Hair Transplantation

Hair Transplantation is a hair restorative technique developed by Dr. Orentreich in 1959. In this procedure, hair is removed from the permanent zone in the back and sides of the scalp (the donor area) and placed into the balding areas in the front and top of the scalp. Dr. Orentreich’s main insight was that the transplanted hair would continue to grow in the new area – a concept he called “donor dominance.” (1)

Unfortunately, with this technique, the hair was removed from the donor area using a round instrument called a punch and then transplanted as plugs (groups of up to 20 or more hairs). Needless to say, this technique did not produce very aesthetically pleasing results – but at least the patients had some hair.

Over the next 25 years the grafts gradually became smaller and slowly evolved from the large plugs, to smaller mini-grafts and then to very small micro-grafts, containing just a few hairs each. The major breakthrough, however, came in the mid-1990s with Dr. Bernstein’s idea that hair should be transplanted in its naturally occurring groups called follicular units and Dr. Limmer’s decision to use a microscope to aid the surgeon in dissecting hair bearing grafts from the surrounding tissue. (2, 3).

In this technique, called Follicular Unit Transplantation (FUT) hair is transplanted exclusively in its naturally occurring groups of 1-4 hairs. Follicular Unit Transplantation mimics the way hair grows naturally, so that the results can be indistinguishable from the patient’s original hair.

In Follicular Unit Transplantation, a thin strip of hair is taken from the back and/or sides of the scalp. This area is closed in such a way that the fine incision is camouflaged by the patient’s existing hair. The donor strip is placed under stereo-microscopes for dissection into individual follicular units containing from 1 to 4 hairs each. Meticulous dissection of the individual follicular units is critical to a successful follicular unit transplant procedure. These grafts are then stored in a holding solution and kept cold under refrigeration until they are placed into the recipient area (the bald or thinning scalp).

Because these are individual follicular units, this form of transplantation enables the surgeon to use very small recipient sites. The smaller sites cause minimal damage to the scalp and enables the surgeon to safely transplant thousands of grafts in a single session, thereby completing the hair transplant in one day. The recipient sites (tiny incisions that the hair is placed into) are created with a very fine needle-like instrument. The hair transplant surgeon can work in between existing hair so that, in areas of thinning, the patient’s hair does not necessarily need to be cut.

A critical part of the hair transplantation process is the creation of the recipient sites. The depth, angle, and distribution of these sites determine the final result and how natural the hair transplant will appear. The experience, art and skill level of the hair transplant surgeon in making these sites will determine the results.

Once the recipient sites are made, the follicular unit grafts are carefully inserted into the scalp. The 1-hair grafts are placed at the hairline, the 2’s immediately behind them and the larger 3- and 4-hair units are placed in the central, forelock region area of the scalp to give this area greater density. The recipient site sizes are matched to the different size follicular unit grafts, so that a “snug fit” is created. This facilitates healing, enhances growth of the follicles, and permits a very easy post-op course.

The hair restoration is detectable for a week to 10 days after the procedure. The new hair begins to grow in at about 10 weeks and the full results of the follicular unit hair transplant are appreciated 10-12 months after the procedure.

1. Orentreich N: Autografts in alopecias and other selected dermatological conditions. Annals of the New York Academy of Sciences 83:463-479, 1959.

2. Limmer BL. Elliptical donor stereoscopically assisted micrografting as an approach to further refinement in hair transplantation. Dermatol Surg 1994;20:789-793.

3. Bernstein RM, Rassman WR, Szaniawski W, Halperin A: Follicular Transplantation. Intl J Aesthetic Restorative Surgery 1995; 3: 119-32.

Robert M. Bernstein M.D., F.A.A.D.
Clinical Professor of Dermatology
College of Physicians and Surgeons of Columbia University
New York, New York
Bernstein Medical – Center for Hair Restoration