Operative Technique in Plastic Surgery – Kevin C.Chung

Surgical
approach
■ Transoral approach provides rapid and precise placement of
mandibular implants.
Implant
fixation
■ Failure to fix the implant to the facial skeleton with a screw may lead
to asymmetry or implant malposition.
■ Screw fixation applies the posterior surface of the implant to the
surface of the bone, obliterating any gaps between the implant and the
skeleton. Gaps result in unanticipated increases in projection of the
implant.
Asymmetry
■ Asymmetry in the early postoperative phase may be related to
asymmetric edema and tends to resolve within 1 to 2 mo.
■ Minor asymmetries are often aesthetically inconsequential due to
overlaying thick masseter.
Secondary
implant
surgery
■ Expose both sides to compare implant position.
POSTOPERATIVE CARE
■ A suction drain is routinely placed at the operative site and removed the
morning after surgery. A supportive tape dressing is placed postoperatively and
is usually removed the morning after surgery (FIG 3).
■ Oral antibiotics are prescribed for 7 days after surgery (cephalexin 500 mg
every 8 hours).
■ Due to the intraoral incisions, patients are asked to eat a soft diet for 72 hours
postoperatively. Patients are instructed to refrain from strenuous exercise for 2
to 3 weeks postoperatively.
■ If there is significant edema the morning after surgery, then a standard steroid
taper is prescribed for 6 days.
■ The patient is instructed to apply ice for 48 to 72 hours and sleep with the head
of the bed elevated greater than 30 degrees or with three or four pillows.
■ Follow-up is at 1-, 2-, and 4-week intervals. Thereafter, long-term follow-up is
at 6 months and 1 year.
OUTCOMES
■ Appropriate patient selection and sound surgical technique provide a vast
majority of patients with satisfactory aesthetic outcomes (FIGS 4A–H, 5A–C,

and 6A,B).
FIG 3 • Placement of supportive tape dressing.
COMPLICATIONS
■ Postoperative complications are uncommon when the before-described
protocol is adhered to.
■ Sensory or motor dysfunctions are usually transient.
■ Epinephrine injection, meticulous hemostasis, and suction drainage minimize
the likelihood of hematoma.
■ Good oral hygiene, meticulous hemostasis, and watertight wound closure
minimize infection risk.
■ The above complications may be minimized with wide subperiosteal exposure
to the area that needs to be augmented and screw fixation to prevent implant
movement.

FIG 4 • (A,B) AP view of preoperative and (C,D)
postoperative result of computer-designed mandibular
implants to correct contour defect after orthognathic
surgery (1 year postop). (E,F) Lateral view of
preoperative and (G,H) postoperative result of
computer-designed mandibular implants to correct
contour defect after orthognathic surgery (1 year
postop).

■ In the senior author’s overall experience with greater than 400 porous implants
used for facial skeletal reconstruction, the infection rate was about 1.5%. If
infection should occur, we recommend removal of the implant. Antibiotic
therapy may temporarily suppress the infection, but the bacterial-induced
biofilm prevents chemical eradication of the infection. Implant replacement 3
to 6 months after resolution of the infection has been effective.2
■ Late implant infections (years after implant surgery) have been reported (eg,
after dental surgery). To our knowledge, none of the senior author’s patients
have encountered this. We believe that infections that become apparent in the
early months after surgery reflect small intraoperative bacterial contamination
that was temporarily suppressed by perioperative antibiotics and host defenses.

FIG 5 • (A) Preoperative (left) and (B) postoperative
(right) results of a patient who underwent bilateral
sagittal split osteotomy with resulting deformity and
asymmetry at the osteotomy site (left) 1 year postop.
C,D. Implants were customized to correct the resulting
deformity (right). E. Preoperative (left) and (F)
postoperative (right) results after custom implants to
correct osteotomy site deformity after bilateral sagittal

split osteotomy (1 year postop).

FIG 6 • (A,B) AP view of pre- (left) and (C,D)
postoperative (right) results of aesthetic mandibular

augmentation (1 year postop). (E,F) Lateral view of pre-
(left) and (G,H) postoperative (right) results of aesthetic
mandibular augmentation (12 months postop).
REFERENCES
1. Selber JC, Rosen HM. Aesthetics of facial skeletal surgery. Clin Plast Surg.
2007;34:437-445.
2. Yaremchuk MJ. Mandibular augmentation. Plast Reconstr Surg.
2000;106:697-706.
3. Yaremchuk MJ, Chen YC. Enlarging the deficient mandible. Aesthet Surg J.
2007;27:539-550.
4. Yaremchuk MJ. Making concave faces convex. Aesthetic Plast Surg.
2005;29:141-147.

