Hair Transplantation to the Chest

78 Hair Transplantation to the Chest

Jeffrey Epstein

Summary

The various indications and techniques for performing hair transplants to the chest are presented. Aesthetic results can be achieved by careful recipient site creation, where as many as 3,000 or more grafts obtained by either follicular unit excision or strip harvesting can be transplanted. The most common indication for this procedure is men with a genetic predisposition to a thin-haired chest, with others including men who have undergone prior laser hair removal that is now regretted, and for the female-to-male transgender patient seeking a more masculine appearance and/or the concealment of breast reduction scars.

Keywords: chest hair transplant transgender hair restoration chest hair restoration

Key Points

•Hair growth of the chest in the lower portion generally grows in a medial inferior direction, and in the upper portion in a medial superior direction, while maximum hair density is created over the sternum through the crossed-hatch direction of hair growth.

•Anesthesia of the chest can be challenging to achieve, and caution must be taken not to exceed safe levels of injected lidocaine.

•The large number of grafts required for filling in the chest can largely deplete the available donor hairs for transplanting into the scalp for the treatment of male-pattern hair loss.

78.1 Introduction

The term “body hair transplantation” or BHT is most commonly thought of as the harvesting of hairs from the chest or beard for transplanting to the scalp. However, there are some cases where patients seek to have hair transplanted from the scalp to the chest to provide a hairier appearance. While these are not commonly performed, they do constitute an important component of hair restoration. There is a long history of transplanting hair into areas of the body, including the pubic and chest areas, with the use of free flaps and minigrafts, and today’s follicular unit extracted grafts constitute the gold standard.1^,²^,³^,⁴^,⁵

There are several significant challenges to these procedures. The first is the relatively large number of grafts—as many as 3,000 or more—that can be required to create reasonable density over what is a large area. The second is the difficulty in anesthetizing the chest. There are no dermatomes, the area is quite sensitive to the injecting of anesthesia, and large volumes of anesthetic can often be required. And Finally, the designing of the recipient sites can be tricky when creating the swirl. In this chapter, techniques for overcoming these will all be presented.

78.2 Patient Selection and Counseling

There are several main groups of patients who seek to have a chest hair transplant. The first is the postadolescent male genetically denied from having much, if any, chest hair who seeks to achieve what he and others may feel is a more masculine appearance, or to conceal acne or surgical scarring of the chest. The second is the male who regrets undergoing laser hair removal, whether due to changes in personal tastes or what has been seen for the past 10 years or so of chest hair being more popular. The last is the female-to-male (FTM) transgender individual seeking to have chest hair as part of the transition and oftentimes to hide breast removal scars. Chest hair growth can continue until a man is in his mid-20s, and similarly testosterone supplementation in the FTM individual can cause some chest hair growth, so these patients are advised to wait an appropriate amount of time to allow for maximum hair growth before undergoing a procedure.

Chest scarring as a motivator for having surgery is not just that from gender reassignment surgery. Other causes of scarring that motivate the patient include that from acne, prior thoracotomy for cardiac surgery, and prior pectus surgery. In all of these cases, the goal is to reduce the visibility of the scar as much as possible, which is often particularly challenging for a variety of reasons including: (1) hypopigmentation or hyperpigmentation of the scar that is quite difficult to conceal and (2) reduced vascularity that can interfere with hair regrowth. This is of particular concern with the breast reduction scar that is located not in the midline aspect of the chest where it is natural to have the greatest density but instead toward the lower periphery of the restoration area. This situation requires a very creative distribution of grafts. Patients are advised that regrowth may be reduced in areas of scarring, and at this time (although still not 100% proven) to improve potential regrowth, the scars are injected with platelet-rich plasma (PRP) with the transplant. In the author’s experience, with severe cases of scarring, pretreatment 3 months prior to surgery with autologous fat transfer can improve regrowth.

In terms of ethnicity, there are few exclusions to having a procedure performed. Thick straight Asian hair is not a problem, with one potential downside being this hair is not likely to develop any degree of curl with regrowth in the chest. We have performed several procedures on men of African ethnicity, but unlike beard transplants in these patients where we have not encountered complications, we recommend the patient undergo a test procedure to assure no problems with hair growth or scarring.

