Early Years

The first hair transplant surgery for male pattern baldness was performed by Dr. Norman Orentreich in 1952 in New York City. After a disbelieving medical community rejected the first few submissions of his paper that described his technique, this landmark study was finally published in 1959. Dr. Orentreich coined the term “donor dominance” to explain the basic principle of hair transplantation which says that transplanted hair continues to display the same characteristics of the hair from where it was taken. In other words, healthy hair that is harvested from the back or sides of the scalp that is transplanted to the balding area on the top of the head will continue to grow as if it were still in its original location.

Unfortunately, the excitement over this discovery took the focus away from the reality that merely getting hair to grow did not guarantee a successful cosmetic result. For years, hair transplants were performed using the original 4-mm grafts sizes – the width of pencil erasers. These large graft techniques – that became the hair transplant standard for many years – made a natural result virtually impossible. Because these large grafts represented the only option for a balding person who wished to have his/her hair restored, the patient accepted a less than optimal outcome. For too many years the surgeon, benefiting from a lucrative procedure, became complacent and failed to push the technology forward and change their techniques.

Through the 1970s, all hair transplantation procedures involved the transplantation of large grafts, commonly known as plugs. Mini-grafting, the technique of using smaller grafts cut from a strip of donor tissue (rather than punched out directly from the back of the scalp) was introduced in 1984. Physicians then began using micro-grafts, small grafts of 1-2 hairs, to soften the frontal hairline. The procedure that used larger grafts in the center of the scalp with smaller grafts around them to make the look more natural was called mini-micro grafting. Mini-micro grafting procedures gradually supplanted the plug technique and slowly became the main form of hair restoration surgery over the next 20 years i.e. through the 1990′s.

Follicular Unit Transplantation

The use of very large numbers of small mini-micro grafts (Mega-sessions) gained popularity in the mid-1990′s. Increasing the size of the hair transplant sessions was a logical extension of the mini-micrografting technique, as it required basically the same skills of the smaller sessions. However, the introduction of Follicular Unit Transplantation (FUT) by Drs. Bernstein and Rassman in 1995, where stereo-microscopic graft dissection is used to transplant hair in its naturally occurring groups, dramatically increased the skills required by the surgeon and staff to perform hair transplants.

Initially, Follicular Unit Hair Transplantation was met with great skepticism and resistance by the hair transplant community. It was not until there was a ground swell of patient demand, mostly fueled by patients touting their great results over the internet, that physicians reluctantly adopted the technique. By the year 2000, Follicular Unit Transplantation had become main stream. It is now consider the “gold standard” of surgical hair restoration. The important events in the history of Follicular Unit Hair Transplantation can be found in the section Milestones in the History of FUT.

Follicular Unit Extraction

Harvesting follicular unit grafts by removing them directly from the donor area gained popularity in the United States with Rassman and Bernstein’s 2002 publication Follicular Unit Extraction (FUE) and gained further momentum with Harris’ paper in 2005. Although this procedure has a number of limitations, it has proven itself to be useful when strip harvesting is not indicated.

Outdated Procedures

Laser hair transplants, or rather using a laser to make the holes to put the grafts into, was promoted in the 1990′s as a “high-tech” way of performing a hair restoration. The laser, however, caused damage to the skin and often scarring and poor growth. The validity of using the laser in hair transplant surgery was challenged in Bernstein’s 1996 paper “Laser Hair Transplantation; Is it really state-of-the-art?” The procedure has since been all but abandoned.

Scalp reductions, the technique where the bald area in the back of the head was literally cut out of the scalp, and flaps where a strip of skin from the side of the scalp was rotated to the frontal hairline, were procedures that had their heyday in the 1980′s and early 1990′s, but the procedures risked excessive scarring and unnatural hair growth. Their use decreased precipitously with the rise of Follicular Unit Transplantation. Unfortunately, by the time the procedure fell completely out of favor, many patient’s had been harmed by these aggressive hair restoration techniques.


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