Follicular Unit Excision to Harvest Beard

68 Follicular Unit Excision to Harvest Beard

Aman Dua, Kapil Dua, and Renu Kothottil

Summary

The use of beard hairs as a donor source in hair transplantation is an alternative when the recipient requirement far exceeds the scalp donor supply, such as in higher grades of androgenetic alopecia. They are the most preferred nonscalp donor source due to their close similarities with scalp hair, and follicular unit excision (FUE) technique to excise the grafts produces minimal scaring. It is quite important to plan a beard hair transplant in detail, from selection of the right patient with good beard hair and patient counseling regarding the differences between a beard and scalp transplant to the proper techniques and steps of the transplant procedure. After giving local anesthesia as a ring block, the grafts are taken out from the shadow area (below the mandibular line) of the beard. The skin of the beard area is very lax and proper traction and countertraction are important. Superficial scoring using sharp punches of 2.5 to 3 mm length just to a depth of 1 to 1.5 mm into the surface of skin helps increase the yield and reduce transection rates. The punch should be focused on the exit angle of the beard hairs or the anagen blush, if it could be appreciated like in Caucasian skin, to get intact grafts. During implantation, these grafts are usually placed behind the hairline zone for better aesthetics. Postoperative hypopigmentation or white spotting is one of the most common side effects seen after the procedure. With the right skills and proper planning, beard hairs help overcome the limitation of scalp donor availability.

Keywords: beard hair transplant beard hair harvesting FUE androgenetic alopecia hair cycle recipient area influence donor dominance wet shave protocol punch postinflammatory hypopigmentation

Key Points

•Beard hairs are the most preferred nonscalp donor source due to their close similarities to the scalp hair cycle.

•Superficial scoring with sharp punches in the beard yield good, intact beard grafts.

•The beard grafts are placed behind the hairline zone and mixed with scalp donor hairs.

68.1 Introduction

One of the major limitations of hair transplantation is the limited supply of donor hair in the scalp region. This has led to the search for donor grafts from other areas of the body like beard, chest, back, forearms, and the legs. Although grafts have been harvested from all the areas of the body, the grafts from the beard are regarded as the best nonscalp donor area.

68.2 Characteristics of Beard Hair

The characteristics of the different hair follicles of the body like size, shape, and distribution depends on the area of their origin (Fig. 68.1).¹ The beard hair growth starts around puberty under the influence of androgens and increases in density till mid-30s.

Fig. 68.1 (a) Beard hair grafts. (b) Scalp hair grafts.

The beard follicles have a broader follicular bulb harboring a larger dermal papilla (DP),²^,³ which is nearly twice that of scalp hair and a cross-sectional area 70 to 100% more than the scalp hairs. Beard hairs also have twice the cuticle layers of scalp hair, making them stiffer. However, they are mostly single-haired follicular units unlike scalp where more of two and three haired units are seen.

The density of the hair in beard is generally less than that in the scalp and it varies within different areas of the beard as well as different ethnicities. In a small study conducted in 10 male Indian patients in our clinic, we found that the density in the cheek varies from 50 to 55 and 70 to 75 follicular units (FU)/cm² in the chin area.

The density of hair also varies among different ethnic groups. There is an increased density of hair in Indians, Middle Easterns,⁴ and Caucasians who have more hair in beard and moustache than Orientals.⁴

The proportion of beard hairs in anagen phase is not well documented. Estimates range from 60 to 90% and the total duration of anagen is around 1 year. These properties are advantageous over other body hairs, where the telogen phase is longer and the anagen phase is much shorter (Table 68.1).⁵

Table 68.1 Hair cycle characteristics based on site

Body site	Anagen duration (y)	Telogen duration	% of anagen	% of telogen
Scalp	2–6	3–4 mo	85	15
Beard	1	10 wk	70	30
Chest	1–2	3–4 mo	30	70
Source: Data from Richards and Meharg.⁶

68.3 Indications for Beard Hair Excision

68.3.1 Higher Grades of Androgenetic Alopecia

A main indication of using beard hair are patients with higher grades of androgenetic alopecia (AGA) who want a greater degree of scalp coverage than can be accomplished with scalp hair alone. The combination of beard and scalp hair allows for a greater number of grafts to be performed in both a single session and over the life of the patient. We usually take out 2,000 grafts from the scalp per session, so when higher numbers of grafts are required in one session, the grafts from the beard come into play. If the patient has already undergone two or three sessions of harvesting from the scalp and no more can be taken from the scalp, grafts are harvested from the beard. Fig. 68.2 shows an advanced grade of AGA treated with scalp and beard grafts.

Fig. 68.2 (a) Class 6/7 with inadequate scalp donor. (b) Same patient with beard grafts.

68.3.2 Beard and Moustache Restoration

More natural results are seen if these areas are restored with the beard hair due to the identical hair characteristics. Beard harvesting can be done when the recipient requirement of grafts is less (around 300–400 grafts) and the patient agrees to taking out grafts from the beard. Fig. 68.3 shows a patient requiring a small area of beard restoration that is done using beard donor grafts. If more area needs to be restored, beard donor may not be sufficient and scalp hairs must be considered. Also, some patients want a long beard and may not consent to beard hair excision.

Fig. 68.3 Small beard defect ideal for beard donor.

68.3.3 Patients with Poor Scalp Donor (Quality or Number) and Good Beard Donor

Depending on these patients, some can help to some degree by follicular unit excision (FUE) technique using a combination of beard and scalp hair. It is essential to set realistic expectations and the need for multiple sessions.

68.3.4 Camouflaging of Donor Scars

Scars from previous strip harvesting, or white dots from FUE, are another good use of beard hairs.⁶ Beard hairs are more suitable for these areas than other sources of body hair as they are coarser, tend to survive well in scar tissue, and cover the scars well. However, transplanting beard hairs only into a donor scar when the patient’s scalp hair is much finer can create an odd appearance when the hair is worn short. In these cases, mixed scalp, torso, and beard hairs are preferable.

68.4 Planning of Beard Graft Harvesting

It is very important to have a detailed plan well ahead of the procedure, to select the right patients, provide full informed consent, and manage expectations. Proper planning requires precise determination of the number of beard grafts to be excised to provide adequate coverage of the recipient area.

68.4.1 Patient Selection and Counseling

The quality and density of the beard hair are important for selection of the right candidates. Individuals with thicker caliber and higher density of beard hair (such as Caucasians and Southeast Asians) are usually the best candidates (Fig. 68.4). If there is hair curl as in patients of African ancestry, or the density is less as in East Asians, it is difficult to obtain adequate graft numbers. In African patients with curl, it is better to harvest test grafts to evaluate the rate of transection of grafts before beard hair harvesting (Fig. 68.5).