Hair Transplant Basics And Its History

about-nhiThe Dermatologist, Dr. Norman Orentreich, introduced hair transplantation in the United States in the late 1950’s. Although the basic concept behind hair transplantation is rather simple, self-proclaimed “experts” have shrouded the field in mystery and these myths have been perpetuated over the years.

The hair growing on the sides and lower part of the back of the head is permanent hair in most people. It persists even in the face of the most extreme degree of Male Pattern Baldness. This permanent hair can be redistributed to cover the areas of the head where the hair has thinned or that have become bald. All hair restoration procedures work through the redistribution of this permanent hair. Women often do not have such a permanent zone of hair in the back and around the sides of the head.

To learn more about the basics of hair transplantation, including what you should know before, during, and after any procedure, please view the following topics:

An Overview of Hair Transplantation: A Very Brief History of Hair Transplantation

The modern technique of hair transplantation was first described by a Japanese dermatologist named Okuda in 1939. Dr. Okuda, working on severely burned patients, transplanted round grafts of skin containing hair follicles from the permanent hair-bearing areas into slightly smaller round openings in scarred areas of scalp. The grafts continued to produce hair in their new location. Dr. Okuda’s findings were published in a Japanese medical journal, but he died in World War II and his discovery was lost. Dr. Okuda limited his treatment to burn victims; he may not have realized the possibilities of using this technique to treat baldness.

Another Japanese dermatologist, Tamura, used very small 1- to 2-hair grafts to restore hair in the female pubic region. His techniques were, in many ways, similar to the techniques used today. Unfortunately, because of W.W.II, the articles describing their techniques were not known to the Western World unit many years after Dr. Orentreich had founded the field of Hair Transplantation in the United States.

Japanese Journal of Dermatology
from Stough: Hair Replacement

The principles and techniques of modern hair transplantation were rediscovered by Dr. Norman Orentreich in New York City in the early 1950’s. He published his work in 1959 in the Annals of the New York Academy of Science. Interestingly, his original paper was rejected three times by other medical journals as the reviewing physicians did not believe that the procedure could work. Unlike those performing hair transplantation before him, Dr. Orentreich was the first to use this technique to treat male patterned baldness.

Dr. Oreintreich’s discovery was that hair maintained the characteristics of the area it came from rather than the area to where it was transplanted. This means that hair that was transplanted from the permanent zone in the back of the scalp into the balding area in the front of the scalp would continue to grow as if it had remained in the permanent zone. He coined the term “Donor Dominance” to explain this basic principle of hair transplantation, that grafts continue to show the characteristics of the donor site at their new location. This principle of donor dominance is due to the fact that the pathogenesis of hair loss is inherent to each individual hair follicle. This is the basic principle behind all hair transplantation.

Standard Graft Compared to Pencil Eraser

After experimenting with a number of different size grafts, Dr. Orentreich chose to use 4mm punches (which are about the size of pencil erasers) as his “workhorse”. He chose this size because larger sizes often didn’t grow hair in the center (from oxygen not reaching the core of the graft) and smaller grafts didn’t seem to contain enough hair. At the time, only 20-30 grafts were transplanted in any one session.

Over the next twenty years, the punch grafts became smaller and the numbers used per session slightly larger. The smaller punches look better than the larger ones, but the problem was that the small punches caused a lot of damage to the hair as they were harvested from the donor area, and the smaller the punch the greater the problem.

The problem was partially solved by removing the donor tissue in thin strips using a multi-bladed knife, but this had its own problems with cutting hair follicles (transection) and causing damage. The era of mini-micrografting of the late 80’s and early 90’s evolved from this multiple-strip method where the thin strips were subsequently cut into different size grafts based upon the approximate number of hairs the doctors wanted them to contain. A more accurate term for the procedure is mini-micrografts “cut to size”, since the doctor cut the grafts to the size he wanted rather than with respect to the way they grew.

Hair Transplantation Today

In 1993, Dr. Rassman introduced the Densitometer, an instrument that could directly measure hair density. He stressed the importance of accurately quantifying donor density and assessing hair supply in the surgical planning. Densitometry made hair transplantation truly “scientific”.


In 1994, Limmer published a paper describing a technique he had been using since the late 1980’s, in which he harvested the donor area in a single ellipse (long oval) and used a microscope to generate small micrografts while avoiding transection of hair follicles. At the International Hair Restoration meeting that year in Toronto, Dr. Rassman presented 22 live patents that popularized the Megasession (a technique using large numbers of small grafts) that was first described by Uebel in Brazil.

In the 1995 publication “Follicular Transplantation”, Bernstein and Rassman proposed that the ideal hair restoration surgery should consist of performing the entire transplant with naturally occurring individual follicular units and that these units should be used in large numbers. They detailed the advantages of this procedure and introduced the term “follicular unit” to modern hair transplantation. In 1998, the name of the procedure was changed to Follicular Unit Transplantation.

