Hair Transplant - Introduction

How Does Hair Transplant Work

Indications for Hair Transplant

Receding Hairline - Men
High Forehead - Women
Thinning Top - Men
Thinning Top - Women
Hair Transplant Repair
Failed SMP

How is Hair Transplant Performed?

Hair transplant is performed as an out patient surgery under twilight local anesthetic. The procedure usually last 6-8 hours depend on the amount of grafts being transplanted. Modern techniques of hair transplant can restore lost hair and replace or re-shape your hairline with your own natural, growing hair, which need no more care than the ordinary washing, styling, and trimming you have always done. Transplant can be done today so well that often a barber or stylist cannot even tell that grafts have been placed.

Hair transplantation involves removing permanent hair-bearing skin form the back and/or sides of the scalp (donor area). Then, using magnification, the tissue is dissected into follicular unit grafts (containing 1-4 hairs each). These small grafts are then meticulously planted into the bald or thinning area of the scalp (recipient area) so as not to injure any follicles already existing in the area, and at the same exact angle as the other hairs present. The creation of very small follicular unit grafts has enabled the hair surgeon to create very natural, feathered hairlines, which do not have the abrupt, pluggy look that was commonly seen in hair transplants of years past. In our clinic we transplant a combination of single and multiple follicular unit grafts to better create illusion of density.

How Many Procedures To Look Good

Depending on the degree of balding 1-2 procedures may be required. We do not rush to offer you a procedure. Considerations must be made regarding the number of grafts required, the area of potential alopecia, the safe donor supply, the textural characteristics of the patients hair, and the specific goals of the patient.

What To Expect

Hair transplant surgery today is remarkably well tolerated. Within 24 hours small crusts will form on each graft that are then shed in approximately 4-14 days. The grafted hairs will often start to grow by 10-16 weeks after the procedure and will continue to grow for most, if not all, of ones life.

What Anesthetic is Used In Hair Transplant?

Hair transplant procedures generally take from 6-8 hours and are performed using local or twilight anesthesia on an out-patient basis. Patients are often awake but feel relaxed as they are given a mild sedative. There is usually little or no pain during the surgical procedure. Nowadays no bandage is necessary on the scalp at the end of the procedure but a small head band will secure the donor to prevent swelling.

Should Medicine be taken afterward (Adjunct Therapy)

Donor hair is permanent but limited. Hair transplant only redistributes hair. It cannot change the progressive nature of AGA. The miniaturization of existing hair may offset the cosmetic results over years.
Hair transplants can be used to fill-in the front hairline and thicken the front half of the scalp, and medical treatments (Adjuvant Therapy) can be used to maintain existing hairs; in order to prolong the cosmetic results. A well trained hair transplant surgeon will work with their patients to design an individualized plan to fulfill their specific needs.

Dr. Orentreich mid-1950s appeared on the television program “World of Medicine.”

Dr Norman Orentreich (USA) was the first American physician to perform hair transplantation for Male pattern Baldness. He suggested a "donor dominance" theory in his 1952 paper, which was later published in 1959. This theoretical foundation made modern hair transplantation possible.

By the 1950s, men had been seeking — and failing to find — a remedy for hair loss since at least 1550 B.C., when doctors in ancient Egypt recommended anointing bald scalps with the fat of a Nubian ibex or a crushed black lizard boiled in oil.Then along came a young dermatologist named Norman Orentreich, who tried an experiment: transplanting hair from the back of the head to the scalp. And lo, the transplanted hair grew. Thanks in part to his discovery, a multibillion-dollar global hair transplant industry now exists to provide long-term relief for receding hairlines. His breakthrough established hair transplant as part of the American culture.

Principle 1: Two Kinds of Scalp Hair

Scientists have all agreed that the human scalp has 2 types of hairs: DHT sensitive and DHT insensitive. The DHT insensitive hair is not affected by the undesired DHT which induces hair miniaturization in Androgenetic Alopecia. They can lasts a lifetime and is labeled "Permanent Hair".

After years of practice we believe that there are actually 3 kinds of scalp hair. Hair in the front (hairline) has a different reponse to Finasteride when compared to hair at the crown.

