Facial Hair in Hair Restoration Surgery

INTRODUCTION

Twenty-one years ago in these Facial Plastic Surgery Clinics, in the early days of these specialized procedures, I coauthored an article on nonscalp hair restoration.¹ In subsequent years the popularity of beard restoration soared. In the mid-2000s the popular Brooklyn “hipster” trend included a beard as a defining characteristic, a trend that is now embraced by society. Another demographic trend is the growing popularity of gender reaffirmation, with some female-to-male patients now seeking fuller beards than that which can be achieved by exogenous hormones alone. An important technical development that has fed the procedure growth is the refinement of the follicular unit excision (FUE) technique. FUE procedures make possible the combination of a full beard and shaved head without the donor-site scar resulting from the follicular unit transplantation (FUT or “strip”) technique. 

With an increasing number of physicians performing beard and scalp restoration procedures, and in increasing number of procedures being performed, an associated increase in the need for corrective procedures occurs. This increase led to two other developments: the use of FUE removal to repair beard transplant and body hair transplantation (BHT) where beard hairs serve as donor hairs for scalp restoration in cases of insufficient scalp-hair donor supply.

Patient Candidacy and Indications

Beard restoration is performed on men seeking more facial hair. In most cases, the patient never had the desired amount of facial hair, but occasionally the condition is due to prior laser hair removal.

Department of Otolaryngology, University of Miami, 6280 Sunset Drive, Suite 504, Miami, FL 33143, USA
E-mail address: jse@drjeffreyepstein.com

Facial Plast Surg Clin N Am (2024)
https://doi.org/10.1016/j.fsc.2024.02.005
1064-7406/24/c 2024 Elsevier Inc. All rights reserved.

Other causes include scarring alopecia such as from cleft palate, lesion-removal surgery, or radiation therapy. Further, beard senescence and the graying of beard hair may cause the beard to lose some of its appearance of density. This issue can be improved by transplanting darker scalp hairs. In all of these cases, procedures ranging from several hundred to as many as 2500 or more grafts can be transplanted in a single-day procedure.

Scalp hairs are the most common donors for beard restoration because of their high reliability in regrowth, natural look once transplanted, and availability in large quantities. Patients must be counseled that if they desire scalp hair restoration in the future their scalp hair donor availability will be affected by their beard transplantation. In certain cases beard hairs can be used as donor hair, particularly in smaller cases (several hundred or fewer grafts) such as those performed to reinforce the mustache or fill patchiness in the cheek beard. Most commonly, the desired hairs are harvested from below the jawline where these missing hairs will go unnoticed.

A different but related procedure is BHT in which beard hairs are used for restoring scalp hair. BHT is a relatively new tool in the armamentarium of hair restoration surgeons, made possible by the more advanced FUE drill systems that overcome many of the challenges in beard hair harvesting. These challenges include ergonomics, skin quality, and hair fragility.^2,3 Beard donor hairs, once placed into the scalp, have a high regrowth rate, and these typically coarser and thicker hairs retain their thickness but largely lose their coarseness. This phenomenon permits their use even in the more visible zones of the scalp including toward the hairline. Beard donor-site punch holes heal rapidly, typically taking only 24 hours as compared with the 3 days for scalp donor areas. In most cases, it is possible to harvest 800 to 1200 grafts from under the jawline in a single procedure without causing any noticeable decrease in density.

Patient candidacy for beard restoration is not limited by age, skin complexion, nor ethnicity. Figs. 1–3 show the results of beard restoration in a Caucasian, Asian, and Black patient. Although there are tremendous variations in skin color, hair texture and curl, and skin healing, these three examples demonstrate the possibility for achieving naturalness in a multitude of patients.^4,5 The typical Asian patient presents challenges in beard restoration due to the tendency of rigidly straight scalp donor hairs thick in caliber. Further, there is significant contrast between light skin color and dark hairs.

