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in PRACTICE Eyebrow transplant procedure of 550 grafts for transgender male to female process. Raising Eyebrows Jeffrey Epstein, MD, FACS, discuses the ins and outs of eyebrow transplants By Jeffrey Epstein, MD, FACS hen it comes to eyebrows, removed then sutured closed. bushy is back. Going, going, These donor sites typically heal as a gone are the pencil-thin, fine-line scar less than 2 mm wide and Take-Home Points overly manicured brows that 5 cm long. The best scalp location is where About Eyebrow W Transplants involved almost daily maintenance with the hairs are least likely to turn gray and tweezing, waxing, threading, or laser hair (ideally) there is a slight curl to the hairs. removal. In patients who want to keep open the But what’s a patient to do now that possibility of shaving their head, the fol- 1) Shallow angulation (less than his/her natural brows are all but gone or licular unit extraction (FUE) technique 15o) is key to assure eyebrow simply too thin? avoids any linear donor-site incision. One hairs grow close to the skin rather Enter eyebrow transplants. The great downside of FUE is the slightly lower per- than sticking out. majority of which are performed to repair centage of hair regrowth. This compounds 2) The use of the smallest pos- the thin or complete absence of eyebrows what is already a challenge in all eyebrow sible recipient sites and follicular due to overplucking. procedures as hair regrowth is typically unit microscopic dissection allows As with all hair transplant procedures, around 85%, versus more than 90% for for the most natural-appearing the goal of eyebrow restoration is to reap- the scalp. Another downside with using and impressive results. proximate the natural direction, angle of FUE hairs is that because the hairs need 3) growth, and distribution of hairs. Because to be trimmed quite short for extraction, For patients who shave their of how reliably they regrow, scalp hairs it’s more difficult to appreciate the natural head, follicular unit extraction can make the best donor hairs. On request curl of the donor hairs, thus making it be a viable alternative to follicular to avoid the need for regular trimming, challenging to achieve proper alignment of unit grafting. I have used both chest and leg hairs each graft so that its curl complements the with less reliable regrowth. The scalp desired angulation of hair growth. donor hairs need to be trimmed usually The great majority of eyebrow proce- (or typically) twice monthly because they dures are performed to repair the overly (patients must no longer pluck), scarring continue to grow as if they were still on thin or complete absence of eyebrows due from prior trauma, and genetics. While the scalp. The preferred technique for to overplucking. Other causes include not a contraindication to having the proce- obtaining these donor hairs is follicular hypothyroidism (thus the need for obtain- dure, occasionally a prior tattoo for perma- unit grafting, where a single donor strip is ing thyroid function tests), trichotillomania nent makeup can result in some hair loss. 24 PlasticSurgeryPractice.com November 2012 Direction of recipient sites is critical for eyebrow transplants. Patients need to understand that the goal what they want, which corresponds to of the procedure is not to achieve “perfect” the fact that the masculine eyebrow is eyebrows, but rather a significant improve- usually rather flat and not very sculpted, SCAN ME! ment in their appearance. A small percent- with some scattered hairs both below and age of hairs will typically not grow in the above the main eyebrow. There can be ideal direction, so they can be plucked out the suggestion of an arch along the lat- or trained to grow in the desired direction. eral limbus region, achieved by having the Patients are also instructed on the need for vertical width (thickness of the eyebrow) trimming of the eyebrow hairs which grow in this area a bit greater. For both men at the same rate as scalp hairs. and women, other factors that impact the shape, size, and position of the eyebrows EYEBROW ARTISTRY include the shape of the orbital region and The design of the eyebrows typically the position of the hairline. differs by sex, reflecting concepts of mas- culine versus feminine beauty. In women, UNDERSTANDING THE EYEBROW there is generally an arch that usually cor- TRANSPLANT PROCEDURE responds somewhere between the lateral These procedures are usually per- limbus and lateral canthus. This design formed under local anesthesia comple- can be slightly or more sharply angled mented by oral sedation with diazepam Scan the QR code above depending on how dramatic an eyebrow and Ambien®. Once anesthetized, the shape is desired. The inner aspect of the donor strip is removed with the patient with your smartphone to eyebrow usually corresponds to the medial sitting in an upright