Hair Transplants have changed dramatically over the past 15 years starting with Standard Punch Grafting then moving to Mini-Micro Grafting and finally ending up with the state-of-the-art procedure Follicular Unit Grafting. It was the patient and physician's desire for complete naturalness that led to this evolution.

Original Technique - Standard Punch Grafting

From 1950 to the early 1980s, the only procedure available for hair restoration was a technique made popular by Dr. Orientreich called Standard Punch Grafting. This procedure used large circular grafts (often called “plugs”) harvested by round punches. Each graft was about the size of a pencil eraser and contained as much as 20-30 hairs per graft. Only 50-100 of these grafts were used at a time. These large grafts had to be spaced far apart due to the constraints of blood supply, and this led to the “doll's head” look commonly associated with transplants of the past. In addition, this technique wreaked havoc on the donor area. The punches used to harvest these “plugs” from the donor area often left a scarred checkerboard pattern in the back of the head.

The only way to resolve this doll's head appearance was to do multiple procedures in an attempt to fill in the gaps between the plugs. Many patients who were frustrated and disappointed with the initial results simply did not finish the process. Even if patients did finish, other problems with naturalness occurred over time due to the inefficient use of the limited donor supply. To fill in the gaps, physicians were forced to use up the entire donor supply in a very small area. Unnatural islands of grafted hair became noticeable over time as hair loss progressed and receded away from these heavily grafted areas.

It was during this time that physicians learned to appreciate and take into account the progressive nature of hair loss when planning hair transplantation in patients with MPB. The technique of Standard Punch Grafting is obsolete and no longer used. Unfortunately, many patients still have the scars of this old technique, and some people mistakenly think that they represent hair transplants today.

Combination Mini-Micro Grafting

The desire to improve naturalness led to the use of smaller grafts. By the late 1980s and early 1990s, a technique called Mini-Micro Grafting became the standard. Graft size had been reduced to 4-12 hairs per graft. Small slit incisions were now used for the recipient area instead of round punches. The decreased vascular trauma associated with these smaller slit incisions enabled a larger number of grafts to be placed closer together in a single session. Procedure size increased to an average of 400-800 grafts per session.

Donor harvesting and graft preparation techniques also improved. Donor tissue was no longer harvested with individual round punches but rather from a single strip of donor tissue (a process called strip harvesting). The harvested strip was subsequently divided into individual grafts. This produced less scarring leaving behind a single linear scar rather than a checkerboard pattern. Strip harvesting also increased the total amount of hair that could be harvested from the donor area. Mini-Micro Grafting was a vast improvement over Standard Punch Grafting, but the results were still not totally natural under all conditions.

Follicular Unit Transplantation – State-of-the-Art

By the mid 1990s, Follicular Unit Transplantation (FUT) became the state-of-the-art procedure used in hair transplantation. This revolutionary advance occurred when physicians observed that hair grows and exits the scalp in tiny, naturally occurring groupings of 1-4 hairs called follicular units.

With this observation, physicians began using microscopic magnification to create grafts that kept these natural groupings intact. These 1-4 hair grafts, called Follicular Unit (FU) grafts are so tiny they can be placed in micro-incision about the size of a needle. The reduction in graft and recipient site size allowed for a larger numbers grafts to be placed closer together with less danger of vascular trauma. By the late 1990s, procedures consisting exclusively of FU grafts could range from 1,500-2,500, depending on the size of the area being treated. FU grafts can be placed at densities of about 20-30 grafts/cm which is significantly closer than mini-grafts. These tiny grafts replaced hair with the same size groupings found in nature.

By placing large numbers of these grafts in patterns that mimic nature, a totally natural and undetectable result could be produced.

The degree of naturalness produced with FUT enabled physicians to treat situations that could not be treated before and expanded the application and use of hair transplantation. FUT enabled more delicate work such as eyebrows, eyelashes, beards and mustaches to be done. FU grafts have also been found to be successful in burns and scar tissue.

Most physicians now exclusively use FU grafts when performing hair transplantation procedures. However, some physicians still use a slightly larger graft called a Double Follicular Unit (DFU) graft in combination with a majority of FU grafts in selected situations. They feel that in some patients, combining FU grafts with slightly larger DFU grafts can achieve better density, and can do so without sacrificing naturalness. This is an ongoing controversy in hair transplantation that has yet to be resolved.

Further Advances In Technique

Further advances continue to be made in the way Follicular Unit Transplantation is performed. Some of the more current advances include:

• Larger sessions in properly selected patients
• Placing the grafts at higher densities in properly selected patients
• The option of using Coronal or Sagittal incisions in the right situation
• Better donor closure techniques that leave less donor scarring, such as the trichophytic closure
• Better holding solutions to improve follicular unit survival
• A better understanding of the principles of naturalness and density leading to better decision-making for the individual patient