Successful results occur with meticulous graft placement and angulation combined with the use of mostly, if not all, single and occasional two-hair grafts. Asian patients are frequently counseled that they may desire a second procedure to achieve sufficient density. In Black patients, curly hairs require larger recipient sites (0.6 mm vs the more typical 0.5 mm) for one- and two-hair grafts. Dense graft packing is more challenging, but fortunately these curly hairs are frequently amenable to some three-hair graft placement, with results both natural-appearing and maximally dense. Prior concerns of folliculitis and hyperpigmentation in these cases have not proved true.

The female-to-male gender reaffirmation patient can attain a much fuller beard with hair transplantation than that typically achieved with hormonal supplementation alone.⁶ These patients, much like any younger male, need to be advised of their risk of future male pattern hair loss, with the reduction in scalp-hair donor supply for future transplantation into areas of scalp hair loss. Meanwhile, the male-to-female gender reaffirmation patient is one of the best possible candidates for BHT beard-to-scalp hair harvesting due to the presence of what are now undesirable beard hairs. If counseled early, instead of laser hair removal, the male-to-female patient with advanced male pattern hair loss can have thousands of beard hairs harvested to contribute to scalp coverage.

Cleft lip and other scars in the beard region are appropriately concealed with hair transplantation. Patients are advised, similar to scalp scars, of the risk of a lower percentage of hair regrowth. To overcome this risk, several steps can be taken to enhance hair regrowth in the scar, including deeper recipient sites, transplanting into mature scar (at least 12–18 months), using mostly two and even three-hair grafts, and injecting platelet rich plasma at the time of the procedure. Fig. 4 shows an example of facial scarring treated with hair grafting.

There are several facial hair zones: the sideburns, the cheek beards, the mustache, the goatee (that in some classifications includes the mustache), and that portion below the jawline. The cheek beards and sideburns are the two zones easiest in which to attain natural and impressive results with transplants.⁷ To achieve moderate density in cases of minimal existing original hairs, each sideburn requires 200 to 250 grafts per side and each cheek beard, 350 to 550 grafts per side depending on the height of the beard line. The mustache is clearly the most challenging area. The pink lip protrusion line and the philtrum indentation, or “cupid’s bow”, increase the difficulty of site placement.⁴

Achieving moderate density in the mustache requires 300 to 400 grafts. Finally, the completion of the goatee includes the chin mound and requires 300 to 400 grafts, whereas the “soul patch” or the small patch of hair directly under the lower lip requires 50 to 150 grafts. These two areas are difficult areas in which to achieve thick density and also at greatest risk for developing bumps around each graft when the skin surrounding the hairs has been insufficiently trimmed. Extension below the jawline can be performed in those patients who desire this coverage, but this may not be the most effective use of what are often limited quantities of donor hairs.

Consultation with the patient can be done either in person or virtually, as well as by photographic review. It is possible for patients to return to public as soon as 1 or 2 days later wearing a mask, and by 5 to 6 days, most patients are fully presentable. Shaving of the beard in the recipient-site area is permitted 10 days postprocedure, whereas the donor area of the beard may be shaved 1 week postprocedure. Younger patients, at risk of developing male pattern hair loss, must be advised that any grafts used in the beard will be unavailable for transplantation into the scalp, thereby reducing the amount of possible coverage. With the advancement in FUE techniques, patients can have both a shaved head and a full beard, a commonly desired look. If patients desire additional density with a second procedure, this can be performed as early as 8 months later. Patients with light skin and dark, fine hair may be particularly interested in this option.

The Surgery

Primary beard transplantation

Design and graft counts Design is typically guided by the patient, who demonstrates his goals with online photos. Multiple options are possible, including a limited amount of goatee coverage, a narrow strap beard, a thick mustache, a full thick “lumberjack”-appearing beard with high borders, and extension in the goatee up to the lower lip line.

Required graft counts are determined by the following: the areas to be filled; the desired density; the preexisting number of beard hairs; and the donor-hair characteristics that include color, thickness/caliber, curl, and average hairs per follicular unit. Some general rules of anticipated graft counts are displayed in Table 1.

It is possible to transplant 4000 grafts into the beard in a single procedure taking one and a half days. On day one the goatee and central cheek regions are transplanted with 2700 to 3000 grafts, typically the maximum that can be transplanted into the facial region in a single day. The balance are then transplanted on the second day. However, a more conservative approach is generally recommended. A typical male has 6500 to 7000 total FUE grafts to donate before the donor area appears patchy.

