1 What’s New in Facial 2 3 4 Transplantation? 5 6 Effective Techniques for and 7 8 Transplantation 9 10 Q2 Anthony Bared, MD* 11 12 13 KEYWORDS 14 57  transplantation  Hair restoration  Beard transplantation  Eyebrow transplantation 15 58  Follicular unit extraction (FUE)  No-shave follicular unit extraction 16 59 17 60 18 Q5 KEY POINTS 61 19 62  20 Advances in techniques allow natural results in facial hair transplantation to be 63 21 achieved. 64 22  Poor hair growth angulation can occur occasionally despite the best efforts in acute recipient site 65 23 angulation and hair placement. 66 24  will start to regrow around 4 to 6 months after transplant and will continue to fill in for a full 67 25 year, gradually increasing in density. 68 26 69 27 70 28 71 29 INTRODUCTION Other reasons for patients seeking facial hair 72 30 restoration are for poorly thought out previous 73 31 Advances in hair restoration techniques have , scarring, burn, or cleft repair 74 32 made it possible to transplant hair in nonscalp (Fig. 2). Another small group are female to male 75 33 Q6 areas of the such as the beard and eyebrows. transgender patients seeking a more masculine 76 34 Refinements in techniques have allowed for the appearance. Treatment goals in beard restoration 77 35 transplantation of beard hair and eyebrow hair are often set by the patient. Patients typically pre- 78 36 with natural appearing results. Thick eyebrows sent with a rather specific understanding of how 79 37 and full are in vogue. Pick up any of the lat- they want their facial hair to appear. A patient’s 80 38 est fashion magazines and you see female models goals may vary from increasing the density of an 81 39 with thick, full eyebrows, or men sporting beards. existing beard while maintaining the same shape, 82 40 Our practice has seen a large increase in the de- to transplanting full beards where few exist. 83 41 mand for beard and eyebrow transplantation. The design and density of the beard may be limited 84 42 This article describes the preoperative consulta- by the quality and quantity of the donor area. 85 43 tion, operative technique, and postoperative care Transplantation of full beards requires a large 86 44 developed from our experience of over 1000 pro- amount of grafts and patients are always made 87 45 cedures in facial hair restoration. aware of the possibility of undergoing secondary 88 46 procedures after 1 year if further density is desired. 47 BEARD TRANSPLANTATION These grafts, it must be made clear, once trans- 48 Preoperative Planning planted, will no longer be available for use in the 49 Most patients seeking facial hair restoration are in the future if male pattern is to 50 men with a genetic paucity of facial hair (Fig. 1). develop. 51 52 53 54 Disclosure Statement: The author has nothing to disclose. 55 Private Practice, Miami, FL, USA 56 Q4Q3 * 6280 Sunset Drive, Suite 504, Miami, FL 33143. E-mail address: [email protected]

Facial Plast Surg Clin N Am - (2019) -–- https://doi.org/10.1016/j.fsc.2019.04.003

1064-7406/19/Ó 2019 Published by Elsevier Inc. facialplastic.theclinics.com

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89 As with other hair transplantation cases, pa- 146 90 tients need to be in good general health and off 147 91 medications, supplements, and vitamins that can 148 92 worsen bleeding. 149 93 150

94 FPO 151 = Surgical Preparation 95 152 96 As mentioned, most patients have a specific idea 153 97 about the design they wish for their facial hair. Us- 154 98 ing the patient’s guidelines, the areas to be trans- 155 planted are marked out using a surgical marking

