Beard Transplant

81 Beard Transplant

Kapil Dua, Aman Dua, and Nirav V. Desai

Summary

The indications and acceptance of beard and moustache reconstruction have increased significantly over time. Indications are diverse and include (1) cultural and religious appearance goals in the Middle East, (2) congenital absence or sparse hair, (3) surgical or traumatic loss, (4) recurrent folliculitis, and (5) traction alopecia among the Sikh population of India. Before undertaking any patient for this procedure, it is imperative to properly understand the anatomy and physiology of this part of the face to produce a natural-looking beard and moustache. The donor grafts can be harvested from the scalp or the beard depending upon the graft number requirement. Strip harvesting or follicular unit extraction (FUE) can be used for the procurement of scalp grafts, while FUE is used exclusively for harvesting beard follicles. Recipient site preparation requires special care to make slits at a proper acute angle and to strategically distribute appropriate densities in the various subunits of the face. The implantation is more difficult and time-consuming as compared to the scalp. When treating well-informed patients with realistic expectations, the authors have found the procedure effective and the results to be exceedingly rewarding.

Keywords: beard hair restoration beard hair transplant moustache transplant moustache reconstruction facial hair transplant facial hair restoration beard and moustache zones

Key Points

•Recipient site creation is one of the most important steps of beard and moustache reconstruction.

•Proper understanding of the subdivisions of the face is necessary to give adequate density.

•Acute angulation nearly flat to the skin surface and proper direction of the slits are mandatory to produce a natural-looking beard.

81.1 Introduction

An increased awareness about the possibility of the beard and moustache reconstruction has led many people to seek transplant in these areas. This is clearly depicted by a recent International Society of Hair Restoration Surgery (ISHRS) survey released in 2015 in which the number of patients undergoing facial beard and moustache hair transplant had increased from 1.5% in 2012 to 3.7% in 2014, a 196% increase.1 This increase has been mainly due to the steady increase in the demand for this procedure in the Middle East.² The number of the beard transplants has also increased in North India because of the socioreligious culture in which it is taboo for the Sikhs (one religion) not to have beard.These along with other indications mentioned later have led to the increased demand for beard and moustache reconstruction. Further developments in the technique of restoration will be discussed later (Video 81.1).

81.2 Indications

Common indications for beard and moustache transplants include the following:

•Scars due to trauma, burns, or surgery (Fig. 81.1).³

•Traction alopecia (especially in Indian Sikh population; Fig. 81.2).

•Congenital hypotrichia and atrichia.

•Scarring alopecia secondary to recurrent folliculitis

•Long-standing inactive alopecia areata following failed medical management.

•To enhance cosmetic appearance, improve density, and strategically shape the beard or moustache (Fig. 81.3a–c).

Fig. 81.1 Scarring alopecia due to burn in beard.

Fig. 81.2 Traction alopecia of beard.

Fig. 81.3 Reshaping of moustache along with camouflage of surgical scar. (a) Preoperative. (b) Immediate postoperative. (c) Postoperative result.

81.3 Physiology and Anatomy

After puberty, secondary sexual “terminal” hairs develop in the beard and moustache from vellus hairs in response to androgens, especially testosterone in males.⁴ These terminal hairs increase in density until the mid-30s. The direct evidence of this relationship was established by the fact that beard growth was prevented by castration before puberty and was stimulated by subsequent treatment with testosterone.⁵ However, both growth hormone and androgens are required for proper maturation of the moustache and beard as growth hormone–deficient boys have been shown to be less responsive to androgens.⁶

Similar to the scalp, beard and moustache hair follicles undergo cyclical changes of regression and regeneration known as the hair cycle, which consists of anagen, catagen, and telogen phases. There is variation with regard to the duration and percentage of hair follicles in anagen and telogen phases at any given time.7 Studies have revealed a 12-month anagen/2- to 3-month telogen duration in beard hair and a 2- to 5-month anagen/1.5-month telogen duration in moustache hair.⁸^,⁹ These same studies have shown approximately 15 to 30% of beard follicles and 34% of moustache follicles to reside in telogen at any given time. Beard follicles commonly measure 2 to 4 mm in length.

