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Surgery and Cosmetics

Reconstruction of the Brows

José Rogério Regis Junior, Rubem Mateus Campos Miranda

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 treatment.

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 without activity.

Anatomy/design of the eyebrows 

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.


Fig 1

Figure 1. Anatomy of the eyebrow


Follicular unit transplantation technique

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 eyebrows.

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.


Fig 2

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.


The head

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.

The body

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.

The tail

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 are necessary.


Fig 3

Figure 3. The correct hair-growth directions in different parts of brow


Fig 4

Figure 4. Eyebrows pre-surgery (top) and 5 months post-surgery (bottom)


Fig 5

Figure 5. Individual eyebrow pre-surgery (top) and 5 months post-surgery (bottom)


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 (<1% cases).



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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