AAMJ, VOL. 11, N. 2, APRIL, 2013 ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ EYEBROW HAIR TRANSPLANTATION MAHMOUD NASEF, SERAG MONIER, AYMAN FARAHAT and AYMAN EI-TRAMSY Department of Plastic and Burn Surgery, Faculty of Medicine, Al-Azhar University. ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ ABSTRACT The eyebrow is one of the most aesthetic features in the face, many causes may lead to loss of the eyebrow, In this article we describes a technique for eyebrow restoration by using single hair micrografts(1-2 hair) transplantation . This study was done for thirteen patients aged from 18 to 40 years old with different causes of eyebrow hair loss where a strip was taken from the scalp occipital hair and cutted to multiple single hair micrograftsthen applied to the recipient eyebrow and followed to review the aesthetic outcomes.
Eyebrows are central to a person’s appearance, as they frame the eyes and give symmetry to the face. The partial or complete loss of one’s eyebrows can produce a profound change in one’s look and have a devastating effect on a person’s sense of confidence and self-esteem.
A variety of conditions can results in a loss or alteration of the eyebrows.Probablyrepeated plucking of the eyebrows for aesthetic reasons, or less often from a compulsive disorder called trichotillomania causes the most common. Those who pluck hair as an obsessive-compulsive disorder (OCD) should not be transplanted without addressing the OCD first, since transplanting the eyebrow will fail as the patient returns to old habits. Other forms of physical trauma that may result in loss of eyebrows include car accidents, burn
MAHMOUD NASEF et al ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ injuries,alopecia aerate, defects from surgical procedures, and radio- and chemotherapy. 
The normal hair cycle varies from months to years; depending upon the part of the body the hair is located. Each hair regenerative cycle has a growth phase called anagen and a resting phase called telogen. The anagen phase for scalp hair ranges from 3-6 years while the anagen phase of the eyebrow hair is significantly shorter. The rate of growth for scalp hairs ranges from .30-.41 mm per day (about a half inch per month), while the growth rate of the eyebrow hair is half of that. Proper angulation is the most important aspect of any eyebrow transplant. The hair in the upper part of the central edge of the eyebrow usually points upward to the hairline, while the hair on the lateral aspects points horizontally, towards the ears. The hair in the upper part of the eyebrow should be pointed slightly downward and the lower portion slightly upward, so that they will converge in the middle, forming a slight ridge and resembling the pattern of a feather.
When scalp hair is transplanted to the eyebrow, the longer hair cycle of the scalp hair makes it grow to a cosmetically unacceptable long length. This necessitates frequent trimming of the eyebrows that is not only a nuisance, but also that produces a cut end that is less elegant than the finely pointed tip of an uncut hair.
In this study, we used a single hair micrografts transplanted from scalp to eyebrow for restoration of eyebrow hair loss, explained the technique and the aesthetic outcomes.
PATENTS AND METHODES
Thirteen patients suffered from eyebrow loss were included in this study from January 2010 to January 2013 five cases were done at Al- Azhar university
AAMJ, VOL. 11, N. 2, APRIL, 2013 ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ hospitals and eight cases were done at private hospitals, ten cases were bilateral loss and three cases were unilateral loss, eight cases were females and five cases were male, aged from 18 to 40 years old all cases were submitted for restoration of their eyebrow by single hair micrografts (1-2 hair ) transplanted from scalp to eyebrow .
The outline of the eyebrow transplantwas carefully delineated using a fine surgical marker according to the design that the doctor and patient had agreed. Markings should also be used to indicate the directional change of the hair as onemovemedial to lateral. It is often helpful to make these markings above the brow (outside the area that will be transplanted) so that they are not lost as, the sites are being made.
Once the markings were completed, the patient given a mirror to make sure that this is what they had discussed and that the design is satisfactory.
Marking of the donor area at the occipital part of the scalp and trimming of the hair at donor area was done.
The patient lies on prone position with elevation of the table head for head and neck decongestion ,sterilization and toweling ,local anesthesia Xylocine (Bubavicine 2% ) injected subcutaneously in the donor area starting near the lower margin figure(IA) , injection of norepinepheren (1:200,000) was done as vasoconstrictor hemostasis and bloodless operative field ,The marked ellipse was excised by surgical plade number 10 figure(1B), dissection was done deeply in the subcutaneous plane just superficial to the galea , hemostats was done figure(1C) , closure of the wound in one layer by using non absorbable sutures ( proline 3/0 ) as showen in figure ( 1D). 328
MAHMOUD NASEF et al ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ The donor strip was placed on hard wooden cutting board and was cut into small slices (2-3 mm wide by sterile razor under magnification power (loope 4x ) maintaining a direction parallel to the shafts and follicles,the follicular units were separated from the slice by sterile razor in the form of micrografts (1-2 hair in each graft)the micrografts arranged in rows on sterilized wooden tongue depressors and covered by soaked saline to avoid dryness figure (2).
