Despite the best efforts at cleft lip repair, whether done as an infant, teenager or as an adult cleft lip revision, the ability to detect the cleft lip scar usually persists. This is most manifest in men because the thickness of the upper lip beard skin on both sides of the cleft lip scar make the hairless scar that much more apparent.
While cleft lip scar revision is the best method to minimize the width of the cleft lip scar, it does not always work as well as one would like. It can be very difficult to get a cleft lip scar that is narrow as one would like, no matter how many efforts are made to revise the scar.
It is important to recognize that the cleft lip scar in a male has two fundamental deficits…lack of hair follicles and skin that is thinner and more atrophic. One simple method to address one of the deficits of the cleft lip scar is that of hair transplants. Placing small hair transplants (follicular extraction units, FUE) into he cleft lip scar not only adds hair growth to the scar but the presence of a follicular unit also has a rejuvenative effect on the lip scar. Whether the man ends up with a fuller moustache that crosses the cleft lip scar or merely ends up shaving (microdermabrasion) the cleft lip scar on a daily basis, the hair transplant helps with cleft lip scar camouflage.
When placing hair transplant into the cleft lip scar it is important to orient the hairs in a completely downward orientation that is nearly parallel to the surface of the skin. This will allow them to grow downward in the same direction as the rest of the upper lip hairs.
Hair transplantation is a well know procedure for men but hair loss concerns are not gender restricted. Hair loss obviously occurs in some women as well and is much more common that many people would think. Statistics from hair loss organizations show that women comprise about one-third of all hair loss patients that seek some form of prevention or reversal of their condition.
Once can argue that hair loss is women is more psychologically devastating than it is for men. There are lots of bald men and men who shave their head that are seen every day. Partial or total hair loss for men is accepted and, although most men would prefer voluminous locks, male hair loss is common and few as a natural event. In almost any form of media today a bald or balding head is even shown as part of a positive image. For women, however, such images are not pervasive and hair loss is seen as a loss of attractiveness or femininity. While men may see hair loss as undesireable, women may see it as devastating.
Many women can benefit from hair transplantation and many are not aware of its potential for them. Using a microfollicular unit extraction method assisted by the Neograft system, women can successfully undergo the procedure just as capably as any man. This approach is revolutionary compared to the traditional approach to hair transplants.
Neograft eliminates the long scar across the back of the head from the older strip method of hair harvesting. Patients have no suture or staples to remove later and no resultant thinning of hair at the donor site. This approach also preserves the maximum amount of hair if the patients needs or desires another hair transplant in the future. As a result, some physicians have called Neograft a game changer in hair transplantation. The Neograft device brings to hair grafting what the laparoscope did for intra-abdominal surgery or the endoscope for browlifting and upper facial rejuvenation.
With the assistance of the Neograft suction harvest method, the hair and the attached follicles can be harvested more gently which can theoretically result in greater graft survival after transplantation. When it comes to the hundreds to thousands of hairs transplanted, any percent survival improvement is a plus.
Of all cosmetic surgery procedures, hair transplantation is one of the few in which the results will be permanent. One may continue to lose existing hairs but transplanted hairs that take will continue to grow for the rest of the patient’s life.
Hair transplantation is an historic procedure that is done very much today as it was decades ago. While the number of grafts transplanted in a single session has increased over the years, from a few hundred to thousands in a single session, the fundamental concept of moving individual hairs from the back or sides of the head to the top has not changed. (and probably never will) One of the major advancements has been the change from large circular plugs that contain many hairs to single or double hair units that create a more natural appearance and hairlines.
But no matter how many hair units are transferred and the location to which they are implanted, they must be harvested. Until the day comes when one’s individual hair follicles can be grown in cell culture and then used as transplants, the patient must be their own ‘recycling’ center. The standard method of donor site hair harvest has been the strip method. But cutting out a strip of hair along the back of the head, hairs can be cut out from the skin strip and prepared for transplantation. While effective, this creates a donor scar that may or may not create a favorable scar. For many men, trade-off of a scalp scar for having more hair on the top of the head may be a risky decision.