Appropriate individuals must have an adequate donor supply of hairs, which in most cases will originate from the typical donor areas of the scalp. However, beard hairs can also be used. Patients must be made aware that hairs transplanted to the chest are no longer available for transplanting into other areas, which is potentially relevant for men currently or at risk of experiencing male-pattern hair loss, particularly considering the very large number of grafts (>2,000) required for acceptable chest coverage.

Because these hairs come from the scalp, it is important to advise patients of the need for regular trimming of the chest hairs, typically monthly. While these hairs do not have the same growth cycle as normal chest hairs, thus the need for regular trimming, they oftentimes will take on other characteristics of chest hair in terms of texture and curl.

78.3 The Procedure

78.3.1 Anesthesia

Many of these chest hair transplant procedures, particularly when large areas of the chest are to be covered, are most safely and comfortably performed under monitored intravenous twilight sedation. Given the large area and challenges in anesthetizing the chest due to random innervation and the need for direct local infiltration of the entire area, patients can be made more comfortable when sedated more deeply intravenously than with oral sedation. Second, high quantities of anesthetic may be required, risking lidocaine toxicity. An anesthesia provider can reduce this risk by monitoring the patient and the dose of lidocaine, administering generous intravenous hydration, and raising the seizure threshold through medications like benzodiazepines. The preferred local anesthetic is a 50:50 mix by volume of lidocaine 1% with 1:100,000 epinephrine and bupivacaine 0.25%, as these agents do not have cumulative toxicity dosages. Our technique for administering anesthesia when the patient is not deeply sedated is to apply ice directly to the chest before, then injecting with 30-gauge needles on 3-mL syringes. Frequent changing of the needles is usually required due to them becoming dull and bent from the somewhat tough chest skin.

78.3.2 Harvesting and Handling of Grafts

In our practice, hairs to be transplanted are most often obtained by follicular unit excision (FUE) harvesting of the scalp, thus avoiding altogether any linear donor site incision that can result in a scar. The appropriate area of scalp is determined, most commonly from the back of the head, but can extend to the sides in larger cases. In general, hairs from the very back of the head are ideal as they tend to be the last ones to turn gray. Our typical approach is to begin the procedure with the patient in the prone position, and from the back of the scalp 800 to as many as 1,800 follicular unit grafts are extracted. Once this area has been harvested, the patient can be rotated into the supine position, allowing for the commencement of the making of recipient sites so that graft planting can begin, as well as further graft harvesting from the side(s) of the head when indicated later on in the procedure.

In most cases, two-hair grafts are ideal for transplanting, providing the optimal combination of naturalness and hair density. In the patient with thick straight hair such as is seen in some Asian patients, we will often utilize only single-hair grafts to avoid the risk of an unnatural appearance. These one- and two-hair grafts can be obtained as needed by dividing of follicular units. In patients with lighter colored finer hair, oftentimes three-hair grafts can be utilized in certain areas of maximum density, particularly over the sternum and mid-chest region. Any four-hair follicular units in these patients will be divided into two-hair grafts, to be used along with the naturally occurring one-, two-, and three-hair grafts. Proper and careful handling and dissecting of these grafts is a demanding process best performed by a highly experienced technician not only because it involves the dividing of larger grafts as called for by the surgeon but also because it is often best to excise the cuff of excess skin of the hair graft as it reduces the risk of scarring.

As many cases require large number of hairs, further harvesting of more grafts can be performed from the sides of the scalp later on in the procedure while the chest is being planted, at least in the cases where a hand-held drill is being used. By not harvesting all of the grafts at the onset of the procedure, the surgeon has the ability to add more grafts as needed instead of potentially overharvesting at the onset, efficiency is optimized by allowing the earliest possible start of graft placement, and hair growth percentage is improved because those grafts transplanted toward the end of what could be an 8-hour or longer procedure will have been harvested later in the day assuming the earlier-harvested grafts are transplanted first.

78.3.3 Recipient Site Formation and Graft Placement

As with any hair transplant procedure, this is the key aesthetic step, as the recipient sites determine the pattern, direction, angulation, and distribution of hair growth. It is best to imitate the most common direction of hair growth, which guides the direction of the recipient sites, as shown in Fig. 78.1.

Fig. 78.1 (a) Before transplant with markings illustrating the ideal direction of hair growth and (b) 10 months after 2,400 grafts were transplanted to the chest.

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