75
CHAPTER
Section XIII: Skeletal
Reduction
Technique for Chin
Reduction
Jong-Woo Choi and Woo-Shik Jeong
DEFINITION
■ Facial contours can greatly affect a person’s facial image. In particular, the
shape of the chin is one of the most important parts in terms of facial image
according to a recent consensus among facial plastic surgeons who perform
facial contouring surgery.
■ There are several ways to perform a chin reduction.
■ One is to reduce the whole mandible, including the chin, which is performed
through mandibuloplasty.
■ The other is to reduce only the chin, which is performed with genioplasty.
■ In terms of the surgical direction for chin reduction, there are two acceptable
methods.
■ One is horizontal chin setback, which is associated with the mandible setback
or chin setback procedure.
■ The other is vertical chin reduction, which is related to vertical reduction
genioplasty. This method reduces the volume of the chin using narrowing
genioplasty.
■ This chapter describes how chin reduction can be properly achieved by
selecting the best solution from among these various options according to the
patient’s status.
ANATOMY

■ The mental nerve innervates the lower lip and chin region and passes through
the mental foramen on the anterior surface of the mandible. The mental
foramen is generally located in the apical region of the first and second
premolars.1
■ However, anatomical variation exists with respect to the mental foramen’s
location, and the anterior loop of the mental nerve should be considered with a
safety zone left when the osteotomy line is planned.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The chin reduction procedure can be applied to patients who complain of a
prominent and wide chin or of protrusion of the mentum.
■ Reduction with mandibuloplasty can improve aesthetic contouring of the chin
and the appearance of a square face.
IMAGING
■ The appearance of the chin is easily visualized on three-dimensional computed
tomography.2,3
■ Panoramic radiographs can also be helpful for locating the mental foramen.
SURGICAL MANAGEMENT
■ Orthognathic surgery could be a good option for skeletal class III prognathism
accompanied by chin protrusion. In contrast to reduction genioplasty, which is
performed on the chin alone, mandibular setback resolves issues related to the
whole mandible. Sometimes, simple reduction genioplasty cannot produce the
desired results for patients with skeletal class III prognathism:
■ Regardless of the occlusion, the protruded mandible or chin should be
corrected based on the whole facial profile. If the patient has a relative
skeletal class III tendency, orthognathic surgery may be a better solution than
simple chin reduction or mandibuloplasty would be. If the patient has a
normal class I occlusion, clockwise rotational jaw/rotational mandibular
setback could be a good alternative.
■ In the past, mandible angle reduction was the common term for facial
contouring surgery in Asia. However, this procedure should now be referred to
as mandibuloplasty, as modern aesthetic facial contouring surgery primarily
deals with the whole mandible, including the chin, body, and the mandibular
angle:
■ To reduce the whole mandible, numerous modifications have been

introduced, such as mandible angle resection, long curved mandibulectomy,
and sagittal mandibular corticectomy.
■ Recent standards for mandibuloplasty include long-curved marginal
mandibuloplasty with or without narrowing genioplasty. This method for one-
piece mandibuloplasty should focus on the shape of the mandible as well as
the amount of the marginal resection. Compared with traditional mandible
angle resection or mandible reduction, one-piece mandibuloplasty affects the
whole mandible.
■ In contrast to mandibuloplasty, genioplasty techniques mostly affect just the
chin. Various genioplasty techniques have been introduced. Advancing
genioplasty is the most commonly used technique. For chin reduction,
however, vertical reduction genioplasty is preferable.
■ Vertical reduction genioplasty can reduce the vertical chin dimension directly
with an approximately 1:1 hard-to-soft tissue ratio, whereas the maxillary
movement was not correspondent at hard-and-soft tissue ratio. This effect
suggests that reduction genioplasty is a very effective and intuitive procedure.
■ Whereas vertical reduction genioplasty primarily affects vertical control of
the chin, narrowing genioplasty primarily affects horizontal control of the
chin. There are various chin shapes, such as the broad chin, square chin, long
chin, short chin, and trapezoidal chin, and the shape of the chin greatly
influences the facial contour. Narrowing genioplasty has become one of the
most popular procedures in facial contouring surgery.
■ Narrowing genioplasty can be performed with mandibuloplasty of the chin,
body, and angle. An alternative method is one-piece mandibuloplasty. There
are few differences in these procedures, so surgeons can choose which to
perform based on their personal preference.
Preoperative Planning
■ The extent of chin correction should be determined individually according to
the patient’s chin width, the degree of mental protrusion, the course of the
inferior alveolar nerve, and the patient’s preference regarding the final chin
shape.
■ For fixation of bone segments, titanium miniplates, lag screws, or wires can be
used and should be available.
Positioning
■ The patient should be positioned supine on the operating table under general

anesthesia via orotracheal or nasotracheal intubation.
■ Horse-shaped supporting head table can be helpful for minimizing the head
during the operation.
Approach
■ The conventional intraoral vestibular incision is best performed after
infiltration of hemostasis.
■ Subperiosteal dissection is performed to expose the symphyseal region, except
for the opening of the mental nerve with no. 15 blades or the cutting mode of
Bovie coagulator.
T E C H N I Q U E S
■ Mandible Setback or Chin Setback
■ Chin reduction related to the whole mandible could be achieved with
mandibular setback based on sagittal split ramus osteotomy or intraoral
vertical ramus osteotomy with a reciprocating saw.
■ After the nasotracheal intubation, a 3- to 4-cm buccogingival incision is
made from the 2 cm above the occlusal plane to the first molar, disclosing the
subperiosteal plane for the sagittal split osteotomy of the mandible.
■ Using the periosteal elevator, the periosteum on the mandible is elevated
laterally and medially. The pterygomasseteric sling is detached with the
round elevator, and the periosteum on the inferior border of the mandible is
stripped from the mandible bone.
■ Using the bur hole in the medial side made before, the reciprocating saw is
used for the sagittal split osteotomy (TECH FIG 1A). Then, the osteotome is
used to split the mandible.
■ For fixation of mandibular setback (TECH FIG 1B), one rigid fixation with
a titanium 6-mm-length miniplate on each side of Champy line can achieve
stable fixation.
■ When a buccogingival incision is used, the periosteum should be sutured
with 3-0 or 4-0 Vicryl for preventing hematoma and infection.
■ Then, the buccogingival incisions are closed with 4-0 Vicryl in continuous
fashion.

