History of Hair Transplantation Surgery

Introduction

Hair loss due to disease, scarring, and, in particular, androgenetic alopecia, has troubled members of the human race since the dawn of history.

A prescription for restoring hair is included in the Ebers papyrus of ancient Egypt, which has been dated to 1800 B.C.

Ancient Attempts at Hair Restoration (1800 BC – 1800s AD)

For millennia, humans attempted to reverse baldness through topical remedies, herbal concoctions, and even wigs.

The ancient Egyptians tried various mixtures, including animal fats and plant extracts.

Greeks and Romans experimented with their own formulas, but none offered permanent solutions.

The first documented surgical attempts would not appear until the 19th century.

The first attempts at surgical restoration of hair loss were recorded by Dieffenbach in 1822.

In his inaugural thesis at Wurzburg, he described animal investigations in all and auto-transplantation of hair, skin, and feathers.

Early Surgical Experiments (1822-1950)

Dieffenbach’s Animal Studies (1822)

The first attempts at surgical restoration of hair loss were recorded by Dieffenbach in 1822.

In his inaugural thesis at Wurzburg, he described animal investigations in all and auto-transplantation of hair, skin, and feathers.

Early Flap Techniques (1890s)

Autografts of the hair-bearing scalp using flaps and large free grafts have been in use since at least 1893.

These early attempts laid groundwork for future refinements but produced inconsistent results.

Japanese Pioneers (1930-1943)

A Japanese surgeon, Sasagawa, reported hair follicle transplantation as early as 1930.

In 1939, Okuda, a Japanese Dermatologist, described the correction of alopecia of the scalp, eyebrow, and mustache areas using small cylindrical punches to remove the donor tissue and slightly smaller ones for the recipient area.

Tamura transplanted single hairs to the pubic area in 1943, and Fujita in 1953 reported the use of this technique for a wide variety of defects.

No Japanese author mentioned the use of this technique for the correction of male pattern baldness.

Because of wartime conditions, the work went unrecognized outside of Japan for decades.

The Birth of Modern Hair Transplantation (1950-1980)

Dr. Orentreich’s Revolutionary Discovery (1959)

Orentreich, a New York dermatologist, studied the donor or recipient dominance of various alopecia conditions and reported this work in 1959.

He noted that donor dominance was observed in all cases of male pattern alopecia and was able to refute the prevailing theories that male baldness was a result of poor blood supply to selected regions of the scalp.

His paper captured the attention of the public, and many other dermatologists were trained by him.

The “Hair Plug” Era (1960s-1980s)

For 25 years, variations on the original Orentreich technique remained in vogue.

Sessions of 40-100 x 4.0 mm grafts were transplanted from the donor site to slightly smaller recipient sites in the bald area.

These large “plug” grafts created an unnatural “corn row” appearance that became stigmatized.

Smaller 2.0 mm grafts were used by some surgeons in the 1970s but received no publicity at the time.

Refinement and Miniaturization Era (1980-2000)

There are three broad categories of surgical hair restoration procedures.

These may be summarized as follows:

• surgical excision (alopecia reduction)
• scalp flaps (advancement flaps, rotation flaps, and free flaps)
• free autografts of hairy scalp from the well-haired to the bald area (these grafts may be from a diameter of about 5mm down to a single hair follicle)

All three categories of operation are still performed at the end of the 1990s, but the most generally accepted are the autograft techniques known as “micrografting”, “mini grafting”, and “follicular transplantation”.

Alopecia Reduction Surgery

This procedure was introduced in the mid-1970s in Canada.

Due to its simplicity and speed of results, it gained rapid acceptance.

Within 1-2 years, the operation was being performed in enormous numbers worldwide.

The basic philosophy of removing part of the balding region and undermining so as to close without undue tension was very appealing.

Many ingenious designs were introduced, and their various merits were argued loud and long at Hair Restoration meetings.

The Problems Emerge

Unfortunately, there are other factors operating which negate the beneficial effects of this procedure.

Within a few years, the first warnings were being given.

The problems were caused by the tendency of the balding area to stretch again if even the slightest tension was present.

More importantly, the natural progression of the androgenetic balding process with time created issues.

Worse still, the stresses of the surgical procedure itself were accused of accelerating the progression of the balding.

The mechanism of this can only be speculated, but the end result was often the rapid recurrence of baldness, visible scarring, and patient disappointment within a few years.

Attempts at Improvement

In recent years, many procedures and devices have been proposed to lessen the effects of “stretch back” and other associated problems.

These include the Frechet Extender, the Seery periosteal anchor flap, the Unger Prolonged A.T.E., and the Nordstrom Silastic suture.

