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Plug graft hair transplants were mass-marketed as "the natural solution to hair loss", even though doctors knew that the results were often terrible.

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Why were the results of surgical hair transplants so bad, for so long? Why did doctors continue to use crude techniques, even though they knew that many patients were being disfigured?

Why have so many incompetent hacks, crooks and quacks found a haven in the hair transplant business?

The second half of the 20th century saw amazing advances in science, technology and medicine. Yet there was one medical specialty that stagnated and festered, while the rest of the world of science and medicine raced forward. Unfortunately, it was a branch of cosmetic surgery that caused an enormous amount of damage to the male population.... the field of Surgical Hair Restoration aka "Hair Transplants".

This introductory section covers two topics:

-A brief overview of the history of surgical hair restoration

-A discussion of why the field of hair transplantation has been so bad, for so long

This page is intended to help provide some additional historical context to the rest of the website.

"The art of surgical hair restoration has been practiced in the United States for about four decades, but it could be said that many of the innovations in the field have largely taken place only during the last ten years."
"Patient Guide to Surgical and Medical Hair Restoration"
2002 Truett Bridges, MD, Paul Rose, MD, and John Cole, MD

Many people working in the hair transplant industry want to whitewash their own shameful history, and pretend that "Dolls Hair" transplants were done "way back in the early days" of hair transplantation. In fact those crude techniques were being used for almost 40 years, and were only just abandoned by the majority of clinics approximately 10 years ago (the early 90s). Over one million men were subjected to crude plug-grafting techniques. Tens of thousands of these men have attempted to regain a normal appearance with additional corrective surgery. Tens of thousands of these men have resorted to wearing a hairpiece, to cover up the surgical damage.

"Since the 1980s, over 50 percent of our patients have come to us in need of repair and reconstruction because of poor results from inferior transplant surgery. Many of these patients just wanted to look normal enough to be seen in public. This was truly sad, because their disfigurements could have been prevented."
The Hair Replacement Revolution
A Consumer1s Guide to Effective Hair Replacement Techniques
James Harris and Emanuel Marritt

Japanese doctors began doing experimental work with hair transplantation in the 30s and 40s. Because of the language barrier and perhaps World War 2, that work was basically unknown to western doctors. In 1952 Dr. Norman Orentreich "rediscovered" the concept of hair transplantation. He was unable to publish his findings because apparently nobody believed that his method could work.


"When Dr. Norman Orentreich first began doing hair transplants in the 1950s, he used a four millimeter circular "punch" to remove and transplant plugs of scalp which contained 16-20 hairs. This was a common surgical instrument used at the time so it seemed to make sense to use it for hair transplants. Unfortunately, the transplanted hair had a plug-like or doll's scalp" appearance."
Jerry Cooley, MD

Notice that the entire 1960's, 1970's and 1980's can be called the "Punch Graft Era". During these three decades, there were very few advancements in surgical technique that have stood the test of time. Despite false advertising that claimed undetectible results, a "Dolls Hair" appearance and massive scarring in the donor area were the typical result during this 30-year period.

The following excerpt is from "The Logic of Follicular Unit Hair Transplantation" by Dr. Bernstein and Dr. Rassman

"A donor (graft) is better if it is as small as possible. The reason is that if a donor is big, hairs grow in... a very unnatural appearance."
Hajime Tamura - 1943

If we had only heeded the advice of the pioneering Japanese hair transplant surgeons in the first half of this century, we could have avoided years of unsightly surgical results that caused dismay to thousands of unwary patients, and literally tarnished an entire field of medicine. Unfortunately, the "Japanese insight" was lost to us during World War II and when we tried to "reinvent the wheel," we did it wrong.

The Punch Graft Technique

After the "rediscovery" of hair transplantation by Dr. Norman Orentreich in 1952, the excitement that hair actually grew, and continued to grow after it was transplanted, clouded the very essence of hair restoration surgery i.e., that it was a cosmetic procedure whose sole purpose was to improve the appearance of the balding patient. The 4-mm plug that had been ordained as the optimal vehicle for moving hair was actually of a size that had no counterpart in nature.

