Hair Loss
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 Punch Grafts  In this image we can see a transplanted patiente with the Punch Grafts method. At the frontal zone and the entrance is easy to recognize each of the inserts and the distance between them. This type of implant had a complety unnatural look. Today is reffered as: Doll Hair.

 Punch Grafts and Mini Grafts  In this case, the technique is better, but not enough. The patiente have Punch Graft on the crown zone, and Mini Grafts at the front and entraces.

With the combination of this techniques we still can apretiate the unnatural look. Thank to new technologies (follicular unit transplantation) , this patiente can improve/repair their implants.

 Micro Grafts  We can observe that using Micro Graft on the frontal zone, the result is still not natural. You can see that the inserts are smaller but easy to identify.

Hair Transplant: Origins and History

There are basically two different ways wich evolved during time. On one side we have the Follicular Unit Transplantation (FUT) or Microtransplantation and in the other side, the Strip Harvesting technique.

This post intend to show the evolution of transplantation to get into the actual follicular unit transplantation. If you want to read more about the history of obsolete texhniques you can follow this link.

Evolution of the Follicular Unit Transplantation technique:

Around 1939, the japanese dermatologist Dr. Shoji Okuda publish -at the Japanese Magazine of Dermatology- his method to transplant hair, eyebrows and mustash.

The Dr. Okuda's process consisted in removing follicles from the back of the head (nape) to implant them into the bald areas of the scalp. During that time, the technique was used in patiente who suffer of scarring alopecia, but NOT for people with androgenic alopecia.

Unfortunately, World War II interfered with communication between nations, and Okuda's work took a long time to reach the hands of trained physicians. Okuda's technique has more than 70 years, and today's techniques do not differ too much from that he used to practice.

Donor Dominance

In the late 50s, the Dr. Norman Orentreich began with some hair transplantation trials from the nape and sides of the head to the baldness areas. Their experiments showed that the hair in these areas were resistant to the Androgen alopecia regardless of the area where they were transplanted.

This principle or condition, is called Donor Dominance, and means that the hair transplanted can live Equally in a neighboring area as in the original. This shows that hair loss is not due to "poor blood supply". If so, the hair transplant should fall and of course, this does not happen.

All modern transplant techniques are based on the principle of Donor Dominance. A surgeon knows in advance that the follicle transplanted to another area will grow normally.

Punch Grafts - Mini Grafts - Micro Grafts

In the 60's and 70's, the hair transplant were still using too big inserts (20-30 hairs) and the distance between them was truly wide. They were "tufts" of hair separated like islands on the scalp. The final appearance was like a typical doll's hair or a strand brush.

The results of this technique called Punch grafts were truly unnatural, and the transplant was detectable to the naked eye. Still, this type of surgery began to gain popularity.

The big jump came in the mid-80's, when the Punch Grafts were replaced by the new mini and micro grafts. The Punch Technique was abandoned to remove the hair so as to implant them. At first they start using the technique of "Strip", which was to surgically removed a strip of scalp from the back of the head, and then cut it in mini/micro grafts.

These grafts were transplanted to bald areas, using tools much smaller and with more precision than those used for grafts Punch.

The minigrafts (4-8 hairs) were used in areas where the density was more important (crown), while micrografts (1-3 hairs) were implanted in areas that required a more natural (frontal area, entraces).
This new technique of mini / micro grafts was more complex because it required hundreds of grafts rather than the 50 or 100 that the Punch Graft used.

Since 1990, the technique was perfected more and more, up to the one used today: The Follicular Unit Transplantation.

This technique is a true work of art. The hairs are transplanted simulating the natural shape and distribution of the original hair.
Our hair grows in small groups called Follicular Units. Each follicular unit may have one, two, three, and in exceptional cases, four hairs.

To create these grafts so small, microscopes are used for isolating and cutting the follicular units from the donor site. This work is typically carried out by technicians who accompany the surgeon during the procedure.

It was Dr. Robert Bernstein, who proposed the idea of transplanting using only follicular units. The method was described by Bernstein and Rassman in a publication called "Follicular Transplantation".

Today, many surgeons still use the technique of mini / micro implant. Others, like Bernstein and Rassman are persuasive Defenders of FUT and consider it the only acceptable technique.

Some surgeons achieve an amazing hair density. With incredibly small incisions and implanting the follicular units at a millimeter of distance. This allows patients - in one intervention - to get high density at most important areas and perhaps not so much in areas where it's not required.

The photographs belong to: Swinehart, JM. Color Atlas of Hair Restoration Surgery.
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