Marzola tackled the problem of the unsightly central scar from a different approach by electing not to fully close the posterior bald area and by using an “M” shaped incision.

The Decline

By the end of the 20th century, the use of alopecia reduction had declined markedly.

Most surgeons were using these techniques only for highly selected cases, if at all.

This is probably an over-reaction, and it is likely that the technique will be revived in future years.

With the benefit of improved techniques, more caution used in case selection, and greater attention to surgical detail during the operation, more satisfactory results may be expected.

Flap Surgery

Scalp flaps for reconstructive surgery of the scalp have been in use since the 1890s.

Short hair-bearing pedicle flaps to disguise scalp scars were first described by Passot in 1919 and again by Lamont in 1957, but made very little impression on the world medical community.

Juri’s Innovation (1972-1975)

Scalp flap surgery received an enormous boost when Argentinean surgeon Jose Juri, who used long Temporo-Parieto-Occipital flaps, described his twice-delayed methods at plastic surgery meetings in 1972 and 1975 and published his results later that year.

The technique was quickly adopted by courageous but inexperienced surgeons worldwide with varying results.

Tip necrosis, wound breakdown, and sloughing of the entire flap were not uncommon.

The technique has a considerable “learning curve” and was unforgiving if shortcuts were taken.

Further Developments

In 1980, Kitaro Ohmori pioneered microsurgically anastomosed free flaps, a lengthy and technically difficult procedure with a varying degree of success.

Gradually, many surgeons abandoned hair surgery altogether or switched back to the safer, shorter flaps.

A number of inventive variations were introduced in the following years by Stough, Nataf, Dardour, Bouhanna, Frechet, Nordstrom, and others.

The introduction of tissue expanders in the 1980s made the flap techniques safer by increasing the area of available donor scalp and enabling tension-free closure of the wounds.

The Decline of Flap Surgery

In spite of these advances, the residual scars in both donor and recipient sites often left a cosmetic problem for which no adequate solution existed.

The operation gradually slipped in popularity with both patients and surgeons.

Newer techniques for free grafting were developed.

By the end of the 20th-century scalp flap surgery had been abandoned by all except a few highly experienced surgeons who specialized in this technique.

3. Scalp Autograft Surgery – The Path to Modern FUE

Free scalp autografts are very reliable, provided they are carefully handled.

The recipient areas can provide enough oxygen and other nutrients to sustain life and growth.

Once the boundaries are pushed beyond certain parameters, problems begin to occur.

The difficulty is that there are as yet no hard and fast rules for graft survival.

Grafts up to 5 mm in diameter will produce 100% growth in certain situations, while grafts of less than 1 mm will fail if trimmed improperly or packed too closely together in some scalps.

The Transition to Smaller Grafts

Sessions of up to 240 grafts created by quartering 60 x 4 mm grafts were being performed by Wayne Bradshaw of Australia in the early 1980s and extended to over 400 later.

Dr. Carlos Uebel of Brazil appears to have been the first to perform and speak on larger sessions of up to 1000 small grafts from around 1983 but the technique did not receive widespread publicity until the Moser Group in Austria introduced their paper and videotape on the procedure at a meeting in Rio de Janeiro in 1992.

Dr. William Rassman of California pushed the boundaries of the procedure out to over 3600 grafts by 1994 and started bringing large numbers of patients, in various stages of completion, to Hair Restoration meetings.

From that time onwards, the technique became widely accepted and underwent continuous refinement.

The Microscope Revolution (1987)

The use of microscopes for the dissection of grafts was introduced by Dr. Bob Limmer in 1987 and was slow to gain acceptance because it tripled the time required for graft preparation.

Growing disquiet concerning the poor growth which sometimes resulted from the dense packing of mini grafts led to its gradual acceptance, however.

Championed by Seager, Bernstein, Norwood, and others, the use of this technique appears to be in the ascendancy as we enter the new millennium.

Follicular Unit Transplantation Techniques

In this increasingly popular procedure, large numbers of hairs are harvested, with the aid of a 10 power binocular microscopes, from a strip of excised full-thickness scalp.

These naturally occurring follicular clusters, each containing 1-4 hairs, are then planted into needle holes in the balding area.

This is a refinement of an earlier technique known as “mini grafting,” in which the follicular clusters and some surrounding skin were planted into slits cut in the scalp with a small scalpel blade.

Large numbers of hairs can be inserted at a single procedure, provided certain safeguards are met.

Quite extraordinary results may be seen within 4-5 months of operation.

Advantages and Disadvantages

The advantage of follicular unit grafting is that a greater hair density can be obtained.

Figures of up to 61 hairs per square cm. in a single procedure have been claimed.