TECH FIG 1 • A. Sagittal split osteotomy. B. Chin
setback.
■ Mandibuloplasty
■ After the nasotracheal intubation, a 3- to 4-cm buccogingival incision is
made from 2 cm above the occlusal plane to the first molar, and subperiosteal
dissection is done using the curved round elevator while preserving the
continuity of the periosteum:
■ The whole mandible should be exposed, except for the mucosal attachment
above the mental nerve.
■ Next, the pterygomasseteric sling is released with the subperiosteal elevator
without tearing:
■ A tear in the periosteum can harm the facial vessels or the marginal
mandibular branch of the facial nerve.
■ There are two ways to cut the lower jaw, depending on surgeon preference:
from the angle to the chin and from the chin to the angle (TECH FIG 2):
■ Generally, an oscillating saw is used for mandibuloplasty, but a modified
reciprocating saw, such a curved one, can also be used.
■ When an oscillating saw is used, the most posterior part of the ramus
should be cut meticulously to avoid following the wrong direction to the

condyle because direct visualization of the most posterior part of the ramus
is not easy.
■ In addition, surgeons should bear in mind the course of the mandibular
nerve inside the mandible. A reduction that is too aggressive might cut the
mandibular nerve, which results in the complete numbness of the lower lip.
■ Finally, after removing the one-piece mandibular segments, the periosteum
should be closed tightly to minimize soft tissue redundancy with 3-0 or 4-0
Vicryl.
■ Of course, the mucosal closure should be both meticulous and watertight
with 4-0 Vicryl in continuous fashion.
TECH FIG 2 • Mandibuloplasty.
■ Genioplasty
Vertical Reduction Genioplasty
■ A 3-cm inverted-V-shaped buccomucosal incision is made from canine to
canine, and subperiosteal dissection is performed, except for opening the
mental nerve.
■ Next, horizontal cutting can be performed with a reciprocating saw:

■ Leave at least 5 mm of bone just above the upper horizontal cutting line, as
the mandibular nerve passes approximately 5 mm lower than the bony
opening.
■ Generally speaking, the chin setback or geniosetback procedure is not
recommended, because the submental soft tissue might be redundant after the
procedure.
■ After osteotomy, bone segment designed for reduction is removed, and lower
segment of the chin is fixed to the mandible with titanium miniplate (TECH
FIG 3).
■ The midline of the chin must correspond to the midline of the mandible but
can be intentionally different to correct an asymmetry of the mandible.
■ The periosteum is closed to minimize soft tissue redundancy with 3-0 or 4-0
Vicryl.
TECH FIG 3 • Vertical reduction genioplasty.

Narrowing Genioplasty
■ The overall procedure is similar to vertical reduction genioplasty.
■ However, a п-shaped osteotomy is made using a reciprocating saw (TECH
FIG 4A), and the central bony segments of the chin are removed to reduce
the horizontal dimension of the chin (TECH FIG 4):
■ The horizontal dimension is controlled based on the amount of bone
resected.
■ A step deformity along the margin can be smoothed easily using marginal
mandibuloplasty with a reciprocating saw.
■ The two segments of the chin are secured together with wiring and fixed to
the mandible with titanium miniplate.
■ The periosteum and the mucosa are closed to minimize soft tissue
redundancy with 4-0 Vicryl.
■ Although mild submental redundancy can occasionally be a problem, the
overall satisfaction is generally very high.

TECH FIG 4 • Narrowing genioplasty.
PEARLS AND PITFALLS
Approach
■ Subperiosteal dissection is performed except the opening of the
mental nerve.
Osteotomy
■ When horizontal cutting is done with reciprocating saw, the important
thing is to keep at least 5 mm bone just above the upper horizontal
cutting line as the mandibular nerve passes the 5 mm lower than the
bony opening.
■ To avoid cutting submental soft tissue during osteotomy, which can
result in submental hematoma, the fingertip of the contralateral hand
can be used to perform slight palpation of the tip of the reciprocating
saw during osteotomy.