99 print & web 4C 156 100 Fig. 1. Male patient with a paucity of facial hair pre- pen with the patient in a seated position. The mark- 157 101 senting for beard hair transplantation. ings are checked for symmetry between the 2 158 102 sides. Measurements are used to help ensure sym- 159 103 metry. Patients are shown the markings in a mirror, 160 104 With the advances and refinements in follicular in case the 2-dimensional perspective provided by 161 105 unit extraction (FUE) techniques, most patients a mirror—which is what the patient sees in a 162 106 seen in our office elect to have the procedure per- mirror—is different than what the surgeon sees in 163 formed in this manner to avoid a linear scar, allow- direct three dimensions. If then needed, alterations 107 1,2 164 108 ing them to maintain a short . FUE has are made according to patient desires (Fig. 3). 165 largely replaced the traditional strip donor extrac- 109 3,4 166 110 Q7 tions for beard transplantation in our office. Procedural Approach 167 111 Regardless of the donor technique used, patients 168 Currently in our practice, the vast majority of pa- 112 are made aware of the potential limitations of the 169 donor hair quantity and therefore “size” and den- tients seeking facial hair restoration elect to have 113 their procedure using the FUE technique to avoid 170 114 sity of the beard that can be achieved through a 171 a linear scar. In these cases, the donor area is usu- 115 single procedure. It is our experience that the 172 ally shaved (a no-shave FUE alternative is also 116 scalp hair transplants to the face have a high 173 regrowth percentage and, if properly performed, offered), and the patient is placed in a supine posi- 117 tion. The donor area is prepped and draped in a 174 118 patients can achieve a natural outcome. As in 175 sterile fashion for the procedure. Local anesthesia 119 any cosmetic procedure, listening to the patient’s 176 exact goals and desires is imperative. Patients is infiltrated into the donor area. The smallest 120 possible drill size avoiding graft transection is 177 121 who desire facial hair restorations, in general, ex- 178 used for the extractions. The donor area consists 122 press a specific desire for how they want their 179 beard designed. Depending on the exact design of the occiput only in smaller cases and extends 123 into the parietal scalp for larger cases. Graft ex- 180 124 and density, graft counts can range from 250 to 181 tractions are evenly distributed throughout the 125 300 grafts to each sideburn, 400 to 800 grafts to 182 donor area to avoid areas of focal alopecia. 126 the mustache and , and 300 to 500 grafts 183 Once the extractions have been completed from 127 per . These numbers can vary based on 184 the occipital area, the patient is then turned to lie 128 the pre-existing hair, design, and thickness of the 185 in the supine position. 129 donor hair. 186 130 187 131 188 132 189 133 190 134 191 135 192 136 193 137 194 FPO =

138 FPO 195 139 = 196 140 197 141 198 142 199 143 print & web 4C 200 print & web 4C Fig. 3. Patients are marked in the preoperative suite 144 Fig. 2. Beard transplantation is an option for male pa- before facial hair transplantation where they are 201 145 tients to help facial scars. shown the outline and design of the beard. 202