The initial problem was that the decision to use 4-mm plugs was based mainly upon technical rather than aesthetic considerations. In the original, ingenious experiments performed by Dr. Orentreich, published in the Annals of the New York Academy of Science in 1959, which established the concept of "Donor Dominance," 6 to12-mm punches (trochars) were used to create the grafts. At these sizes, there was an unacceptably high rate of hair loss in the center of the grafts due to the difficulty oxygen has diffusing over such large distances. The initial effort to decrease graft size was thwarted by the concern that much smaller grafts would not move enough hair to make the procedure worthwhile. Eventually a compromise was reached, and the 4mm graft was born.

In addition, a logic developed which postulated that, by replacing bald skin with hair bearing skin, most of the balding area could eventually be replaced with hair. No adjustments for scar contraction were accounted for, and no changes in the size of the newly transplanted grafts were expected, despite observations to the contrary. More important, these assumptions were based upon the mathematically impossible feat of covering a large area of balding with a much smaller donor supply, while maintaining the same density.

The punch-graft, open-donor technique was developed with tools in routine use by dermatologists of the time. In the "open-donor method" devised by Dr. Orentreich, the same trochar that was used to make the recipient sites was also used to harvest the hair. Since hair in the donor area emerges from the scalp at rather acute angles that vary in different regions, the physician was required to have the angle of the trochar exactly parallel to the angle of the hair. If there was even the slightest deviation from a perfectly parallel orientation, significant waste of hair would occur from follicular transection. In fact, in many patients, so much transection would occur that the potentially "pluggy" appearance was reduced to a thinner look by the inadvertent reduction in the number of hairs per graft.

The hidden problem, of course, was that this harvesting technique reflected a grossly inefficient use of the donor supply, and patients often became depleted of donor hair long before the transplant process was completed. These problems were compounded by the fact that in the "open donor method" the wounds were left to heal by secondary intention and the resulting fibrosis further altered the direction of the remaining donor hair, making subsequent harvesting even more difficult.

The large donor and recipient wounds created by these punches necessitated that the procedure be performed in small sessions, usually 20 to 50 grafts at a sitting, with the sessions spaced apart in time due to the prolonged healing. As a result, one of the truly unfortunate problems intrinsic to the early techniques was that neither the long-term cosmetic issues, nor the ultimate depletion of the patient's donor supply, could be appreciated for many years. Possibly because of Dr. Orentreich's deservedly high esteem in the medical community (he also did pioneering work in dermabrasion, intra-lesional corticosteroids, injectable silicon, and the hormonal treatment of hair loss (to name just a few), the 4mm size went unchanged for years.

"The Logic of Follicular Unit Hair Transplantation"
Robert M. Bernstein, MD & William Rassman, MD


Even more unfortunately, some hair transplant doctors still utilize these larger grafts."
Raymond J. Konior, M.D history.html

Between 1959 and 1970, the biggest development in hair transplant technique was the addition of electric drills to the procedure. Early doctors like Orentreich and Norwood used sharp hand-held punches to harvest the donor plugs, which they drove into their patients scalp using physical force and rotation. In the late 70s, some doctors began fastening these punches into the chuck of a "Black and Decker"-type electric drill, and using the drill to drive the punches. This sped up the procedure dramatically, and launched the mass-marketed "surgical factory" approach that was adopted by large franchises, that are now commonly known as "hair mills".

Dr. O'Tar Norwood "Hair Transplant Surgery", 1973, Charles C. Thomas- Publisher

Inferior new techniques were developed, instead of trying to understand the basic anatomy of the hair follicle. What was passed off as "progress" often consisted of just modifying an already crude and terrible surgical technique. In the mid-70s, doctors in the business also developed radical new techniques that have mutilated hundreds of thousands of men:

Scalp reductions (galeoplasty): a technique where portions of the balding patient's scalp is cut away, and the remaining scalp is stretched together and sutured up. This creates massive scarring in the middle of the patient's balding zone, which makes the patient appear as if he had been hit in the head with an axe. Often these scars cannot be concealed with hair grafts. See the section on Scalp Lifts and Scalp Reductions for more information.

Hair Flaps: A technique where a large section of hair-bearing scalp is surgically detached and then rotated so that it is seated in the patient's balding area. As a result, the hair is now angled in an unnatural direction. This technique also creates a tremendous amount of scarring. There is also an unnacceptably high risk of tissue necrosis or "flap death".

