Taking It On the Chin - December 2012 PSP
Taking it on the Chin - December 2012 PSP
By Jeffrey S. Epstein, MD, FACS
Advances in hair transplantation techniques have paved the way for niche procedures, including beard, goatee, and sideburn restoration. These procedures are also surging in popularity due to Facetime and other video chatting modalities that focus on the lower part of the face. In addition, the trendy “hipster” look includes at least partial facial hair growth.
Most beard, goatee, and sideburn restoration patients are men with a genetic predisposition to having thin or a near absence of facial hair. The hair loss can also be the result of overaggressive or simply regretted laser or electrolysis hair removal, scarring from trauma or prior cleft lip surgery, and loss of sideburns from a prior facelift. I have also treated several trangender female to male patients who, despite the administration of exogenous testosterone, still have a weak beard.
The donor area is almost always the back and/or the sides of the head, depending on the closest match to beard hairs in terms of color and texture. Growth of these scalp hairs will be similar to beard hairs in most cases and able to be shaved as desired. A major concern of patients is how natural the results will look. In particular, men are worried about the smoothness of the skin with shaving. This fear can be alleviated if well-dissected follicular unit grafts are placed into appropriately angled small recipient sites.
Facial Hair Grafting: Explained
Some patients prefer the follicular unit extraction (FUE) technique for harvesting of grafts. I have found that FUE grafts, when transplanted into the beard region, have almost as good a percentage of regrowth as strip grafts, probably due to the generous blood supply of the facial region. While most of these FUE cases involve scalp donor hairs, occasionally donor hairs from another part of the beard will be used. Whether done by strip or FUE, the high rate of hair regrowth in the face means that good-to-excellent density can usually be achieved with just one procedure provided the patient understands the large number of grafts that may be required. While the following numbers can vary widely, depending upon the density of the donor hairs and the desired shape and density of the beard, graft counts can be anticipated to be 200 to 300 grafts per sideburn; 400 to as many as 750 grafts to the mustache/goatee; and 400 to 600 grafts per cheek beard. With such large graft counts, the risk of future male pattern hair loss must be both accounted for and explained to the younger patient who may not be so receptive to saving hairs for the future, but must be counseled on such.
There is no ideal facial hair pattern, so patient input is important. Nearly all beard transplant patients have their own idea of his ideal facial hair appearance. Most common is a strong goatee/mustache region, often complemented by full sideburns. Other patients simply want as many grafts as possible to restore a full beard, while other still whether because of personal preference or in order to reduce the graft count request a “strap” beard, a narrow band of beard that runs along the jawline.
I prefer, for most men, a strong goatee with a well-defined, but not overly thick mustache that extends inferiorly along the lateral commissures, then curves inward slightly toward the chin mound. It is very important that patients understand the risk of bump formation that can occur with transplants into the actual chin mound and “soul patch”—that central area below the lower lip that I call the “danger zone.” These bumps, more common with thick dark donor hair, can form in the danger zone at the site of each graft, and are very difficult, if not impossible, to eliminate. Patients who strongly want this area transplanted are advised to first undergo a test procedure of 20 or so grafts. If no bumps form after 6 months, it can probably be considered safe to further fill in the area.
The Beard Restoration Procedure
Similar to an eyebrow transplant, the donor strip is removed and the area is sutured closed with the patient sitting upright. The area is anesthetized, and oftentimes the patient is receiving some oral sedation. The length of the strip varies depending on the anticipated number of grafts, ranging from as short as 3 cm in length for a 300-graft procedure and 20 cm in length for a much more extensive beard/goatee restoration of 2,200-plus grafts. Because three hair grafts are rarely if ever used (except when transplanting into certain thick scars where regrowth percentage is anticipated to be lower than 80%, or when the donor hairs are fine in texture), and two hair grafts oftentimes cannot be used in certain areas of the face without looking unnatural, especially in patients with dark thick donor hairs, a large number of one- and some two-hair follicular unit grafts can be obtained per donor strip.
Occasionally, I will use two separate donor strips from different areas of the scalp to give the appearance of some type of trauma rather than a hair transplant donor scar. With the FUE technique, the patient will usually lie face down for several hours to permit harvesting of grafts from the back of the head. For smaller FUE cases, the donor hairs will often come from the sides, permitting hairs to be extracted from one side of the head while at the same time recipient sites are made and grafts planted from the other side.
As the grafts are being prepared for planting under microscopic visualization, the recipient sites are made. Any already existing hairs—even those that are quite fine (“peach fuzz”)—can help guide in the angulation and direction of recipient-site formation. Using typically 0.6-mm and 0.7-mm-sized blades, the recipient sites are made as shallow angled to the face as possible so that the hairs grow flat and don’t stick out, typically in a downward direction, although variations in different areas of the face can exist. One area where the hairs don’t grow directly downward is in the lateral aspect of the mustache where hairs usually grow slightly lateral.
Grafts get carefully placed using jeweler’s forceps, minimizing trauma and keeping them moist. Single-hair grafts are placed along the borders of the restoration, while any two-hair grafts alternated with one-hair grafts into the more central areas to achieve better density. The immediate post procedure results essentially mimic what the beard will look like with 3 to 5 days’ growth, enabling the patient to provide reliable feedback at the conclusion of the procedure.
Beard/Goatee Transplant Recovery
Five days of keeping the grafted areas dry helps minimize graft loss and/or changing of direction. The No. 1 complaint of patients seeking the repair of facial hair procedures done elsewhere is that the hairs grow sticking out rather than flat to the skin. This most commonly occurs in the mustache area, given the challenge of making flatly angled recipient sites due to the protruding lip as well as the mobility of the skin in this area, but it can happen anywhere along the beard. Many of these misangled grafts need to be removed using FUE techniques, then discarded or replanted into new recipient sites after being dissected down into one- or two-hair grafts if larger than that.
Antibiotics and analgesics are given for the first 3 to 5 days as needed, and nondissolvable sutures are removed on the 10th day. Shaving is permitted on the eighth day, with most crusts falling off by 6 days. Any prolonged pinkness to the area usually resolves by the second week, but in rare cases it can last for as long as several months for unknown reasons. Once the transplanted hairs start growing out at 4 to 5 months, they can be shaved normally or allowed to grow as desired. The occasional patient desires a touch-up, but most are very happy with the density achieved with a single procedure. The cost of the procedure depends on the number of grafts being transplanted, ranging from $3,000 to as much as $12,000.
Jeffrey S. Epstein, MD, FACS, is the director of the Foundation for Hair Restoration, and maintains full-time offices in Miami and New York City. He is also a voluntary assistant professor at the University of Miami Department of Otolaryngology, Division of Facial Plastic Surgery. Read the full article in Plastic Surgery Practice December 2012 Issue.