Reconstruction of the Brows
Saturday, November 01, 2014
Madarosis is a term that refers
to the loss of the eyebrows, which is attributable to various
causes, including voluntary plucking, trichotillomania, tumor
resection, hypothyroidism, alopecia areata, lichen planus/frontal
fibrosing alopecia, discoid lupus erythematosus, and aging.
Appropriate diagnosis is essential for management of the condition
and follicular unit transplantation is an effective
The eyebrows play an important
cosmetic function and are crucial for facial expression and body
language. Indeed, the eyebrows are the most popular non-scalp area
routinely requested to be restored. Nearly all patients with an
absence or thinness of the eyebrows can be treated with follicular
unit transplantation; however, it is widely accepted that in
inflammatory/autoimmune diseases it is necessary to wait 2 years
Anatomy/design of the
The eyebrows can be divided into
three parts: Head, body, and tail. The head is the most medial
portion of the eyebrow, measuring 5-10 mm in length, and is usually
below the orbital margin, with the hairs oriented vertically. The
body is approximately 25-30 mm long and is usually the densest,
widest, and most prominent portion of the eyebrow. The hairs here
are oriented obliquely or horizontally. The tail is approximately
10 mm long, is the narrowest portion of the eyebrow with the least
density (especially laterally), and lies above the orbital margin.
Eyebrow hair can vary according to ethnicity, with Asians
possessing thinner, very straight-growing hairs and Africans
possessing thicker hair with an extensive curl.
Figure 1. Anatomy of the
Follicular unit transplantation
The goal of follicular unit
transplantation is not to create perfect eyebrows, but to
significantly improve their appearance. This procedure is most
common in females, and a difference in growth rates among gender
and ethnic groups has not been described. However, in smokers,
diabetics, the elderly, and in cicatricial cases, the growth rates
may be slower. Usually, 80% or so of the hairs transplanted
will grow, and of these, 10% to 15% will grow in a different
direction likely due to the contracture of the skin. These hairs
can be cut short or trained with gel to grow in more aesthetic
directions. The central occipital area of the scalp is generally
the most appropriate donor area, but some surgeons prefer to
explore other scalp areas with hairs similar to the
The donor hair can be harvested
by either strip removal or follicular unit extraction (FUE). It is
important to consider when FUE is used, as it is necessary to trim
the donor hair, making it difficult to orient the correct angle and
direction of the hairs. Generally, 200-300 follicular units are
necessary for each eyebrow. In a donor strip 1 cm in width by 4-8
cm in length it is possible to obtain 400-450 one- and two-hair
grafts. It is preferable to obtain the follicular units using the
strip technique over FUE as it allows for the collection of longer
hair (1-2 cm in length).
The anesthesia administered is
made with lidocaine plus bupivacaine and blocks supraorbital and
supratrochlear nerves. To reduce the bleeding, a tumescent solution
with saline plus adrenaline (1:200000) can be used. Two-hair grafts
should be implanted in the central area of the eyebrow and one-hair
grafts in the external area. This pattern allows a soft and natural
appearance. The angle and direction of the grafts should be
individualized according to each part of the eyebrow.
Figure 2. Follicular
unit with two (left) and one (right) long hairs. One hair
is used in the external area and two hairs in the central area.
Long hair (1-2 cm) is used in order to guide the appropriate
direction and angle of the hairs.
At the most medial aspect of the
head, the hairs tend to grow vertically and the grafts can be
placed sparsely to accentuate a feathering appearance. Moving
laterally, the hairs then change from a vertical to a horizontal
direction of growth.
Along the body, the superior
hairs tend to grow at a slightly inferior angle, while the inferior
hairs tend to grow at a slightly superior angle, allowing a greater
density and natural aspect.
When the tail section is
reached, the hairs grow horizontally in a slightly caudal
direction. At the end of the tail, a second feathering zone is
created by placing the finest one-hair grafts in a progressively
sparse concentration. It is very important to pay attention to the
exit angle; the angle of the recipient site should be as acute as
possible to allow the hairs to grow in a parallel position relative
to the forehead. Implant incisions (sagittal or coronal) can be
made with blades or needles (0.5-0.7 mm in diameter). The growth
direction of curly hair must be considered to enhance the natural
effect. At the end of the implant process, it is important to
reassess the symmetry and overall appearance; sometimes adjustments
Figure 3. The correct
hair-growth directions in different parts of
Figure 4. Eyebrows
pre-surgery (top) and 5 months post-surgery
Figure 5. Individual
eyebrow pre-surgery (top) and 5 months post-surgery
There are many recommendations
for post-procedure care, including occlusion with a transparent
dressing for 4 days, followed by the use of petroleum jelly. 2-4
weeks post-surgery, the implanted hairs fully embed. These hairs
will then begin to grow at 8-16 weeks following the procedure. It
is necessary to cut the hairs short once to twice a week in order
to obtain the ideal length and shape.
Follicular unit transplantation adverse-event profile
Edema and periorbital hematoma may occur and usually resolve in
2 days. Furthermore, in the first 2 months, as the follicles begin
to grow, pseudofolliculitis can occur in the transplanted area -
this usually resolves spontaneously. Occasionally, some follicles
can heal with a different direction of growth to that originally
intended during transplantation and require trimming. In addition,
mild pain at the donor site scar can occur in the early days -
generally with spontaneous improvement. Infection in our clinical
practice and in correlation with the medical literature is low
Eyebrow reconstruction by hair
transplantation offers satisfactory aesthetic outcomes, with a 3D
effect. It is a relatively safe procedure with low morbidity.
Throughout the surgery, it is important to preserve the correct
angle of the hairs to achieve a natural design.
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