The technique has the disadvantage of being more time consuming, taking between two and three times the number of work hours to dissect and insert the same number of hairs.

This has a considerable economic impact on the patient.

Proponents defend this by claiming that in good hands, the number of donor hairs damaged during the procedure is at least 20% less than with non-microscopic methods of dissection.

However, it has been suggested that follicular trans-section and bulb amputation are not as important as once thought.

Considerable hair regeneration will occur if the follicular stem cells have been preserved.

These points and the future direction of free grafting remain highly debatable points as we enter the new millennium.

The FUE Revolution (2000-2025)

The Early FUE Pioneers (2000-2003)

While FUT (strip harvesting) dominated the 1990s, a few surgeons began revisiting the punch extraction methods pioneered by Dr. Okuda in the 1930s.

Dr. Ray Woods of Australia publicly demonstrated his “Woods Procedure” in 1989, using small punches to extract individual follicular units.

In 2002, Drs. William Rassman and Robert Bernstein formally introduced “Follicular Unit Extraction (FUE)” in their publication “Follicular Unit Extraction: Minimally Invasive Surgery for Hair Transplantation.”

This marked FUE’s entry into mainstream hair restoration surgery.

Dr. Cole’s CIT® Technique (2003)

In 2003, Dr. John P. Cole pioneered the successful methods of performing follicular unit extraction or FUE hair restoration and began developing the instruments necessary to perform FUE.

His proprietary method became known as the Cole Isolation Technique (CIT®).

Dr. Cole also began teaching FUE to other physicians in 2003 and continues to train physicians on how to perform FUE.

CIT® Innovations

CIT® introduced several key advancements over traditional FUE:

Minimal Depth Principle – Precise depth control minimizes transection rates to under 3%.

Stem Cell Preservation – Shallow extraction preserves stem cells in the donor area, enabling 30-40% follicle regeneration.

Sharp Punch Design – Cole Instruments punches feature razor-sharp edges, thin walls, and recessed internal diameters to reduce tissue torsion.

In 2005, Dr. Cole developed the first complex motion profile device, including oscillation, for FUE.

Dr. Cole filed patents on all significant alterations in punch designs for FUE in 2006.

Manufacturers continue to copy these designs.

In 2003, Dr. Cole opened the first FUE clinic in Europe and, in 2007, the first FUE clinic in Asia.

The Robotic Era Begins (2011)

On April 14, 2011, the FDA granted 510K clearance to the ARTAS System for follicular unit extraction of the scalp on androgenic alopecia patients.

Developed by Restoration Robotics, Inc., Mountain View, California, the ARTAS robot was FDA-approved for robotic hair transplant surgery since the spring of 2011.

The system uses a robotic arm fitted with a sharp/blunt dual punch harvesting mechanism, an optical imaging system, and computer-guided precision.

ARTAS Evolution and Limitations

Early prototypes had unacceptably high transection rates of 30% at the 2007 ISHRS meeting.

By 2008, this improved to 6-15%, and by 2011, the company reported 2-7%.

However, several limitations persist:

• ARTAS is only approved for patients with straight hair that is dark brown or black in color
• Higher transection rates than experienced manual FUE surgeons (3-8% for ARTAS vs. under 3% for skilled practitioners)
• Cannot perform the implantation phase – only extraction
• Requires patients to remain absolutely still, with head restrained by straps
• Lacks the artistic judgment required for natural hairline design
• Operated by technicians

No-Shave FUE Development (2010s)

A major patient concern with traditional FUE was the need to shave the entire donor area.

Long-Hair FUE was developed using advanced techniques that eliminated the need for shaving.

Dr. Cole is one of the first and only hair surgeons to offer No-Shave FUE Hair Transplants globally.

This technique, also called C2G No-Shave, allows patients to have hair transplants without anyone knowing they had surgery.

Integration with Regenerative Medicine (2015-2025)

Dr. Cole entered the field of regenerative medicine in 2007.

In 2015, Dr. Cole developed a means to lyse platelets to achieve five times the concentration of high molecular weight proteins compared to standard activated PRP with calcium gluconate or thrombin.

This became known as CRP (Cytokine Rich Plasma), a significant advancement over traditional PRP treatments.

Modern FUE procedures now routinely incorporate:

• PRP/CRP injections – Growth factors to improve graft survival
• Exosomes treatments – Stem cell-derived regenerative therapy
• ReyaGel applications – Extracellular matrix for follicle regeneration

Current State of FUE (2025)

Today, FUE is the most popular hair restoration surgery procedure globally.

FUE still depends on the basic principles and mechanisms described by Dr. Cole.

Over 500 surgeons worldwide use Cole Instrument tools.

