Hair Transplantation underwent hardships. Despite the fact that Orientreich has been honored as the father of hair transplantation, in reality history of hair transplantation starts from Asia, Japan.
Dr. Okuda published five series of articles titled “Clinical and experimental study of living hair transplantation” in the Japanese Journal of Dermatology in 1939, reported 200 cases of reconstruction in cicatricial and congenital alopecia. His techniques employed transplantation of grafts in 1,0-5,0 mm in diameter.
In the Okuda papers we can find almost everything relevant to modern hair transplantation, including the principles of “donor dominance” and the miserable results of hetero-transplantation of human hair. Unfortunately, Okuda did not mention male pattern hair loss (MPHL) as a treatable condition, and thus Dr.Orentreich is honored as the first to use these innovative techniques for MPHL.
Because of the chaos of World War II, his papers drew little attention for some time. Nevertheless, his techniques have been spotlighted again and termed the “Okuda/Orentreich technique” by a German doctor, H.C.Friedrich, who discovered Okuda’s work and thesis in his German translated abstracts.
Okuda papers were written in old Kanji (old pictographs) and the writing often was unintelligible. Even Japanese found it difficult to understand , until the complete English version translated by Yoshihiro Imagava appeared in 2003.
Hajime Tamura (1897-1977) performed many hair transplant procedures when he was Professor of Urology at Tokyo Women’s Medical University. It was reported that 127 cases in 1937 failed but 136 cases after 1939 showed good results. His techniques using single-hair grafts produced an excellent natural appearance. However, he seems to have lost interest in hair restoration after he became Professor of Urology at Keio University in 1944.
Doctors in Western countries become aware of his achievements earlier and adopted his techniques, the history of hair transplantation would have taken a different course and punch grafting may not have become the standard procedure for more than 30 years. "A donor (graft) is better if it is as small as possible. The reason is that if a donor is big, hairs grow in … a very unnatural appearance."- Hajime Tamura - 1943.
In 1998 Robert Bershtein recognised: "If we had only heeded the advice of the pioneering Japanese hair transplant surgeons in the first half of this century, we could have avoided years of unsightly surgical results that caused dismay to thousands of unwary patients, and literally tarnished an entire field of medicine. Unfortunately, the "Japanese insight" was lost to us during World War II and when we tried to "reinvent the wheel," we did it wrong."
In the original, ingenious experiments performed by Dr. Orentreich, published in the Annals of the New York Academy of Science in 1959, which established the concept of "Donor Dominance," 6 to12-mm punches (trochars) were used to create the grafts. At these sizes, there was an unacceptably high rate of hair loss in the center of the grafts due to the difficulty oxygen has diffusing over such large distances. The initial effort to decrease graft size was thwarted by the concern that much smaller grafts would not move enough hair to make the procedure worthwhile.
Eventually a compromise was reached, and the 4mm graft was born.
Presently nobody uses this technique. For obtaining 4 mm graft shown on the picture, special punch, 4 mm in diameter, has been manufactured by ourselves.
Dr. Orentreich established the concept of “donor dominant” which stated that transplanted hair roots (follicles) function at any location is the same just as at their initial “donor” location. This means that hair produced after transplantation has exactly the same anatomical and physiological properties as hair at donor location (back of the head) and therefore they will never fall out.
The punch-graft, open-donor technique was developed with tools in routine use by dermatologists of that time. In the "open-donor method" devised by Dr. Orentreich, the same trochar that was used to make the recipient sites was also used to harvest the hair. Since hair in the donor area emerges from the scalp at rather acute angles that vary in different regions, the physician was required to have the angle of the trochar exactly parallel to the angle of the hair.
If there was even the slightest deviation from a perfectly parallel orientation, significant wast of hair would occur from follicular transection. In fact, in many patients, so much transection would occur that the potentially "pluggy" appearance was reduced to a thinner look by the inadvertent reduction in the number of hairs per graft.
The hidden problem, of course, was that this harvesting technique reflected a grossly inefficient use of the donor supply, and patients often became depleted of donor hair, long before the transplant process was completed
In the "open donor method" the wounds were left to heal by secondary intention and the resulting fibrosis further altered the direction of the remaining donor hair, making subsequent harvesting even more difficult.