81.4 Zones

It is well known that we can never transplant the same number of hairs in the beard as are typically present in the average normal person. It is imperative, as in the scalp, to place the limited number of available hairs in important areas so to optimize the final result. With this idea in mind, the face is divided into frontal and lateral zones with various subdivisions Fig. 81.4).¹⁰

Fig. 81.4 Zones of beard and moustache.

Subdivisions of beard for transplant purpose
Frontal zone	1	Moustache
	2	Goatee
	3	Central portion of the upper part of the neck
Lateral zone	4	Side burns
	5	Cheek beard
	6	Jaw beard
	7	Submandibular beard extending to the upper neck
	8	Lateral portion of the upper part of the neck

Of the various zones described, the moustache, goatee, and cheek beard are cosmetically most important and require special attention. The density is kept higher in these areas as compared to the remaining areas. The neck portion of beard is cosmetically less important so it is usually not covered during the full beard transplantation in order to limit the number of required grafts.

81.5 Characteristics and Distribution of Density in Beard Hair

A follicular unit in the beard and moustache area usually contains a single hair. The diameter of beard hair is larger than that of scalp hair.¹¹ This is consistent with beard follicles having a broader follicular bulb, which harbors a larger dermal papilla.¹² Hair density in the beard varies greatly within the individual and also among various ethnic groups. Indian and Middle Eastern men have relatively higher density as compared to Japanese men.³ The authors have observed that the maximum density occurs over the chin and moustache. Density in the centrally located philtrum region of the moustache can vary compared to the lateral moustache area, being less dense in some individuals and being the same in others. Density is also higher along the jawline and in the sideburns compared to the density in the cheek. Hair density in the submandibular region and the upper part of the neck can vary greatly among different individuals. A small study conducted on 10 Indian patients found the density to vary from 50- to 55/cm² in cheek, 70 to 75/cm² in the goatee of beard, and 70 to 85/cm² in the moustache.

81.6 Nerve Supply

The sensory innervation of the face is derived from the trigeminal nerve, which is divided into ophthalmic, maxillary, and mandibular divisions, each supplying the upper, middle, and lower face, respectively. Anesthetic block of the maxillary division will be required for centrally located mustache restoration and of the mandibular division for lower face and upper neck beard restoration.

81.7 Planning and Execution

The basic principles of the beard and moustache reconstruction are similar to other surgical hair restorations with minor modifications. A detailed examination of the face and proper understanding of patient expectations are required to determine the number of grafts required for achieving individual goals.

In the case of complete absence of beard and moustache, an in-depth discussion should be done with the patient regarding the boundaries and the shape of the beard that can be achieved. A scalp donor area would be required for such a case.

In the cases involving the restoration of a small area of beard or moustache, that is, secondary to scar, long-standing inactive alopecia areata, traction alopecia, etc., the surgeon may choose beard as donor source if agreeable to the patient. The choice of donor area will depend heavily on the number of grafts required for the reconstruction.

81.7.1 Administration of Local Anesthesia

In contrast to the scalp, anesthesia in the facial region can be painful. Nerve blocks can be used to limit pain caused by multiple anesthetic injections. Infraorbital blocks are best utilized for anesthesia in the moustache region and mental nerve blocks are used for the goatee region.

81.7.2 Infraorbital Nerve Block

The infraorbital nerve, a branch of the maxillary nerve, emerges from the infraorbital foramen located 6 to 10 mm below the infraorbital margin in the mid-pupillary line. This block can be achieved by injecting 1 to 2 mL of local anesthetic via either an intraoral or a transcutaneous route. Using an intraoral route, one hand guides the needle upward in the gingivolabial sulcus between the canine and the first premolar, while the other hand palpates for the tip of needle to reach the location of the infraorbital foramen. Anesthetic solution is administered once the tip of the needle reaches the foremen (Fig. 81.5a). In the transcutaneous approach, the needle is inserted through facial skin at the site of infraorbital foramen in the mid-pupillary line (~1 cm below the infraorbital ridge) by aiming at the foramen in a perpendicular direction. Once the bone is reached, 1 to 2 mL of local anesthetic solution is injected. This will anaesthetize the infraorbital area, upper lip, and moustache on the side of injection (Fig. 81.6).¹³