The History & Future of Hair Restoration
Hair Patch Grafts of the 1800’s
The earliest successful hair transplants were first described in 1822 in Germany. These procedures involved grafting a patch of tissue with hair to another area that did not have hair. Later in the 19th century these procedures found a use in the treatment of burns and other traumas that led to patches of hair loss on the scalp. The 19th century did use hair transplantation to treat male or female pattern hair loss or baldness.
Origin of Modern Hair Restoration Techniques in the 1930’s
Modern hair transplantation procedures can be dated back to Japan in the late 1930s when Dr Okuda began using a “punch technique” to remove small hair bearing skin grafts and transplant them into areas of hair loss. The goal of these procedures were similar to those prior, which was to improve the appearance of burns or other injuries.
The Plug procedure of the 1950’s through 1970’s
After the war, Dr. Okuda’s procedure made its way to the United States by way of New York City where Dr. Orentreich performed the first hair transplant in the Country in 1952. Dr. Orentreich was the first to leverage this procedure to specifically treat hormonally mediated androgenetic alopecia aka male pattern baldness. These early hair transplants were often unsightly, with large patches of around 30 hairs being transplanted at once. This led to a “pluggy” or “doll’s hair” appearance that was far from natural. Despite the unnatural results, the procedure gained massive popularity and spread around the world. The plug procedure maintained dominance for nearly 25 years and became synonymous with hair transplantation.
Strip Harvesting with Mini-grafts and Micro-grafts of the 1980’s
In 1984 “mini-grafting” replaced the Plug procedure due to its much more natural appearance. Mini-grafting, as the name implies, used smaller grafts. Instead of punching out grafts, as with the Plug procedure, mini-grafts were isolated out of the body from a strip of skin taken from the back of the head. The problem with mini-grafts was that they still didn’t look perfectly natural and had the look of mini plugs. This procedure was improved upon throughout the 1980s with the advent of “micro-grafts” which were 1-2 haired grafts used in between mini-grafts and throughout the hairline. While this improved results more, it did not fully reproduce the natural anatomy. In addition, these procedures would leave a linear scar in the back of the head; however at the time this was considered more acceptable than the large punch scars from the prior Plug days.
Follicular Unit Transplant aka FUT aka The Strip Procedure of the 1990’s
Ten years after the first strip procedures with mini and micro-grafting, the FUT, or Strip, procedure was described in the early 1990’s by Dr. Bobby Limmer in Texas. This procedure, like its predecessor from the 1980’s began with harvesting a strip of tissue from the donor area of hair at the back of the head. The advancement in FUT over the mini/micro-grafts was that microscopic dissection of the strip tissue was performed to isolate individual follicular units. Follicular units are the basic anatomical building blocks of our hair. On average there are 1-4 hairs per follicle unit (ethnic variation is common). Each follicular unit shares a hair pore, a muscle (to make the hairs stand up to trap heat), and a sweat gland. This was the first procedure in the history of hair restoration to finally be able to produce fully natural results and it was no surprise that it became the mainstay treatment for the next 23 years.
Follicular Unit Extraction aka FUE of the 2000’s
With FUT a mainstay, the next advancement was to not only transplant follicular units, but to also harvest follicular units directly from the scalp without the need for strip scar harvesting. The Follicular Unit Extraction aka FUE procedure was first described by Dr. Ray Woods in Australia in 1989. Without any specialized FUE instruments, this procedure was very slow leading to poor adoption for nearly a decade. In the early 2000’s many new instruments were being developed to aid in the FUE procedure. These instruments began as small dermatologic biopsy punches and evolved into motorized rotary instruments with both sharp and dull dissection capabilities. The main advantage of FUE over FUT was no scalpel and sutures. This meant much less postoperative pain, no linear scarring in donor area, and no risk of permanent nerve damage to the back of the head that could be a complication with the FUT procedure.
Advanced FUE of the 2010’s
With the Follicular Unit Extraction (FUE) procedure gaining popularity throughout the early 2000’s, the Follicular Unit Transplant (FUT) procedure started to see a decline. 2015 was the year FUE procedures caught up to FUT, and since then, FUE procedures have dominated. As of 2022, around ¾ of all transplants are FUE and ¼ FUT vs 11 years prior in 2011 when around ¾ of all transplants were FUT and ¼ were FUE.
This marked shift from FUT to FUE is a result of much improved FUE tools and techniques which made the procedure much quicker and more precise. FUE was always much less invasive than FUT, but its initial slow speed made it less popular. Furthermore, the 2010’s saw tight fades in vogue, which made hiding FUT scars impossible. Many hair restoration centers started performing only FUE, while some still held onto the FUT procedure. While FUT continues to decline significantly year over year, it still exists as a lower cost option for those who FUE is out of their budget. Even though FUE is currently priced around where FUT was years ago, the cost of FUT has been declining as FUE has become the primary procedure of choice.
