Most hair transplants are to the scalp; but the eyebrows, eyelashes, lower face, and chest can also benefit from this technique
The refinements in today’s hair-transplantation techniques have not only dramatically improved the results of surgical hair restoration, they have also extended the ability to restore hair to nonscalp areas. The experienced surgeon who uses follicular-unit micrografting can restore natural-appearing hair growth to such areas as the eyebrows, chest, beard, mustache, eyelashes, and pubic escutcheon.
Given the emphasis the beauty world has placed over the past 10 years or so on the absence of body hair, it may seem surprising that there would be a demand for hair in many areas of the body and face. However, the reality is that every individual has his or her own concept of sexual identity and attractiveness, and, for some, the lack of hair in certain body areas can cause insecurity and unhappiness.
For others, a history of overplucking the eyebrows, overzealous laser removal of chest or beard hair, or an earlier trauma that resulted in scarring of the beard or eyebrow region are unwanted reminders of the past that can be erased by hair transplantation. Finally, for those following the newest grooming trends, the metrosexual look is now evolving into the retrosexual look, dictating that men are most attractive when unshaven, hairy (especially on the chest and sporting a heavy 5-o’clock shadow), and natural appearing.
Over the past several years, perhaps the fastest-growing subset of my practice has been the performance of nonscalp hair transplants. In a typical week, 30%of the 10 or so procedures I now perform, in descending order of frequency, are transplants to the eyebrows, beard–goatee region, chest, and eyelashes. (Pubic and axillary procedures are rarely performed.) These patients are among the most grateful, willingly expressing their relief over finding a surgeon who not only is sympathetic to their concerns—some physicians dismiss their goals as “obsessive”—but can actually solve their problems.
In the past, restoring hair to some of these areas, such as the chest and beard, would never have been undertaken because of the limitations in techniques; whereas other areas, such as the eyebrows or sideburns, would have been restored with less aesthetic, more invasive procedures such as rotation, or advancement flaps or strip grafts. Today, however, follicular-unit grafting permits the extremely close placement of primarily one- and two-hair grafts, restoring hair to its desired density while improving upon the naturalness of antiquated flap techniques, or in the case of such areas as the chest and face, making these restorations possible at all.
These procedures are effective for treating all hair-loss patterns of the eyebrows, whether they be low density, a shape and size that is overly narrow or too short, or alopecic scarring. Regardless of the indication, it is possible for the majority of the transplanted hairs to grow in their proper direction and angle.
Using recipient sites that are just 0.5 mm (occasionally 0.6 mm) in size, hairs can be placed between existing hairs without damaging them—or in areas absent of hair—with as many as 350 grafts placed into each eyebrow in a single procedure (Figure 1, page 30). These grafts contain primarily one hair, but when the donor hair is relatively fine, two-hair grafts can be aesthetically placed in the centers of the eyebrows. The use of such small recipient sites is made possible by careful microscopic dissection of the grafts—the same technique used for scalp-hair follicular-unit transplants.
The donor area for eyebrows, as well as for all other body- and facial-hair transplants, is in nearly all cases the occipital scalp. This location is chosen because of its greatest donor density and because it is usually the last area in which the hairs turn gray.
For eyebrows, a 1- x 4-cm area is more than sufficient to provide 450 grafts, allowing for the discarding of any gray or imperfect hairs. Procedures can consist of as many as 700 grafts altogether, in which case a larger donor strip is harvested.
I have experimented using body hair for donor grafts, including those from the toes and legs. In the three cases I have performed, the hairs seem to grow and do not need to be trimmed. However, this small number of cases does not provide enough feedback to allow me to recommend this technique; also, the number of hairs that can reasonably be harvested in a single procedure is nowhere near the amount that can be obtained from a donor strip.
The eyebrows play an essential role in facial aesthetics, serving to complement the most important component of the face—the eyes—which serve as our vital nonverbal communicator of emotions and intelligence, to say nothing of beauty. There are many etiologies for the loss of eyebrows: overplucking or overaggressive laser hair removal or electrolysis, trauma, hormonal imbalances such as hypothyroidism, genetics, and medical conditions.
Overplucking usually occurs when the patient was a teenager and for aesthetic reasons, and it is different from trichotillomania, or obsessive plucking. When hair loss is the result of trauma, such as burns, skin avulsion, or prior surgery, it is more noticeable because of the skin’s scarred appearance.
Whereas it is important to identify any potentially treatable etiologies so as to slow down or stop the further progression of hair loss, nearly all patients with an absence or thinness of eyebrow hair can be successfully treated with transplants. Even in areas of scarring, significant hair growth can be achieved.
I counsel patients that my experience is that 75% to 80% of the transplanted hairs will grow, and, of these, 10% to 15% will grow in a less than perfect direction (too vertical or not flat enough to the skin), despite being planted in an aesthetic direction. These “rogue” hairs can sometimes be “trained” with gel to grow in the desired direction, or be cut short or simply plucked out. This seems to be a relatively minor downside, and for my patients it has not been enough of a deterrent to having the transplant.