The technique has evolved to include:

• Punch sizes ranging from 0.75mm to 1.30mm
• Motorized extraction devices for speed and precision
• Real-time graft quality assessment
• Advanced graft storage solutions
• Body hair transplantation (BHT) for donor area expansion

Technical Innovations Through the Decades

There is a wide variation in the technique used by the various surgeons performing hair transplantation.

We need not be concerned about the finer points of the procedure in this review, as many excellent descriptions are available in print and video format.

There are numerous minor variations, such as whether the surface epithelium should be removed or not, or whether a razor blade or a scalpel is used for the dissection.

Whether sutures or staples are employed may be a matter of convenience for the surgeon or comfort for the patient, but have little effect on the cosmetic result.

These are points of individual preference, and there are broader issues that must be addressed.

I have listed these as follows:

• Graft Numbers and Graft Density
• Tumescent Anaesthesia
• Single Blade Vs Multi-blade knife.
• Role of the Stereoscopic Microscope
• The Recipient Site
• Role of the Surgical Laser

1. Graft Numbers and Graft Density

For an average Type 6 bald scalp of dimensions 12 cm. x 20 cm., there is a bald area of about 200 sq. cm.

Even at a density of only 40 hairs per sq. cm., this will require 8000 hairs.

This can be achieved with the use of 3500 follicular unit grafts or 2000 small mini grafts if distributed evenly throughout.

Most surgeons prefer to place in excess of 60 hairs per cm² along the frontal hair zone.

This can be achieved in a single session by some skillful surgical teams with very suitable patients.

One cannot safely place large numbers of bulky mini grafts containing excess skin elements into Slits or holes at a density of much greater than 16 per sq. cm in a single session.

Although this would yield a result in excess of 60 hairs per sq. cm if all grew successfully.

To achieve density, the grafts must be more carefully prepared to discard redundant tissue and isolate the pilosebaceous units.

If single or double hair groupings are required, it is best if these are selected from naturally occurring groupings rather than artificially creating small units by cutting down larger ones.

The Dense Packing Debate

The placing of grafts very close together has been termed “dense packing”, and it is this aspect that has attracted the most criticism.

Cases presented at meetings have shown how successful the technique can be with ideal patients.

But opponents have described instances where hair growth is much less than optimal, and even cases where, allegedly, “no growth” has occurred.

Drs. Rassman and Bernstein have agreed that such cases have been seen in their practice, but call them “delayed growth”.

They insist that significant growth can occur after 12 months in some cases.

This point awaits further clarification.

2. Tumescent Anaesthesia

First introduced as an aid to liposuction, this technique, in a modified form, has been embraced by hair transplant surgeons.

The aim is to distribute very dilute solutions of local anesthetic and vasoconstrictor evenly throughout the donor and recipient sites.

At the donor area, this results in a bloodless, firm cutting surface.

For the recipient site, the dermis is thickened so that one is less likely to strike the larger blood vessels, which lie just above the galea.

Benefits

Operative blood loss may be greatly reduced with this technique, with beneficial effects for patients and surgeons.

The operation proceeds much more smoothly without the operative site obscured by blood and recently inserted grafts continually “popping”.

For the patient, there is the advantage of less total blood-loss and decreased postoperative swelling and bruising around the forehead and eyelids.

Vasoconstrictor Options

Epinephrine (adrenaline) is the most commonly used vasoconstrictor and is generally added to the anesthetic agent in a concentration of 1:100,000.

In Australia, New Zealand, and some European countries, the excellent synthetic drug 8-ornithine vasopressin (P.O.R-8, Sandoz) is available.

Unfortunately, vasoconstriction is not always fully adequate with any currently available technique or vasoconstrictor.

Vigorous and persistent bleeding is frequently encountered in young men who are very active physically.

It is known that preoperative anti-inflammatory agents can have a profound negative effect on the speed of coagulation.

Alcohol, aspirin, and vitamin E are known offenders, and it is possible that other agents such as marihuana may be detrimental to coagulation.

Some surgeons like to infiltrate troublesome regions with small amounts of anesthetic containing adrenaline 1:25,000.

Significant changes in pulse rate or regularity are surprisingly rare in these cases.

3. Single Blade Vs Multi-blade Knife

In a survey, 73% of respondents were using the multi-blade knife.

On the other hand, it is interesting that most of those using the stereoscopic microscopes now use a single blade.

The argument is that follicular damage is proportional to the length of the unmonitored incision line.

For a single 15 cm strip, there will be approximately 30 cm of cut, which is all made under visual control.

With a multi-blade knife, it is claimed that only the top blade can be closely supervised, and the other 2 – 9 blades cut blindly through the donor tissues.

