Journal of Aesthetic Dermatology & Cosmetic Dermatologic Surgery, Volume 1, Number 1, 1999, Pages 55-89

The Future in Hair Transplantation

Robert M. Bernstein, MD, William R. Rassman, MD, David Seager, MD
Walter P. Unger, MD, FRCP(C), Bobby L. Limmer, MD, Francisco Jimenez, MD
Jose M. Ruifernandez, Joseph F. Greco, PhD, PA/C, James Arnold, MD,
E. Antonio Mangubat, MD, Albert J. Nemeth, MD, Jung-Chul Kim, MD, PhD
Jennifer Martinick, MD, Edoardo Raposio, MD, FICS, Leonard M. Patt, PhD
Marty E. Sawaya, MD, PhD, Angela M. Christiano, PhD, Emanuel Marritt, MD

Abstract

The 1990’s have witnessed major changes in hair transplantation, most notably the trend towards the use of large numbers of very small grafts and the emergence of follicular unit transplantation as possibly the new "gold standard." This article reviews the new developments that will shape hair restoration surgery as we enter the next millennium. Many aspects of hair transplantation will be explored including: the follicular unit/mini-micrograft controversy, ways to measure and maximize the donor supply, new concepts in graft storage, advances in wound healing, new instrumentation, automated graft cutting and placing, advances in laser technology, the role of new medical treatments, and finally the status of research in cloning and genetic engineering.

Introduction

Robert M. Bernstein, MD

The 1990’s have witnessed major changes in hair transplantation, most notably the trend towards the use of large numbers of very small grafts and the emergence of follicular unit transplantation as possibly the new "gold standard." In addition to improved surgical techniques, new developments in medical treatments, marketing on the part of physicians, and coverage by the media, have produced an increased public awareness of this rapidly evolving field.

The long-term observations of patients treated with the older hair transplant techniques and the use of new objective means to measure donor supply, have made the modern hair restoration surgeon more keenly aware of the importance of maximizing the patient’s finite donor reserves. As a consequence, new ways of harvesting and dissecting donor tissue have been developed to better preserve this supply, and new ways of handling and storing grafts awaiting placement have been devised to enhance the viability of the grafts. In addition, long-term planning has assumed greater prominence in surgical decisions. It is somewhat ironic that after four decades of wrestling with supply/demand issues, new medications for hair loss may soon necessitate a complete re-thinking of the way we plan our procedures.

The use of large number of very small grafts has made the transplant process much more laborious and this has prompted the development of new technologies to automate various aspects of the transplant process. Long transplant sessions requiring greater numbers of staff and involving the movement of large numbers of small, fragile grafts has also made quality control a central issue.

The decade has seen a dramatic decline in the popularity of scalp reductions and flaps, and fortunately the "pluggy look" that was once the hallmark of many older transplant procedures is now deemed to be unacceptable. Unfortunately, many patients still carry the telltale cosmetic deformities caused by the older techniques and "repair work" has become an increasingly larger part of many physicians’ practices.

The initial excitement over laser assisted hair transplants appears to have subsided, because the very tiny sites needed in the newer procedures seems to be best made by cold steel incisions. However, laser technology is rapidly changing and this tool may still have a future role in hair transplantation, possibly in ways we have not yet considered.

The development of 5-alpha reductase inhibitors and other medications that specifically attack the biochemical pathways involved in androgenetic alopecia will have a profound influence on the future of hair restoration surgery. Once drugs are able to successfully limit the extent of balding, supply/demand ratios will change, long-term planning may become less important and the aesthetic demands of all patients may substantially increase. As medications become more effective, their long-term safety profile established, and their use more widespread, it is possible that baldness may be preventable. When this happens, surgery may be reserved for those already bald or for persons without significant androgenetic hair loss who want to improve upon their natural attributes.

Although hair loss in women is generally a far more significant cosmetic problem than in men, a much smaller proportion of women are surgical candidates, since they generally exhibit a diffuse type of hair loss. When medications are developed that are useful in women, an entire new population of patients may benefit from surgery. The increase in female patients, might then more than offset any decrease in the number of procedures performed in men.

Cloning is another technology that has made significant progress in recent years and may supply the surgeon with an unlimited source of donor hair. Genetic engineering, on the other hand, is a technology still in its infancy, but that may someday render the hair transplant surgeon’s role obsolete.

The move towards smaller grafts in the 90’s has produced a number of controversies that are receiving a great deal of attention in the hair transplant community. Among the most hotly debated are 1) the "supremacy" of the follicular unit over traditional mini-micrografting, 2) the practicality of microscopic dissection, 3) the importance of single strip harvesting, and 4) the "ideal" transplant density. As this decade draws to a close, however, no issue is possibly more critical to the future direction of surgical hair restoration as the debate over economy vs. quality.

The newer hair transplant techniques have enabled the surgeon to produce unprecedented naturalness, the ability to complete the process in a smaller number of sessions, and the means to accomplish this with a more limited amount of donor tissue. However, these newer procedures are technically more difficult, require a significant number of well-trained staff, are more costly to deliver, and are too impractical for some cosmetic surgeons to perform. These limitations have stimulated a number of enterprising physicians to try to facilitate the more tedious aspects of the procedure with the use of automated devices.

Although much of the new technology has served to speed up the procedure, some mechanized devices accomplish this at the expense of quality and the preservation of donor tissue. To what degree this occurs, and what its clinical significance may be, still needs to be assessed in well-controlled, scientific studies. Until then, the subjective value that surgeons and their patients place upon each of these aspects of the transplant may ultimately define the type of procedures offered over the next few years.

As we approach the beginning of a new millennium, it is tempting to speculate about the future of hair restoration surgery. This article has been a collaborative effort to review many of the new developments that will most likely shape this future. The various opinions expressed in this article do not necessarily reflect the views of all the contributing authors and some areas covered are so new that their practical value is not yet known. The purpose of this article is intended to be provocative rather than dogmatic. We trust that the reader will enjoy our exploration into the future keeping this in mind.

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