NHI Staff dissecting follicular units under the stereo-microscope.
Today, the majority of physicians use mini-micrografting techniques which, compared to Follicular Unit Transplantation, are faster and easier to perform. Those physicians who practice Follicular Unit Transplantation feel that this procedure offers the patient so many advantages in naturalness, undectability, and preservation of donor supply, that it is well worth the additional effort. The majority of this Web Site is devoted to understanding Follicular Unit Transplantation.

Besides Mini-micrografting and Follicular Unit Transplantation, some doctors still use small punches or slivers of tissue placed into long slits (slit grafting). The use of scalp reductions, scalp lifts and flaps, as well as laser hair transplantation, has fallen from popularity in recent years (with good reason), but patients can still find doctors using all of these techniques.

The newest method, NHI’s FUE procedure (Follicular Unit Extraction) enables the surgeon to literally extract individual follicular units, one by one, from the donor area without a linear incision.

These different procedures are described on this web site and can be found by clicking on Follicular Unit Transplantation, Follicular Unit Extraction, and Drugs & Other Treatments. Additional information on these subjects can also be found in Chapter 8 of The Patient’s Guide to Hair Restoration.

Understanding the Procedure

My Hair Transplant Experience and Yours

by William Rassman, MD (both a patient and doctor)

Dr. Rassman’s Hair Transplant: My hair transplant experience was slightly different than yours will be because I have been involved in doing them for years. My first hair transplant was one year after the third of three scalp reduction procedures that were supposed to fix the bald spot in my crown. The scalp reduction surgeries required more anesthesia than the hair transplant and were much more uncomfortable afterwards, so they are not really comparable procedures. These procedures are considered malpractice today in most situations.

The hair transplant was performed under local anesthesia. I washed my hair the night before with a special soap (Hibiclens) and repeated the wash in the morning with the same soap. I then had an English muffin for breakfast with a full glass of OJ, went to work that morning ate a good lunch and then had my transplant immediately after lunch. The doctor gave me some pills that were a mild relaxant. As I am very sensitive to medications, I started to slur my speech within 10 minutes of taking the pills.

I was moved into a very comfortable reclining chair. A narrow area of my scalp was shaved in the back and then bandages were placed around my head that made me look like a tennis star. My surroundings were warm and friendly. I remember the doctor telling me to expect a needle stick in the back of my head and that it might hurt, but it felt more like a mosquito bite than a needle. When I told him that, everyone started to laugh, so I started laughing as well.

Somehow, I believe that my staff was enjoying the experience of watching their boss get the needle, hoping that they would get some ammunition to tease me with. The jokes and teasing by my staff seemed to continue non-stop and I found every comment funnier than the comment before. My doctor asked me to stop talking so much and warned me that he could not do the surgery with my head bobbing with each word my mouth uttered, so I tried to calm myself down and stop laughing. After that I watched some TV and then seemed to have fallen asleep. The next thing that I can remember was my surgeon asking me if I wanted a dressing on my head. I asked him when he was going to start the surgery and the entire staff told me (with great laughter) that the surgery was over. I had apparently slept through the entire operation. I did not remember a thing.

How do I tell you about an event that I slept through? Well maybe I can tell you what happened at 4 P.M. when I went home. I took a nap and slept till about 9 P.M. It was New Year’s Eve and I had been invited to some parties, so having felt fine, I went off to the first that lasted well past midnight. The second, lasted until 2 and then I went to a third. At each, I showed off my hair transplants and to everyone’s surprise, it was barely noticeable, even when the sun came up.

In conclusion, unlike New Year’s, the hair transplant was a non-event, something that many of our patients have echoed over the years.

Your Procedure

When you arrive for your hair transplant, the NHI staff will begin by going over the activities for the surgery. Your NHI physician will review the goals that have been established and will answer any last minute question that you might have. The doctor will take the time to be sure that there are no outstanding issues, areas of confusion or concerns. The surgical consent forms that had been sent to you is reviewed and signed followed by the taking pre-surgical photographs. Mild medication is given to relax you and to make you more comfortable. We also give routine antibiotics during the procedure, but not afterwards.

Length of the Procedure

Your Follicular Unit Transplant may require many hours of work by a team of professionals. Some of the longest procedures (between 2000-2500+ grafts) may take hours of surgery and during that time, many highly trained technicians and nurses will participate in the process. The work must be organized efficiently so that the total length of the procedure for the patient will be minimized. On average, a procedure of 1500 grafts would last about 6 hours.