Minimizing Multi-Blade Damage

While there is undoubtedly a measure of truth in this argument, Dr. James Arnold of San Jose, California, has shown us ways to minimize the potential damage caused by the multiple parallel scalpel blades.

This includes thorough infiltration of the superficial donor tissues with saline and vasoconstrictor.

Use of the Persona Plus #10 blade for extreme sharpness.

Slow movement of the cutting knife using the fingers and wrist only.

Frequent checking of the several strips for change of direction of the emergent hairs.

Using these techniques and a little practice, the strip is almost perfect every time.

Soft Dermis Challenge

The donor skin in some individuals is very soft and difficult to cut accurately.

This has been termed “mushy dermis,” and the multi-blade knife should not be used with these individuals.

Dissection of a single broad strip into thin cross-slices or “slivers” is extremely difficult, as it has no remaining turgor.

Unless great care is taken, any advantages achieved by the single blade strip excision may be lost in the slicing process.

This is where microscopic control is so useful, although frustratingly slow.

Semi-automatic dissection devices constructed from an array of closely spaced blades have been available for several years.

The merits and demerits of these devices are still being hotly debated.

4. Role of Stereoscopic Microscopes

The use of stereoscopic dissecting microscopes was pioneered by Dr. Robert Limmer of San Antonio, Texas, in 1987, but has been slow to gain acceptance.

Apart from the sheer technical difficulty of graft preparation at high magnification, there is considerable disruption to existing staff work-practices.

The number of work-hours per operation is more than doubled compared with regular mega-session work.

This means long hours of work or the employment of more assistants.

Either way, there is a considerable disruption to the equilibrium of any Hair Replacement Clinic, making the change.

The possible advantages must be weighed against the disadvantages.

The Debate Continues

Whether a general change to stereoscopes is justified at this time is still being debated.

Many Clinics obtain outstanding results with naked-eye dissection or with the use of low power binocular loupes.

Careful inspection reveals that there is certainly the potential for less damage to follicular units with the use of higher power magnification.

But it is all very much dependent on the skill of the Assistants.

It has been stated that when using the microscope, 20% less donor strip is required to obtain the same number of well-trimmed follicular units.

If donor tissue is in short supply, stereoscopic microscope dissection would certainly appear to be the method of choice.

The Reality of Donor Supply

It is worth remembering that although lip service is paid to the adage that “every scalp hair is precious”, there is, in fact, an awful lot of them.

Surveys show that only 23% of men have so much baldness by the age of 70 years that there is likely to be a severe shortage of donor follicles if they choose to push the technique to the limit.

Experience has shown that only a tiny percentage of men present for transplants or continue to have transplant sessions into their 7th decade, even if adequate follicles are available.

Hair graying and a general decrease in motivation seem to lessen the obsession for more hair that so dominated the earlier years of these individuals.

The change to microscopic dissection might be forced by factors in addition to donor supply.

If, for instance, it could be shown that there was faster hair growth or less hair “crinkle” after microscopic preparation of the follicular units, this would potentially affect all patients and not just the small percentage for whom the future supply is a critical factor.

5. The Recipient Site

Once the spacing in mega sessions becomes closer than about 16 per sq. cm., it is no longer advisable to make all the recipient sites with a No. 11 or 15c blade.

The slits or holes must be tailored much more precisely to the size of graft being used.

Most operators have moved to the use of 16 and 18 gauge Nokor needles.

An alternative system is provided by A-Z Instrument’s “Lightning Knife”.

The handle takes SP 91 blades and has a depth control mechanism.

For finer work with density up to 40 follicular units per sq. cm, a 20 or 21 gauge solid or hollow needle is employed.

6. Role of the Surgical Laser

It is clear that the lasers of 2-3 years ago are generally not satisfactory for mega-session work because of potential thermal damage to the remaining skin elements.

This can be serious enough to cause large areas of scalp necrosis if grafts are closely spaced.

Research is continuing, and laser technology is changing so rapidly that it is very likely that the new age Erbium lasers will be useful aids in future years.

Complications of Follicular Unit Transplantation

There are no complications specific to the follicular transplantation technique.

But because of the large number of units involved, there is, with the mega-session technique, a higher probability of some inclusion cysts and graft ischemia occurring.

While some of this increase is due only to the larger numbers, in other cases, increased boredom and fatigue in the surgical Assistants is a contributing factor.

This is particularly true when the sessions involve more than 2000 closely spaced grafts.

Poor growth.

Poor growth or failure of growth have been much discussed sequelae of mega-sessions in past years.

There seems little doubt that much of this may be due to human factors (termed “H-factor” by Dr. Joseph Greco) and will be discussed below.