One major improvement in hair restoration has been the Neograft system. This is lower power suction system that allows the donor harvest to be done without a long scar across the back of the head. The device extracts a 1mm section of skin with the hair follicles in them. In essence it cuts out 1mm plugs if you will all along the desired donor area. It does this automatically and then sucks the grafts into a container which captures them. By spacing out this small 1mm sections throughout the donor area, a long linear scar is avoided. These 1mm holes do not require closure and heal by contraction within a few days. While every incision on the scalp will leave a scar, these many ‘dot’ scars heal imperceptibly by the scalp’s native ability to contract. This is in essence a scar dispersement strategy.This not only avoids the scalp scar’s potential to widen and become noticeable but enables the donor area to be reharvested later. (provided that the spacing of the Neograft harvest is 20% or less of the total surface area)
One other advantage of the Neograft system is that the harvested grafts are already prepared for implantation. Unlike strip grafts where a technician must prepare all of the grafts from the donor strip, the Neograft extraction process does that at the time of suction harvest. Whether that leads to better graft survival (less of a shock effect) has been debated and has not yet been scientifically proven, users of the system feel that is another one of the method’s benefits.
Neograft also has a power method of graft implantation. In a reverse method to extraction, the device sucks up the individual grafts and then injects them into the prepared slits in the recipient site. This is a very clever and, quite frankly, cool method of insertion but there does not appear to be a biologic or time-saving value over the traditional method of individual forceps insertion.
Neograft has been touted as a ‘game changer’ in hair transplantation surgery. And it is but not because it makes hair transplantation faster, more effective, or cheaper. It does so because it eliminates the donor scar. That may seem to be a trivial issue but it is a major consideration for many potential hair transplantation patient.s As I always tell my cosmetic surgery patients for any procedure, it is all about trading off one problem for another. Every cosmetic procedure has trade-offs (some major and some minor) so you had better like and be accepting of whatever the trade-offs are. When a long scar exists across the back of your head that will be a major aesthetic issue if one ever decides that they need or want to wear short hair or have a buzz cut. (and some hair transplant patients do end up making that decision based on their genetic predisposition to balding and the quality of their hair transplant result) Neograft ‘s minimally invasive approach to harvest now makes that a safer decision and one never ends up in a worse place with the appearance of their scalp no matter how their hair transplant result turns out.
The creation of a fuller and more hair dense eyebrow is done by single follicular transplants from the scalp. The grafts are usually harvested from the scalp hair above the ear. The single grafts are placed in a flush radiating pattern along the thin or deficient eyebrow from the inner aspect near the nose to the tail of the brow bone.
The following are the typical postoperative instructions after the procedure:
1. Most eyebrow hair transplant procedures have virtually no discomfort from either the donor (scalp) or the recipient (eyebrow) site. Patients usually only feel the need to use Tylenol or Ibuprofen for just a few days after the procedure, if any medication at all.
2. There are no dressing used on the eyebrows after the procedure. One should sleep with their head elevated for a few days and be careful to not sleep on your sides, so as to not rub out any hair transplants.
3. There often is some bruising around the eyebrows which will take up to one week to
clear. One may take ArnicaMontanatablets (30x or 30c) one week before and after the procedure to help with bruising prevention and clearance.
4. The sutures used in the scalp donor site above the ears are not dissolveable. They will be removed in the office 10 to 14 days after the procedure. They require no topical care.
5. You may shower and wash your hair as normal the following day. There is no harm in getting the scalp suture lines wet.
6. For the first 24 hours after the procedure, leave the eyebrows and their crusts alone. On the second day after the procedure, you may gently irrigate the transplanted area to remove any dried crusts. (you will be supplied with a syringe) This can be done in the shower every day for a week after the procedure.
7. After each syringe washing, gently apply antibiotic ointment to the brows to help soften any crusts so they are more easily removed with the next washing.
8. There are no limitations to any physical activities after eyebrow hair transplantation surgery. You may feel free to run, workout and do any non-contact sporting activity as soon as you feel comfortable.
9. You may wear regular glasses or sunglasses right after the procedure but be careful that they do not rub on the eyebrows.
10. If any eyebrow or scalp redness, increased tenderness or swelling, or drainage develops after the first week of surgery, call Dr. Eppley and have your pharmacy number ready.