Graft Sectioning: In the mid-80s doctors began to experiment with smaller grafts, by cutting the punched-out plugs into halves and in quarters. These were known as "Hemigrafts", "Quartergrafts", "Split Grafts", "Minigrafts" etc. These "garbage grafts" did nothing to address the problems of open donor harvesting and the massive amount of scarring that was being created. Splitting grafts also destroyed a high percentage of precious hair follicles. So the grafts became smaller and less pluggy, but produced less hair and wasted even more of the patient's limited donor supply.

In 1976 a Dr. Coiffman proposed that doctors excise a solid block of donor tissue, and dissect grafts from that tissue. This is essentially the "strip excision" technique that is currently used by most clinics today. However, his proposal was ignored or rejected by doctors in the field, and doctors continued to use punch grafting techniques for an additional 15 years. It was not until the early 90s that the majority of clinics abandoned the crude punch graft method. As a result, hundreds of thousands of additional men were unnecessarily mutilated by crude punch graft techniques during the late 70s as well as the entire 1980s.

"Coiffman was the first to propose the advantages of a "block excision" of the donor area. Initially, he had described a technique that left no hairs between excised round grafts. Later, he proposed a block excision of a solid donor area leaving a single donor scar. (Coiffman F. Use of Square Scalp Grafts for Male Pattern Baldness, Plastic Reconstructive Surgery, 1977, 60:228-32 + 1979 Unger Text). In retrospect, it is both remarkable and sad that it took as long as it did for this concept to become widely adopted, but in the last decade, the scalpel has essentially replaced the punch for donor area harvesting."
"Donor Harvesting"
co-written by John Cole MD and Walter Unger.

It wasn't until 30 years after Orentreich's original punch-grafting studies in the late 50s, that any of the doctors in the hair transplant field had enough common sense to study the natural anatomy and patterns of distribution of hair follicles in the scalp... the breakthrough acknowledgement of the importance of "follicular groupings" in 1988. It took over thirty years for hair transplant surgeons to begin to study and respect the basic anatomical realities of how hair follicles are arranged in the human scalp. Instead, during the 70s and 80s, these doctors were devising ways to divide the punched-out plug grafts into halves and quarters, and other crude and simple-minded variations on the work that Orentreich had done 30 years earlier. Because hair transplant surgeons were mainly interested in commercializing the existing crude surgical techniques of the 60s, doctors in the field overlooked the importance of the BASIC ANATOMY of the human scalp and hair follicle.

Why has the field of hair transplantation been so bad, for so long?

1. Quacks and con men have always been attracted to the "Hair Loss" field. There is a long tradition of crooks and snake oil salesmen in the hair loss industry. When Orentreich and other doctors proved that hair transplantation was commercially viable, it attracted the attention of crooked and incomptetent doctors. The use of power drills to speed up the process gave rise to the multi-clinic chain of surgery centers known as the hair mill, where hair transplants were mass-marketed as a way to "end hair loss". The emphasis shifted from patient care to profits.

Hair transplants are a CASH ONLY specialty that requires absolutely no training whatsoever; Anyone with a medical degree can legally perform hair transplant surgery, without any previous experience in hair transplantation, plastic surgery, or dermatology.

"The industry itself has not been known for its good quality work in the past, nor its ethics. The industry has been laden down with a sleaze factor to a high degree."
Interview with Dr. Rassman, June 25th 1997

2. Hair transplants are technically less demanding than other types of surgery, which has attracted many untalented and lazy surgeons, who want a specialty that produces maximum profits with minimal effort. Many of the doctors who are attracted to the field are bottom-of-the-barrel doctors who are looking for easy money. For years, "progress" in the field consisted of doctors creating variations of already existing "garbage techniques". Basic anatomy of follicular groupings was not recognized or understood until the late 80s. Essentially none of the techniques that dominated the field between 1960 and 1990 are still in use. Advancements have been proposed and then rejected by the status quo. This proves that research and science in the field has traditionally been exceptionally weak. Hair transplantation attracted mediocre thinkers and lazy doctors, who wanted a simple procedure that they could do over and over. Doctors resisted doing meaningful research or changing their procedure, or doing anything that would require learning new skills.