There may be ischaemic elements as well, due to prolonged vasoconstrictor action or the very close spacing of the grafts in some cases

H-factor

Dr Joseph Greco Jr. first wrote of the human or “H” factor in hair transplantation in 1994 and enlarged upon this in 1996.

Without doubt, human error and carelessness have always been a hazard to hair transplants.

Physical damage may be caused by desiccation, forceps pressure, or by scalpel slip.

Biochemical damage caused by the effect of water, saline, antiseptics, alcohol, or hydrogen peroxide.

With the smaller grafts and the use of finer instruments the risk of damage to growth centers is greatly increased.

The pressure exerted by a micro-dissector tip may be up to 10 times greater than that with the larger graft forceps.

This is analogous with the damaging effects of a 100 pound woman’s stiletto heel on a vinyl floor.

Her heel pressure exerted per square cm. of surface is approximately 10 times greater than that of a 4 ton elephant’s foot.

Because of the vast number of follicular cells involved at the growth center of even a single hair, some surgeons doubt if forceps pressure can be a significant factor in growth retardation.

Further research is being undertaken into this important subject.

Gandelman showed in 1998 that the main damage to grafts did not come from forceps pressure but from desiccation.

He demonstrated that in an air conditioned O.R. at 20 degrees, grafts placed on the dorsum of the gloved hand were irreversibly damaged within 3 minutes.

Donor area scarring.

This can be a problem at times.

Some patients scar badly after the removal of even a narrow strip.

A large session may involve removing a tapered donor strip 25 cm long and 2 cm wide from the occiput.

In most cases, this gap closes with ease but may widen in subsequent months.

Attempts to correct these scars usually result in only minimal improvement.

Some scar problems occur only after a second wide donor strip is removed.

Others may result from taking the strip too low in the donor site.

This region seems to be more prone to scar widening and hypertrophy, possibly because of the neck mobility in that region.

Attempts to correct or even slightly improve these scars are often exceedingly difficult.

The Dissatisfied Patient

No review of hair replacement techniques would be complete without a discussion of the factors which lead to patient dissatisfaction with their results.

The dissatisfaction rate is approximately 2% even in the best clinics.

Furthermore, it is apparent to the author that the satisfaction rate with hair transplant procedures has not changed substantially over a period of 30 years, although the objective standards have improved enormously in this period.

Indeed, as more is now expected of modern techniques and total surgical fees increase, patients are more likely to be unhappy and even litigious if the results fail to meet their heightened expectations.

Contributing Factors

There are several factors at play here, not the least of which (encouraged by aggressive litigation lawyers) is the rapidly increasing tendency for dissatisfied patients to sue their surgeon.

Some doctors aggravate the problem by advertising that results are “undetectable” and “painless” and that “only one session is needed”.

Although all these claims may be true for some fortunate individuals, they are by no means the general rule.

Post-operative pain and lack of graft hair density are common grumbles by patients at follow-up.

Some patients are acutely disappointed with their results and angry with the surgeon.

This is particularly the case if they have not been carefully counseled before surgery.

As Hair Restoration Surgery has become ever more commercial, some physicians’ claims have become outrageous.

This unfortunate trend may be expected to continue as competition for patients becomes even more intense.

The Difficult-to-Satisfy Patient

It must not be forgotten that, however careful and ethical the operating surgeon, there is a small group of patients who are very difficult to satisfy.

It is unlikely that these individuals would ever be completely happy, even if their results were in the top percentile of excellence.

Their expectations are so high, and their self-image is so low.

Many of these patients suffer from endogenous depression, but this can be notoriously difficult to diagnose in the initial consultation.

Sometimes the surgeon can get a clue from the patient’s past history, but many patients conceal psychiatric problems during the initial consultation.

Thus, the surgeon must rely on his intuition and experience to try to identify these difficult individuals.

One is bound to be caught occasionally.

The Young Patient Dilemma

The very young and over-anxious patient is an obvious potential problem case.

But how young and how anxious do they have to be before we exclude them from our operating lists?

Some surgeons insist that their patients be 35 or older.

But most select a figure of somewhere between 22 and 25 as the minimum age and are resigned to having a small percentage of dissatisfied patients.

There is also the common presentation of young men with very early hair loss and a psychological reaction out of all proportion to the loss.

Experience has shown that young men aged 18-28 have a later dissatisfaction rate, which is vastly higher than any other later age group.

This is due to a variety of factors that have been discussed at length in the journals and textbooks.

Chief amongst these is emotional immaturity.

These men will drop out of work or university, withdraw from all social contact, and will sit in the surgeon’s office with a cap pulled firmly around their ears.

