of hair growth was not
honored. Hair from the crown up to the front grows in a generally forward
direction; there is a "whorl", or circular effect at the crown,
and at the temples the hair abruptly changes to a downward, and then backward,
direction. Often the large grafts pointed up at right angles regardless
of location, which added to the less than natural appearance, and could
severely limit styling options.
From a logistical standpoint, grafting with standard plugs could
be a nightmare. Usually, these were done in small sessions of 20 to 50 grafts
at a time; then sessions were repeated after a period of time. This might
require 4 or 5 sessions to "complete" the work; if financial,
health, job, or other circumstances supervened, the work might not be finished,
leaving the patient in an embarrassing state of incompleteness. Moreover,
if baldness progressed, the rear or side margins of the plugs could then
be seen by the casual observer.
Finally, using large, round grafts is an extremely inefficient
use of the donor hair supply. Much hair is left in the scarred spaces between
the circular holes in the donor area. The punch tool must be held perfectly
parallel to the angle at which the hair emerges from the scalp; otherwise,
many of the hair follicles at the edges of the graft will be transected,
or cut in two. This destroys the hair, or, at the very least damages its
ability to grow and thrive. Making the punch tools smaller failed to solve
the problem the problem of transection; with a smaller graft, an even higher
percentage of hairs per graft could be damaged. Likewise, when 4mm grafts
were "quartered" or otherwise divided into smaller grafts, this
required further trauma and manipulation with resultant follicular damage
or destruction.
Many men were happy just to have hair again, and never complained
about these cosmetic conundrums, or were aware of the technical limitations.
However, certain creative surgeons begin to move toward a higher aesthetic
ideal. In the early 1980’s, hair restoration specialists began utilizing
minigrafts and micrografts. We define minigrafts as containing 5-10 hairs,
and being between 1 and 2.5mm in diameter. Micrografts are smaller still:
1 to 1.5mm, with 1 to 3 hairs. Follicular unit grafts are the naturally
occurring growth units of hair, and will be discussed in great detail in
subsequent sections.
What were the benefits of these smaller grafts? For one thing,
they could be used to "soften" the hairline. The hairline is naturally
a feathered, indistinct, and variable entity; it is not abrupt, extremely
dense, or regular. Usually, the first row or two of the hairline are single
hairs, a "transition zone" between the hairless forehead and the
hair-covered scalp. Also, the line is not straight at all, but irregular.
Placing these small grafts at the hairline, in front of the larger, round
grafts, gave a more pleasing, natural look, especially with the hair swept
back or diagonally to the side.
Despite this and other benefits of using mini- and micro-grafting
techniques, there was still a major downside (and still is today, as some
hair transplant surgeons stubbornly cling to the old but familiar ways).
Minigrafts can still produce the artificially high, local density leading
to the doll’s hair look; they have a tendency to appear "pluggy".
Also, grafting large areas with micrografts often can give a "see-through" or
excessively thinned look. The reason for this is quite important to understand;
although a 2 hair follicular unit and a 2 hair micrograft contain the same
number of hairs, the devil is in the details; the major detail is in the
way they are cut. Follicular units are dissected out intact, using a microscope,
and thus have the minimal amount of tissue present to support the hairs.
Conversely, micrografts are cut without regard for the follicular unit structure;
a 2 or a 3 hair micrograft may contain hairs from as many as 2 or 3 separate
follicular units! As such, they contain much more tissue than corresponding
follicular units, require larger recipient incisions, or even holes, and
cannot be placed as closely together. Healing takes longer with these excess
tissue-containing grafts, and their larger incisions, and it may be that
breaking up the fundamental unit of hair growth inhibits the very survival
of the grafts themselves.
Scalp Flaps
Plastic surgeons have developed methods of advancing hair-bearing "flaps" of
tissue from one area of the scalp to another. For example, a strip of scalp
from the non-bald temple might be freed up, and rotated forward to the bald
frontal hairline. A small area of the flap is left attached in order to
preserve the blood supply of the tissue. Unfortunately, sometimes the blood
circulation is compromised, leading to tissue necrosis, or death of part
of the flap. This can cause visible scarring, as well as loss of the hair
(!) from that portion of the flap.
The benefit of flap procedures is that one has an instant "growth" of
mature, full-length hair in the previously bald area. There is nothing subtle
or gradual here! This may be a social liability if one desires privacy regarding
the surgery.
