hair transplant

1. The History of Surgical
Hair Restoration

2. • There are many stages of hair loss that occupy so many
of our scalps worldwide.
• It has been a problem that men have tried to deal with
in many ways for thousands of years.
• The oldest known prescription for hair loss is from Egypt
and is 3500 years old.
• It consisted of hippopotamus fat, crocodile, cat, and
porcupine hair boiled in water.
• Thankfully, no one tried to invent hair transplant
technology back then!

3. Hippocrates, the
father of western
medicine, use
pigeon poo to fight
hair loss!

4. • Hippocrates also suffered from hair loss 2500 years ago
and he used a mixture of pigeon poo, horseradish, opium
and spices.
• However, Hippocrates also noticed and recorded that
eunuchs never seem to lose their hair and suggested
castration would be the answer to the problem.
• Yeah, that’s a bit rough but he was actually correct in his
assumption as confirmed by researchers at Duke University
in the mid 1990’s.

5. Dr. Orentreich,
the father of
the "plug".

6. • But it wasn't until the middle of the twentieth century that
something started to take shape that could be called real progress,
more or less.
• Dr. Normal Orentreich performed hair transplant surgery in his New
York office in 1952 and this was the beginning of what we know
today as surgical hair restoration.
• He published a paper in 1959 where he introduced the "theory of
donor and recipient dominance" where he described how the
transplantation of androgen insensitive hairs could successfully
allow hair to grow in previously bald areas.
• This laid the foundation for surgical hair restoration as we know it
today.

7. Early Hair Transplant Technology

8. Hair transplant machine used in 1921.

9. Let's back up for a moment
• Dr. Orentreich was not the first person to transplant hair.
• No, this was done in experiments as early as the late
1800's, with some success too.
• In 1921 there was Dr. J. S. Parsegan who had this crazy
idea that if you transplant a woman's hair onto a balding
man's scalp it would reactivate dormant follicles.

10. • Anyway, it was Dr. Orentreich who was the first in North
America to successfully transplant hair for the cosmetic benefit
of men with male patterned hair loss (the term had not been
used yet) and it was his work that opened the gates to hair
restoration being a cosmetic procedure to "cure" baldness.
• Before Dr. Orentreich there was work being performed in other
parts of the world, most notably in Japan.

11. • Dr. Shojui Okuda (1886-
1962) is the unsung hero
of hair restoration.

12. • Dr. Okuda, however, built upon Sasagawa's work and was
transplanting anything and everything he could think of.
• He transplanted hair from the scalp to the arm for experimentation.
He rebuilt eyebrows, pubic regions, and even eyelashes. His tools
included surgical punches up to 4mm in diameter (a true punch plug)
and as small as 1mm in diameter. He noted that the smaller punches
were much more difficult to get viable hair so he usually stuck with
2mm to 2.5mm incisions but the point is that he used 1mm punches
on many occasions and noted in his journal how the cosmetic effect
was superior to that of the larger punches he used.

13. • The "Okuda papers" were published in 1939 and at this point he had
already been performing surgeries for ten years. Dr. Okuda never
wrote about using his hair transplantation methods for treating male
patterned hair loss. However, in 2009, Dr. Okuda's grandsons opened
up a room that had been storing their grandfather's equipment and it
had previously remained undisturbed for at least 30 years. Among
the items in storage were before and after photographs of successful
hair transplant procedures that were undocumented in his papers
thus indicating that Dr. Shojui Okuda is the true pioneer and father of
punch grafting.
Atlas Oral Maxillofac Surg Clin North
Sep; 6(2):39-53.

14. • About four years after Dr. Okuda's papers were published there
was a second Japanese doctor that started to improve on
Okuda's hair transplant technology by using smaller punches
on a regular basis. Dr.Tamura used smaller punches of roughly
1mm more frequently than Dr. Okuda and even went so far as
to refine the grafts that were harvested by trimming and
dissecting them before implantation. He published his papers
in 1943 in the Japanese Dermatological Journal during the
height of the Pacific campaign ofWWII.

15. • Dr.Tamura's refinement of Dr. Okuda's work is a more direct fore
bearer to the modern FUE procedure we have today and in effect it
renders any recent claims of being "the first" null and void.The first
was Dr. Okuda and subsequently Dr.Tamura. It would be a long time
before western medicine would learn of these two true pioneers as
the information they documented was inaccessible due to WWII and
it's aftermath.(Credit: American Hair LossAssociation). It wasn't until
1959 with Dr. Norman Orentreich, mentioned at the top of this page,
that western medicine caught on but unfortunately it was not in the
form of refinement that one would expect with time.

16. Fast forward to 1975.
• Disco was king and so was polyester and crazy hair.
• Lots of great things came out of the 70's including Dr. O'tar
Norwood and his classification system known as the Norwood
Hair Loss Chart.
• this was fairly important as it helped to standardize how hair
loss was measured and this allowed for easier diagnosis and
treatment recommendations by hair restoration clinics.