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203 Local anesthesia is then applied to the face and then transition downward along the goatee. 260 204 starting in each sideburn and cheek area. The Patients need to be made aware of the difficulty 261 205 area around the mouth is not anesthetized at this in creating density along the entire mustache, 262 206 point; the area around the mouth is typically particularly centrally within the “Cupid’s bow.” 263 207 worked on after the patient has eaten lunch. The The creation of density in this area is difficult owing 264 208 recipient sites in the sideburn and cheek area are to the undulations created by the upper lip’s Cu- 265 209 made first. The smallest possible recipient sites pid’s bow area. It is also important to maintain as 266 210 are made using 0.5-, 0.6-, or 0.7-mm slits. The 1, acute an angle as possible in this central area of 267 211 2, and (if used) 3 hair grafts are tested to ensure the upper lip because grafts have a tendency to 268 212 size compatibility with the recipient sites. In the grow straight outward in nonacute angles. The 269 213 periphery of the , 1 hair graft is used transition from the mustache to the goatee is an 270 214 whereas 2 hair grafts can be placed in the central important area for the creation of density, which 271 215 aspect of the sideburn to allow for more density is usually created by the maximal dense packing 272 216 (Fig. 4). Counter traction is provided by the of 2 hair grafts. 273 217 nondominant and an assistant while making The grafts are placed into these recipient sites 274 218 the incisions. The key esthetic step is to make the using jeweler’s forceps. Counter traction splaying 275 219 incisions at an ultra-acute angle to the , with the incision sites open with the nondominant 276 220 the direction of the incisions determined by either hand helps in the placement of the grafts given 277 221 existing surrounding hairs or the fine “peach the laxity of facial skin. The importance of having 278 222 fuzz” of the face. This being said, the direction of experienced assistants for this process is critical, 279 223 growth is generally downward, but more centrally as they need to understand the “pattern” of graft 280 224 closer to the mouth/goatee region can be some- distribution, as created by the surgeon. Toward 281 225 what anterior. In the cheek area, 3 hair grafts are the conclusion of the procedure, the patient is 282 226 sometimes used in the central beard in patients given a mirror before all grafts are placed. Given 283 227 with finer hair to allow for the achievement of that the immediate results closely replicate the 284 228 greater density without a compromise of natural- final results, it is helpful for the patient to view their 285 229 ness. If further grafts are needed, they are beard to assess the design and density of the 286 230 extracted at this time from the parietal scalp. The grafts. This allows for feedback, fine-tuning, and 287 231 patient’s head is slightly turned, allowing for the alteration before the conclusion of the procedure 288 232 simultaneous extraction of grafts from the parietal (Fig. 5). 289 233 area and the placement of grafts in the ipsilateral 290 234 cheek and sideburn. Postprocedure Care 291 235 292 After the patient is given lunch, the area around Patients are told to keep their face dry for the first 236 293 the mouth is then anesthetized. Infraorbital and 5 days after the procedure. This allows for the 237 294 mental nerve blocks are used to provide initial grafts to set properly, helping to assure the main- 238 295 anesthesia. Anesthesia in the goatee and tenance of proper angulation. Topical antibiotic 239 296 mustache area is then reinforced with field subder- ointment is applied to the donor area. Patients 240 297 mal local anesthesia complemented by epineph- are then to wet their face with soap and water, 241 Q8 rine 1:60,000 to minimize bleeding. Incisions in 298 242 the goatee and mustache area are then made. 299 243 On the mustache, hairs will grow slightly laterally 300 244 301 245 302 246 303 247 304 248 305 249 306 250 307 251 308

252 FPO FPO 309 253 = = 310 254 311 255 312 256 313 257 314 print & web 4C print & web 4C 258 Fig. 4. Image demonstrating the typical graft size Fig. 5. Immediate postopereative results where pa- 315 259 placement for beard transplantation. tients are able to see their beard design. 316

