c

Fig. 13.34 (a) Seventy-eight-year old male before first session showing extensive baldness. (b) After three sessions to the frontal scalp and one session to the crown of approximately 6,000 FUs and MFUs. (c) This patient has ideal hair characteristics: fine, salt and pepper hair with some wave to give added body, and a pale scalp with a well-established thinning pattern

13.22.4 Transplants After Burns

Extensive burn patients can benefit from transplantation after scalp extenders or expanders have been tried

13.23 Non-scalp Areas

The use of single-haired FUs has allowed almost any part of the body to benefit from transplants. Eyebrows are transplanted commonly to increase thickness due to genetic loss, over plucking, or scarring (Figs. 13.40 and 13.41). Traditional donor areas include the lower occipital region and temples with the aim of matching the texture of the transplanted hair. It is important to stress that the transplanted scalp hair will have to be trimmed every 5–7 days. Due to the greater tendency for scalp hair to have more curl and wave compared to eyebrow hair, it can be a challenge to find hairs that are straight. Errant eyebrow hairs can often be “trained” to lie flatter to the skin. Techniques to train eyebrows include applying clear mascara to the eyebrow to make them stick in one place or by using an eyebrow brush that has a small amount of hair spray put on the brush and then brushing the eyebrows in the direction you want them to fall. The physician, at the time of making the sites, should be very careful to keep the angle of placement very oblique with the skin. When appropriate, other body areas, such as the chest in men, can be used. The chest hair has the added benefit of not growing as long as scalp hair and as such trimming of the transplanted hair is less frequent.

Fig. 13.36 (a) Preoperative, showing scarring and hair loss from a previous face lift. The temporal hairline was lifted extensively. Hairline is drawn on to show where the new hairline will

be created. (b) After two sessions of approximately 2,500 FU and MFUs. The scar is hidden by hair growing in front of and into scar

Eyelash transplants are typically performed for congenital loss, trauma, or burns [36]. There are more potentially serious complications with eyelash transplants compared to other types of hair transplants. This includes scarring, cysts, infections, entropion, and ectropion. As such, the author suggests caution when considering eyelash transplants for routine cosmetic enhancement. The FDA recently gave approval for an ophthalmic solution, bimatoprost 0.03%, previously used for glaucoma, as a new treatment for hypotrichosis of the eyelashes. The solution is to be applied daily to the lash line of the lids and has been reported to lengthen, thicken, and darken the eyelashes. Side effects, reported in 4% or less of patients, include

itching and redness to the eye. Less common side effects include skin darkening, eye irritation and dryness, and redness of the eyelids.

Other non-scalp areas that can benefit from transplants include the pubic region (Fig. 13.42), moustache (Fig. 13.43), beard, and chest.

13.24 Transgendered Patients

Hair restoration surgery for the transgendered (TG) patient is almost always for male to female patients. The TG patient seeks hairline feminization which involves creating a rounded frontotemporal recession

Fig. 13.38 (a) Before first session. This patient was involved in a plane crash and suffered extensive burns to his face, scalp, and body. Subsequent scalp reductions or expanders to minimize the scalp scarring were inadvisable due to the tightness of the skin.

(b) After two sessions of a total of 1,350 FUs and MFUs. Grafts can grow very well when the placement of the grafts and the timing of sessions are appropriate

and a lowered mid-frontal point for the anterior hairline (Fig. 13.44). The TG patient is often undergoing other facial cosmetic surgeries that should be timed with any hair transplantation (Fig. 13.45). Often the MPHL is too severe and the patient may not be

happy settling for a frontal frame to the face or less than total coverage, which may be satisfactory in a typical male. Expectations are often higher in the TG patient and as such a full hair piece or wig may be more appropriate.

Fig. 13.39 (a, b) Patient had one session of poorly selected large grafts placed too far apart to create a very unnatural hairline. Adding to the improper placement is the patient’s coarse, black hair, which makes creating a feathered, soft hairline a

challenge. (c, d) After a session of approximately 1,900 FUs and MFUs. The hairline is softened considerably with the use of one-haired FUs placed at the hairline zone, but a further refining session is suggested

Fig. 13.40 (a) This patient had a tumor removed from the right eyebrow causing scarring hair loss. (b) After one session of single-haired FUs

Fig. 13.41 (a) A young woman that was always unhappy with her low eyebrows, such that she shaves and plucks preexisting hairs and draws on desired eyebrows with pencil. (b) After one session of 180 FUs to define new eyebrows. The hairs must be kept short to maintain appropriate length and to minimize any curl

Fig. 13.43 (a) Patient with scarring from previous cleft lip repair. (b) After one session and the hair has grown in

Fig. 13.44 (a) TG patient before first session showing feminine hairline desired. (b) TG patient before surgery showing extent of MPB involvement. (c) After two sessions with hairline showing. (d) After two sessions with hair brushed forward to illustrate amount of coverage achieved

Fig. 13.45 (a) TG patient before transplant as well as showing recent scalp advancement and nasal/brow work. (b) After two sessions of grafting, hair is pulled back to show new feminine hairline and camouflage of scalp advancement scar. (c) Recent

grafting to thicken eyebrows and cover incision scars. (Reprinted with permission from Berg and Cotterill [24]. Copyright Elsevier Limited 2009)