The advanced forms of FUE which evolved in the 2010’s were based on the mechanical drill style motorized devices developed the decade prior. These newer generations of devices took two very different approaches: Automated FUE and Robotic FUE.
“Automated FUE” is a terrible misnomer as there is nothing automated about the procedure. It likely was a marketing term used to promote and distinguish this subcategory of FUE. Automated FUE devices such as Neograft® which was first FDA cleared in 2008, then Smartgraft® in 2014 use a long suction tube connecting the harvesting handpiece into a graft storage device. The goal of these procedures was to speed up the process by eliminating the need to gently remove the grafts by using suction instead. The problem with these procedures was that a new variable was introduced which is the graft trauma caused by delicate tissue being vacuumed up a tube. In addition, if saline was not routinely aspirated by the handpiece along with regular transfer of grafts to a chilled environment, the grafts would dry out and die. Smartgraft attempted to resolve this issue with a lubricated and chilled collecting chamber, but the graft vacuum journey through the tubing remained. With the massive increased price tag for doctors to acquire Automated FUE devices along with these new risks, the majority of handheld aka manual FUE remained “non-automated”. Neograft® did have a large adoption rate for a number of years as the company would sell the device to doctors with the promise of supplying them with “Neografters”, unlicensed employees of Neograft® who would come and perform the procedures for a fee to the Neograft® company so the doctors would no need to learn hair restoration themselves. This unethical practice led to a number of lawsuits, as well as Neograft® being banned by the International Society of Hair Restoration Surgery (ISHRS), and the dissolution of the Neografter program. While unlicensed “Neografters” no longer exist, it was this model that really made the device gain popularity.
The other form of advanced FUE that gained popularity in the 2010’s was Robotic FUE. Robotic FUE was first FDA cleared in 2008 by the company Restoration Robotics® with the ARTAS® Hair Restoration Robot. The ARTAS® Robot remains the only FDA cleared Robotic FUE. Upon initial release, the ARTAS® robot was quite slow, and the lack of diversity of types and sizes of punches left hair restoration surgeons unimpressed. In addition, the cost to acquire an ARTAS® Robot was significantly higher than that of an Automated FUE device like Neograft®, not to mention the ARTAS® Robotic FUE device would charge a usage fee, which would often equate to thousands of additional dollars per procedure in such royalties. No hair restoration device other than the ARTAS charges such a usage fee model in addition to the cost to acquire the device. This usage fee however is not unique in the cosmetic medical device world. Such popular devices like CoolSculpting® use the same purchase plus usage fee model. Highly advanced devices such as ARTAS® and CoolSculpting® would never recapture their massive R&D exposure, let alone gain profits, with only the sale of their specialized devices to such a specific and limited market. Due to the slow speed of the ARTAS® Robot, along with the very high price tag and the usage fee, it was very poorly adopted initially.
Over the years, the ARTAS® Robot gained a number of major software and hardware updates which made it much faster, more precise. In addition a diversity of punch types was made available. The ARTAS® Robot began to rival, if not outperform, the best hair restoration surgeons when it came to harvesting follicles. The ARTAS® Robot also has some unique harvesting features that do not exist when manually harvesting, namely: the ability to leverage computer vision with 60x zoom vs the 2.5x with surgical loupes, the ability to measure in real time the distance between every hair and ensure a blockout radius of a doctor designated value is respected around each harvested hair to prevent localized overharvesting which can mimic linear scarring, the ability to have a live read of donor density in follicular units per square centimeter – which aids the doctor to decide how many hairs to safely remove to leave enough density behind. In addition, being an FDA cleared harvesting device, the doctor no longer needed to manually harvest all the grafts on top of manually harvesting all of the grafts. Performing thousands of manual recipient sites plus manually harvesting thousands of grafts on a regular basis inevitably leads to some degree of fatigue and human error. The advantage of robots is they never fatigue with repetitive tasks.
FUE in the 2020s and Beyond
There is no doubt that the trend of increasing FUE and decreasing FUT will continue to the point of FUT becoming obsolete. This statement may go against some popular belief, however, it was popular belief in the early 1990s that the FUT procedure would never catch on, and it was popular belief in the early 2000’s that FUE procedure would never catch on.
Upon FUT’s exit, the landscape will shift from FUE vs FUT to Robotic FUE vs Manual FUE. Currently there are more Manual FUE procedures (which includes the manual “automated” procedures like Neograft® and Smartgraft®, as well as the manual “non-automated” procedures like the traditional FUE devices) performed over Robotic FUE procedures. The reasons for this are mainly due to the cost to acquire an ARTAS® Robot, the usage fee to operate the ARTAS® Robot, and coming in at a distant third, the need to acquire new skill sets and workflows to incorporate the ARTAS® Robot into a clinical practice.