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317 starting to remove the dried blood and crusts. and angle of growth of eyebrow hair. The most 374 318 is permitted after 10 days. Hair regrowth common presentation in women is the thinning of 375 319 usually starts around 4 to 6 months. The trans- the eyebrows, either from over-, aging, 376 320 planted hair can be treated as any other facial or genetic causes. In cases of complete eyebrow 377 321 hair and allowed to grow out or shaved. Most pa- absence, types of alopecia (such as alopecia 378 322 tients are satisfied with the initial density from 1 totalis) need to be ruled out before considering 379 323 procedure but a secondary, touch-up procedure, transplantation.6 Men typically lose the lateral 380 324 can be performed after 1 year to create further aspect of the eyebrows with aging and are seeking 381 325 density. overall thicker eyebrows. Some of our female pa- 382 326 tients have had previous , 383 327 Potential Complications and Their and are advised that this may compromise 384 328 Management regrowth in the occasional case. These tattoos 385 329 can often help guide the design of the eyebrows, 386 Poor angulation 330 but oftentimes we find that they were made asym- 387 Hairs can grow out perpendicularly giving the 331 metrically and/or not esthetically. Most of our fe- 388 beard an unnatural appearance. As previously 332 male patients are able to draw their desired 389 mentioned, the area of the face where improper 333 eyebrows, which we encourage, but then often 390 angulation poses the greatest challenge is in the 334 require some fine-tuning by the surgeon to create 391 mustache. To avoid the improper angulation it is 335 a nicer look. 392 helpful to use the smallest possible incision at an 336 The donor hair is almost always the scalp 393 acute angle. It is helpful to use a longer blade so 337 because of its reliable regrowth, although other 394 as to allow it to lay flat across the skin permitting 338 areas of the body can be used as well, but the 395 a sharply acute angle. If needed, the perpendicular 339 regrowth is not as reliable, nor is supply often 396 hair grafts can be removed via the FUE technique 340 readily available. In most cases, scalp donor hair 397 and the resulting hole is left to heal by secondary 341 extraction is performed from a small “strip” from 398 intention. 342 the occipital scalp. The strip technique allows for 399 343 Bump formation the hair to be maintained slightly longer as it exits 400 344 Tiny bumps can form, particularly under the lip in the skin, allowing for the visualization of the direc- 401 345 the “” and mound areas at the tion of growth of the hair. In some cases, particu- 402 346 site of the transplanted grafts. The cause of the larly in men, the FUE technique is used. Overall, 403 347 formation of these bumps is not known; however, given the small number of grafts needed, patients 404 348 this is mostly seen in patients with thick, dark hair. are given the option of the “no-shave” FUE tech- 405 349 As the hair grows in this soul patch and chin nique so that they can avoid the trimming of the 406 350 mound area, a small bump can form where the donor area and maintain their hair longer. 407 351 hair exits the skin. For this reason, if a patient de- 408 352 409 sires hair in these regions, a small “test” procedure Surgical Preparation 353 can be performed at the time of the initial proced- 410 354 ure, or alternatively, only single-hair grafts trimmed Patients are seated in front of a mirror in the preop- 411 355 of surrounding skin can be used safely. If, in 6 to erative suite. Women generally have a good idea of 412 356 8 months, no bumps have formed then further the shape they desire for their eyebrows. They are 413 357 hair can be transplanted.5 Patients of Asian asked to bring in photos of “model” eyebrows to 414 358 ethnicity, particularly those with dark thick hairs, help guide their design. After preoperative photos 415 359 are the most challenging on whom to avoid com- are obtained, if the patient has a good idea of the 416 360 plications, both in this bump formation, but also shape they desire, they are offered an -liner 417 361 in achieving naturalness owing to the difficulty in pen and are given the time to draw in their desired 418 362 getting the grafts to look natural, particularly in eyebrow shape. The patient’s active involvement 419 363 angulation. With these Asian patients, the less- in the design of their eyebrows is important. After 420 364 experienced surgeon is strongly encouraged to they are given some time to design their eyebrows, 421 365 proceed conservatively, with the primary use of final markings and refinements are made by the 422 366 all single-hair grafts and a smaller number of surgeon with a semipermanent fine marker. Mea- 423 367 grafts, until proficiency is achieved. surements are taken for symmetry. Men seeking 424 368 eyebrow restoration typically are seeking to fill in 425 369 areas within the eyebrows that are lacking density. 426 EYEBROW TRANSPLANTATION 370 The male eyebrow is designed with less of an arch 427 Preoperative Planning 371 and as an extension of the existing eyebrow. 428 372 The goal in eyebrow restoration is to restore the Photos are obtained after the final markings have 429 373 desired shape and density, and natural direction been made. 430