POSTOPERATIVE CARE
■ To prevent submental hematomas, an elastic bandage on the chin area and a
facial bandage can be applied 2 or 3 days postoperatively.
OUTCOMES
■ Lee and Ahn retrospectively reviewed 52 patients who underwent narrowing
genioplasty.4 All patients were satisfied with the more slender appearance of
their chins:
■ The subjective grading was “much improved” in 67% of patients and
“improved” in 33%.
COMPLICATIONS
■ Complications are uncommonly noted in Sykes and Suarez’s study.5
■ Submental hematoma
■ Decreased sensation of the lower lip
■ Submental bulging and soft tissue sagging
■ Malunion or nonunion of bony segment
■ Infection
REFERENCES
1. Cutright B, Quillopa N, Schubert W. An anthropometric analysis of the key
foramina for maxillofacial surgery. J Oral Maxillofac Surg. 2003;61(3):354-
357.
2. Choi JW, Kim N. Clinical application of three-dimensional printing
technology in craniofacial plastic surgery. Arch Plast Surg. 2015;42(3):267-
277.
3. Jeong WS, Choi JW, Choi SH. Computer simulation surgery for mandibular
reconstruction using a fibular osteotomy guide. Arch Plast Surg.
2014;41(5):584-587.
4. Lee SW, Ahn SH. Angloplasty revision: importance of genioplasty for
narrowing of the lower face. Plast Reconstr Surg. 2013;132(2):435-442.
5. Sykes JM, Suárez GA. Chin advancement, augmentation, and reduction as
adjuncts to rhinoplasty. Clin Plast Surg. 2016;43(1):295-306.

76
CHAPTER
Section XIV: Osseous
Genioplasty
An Osseous Approach to
Chin Deformities
S. Anthony Wolfe and Saoussen Salhi
DEFINITION
■ Osseous genioplasty was introduced in 1942, when Otto Hofer described a
horizontal osteotomy of the mandibular symphysis through an external
approach to correct the deficient chin on a cadaver.1,2 However, we owe the
first description of a genioplasty performed on a living patient to Gillies and
Millard in 1957. They described a jumping genioplasty, through an external
approach, where the lower border of the mandibular symphysis was
osteotomized, advanced superiorly, and positioned on top of the upper
mandibular segment.2
■ In 1957, Richard Trauner and Hugo Obwegeser described the intraoral
approach to the osseous genioplasty,1–4 and later, in 1964, Converse and Wood-
Smith expanded on the possible variations of the procedure.1,2 In their
description of the surgical technique, the osteotomized caudal segment of the
mandibular symphysis was stripped of all of its muscular attachments before
advancing it, thereby converting it to a free bone graft. This resulted in
significant bone resorption, which prompted these surgeons to preserve the
blood supply to the caudal segment.4
■ Despite its description more than half a century ago, osseous genioplasty
remains less frequently performed than alloplastic chin implants.3 In 1950,
Converse described the use of intraoral bone grafts for chin augmentation.
These quickly fell out of favor because of their variable resorption, donor-site

morbidity, and the successful introduction of alloplasts.1 In 1953, Safian
introduced the first silicone chin implant.1
ANATOMY
■ When performing a genioplasty, pertinent anatomy relates to the mental nerve.
■ The mental nerve is the terminal sensory branch of the inferior alveolar nerve,
which is itself a branch of the mandibular division of the trigeminal nerve.
■ The mental nerve provides sensory innervation to the lower lip and the chin.
■ It exits the mandible through the mental foramen at the level of the second
premolar.3
■ The inferior alveolar nerve courses inferiorly prior to heading cephalad toward
the mental foramen.5 For this reason, the horizontal osteotomy of the
mandibular symphysis performed during a genioplasty has to be placed 5 to 6
mm below the mental foramen.5
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Physical examination starts by dividing the face along the trichion, glabella,
subnasale, and menton.3 When these landmarks divide the face into equal
thirds, the face is considered ideal.2,3
■ The lower third of the face, delimitated superiorly by the subnasale and
inferiorly by the menton, is further divided by the oral commissure into an
upper third, the upper lip, and lower two-thirds: the lower lip, labiomental
sulcus, and chin.2 This allows assessment of the volume of the chin relative to
the overall facial profile.
■ The chin pogonion projection is assessed relative to the facial plane, the zero
meridian, which is a line started at the nasion and dropped perpendicular to the
Frankfurt horizontal. Ideally, the chin pogonion should be at or near the zero
meridian, being more projected in men than in women. It should not be beyond
the lower lip border.3
■ Chin deformities are commonly divided into two categories: macrogenia and
microgenia. Guyuron et al. distinguish seven different chin deformities based
on the volume of the chin:
■ Class I: macrogenia or chin excess
■ Class II: microgenia or chin deficiency
■ Class III: combined excess in one dimension and deficiency in another
■ Class IV: asymmetric deformity

