Beard and Mustache Hair Transplant
With the experience and advances in hair transplantation techniques, it has been possible to successfully perform transplantation of follicular units (FUs) in the facial zone. Beard and mustache transplant procedures have increased in demand in recent years to improve appearance and highlight masculine features with natural results.
Based on the statistics of the the ISHRS 2020 Practice Census, facial implants (beard and mustache) increased 196% worldwide from 2012 (4,707) to 2014 (13,956), and 121% from 2014 to 2019 (30,957). While all components of a beard are important, the highest ranked features included strong goatee (15.8%) and strong cheek beards (15.8%).
Normally, around puberty male hormones stimulate beard hair growth. Along with a strong genetic basis, the hair follicles of the beard produce terminal hairs (thick hair) under the actions of the hormone dihydrotestosterone (DHT).
According to some studies, men who grow an unshaven beard are perceived as older, more masculine, and more dominant and aggressive, and attract more positive female attitudes than those men whose face is clean-shaven.
Authors of this Article: Mario García, MD I Mexico City, Mexico [email protected] Miriam Garces, MD I Mexico City, Mexico
Patients who are candidates for facial hair transplantation are:
• Those who have total absence of hair or low density from birth with spaces in the beard.
• In scarring hair loss due to: burns, injuries from traffic accidents, as a consequence of acne, from correction of cleft lip, or any other surgery, etc.
• In the masculinization of transgender patients.
The main cause of transplantation is in patients with little hair and spaces in the beard.
During the evaluation, a design is drawn that includes the areas to be grafted, and the surface area and number of FUs required are determined. Anatomically, the facial region of the beard can be divided into different zones to determine where the FUs will be placed:
1) The upper lip: mustache
2) Chin region
3) Genian area: beard of the cheek
4) Descending section of the jaw: sideburns
In the chin region, we can distinguish a) the outer (lateral) pillars and b) the inner (medial) pillar (Figure 1).
When the mustache connects to the chin region (medial pillar) through the lateral pillars, it is commonly known as the “goatee.”
The follicular density to be implanted is highly variable; the higher the density, the thicker the result, and the lower the density, the larger the beard should be to cover the spaces. The quantity is determined factoring in the expectations of the patient, the size of the face, the design of the implantation, the square centimeters to be implanted, the quantity of FUs to be implanted per centimeter, the thickness of the hair to be transplanted, the amount of preexisting hair in the recipient area, and, mainly, the quantity of FUs that can be harvested from the donor area.
Sometimes, a second or a third procedure may be necessary to fulfill patient expectations.
The recipient area has to be in good condition. In the case of any alteration in the skin such as infection, inflammation, active acne, etc., pre-operative treatment is administered to correct the issue. Topical minoxidil-based products should be discontinued in the recipient area, and the patient should be in good health. The overall result of the growth of the grafts is seen after 10-14 months, considering that there is shedding of the grafts in the post-operative period with regrowth after 3-4 months.
The physician should warn the patient about the risks when implanting FUs in the facial region and removing an unrenewable resource from the donor area, which could otherwise be used for the scalp in the treatment of genetic balding. This is particularly important when a large amount of FU is used.
The main donor area is the safe area of the scalp (occipital and lateral which do not undergo balding) given that it usually has the sufficient quantity of follicles to be transplanted. The hair of the scalp is normally thick enough compared to the beard, as compared to the hair which is finer in other areas of the body.
There are some characteristics of the follicular units and the hair shaft that are known to suggest a better prognosis, such as the color and thickness of the hair; the darker and thicker the hair, the better the appearance.
The second donor area that can be used is the beard itself, generally from the area under the jawline. It is ideal in terms of the physical characteristics of the follicle, but limited in the number of FUs to be extracted; it is chosen when less FUs are needed or if the occipital zone is not sufficient.
On the day of surgery, definitive design of the area to be grafted is made (Figure 2).
The follicular unit harvest can be done in two ways:
- With the FUE (Follicular Unit Excision) technique, follicular units are individually extracted from the patient’s donor area using a small round micro punch (Figure 3).
- The other method of donor harvesting involves taking a full thickness ellipse of skin and hair and is referred to as a linear excision, or linear ellipse strip harvesting, and the small grafts are individually dissected using a microscope. The wound is closed usually with stitches, and this leaves a linear scar, confined to one area rather than diffusely distributed like the FUE.
Implantation of Follicular Units
If the patient has an existing beard, it is necessary to trim it to 3-5mm to be able to see the spaces where the grafts will be implanted, using local anesthetic. If the patient is not tolerant to pain, sedation can be administered, but this is not very frequent.
There are two techniques for implanting the grafts: forceps and implanters.
- With forceps, the individual graft is held gently and inserted into a pre-made incision taking care not to damage the bulb (the base of the hair follicle). The implantation can be done after all the incisions required have been made or after each incision has been made, known as the ‘stick and place’ method.
- Implanters are tools where the grafts are loaded into a channel and then a plunger is deployed to insert the graft into the skin. Implanters can be dull or sharp. Dull implanters are used to insert the grafts into pre-made incisions. Sharp implanters are used to make an incision in the skin and immediately implant the graft. The advantage of implanters is that the bulb is not handled directly and therefore is potentially subject to less trauma than when handled with fórceps.
When implanting the FUs, it is important to check the direction of the implantation: they should be as parallel as possible to the skin following the direction and angle of the hair of the área.
Post-operative care is very important for the success of the transplantation. The patient should not touch the implants with excessive pressure in the first few days. It is not recommendable to expose to intense sunlight after the transplantation.
The patient should be aware that there can be post-inflammatory hyperpigmentation (darkening) in the implantation zone, mainly with dark skin, hence a depigmentation treatment would need to be administered for a good aesthetic result.
Incorrect placement in the direction or angle of the FUs during implantation is another complication that may occur, thus causing unaesthetic growth that may require removal if there are too many.
Folliculitis (infection) seldom occurs in the implanted area. However, the region with the highest incidence is often beneath the lip, in the chin region.
Small cobblestones or bumps can form in the skin around the grafts, under the lip and on the mound of the chin, which can be avoided with a good quality of grafts and implantation technique (Figure 4).
During the extraction, hypopigmentation (lightening) is common in the scar from where the FUs were extracted, especially in dark skin. Therefore, the extraction in the case of the beard should be made in the area under the jawline so avoiding the facial region.
It is very important to make a good pre-operative diagnosis, take an adequate medical history, evaluate all the variables of the donor and recipient areas, as well as verify the realistic expectations of the patient.
One of the aesthetic benefits of the beard is being able to highlight the masculine facial features such as the chin, and angle and inferior border of the jaw, while masking or attenuating features of the lower third of the face.
To perform hair transplantation in the facial area requires an experienced physician in order to obtain natural and satisfactory results. (Figure 5). It is important to make the patient aware that the trends in beard design such as the sharp upper edge illustrated may change in time but the design they choose now is permanent. This is especially relevant if the patient decides that they will shave their beard in future.
The ISHRS urges consumers to do their research before choosing a hair restoration surgeon and be sure your doctor is actually going to be performing your surgery, and not delegating it to an unlicensed technician. The photos shown are for illustrative purposes only and there is no guarantee that everyone will get the same result.
Article written by Mario García, MD I Mexico City, Mexico I [email protected]; Miriam Garces, MD I Mexico City, Mexico