17. • It isn't entirely accurate however as there are several
patterns found in nature on a regular basis that are not
represented on the NW chart but it gets the basics down
well enough.
• Dr. Norwood's classification system also gave the public a
way of understanding their own hair loss.
• They could simply look in the mirror then look at the
chart.

18. • Once a balding man knew where he was on the chart it
would psychologically give them a solid base to associate
themselves so they could take action to actually do
something about their problem.

19. Hair Flap Surgery

20. • The 1970’s also introduced a few alternatives to plug hair transplant
technology but mainly they were adjuncts to the procedure overall. First
you have the scalp flap.
• The scalp flap was first performed in the 1930’s but it never caught on till
Dr. Jose Juri ofArgentina introduced the Juri Flap in 1969.
• A scalp flap is an extremely invasive procedure that requires a high
degree general and plastics surgical skill to perform successfully and
even then the outcome is questionable.
• Basically this involves removing a large piece of tissue from one area of
the scalp and rotating it to another area in need of hair.

21. Various forms of
scalp reduction
surgery.

22. Scalp reduction
• Another hair transplant technology alternative is the scalp reduction.
• Scalp reductions were procedures that literally remove the area of scalp that had
hair loss and then pull the edges of the wound together so that the areas of still
strong growing hair would be much closer to each other thus you have a
reduction of hair loss from this reduction of scalp.
• It made sense at first glance because you’re just cutting out the problem and
throwing it away but the problems emerged when arteries would be cut thereby
inducing nearly uncontrollable bleeding or when the final result matured the
patient would have difficulty styling their hair.
• This was due to the natural hair geometry being completely distorted from the
procedure. Both scalp flaps and scalp reductions have thankfully had their short
time in the history

23. • Punch grafting survived the 1970’s and continued to thrive into
the 1980’s.There were some doctors that had tried to use
punches significantly smaller than 4mm but none were
successful, or at least not enough to warrant creating change,
but there was something different that started to push the
industry forward. It was the pattern of plug extractions that
helped to usher in the next big change.The way that doctors
would traditionally remove punch grafts is that they would
take their plugs from random areas of the scalp.

24. • Sometimes in close knit groupings and other times
spread out over the entire safe donor zone and
sometimes well outside of the safe donor zone. But some
doctors started to see that when the plugs were extracted
close enough together, and in a pattern that formed
something similar to a rectangle, they would see that
they were creating one large wound that forced them to
suture the wound closed. EUREKA!!! No more punch
scars!

25. • Eventually someone got the bright idea that a scalpel
might be a better way to get out this new rectangular
pattern of hair bearing scalp so that patients wouldn't
have the buckshot scarring from surgery any more. It kind
of makes sense, right? Well, the problem is that someone
still decided that it should be easier, not better, so now
we have the multi-blade scalpel.

26. Typical multi-blade scalpels.
• The multi-blade scalpel is a medieval looking piece of hair
transplant technology that takes two to four scalpel blades and
puts them in one handle.This means that the doctor can just
make one swipe of the scalpel(s) and you've pretty much got
up to four narrow strips to dissect hairs from for placement
into the recipient scalp. Don't worry about follicular
transection because there's plenty of that to go around. Enter
the age of the mini-micro graft.This is where the experience of
yours truly comes into the picture, as this is the procedure I had
performed in the early 90's.

28. • Mini-micro grafting is not such a bad procedure if performed by someone
that gives a damn.
• No, it can work well but there are several disadvantages to the method.
• If a multi-blade scalpel is used to harvest the donor hair then many of the
grafts in the donor zone, both in the strip removed and the adjacent areas
of the donor zone left behind, will be transected and rendered useless.
• This leads to permanent shock loss in the donor zone and less growth of
transplanted hairs for the final result months later.
• It was a step in the right direction but not quite there.

29. Current HairTransplantTechnology

30. • In 1994 there was a good ole boy in SanAntonio,Texas by the name
of Limmer, Dr. Bobby Limmer, and we have him to thank for the
common sense approach of actually caring about how hair
transplants look.What Dr. Limmer did was basically take the industry
of hair restoration, shove it down a cannon tube and fire it forward
into the age of common sense. Dr. Limmer presented the world with
the idea that using stereoscopic dissecting microscopes for the
dissection of follicular units would provide for a more natural result
and a higher yield (growth rate) of transplanted hair

31. • As it turns out he was right and with that he ushered in
the age of the follicular unit transplant. Follicular unit
grafting via stereoscopic microscopes allows for 30%
higher yield of the transplanted grafts and it allowed for
refinement that was much more difficult to detect.
Finally, it only took about sixty years after Dr.Tamura for
the western world to finally get it.