■ Class V: witch’s chin characterized by ptotic soft tissue and a deep labiomental
groove
■ Class VI: pseudomacrogenia or chin excess secondary to soft tissue excess
overlying normal bony anatomy as evidenced by a normal cephalogram.6
■ According to Guyuron et al., class II microgenia is the most commonly
encountered chin deformity, followed by class II macrogenia and class III, a
combination of both.6 It is important to note that the microgenia or macrogenia
can be present in a number of planes: vertical, horizontal, or both.3
■ The chin can also be characterized by its spatial position. It can be positioned
posterior to its ideal position at the zero meridian, which is referred to as
retrogenia.
■ When the retrogenia is secondary to mandibular retrognathia (class II
malocclusion) or vertical maxillary excess leading to a clockwise rotation of
the mandible, this is referred to as pseudoretrogenia.3
■ Osseous genioplasty alone cannot address this issue, and the patient likely
needs orthognathic surgery to correct the underlying malocclusion.
■ Often, patients who present complaining of a deficient chin have mandibular
hypoplasia with or without chin deficiency.
■ For this reason, all patients should undergo an intraoral examination including
an evaluation of the skeletal relationship of the maxilla and mandible to
exclude any underlying malocclusion.3
■ Finally, the experienced surgeon needs to rely on his or her eye and the
patient’s desired result.3
IMAGING
■ In most patients, clinical examination and photographic analysis are sufficient
to determine if the chin shows any abnormality in both its position and its
volume.3
■ A lateral cephalogram can provide quantitative confirmation of these
abnormalities.3
■ A frontal cephalogram can be helpful in planning the genioplasty osteotomy
aimed at correcting an asymmetrical chin.3
■ A panorex is used to identify the mental foramen and the dental roots and to
plan the osteotomy and hardware placement to avoid injury to these
structures.3

SURGICAL MANAGEMENT
■ Many aesthetic surgeons favor alloplastic genioplasty1,4 for its simplicity,1,3,4
shorter operating time, ease of reversibility, decreased risk of injury to the
mental nerve, and ability to perform under local anesthesia.1 However, they are
associated with higher infection rates, risk of extrusion,1,7 erosion into the
mandibular symphysis,1,3,7 migration, capsular contracture, and unpredictable
soft tissue response.1
■ In contrast, osseous genioplasty eliminates the use of a foreign body, thereby
avoiding the risk of infection, extrusion, migration, and bony resorption.8 It
also results in a more predictable soft tissue response1 and improves the
cervicomental contour1 when the lower symphyseal fragment with its attached
musculature is advanced, thereby tightening the submental region.8 It is also a
more versatile procedure1,3,4,8 to correct chin deformities that an implant
cannot, such as vertical macrogenia or microgenia,3,4,7,8 chin asymmetry,3,4,8
and significant sagittal microgenia.3,7
■ We are not condemnatory of the use of alloplastic implants for the chin if they
are used for the proper indication, ie, mild sagittal deficiency1,4 (generally less
than 5 mm3) in a previously unoperated patient3,4 and properly performed
(placed through a submental incision and rigidly fixed to the underlying bone).
Several contraindications to chin implants are cited in the literature, including
systemic diseases such as cardiovascular diseases, diabetes, severe periodontal
disease, and young age.1
■ We do not however use them ourselves because we can do a genioplasty for
every type of deformity, including mild retrogenia. Once a comfort level has
been reached using power equipment to cut the mandibular symphysis, one can
advance the chin, vertically shorten or lengthen the chin, and correct lateral
deviations. This enables one to be able to treat the whole spectrum of chin
deformities, not just the cases of mild retrogenia. A genioplasty has the added
advantage of being a vascularized bone flap with its inferior attachments of
geniohyoid, genioglossus, and anterior belly of the digastric muscle.8,9
Therefore, the advanced segment does not undergo resorption,8,9 and any
postoperative buccal incision dehiscence maintains the potential to heal.
Positioning
■ General anesthesia is preferred not because of pain issues but rather a concern
that a good bit of blood and irrigating fluid in the mouth of a sedated patient

might result in aspiration.
■ If a patient is adamant about having the procedure performed under local
anesthesia, good anesthesia can be obtained by mental nerve blocks and
infiltration of the submental muscles.
■ If general anesthesia is used, a nasal intubation is not essential because an oral
tube does not interfere with access. The head should be extended, without a
doughnut.
T E C H N I Q U E S
■ Osseous Genioplasty
Video p1-c076_01
■ The lower labial sulcus is infiltrated with a vasoconstrictive solution.
■ An incision is made with the needle-tip electrocautery, from to cuspid to
cuspid, on the labial side of the gingivobuccal sulcus leaving a cuff of 3 to 4
mm superiorly containing mucosa and very little mentalis muscle and sparing
the frenulum.
■ Cutting through large amounts of mentalis muscle denervates the superior
portion of the muscle and may lead to lower lip incompetence and incisive
show, which is very difficult to correct.
■ The periosteum is incised and a subperiosteal dissection is immediately
begun. This dissection is intentionally limited at the level of the anterior
00:00 / 00:00

