Watch the 3D Animation: Hair Transplants

Even though terms such as capillary transplant, hair transplant, capillary grafts, micro hair transplant and micro hair grafts are very often used, the word “transplant” is not included in the official Spanish language dictionary (Real Academia Española). For a better understanding of the “hair transplant” term, we need to expand our knowledge on the anatomy of the scalp.

Each hair in our head is born and grows inside what we call the root, or hair follicle in technical terms. If we observe the surface of the scalp under a follicular microscope, we can see that our hair grows naturally in small groups known as “Follicular Units”.

These groups are composed of one, two, three, four, or sometimes (on rare occasions) five hairs, which share their vital survival structures in a critically narrow and tight atmosphere.

In this illustration we can observe two groups of hairs belonging to different follicular units. Each hair belongs to a follicle and each follicle to a follicular unit, so “1,000 hairs” is not equivalent to “1,000 follicular units”, for each follicular unit may contain more than one hair.

According to the International Society of Hair Restoration Surgery (ISHRS) our average hair production rate is 2.4 hairs per follicular unit, so it is safe to say that there are approximately 2,400 hairs within 1,000 follicular units.

Historical Origins

There are two main tendencies that have evolved as parallels throughout time:

	Follicular Unit Transplantation or Micro Hair Transplant.
	Flap Technique

The evolution of hair transplantation

In 1939, the Japanese dermatologist Dr. Shoji Okuda published his method for transplanting hair in the scalp, eyebrows and mustache, in a Japanese dermatology magazine. Dr. Okuda explained his technique for removing hair follicles from the back side of the head, to be subsequently implanted in the bald areas of the head. In those times, this technique was exclusively used in medical cases such as patients with scars and burns where hair no longer grew, and not in cases of genetic baldness. Unfortunately, the second world war hindered communications between nations, and the works of Dr. Okuda took a long time to reach western physicians and specialists.

In the late 1950’s, Dr. Norman Orentriech resumed Dr. Okuda’s technique and started experimenting with hair transplantation from the back and sides of the head, into the areas affected with baldness. He then scientifically demonstrated the dominant donor area principle.

Dominant Donor

Due to Dr. Orentriech’s research, this is the term used to determine the back and sides of the head. The condition of the hair in this area is a great resistance to baldness, which allows it to be transplanted into other areas, and it will just as well reside in neighboring areas of the head, as it will in its original location.
Consequently, all hair transplantation methods and techniques that have emerged to this day, have their foundation in Dr. Orentriech’s Dominant Donor Area principle.

Hair Transplantation Techniques

Ever since the 1960’s, the following hair transplantation techniques have been developed (the evolution of these techniques is based on achieving a more natural result):

	Punch Grafts
	Mini y Micro Grafts
	Follicular Unit Transplant
	Follicular Micro Selection
	Follicular Unit Extraction

Punch Grafts

In the 60’s and 70’s, capillary transplantation was still being performed with grafts that were too large (20 to 30 hairs) and the distance between them was also too wide. These were tufts of hair that were separated among each other like small islands over the scalp.

The instrument used to perform this technique is the circular shaped scalpel named “punch scalpel” (thus the name of the technique).

The results of this technique called “Punch Grafts” did not look very natural, and the transplant procedure was evident at plain sight.   The final outcome was something very similar to a doll’s hair or a comb’s strand pattern. Even so, the technique became very popular in its time

Mini and Micro Grafts

In the mid 80’s hair transplant technique took a giant leap when punch grafts were replaced with the new micro and mini grafts. The punch scalpel was abandoned for extraction as well as implantation purposes.

The “Strip Technique” was implemented, which consisted in surgically removing a strip of scalp from the back part of the head, to be subsequently divided into mini/micro grafts

These grafts were transplanted into the bald areas using tools that were much smaller and precise than those used in punch grafting.   Mini Grafts (4-8 hairs) were used where density was an important factor (crown part of the head)

While Micro Grafts (1-4 hairs) were used in areas which required a more natural appearance (frontal areas)   This new mini-micro graft technique was more complex because it required the extraction and implantation of thousands of grafts instead of the usual 20 to 50 that were common in the Punch technique. Nevertheless, the result of this technique has a completely natural appearance.

Follicular Unit Transplantation

This technique by doctors Rassman and Bernstein has revolutionized the hair transplant practice since the 1990’s.

It was Dr. Robert Bernstein’s idea to stop using punch as well as mini and micro grafts, to exclusively start transplanting individual follicular units. This method was described by doctors Bernstein and Rassman in a publication entitled “Follicular Transplantation”.   The most advanced hair transplant techniques have been developed parting from this model, because the results of transplanting individual follicular units, in the hands of a good surgeon, can be as natural looking as original hair. The results are virtually undetectable, it is very hard to tell apart the transplant procedure from naturally grown hair.

Modern Follicular Unit Transplantation Techniques

In order to explain this technique, we must observe our scalp with a microscope so we can see how our hair grows individually into small groups called follicular units (hence the name of the technique).

Each hair has its own follicle or root, and each follicle belongs to a follicular unit that can be composed of one, two, three, four or in very rare cases five hairs.

This technique basically consists of extracting follicular units from the donor area and placing them in the receiving area where balding has occurred.

In this type of surgery, the technique used to implant the follicular units will always be the same, however, the extraction techniques will vary according to the patients possibilities and the criteria of the surgeon.

To this day, the 3 best techniques for extracting follicular units are:

	Trichophytic Technique Transplant
	Individual Follicular Unit extraction (FUE)
	Mixed Technique (Trichophytic + FUE)