These men undoubtedly have psychiatric problems, and surgery should be firmly rejected or deferred.

If a decision is made to proceed, it is comforting to have a psychiatrist’s opinion and blessing well before surgery.

There is no doubt that the conservative surgeon will have fewer problem patients.

But then he will also have a lot fewer patients in general, as the 20-35-year-old group makes up at least one-third of the average hair replacement clientele.

This high rejection rate would result in a large number of otherwise suitable young men being denied the undoubted benefits which would result from a more luxuriant head of hair.

Unsuitable Candidates

Finally, but most important of all, is the undoubted fact that not all patients are suitable for surgery.

It is imperative that the surgeon ascertains the patient’s wishes and requirements during the initial consultation.

If these desires are unrealistic, then this must be carefully discussed with the patient.

The donor hair varies enormously in both quantity and quality, as does the size of the balding area.

Add to this the almost inevitable further expansion of the patient’s bald area with time, together with a concurrent reduction of potential donor hair, and one has an equation which is sure to lead to distress for some men in years to come.

The Future of Hair Transplant Surgery

At the time of writing [2006], the possibilities for further surgical advances seem slim, and the way ahead appears to be mostly medical.

Better 5 alpha-reductase inhibitors are under trial at present, and cloning and gene therapy are being actively discussed.

Nearly two decades later, the landscape has evolved in unexpected ways.

While hair cloning remains elusive, several promising developments have emerged:

Medical Advances (2006-2026)

Finasteride and Dutasteride – Now well-established for preventing further hair loss in appropriate candidates.

Topical Finasteride – Lower systemic absorption reduces side effects while maintaining efficacy.

Minoxidil Improvements – Foam formulations and higher concentrations offer better results.

Regenerative Medicine Integration

PRP Evolution – Platelet-rich plasma has become a standard adjunct to hair transplant surgery.

CRP (Cytokine Rich Plasma) – Dr. Cole’s 2015 innovation concentrates growth factors 5x higher than standard PRP.

Exosomes – Stem cell-derived signaling molecules show promise for follicle regeneration.

ACell (And now ReyaGel and ECM therapies – Extracellular matrix applications enhance donor area healing and follicle regeneration.

Surgical Refinements

There are, however, a few openings for further improvement in the surgical department.

Most transplanted hair seems to undergo immediate telogen, and 3 months generally elapses before regrowth occurs.

If a way was found to bypass this phase, long hair could be transplanted with obvious cosmetic benefits to the patient.

The topical use of 2% minoxidil before and after surgery has been claimed to increase the percentage of growing hairs, but further careful studies are needed on this point.

Mechanization Developments

Mechanical harvesting of grafts and mechanization of the implantation process are both currently under investigation.

A number of mechanical devices have already been patented by Crassas, Choi, Boudjema, Rassman, and Markman.

Although these do not yet meet with general approval from the profession, further advances in this direction may be expected in the years ahead.

Several automated systems have reached market:

• ARTAS robotic FUE (FDA-approved 2011)
• NeoGraft automated extraction (FDA-cleared 2009)
• DHI (Direct Hair Implantation) Choi implanters
• Motorized punch devices from multiple manufacturers

However, the consensus remains that skilled manual techniques produce superior results.

Ongoing Research Needs

There is still no general agreement about such fundamentals as the best methods of wound suturing, post-operative wound care, or the management of the implanted grafts.

All these facets of hair restoration and others need to be subjected to closer scientific scrutiny in the years ahead.

What’s Actually on the Horizon

Hair Multiplication – Research continues into methods to grow new follicles from existing cells.

3D-Printed Skin Grafts – Bioprinting technology may eventually create hair-bearing skin.

Gene Therapy – Targeting genes responsible for androgenetic alopecia remains theoretical.

Artificial Intelligence – AI-assisted hairline design and graft selection are already emerging.

Enhanced Regeneration – Better understanding of the hair growth cycle may unlock dormant follicles.

Key Takeaways: What Patients Should Know

Hair transplantation has come remarkably far since the “hair plug” era of the 1970s.

Modern techniques like FUE produce completely natural results that are undetectable even under close examination.

The shift from large 4mm plugs to follicular unit grafts (1-4 hairs) in the 1990s represented the biggest aesthetic breakthrough.

Dr. Cole’s CIT® technique (2003) further refined FUE by minimizing transection rates to under 3% and preserving stem cells for donor area regeneration.

Today’s patients benefit from 200+ years of surgical refinement, resulting in procedures that are safer, faster, and produce superior cosmetic outcomes.

The introduction of no-shave techniques means you can now have a hair transplant without anyone knowing you had surgery.