Every plastic surgery procedure has numerous issues that every patient who is undergoing a procedure should know. These explanations are always on a consent form that you should read in detail before surgery. This consent form, while many perceive as strictly a legal protection for the doctor, is actually more intended to improve the understanding of the eyebrow hair transplant procedure. The following is what Dr. Eppley discusses with his patients for this procedure. This list includes many, but not all,of the different outcomes from surgery. It should generate both a better understanding of the procedure and should answer any remaining questions that one would have.
Alternatives for improving the appearance of the eyebrows include temporary(pencil) or permanent eyeliner. (micropigmentation/tattooing)
The goal of eyebrow hair transplantation is to create greater hair density in the eyebrow. This fuller density strives to achieve a more natural eyebrow look that does not require the application of pigmented liners to create the shape and outline of the eyebrows.
The limitations of eyebrow hair transplants, like all hair transplants, is how many hairs can be inserted at the time of the procedure and how many hairs will survive and grow afterwards.
Expected recipient site outcomes include the following: temporary swelling and bruising of the eyebrows, temporary clots or crusts of the eyebrows, initial long transplants in which the hair shaft will shed two to three weeks after the procedure, and four to six months after surgery to see the full transplanted hair growth. Expected donor site outcomes include suture lines in the scalp above the ears from the harvest and very mild temporary harvest site discomfort.
Significant complications from eyebrow hair transplants do not occur. More likely risks include infection, inadequate take/density of the transplanted hair, undesired angulation of the transplanted hair, and the possible need for additional hair transplantation sessions. Any of these risks may require revisional surgery for improvement.
Should additional surgery be required for additional hair transplants to be placed, this will generate additional costs
Eyebrows are the one piece of hirsuitic artistry that adorns the forehead. They separate the forehead from the eyelids and produce a partial frame for the entire orbital area. The desired shape and size of the eyebrows has changed over the years. Pencil-thin eyebrows were once the way to go, requiring considerable maintenance with waxing and tweezing. While waxing and maintenance is still needed, fuller more bushy eyebrows are now in.
But for the woman who has naturally thin eyebrows or has lost a lot of eyebrows due to years of plucking, what is she to do? Applying topical Rogaine or Latisse is one option but that will only be effective if there are enough hair follicles to stimulate. It may make existing hairs longer and thicker which can help but will not repair lost follicles.
This is where hair transplantation comes in. Transplanting hairs to the eyebrows has the obvious goal of adding follicular density but eyebrow restoration is so much more than just throwing hairs into the skin on top of the brow bone. The eyebrows are a unique patch of hair, small as it may be. The direction and angulation of the hairs must be precisely done to look natural and to grow in harmony with the eyebrow hairs that already exist. The shape of the eyebrow is gender-specific with women having an arch to the outer aspect of the eyebrow while in men the eyebrow is flat with little to no arch.
Like the scalp, eyebrows use hairs harvested from the scalp. Up to 500 hairs may be needed for both eyebrows and this requires a scalp donor strip of at least 1 x 4 cms if not longer. Such smaller donor strips has the luxury of trying to find a patch of hair that is not gray (or likely to go gray), has a curl to it that matches as close as possible the existing angulation of the eyebrow hair growth and is not thicker than an eyebrow hair. (thinner is better)
When placing grafts into the eyebrows, the most important aspect is their placement. The eyebrow have a fanning effect from the inner aspect of the brow out to the tail. In the most inner aspect, the hairs point directly upward but then start to turn quickly into a more horizontal orientation. At the tail of the brow, the hairs may actually be less than horizontal and turn downward. Besides the angulation, eyebrow hairs lay almost flat against the surface of the skin and don’t stick up like those on the scalp.
While hair transplantation to the eyebrows seems like one is transplanting hairs, the reality is that follicles (hair bulbs) are being transplanted. The attached hair (which is dead) is just the handle to carry and insert the follicles. This is why it is important after the procedure to not touch or manipulate the eyebrows. Let the eyebrows dry out and form a crust, that will help stabilize the follicles so they take better. The crust will come off after a week and the visible hairs will fall out weeks later. This does not matter as what counts is the implanted follicles. It is expected to lose all the transplanted hair shafts which naturally shed from the trauma of the procedure. It will take up to six months to see regrowth and the results of the procedure.
The success of eyebrow transplants, as defined by graft survival, is somewhere between 50% to 75%. This is why a second touch-up may be needed within the first year of the procedure. Scalp hairs will grow much faster than natural eyebrow hairs so regular trimming will be needed. While this involves a little time, that is more than made up by avoiding the much greater time needed in applying eyebrow liner.