surface of the symphysis, below the planned osteotomy line, to avoid ptosis
of the chin pad.
■ The dissection then proceeds laterally for identification and preservation of
the mental nerves, located between the first and second bicuspids (TECH
FIG 1A). Their vertical distance from the inferior border of the mandible can
vary considerably. Dissection is carried beneath the nerves laterally and over
the inferior border of the symphysis.
■ The most important step is in marking for the cut. One must be able to see
the patient’s eyes. The midline is marked (a soft pencil is best), and then at
right angles to this, a transverse line is drawn, being sure that it is parallel to
the interlateral canthal line. This line must be at least 5 mm below the canine
root and 6 mm below the mental foramen when extended laterally (TECH
FIG 1B). This is to avoid injury to the inferior alveolar nerve, which dips
down slightly before it exits the foramen. These lines are then scored using
an oscillating saw (we prefer Aesculap, but the Stryker is also fine).
■ The operator’s left hand then holds the lower lip out of the way, and if
possible, the entire full-thickness cut is made with the oscillating saw.
Frequently, the bone laterally beneath the nerve may need to be cut with a
reciprocating saw (the nerve should be gently shielded during the maneuver).
■ The lower border should be cut free entirely with the saw; if one tries to
wedge the basilar segment down with an osteotome, a fragment will remain
on the basilar segment that interferes with proper movement.
■ The basilar segment then can be moved as desired: forward, for retrogenia;
upward, after removal of an appropriate strip of bone (remember the nerves),
for macrogenia; downward with an interpositional bone graft for microgenia;
and laterally for chin point deviation. An advancement genioplasty can be
fixed with wires or several long screws; other movements often require
titanium miniplates and screws.
■ The buccal incision is closed in one layer with 4-0 chromic catgut sutures,
incorporating as much of the mentalis cuff as possible. If bone graft has been
placed, a few deep sutures are placed in the mentalis muscle. Drains are not
used.

TECH FIG 1 • A. The right mental nerve can be seen
just right of the pencil mark, exiting from the mental
foramen. B. The superior horizontal pencil marks
indicate the bilateral mental foramina. The inferior
horizontal pencil mark indicates the level of the
horizontal osteotomy, marked 6 mm below the level of
the mental foramina. The vertical line marks the
midline of the mandibular symphysis.
■ Variations
Video p1-c076_02
■ Variations of the osseous genioplasty technique have been described to
address all possible chin deformities.
00:00 / 00:00

■ Sliding genioplasty: The basilar segment is moved anteriorly or
posteriorly.3,9
■ Jumping genioplasty: The basilar segment is used like an implant, placed
anterior to the mandible. The muscular attachments to this segment are
carefully maintained to maintain its vascularity and minimize postoperative
resorption.
■ Interpositional genioplasty: A bone graft is interposed at the osteotomy line
to increase the height of the lower third of the face.2,3,9 Converse et al.
describe the use of iliac bone as bone graft.9 However, we favor using the
outer table of the cranium harvested in the parietal region as a bone graft in
these procedures.
■ Wedge genioplasty: Two osteotomy lines are performed below the mental
foramen, and the intervening bone segment is removed.2,3,9
■ Stepladder genioplasty: Two osteotomies create two bone segments. The
most caudal of these segments is advanced over an already advanced more
proximal segment.3,9
■ Centering genioplasty allows correction of chin asymmetries.3,9
PEARLS AND PITFALLS
Occlusion
■ Occlusion has to be assessed preoperatively to rule out
pseudoretrogenia secondary to mandibular hypoplasia, which is
better managed with orthognathic surgery.
Intraoral
incision
■ Incision has to be placed on the labial side of the gingivobuccal
sulcus by leaving a mucosal cuff of 3–4 mm to facilitate closure.
Surgical
technique
■ Subperiosteal dissection is limited to the anterior surface of the
mandibular symphysis to avoid postoperative ptosis of the chin pad.
Mental nerve
identification
■ The mental nerve is identified between the first and second
bicuspid.
Mandibular
osteotomy
■ The midline of the symphysis should be marked and the osteotomy
line is drawn perpendicular to the midline, 5 mm below the canine
root, and at least 6 mm below the mental foramen.
Incision

closure
■ Closure of the incision can be done in one layer making sure to
incorporate the mentalis muscle in the closure.
FIG 1 • Preoperative (A,B) and postoperative (C,D)
photos of a patient who underwent jumping genioplasty
for retrogenia.
POSTOPERATIVE CARE
■ A light tape dressing is maintained for a few days.
■ Patients may begin on a soft diet immediately.
■ Patients are maintained on a soft diet for 3 weeks postoperatively.
OUTCOMES
■ Before and after patient photos are shown in FIGS 1 to 3.

COMPLICATIONS
■ Among the disadvantages cited for osseous genioplasty, when compared to
alloplastic chin implants, need for general anesthesia, technical complexity,
need to use power tools, risk of tooth root devitalization, and higher incidence
of postoperative mental nerve paresthesias and postoperative discomfort were
all cited.1
FIG 2 • Preoperative (A,B) and postoperative (C,D)
photos of a patient who underwent removal of a chin
implant and jumping genioplasty for long retrogenia.

