Hair Transplant Surgery Sharad Mishra
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History of Hair TransplantationCHAPTER 1

 
INTRODUCTION
Human hair is considered a skin vestige because it serves negligible biological function. Famous biologist Charles Darwin called hair loss an evolutionary advantage, because less amount of hair reduced the possibility of parasites and helped to be healthier and cleaner. This evolutionary reduction of hair matches with the discovery and domestication of fire, use of clothing, made of animal skins and use of shelter for cold weather. The question “Why scalp was spared evolutionary hair loss?” is still opened.
Today, human scalp hairs have mostly esthetic value. Loss of hairs does not cause any illness or disease. That is why it is surprising to note that hair care constitutes a billion dollar industry. Perhaps, it is not so surprising when we look at the social significance of hair through ages. From the famous comb of Mohenjo-daro to elaborate head gears of Egyptian queens, time has always attested to the importance of hair in society. Hair is a powerful metaphor of fertility throughout the world. The power of Shiva's tresses that could hold wild and unruly Ganga exemplifies his virility in Hindu culture. Similarly, the fable of Greek warrior Samson extolls the power of hair in western mythology.
History of hair care is also ancient. In 2,000 B.C., Egyptians mixed water and citrus juice to make shampoo, and they applied animal fats and plant oils to their hair for conditioning. In 1,800 B.C., Babylonian men powdered their hair with gold dust, and Indians used herbs to retain youthful hair. Remedies for hair loss are strewn across old medical texts. The profusion of remedies underlines the fact. None worked.
 
HISTORY OF HAIR RESTORATION SURGERY
Although there is mentioned of hair transplant by Dieffenbach, it can be safely said that modern hair transplantation started in Japan. Many Japanese surgeons were performing hair transplants and reporting their results before it was ever used in western world. The earliest of these was reported by Keio University professor, Dr Masao Sasagawa in 1929.1 He reported use of special needle for implantation and discussed 10 months follow-up results.
Perhaps the most important and advanced work in this field was done by Dr Shoji Okuda (1886–1962). He published five series of articles titled “Clinical and experimental study of living hair transplantation” in the Japanese Journal of Dermatology in 1939, reporting 200 cases of hair transplantation.2 His techniques employed specifically designed “round saws” 1.0–5.0 mm in diameter. In the Okuda papers,3 almost all the tenets of modern hair transplant surgery can be found, including the principle of “donor dominance”. It is notable; however, that Okuda did not use hair transplantation for treatment of androgenic alopecia, and restricted its use to cicatricial alopecia, congenital alopecia and pubic atrichia. It is rather unfortunate that these papers were not available to wider audience as they were written in old Japanese script and got lost due to the onset of Second World War.
Next in the series of illustrious Japanese surgeons is Hajime Tamura (1897–1977) performed many hair transplant procedures. It was reported that 127 cases in 1937 failed but that 136 cases after 1939 showed good results.4 His techniques using single hair grafts produced an excellent natural appearance.2
When we read the description of his technique, we are startled by its striking similarity with today's modern techniques. Following is an excerpt from his published paper.5
“From 1937 onward, I tried the following method in 136 cases….
The scalp is excised in a ship-shaped manner, leaving the hair 3–4 mm long and sutured immediately. The excised scalp is then cleansed in physiological saline and the subcutaneous fat is excised. It is then dissected in small pieces with scissors cutting parallel to the direction of hair shafts. In the case of single hair grafting, the surrounding tissue must be included.
The recipient sites are made with a 1 mm punch or a thick injection needle and the hairs are inserted one by one…I usually use a combination of small grafts in 1 mm punch holes and single hairs into needle sites.
The donor is better if it is as small as possible. The reason for this is that a big donor graft the hairs grow in a bundle and in a most unnatural manner. It is best to conduct the operation with single hairs entirely.
The grafted hairs fall out after 2–3 weeks, but afterward the hairs regrow from the same region.”
Had these techniques been adopted earlier, the history of hair transplantation would have taken a different course and there would have been no cornrows and transplant cripples.