Note, however, that because in most cases of beard hair restoration most three and four-hair follicular unit grafts are divided into smaller grafts, this increases the total lifetime donor supply of beard FUE grafts to 8000 to 9000 grafts. Further, many patients will be happy with the results of 2400 to 2700 grafts transplanted in a single day with the option to fill in as needed with a second procedure in 8 months.

Graft harvesting and handling Nearly every beard transplant I perform is done by the FUE rather than the FUT technique. Although most patients are fine with a full shave of the sides and back of the head for facile graft harvesting, some patients prefer modified shaving including a partial-shave FUE (just the lower back of the head) or a no-shave FUE (only the hairs to be extracted are trimmed). These latter approaches present increasing levels of difficulty in harvesting but allow for patients to be presentable faster. For donor-area preparation 2% lidocaine is infiltrated, followed by a tumescent solution of bupivacaine, lidocaine, epinephrine, and triamcinolone in a saline base, providing prolonged anesthesia and reduced bleeding. Sedation with oral medications including diazepam and zolpidem can be complemented by ProNox nitrous oxide during injection.

Our choice of FUE harvesting systems is a handheld drill that uses an oscillating (rather than rotary) motion. A hybrid punch has a fluted sharp outer edge and only the smooth inner punch surface contacts the hair follicle. The result is a lower rate of transection and the ability to use a smaller punch, usually 0.85 mm. In a typical case, the first 1800 to 2000 grafts are harvested from the back of the head with the patient prone, followed by rotation to supine position with the head tilted slightly back to allow for recipient site formation and graft placement. The grafts are separated, as previously noted, into one- and two-hair grafts, and very importantly the excess skin surrounding the hair follicles is trimmed while leaving the small cuff of fat around the follicles. Excising the excess cuff of skin is the single most important factor in reducing the risk of scarring with tiny bump formation around the grafts, particularly those placed into the chin mound and “soul patch” regions under the central portion of the lower lip. Maintaining graft moisture throughout is critical for reliable regrowth.

Table 1
Minimal and maximal graft counts indicated for restoring areas of the beard

Recipient Site Formation and Graft Placement

In most cases, the goatee region is the first area approached for three reasons: first, the donor hairs from the back of the head tend to be the best color and texture match to those beard hairs in this region; second, this area tends to be the most important, so starting in this area first allows for full attention to restoring; and third, anesthesia in the perioral region is best achieved with nerve blocks of the infraorbital and mental nerves, and this prolonged anesthesia will start to dissipate after 4 to 6 hours coinciding with the patient’s lunch break. Supplementing the nerve blocks, small amounts of 2% lidocaine with 1:50,000 epinephrine for prolonged anesthesia and sufficient vasoconstriction are directly infiltrated. Later in the morning and continuing through the rest of the day, once the goatee region has largely been filled, the anesthesia can be extended out laterally into the cheeks and sideburns to allow these areas to be planted. In the posterior cheeks and sideburns, most of the grafts can be those harvested from the sides of the head, as their color and texture are a closer match. In addition, these hairs that are planted later in the day have likewise been harvested later in the day, theoretically improving regrowth.

The occasional patient, particularly in smaller cases, desires the use of beard rather than scalp donor hairs. Beard donor hairs can grow quite reliably and seem natural in the beard.² Although it is my experience that scalp hairs yield perfectly natural appearances when transplanted into the beard, the occasional patient insists that only beard donor hairs will be suitable. As long as the patient has enough donor hairs in what is typically the portion of the beard below the lower border of the mandible extending into the upper neck, these hairs can in fact be used instead of or as a supplement to scalp as donor material. Patients are advised that beard donor hairs have a slight risk of a lower percentage of regrowth, but note that in most cases regrowth rates approach that of the gold-standard scalp donor hairs.

Once anesthesia has been obtained, recipient sites are made using most commonly a 0.5-mm beaver-type blade that we cut ourselves from sharp single-edged razor blades.

