Natural-looking transplantation results - a combination of different factors

The objective of any hair transplant is to achieve a natural-looking result. This is not just a question of knowing and applying an improved technique - there are a number of different factors needing to be taken into account.


These factors have a decisive influence on the transplantation options available and their chances of success, as well as on the transplantation technique to be used:

History of hair transplants

History of hair transplantation: from the first hair extraction to state-of-the-art standards

According to reports, the first attempts to transplant human and animal hair were made in the 18th/19th century, though it is difficult to find any evidence of results. The first own-hair transplants were performed in the 1940s in Japan on people suffering from burn wounds incurred during the Second World War. However no documentation of these operations exists. Smaller strips of the scalp were gouged out using the punch technique and transplanted to other places of the body, for example the eyebrows, the scalp or the moustache. The transplanted hairs rooted successfully and carried on growing.
Also in Japan, a first hair transplant took place in 1943 using small grafts. These micro-grafts contained 1 - 3 hairs and were only implanted in female patients. Due to the Second World War, this hair transplant was for a long period only known in Japan. In the Western world, the first own-hair transplantation was performed in the late 1960's. A New York publication describes the extraction of hair follicles from the tonsure and their successful transplantation, with the transplanted hair rooting and growing well and with hardly any hair loss.

Successful only to a certain extent - standard punch grafting

The technique used up till the early 1980s was known as "standard punch grafting". This involved a round patch of hair being removed from the scalp using a cylinder. The graft often contained 20 - 30 hairs. Individual grafts were about 4 mm in diameter and only 50 - 100 grafts could be transplanted in one treatment session.

Example of patient with ‘punch grafts’ from a previous surgery (performed ex domo)

Due to their size and the necessity of providing each graft with its own adequate blood supply, enough room had to be left between the implanted grafts. This led to the implant area looking like a doll's head with an unnatural hairline. A further problem involved the excessive damage caused to the donor area, with the back of the head, the main donor area, often looking like a scarred chess-board.

Example of patient with severe scarring from previous surgeries (performed ex domo)

To compensate as much as possible for the unnatural appearance, the gaps between the individual grafts were then filled in during further treatment sessions. These time-consuming and repeated treatment sessions did not always fulfil expectations, and patients were often disappointed with the results. For many patients there was a further undesirable effect - the further age-related hair loss / baldness progressed, the more visible the transplanted "hair islands" became, giving the head a completely unnatural look. Hair restoration surgeons therefore started taking natural hair loss into account when planning hair transplantation. The standard-punch-grafting method is now totally outdated and not used any more. Even so, many people still suffer from the unnatural appearance and the scars caused by this method, erroneously thinking that this method remains in common use.

Minigrafts & micrografts - a new combined method gains the upper hand

Example of patient with ‘micrografts’ from a previous surgery (performed ex domo)

In the late 1980's and early 1990's, so-called mini- and micro-grafts were developed. In contrast to the previously used method, this involved taking from the scalp a contiguous strip. All that was left after removal was a very narrow, linear scar instead of many relatively large scars. This strip of skin was then divided up into different-sized implants, allowing the hair surgeon to form a more natural hairline through combining different sizes of grafts. Smaller grafts lead to smaller wounds, meaning that more transplantation could take place in a single session, and with implants closer together. Mini-grafts contained 4 - 12 hair follicles, whilst micro-grafts only had 1 - 4 follicles. However, in the course of preparing the grafts for transplantation, many follicles were unnecessarily damaged, making them unusable. The situation changed in the late 1990's, with high-resolution microscopes being increasingly found in hair restoration surgeries. The high resolution and accuracy of these microscopes led to the discovery of the fact that hairs do not grow individually but in bunches or units of 1 - 4 follicles. These bunches are known as follicular units, and new transplantation methods are based on them, as they allow a natural-looking result to be achieved.

FUE – FUT: setting new standards in hair surgery

Follicular Unit Transplantation, or FUT for short, became the new standard in the field of hair transplantation in the early and mid-1990s. Using the FUT method, a narrow strip of skin is taken from the back of a patient's head. The individual hairs and hair bundles are then extracted from this strip and transplanted to previously determined places on the scalp. This means that a great number of grafts can be transplanted during any one session, with a natural and aesthetic hair growth pattern being achieved.

In 2003, the first FUE surgery was presented. After initial problems had been overcome, FUE (Follicular Unit Extraction) soon became established as an extraction method on a par with FUT. Both FUE and FUT provide the opportunity of extracting individual FUs and transplanting these to the target areas in an aesthetic and harmonious manner. In a FUT transplantation, anything up to 5000 - 6000 FUs can be transplanted. The corresponding figure for the FUE method is about 3500 FUs. Which extraction method is better depends on each patient and needs to be weighed up once an examination has been performed.

For the good of the patient: continual development and permanent improvement

Since the first hair transplants took place, hair extraction and transplantation methods have been perfected. Sound knowledge about natural hairlines and hair patterns has contributed greatly to transplantation results looking increasingly natural. For properly selected patients, all that is now often needed is a longer treatment session, as grafts can now - in contrast to the early days of hair transplantation - be implanted in greater density. A further advantage is the ability to perform coronal and sagittal incisions at the right time and at the right place, thereby generally causing less scarring. Improved survival chances of extracted FUs and obviously the experience gained over the last 15 years with these new techniques have led to the development of extremely advantageous know-how about the fundamental principles governing naturalness and hair density. Such knowledge positively influences decision-making processes and the results of any hair transplant - thereby boosting patient satisfaction and well-being.

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