Hair transplantation has a long history of use with many recent advancements. The old style hair transplant of a plug has long given way to single follicular transplants which look more natural and have better survival rates. Rather than strip grafts, harvest techniques include follicular extraction methods. These advancements have allowed hair transplants to be applied in many new and imaginative ways. While once used exclusively in the scalp, new applications have included smaller areas like the eyebrows.
One of the newest and more unique areas in hair transplantation is that of the moustache. A recent report from CNN discussed the moustache implant which appears quite popular in the Middle East. Cultural and fashion trends in the Middle East make thick moustaches prized as upper lip adornments as they reflect enhanced masculinity, maturity and dignity. While thick and dark haired facial hair is the norm amongst Middle Eastern men, apparently not all can grow a moustache that meets the highest standards…thicker and fuller is better.
Hair transplants are now being increasingly done to the moustache to achieve this more hirsutic lip look. Using follicular unit extraction techniques, hair follicles are transplanted into the moustache area in an individual fashion to create more dense hair growth. It is important to get the proper hair angulation, slightly downward, to make sure the new hairs grow in the right direction. Using slightly less hairs than for the eyebrows, increased density can be achieved with as little 100 to 150 transplants. The procedure is performed under a local anesthetic.
Recovery from moustache implants is very quick. Showering and washing hair can be done the next day and will not affect the harvest site. The moustache area, not that it is frequently shaved anyway, should not be shaved for several weeks. It will take up to six months to have the new hairs grow to good moustache length.
While moustache hair transplants seem like quite an oddity in the West, it is reflective of a very different culture in the Middle East. Facial hair and moustaches have a long history in the Arab world, dating back thousands of years. I have seen few if any Arab leaders without them. Clearly their presence is more than just a happenstance, it is a strong male statement that casts an image of enhanced virility and power…very much like the strong jawline does for the Western male.
On this week’s Doc Chat Radio show on WXNT 1430AM in Indianapolis from 1:00 – 2:00PM on Saturday afternoon, hosted by Dr. Barry Eppley Indianapolis plastic surgeon, the topic of Hair Transplantation was discussed. With guest host hair transplant surgeons, hair transplantation surgery and hair treatment programs were reviewed. How is a good candidate for hair transplantation, how is the procedure done, are the results natural looking, how does multiunit hair grafting differ from single follicular grafts, what is the after care, what happens to the hair after grafting, what about the donor site and where do the grafts come from, and the costs of the procedure were all discussed over the hour.
Eyebrows occupy a very visible location on one’s face and are critical to the appearance of the eye area. They frame the eye and serve as an important aesthetic landmark between the eye and the frontal scalp hairline. Significant loss or changes in eyebrow hair density are usually very noticeable and can be quite troubling. While eyebrow shapes and styles change over the years, thin or sparse eyebrows are not usually aesthetically desireable.
Hair transplants to the eyebrows can be done for both men and women. While most commonly done for eyebrows lost due to injury (lacerations, avulsions, burns), disease (alopecia areata, trichilomania), or age (thinningof the hair) it may also be done for cosmetic enhancement (thickening of the eyebrow and/or extension of the tail) as well. Thin eyebrows in women occur from a congenital thinness and limited ability for the eyebrows to grow or loss of eyebrow hairs due to excessive plucking.
Tattooing of the lost or thin eyebrow is a very common technique that is simple and relatively quick to do with an immediate result. Unfortunately, eyebrow tattoos if not done professionally with good technique can look very unnatural with less than ideal color matches. Over time the tattoo will have some fading, which will require some touchups or long-term maintenance. Eyebrow tattoos essentially can not be removed. If unhappy with an eyebrow tattoo result, hair transplants can be done right into the tattooed skin.
Hair transplantation to the eyebrow is a more refined technique of that used in scalp hair grafting. It is based on two important principles; individual follicular grafts and precise placement into the unique shape and orientation of eyebrow hairs. While the eyebrow area is not big (compared to the scalp), the harvesting and placement of individual follicles into the eyebrow is a meticulous procedure that can take almost as long as scalp hair transplant sessions.