Principle 2: Donor Dominance

This theory stated that the transplanted hair keeps the original nature of the donor site (color, curl, texture and growth rate) even after being transplanted. This donor dominance theory became the most fundamental theoretical base of modern hair transplantation. This explains why hair transplant is possible as there is no rejection of transplanted hair as hair are transferred from one part of the scalp (donor site) to another (recipient site) of the same person.

In the 2000s Dr Tommy Hwang (Korea) discovered that the recipient site can exert certain effects on the transplanted hair. For example scalp hair transplanted to the eyebrow will gradually slow down its growth. He later received the ISHRS Gold Follicle Award for his "Recipient Dominance Theory'

In Memory of Dr Norman Orentreich, the Father of Hair Transplant (1922 – 2019)

The first records of the demand for "additional hair" extends clear back when Julius Caesar ruled. However, in 1939, the first published methods for hair transplant (also called grafting) was achieved by a Japanese Dermatologist, Dr. Okuda. Unfortunately, much of the hair transplant history was not credited to him since World War II crumbled the Western Hemisphere.

The actual process of the remedy for a balding head surfaced in 1952 in New York City. Dr. Normal Orentreich submitted the first proposal for a hair transplant operation. His first few drafts about hair transplant were actually rejected by the medical community. However, during the latter months of 1952, he performed the first hair transplant for male baldness. This operation worked under the principle that transplanted hair will continue to grow normally and will even exhibit the same characteristics it had where it originally grew. Here we would examine how hair transplant evolutes over the last 75 years


J. Dieffenbach of Wurzburg, Germany had written thesis about concept of autotransplantation of hair, feather, and skin in animals and fowl. Success with the use of goose quills as trephines.


Okuda had written a paper in Japanese Journal of Dermatology on punch grafting of hair for alopecia on the scalp, eyebrow, moustache and pubic areas.


Dr Orentrich's Punch Graft
The world first hair transplant surgery for Androgenetic Alopecia was performed by Dr. Norman Orentreich in 1952. he relocated balding resistant hair follicles (10 4mm grafts) from the back and sides of the head to the balding scalp for MPB. His first paper appeared in NewYork Academy of Sciences in 1959. He established the first medical hair clinic in USA. Director of the Orentriech Foundation for the Advance of Science. This early procedure involved punching out a round piece of hair-bearing tissue 4-mm in diameter directly from the back of the scalp. Such graft contained about 20 hair and produced a rather pluggy appearance. This punch graft technique remained the standard for 20 years.


With this hair transplantation concept, physicians began to perform hair transplants for cosmetic improvement. And like most new developments, the first attempts were less than perfect. Doctors were successful in transplanting hair from the sides and back of the head to the top, but the results looked unnatural and obvious. These older and obsolete methods of hair transplantation practiced in the 1960's and 1970's nearly always resulted in a "clumped" or "bristle brush" appearance. The "Barbie Doll" appearance of hair transplant plugs (round grafts containing generally 15-25 or more hairs) is unfortunately nearly always quite conspicuous, and worse, permanent.

1967 Richard Shiell pioneered Hair Transplantation in Australia

Micrografting and minigrafting
These were introduced by Sam Ayres III using 1.5 to 2.0mm punch. He also described the term “follicular units”. He omitted pressure bandage in his patients.


Norwood Classification
1973 O’Tar Norwood introduced the classification of MPB, co-founder with Dow Stough of the International Society of Hair Restoration Surgery, and later founded the Hair Transplant Forum International (1990-1995).

Automatic Graft Extraction
Marcelo Gandelman pioneered the use of motorized punch transplantation. Basically automatic FUE started in the 70's.


Obviously these procedures required dramatic improvements. Over the course of years the technique of hair transplantation evolved. During the 1980s, minigrafts ( smaller clumps containing 5-8 hairs ) were an improvement, but only served to generate smaller "plugs". Indeed, many hair restoration procedures involve the repair and/or hairline camouflage of these "plugs" or "minigrafts". Even more unfortunately, some hair transplant doctors still utilize these larger grafts.