In nearly all cases, 0.5-mm incisions are appropriate for one and two-hair graft insertion. This is the key aesthetic step in the transplantation process, for these recipient sites, made by the surgeon, determine hair angulation, direction, distribution, and density. The recipient sites should typically be made as acutely flat to the facial skin as possible, following natural hair growth direction, which changes depending on the anatomic part of the beard. To permit the surgeon full control of where individual grafts get placed, it is best that the surgeon first make most of the two-hair (and if appropriate, three-hair) recipient sites to then be filled by the appropriate grafts, repeating this over several passes until the desired density is achieved, followed then by the surgeon making one-hair recipient sites in between the two-hair grafts as well as along the borders of the restoration to achieve feathering and the ideal naturalness.

For the most expeditious graft planting with least graft trauma, dull implanters are used to insert each graft. This graft placement process is achieved by one team of four assistants, with two loading the implanters one graft at a time and handing this off to the two more experienced assistants who then insert the grafts into the recipient sites. The grafts must be kept moist to avoid desiccation and be gently placed to avoid damage. With this four-person team, it is possible to place 600 grafts per hour.

Graft placement continues with these repeated cycles until all recipient sites are filled. Toward the end of the case, the patient is given the opportunity to observe the restoration and provide feedback, assuring the desired look is achieved. Although there is not uncommonly moderate swelling, the patient and surgeon can largely assess symmetry and overall appearance. Once the procedure is completed, a 4- to 10-hour process, antibiotic ointment is applied to the donor area while the grafted beard is cleaned but left dry.

After the procedure the transplanted areas are to be kept absolutely dry for the first 5 days, whereas normal scalp washing is permitted. On day six, normal face washing can proceed, helping to accelerate the falling off of the tiny crusts, a process that is usually completed at 9 to 10 days, at which point shaving can be resumed. The scalp donor area where FUE was performed is typically healed in 3 days. Normal exercise and activity can be resumed on day six. Most, if not all, of the transplanted hairs will fall off by 2 weeks, with the patient returning to essentially the same appearance as before surgery. Any prolonged erythema can be treated with oral antihistamines or, if indicated, a course of antibiotics or oral steroids. Regrowth of the transplants starts by 3 to 4 months, and by 8 to 10 months the final result is largely achieved. At this time, if more coverage is desired a second procedure can be performed.

Reparative Beard Transplantation

An unfortunate sequela of the growth in popularity of beard restoration is the increase in patients with unnatural appearances. Most commonly patients are disappointed because of improper hair growth direction that is not sufficiently acute or the use of hair grafts containing three or more hairs. Other reasons for disappointment are unaesthetic beard design, “row” appearance of grafts, and bumps at the base of the hairs most commonly in the chin mound but that can occur anywhere in the beard.

Fortunately, in most cases these appearances can be repaired. Laser hair removal is not the repair procedure of choice due to two limitations: first, it destroys the hairs rather than allowing them to be recycled by being planted either back into the beard or the donor-site scars, and second, it does not usually improve whatever skin scarring exists. Rather, FUE is the preferred method for repairing prior beard transplants, with each prior-placed graft extracted one at a time, using refined FUE techniques, and ultimately minimizing surrounding scarring, as shown in Figs. 5 and 6. In nearly all cases, a 0.85-mm punch can fully extract each prior graft and the small surrounding cuff of skin that often contains scar tissue.

Once extracted, these grafts can then be dissected down into one- and two-hair grafts with their excess skin excised, then replanted either into adjacent areas of the beard into newly made recipient sites or returned to the donor-area scars.

Care for these FUE removal sites involves the application of antibiotic ointment for the first 3 days. Normal face washing can be resumed on the second day unless grafts were placed back into the beard in which case dry-face precautions are followed for the first 5 days. Healing is typically rapid with these FUE removal procedures, with most patients having at most only minimal pink dots after 3 days. If a subsequent beard transplant is desired, it can be performed as soon as 6 weeks later.