Sometimes the application of hair gel may also be of benefit to control the direction of hair growth. Why the percentage of hair growth is lower, and why the direction of hair growth is not as reliable as that achieved with transplants to the scalp,is a matter of speculation. However, this percentage of growth has steadily improved the more experience I obtain with performing these procedures.
Demographically, approximately two thirds of my patients are women; one third are men. Asians, who constitute 20% of my patients, tend to have very straight hair, taking a secondary element of control of having the hairs grow at a flat angle to the skin (the main control is the direction of the recipient sites).
While a slight curl of the scalp hairs is desirable, an extensive amount of curl can be a challenging situation. However, even individuals of African descent, especially those with a “soft” curl, are appropriate candidates, and I have had very good results with this population.
Over the past 3 years, I have performed 135 of these procedures. Existing permanent makeup is not a contraindication, and in fact it can serve as a template for the transplant. Any existing hairs can serve as a guide to the natural shape and the direction of hair growth.
I divide the eyebrows into three parts: medially, the head; centrally, the body; and laterally, the tail. While there are variations between the sexes and among individual patients, some generalities can be made about the shape and size of each part. The head tends to be the widest part; has hairs that grow vertically in its most medial aspect; and has a horizontal lower border that transitions into an arc, signaling the start of the body of the eyebrow.
In the body, the hairs largely cross-hatch (the cephalic hairs grow in a somewhat caudal direction, and vice versa), and the arc tends to be more pronounced in women than in men, although this is an aesthetic call. Finally, the tail usually represents the tapering of the eyebrows, with density progressively decreasing.
Meticulous attention to the 3D direction of natural hair growth is essential. In addition to the vertical and horizontal axes, the angle of the recipient sites should be as shallow to the skin as possible to allow the hairs to grow in a flat position relative to the forehead, avoiding sticking out or growing out. At the end of the initial placing of grafts into all of the recipient sites, the patient is provided the opportunity to look at the eyebrows and provide feedback.
The postprocedure course is quite simple. Cautious face washing is permitted on the third day, and the small crusts usually fall off by the fourth day, leaving only mild pinkness and the short transplanted hairs. Like scalp hairs, these hairs will fall out and begin to regrow in as soon as 2 months. Touch-up procedures have been requested by about 5% of all patients.
Over the past 3 years, I have performed 135 procedures; four have been reparative procedures. Figures 2 through 4 show three patient examples.
This is a procedure that I once limited to patients with a complete absence of upper-lid eyelashesdue most commonly to scarring from surgical or other trauma. Recently, I have begun performing them for purely aesthetic indications in patients who desire longer, fuller eyelashes.In addition, I recently performed my first lower-eyelashtransplant.
Several techniques have been described, including one in which hairs with follicles attached are “threaded” through the eyelid skin using a French-type curved needle and emerge at the lid margin. These donor hairs, removed from a single strip of scalp, are left long to enable them to be threaded through the needle. An alternative technique is the direct planting of single-hair grafts into the lid margin through tiny incisions typically 0.6 mm in size.
When performing the procedure, topical anesthesia of the cornea is obtained to permit the placement of a corneal protector. A very small strip of hair is harvested from an area of the scalp that contains curly hair, if possible. These hairs are then dissected into single-hair grafts, which can then be placed into the recipient sites one at a time.
Procedures can range from 10 to as many as 50 hairs per lid. Once placed, patients are instructed to be gentle with the area, and washing is permitted on the fourth day. Figure 5 shows a case example. [See next month’s PSP for a full article on eyelash transplants.]
Beards and Goatees
Beard transplantation is performed less frequently than eyebrow transplants, but nevertheless is much in demand.These men have longed since puberty for a thicker or even any type of beard. I have also performed two procedures in female-to-male gender-reassignment patients.
The absence of hair is, for most patients, congenital in origin. Other causes include alopecic scarring from trauma, or bad acne and patchy or complete alopecia from laser hair removal. Even in the presence of scarring, hair growth is extremely reliable, reaching the 90%-plus rate seen with the scalp.
For most patients, the most important area of the face is the goatee. This area helps to define the mouth and serves as the framework for a masculine appearance. Even for patients who do not anticipate growing a beard, the ability to sport a thick 5-o’clock shadow in the goatee or the entire beard is very desirable.
The number of grafts transplanted depends upon the patient’s goals, the indication for the procedure, and the existing amounts of hair. Typically, these procedures range from 50 grafts (for areas of scarring) to as many as 2,200 grafts or more.
The donor area is the occipital and temporal scalp, which means that male-pattern hair loss in the future must be considered, for there will be fewer grafts available for transplanting into the scalp. These donor hairs grow just like beard hair, and in many cases the temporal hairs are the closest match, especially to the upper beard–sideburn area.
Careful attention must be paid to the natural direction of hair growth. The proper angulation of the hairs is an important factor for achieving a natural appearance. In most cases, the existing hairs can serve as a template for hair-growth direction.