FIG 3 • Preoperative (A,B) and postoperative (C,D)
photos of a patient who underwent wedge genioplasty
and jumping genioplasty for long retrogenia.
■ However, Guyuron et al. who compared osseous genioplasty and alloplastic
chin implants, performed by a single surgeon, on two groups of patients, found
no statistically significant difference in the amount of postoperative pain
between the two groups of patients.1
■ They did show a statistically significant higher incidence of temporary sensory
loss over the mental nerve distribution in the osseous genioplasty group.1
■ However, all patients experienced improvement over time, and this difference
in incidence of nerve damage was no longer statistically significant over a long
follow-up period.1

REFERENCES
1. Guyuron B, Raszewski RL. A critical comparison of osteoplastic and
alloplastic augmentation genioplasty. Aesthetic Plast Surg. 1990;14(3):199-
206.
2. Wolfe SA. Shortening and lengthening the chin. J Craniomaxillofac Surg.
1987;15(4):223-230.
3. Ward JL, Garri JI, Wolfe SA. The osseous genioplasty. Clin Plast Surg.
2007;34(3):485-500.
4. Wolfe SA, Rivas-Torres MT, Marshall D. The genioplasty and beyond: an
end-game strategy for the multiply operated chin. Plast Reconstr Surg.
2006;117(5):1435-1446.
5. Kawamoto H. Osseous genioplasty. Aesthet Surg J. 2000;20(6):509-516.
6. Guyuron B, Michelow BJ, Willis L. Practical classification of chin
deformities. Aesthetic Plast Surg. 1995;19(3):257-264.
7. Cohen SR, Mardach OL, Kawamoto HK Jr. Chin disfigurement following
removal of alloplastic chin implants. Plast Reconstr Surg. 1991;88(1):62-66.
8. Wolfe SA. Chin advancement as an aid in correction of deformities of the
mental and submental regions. Plast Reconstr Surg. 1981;67(5):624-629.
9. Converse JM, Wood-Smith D. Horizontal Osteotomy of the Mandible. Plast
Reconstr Surg. 1964;34:464-471.

77
CHAPTER
Section XV: Hair
Transplantation
Indications and Techniques
for Hair Transplantation
Walter Unger and Robin Unger
DEFINITION
■ Hair transplant surgery involves the transfer of hair from an area of anticipated
lifelong permanence to an area of alopecia or evolving alopecia.
■ The principle of donor dominance, for this procedure, was established in
1959 by Dr. Norman Orentreich.
■ Appropriate patients may include those with male pattern baldness (MPB),
female pattern hair loss (FPHL), post-trauma and postsurgical areas of
alopecia, as well as some cicatricial alopecias.
■ Human scalp hairs grow naturally in individual bundles, called follicular units
(FUs), composed of clusters of one to four follicles surrounded by layers of
concentric collagen fibers.
■ Follicular unit transplantation (FUT), when performed properly, consistently
results in a cosmetic appearance similar to natural scalp hair growth (FIG 1).
■ The two primary methods of harvesting the donor hair are the strip excision
method and follicular unit extraction (FUE).
■ The ratio of the donor/recipient area has expanded. Though it is 1:1 with
large punch grafts, it is 1:2 to 4 with a strip excision and FUT, thus allowing
surgeons to cover larger areas of alopecia with a natural appearance and good
cosmetic density.
• A 1 cm2 section from the donor strip can cover 2 to 4 cm2 of alopecia.
• FUE in conjunction with strip harvest has further expanded the donor

availability.
■ When FUE is used as the exclusive method for donor harvest, this decreases
the number of relatively permanent scalp hairs that can be transplanted
during a patient’s lifetime, because each of the resultant punctuate scars
(typically thousands) must be camouflaged by relatively permanent hairs.
■ Good surgical planning in hair transplant surgery addresses current and future
areas of alopecia. This principle is especially important when treating younger
patients (because of their long-term donor/recipient area ratios) and those with
limited long-term donor hair availability.
■ Preoperative evaluation and determination of candidacy should include a
physical exam, review of relevant laboratory tests, and a review of the family
history of hair loss.
ANATOMY
■ The scalp is composed of five distinct layers: skin, subcutaneous layer, galea
aponeurotica, loose connective tissue, and pericranium.
■ The scalp has an excellent blood supply provided by a system of anastomoses
between branches of the external and internal carotid arteries. The arteries run
centripetally within the subcutaneous layer. This rich blood supply helps
promote exceptional healing after scalp surgeries (FIG 2A).
■ The sensory nerve supply is also centripetal and subcutaneous. If larger nerve
trunks are injured in surgery, there can be significant hypoesthesia in the
postoperative period (FIG 2B).
■ The anatomy of the hair follicle has been described in many texts. The
terminal hair is divided into an upper (infundibulum), middle (isthmus), and
lower (inferior segment) region. A good harvest will remove intact follicles,
and all segments will be transplanted (FIG 2C).
PATHOGENESIS
■ Androgenetic alopecia
■ Androgenetic alopecia is the most common cause of hair loss in both men
and women. It is also the most common reason for hair transplantation.
• In unaffected scalp, the hair has a growing anagen phase of 2 to 6 years, an
involution catagen phase of 2 to 3 weeks, and a resting telogen phase of 2 to
3 months.
• In affected scalp, the anagen phase is significantly shortened, leading to the
production of shorter and finer hairs.

FIG 1 • A. Patient before surgery. B. Results after 1
year.