position, then the connect to our canthal region, keeping in mind that there area is sutured closed with a running 3-0 Online Buyer’s Guide. will be progressive medialization of the Prolene® or Caprosyn® suture. The latter eyebrow with aging which connotes senes- is self-absorbing, making it convenient cence. Not uncommonly, female patients for out-of-town patients. With the typical will already have a good idea of the desired procedure consisting of 600 grafts, this shape and size of the brows and are donor strip is on average 4 to 5 cm in offered the opportunity to bring in pho- length and approximately 1 cm in width. tos of eyebrows they like and even mark Care is taken to find the best possible out the eyebrows. donor location, which is where the hairs Men usually have less of an idea of are least likely to turn gray, have a slight to November 2012 PlasticSurgeryPractice.com 25 in PRACTICE moderate curl as desired (if available), and are of somewhat thin caliber (once again, if available). If the procedure is to be done by the FUE technique, these donor grafts are typically extracted from the back of the head with the patient lying in a prone position. Rather than having to divide three and four hair follicular units into one and two hair grafts, it is best to extract just one and two hair follicular units (the ideal number of hairs per graft with these eyebrow procedures) that will likely have a higher percentage of hair regrowth than these divided grafts. For most patients, one hair graft will achieve the most natural- appearing results. Patients with fine hairs often require use of some two hair grafts in the center aspect of the eyebrows to increase the density. As the grafts are being dissected under microscopes by trained hair technicians, I will craft the recipient sites (between any already-existing hairs) into which the hair grafts will get placed. These recipient sites are made with the small blades 0.5 and occasionally 0.6 mm in size to minimize movement of the grafts during the early postop period that can result in a direction of hair growth different from what was intended, as well as to reduce crusting and the healing. Working within the surgical markings, any existing hairs can serve as Natural-appearing eyebrows can be achieved in patients with curly hair. a template for direction of growth (unless that direction is distorted as a result of recipient sites to maximize density and The cost of an eyebrow transplant rang- scarring in the area). It is important that assure symmetry. The procedure is only es from $4,000 to $8,000, and requires the surgeon understand the aesthetics of completed once the patient approves of routine trimming and some grooming, but natural direction of hair growth because the final appearance, helping to achieve these costs seem well worth it for patients sometimes there are no original hairs. the highest patient satisfaction. who can now wake up and go swimming The direction of growth of eyebrow without having to worry about how their hairs varies from patient to patient and EYEBROW TRANSPLANT RECOVERY from one region to another. In general, eyebrows look. Challenges do exist, but from medial to lateral, the hairs first grow For the first 5 days, the eyebrows are eyebrow patients are among my happiest ■ upward/vertical then quickly become more kept dry to minimize the chance of the and most appreciative. hairs moving or falling out, after which horizontal as they create a crossed-hatch Jeffrey S. Epstein, MD, FACS, is the direc- pattern. The cephalic hairs grow gently makeup if desired can be used. Antibiotics and analgesics (for the donor site) are tor of the Foundation for Hair Restoration, and downward and the caudal hairs grow gen- maintains full-time offices in Miami and New tly upward. In the lateral one-third of the provided for the first several days. The York City. He is also a Voluntary Assistant eyebrow (the tail), the hairs grow mostly tiny crusts usually fall off usually by day 5, Professor at the University of Miami. He can lateral and sometimes slightly downward. leaving in place the transplanted hairs for be reached at [email protected]. The other important consideration for 1 to 2 more weeks before they fall out. making recipient sites is to have the hairs The transplanted hairs start growing grow as flat as possible along the surface of back in 4 to 6 months and require trim- ming every few weeks. A variety of tech- the skin so that they don’t stick out. WATCH THE VIDEO The grafts get transplanted into the niques can be used to “train” any misdi- recipient sites with jewelers’ forceps, a del- rected hairs so that they grow closer to the In the PSP Digital Edition, watch three videos of icate process requiring minimal mechani- desired direction, which include the appli- Dr Epstein performing eyebrow procedures: cation of some gels and other products.

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