The patient was turned to supine position, we didsupra-orbital and supra trochlear nerve block to Anaesthetize the recipient eyebrow also local tumescent infiltration was done. Recipient sites were created using (18-2og needles) depending upon the coarseness of the hair. If the patient’s scalp hair is very light and fine, 2-hair grafts were used in the central part of the brow to create extra density, but these grafts should not be placed near the edges. The grafts should be inserted using fine jeweler’s forceps under loop magnification. The hair must be literally stuffed, rather than inserted, into the sites, as the site is too small to accommodate both the graft and the forceps figure (3)
Postoperative follow up
No dressing was required post-operative and the patient was instructed to sleep with his/her head elevated. The following morning, the patient should gently irrigate the transplanted area to remove any dried crusts. This should be done in the shower at least three times the day following surgery and twice daily for a week. After each shower, an antibiotic ointment was applied to the brow to help soften any crusts and enable to them to be more easily removed with the next washing. There was often bruising after the surgery that may take a week or more to subside to normal. Broad-spectrum antibiotic and anti edamotus was given to patient for 5 days.Hair tonics were taken for one month. Removal of donor suture was done after 10 days and the patient followed every two months for six months.
AAMJ, VOL. 11, N. 2, APRIL, 2013 ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ Figure (1)
(A) (B) (C) (D)
(A) (B) (C)
(A) (B) (C)
There have been thirteen patients presented with eyebrow hair loss treated by using single hair micrografts from the donor strip of the occipital area of the scalp , the average grafts were 150 per each eyebrow , the post-operative follow up was average 6 months . there was great satisfaction in 10 cases (76.9 %) about the direction and the density of the transplanted hair figure (4,5,6) , three 330
MAHMOUD NASEF et al ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ cases (23.1%) were unsatisfied by the density and distribution of the transplanted hair , two of them also had unsatisfaction about the direction of the transplanted hair specially in the central part of the transplanted eyebrow , one case had implantation dermoid cyst at the eyebrow which need excision, there no a symmetry in bilateral cases , no morbidity at the donor side ( no widening of the scare and no areas of alopecia )
Female patient 24 years old preoperative and postoperative Figure (5)
Figure (5) preoperative Male patient 33 years old with alopecia areata
Figure (6) Female patient 35 years old preoperative and preoperative postoperative
AAMJ, VOL. 11, N. 2, APRIL, 2013 ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ DISCUSSION The eyebrow hair loss is one of challenges, whichfaces a plastic surgeon, many techniques were used to reconstructe the eyebrow as tattooing. Which was un satisfactory for some patiets. Eyebrow reconstruction is based on the technology first reported by Krusis in Germany in 1914 and later by the Japanese in the 1930 and 40s. In 1943, Tamara reported that single-hair grafts should be used for the restoration as these would look the most natural. Nearly a half-century later, w the most advanced type of scalp hair transplantation consists of using naturally occurring follicular units containing 1-4 hairs, the most refined type of eyebrow transplant still consists of using individual hair follicles .
The advance in eyebrow restoration lies, therefore, not in the use of individual hairs – this has been known for a long time – but in the adoption of techniques used in scalp hair transplantation that enable the physician to carefully isolate these individual hair follicles from the donor scalp. Argentaetal , 1983 used strip graft (2.5 cm length ) from the parital area of the scalp and apply it as graft to restore hair eyebrow , the result was un satisfactory due to loss of great numbers of hair from the strip and abnormal direction of the transplanted hair which give unnatural look of the eyebrow .Hogan etal 1997  used punch graft knife (3 mm diameter ) for harvesting the donor follicles from the scalp hair and transplanted to the eyebrow , but because of the large punch diameter he harvest more than one follicular unit and thus giving a final look of hair doll appearance with unnatural look of transplanted eyebrow.
Nordostome and Marrite ,1980 introduce the concept ofmicrografts (1-2 hair) and mini grafts (3-4 hair ) in hair transplantation .
Uebel,1997use a single micrograft for restoration of the eyebrow after burn to the face. Over time, the transplanted hair will assume some of the
MAHMOUD NASEF et al ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ characteristics of the site that it was transplanted into and the length of the transplanted hair will begin to gradually decrease. It is not known if the transplanted follicles will eventually assume the full characteristics of the surrounding eyebrow hair, but work byNilforoushzadehetal, suggests that influences of the recipient are more significant than was previously thought.
Our results meet Toscani’s results that The eyebrow transplanted hairs must be put in flat, or they will stick out pointing forward. The surgeon controls the direction and the distribution as the hair is transplanted into the eyebrow, and fine skills are required to densely pack single hairs into the small needle tracks that make for an undetectable wound..