Many physicians who enter this field are "burned out" and are looking for the "easy job".
"Top 10 Things to Avoid in Hair Transplant Surgery"
Norwood & Lehr Hair Transplant Clinic

"It is difficult to say with complete confidence why such bad business practices have invaded the field of hair replacement. It appears that a combination of greed and declining standards have conspired to help the invasion..."

"Why do some doctors choose an unethical path? Perhaps it is because they have little incentive to change. In addition to the money they can make, the system of medicine is set up in such a way that it almost discourages doctors from changing. The concept of voluntary compliance means that it is the individual doctor alone who decides which new ideas he will or will not incorporate into his own private practice."
The Hair Replacement Revolution
A Consumer's Guide to Effective Hair Replacement Techniques
James Harris MD and Emanuel Marritt MD

3. Instead of concentrating on science and research, doctors in the field have put their emphasis on advertising and franchising. That continues to be true even now. In the 70s, doctors began mass-marketing hair transplants as a remedy for hair loss. The use of power drills allowed the surgery to become much faster, giving rise to the "hair mill". The focus was placed on marketing and expansion into new markets. Franchises like Bosley Medical Institute and Puig Medical Group dominated the field. Clinics began hiring salesmen dressed in white lab coats, using false advertising, showing patients airbrushed photos, and other illegal and unethical sales tactics.

"...some time in the early 1980s, the balance in the field of hair replacement changed, and the number of people trying to take advantage of hair clients grew, eventually appearing to constitute the majority in the field. As this balance shifted, the profession of surgical hair replacement was transformed into a business, with the search for profits -not a search for healing- as the driving force."
The Hair Replacement Revolution
A Consumer's Guide to Effective Hair Replacement Techniques
James Harris MD and Emanuel Marritt MD

5. Hair transplant doctors have traditionally set very low standards for themselves, and typically considered bad results to be 'good enough'. Even though doctors knew that they were giving their patients cosmetically unnacceptable results, they continued to perform crude surgical techniques to keep the money flowing. Rather than choose the ethical path, perhaps by "going back to the drawing board" and re-thinking a new and better approach to hair transplantation, or perhaps limiting the number and type of patients they would operate on, many surgeons decided to take the "hair mill" route and put their own profits ahead of their patient's well-being.

"Whether you call the results 'doll's hair' or 'corn-rows,' the unfortunate fact is that hair transplants done with old techniques typically look unnatural. Years before surgical micrografting techniques, Propecia (finasteride) pills or Rogaine (minoxidil) spray, the 'plug' was the only defense against balding or thinning hair. The accepted 'standard-of-care' was that some hair was better than no hair-even if the result wasn't so natural looking."
Dr. Alan Bauman
M.D. News, April 2000
"Repair of Previous "Plug-Type" Hair Transplants"

6. There are no rules or regulations in the hair transplant field, so if doctors adopt any new advancements, they do it voluntarily. Unfortunately there is usually very little incentive for a doctor to update his surgical techniques. Advertising is considered a bigger factor in attracting new patients than new surgical advancements. The industry is dominated by big franchise clinics that spend millions of dollars every year on advertising. Their preferred clientele is the completely uneducated consumer who does not know which techniques are available. The vast majority of patients do not understand how hair transplants work, and if their doctor claims that he is using the latest techniques, most patients will trust their doctor is telling the truth. Doctors also get attached to their surgical repertoire and get "set in their ways" and will often not learn new techniques until they are forced. Abandoning current techniques can appear like an admission of previous inadequacy; Many doctors in the field have portrayed themselves as experts to their colleagues and in their own advertising, and a switch in technique would appear to contradict that.

"After years of building a reputation and an office empire, suddenly, long-term study and observation of his procedure reveals unsuspected complications. What seemed brilliant at one time is now exposed by objective scientific observation as not just mediocre but even damaging to the patient. The doctor faces a moral dilemma. Does he sacrifice his status and income in light of this new information? Who would want to start over at age fifty, learning new techniques, training new staff, and downsizing expenses and lifestyle?"
The Hair Replacement Revolution
A Consumer's Guide to Effective Hair Replacement Techniques
James Harris MD and Emanuel Marritt MD

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