Refinements in hair transplantation techniques allow the experienced surgeon to create natural-appearing facial hair transplants. Restoring eyebrows, beards/goatees, and sideburns have all become popular procedures, and the results can be outstanding. This article provides a comprehensive review of hair grafting techniques to achieve the best results in restoring various hair-bearing areas of the face, including the eyebrows, beard/goatee, and sideburns, and repairing the alopecic scarring from prior facial plastic surgery.
Key points
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Facial hair transplant procedures are best performed using follicular unit grafting, using the smallest recipient sites into which the surgeon and his team are able to insert grafts.
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Angulation is the most critical step in achieving aesthetic results, taking care to make recipient sites at as shallow an angle to the face as possible.
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In the beard, the “danger zone” where bumps can occasionally form is located in a vertical central column extending inferiorly from the lower lip to the entire chin mound.
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Eyelash transplantation should be performed only if the patient fully understands the potential risks.
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For patients who shave their head, follicular unit extraction can be a viable alternative to the strip–follicular unit graft technique.
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The realistic goal of eyebrow and eyelash procedures in not perfection but rather significant improvement.
Introduction
Refinements in hair transplantation techniques have made natural-appearing facial hair transplants possible. Restoring eyebrows, beards/goatees, and sideburns have all become popular procedures, because of the amount of information readily available and the fact that the results can be outstanding. Eyelash restoration for purely aesthetic, nonreconstructive purposes is a controversial procedure because of the higher incidence of complications and because Latisse (bumatiprost) can safely and effectively make eyelashes look thicker and longer. A variety of factors can cause lack of hair on the face, including genetics, prior laser or plucking, trauma, and the sequelae of prior cosmetic surgery. The scarring and hairline distortion caused by cosmetic surgery can be nicely repaired with hair transplant techniques.
The author has a large case experience with these facial hair procedures, having performed more than 500 eyebrow hair transplants, 700 beard/goatee/sideburn transplants, and approximately 50 eyelash procedures. This extensive experience has provided an appreciation of the aesthetics of these anatomic areas and the best techniques to be used, and a sense of what can be accomplished so as to provide patients with realistic expectations. Although results can truly be undetectable and impressive, patients are always reminded that the goal is an improvement—sometimes conservative, sometimes significant—but perfection is left for Mother Nature, and is something humans can only attempt to emulate. Provided with realistic expectations, patients are typically very happy with the outcome of their procedures, when performed to the highest aesthetic standards of surgical technique described in this article.
Introduction
Refinements in hair transplantation techniques have made natural-appearing facial hair transplants possible. Restoring eyebrows, beards/goatees, and sideburns have all become popular procedures, because of the amount of information readily available and the fact that the results can be outstanding. Eyelash restoration for purely aesthetic, nonreconstructive purposes is a controversial procedure because of the higher incidence of complications and because Latisse (bumatiprost) can safely and effectively make eyelashes look thicker and longer. A variety of factors can cause lack of hair on the face, including genetics, prior laser or plucking, trauma, and the sequelae of prior cosmetic surgery. The scarring and hairline distortion caused by cosmetic surgery can be nicely repaired with hair transplant techniques.
The author has a large case experience with these facial hair procedures, having performed more than 500 eyebrow hair transplants, 700 beard/goatee/sideburn transplants, and approximately 50 eyelash procedures. This extensive experience has provided an appreciation of the aesthetics of these anatomic areas and the best techniques to be used, and a sense of what can be accomplished so as to provide patients with realistic expectations. Although results can truly be undetectable and impressive, patients are always reminded that the goal is an improvement—sometimes conservative, sometimes significant—but perfection is left for Mother Nature, and is something humans can only attempt to emulate. Provided with realistic expectations, patients are typically very happy with the outcome of their procedures, when performed to the highest aesthetic standards of surgical technique described in this article.
Beard/goatee/sideburn restoration
Treatment Goals
Patients have a variety of personal desires regarding how they want their facial hair to appear. For many men, a strong goatee/mustache is the priority, often complemented by full sideburns. For those willing to have a larger number of grafts, restoration of a full beard is a common request, whereas other men want just a “strap” beard, a narrow band of beard that runs along the jawline.
More common than with eyebrows, patients occasionally choose the FUE (follicular unit extraction) technique for graft harvesting so that the hair can be cut short or even shaved in some cases, because of the absence of a linear donor site scar. Whether the FUE or the strip-FUG (follicular unit graft) technique is used, a scalp donor site is chosen using hairs similar in texture and color to normal beard hairs to help assure the most natural appearance.