32. • Follicular unit grafting did not actually take off quickly
from the start. As with any new development, when it
comes to hair transplantation, it was met with massive
resistance but eventually it became the gold standard in
the field and this is still the case today (2015) where
approximately 67% (as of 2014) of all hair restoration
surgeries are carried out via FUT

33. • . In the beginning of FUT the biggest procedures were in the
range of 800 grafts to 1200 grafts but with time there were
improvements to follicular unit grafting and the donor
harvesting process as well.Yields continued to climb and
harvests of hair continued to grow to the point that today
there are many clinics that routinely harvest up to 4000 grafts
in a single procedure.There have been many cases of clinics
going larger but going beyond the 4000 to 4500 graft range is
considered by many to be pushing the envelope just a little too
much.

34. • . A lot of people call themselves pioneers but the true, original pioneers
of FUE were Okuda andTamura.When you're using 1mm punches for
moving hair, you're performing FUE. But, the “modern” pioneer of FUE is
Dr. RayWoods. No one else can make this claim simply because no one
else can back up their claims with solid and unquestionable proof. Dr.
Woods can and anyone that says otherwise is simply lying. So FUE got its
start in North America with Dr. Rob Jones ofToronto and Dr. Alan Feller
of NewYork. Both of these doctors saw the merits of the procedure and
Dr. Feller in particular, who is kind of a gadget geek to begin with, started
working on his own tools and he was the first in North America to create
his own FUE hair transplant technology

35. • The hair restoration industry has slowly but surely started
to transition away from strip toward FUE but the real
push began around 2008 with the introduction of
Neograft® hair transplant technology. Neograft® is a
motorized, hand held FUE device that has a rotating
punch that “scores” the follicular unit.

37. • This is nothing new as there were other motorized punches being
developed and introduced around the same time but the Neograft
was different in that it offered extraction AND implantation. It was a
novel and unique idea.The way that it works is that once the graft is
scored a high powered vacuum attached to the end of the hand held
wand would suck the graft out of the donor scalp, through a tube,
and into a reservoir filled with chilled saline as a storage medium.
Once the grafts were extracted the user would make some
adjustments to the machine and then the system would push the
grafts back through the tubing to be inserted into the recipient sites
made by the wand.

38. • First, it introduced an opportunity for the industry to gain more main
stream appeal as Neograft created a massive media and advertising push
that had one simple but very effective message.There is no strip scar
from the procedure. People that took the time to investigate and
research hair restoration techniques knew about FUE in general but the
lay public had no idea what was involved and they only knew that strip
surgery meant a strip scar and the “Neograft technique” as many later
referred to it, offered no strip scar.The company focused on this
message and completely avoided the issue of quality of growth and let
the public assume that all results would be the same.

39. • The second reason that Neograft made an impact on the industry is
because they introduced what was essentially the first “turn key” hair
transplant clinic in the world. For a fairly nominal fee one could purchase
a Neograft machine, rent a small office and maybe hire a receptionist
and they could start offering surgery after taking a single weekend
training course. Neograft has a team of traveling technicians that would
also travel to new clinics to help get them up and running but the
formula was simple. Sell as many machines as possible for a decent price.
It worked and now Neograft is one of the more recognized names to
anyone researching hair restoration. Any doctor or clinic that has the
slightest interest in offering hair restoration alongside tummy tucks and
Botox injections can now do so.

40. The Future of HairTransplant
Technology
The ARTAS robotic
surgical hair
transplant system

41. • In 2011 the potential future of hair transplant technology received
510K clearance by the United States FDA.The ARTAS® system by
Restoration Robotics was introduced shortly thereafter.This is the
first and currently the only robotic hair restoration system. It is
exactly as it sounds. A robotic arm with a punch tipped apparatus
makes incisions and scores grafts for extraction.The system is
actually fairly limited in that it does not remove grafts on it’s own and
it does not place any grafts.Trials are currently underway however to
allow the system to make incisions for placement

42. • The idea behind the ARTAS® system is that it takes the
element of fatigue away from the procedure and introduces
the use of highly developed algorithms that supposedly offer
faster and more reliable scoring of grafts. One unique aspect of
the system is that it is constantly being updated based on
regular system feedback from each individual machine in use.
This means that with every software update that the system
goes through it is bringing the lessons learned from the
cumulative number of surgeries performed prior to the update.

43. • This has the potential of offering exponential
improvements for the accuracy and reliability of the
system. Currently the system is using punch sizes of
.9mm to 1.1mm but in the early days of its use it was
using punches as large as 1.6 and 1.7mm respectively.The
progress has been steady and currently Restoration
Robotics is working on improving the system to allow for
.825mm punches.

44. • Current limitations of the ARTAS® hair transplant
technology include the ability to only work on darker,
straighter hair. It has trouble removing grafts from certain
areas of the scalp on even the best candidates so
supervising doctors must have the ability to compensate
by offering alternative means of extraction with either
hand held motorized punches or manual punches.