This is major surgery, requiring a hospital operating room. Bleeding
and infection are other possible complications. Also, there is a cosmetic
downside. A hairline constructed with a flap is likely to be unnaturally
straight and overly dense, unlike the natural "feathered" transition
zone found in a natural or surgically well-constructed hairline. The inevitable
scar at the leading edge of the flap may also be apparent to the observer.
Also, there may be thinning or balding scalp behind the flap, which requires
camouflage. Alterations from the normal direction of hair growth can appear
nothing short of bizarre. Thus we see little benefit and abundant potential
for negative outcomes with flap procedures.
Scalp Reductions
This group of procedures are collectively known as alopecia reductions,
baldness reductions, male pattern reductions, and by other names. The basic
premise is, that by excising, or cutting out, a segment of bald scalp, the
baldness is reduced. This provides an immediate and relatively dramatic
improvement in the balding appearance, and the added benefit of less area
needing to be grafted. This would limit the strain on the patient’s
finite "donor reserves", meaning the hair available from the permanent
zone that can be harvested for grafting. This may seem intuitively obvious
at first glance, but consider this: when scalp is removed from the crown
area and the top of the head, the sides and back are pulled up in order
to approximate the wound and suture it closed. The effect this can have
on the donor hair in the back and sides of the head is to decrease the density
of this hair.
Other problems that slowly became evident included the phenomenon
of stretchback, whereby the natural elastic properties of the scalp skin
overcame the tension element of the scalp reduction, and some or all of
the benefit would be lost. Hair loss may be accelerated by scalp reductions,
in the opinion of some hair surgeons; we definitely know that "shock
loss", or effluvium, can occur around the incision. Some of this shock
loss hair may or may not grow back, largely depending on its state of miniaturization.
Scarring is one of the most significant complications seen after
scalp reduction. There are a number of incisional patterns that surgeons
use: the midline ellipse, Mercedes star, Z-plasty, and lazy-S. The end result
of any of these will be a scar in the shape of the sutured wound. This scar
may be more or less noticeable depending, in part, on whether there is continued
balding in the area, or how closely adjacent to the scar dense hair is found.
The fact of the matter is that the patient’s donor density and scalp
laxity can be reduced by the procedure. These are two of the determinants
of the amount of donor "reserves" remaining. If they are reduced
enough, there may not be enough hair left to graft over the scar if it is,
or becomes, obvious to the casual observer. This is a major cosmetic problem.
While scalp reductions are often done as series of two or three,
some surgeons will substitute for the series by doing one large procedure.
This is known as a scalp lift or hair lift. It requires general anesthesia,
and essentially undermines the scalp down to the ears and down to the neck.
Then, the loose scalp is pulled up, the balding area removed and the wound
edges stitched together. It is also standard procedure to ligate, or tie
off, the major arteries to the back of the head, called the occipital arteries.
Usually, the occipital nerves are sacrificed in the bargain, leading to
significant and long lasting scalp numbness.
There are also various types of scalp expanders, both inflatable
and spring-type. Both types are surgically implanted, and are designed to
stretch the scalp prior to the reduction surgery. Their effects are variable,
and although some surgeons seem to do well with their use, many of the same
potential drawbacks of scalp reductions may occur.
Two other well-known cosmetic deformities resulting merit mention
here. One is the loss of normal hair direction, often manifesting as the "parting
of the Red Sea" phenomenon. This occurs because when the scalp is pulled
up from the sides, and then becomes situated on top of the head, its hair
will still emerge at its native angle. In short, it may appear to stick
out to the sides from the midline in an unnatural way, like the biblical
parting of the Red Sea. Another is the "posterior slot" formation,
which also occurs as the result of scalp reduction surgeries. This "slot" appears
as vertical scar running down the crown of the head, with the adjacent hair
angled out flatly. This is a very obvious deformity; there is a flap surgery
designed just to correct this problem (!), but it is complex and not performed
well by many surgeons.
We feel that scalp reduction procedures generally have a very high
risk to benefit ratio. As such, we would rarely recommend these surgeries,
except in certain selected patients with the ideal hair and scalp characteristics,
of the optimal age, and who are highly motivated. With all other factors
considered, properly performed follicular unit transplantation (FUT) can
produce natural, undetectable results, without cosmetic deformity, in patients
who are candidates for this procedure. In the next section, we will discuss,
at length, FUT, why and how it is done, the rationale for, and history of,
its development, and its potential drawbacks.
Credits
- Information Provided by John P. Cole, MD - International Hair Transplant Institute
Hair Transplant Adviser Blog
Provided by The International Alliance of
Hair Restoration Surgeons,
the Hair Transplant Adviser blog provides the opportunity for prospective
hair transplant patients to ask questions and find answers.
