What's New in Facial Hair Transplantation?
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1 What’s New in Facial Hair 2 3 4 Transplantation? 5 6 Effective Techniques for Beard and Eyebrow 7 8 Transplantation 9 10 Q2 Anthony Bared, MD* 11 12 13 KEYWORDS 14 57 Facial hair 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 hair transplantation 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 Eyebrows 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 laser hair removal, scarring, burn, or cleft lip 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 face 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 beards 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 hairs 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 scalp in the future if male pattern hair loss 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 FSC944_proof ■ 24 April 2019 ■ 6:33 pm 2 Bared 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 hairstyle. 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 goatee, and 300 to 500 grafts 183 Once the extractions have been completed from 127 per cheek. 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 camouflage facial scars. shown the outline and design of the beard. 202 FSC944_proof ■ 24 April 2019 ■ 6:33 pm Q1 What’s New in Facial Hair Transplantation? 3 203 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 sideburns, 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 hand 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 skin, 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.