The Surgical Experience

The procedure may be long, but for the patient the time goes by quickly. You are lightly sedated so that you can sleep if you desire. Most patients choose to watch TV or movies for at least part of the time. We try to make your experience enjoyable so that the actual time the surgery takes is transparent. Some patients may choose to be fully awake the entire procedure.

Usually the patient sleeps for a few hours, watches a movie or two, chats with the doctor, nurses, and staff doing the work, or listens to music in a “dream-like” somewhat euphoric state. A relaxed and informal atmosphere is encouraged so that the day stands out as one of the better, more pleasurable experiences ever encountered. The patient takes a series of breaks, to the bathroom, to eat lunch, an ice cream sundae, or to just stretch and move around. Not infrequently, patients tell us that the experience of being the center focus of the day’s activities is wonderful, and they further report that watching all of those people working on them was like watching an orchestra playing beautiful music, while having people catering to their every need!

Local Anesthesia

After preparatory medication is given orally, the actual anesthesia begins. We use a combination of Lidocaine (Xylocaine) which you have probably been given by your dentist, and a longer acting local anesthetic called Marcaine. Injections around the perimeter of the scalp (called a ring block) will make your entire scalp numb, and although this is uncomfortable, a little hand-holding will get you through it just fine. With this technique, there is no need to use anesthesia directly in the area that is being transplanted. Once anesthetization is complete, there is generally no pain or discomfort during the remainder of the procedure. If you do require more, it will be given before the first wears off.

The Surgical Team

The procedures can be long, and during the initial period when the donor hair is removed, the surgical team must work without stopping. NHI boasts what we consider to be the world’s most highly skilled surgical team performing Follicular Unit Transplantation. The team must prepare the grafts according to the surgeon’s exacting specifications. The preparation of 2,000 or more grafts and placing them into the recipient area may take a team hours of intensive, concentrated work. Care must be taken to keep the surgical team free of stress. Just as the patient needs a break, so do team members. At NHI we focus on the needs of our staff as well as the patient to ensure that the best-trained staff in the world is always operating at peak performance.

Donor Scalp

After a strip of donor scalp is removed, it is temporarily placed into a container with chilled Lactated Ringer’s, a solution that closely mimics the body’s own natural fluids. The area from where the donor strip is removed is sutured closed. This usually leaves a fine scar that heals in a week or two with the sutures either self-dissolving, or being removed in that time frame. Ideally, the scar may heal well enough that it is almost undetectable even when the hair is combed back by a barber or hairdresser. After the tissue has been harvested, the individual follicular units (each containing from 1 to 4 hairs) are meticulously dissected out in their naturally occurring groups under strict stereo-microscopic control. The grafts are trimmed of extraneous fatty tissue and the bald intervening skin between the groups is discarded.

The isolation of individual, naturally occurring follicular units, that were obtained from the donor area as a single strip, and then carefully dissected under microscopic control, is an essential part of Follicular Unit Transplantation. If this step is not done correctly the follicles can be injured and growth impaired. It is important that these steps be carried out only by a highly experienced surgical team.

Length of Time the Grafts Are Away From Their Blood Supply

A number of hours may pass between the time the donor grafts are removed from the back of the scalp to the time they are placed into the recipient area. Care must be taken to preserve the viability of the grafts during this process. The procedure starts with the removal of a strip of scalp from the donor area. Once the strip is removed, it is immediately immersed into a cold bath of Lactated Ringer’s saline to lower its temperature. Once the individual follicular unit grafts are prepared, they are cooled to 38-40C and kept at this temperature while awaiting placement. The solution, in our hands, is an organ preservation solution used in many organ transplants as it has the best track record for preserving the hair grafts. I felt if it is good enough for your lungs, heart or kidneys, it is good enough for your hair. The solution is expensive, so most hair transplant doctors don’t use it to save a few hundred dollars.


Many people have the impression that hair transplantation is a “bloody procedure.” In our hands it is not. At NHI, we have developed surgical techniques that greatly minimize the amount of bleeding in all aspects of the procedure. Of course, we take great precautions to protect ourselves from all blood-born agents, and our patients and staff are routinely tested for HIV and hepatitis for everyone’s protection and safety.

The Surgical Suite

The surgical team wears masks, surgical gloves, and gowns and uses instruments that are sterile. The procedure is performed while the patient sits in a comfortable, adjustable reclining chair. For added comfort the Suites are equipped with music, TV, and an assortment of movies.

After the anesthesia is administered, the patient should feel nothing other than pressure sensations. Many patients have long, friendly conversations with the doctor and assistants during the time it takes to complete the transplant. Occasionally, a patient will speak to friends or conduct business transactions during the surgery on their cell phones. Of course, we would prefer that you just take the day off and relax.