As techniques have improved, the grafts have become smaller and the number transplanted per session has increased. Today most hair transplant surgeons use grafts that have from one to eight hairs, with 200 to 800 grafts transplanted in each session. Although this is a major improvement over the larger grafts, this procedure still can produce a slightly unnatural look.

1981 The micrograft hair transplant procedure represented a bold achievement in the field of hair restoration. It was first used to create a subtler and more natural end result. Prior to the development of the micrograft procedure, hair transplant surgeons would extract large sections of hair from the donor area that would leave large scars and produce obvious signs that a transplant had been performed.

1982 Pierre Bouhanna developed the Photorichogram.

Strip Harvesting
In 1984 a strip of tissue was excised from the donor area and then dissected into smaller grafts containing about 6 hair mini graft. Later the size of the grafts was further reduced to contain just 1-2 hair micro-graft

Follicular Unit Transplant
1988 Robert Limmer carried out the first pure follicular unit transplant. This opened the new era in surgical hair restoration techniques. With this follicle-unit micrografting, many hundreds or thousands of tiny, living grafts containing only one, two, three or four hairs are inserted in closely spaced fashion over the entirety of the bald and thinning areas. These follicle-unit micrografts, which approximate the one to four hairs which naturally originate from each of your original follicles, result in a very natural, aesthetic appearance. Randomly-spaced single hair micrografts are used in the very front of the hairline to create an especially pleasing, feathered hairline.


Scalp Extension
1992 Patrick Frechey described Scalp Extension.

Mixed Grafting
Surgeons began to combine both mini- and micro-grafts in their procedures. The small micro-grafts were use to soften the frontal hairline, while the larger mini-grafts were placed in the center of the scalp to create a high density appearance. Mixed grafting slowly replaced the plug technique and became the new standard in the 1990’s. However the result is still not natural on close inspection.

Microscopic Graft Dissection
In 1994 Dr. Bobby Limmer (USA) first described the technique for isolating follicular units (FUs) using a microscope. This process enables the removal of redundant tissue. The grafts were kept as small as possible while preserving the integrity and all growth elements. Transplanting exclusively FUs produced far superior results.

Since 2000 Follicular Unit Transplant (FUT) has become the gold standard of surgical hair restoration.

Follicular Unit Extraction - FUE
In the mid-1990s, Dr Rassman (USA) set out to extract Follicular Units using a small punch. The same approach was described by Dr Inaba (Japan) in his 1996 textbook. The problem remained to be solved was the high transection rate. Rassman addressed that only 60% of all patients were good FUE candidates.


Trichophytic Closure
The main drawback of strip is a linear donor scar. The Trichophytic Closing Technique was introduced by Dr Marzola (Australia) and Dr Frechet (France) in 2005 to minimize the donor scar. This allows hair to grow through the scar as camouflage so that in most cases the scar is minimal if not invisible.

Automatic FUE
To speed up the extraction automatic devices were introduced. This included the Neograft, Dr Harris S.A.F.E. System, and Dr Cole C.I.T. System. All involved a motorized punch, sharp or dull.

Ultra-Refined Follicular Unit Transplant (UR-FUT)
Dr Jerry Wong of Canada pioneered dense packing and megasession, the hallmarks of Ultra-Refined FUT. From 2005 to 2010 the number of graft has increased from 3,000 (megasession) to over 5,000 (gigasession). In just one session a large area can be covered by a high density (of grafts (40-60 FUs/

Laser Hairline Design
Adopting the concept of Dr Shiao (Taiwan), Dr Bertram Ng (Hong Kong) invented the first hand-held laser in hairline placement. The device was later used by Physicians all over the world.


The Robotic system was first introduced in USA, when FUE harvesting was partially performed by a remotely controlled mechanical arm. Since 2012 the machine was sold to Physicians all over the world.

This technique was developed by Dr Bertram Ng in 2010 to increase graft survival by combining different FUT techniques. FUT-X differs from the Mega- or Giga-session approach in using the minimal number of grafts to achieve the best comestic result. This technique was later replaced by Mixed Graft Transplant.

Female Hairline Extension Technique
A new approach in hairline restoration for female was first described by Dr Bertram Ng in the 2013 ISHRS Annual Scientific Meetings. He emphasized that the new hairline is simply an extension of the flows of existing hair.