Looking ahead, the integration of regenerative medicine (PRP, exosomes, stem cells) promises to enhance graft survival even further.

Frequently Asked Questions

Looking Back, Moving Forward

Hair restoration surgery is undoubtedly here to stay, even if the medical prevention of male baldness becomes more commonplace in the future.

A mega session with dense packing of follicular units may not be the optimal treatment in every case, however, and larger units are acceptable to many patients with fair or gray hair.

It is not essential that all physicians should equip their offices with the staff and facilities for performing 3000 grafts at a sitting.

Sessions of up to 1500 mini grafts or follicular units are safe and within the scope of any small office possessed of at least two capable assistants.

If three or four assistants are available, then the procedure becomes much less fatiguing.

For larger operations, proportionally more staff members are required, and the technical difficulties, staff management problems, and potential for surgical complications begin to climb exponentially.

Whatever the technique, the benefits of new hair growth resulting from carefully planned and executed hair restoration surgery cannot be denied, and the operation is firmly entrenched in the surgical repertoire.

Looking back from 2026, Dr. Cole’s observations from 2006 have proven remarkably prescient.

Hair restoration surgery has indeed remained “firmly entrenched” and continues to grow in popularity worldwide.

The techniques he helped pioneer – particularly FUE and CIT® – have become the global standard.

The future of hair restoration is brighter than ever, combining surgical precision with regenerative medicine for outcomes that would have seemed impossible in 2006.

References

1. ISHRS (International Society of Hair Restoration Surgery). (2024). “History of Hair Restoration Surgery.” Retrieved from https://ishrs.org/about/history/
2. Okuda, S. (1939). “Clinical and experimental studies of transplantation of living hairs.” Japanese Journal of Dermatology and Urology, 46:537-587. English translation available at https://ishrs.org/okuda-papers/
3. Jimenez, F., & Shiell, R.C. (2015). “The Okuda Papers: an extraordinary – but unfortunately unrecognized – piece of work that could have changed the history of hair transplantation.” Experimental Dermatology, 24:185-6. https://onlinelibrary.wiley.com/doi/10.1111/exd.12628
4. Orentreich, N. (1959). “Autografts in alopecias and other selected dermatological conditions.” Annals of the New York Academy of Sciences, 83:463-479.
5. Bernstein, R.M. “Donor Dominance Revisited.” Bernstein Medical. Retrieved from https://www.bernsteinmedical.com/research/donor-dominance-revisited-summary/
6. Imagawa, K. (2009). “A visit to the house of Dr. Shoji Okuda.” Hair Transplant Forum International, 19(6):200. https://www.ishrs-htforum.org/content/19/6/200
7. International Society of Hair Restoration Surgery (ISHRS). “History of Follicular Unit Excision.” Indian Journal of Dermatology, Venereology and Leprology. Retrieved from https://ijdvl.com/history-of-follicular-unit-excision/
8. Medart Hair. (2025). “History and Evolution of Hair Transplant Surgery from 1897 to 2025.” Retrieved from https://www.medarthair.com/hair-transplant/history/
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13. Bernstein Medical. (2025). “ARTAS Robotic Hair Transplant System.” Retrieved from https://www.bernsteinmedical.com/robotic-hair-transplant/artas-robotics/
14. DermHair Clinic. (2018). “ARTAS – Automated FUE: Robotic Hair Transplant Technology.” Retrieved from https://www.dermhairclinic.com/artas-robotic-hair-transplant/
15. PMC (PubMed Central). “Design, proof-of-concept of single robotic hair transplant mechanisms for both harvest and implant of hair grafts.” Retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC10755542/
16. PMC (PubMed Central). “A Comparative Study on the Application of Robotic Hair Restoration Technology Versus Traditional Follicular Unit Excision in Male Androgenetic Alopecia.” Retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC11626372/
17. Hair Transplants Los Angeles. (2025). “How It All Began: Dr. Norman Orentreich and the First Hair Transplant in the U.S. (1952).” Retrieved from https://hairtransplantslosangeles.com/the-first-hair-transplant-how-it-all-began-with-dr-norman-orentreich-in-the-u-s-1952/
18. ResearchGate. (2020). “Norman Orentreich: Father of Hair Modern Transplantation.” Retrieved from https://www.researchgate.net/publication/346890712_Norman_Orentreich_Father_of_Hair_Modern_Transplantation
19. ForHair. (2025). “CRP – Cole PRP Treatment (Cytokine Rich Plasma).” Retrieved from https://www.forhair.com/crp-cole-prp-treatment/
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22. ForHair. (2025). “No Shave FUE – C2G (Cole to Grow).” Retrieved from https://www.forhair.com/no-shave-fue/
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