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431 The author likes to divide the eyebrow into 3 sites are created by the surgeon using the small- 488 432 sections: est blade size appropriate for the grafts, most 489 433 commonly 0.5 mm, but sometimes 0.6 mm for 490 434 1. Head (innermost 5–8 mm) the occasional larger 2 hair grafts and even 3 491 435 2. Body (central 2.5–3.5 cm) hair grafts. Recipient sites are first made along 492 436 3. Tail (outer 2–2.5 cm) the boundaries of the eyebrow along the preoper- 493 437 494 In women, the point at which the tail and body ative markings, as these markings can be lost 438 495 meet forming the arch is usually located at or just with the subsequent bleeding and wiping of the 439 496 lateral to the lateral limbus of the eye. For a more blood from the recipient sites. Paying attention 440 497 dramatic look, this arch can be as far lateral to to the proper direction of growth is critical. Within 441 498 the lateral canthal region. However, it can vary in the head of the eyebrow, hair usually grows in a 442 499 position and roundedness. In men, the arch of more vertical/superior direction. Moving from 443 500 the brow is not so much as a peek but rather a the more inferior to the more superior aspect of 444 501 widening of the eyebrow along the area correlating the head of the brow the hairs quickly change di- 445 502 to the lateral limbus. This is best demonstrated in rection to grow in a more horizontal then inferior/ 446 503 Fig. 6. downward direction, particularly along the supe- 447 rior border. Moving laterally, the hairs along the 504 448 superior border are oriented in an inferior/down- 505 Procedural Approach 449 ward direction, while the hairs along the inferior 506 450 If a strip harvesting technique is to be used, the pa- border are oriented in a superior/upward direc- 507 451 tient remains in the upright, seated position for the tion, creating a herring-bone pattern (Fig. 7). 508 452 excision. The strip is typically harvested from the This cross-hatching continues throughout the 509 453 occipital scalp and, depending on the number of body of the eyebrow until the tail portion, where 510 454 grafts needed, varies in length and width from the hairs then are primarily oriented horizontally. 511 455 about 3 to 5 cm and 10 to 15 mm, respectively. If Incisions are made as flat (acute an angle) as 512 456 the FUE technique is used, the patient is placed possible to the skin (Fig. 8). Once all the recipient 513 457 in the prone position for donor harvesting. Given sites are made bilaterally, the grafts are then 514 458 the smaller number of grafts needed, shaving of inserted. Care is taken to orient the hairs so that 515 459 the entire donor area can be avoided. Once the the direction of growth (ie, the curl) of the hair is 516 460 donor hairs have been harvested the patient is in an acute angle with the skin. We like to place 517 461 then positioned in a supine “beach chair” position as many 2-hair grafts as possible, except along 518 462 for incision site placement. Highly experienced the innermost head and lateralmost tail portion, 519 463 technicians perform the dissection of the har- where 1-hair grafts are used. If 3-hair grafts are 520 464 vested donor hairs under the microscope, under deemed appropriate, they are placed in the cen- 521 465 the supervision of the surgeon. Naturally occurring tral aspect of the body portion, to achieve 522 466 1- and 2-hair follicular units are dissected, maximal density. It is critical to make just about 523 467 although, in some cases, 3 hair follicular units are all of the recipient sites before any planting is to 524 468 used to achieve maximal density without compro- be done, then, after all these recipient sites are 525 469 mising naturalness. filled with grafts, the patient is asked to sit up 526 470 The eyebrows are anesthetized, and 1:50,000 and the eyebrows are inspected; small adjust- 527 471 epinephrine is injected for hemostasis. Recipient ments can then be made with the placement of 528 472 more grafts. The patient can then view the eye- 529 473 brows to obtain his/her feedback regarding sym- 530 474 metry and the desired shape. 531 475 532 476 533 477 534 478 535 479 536

480 FPO FPO 537 481 = = 538 482 539 483 540 484 541 485 542 print & web 4C print & web 4C 486 Fig. 6. Male eyebrow demonstrating the lateral thick- Fig. 7. Image demonstrating the direction of eyebrow 543 487 ening over the area of the lateral limbus. graft placement and the size of the grafts. 544

