Cosmetic and Reconstructive Eyelash Transplantation

79 Cosmetic and Reconstructive Eyelash Transplantation

Alan J. Bauman

Summary

Recent beauty trends have prompted greater demand for treatments and procedures that enhance or restore eyelash growth. The quest for surgical improvement of a deficient eyelash line dates back over a century. Surgical advancements over this time period now allow for predictable and satisfying results in the restoration of eyelid hypotrichosis. Contemporary techniques for surgically restoring a full lash line focus on the meticulous placement of microscopically dissected single- and double-hair grafts using a French-eye needle. Other than short-term ecchymosis and edema, complications following surgical lash restoration are extremely uncommon.

Keywords: eyelash eyelid hypotrichosis bimatoprost Latisse

Key Points

•Eyelash transplantation can be used for cosmetic enhancement and reconstruction.

•The color, curl, and caliber characteristics of the transplanted follicles will be the same in the eyelid as they were in the donor region.

•Patients must fully appreciate and accept the long-term need for routine trimming, curling, and possibly perming and tinting of the transplanted lashes.

79.1 Eyelashes: Form and Function

Beyond the simple eye protection from dust motes and other debris that eyelashes afford, beauty has been enhanced through the ages by the outlining of one’s eyes, the use of mascara, false lashes or eyelash extensions, and more recently with Food and Drug Administration (FDA) approved eyelash growth medication and eyelash transplant surgery.

Although eyelash transplantation had been described in the medical literature in the early 1900s, it still makes up a small but increasing percentage of all procedures performed by hair restoration physicians. More recently, cosmetic and reconstructive eyelash transplants have been the specific focus of Live Surgery Workshops. In 2006, approximately 1.4% of all hair transplant procedures were performed on eyelashes versus 0.35% in 2004.1^,²^,³ Recent trends in patient enquiries in the author’s practice are showing a steadily increasing demand for treatments and procedures that enhance or restore eyelash growth.

79.2 Hypotrichosis of the Eyelashes

Eyelash hypotrichosis is, by definition, a lack of eyelash length, caliber, density, or other characteristics that cause lashes to be missing, weak, or otherwise inadequate. Some causes of eyelash hypotrichosis are listed in Table 79.1.

Table 79.1 Causes of eyelash hypotrichosis

•Age

•Heredity

•Injury (i.e., burn, car accident, eyelid surgery, other trauma)

•Trichotillomania

•Alopecia areata

•Severe inflammation of the lid

•Chemotherapy

•Eyelash extensions, false glue-on lashes

79.3 Eyelid and Eyelash Anatomy

Familiarity with eyelid and eyelash anatomy is essential in order to understand the complexity and intricacy of surgical eyelash restoration (Fig. 79.1).

Fig. 79.1 Eyelid anatomy.

79.4 History of Eyelash Transplantation⁴

In 1914, Krusius published his technique in Germany for reconstruction of lost eyelashes by harvesting donor follicles from the scalp with a small punch and transplanting them into the eyelid with a specially designed needle.⁵ A version of the Krusius needle is still used today. In 1917, Knapp inserted a composite free graft strip harvested from the eyebrow into the eyelid.⁶ Sasagawa reported a single-hair follicle insertion method in 1930.⁷

In 1980, Marritt published his technique for transplantation of single-hair grafts from the scalp into the eyelid for eyelash reconstruction.⁸ Caputy and Flowers also described using single-hair follicles for eyelash reconstruction using a “pluck-and-sew” technique.⁹ A revised version of the “pluck-and-sew” technique was described by Gandelman¹⁰^,¹¹ using “reverse follicular unit extraction” in which donor follicles are separated from an elliptical donor strip or circular punch harvest using a “pluck” method from below. The author has found that eyelashes may be implanted two at a time using the sewing method, if careful alignment of the follicles is maintained.¹²^,¹³ A variety of other eyelash harvest and transplant techniques proposed over the years are listed in Table 79.2.¹⁴^,¹⁵^,¹⁶^,¹⁸

Table 79.2 Eyelash transplantation techniques

•Strip grafts from eyebrows

•Strip composite sideburn grafts¹⁴

•Pedicle flaps from eyebrows

•Single follicles inserted into the eyelid with a French-eye needle

•A pair of single follicles inserted into the eyelid with a French-eye needle¹²

•A two-haired follicular unit inserted into the eyelid with a French-eye needle¹²

•Single follicles inserted into the eyelid with a curved 18-gauge needle¹⁵

•Use of automated needles¹⁶

•Reverse follicular unit extraction of long hair¹¹

•Direct placement of grafts into overlapping coronal slits in the eyelid¹⁸

79.5 Patient Selection

Eyelash transplantation can be used for cosmetic enhancement as well as reconstruction. Appropriate candidates should display a good understanding of the risks, benefits, alternatives, and common sequelae of the procedure. As with any cosmetic procedure, candidates for eyelash transplantation should be carefully screened for body dysmorphic disorder.

