History of Hair Loss 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.