Growth of these scalp hairs when placed into the beard is exactly what beard hairs should do, so this is not the potential issue it can be with eyebrow transplants. When performed properly, the number one goal can be achieved: the hairs grow out in a natural direction, angle, and pattern, and once shaved off, the facial skin looks normal and is free of scarring and other obvious signs.
Preoperative Steps
Proper understanding of the patient’s goals is critical for having a successful outcome with these facial hair procedures. Because of how these patients have suffered or have been concerned about their undesirable beard/goatee appearance, most tend to have a very good idea of what they hope to achieve. Because my experience has shown the regrowth rate for hairs transplanted into the face to be very high, achieving good to excellent density is typically a realistic goal, provided the patient understands that a large number of grafts may be required. To get an idea of graft counts, to restore sideburns, 250 to 300 grafts per side are usually required. For the goatee/mustache area, this number ranges from 300 to 400 grafts for a mustache to as many as 850 grafts for mustache and full goatee, and 350 to as many as 500 grafts per cheek beard. These numbers can vary depending on how much if any preexisting hairs are present, the thickness of the donor hairs, and of course the exact desired shape and density.
In younger patients particularly, the presence of already existing or risk of future male pattern hair loss must be accounted for and explained to the patient. Performing a facial hair transplant, while providing the masculine look the patient desires, reduces the number of hairs available for transplanting into areas of male pattern hair loss.
Although most patients for these procedures are men with genetically thin facial hair, the occasional case is caused by other factors, including poorly performed or poorly thought-out prior laser hair removal, scarring from a burn ( Fig. 1 ) or cleft lip repair, or loss of sideburns from prior plastic surgery ( Fig. 2 ). Another small group of patients are female to male gender reassignments seeking the most masculine appearance. Although exogenous testosterone can help regrow some facial hair, usually this hair is of a low quantity, and therefore a transplant can be an important part of the transition.
As with other hair transplants, certain medications and vitamins that can increase bleeding are to be avoided.
Surgical Preparation
After a review of the patient’s goals discussed in the original consultation, whether conducted in person or via e-mail (>70% of the author’s patients travel in to have their procedure performed after learning about it on the Internet), the areas to be transplanted are marked out. There is no ideal facial hair pattern, because this is a personal decision guided by family history, ethnicity, religion, and the shape of the face and facial features.
Although no rules exist as to what looks natural, the author advises patients that transplants into the central region right below the lower lip (the “soul patch”) and into the chin mound are risky, especially in patients with dark or especially thick donor hairs, because small bumps can form at the site of each graft. This “danger zone” is discussed further later, but because of this, the goatee is usually designed to dip down under each lateral two-fifths or so of the lower lip, and not have any hairs in this area at all (see case examples) ( Fig. 3 ). If the patient is highly motivated, the author recommends transplanting 20 to 40 test grafts into this area to assess healing. If no bumps form after 6 months or so, then further grafting can be safely performed in this area.
Patient Positioning
If a strip is to be the source of the grafts, the already anesthetized donor area is removed with the patient sitting upright, then the area sutured closed. Most patients are given Valium, 10 mg and Ambien, 10 mg. The length of this donor area can vary widely, depending on the anticipated size of the procedure. The donor strip can be as short as 3 cm if only a limited graft number is required for filling in a patchy area or a small scar. Alternatively, procedures of at least 1800 grafts are not uncommon, and require donor strips as long as 12 to 20 cm. In most cases, follicular units containing 1, 2, and 3 hairs compose the grafts; the exception is in patients with thick dark hairs, in whom these naturally occurring 3-hair follicular unit grafts are dissected into single- and 2-hair grafts.
For some patients, particularly those younger than 30 years, in whom a relatively large number of grafts will be transplanted, the author will take 2 separate donor strips from different areas of the scalp. This technique will make the patient’s scalp look like it experienced some trauma (eg, an old hockey injury) rather than was the donor site for a hair transplant. Approximately 25% of these facial hair patients choose the FUE technique, and therefore the areas of the scalp from which the grafts are to be harvested are trimmed. If the occipital scalp is to serve as a major donor source, the patient lies face-down for the first 2 to 5 hours necessary to extract the grafts from the back of the head, then flips over onto his back to so that the recipient site formation and planting can begin. However, for many smaller cases, some or all of the donor hairs will come from the sides, permitting hairs to be extracted from one side of the head while the surgeon and assistant sit on the other side, first creating the recipient sites and then inserting the grafts. This efficiency is key for inserting grafts rapidly once extracted, potentially helping to increase hair regrowth.