Eyelash transplant candidates should have healthy donor follicles, as well as a donor scalp free of skin irritation or other conditions.

Since donor hair follicles are being harvested from the scalp, the patient must be made aware that the color, curl, and caliber of the harvested follicles will produce the same characteristics in the lid. Exceptionally coarse, straight hair and exceptionally kinky-curly or tightly spiraled hair may be less suitable for eyelash transplantation due to the necessary management of the resulting hair growth.

Patients should be well informed regarding the long-term need for routine trimming and curling (as well as perhaps perming and tinting) of the transplanted lashes. Patients unwilling to commit to the necessary maintenance of the transplanted lashes should be excluded from undergoing the procedure. Several before and after results are shown in Fig. 79.2, Fig. 79.3, and Fig. 79.4.

Fig. 79.2 A 36-year-old woman (a) before and (b) 12 months after eyelash transplantation.

Fig. 79.3 A 23-year-old female patient who underwent eyelash and eyebrow transplantation after a car accident left her with right eyelash and eyebrow loss. (a) Before eyelash and eyebrow transplantation. (b) After eyelash and eyebrow transplantation.

Fig. 79.4 Successful eyelash transplantation in a recovered trichotillomania patient. (a) Before. (b) After eyelash transplantation.

Preoperatively, the eyelids should be free from any visible inflammation and anatomical abnormalities, especially in trauma patients. Recovered trichotillomania patients should be “pull free” for at least 1 year or longer and be made aware that recurrence of eyelash pulling will put the transplanted lashes at risk. Trichotillomania patients with severe eyelash hypotrichosis often complain of the irritation they experience from dust motes and debris entering the eye and have a high degree of satisfaction after eyelash transplantation. The author refers these patients to Cognitive and Behavioral therapists and response has been very satisfactory.

Patients should be educated regarding the need for additional transplantation in the cases with significant eyelash loss or if a particularly high density of lashes is a goal. Patients should also be questioned regarding the use of glued-on eyelash extensions or false strip lashes, which can damage existing lashes as well as transplanted ones. Some of the absolute and relative contraindications to eyelash transplantation are listed in Table 79.3.

Table 79.3 Eyelash transplant contraindications

•Absolute contraindications (poor candidates)

•Trichotillomania (active or within 1 y)

•Inflammation of the lid/lid margin (active or within 1 y)

•Bleeding disorders

•Body dysmorphic disorder

•Alopecia totalis/alopecia universalis

•Relative contraindications (may make the procedure more difficult or outcome less predictable)

•Blood thinners

•Hypertension

•Wound healing disorder

•Alopecia areata of the lid

•Autoimmune diseases that affect the eye, eyelid, or lacrimal glands

•Scalp hair length <4cm

•Abnormal lid anatomy (e.g., due to trauma)

•Patient has poor understanding of routine eyelash transplant maintenance

•Very “kinky-curly” donor hair or very coarse, straight hair

79.6 Methods

After a complete discussion of the known risks and benefits of eyelash transplantation, informed consent is obtained and the patient is escorted to the procedure room. The technique described requires the operating surgeon to have two assistants proficient in microscopic dissection and handling of single-hair follicle grafts. A complete understanding of eyelid anatomy is essential for performing this procedure. See Video 79.1, 79.2, and 79.3 for demonstration of both reverse needle and direct methods of eyelash transplantation.

79.6.1 Preoperative Preparation

Preoperative preparations include the following: Diazepam 10 mg administered orally; scalp wash; alcohol swab prep of eyelid; topical 4% lidocaine cream applied to eyelid and donor area.

79.6.2 Donor Area

Local anesthesia (2% lidocaine with 1:100,000 epinephrine) is applied to the occipital scalp in an area with untrimmed, long hair (approximately 10 cm or more). Bupivacaine 0.5% is also applied. A small linear harvest (e.g., 5 cm× 0.5 cm) with trichophytic closure is performed using single layer, running 5–0 Monocryl. Excising an area of this size allows one to obtain a sufficient number of high-quality grafts.

79.6.3 Dissection

Surgical Technique 1

High-quality single-follicle grafts are carefully dissected under high-powered magnification, leaving the hair length long (~10 cm). Follicles producing “split,” damaged, or otherwise frayed hairs are not used.

Surgical Technique 2

Hair shafts are threaded into French-eye needles (single or paired, as desired), taking care to keep grafts moist with normal saline on a cold, moist surface (Fig. 79.5).

Fig. 79.5 Typically, single follicles are implanted into the lid. Although it is more technically challenging, the author also uses pairs of follicles to increase lash density. A pair of follicles, ready for implantation with a single stroke, are loaded on a French-eye needle.

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