The atmosphere in the treatment area will make the patient feel secure and relaxed. Concern and compassion on the part of the doctor and medical staff make a tremendous difference and we will expend great effort to make sure that your experience is a pleasant one.

Making the Recipient Sites

The creating of the recipient sites determines much of the aesthetic look of the transplant. It determines the angle at which the new hair grows and determines the distribution and density of the grafts. This is a very important part of the procedure and requires considerable artistic knowledge and surgical skill. It may be the one part of the procedure where your NHI physician is silent as he concentrates on making these sites. Don’t be concerned if he isn’t chatty during this time.

Your NHI physician is accustomed to working in, and around, existing hair so you need not cut your hair short for the procedure. Your existing hair may help to cover any traces of the transplant.

Placement of New Grafts

Placing is the longest part of the procedure. The placement process is exacting and during this time you will be asked to keep your head relatively still. Watching TV, looking at movies or even sleeping will make the time go quickly. You can takes breaks as needed, to eat and use the bathroom.

When placing is complete, photos are taken and post-op instructions are given to you verbally and in writing. A tennis bandage is placed around your head and a baseball cap is worn home. No bandages are required on the transplanted area.

After Your Procedure

The night of the surgery, and for the next few nights afterwards, you are encouraged to sleep with your head elevated on pillows. You will be given medication to help you sleep if needed. The morning after surgery, you can remove the tennis band and you will be instructed to shower and gently clean the transplanted area with a special shampoo. The follicular unit grafts are made to fit snugly in the recipient site and will not be dislodged in the shower provided you follow the instruction given to you. After your first shower, no further bandages are required.

If the post-operative instructions are followed carefully, in most patients the transplant is barely detectable after a few days and practically undetectable after the first week. We will give you medication for swelling, but in spite of this, some patients experience swelling of the forehead that settles around the bridge of the nose over the course of the next several days. If this occurs, it is almost always gone in the first week and should not be a cause for concern.

Frequently, the newly transplanted grafts can be made less noticeable by minor changes in hair style and a little bit of hair spray (using the surrounding hair if it is present) to cover the area. Skin colored makeup can be used to cover any redness that lasts more than a week. Makeup consultants in large drug stores and department stores can help you choose the appropriate shade and type of makeup. Any problem of visibility can also be minimized by altering the appearance of your face. If you do not shave for a while, most people will focus upon your new beard, not on your head. If you have a mustache or a beard, consider taking it off for the first few weeks and then letting it grow back.

We like you to come into the office the morning after your procedure to give you your first hair wash, teach you how to do it and to answer questions and to see if there is anything that you need. You will be given a follow-up appointment approximately two weeks after your procedure. For patients who live far from the office, we will often use absorbable sutures that don’t have to be removed so that their follow-ups can be handled by phone.
Post-Op Course in Follicular Unit Transplantation
Patients often worry about the potential visibility of their new grafts. Scabbing or crusts that tend to form on the scalp surface should be washed off as they accumulate for the first few days following the surgery. With the very small sites used in Follicular Unit Transplantation, no new crusts may form after the second day unless the wash is not done properly. Other than the stubble transplanted hair and some faint redness in a few patients or some swelling on the third day for a few patients who do not respond to the steroids we give them to reduce the swelling, the transplant should not be visible after the first week.

The following chart shows the anticipated course for the average patient undergoing Follicular Unit Transplantation, regardless of the size of the session. It is intended to serve as a general guide. It is normal for there to be significant variability between people and even between sessions in the same person. Therefore, if you do not follow the course exactly as outlined, do not be concerned.


Next Day Hair is washed thoroughly. Grafts should be clean of blood. Some soreness, tightness and numbness.
2-3 Days Scabbing is largely gone. Moderate redness may be present. Some swelling may appear on forehead. Soreness begins to disappear. Some numbness may continue.
1 Week Redness is minimal to absent. Swelling is usually gone. 1st Post-op Visit. Soreness is generally gone. Occasionally some numbness persists.
2 Weeks Looks and feels like a 4-day-old beard. Sutures begin to absorb. Discomfort is gone. Numbness is uncommon.
2-8 Weeks Transplanted hair is shed as the follicles enter a dormant phase. Knots at the ends of the absorbable sutures fall off.
2-4 Months Some original hair may be shed in the transplanted area. Any residual numbness in the donor area is generally gone.
3-6 Months Transplanted hair begins to grow first as very fine hair.
5-10 Months Some or all of the original hair that was shed begins to grow.
8 Months Hair is groomable, but transplant appears thin as hair continues to grow and thicken. Slight textural change in hair is occasionally present.
8-12 Months Patient is evaluated for a possible second procedure.
1 Year 90% of the final appearance of procedure is usually present.
1-2 Years There may be additional fullness during the second year. Any textural change in hair usually returns to normal.