The large donor and recipient wounds created by these punches necessitated the procedure to be performed in small sessions, usually 20 to 50 grafts at a sitting, with the sessions spaced apart in time due to the prolonged healing. As a result, one of the truly unfortunate problems intrinsic to the early techniques was that neither the long-term cosmetic issues, nor the ultimate depletion of the patient’s donor supply, could be appreciated for many years.
Possibly because of Dr. Orentreich’s deservedly high esteem in the medical community (he also did pioneering work in dermabrasion, intra-lesional corticosteroids, injectable silicon, and the hormonal treatment of hair loss (to name just a few), grafts of 4mm size went unchanged for years.
In 80th of previous century, Uebel, Unger and Shiell had started using one-hair grafts to avoid pluggy “Doll head” affects. These cases were mentioned at meetings but were not published in the literature until Emmanuel Marritt’s paper in the very early 1980s and the textbook by Norwood and Shiell in 1984.
So, only after 30 years from Orentreich’s 4 mm grafts discovery, American surgeon E. Marritt attempted to transplant hair not in the form of skin islets, but as individual hair roots (follicles). Later, transplanting hair in the form of thinnest grafts (0.8-1 mm in diameter) was named micro grafting.
Initially, single hair grafts and micrografts transplantation had many opponents because of high time and labor intensive. For that time many hair transplant surgeons believed that they were spending too much time for several decades of large 4 mm grafts. Imagine their reaction on present transplantation of several hundreds of micro grafts. In few years 4 mm grafts completely have been replaced by single, two and three hair grafts.
"Protestation of additional time and tedium meant nothing to our patients… that was the doctor's problem. They cared only how they looked. The future of hair replacement will be determined not be the doctor, but by the patient." - Dr. E. Marritt
In 1995-2000 American hair transplant surgeons R. Bernstein and W. Rassman have developed the Concept of Follicular Units Transplantation.
According to this concept hair is transplanted in the form of follicular units, exactly as in its natural occurring. Follicular unit is morpho-functional unit of the scalp that contains one, two, four hairs (hair roots, follicles).
Transplantation of follicular units creates impression of maximal naturalness, minimizes follicular loss during the operation and is considered as a “gold standard” of hair transplantation today.
But this method requires complicated techniques of harvesting donor material, dissecting donor material under special stereomicroscopes by 3-8 experienced assistants which is extremely time-consuming and expensive process.
Follicular Unit Transplantation (FUT) beside of excellent result had one disadvantage. Harvesting of donor material as strip always leave linear scar in occipital area. Sometime scar was too wide and discomforted patient.
To avoid this problem, same tandem, Dr. R.Bernstein and Dr. W.Rassman has developed new technique so called FOX-procedure (today well know as FUE), when individual follicular units were harvested directly from donor area using small punches with approximately 1,0 mm diameter.
It might be mentioned, that FUE has been born in Asia (Japan). Dr.Inaba was inverter of individual follicular units harvesting with small punches. Later it was used by Dr. Woods from Australia. Thanks to Dr.Shiell this technique has been adopted by Dr.R.Bernstein and Dr.W.Rassman and was promoted in USA.
In current century Follicular Unit Transplantation underwent further evolution. Dr. M.Marzola developed trixophitic closure of donor wound.
Trixophitic closure of donor wound allows us to make linear scar after strip excision invisible due to hair grow through the scar.
The invention of FUE method allowed hair transplant surgeons to use a body hair as a donor supply and this method was named as BHT.
In 2004 famous Brazilian surgeon - Marcelo Pitchon started performing long hair transplant which is incredibly new trend in hair restoration surgery.
Long hair transplantation is absolutely a new trend in hair restoration field. The main purpose of long hair transplant is the opportunity of seeing the final result of hair transplantation straight after the surgery and not after a year, as it happens in case of ordinary hair transplant procedures. Of course this is provisional effect and transplanted long hair starts to fall out in a month and regrows after 2-3 months. Exactly this and also programming of successful hair transplant final result are the main motivations for performing this type of surgery.
Modern Hair Transplantation is represented of all above mentioned methods: FUT (Follicular Unit Transplantation - Follicular Unit Strip Surgery), FUE (Follicular Unit Extraction), BHT (Body Hair Transplantation) and Long Hair Transplant. All of them are giving excellent cosmetic results and have their own indications.