Hair restoration has long been thought of as restoring hair predominantly in the scalp in men and women who have lost hair for various reasons. Advances in hair restoration techniques have made it possible to transplant hair in non-scalp areas of the face where patients may have never had hair. Refinements in techniques have allowed for the restoration of beard hair and eyebrow hair with very natural appearing results. Pick up any of the latest fashion magazines and you see female models with thick, full eyebrows, or men sporting full beards. In part, due to these fashion and culture trends, along with advancements in techniques that we have developed, our practice has seen a large increase in the demand for beard and eyebrow restoration. This article describes the pre-operative evaluation, operative technique and post-operative care developed from the experience of over 1,000 procedures in facial hair restoration.
Treatment goals in beard restoration are often set by the patient. Patients typically present with a rather specific understanding of how they want their facial hair to appear. A patient’s goals may vary from increasing the density of an existing beard while maintaining the same shape, to transplanting full beards where very few hairs exist. The design and density of the beard may be limited by the quality and quantity of the donor area. Transplantation of full beards requires large amount of grafts and patients are always made aware of the possibility of undergoing secondary procedures after around one year if further density is desired. These grafts, it must be made clear, once transplanted will no longer be available for use in the scalp in the future if male pattern hair loss is to develop.
With refinements in FUE, most patients seen in our office elect to have the procedure performed in this manner so as to avoid a linear scar, allowing them to maintain a short hairstyle. FUE has largely replaced the traditional strip donor extractions for beard transplantation in our office. Regardless of the donor technique used, patients are made aware of the potential limitations of the donor hair quantity and therefore “size” and density of the beard which can be achieved through solely one procedure. It is our experience that the scalp hair transplants to the face have a very high regrowth percentage and if properly performed patients can achieve a very natural outcome.
As in any cosmetic procedure, listening to the patient’s exact goals and desires is imperative. Patients who desire facial hair restorations, in general, express a very specific desire for how they want their beard designed. Depending on the exact design and density, graft counts can range from 250 to 300 grafts to each sideburn, 400 to 800 grafts to the mustache and goatee, and 300 to 500 grafts per cheek. These numbers can vary based on the pre-existing hair, design, and thickness of the donor hair.
Most patients seeking facial hair restoration are men with a genetic paucity of facial hair (Figure 1). Other reasons for patients seeking facial hair restoration are for poorly thought out prior laser hair removal, scarring, burn, or cleft lip repair (Figure 2). Another small group is female to male transgender patients seeking a more masculine appearance.
As with other hair restoration cases, patients need to be in good general health and off medications, supplements and vitamins which can worsen bleeding.
There is no ideal facial hair pattern and there are many differences among different ethnic groups . As mentioned, most patients have a specific idea of the design they wish for their facial hair. Using the patient’s guidelines, the areas to be transplanted are marked out using a surgical marking pen with the patient in a seated position. The markings are checked for symmetry between the two sides. Measurements are used to help ensure symmetry. Patients are shown the markings in a mirror, for the two-dimensional perspective provided by a mirror which is what the patient sees in a mirror- is different than what the surgeon sees in direct three-dimension. If then needed, alterations are made according to patient desires.
The one area of caution in patients with thick or dark hair is the area immediately inferior to the lower lip referred to as the “soul patch” area and the chin mound. Particularly in patients with thick and dark hairs this area is susceptible to bump formation at each graft site. Because of the risk of bump formation this area is avoided or a few “test” grafts are placed in this area at the time of the initial procedure. If no bumps form after eight months, then further grafting can be done to this area.
Currently in our practice, the great majority of patients seeking facial hair restoration elect to have their procedure via the SMARTGRAFT* FUE technique in order to avoid a linear scar. In these cases, the donor area is shaved and patients are placed in a supine position. The smallest possible drill size avoiding graft transection is used for the extractions. The donor area consists of the occiput only in smaller cases and extends into the parietal scalp for larger cases. Graft extractions are evenly distributed throughout the donor area to avoid areas of focal alopecia. Once the extractions have been completed from the occipital area, the patient is then turned to lie in the supine position.