Dr Keiichi Fujita performed extensive work on eyebrow transplant while working on leprosy patients at Tama Zensei Yen in the Institute of Hansen Disease. Fujita reported that scalp hair transplanted as eyebrows initially grew long but behaved more like eyebrow hair with passage of time. This phenomenon is now known as “recipient influence”.6
The concept of hair transplantation was introduced to western physicians by Dr Norman Orentreich who is generally regarded as father of modern hair restoration surgery. He discovered the technique while investigating whether common skin disorders have donor or recipient site dominance. In the original, ingenious experiments performed by Dr Orentreich, 6–12 mm punches (trocars) were used to create the grafts. He was the first person to apply hair transplantation in common male pattern baldness.7
As punch grafting became popular, new set of complications were observed. First was that while using large size punch, there was an unacceptably high rate of hair loss in the center of the grafts due to poor oxygen diffusion. When smaller punches were used for harvest, there was an unacceptably high rate of follicular transection, so that hair growth was poor in transplanted area. Eventually, 4 mm punch was decided upon as ideal for punch grafting, and by the 1970s this procedure was quite popular.
The chief fallacy of this approach was that hair growth was taken as the parameter of success and not esthetic improvement in facial appearance. As there was no anatomic basis to this technique the results were unnatural. Often, a successful hair transplant gave permanent bad hair days to its recipient. This unnatural growth later condemned as “Doll's hair” and “Cornrows” forced many to wear a hat.
Later on, it was felt that the size of “plug” was too large and some surgeons used to randomly split it. This was arbitrarily termed as minigraft and contained four to six hairs as compared to more than six hairs in punch grafts. This was further refined to get a micrograft of two to four hairs, but these grafts were created by random splitting of bigger grafts and did not conform to any natural anatomic pattern.
It was also observed that use of punches led to extensive follicular trauma. Therefore, strip excision was popularized. While performing this technique, only region of blind cutting was at the edge of the strip and so unnecessary follicular transection was minimized. Many innovations followed to speed-up the speed of surgery. This included multiblade knives, graft cutter, etc.; but being blind techniques, all of them increased follicular transection along with surgical speed. This era of micro-mini grafting lasted throughout the 1980s and in good part of the 1990s. Although, many surgeons produced impressive results in this era, the results were not consistent. As the esthetic quality improved, smaller issues were discussed and fine-tuned.
The concept of follicular unit as the building block of hair transplant along with smaller recipient incisions have rendered todays hair transplants almost undetectable. Follicular unit was first described by Headington as a histologic entity8 and was later incorporated into surgical practice as anatomic unit for hair transplant. There are many advantages to this approach including natural appearance, better growth and survival, higher transplant density and lesser recipient scalp tissue trauma.9 The details of follicular unit hair transplantation will be discussed in detail in chapter 9 “Follicular Unit Extraction”.
The concept of follicular unit extraction was perhaps first published in 1996 by Dr Inaba using 1 mm needles.10 Inspired by these works, Bernstein and Rassman published their work on “Follicular Unit Extraction” technique in 2002.11 Initial enthusiasm for the concept slowly gave way to dissatisfaction since many surgeons reported very high follicular transection rates using this technique. With the passage of time, the technique has been improved greatly 3and is now slowly but steadily gaining foothold in hair transplant practice.
REFERENCES
  1. Sasakawa M. Concerning hair transplantation. Jpn J Dermatol Urol. 1930;30:76.
  1. Okuda S. Clinical and experimental studies on hair transplanting of living hair. Jpn J Dematol Urol. 1939;46:537–87.
  1. Shiell RC. The Okuda papers. Hair Transplant Forum Int. 2004;14:1–6.
  1. Tamura H. Concerning hair transplantation (2nd report). Jpn J Dermatol Urol. 1943;53:76.
  1. Shiell RC. Tamura, Sasakawa and Fujita now translated. Hair Transplant Forum Int. 2004;14:41–6.
  1. Fujita K. Brow plasty. Lepra. 1953;22:218.
  1. Orentreich N. Autografts in alopecias and other selected dermatological conditions. Ann N Y Acad Sci. 1959;83:463–79.
  1. Headington JT. Transverse microscopic anatomy of the human scalp. A basis for a morphometric approach to disorders of the hair follicle. Arch Dermatol. 1984;120(4):449–56.
  1. Bernstein RM, Rassman WR, Szaniawski W, et al. Follicular transplantation. Intl J Aesthetic Restorative Surgery. 1995;3:119–32.
  1. Inaba. Masumi Androgenetic Alopecia. Modern Concepts of Pathogenesis and Treatment. Springer-Verlag;  Tokyo:  1996. pp. 238–45.
  1. Rassman WR, Bernstein RM, McClellan R, et al. Follicular unit extraction: minimally invasive surgery for hair transplantation. Dermatol Surg. 2002;28(8):720–7.