Procedural Approach
Once all of the FUE grafts from the back of the scalp have been harvested, or as the grafts are dissected out using microscopes from the donor strip, the recipient sites are made. To not have at least some original naturally existing beard hairs present is rare, even if they are fine “peach fuzz” hairs that can guide the direction and angulation of these recipient sites.
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To minimize the chance that the grafts will shift in angulation during healing, the smallest possible recipient sites are made, usually 0.6 and 0.7 mm, sometimes 0.8 mm.
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Each recipient site is made so that the resultant hair direction will be as normal as possible (see Fig. 3 ). Although variations occur, generally the angle the hairs make with the skin is as shallow as possible and the direction of growth is directly downward. On the mustache, the hairs will grow slightly laterally, which usually continues as the mustache extends downward along the lateral aspect of the mouth, where it then becomes the lateral goatee along the jowl region.
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The grafts are then placed, using jeweler’s forceps, into each recipient site. This process is performed carefully by highly experienced technicians. Following the plan created by the surgeon, usually single-hair grafts are placed along the borders of the beard/mustache/goatee, whereas 2- and sometimes 3-hair grafts are transplanted into the more central areas of the sideburn and cheek beard, and 2-hair grafts are placed into the mustache to achieve the desired density.
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Because the immediate results are very close to what will be the final result, this allows the patient to assess the shape and density of transplanted areas, permitting feedback and making desired alterations before the procedure is completed.
Potential Complications and Their Management
Angle of hair growth
Given the author’s experience treating patients who are dissatisfied with prior work performed elsewhere, the biggest challenge is achieving proper angulation of hair growth. All too often these hairs grow out too perpendicularly from the skin, giving an unnatural appearance. The areas of the face where this is most difficult to avoid is the mustache, followed by the lateral goatee region, but this can occur anywhere. In the author’s experience, the key to avoiding this cosmetic problem is to create the smallest possible recipient sites and angle them as flat as possible to the face, which is achieved using a long blade that permits the blade handle to lay flat to the face. To repair these unaesthetic results, the poorly directed grafts can be removed using FUE techniques, allowing the remaining small holes to heal through secondary intention rather than through suturing, which leaves essentially no perceptible scarring.
Bumps around transplanted hair
Tiny bumps can form in the soul patch and chin mound. These bumps seem to occur because of the different texture of the skin in this area, the chin mound in particular being more “meaty.” Although who exactly is at risk for this happening is unclear, nearly every instance the author has seen—in 3 patients when the author first began to perform these procedures and on a few others who have been in contact—has been in a patient with dark and, in particular, thick donor hairs. These bumps seem to form as the thick hairs emerge from the skin, raising it up. Shaving or lasering these bumps is not usually curative; rather, the entire hair must be removed, which, because of the poor healing qualities of the skin in this area, can result in scarring. As a result of this experience, the author advises any patient desiring hairs in these zones to undergo a test procedure to assess healing.
Immediate Postprocedure Care
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For the first 5 days, the areas transplanted must be kept dry. This allows the hairs to set properly, helping assure the maintenance of proper angulation of hair growth.
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Antibiotics and analgesics (for the donor area) are given for several days.
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Shaving is not permitted until the eighth day.
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Donor site sutures (3-0 Prolene) only need to be removed on patients who live locally; otherwise, dissolvable 4-0 Caprosyn sutures are used.
Long-term Follow-up and Care
Pinkness in the area usually resolves by the second week, but occasionally can last for as long as several months, for reasons that are unknown. Transplanted hairs start to regrow by the fourth month, and can be shaved or allowed to grow out. Because of the high percentage of hair regrowth, most patients are more than satisfied with the coverage and do not request touch-up fill-in procedures ( Fig. 4 ).
Related posts:
Hair Restoration: A Sophisticated Art Form
An Analysis of Follicular Punches, Mechanics, and Dynamics in Follicular Unit Extraction
Scalp Micropigmentation
Hair Restoration: A Sophisticated Art Form
An Analysis of Follicular Punches, Mechanics, and Dynamics in Follicular Unit Extraction
Complications in Hair-Restoration Surgery
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