Local anesthesia is then applied to the face starting in each sideburn and cheek area. The area around the mouth is not anesthetized at this point but rather the area around the mouth is typically worked on after the patient has eaten lunch. The recipient sites in the sideburn and cheek area are made first. The smallest possible recipient sites are made using 0.6, 0.7 or 0.8 mm slits. The one, two and (if used) three hair grafts are tested to ensure size compatibility with the recipient sites. In the periphery of the sideburns one hair grafts are used while two hair grafts can be placed in the central aspect of the sideburn to allow for more density. Counter traction is provided by the non-dominant hand and an assistant while making the incisions. The key aesthetic step is to make the incisions at an ultra-acute angle to the skin, with the direction of the incisions determined by either existing surrounding hairs or the fine “peach fuzz” of the face. This being said, the direction of growth is generally downward, but more centrally closer to the mouth/goatee region can be somewhat anterior. In the cheek area, three hair grafts are sometimes used in the central beard in patients with finer hair to allow for the achievement of greater density without a compromise of naturalness. If further grafts are needed, they are extracted at this time from the parietal scalp. The patient’s head is slightly turned, allowing for the simultaneous extraction of grafts from the parietal area and the placement of grafts in the ipsilateral cheek and sideburn.
After the patient is given lunch, the area around the mouth is then anesthetized. Infraorbital and mental nerve blocks are used to provide initial anesthesia. The goatee and mustache area anesthesia is then reinforced with field subdermal local anesthesia complemented by epi 1:50,000 to minimize bleeding. Incisions in the goatee and mustache area are then made. On the mustache, hairs will grow slightly laterally and then transition downward along the goatee. Patients need to be made aware of the difficulty in creating density along the entire mustache, particularly centrally within the ‘cupid’s bow.’ The creation of density in this area is difficult owing to the undulations created by the upper lip’s ‘cupid’s bow’ area. It is also important to maintain as acute of an angle as possible in this central area of the upper lip as grafts have a tendency to grow straight outward in non-acute angles. The transition from the mustache to the goatee is an important area for the creation of density, which is usually created by the maximal dense packing of two hair grafts.
The grafts are placed into these recipient using jeweler’s forceps. Counter-traction splaying the incision sites open with the nondominant hand helps in the placement of the grafts given the laxity of facial skin. The importance of having experienced assistants for this process is critical, as they need to understand the “pattern” of graft distribution as created by the surgeon. Towards the conclusion of the case, the patient is given a mirror before all grafts are placed. Given that the immediate results closely replicate the final results, it is helpful for the patient to view their beard in order to assess the design and density of the grafts. This allows for feedback, fine-tuning and alteration before the conclusion of the case (Figure 3).
( just remind me to send you figure 1-2-3)
Potential complications and their management
Given the senior author’s (JSE) experience with treating patients who are seeking revision work secondary to their dissatisfaction from prior facial hair restoration work, the most common complaint seen is the improper angle of hair growth. Hairs can grow out perpendicularly giving the beard an unnatural appearance. As previously mentioned, the area of the face where improper angulation poses the greatest challenge is in the mustache. To avoid the improper angulation it is helpful to use the smallest possible incision at a very acute angle. It is helpful to use a longer blade so as to allow it to lay flat across the skin permitting a sharply acute angle. If needed, the perpendicular hair grafts can be removed via the FUE technique and the resulting hole is left to heal by secondary intention.
Tiny bumps can form in the soul patch and chin mound areas at the site of the transplanted grafts. The etiology for the formation of these bumps is not known, however, this is mostly seen in patients with thick, dark hairs. In fact, patients of Asian ethnicity, particularly those with dark thick hairs, are the most challenging on whom to avoid complications, both in this bump formation but also in achieving naturalness due to the difficulty in getting the grafts to look natural particularly in angulation. With these Asian patients, the less experienced surgeon is strongly encouraged to proceed conservatively, with the primary use of all single-hair grafts and smaller number of grafts until proficiency is achieved. As the hair grows in this soul patch and chin mound area, a small bump can form where the hair exits the skin. For this reason, if a patient desires hair in these regions, a small “test” procedure can be performed at the time of the initial procedure. If in six to eight months, no bumps have formed then further hair can be transplanted
Patients are told to keep the face dry for the first 5 days after the procedure. This allows for the grafts to set properly, helping assure the maintenance of proper angulation. Topical antibiotic ointment is applied to the donor area whether a strip or FUE technique was used. Patients are then to wet the face after 5 days with soap and water, starting to remove the dried blood and crusts. Shaving is permitted after 10 days.
Pinkness to the face can be present after the procedure and usually resolves after a few weeks. In patients with very light complexion this pinkness can persist for longer periods. We have found that the oral antihistamine diphenhydramine taken once or twice daily can help reduce this pinkness. Hair regrowth usually starts around four to six months. The transplanted hair can be treated as any other facial hair and allowed to grow out or shaved. Most patients are satisfied with the initial density from one procedure but a secondary, touch-up procedure can be performed after 1 year to create further density.