Body Hair Transplantation (Beard-To-Scalp Transplantation)

BHT has grown tremendously in the field of hair restoration because it overcomes the limited supply/ high demand paradigm of hair restoration. In BHT for beard to scalp, beard hairs are extracted by FUE and transplanted into the scalp. Far and away the most common indications for beard-to-scalp transplantation are in cases of advanced degrees of scalp hair loss where patients desire maximal coverage and in reparative cases where prior hair transplant procedures, whether FUT or FUE, have partially or nearly completely depleted scalp-hair donor supply.

Table 2
Total donor supply of the beard (graft numbers) that can be harvested over two to three procedures

The beard area contains a large quantity of potential donor hairs. The actual number is determined by the size and the concentration of hairs in the beard and limited by the number of areas the patient will accept having thinned out.

Table 2 summarizes the approximate quantity of hairs that can be harvested from a given area in a typical patient. Note that this table shows two variants—minimal to undetectable thinning and near to total removal of all the hairs in the area.

It is uncommon for most patients to be willing to lose their entire beard. Most prefer to add 800 to 1000 beard grafts to the maximal number of scalp hair grafts of 2400 to 2800 that can be harvested in a single procedure, thus increasing the total graft count by 30% to 40%. These beard hairs will most commonly come from the portions of the beard in the upper neck and below the jawline, essentially leaving no detectability that these hairs were harvested while providing a significant greater amount of scalp coverage (Fig. 7). There are, however, some patients, including male-to-female gender reassignment patients and older men, who are motivated to have as many as 3500 grafts removed from the beard in a single procedure to achieve maximal scalp coverage in addition to the available scalp hairs (Fig. 8). Even with these large graft extraction numbers, there is essentially no visible scarring of the beard region, with a small risk of delayed healing of the chin mound. Thus, this area should be an area of last choice.

Beard donor hairs have a high reliability of regrowth, coming close to that of scalp hair. Once transplanted, like scalp donor hairs they fall out, start to regrow in 4 months, and then continue to grow as long as scalp hairs, despite having a somewhat different anagen-telogen growth cycle.⁸ Typically, these beard hairs will retain their thickness, which is almost twice the shaft caliber of scalp hair, whereas almost all are in one-hair follicular units⁸—an advantage as they provide more coverage—while they tend to lose their coarseness, which in turn improves patient acceptance. The beard donor area is healed in 24 hours, with no detectability as soon as the very next day after the procedure.

SUMMARY

The role of beard hairs in the field of hair restoration surgery is a vital one. Beard transplants permit the creation of more masculine appearances, where transplanting of scalp hairs to the beard can provide natural appearances, even permitting patients to shave without any visible scarring. BHT, involving beard donor hairs for restoring the scalp, is a growing technique in hair restoration surgery. It expands the amount of coverage by expanding the total scalp donor supply achievable in cases of male pattern hair loss as well as in reparative scalp hair transplants when prior procedures have largely exhausted the scalp donor supply.

REFERENCES

1. Gandelman M, Epstein J. Hair transplantation to the eyebrow, eyelashes, and other parts of the body. Facial Plast Surg Clin North Am 2004;12:253–61.
2. True RH. Using nonscalp hair in scalp hair restorationtheory and execution. Ind J Plas Sur 2021;54(4): 463–70.
3. Anastassakis K. Androgenetic alopecia from A to Z. In: Chapter 94: body hair transplantation FUE (BHT FUE)3, 1st edition. Switzerland: Springer; 2023. p. 151–67.
4. Epstein J, Bared A, Kuka G. Ethnic considerations in hair restoration surgery. Facial Plast Surg Clin North Am 2014;22:427–37.
5. Franbourg A, Hallegot P, Baltenneck F, et al. Current research on ethnic hair. J Am Acad Dermatol 2003; 48(6):115–9.
6. Bared A, Epstein J. Gender-affirmation hair transplantation techniques. Facial Plast Surg Clin North Am 2023;31:375–80.
7. Bared A. Beard hair transplantation. Facial Plast Surg Clin North Am 2020;28:237–41.
8. Tolgyesi E, Coble DW, Fang FS, et al. A comparative study of beard and scalp hair. J Soc Cosmet Chem 1983;34:361–82.