Placement and proper angulation of the hairs is the key to a good, natural-looking eyebrow transplant. The eyebrow has hairs that have unique orientations in different parts of the eyebrow. The hair in the upper part of the middle of the eyebrow points upward to the hairline, while the hair on the tail will usually point towards the ears. The eyebrow hairs are also oriented much like a feather with the upper part of the eyebrow pointed slightly downward and the lower portion slightly upward forming a slight ridge.
Eyebrow hair transplantation may require more than one session of grafting to get the best results. Not all follicles completely survive each grafting session and optimal density of the eyebrow may require a second set of grafts. My goal is to get the best result in one session, not two, but hair transplant growth and density is not completely predictable. Second graft sessions are not done for six months after the first to give optimal time for the hair to grow and for the patient to adjust to the changes in the appearance of the eyebrow.
The hair used for eyebrow transplants comes from the scalp. Because most scalp hairs are more coarse than fine eyebrow hairs, the donor site is usually taken from the scalp hair right abobe or behind the ear. Scalp hair in this area is thinner and a better match for the eyebrows. Each eyebrow usually requires about 50 to 75 hair transplants, sometimes up to more than 100 per eyebrow depending upon the goals of the patient. These hair transplants, like the rest of the scalp,will continue to grow for the rest of your life and will need to be trimmed regularly. Over time, the transplanted scalp hairs will take on some of the characteristics of eyebrow hairs and growth will slow down. (eyebrow hair grow is about half that of scalp hairs)
Be aware that although the eyebrow hair transplants will be seen immediately after the procedure, the hair shaft attached to the follicle will fall out. In essence, follicle transplants are being done and the hair shaft is a good handle to place them. The hair shaft will quickly shed leaving the eyebrow looking like it did before the procedure. Hair growth from the follicle will require at least 3 months to become visible again and up to 6 to 9 months to grow in and see the final results.
There is no significant recovery from the procedure other than some crusting of the eyebrows and occasionally some slight upper eyelid swelling or bruising. There are no dressings used on the eyebrows other than ointment to keep them moist for the first few days. One can usually return to work within a few days.
As one can see, eyebrow hair transplants require much greater commitment and patience than eyebrow tattooing methods. But if one is looking for the most natural eyebrow result, particularly in a young person, eyebrow hair transplants may be a good long-term solution.
Hair Restoration for the Thinned or Absent Eyebrow
I used to see one or two patients a year who had lost their eyebrows due to an accident such a burn injury or an avulsion from a motor vehicle accident. While these still do occur, I am now seeing more patients that have very thin eyebrows due to original underdeveloped thin eyebrows, over-tweezing, or loss of eyebrow hairs due to age. In some elderly patients due to decreased vision, I have had a few requests for eyebrow management as they could no longer see well enough to ‘paint on their eyebrows’. In the past, all of these eyebrow problems were treated with tattooing or medically speaking, micropigmentation. While placing permanent tattoo colors in the skin was effective, it was not the most natural as it was not real hair or even looked like hair. It was just a painted on eyebrow so to speak.
It is now becoming more popular to consider hair transplants as an option in these cases. Eyebrow hair transplantation has been done for decades but only more recently is it now being performed regularly. Its emergence as an alternative to tattooing is the general hair transplantation concept of follicular unit grafting. Hair transplants in the scalp have gone from the old-fashioned ‘corn row’ look to single hair follicle transplants. This has produced more natural hair restoration in the scalp and is perfectly suited for the eyebrow. Given that the eyebrow is a small area, the number of transplants needed is less than 200 per brow. Since this requires only a small donor area from the scalp, almost any patient is a candidate for the procedure. Eyebrow hair transplants are done in the office, under local anesthesia, and both brows can be completed in a few hours. Other than some potential for upper eyelid swelling and bruising, there is very minimal discomfort after the procedure.
Several important concepts for patients to know are: 1) The transplanted eyebrow hairs will grow like the scalp so they will have to be trimmed and shaped regularly (more so than your normal eyebrow hairs), 2) After transplantation, the new hairs will fall out in a few weeks (remember hair is dead, it is the follicle that is alive). The follicles must grow new hair which will take several months to be seen again, 3) Not all transplanted hairs will survive, although 90% or greater take is the norm. Touch-up grafting may be needed, and 4) Like scalp hairs, eyebrow transplanted hair can be dyed as well.
Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.