In time, it is likely that additional robotic companies venture into the hair restoration space and produce a competitive device to the ARTAS® Robot, which would drive down costs due to competition and thereby increase acquisition demand by doctors. In addition, as Venus Concepts®, the current owner of the ARTAS® Robot, finds it cost prohibitive to sell any more units globally, they will shift towards utilization by decreasing their usage fees. This will also increase doctor adoption, and thereby, consumer demand.
Robotic FUE is the future of FUE. As expertise stems from experience, human surgeons have limited experience when compared to robotic AI. The AI the operates the autonomous movements in Robotic FUE has the experience of every robotic restoration procedure performed in the entire world. While demographic information is privacy protected, the surgical log files stripped of any unique patient information for every ARTAS® procedure is transmitted to the company’s headquarters for dataset analysis and algorithmic improvement. This “collective consciousness” is a main reason why AI can learn much faster than humans. Already Robotic FUE offers superior harvesting consistency over manual FUE, and in time that degree of superiority will only improve drastically.
Future of Hair Restoration
As innovation never ceases, FUE will certainly not be the pinnacle of hair restoration surgery. Current technology allows for very accurate reconstruction of lost hair with natural anatomy, but it does not solve for the supply constraints of donor graft availability. The holy grail of hair restoration has been considered cloning, which is still far from being a reality. The most likely avenue for the development of cloning will come in the form of tissue engineering. In such a case, a 3D printer could use patient derived stem cells and layer cell by cell on a bioscaffold matrix to print unlimited viable grafts. Each graft will need to be implanted either manually or robotically, however no harvesting will be required. This will allow for an unlimited number of grafts to be used to restore hair to its entirety. Upon it’s development, it will likely be quite expensive and for that reason it will not replace FUE for some time. Non-FUE candidates (due to limited donor supply), and those unconcerned with cost will be the initial consumers of this new technology. Eventually, costs will come down and it will fully replace FUE. There is plenty of very interesting research in this space, and in time it will become a reality.
Additional Considerations Affecting Hair Restoration Outcomes
It is very much worth discussing additional variables which may affect hair restoration outcomes. The discussion above on the history of hair restoration focuses on the types of procedures, however it does not get into why some procedures of the same type are much more successful than others. Hair restoration is not a standard commodity and for this reason there is great variability in procedures, even for procedures of the same type and graft count. A few of the major variables are listed below:
- By far the most important variable is the plan. A bad plan with perfect growth will be a major failure. A good plan will take into consideration the patient’s donor availability, the patient’s goals, and create an appropriate design that will align with the donor supply and create a natural look that the patient can gracefully age into.
- Managing expectations is crucial. Based on the amount of hair loss, it may take a series of procedures to create the desired outcome. This needs to be discussed with the patient in advance.
- Graft out of body time is a known factor affecting graft survivability. Placing the grafts back into the scalp quicker will mean the grafts will experience less anoxic (lack of oxygen) stress, and have a greater chance of growth. For this reason, Barber Surgeons Guild doctors always make the recipient sites prior to graft harvesting. This way the grafts can be placed without the need to wait on make sites after harvesting. This may sound obvious, but many places will still choose to harvest first; perhaps due to this being the standard order from the days of FUT.
- Graft holding solutions and temperature affect graft viability as well. When grafts are out of the body, they need to be kept in an isotonic (pH balanced) environment that is chilled. Failure to preserve grafts will result in decreased growth.
- The process of recipient site making involves a deep understanding of hair growth patterns, and angles of exit of the hair. Some tell-tale signs of bad restoration include too large of angles of exit from the hairline, too straight of a hairline that mimics a toupee, and placement of larger multi-haired haired grafts in the hairline instead of all single haired grafts.
- Style considerations are paramount. The goal of restoration is not to graft hair, but to restore hairstyle! For this reason, prior to graft planning, it is important to think about how the hair will be styled after the grafts grow in. At Barber Surgeons Guild we take style considerations very seriously and often loop in our Master Barbers to assist in planning, as well as help style the new hair growth to maximize the procedure’s potential.
- It’s not all about the number of grafts. As you can see above, there are many other factors at play. In addition, based on the hair type, a different number of grafts will be needed to achieve the desired density in one person vs another. An individual with very fine hair will often need more grafts than one with thick hair. An individual with very straight hair will often need more grafts than one with curly hair to gain more volume. Caucasian hair tends to have follicular groupings of 1-4 hairs, whereas Asian hair tends to have follicular groupings of 1-2 hairs. Clearly this affects the total number of grafts needed. Hair color also plays a role. Greater the contrast difference between hair and scalp will require more grafts ie black hair and light skin or gray hair and dark skin.