FROM HEAD TO TOE
HAIR TRANSPLANTATION: AN UPDATE
H
Mark Waldman, MD
air has an important but often
overlooked role. In humans it
serves multiple functions: tem-
perature regulation, protection,
touch sensation and sensory
awareness. Hair has been associ-
ated with health, strength, virility,
sexuality, emotions (eyebrows) and can be
used as an expression of our personality. It can also show aging as
our hair turns gray or with pathologic conditions such as scurvy
where we see “corkscrew hairs.”
The loss of hair (alopecia), especially on the head has been asso-
ciated with a decreased quality of life, regardless of the etiology 1,2,3 .
Patients with hair loss have an increased risk of low self-esteem,
depression and social anxiety. Compared to normal controls, pa-
tients in their 20s with androgenetic alopecia have even greater
risk of these symptoms 1 . People without hair loss have been re-
ported to view patients with advanced genetic alopecia as older,
less masculine and physically and socially less attractive 4 .
Modern day hair transplantation was described by Dr. Shojui
Okuda in the Japanese Journal of Dermatology and Urology in
1939 5 . This work was divided into five separate sections that de-
scribed his research and how he performed his procedure 5 . A very
similar technique was written by Dr. Norman Orentreich in 1960
where he demonstrated that circular grafts taken from non-bald-
ing areas on the scalp transplanted to balding areas would success-
fully grow 6 . It was reasoned that the transplanted grafts exhibited
“donor dominance” in the recipient area; it would grow as if it
Fig. 1. Natural groupings of hairs in individual follicles.
22
LOUISVILLE MEDICINE
were still in its original location. The transplanted hair would grow
at the same rate and exhibit the same characteristic such as color
and texture. Subsequent studies have shown that recipient areas
can influence the donor hair, especially recipient areas away from
the scalp 7,8 . Cell cycle, growth rate and survival rate can be influ-
enced by recipient site location, however the exact mechanism is
unknown. It was noted that the overall hair follicle volume tends
to remain stable regardless of recipient site 7 .
The greatest advance in hair transplantation is the use of the
follicular unit. Hair follicles naturally grow in groups of one to
four hairs (Fig. 1) 9 . The follicular unit is the gold standard of
modern hair transplantation. The combination of elliptical donor
strips dissected using stereomicroscopes first described by Dr.
Bobby Limmer and the use of individual follicular units employed
by Drs. Bernstein and Rassman led to this major change in hair
transplantation 10,11 . There are several benefits to this technique:
natural looking results, increased graft survival and improved
scarring. Today, the standard of care is to prepare hair follicle
grafts into their natural groupings using stereomicroscope. This
technique is used to prepare grafts whether donor harvesting is
done with an elliptical strip (FUT) or individual grafts, Follicular
Unit Excision (FUE).
The hallmark of hair transplant today should be natural, unde-
tectable results. Genetic hair loss in both men and women is the
most common reason that patients seek hair transplantation. Pa-
tients with eyebrow hair loss or surgical or traumatic scars are also
good candidates and can have excellent results. All patients should
undergo a consult with a hair transplant surgeon that includes a