Transplanting into the Pubic Area

77 Transplanting into the Pubic Area

Young-Ran Lee

Summary

Pubic atrichosis or hypotrichosis is a common condition in females of Asian origin. Pubic hair transplantation is considered a definitive treatment for pubic atrichosis and hypotrichosis, and it is the one and only permanent treatment that exists to date. It is important to understand the natural pubic hair patterns and normal physiologic features in order to design a realistic and natural-looking transplanted hair. In order to design an abundant look, it is preferable to transplant one- and two-hair follicular unit grafts, rather than simple single-hair grafts. Finally, follicular unit extraction may become one of the useful donor harvesting methods for pubic hair transplantation.

Keywords: pubic hair transplantation pubic atrichosis pubic hypotrichosis pubic hair design pubic hair pattern

Key Points

•It is important to understand the natural pubic hair patterns and normal physiologic features in order to design a realistic and natural-looking transplanted hair.

•In order to design an abundant look, it is preferable to transplant one- and two-hair follicular unit grafts.

•De-epithelization of the grafts is important in order to prevent complications, such as epidermal cyst and folliculitis.

77.1 Introduction

Pubic atrichosis or hypotrichosis is a common condition in Asian females.1^,² Women with pubic atrichosis or hypotrichosis may experience low self-esteem, social embarrassment, and psychological stress, even though their reproductive and sexual abilities are normal. An increasing number of patients with this condition choose to undergo hair transplant surgery, which is considered the only definitive therapeutic treatment at the present time. In this chapter, the author reviews the practice of pubic hair transplantation using hair implanters.

77.2 Preoperative Assessment

Preoperative clinical considerations and surgical contraindications for pubic hair transplantation are similar to those of hair transplantation in the scalp area.³ A detailed patient history is obtained, followed by a grading on the Tanner scale. Tanner’s staging divides pubic hair development into five stages, which range from females without pubic hair (PH 1) to females with a classical hair pattern (PH 5).⁴ A routine preoperative blood test should be performed in order to exclude candidates who are not qualified for surgery due to endocrine disorders, systemic diseases, infectious diseases, coagulation defects, etc. Patients with psychological problems or patients with unrealistic expectations of the procedure are also not eligible and should be excluded.⁵^,⁶

77.3 Surgical Technique

77.3.1 Donor Harvesting and Graft Preparation

Either follicular unit transplantation (FUT) with strip excision or follicular unit extraction (FUE) can be used for donor harvesting. Both methods have their own advantages and disadvantages. The surgeon should chose the technique he or she feels is most appropriate based on each patient’s individual case.⁷ The surgical technique for strip harvesting and graft preparation is the same when transplanting either the pubic or the scalp area. For FUE technique, we preferred extracting grafts with a motorized system using continual rotation and a sharp punch with an inside diameter of 1.0 mm. For pubic hair transplants, we deliberately leave the hair shaft on the grafts longer and only cut or shave the hair to a length of 4 to 5 mm. Recently we could consider using a long-hair punch extraction. Normally for FUE, the hair is cut or shaved much shorter, to 1 to 2 mm. At this shorter length, grafts are prone to embedding under the skin, and therefore, considered unsuitable for pubic hair transplantation. Both one- and two-hair FU grafts were extracted for use, and the epidermal tissue was trimmed away from the top, as much as possible while still leaving the hair shaft intact. De-epithelization of the grafts is important in order to prevent complications, such as epidermal cyst formation and folliculitis.

77.3.2 Design Elements of Pubic Hair Transplantation

The important design considerations for creating a natural pubic transplant are as follows: (1) pubic hair pattern, (2) density and distribution of transplanted hair, and (3) direction and angle of the hair shaft. In order to have a successful pubic transplant, it is essential for a physician to have knowledge of, and be able to mimic, natural public hair patterns and physical characteristics. In order to produce a more natural appearance, the surgeon must adjust the transplanted hairs to fit the natural pubic hair pattern and normal physiologic features, in which knowledge is essential for a successful transplantation.⁵^,⁶

Hair Pattern

Horizontal pattern is considered to be the closest shape to that of normal, natural female pubic hair.¹ The author adopted a modified horizontal pattern (fan shape or escutcheonlike shape) modified into a natural form according to anatomical structure from typical horizontal patterns (Fig. 77.1a, b). The recommended line of this pattern is 2 to 3 cm inward from the inguinal region, and it is 1 to 2 cm above the pubic sulcus, which connects the pubic area with a natural curve. Other pattern types include modified rhomboidal type (Fig. 77.1c), classical horizontal type, and diffuse type, among others. In the author’s previous study, the modified horizontal pattern was used for 87% of the cases, the modified rhomboidal type was used for 7% of the cases, the classical horizontal type was used for 4% of the cases, and the other types were used for 2% of the cases.⁵^,⁶ The drawing methods and patterns proposed by the author are only suggested standardized guidelines. It is important to design suitable patterns according to the situation, since the anatomical structure and status of the pubic area varies for each case.