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545 procedure can be performed after 10 months or 604 546 more to achieve greater density. 605 547 Lastly, poor hair growth angulation can occur in 606 548 607 the occasional case despite the best efforts in 549 608 550 acute recipient site angulation and hair placement. 609 551 This is likely because of the effects of healing and 610 552 subtle contracture. It is most commonly 611 FPO 553 = seen in patients with straight hair, in whom the har- 612 554 vesting of the natural curl to assure flat growth of 613 555 hairs is difficult. To best prevent this, an acute 614 556 angle is taken with the skin when making recipient 615 557 sites and rotating the hair on insertion, so that the 616 558 print & web 4C natural curl of the hair is aimed downward. It is also 617 559 Fig. 8. Incisions are made in an angle as acute as 618 best not to trim the hair in the donor area—if by 560 possible to the skin. 619 561 strip method—to better visualize the hair curl. 620 562 621 563 Potential Complications and Their Postprocedure Care 622 564 Management 623 Patients are instructed to keep the eyebrows dry for 565 624 the first 5 days. If strip harvesting was performed, 566 The most common complications related to 625 567 eyebrow hair restorations are asymmetry, rather sutures are removed approximately 10 days post- 626 568 than anticipated hair regrowth, and poor hair operatively, or the dissolvable sutures are expected 627 569 angulation. It is important when marking the eye- to be gone by 4 weeks. Antibiotics and pain medi- 628 570 brows that symmetry is checked and rechecked. cations are given for the first several days. Patients 629 571 It is also helpful to view the immediate photo are allowed to use makeup in the eyebrow area af- 630 572 once the markings have been made. The viewing ter all the crusts have fallen out at typically 5 days. 631 573 of the photos helps to provide a “third” eye and Eyebrows will start to regrow 4 to 6 months after Q9 632 574 633 different perspective, often revealing asymmetries transplant and will continue to fill in for a full year, 575 634 that may not have been immediately apparent. As gradually increasing in density. A variety of prod- 576 635 ucts can be used to train any misdirected hairs. 577 mentioned previously, recipient sites are first 636 578 made along these markings, along the boundaries The hair must be trimmed to the patient’s desired 637 579 of the eyebrow, before they can be rubbed off and length. If a patient so desires, second smaller pro- 638 580 lost. The local anesthesia and the swelling can cedures to increase density are performed 639 581 create asymmetries during the procedure, making 10 months or later. 640 582 1 eyebrow appear higher than the other and thus 641 583 creating artifactual asymmetric appearances that REFERENCES 642 584 are more difficult to correct at the end of the pro- 643 585 644 cedure. To limit this phenomenon, it is best to 1. Rassman WR, Berstein RM, McClellan R, et al. Follic- 586 645 administer the local anesthetic at the beginning ular unit extraction: minimally invasive surgery for hair 587 646 transplantation. Dermatol Surg 2002;28:720–8. 588 of the case and to have the patient sit up to check 647 589 for symmetry before adding more local anesthetic 2. Harris J. Conventional FUE in hair transplantation. In: 648 590 during the procedure. Unger W, Shapiro R, Unger R, editors. Hair transplan- 649 591 Another potential complication is related to poor tation. 5th edition. New York: Thieme; 2001. p. 291–6. 650 592 eyebrow density. This is most likely because of 3. Donor area harvesting. In: Unger W, Shapiro R, 651 593 lower than expected percentage of hair regrowth. Unger R, et al, editors. Hair transplantation. 5th edi- 652 594 Despite the best efforts to keep the grafts moist, tion. New York: Thieme; 2011. p. 247–90. Q10 653 595 as well as the atraumatic placement of the grafts, 4. Gandelman M, Epstein JS. Reconstruction of the 654 596 655 in certain cases 20% to 25% of the hair may fail sideburn, , and beard. Facial Plast Surg 597 656 to regrow. To minimize poor regrowth rates, the Clin North Am 2004;12:253–61. 598 657 599 grafts are kept “chubby” with a small cuff of sur- 5. Epstein JS. Hair restoration to eyebrows, beard, side- 658 600 rounding protective , and the most experienced burns, and . Facial Plast Surg Clin North 659 601 assistants perform the insertion of the grafts. Pa- Am 2013;21:457–67. 660 602 tients are advised that this is not necessarily a 6. Tosti A, Piraccini BM. Diagnosis and treatment of hair 661 603 complication, but rather something that simply disorders: an evidence based atlas. New York: In- 662 sometimes occur, and thus a second smaller forma Healthcare; 2005.

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