Patients should understand that two or more sessions may be required to achieve a desired look. Sessions are best spaced a minimum of eight months apart so that the doctor may have the benefit of seeing the first session actually grow in before planning the second.
CONCLUSION Eyebrow transplantation is a safe, out-patient procedure that can significantly enhance one’s appearance. It is particularly helpful for those individuals who have defective eyebrows caused by disease, accidents or that have been self-induced. However, eyebrow restoration is a nuanced procedure that demands technical skills and artistic knowledge,Theuse of single hair micrografts(1-2hair) through small and nearby puncture increase the density and distribution of the transplanted eyebrow. The angulation and direction of the transplanted hair is the key for successful eyebrow transplantation which give natural look for the eyebrow
AAMJ, VOL. 11, N. 2, APRIL, 2013 ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ
REFERENCES 1-Argenta,L.C.Brandy,D,A.and Anderson, R.D.(1987) : Punch grafts : A6 years experience with over 400 cases : J. Dermatol surg.: (19) : 1005_1014 . 2-Barrera, A. (2004) :Hair transplantation the art of micro grafting and mini grafting St.Louis : Quality Medical Publishing , 3-Beehner,M. (1995) : Complete pre-operative and post-operative care for hair transplantation patients :H T . Forum Int.: (143) : 651-657 . 4-Bernstein ,R.M. (2007) : Experince of hair Transplantation : Int.J. ofAesth. Restor.Surg : (4) : 229 -232. 5-Choi Y-C, Kim J-C. (2004); In: Unger WP, Shapiro R, editor. Hair Transplantation. New York: Marcel Dekker, Inc; Eyebrow, eyelash, mustache and pubic area hair transplantation. pp. 579–584. 6-Gandelman, M.A technique for reconstruction of eyebrows and eyelashes.SeminPlast Surg. 2005; 19: 153–158 7- Hogan, D.J. :Bergfeld , W.F. : Savin , R.C. (2000) : Variation in hair Transplantation Surgery : H.T. Forum Intl, 10 (3) : 5_9 . 8-Marritt E. Transplantation of single hairs from the scalp as eyelashes. Review of the literature and a case report. J DermatolSurgOncol. 1980;6:271–273. 9-Nilforoushzadeh, M.A., Adibi, N., and Mirbagher, L., (2012) : A novel treatment strategy for eyebrow transplantation in an ectodermal dysplasia patient. J Res Med Sci. ; 17: 407–411 10-Toscani, M., Fioramonti, P., Ciotti, M., and Scuderi, N. (2011): Single follicular unit hair transplantation to restore eyebrows. Dermatol Surg.; 37: 1153–1158. 11- Uebel , C.O.; 1997 Follicular Unit Transplantation : A new approach for hair loss surgery , Ann.Plast.Surgery., (27) : 476-487
MAHMOUD NASEF et al ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ
ؼٌزجش الحبجت مه اهم ػالمبد الجمبل ثبلىجه وؼٌذ فمذ الحبجت مه االمىس السٍئخ الزً رفمذ االوسبن ثكرخ ثىفسخ ورىاصله مغ المجزمغ و هىبن اسجبة ػذٌذح لفمذان شؼش الحبجت مثل الحشوق واالصبثبد الىبرجخ ػه الحىادس والؼبداد الؼصجٍخ السٍئخ لجؼض الىبط والمصبحجخ للزىرش والزً ٌزم مؼهب شذ الحىاجت
ولذ حذس رطىس وجٍش فً صساػخ شؼش الحىاجت فً الفزشح االخٍشح سىاء ػه طشٌك اخ ر ششٌحخ مه شؼش الشا ط او ثطشٌمخ الزطبف الجصٍالد وؼٌذ المحبفظخ ػلى ارجبح الشؼش فً ػملٍخ صسع شؼش الحىاجت مه اهم الؼىامل الزً رؤدي الى وجبح وسضبء المشٌض ػه الؼملٍخ
ولذ اجشٌذ هزح الدساسخ ػلى 13 مشٌض مىهم 8 وسبء و5 سجبل رزشاوح اػمبسهم مه 18 _40 سىخ ؼٌبوىن مه فمذ شؼش الحىاجت ػه طشٌك اخز ششٌحخ مه شؼش الشاط مه المىطمخ الخلفٍخ ورم ومل ثصٍالد الشؼش مزىبهٍخ الصغش ) رحمل مه 1-2 شؼشح فمط ( الى الحىاجت المشاد صساػخ الشؼش ثهب ووزج ػه رله وزبئج مشضٍخ لهزح الؼملٍخ وهزح الىزبئج رؼزمذ ػلى خجشح الجشاح ودلخ فصل الجصٍالد وطشٌمخ وضغ الجصٍالد وارجبح الشؼش المضسوع فً الحبجت