The punch grafting technique popularized by Dr. Orentreich continued to gain popularity in the 1970’s and was used as an adjunct to the scalp reduction and flap procedures that were also gaining in popularity. In the 1980’s punch plugs and the other alternatives were beginning to wane in popularity as doctors realized they could take more hair from a concentrated region of the posterior donor scalp and then suture the area closed. Up to this point doctors would allow the 4mm donor wounds to heal through secondary intention, or “open donor healing”. This would result in large 4mm wide, round scars that were unappealing cosmetically. When the 4mm punch plugs were removed in a tight, rectangular pattern the final extraction pattern would resemble one larger overall wound which could be pulled together with surgical sutures resulting in more of a linear, single scar. This is how “strip” surgery was born.
Strip surgery is the excision and removal of longer slivers or strips of hair bearing tissue which is a direct result of doctors wishing to reduce the amount of visible scarring in the patient donor area. Early on in the development of this new procedure doctors would use multiple scalpel blades used in tandem to make narrow parallel incisions at once. The incisions would extend across the back of the patient scalp and would be closed into one linear closure using sutures. This was a very fast approach to donor harvesting that matched the speed of punch grafting but would result in high transection rates.
Two additional developments transformed strip surgery into the gold standard of the mid-to late nineties and well into the twenty tens. The first was the addition of high powered stereoscopic microscopes as introduced by Dr. Bobby Limmer of San Antonio, Texas. Dr. Limmer has been using microscopes for a number of years and was being recognized for his natural results that were well beyond that of his peers. His use of microscopes allowed his technicians to separate the natural hair groupings, termed “follicular units” as they grow naturally in the scalp. Dr. Limmer argued that by transplanting these “units” that the naturalness will be far superior to other techniques. His observations and methods caught on and became the industry standard approach to hair restoration for many years. The second development was the elimination of the multi-blade handle and the move to a single scalpel for donor strip harvesting. Some studies noted that the addition of stereoscopic microscopes helped to improve hair transplant yield by up to 30%. The addition of the single blade scalpel also helped to raise the final yield percentages due to the greatly reduced donor zone transection.
Follicular unit extraction, or “FUE”, can trace it’s roots all the way back to Dr. Okuda in Japan in the late 1920’s and early 1930’s with his use of 1mm punches for surgical hair transplantation. It was in the late 1980’s that Dr. Ray Woods of Sydney Australia continued this development and became known as the father of modern FUE. Dr. Woods, and his sister Dr. Angela Campbell, wished to enter the field of surgical hair restoration but did not want to contribute to the potential negative scarring side effects seen on many patients of the era. They sought to find a minimally invasive alternative and that eventually ushered in the current era of FUE. It is not known if Dr. Woods gained access to the “Okuda papers” or had some other method of learning of Dr. Okuda’s work. Dr. Woods campaigned to have his procedure accepted in the industry but it was met with a negative response from the industry for several years.