Hair transplantation continued to have very little progress in the early 20th century and it could even be said to have been moved backward. Dr. J. S. Parsegan developed the first handheld hair transplant machine in 1921. Dr. Parsegan would use his device to pluck long strands of hair from women (18 to 20 inches in length) and transplant them into the scalps of men. The reasoning was that men did not have such long hair so it was more feasible to use hair from women. The hair would then be injected into the patient scalp and cut above the dermis. The operator would then move on to another area to do the same thing. The logic presented at the time stated that the injection of these hairs into the male scalp would stimulate new hair growth as the hairs transplanted were never intended to grow on their own. There are no known reports of the efficacy of this approach.
Eight years later in Japan Dr. Sasagawa created his own custom tools consisting of various needles for what could be considered to be true hair transplant surgery. Previously known efforts involved transplanting only cut hair shafts but Dr. Sasagawa attempted to transplant complete and intact follicles. These attempts are thought to have mostly resulted in failure but in the 1930’s Dr. Shojui Okuda improved on the work of Dr. Sasagawa and successfully transplanted complete hair follicles with documented subsequent growth. Dr. Okuda carried on his work with hundreds of documented cases. Ironically, there isn’t a single documented case of hair transplantation to treat androgenic alopecia but rather Dr. Okuda’s focus was transplanting hair for burn victims and for reconstruction of pubic regions, eyebrows and even eyelashes. Dr. Okuda’s own custom instrumentation consisted of 4mm punches but some of his punches were as small as 1mm in diameter. It would take nearly sixty years for the more refined variation of his method to be reintroduced to the field.
In 1943 another Japanese dermatologist, Dr. Tamura, published a paper in the Japanese Dermatological Journal describing his efforts for transplanting hair. He used 1mm punches more often than Dr. Okuda from several years prior and even went so far as to trim his harvested grafts for additional refinement. Dr. Tamura created an historical mirror of modern follicular unit extraction with his approach which unfortunately was overlooked and forgotten.
In 1952 Dr. Norman Orentreich performed the first hair transplant surgery in North America and is mistakenly credited as being the father of modern hair restoration. He used 4mm punches to core out multiple groupings of hair, much like Dr. Okuda in Japan twenty years prior. After he published his results and findings the field of surgical hair restoration was born and has grown year after year ever since. These punch “plugs” were transplanted, in whole, into similar sized incisions made into the recipient scalp which looked largely unnatural but with this being the only proven alternative to baldness the procedure gained in popularity.