Recipient sites are made with blades 0.7 to 0.8 mm in size. Grafts, dissected as microscopic follicular units, each contain one or two hairs. The single-hair grafts are typically placed along the periphery, while a combination of one- and two-hair grafts is dispersed throughout the rest of the restoration.
Anesthesia is administered to the donor and recipient area using a computer-guided anesthesia-injection device. Regional anesthesia is obtained in the goatee region through infraorbital and mental nerve blocks, prior to the direct injection of anesthetic into the area.
Postprocedure care is typically quite simple. Full resumption of normal face washing and exercise is permitted, as with scalp transplants, at 5 days. Shaving can be resumed on the eighth day. Most of the transplanted hairs will fall out and begin to regrow in 3 months.
I have performed 85 of these facial-hair transplant procedures over the past 5 years. Figures 6 and 7 illustrate two cases.
Chest and Other Body Areas
For men who have always wanted a chest full of hair, this procedure has brought much happiness and satisfaction. Furthermore, the recent retrosexual trend suggests that a hairy chest (although not a hairy back or shoulders) is considered masculine and sexy. Some men who underwent laser removal of body hair are now seeking to have that masculine chest hair replaced.
Female-to-male gender-reassignment patients constitute another group who desire this procedure, for the chest hair not only makes for a more masculine appearance, it also serves to help conceal the breast-reduction scars. Alopecic scarring due to surgical or accidental trauma to the body is also successfully treated. In one patient, abdominal surgery as an infant left him without an umbilicus, a defect he chose to partially conceal with hair transplants.
Body-hair transplantation is a procedure designed to restore hair most frequently to the chest and abdominal areas. However, it can also be applied to the pubis, axilla, and any other area where hair is desired, to thicken the existing hair or to provide hair growth where there is none. Pubic-hair transplants, while rare, are occasionally requested.
Like the chest-hair-transplant patients, the four patients (two women, two men) on whom I have performed pubic-hair transplants have been properly motivated in their desires and very satisfied with the results. One of the earliest scientific articles on hair transplantation came out of Japan in the 1940s and described single-hair grafting to the pubic region. This article became available to Western medicine only 20 years ago and coincided with the development of the single-hair micrograft.
The number of grafts needed to restore the chest hair depends upon the patient’s goals and the amount of existing hair. For limited coverage of the sternum and the pectoral regions, as few as 1,200 to 1,400 grafts are sufficient. However, in patients who desire the maximum amount of coverage and density, I have transplanted as many as 5,500 grafts in two procedures.
Some patients seek only a thin amount of coverage or the restoration of a limited area (such as the central chest or pubic triangle), whereas others desire a thick chest and central abdomen area. For the individuals who desire maximum density, a second procedure must typically be planned.
The grafts consist of one and two hairs, and they can be placed into recipient sites 0.8 and 0.9 mm in size. With the maximum-coverage cases, an adequate donor supply is a necessity—especially when there is a risk of male-pattern hair loss causing the donor hairs to no longer be available. Patients are also counseled that these hairs will continue to grow like scalp hair, and therefore they will have to be trimmed monthly.
When hair is transplanted to the chest, achieving anesthesia is a challenge. Because of the large area to be covered, the thick skin, and the absence of regional innervation, large quantities of local anesthetic are required.
Whereas most procedures are performed under oral sedation, intravenous sedation may be preferable in certain chest-hair-transplant patients. Intravenous fluids are sometimes administered to hydrate these patients to avoid any potential complications from large quantities of anesthetic. The computer-guided device mentioned above is used for injection in all cases to reduce the discomfort of the anesthesia.
When designing the restoration, several hair-growth features need to be understood. There is a natural circular pattern of chest-hair growth that tends to be centered around the nipple region. It is particularly important to attain the greatest hair density over the sternum; this is achieved by concentrating a greater number of grafts that grow toward one another from each side in this area, essentially creating a cross-hatching effect. Similar to the eyebrows, the hairs grow from the skin in a flat angle so that they do not stick out but rather grow flat along the chest.
Typical recipient sites are 0.8 to 0.9 mm to accommodate one- and two-hair grafts. Most of the single hairs are placed along the periphery, ensuring peripheral feathering for the most natural appearance. Healing after these procedures is usually quite rapid, with crusting typically gone by the sixth day. By the second day, patients are able to return to normal activities. Wearing normal clothing conceals any sign of having had the procedure.
Over the past 5 years, I have performed 22 procedures to the chest and torso, four to the pubic region, and one to the axilla. Figures 8 and 9 present case examples of chest- and pubic-hair transplant procedures.
Nonscalp hair transplantation has become one of the most challenging, yet rewarding, parts of my practice. These patients are among the most grateful, and the rewards of hearing patients thank me for allowing them to feel whole again—or to wake up without having to run to the mirror to make up their eyebrows—makes this a wonderful part of my practice.
Jeffrey S. Epstein, MD, FACS,is a board-certified facial plastic surgeon and hair-restoration surgeon and a member of the International Alliance of Hair Restoration Surgeons. He is the director of the Foundation for Hair Restoration in Miami and New York City. He can be reached at (305) 666-1774 or via his Web site, www.foundhair.com.