FIG 2 • A. Arterial distribution of the scalp. B. Nerve
distribution of the scalp. C. Structure of the hair follicle.
■ Androgens play a significant role in both MPB and FPHL, although FPHL
has a more complex etiology involving multiple other potential sources,
including inflammatory reactions and changes in estrogen and other hormone
levels and the enzyme aromatase.
■ Genetic factors are important in determining the likelihood of developing
MPB and FPHL—however, it is a polygenic mode of inheritance, with
incomplete penetrance.
■ Cicatricial alopecias
■ Cicatricial alopecias are, for unknown reasons, increasing in incidence in the
population and therefore need to be considered in patients presenting with hair
loss. The imposters of patterned hair loss to be wary of include frontal

fibrosing alopecia (FFA), lichen planopilaris (LPP), and central centrifugal
cicatricial alopecia (CCCA). Their pathogenesis is described in detail in other
texts.1
■ Dermatoscopic exam and biopsy are helpful in diagnosis and evaluation of
activity.
■ Surgery should ideally be avoided until the condition has become quiescent
for at least 1 year.2
NATURAL HISTORY
■ The natural history of male and female pattern alopecia is one of progressive
hair loss over the patient’s entire lifetime. Current treatments may slow the
progression, but as yet, there is no known treatment to stop the evolution.3
■ The Norwood pattern is shown in FIG 3.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patient history should focus on factors that may contribute to hair loss,
including symptoms of hypo- or hyperthyroidism, adrenal imbalances,
prolactinomas, nutritional deficiencies, and scalp symptoms noted by the
patient (burning, itching, tenderness, flaking).2
■ The history in female patients should also include questions that may indicate
symptoms of androgen excess, such as those seen in women with polycystic
ovarian syndrome (hirsutism, irregular menses, reproductive challenges,
indicators of insulin resistance).4

Type | Type IV Type Il Type IV a Type II a Type V Type Ill a Type V a Type III Type VI Type Ill vertex Type VII

FIG 3 • Norwood classification. (From Landeck L,
Otberg N. Hair loss. In: Schalock PC, Hsu JTS, Arndt
KE, eds. Lippincott’s Primary Care Dermatology.
Philadelphia, PA: Wolters Kluwer; 2010:410-436, with
permission.)
■ Events or conditions that cause telogen effluvium should be ruled out; these
most often include major physical or emotional stresses, post–severe febrile
illness, postsurgery, and postpregnancy. Hair transplant surgery should not be
performed until at least 6 months after the resolution of the effluvium—this
allows the donor hair to start regeneration and helps identify major areas of
concern.
■ The history should also clarify the pace of the hair loss and unusual
accelerations—a very rapid onset of shedding raises suspicion for etiologies
other than androgenetic alopecia.
■ The family history of hair loss is pertinent as a guide to determine the eventual
degree of patterned loss but is not accurately predictive in many patients.
IMAGING
■ Dermoscopy has become a very useful tool in evaluating patients for hair
transplant surgery (FIG 4).
■ A thorough dermatoscopic exam may reveal more subtle signs of diseases
more appropriately treated with a medical rather than surgical approach—
including frontal FFA, LPP, CCCA, and alopecia areata patchy or diffuse
type.
■ Dermoscopy can also help to determine the degree of miniaturization in the
hair-bearing rim. This may inform the surgeon as to how conservative or
aggressive the surgical plan should be.5
■ Biopsy and dermatopathological evaluation may be useful to confirm the
underlying condition responsible for the alopecia. Again, dermoscopy
guidance may be helpful in this process to guide the surgeon in the area most
appropriate for biopsy.
DIFFERENTIAL DIAGNOSIS
■ Patterned hair loss may be difficult to distinguish from these entities,
especially in their less active periods.

■ There also may be some coexistence with MPB/FPHL:
■ Alopecia areata and diffuse alopecia areata (“incognito”)
■ Telogen effluvium
■ FFA
■ LPP
■ Tinea capitis
■ CCCA
■ Discoid lupus erythematosus
■ Folliculitis decalvans
■ Syphilis
NONOPERATIVE MANAGEMENT
■ Medical therapy
■ FDA-approved treatments with proven efficacy for MPB include minoxidil
and finasteride (FIG 5A,B).
■ FDA-approved treatment with proven efficacy for FPHL is topical minoxidil
2% twice daily or 5% once daily. Off-label treatments include antiandrogens
such as finasteride, spironolactone, and cyproterone acetate.2
■ Dutasteride 0.5 mg daily may also be used (off-label) in patients who fail to
show response to finasteride.
■ Prostaglandin analogs: Studies thus far have been limited and have failed to
show a significant positive effect.
FIG 4 • A. Distribution of hair loss in a patient with
frontal fibrosing alopecia (FFA). B. Dermatoscopic
photo showing the periphery of FFA. Characteristics

include alopecic area devoid of follicular ostia, slightly
white in color; hair in the periphery shows perifollicular
casts and relative absence of vellus hair.
FIG 5 • Male patient before (A) and 1 year after (B)
initiating medical treatment with finasteride 1 mg daily.
Female patient with typical hair loss in the
frontotemporal regions before (C) and 4.5 months after
(D) one treatment with PRP/ACell/microroller.
■ Low-level laser and light devices for hair loss have been shown in limited
studies to produce some benefit as compared to sham devices—proposed
mechanism of action is mediated by absorption of cytochrome oxidase,
resulting in increased oxygen consumption and adenosine 5′-triphosphate
(ATP) production. In some patients, it may also produce and anti-inflammatory
effect.2
■ Mesotherapy: Superficial scalp injections of pharmaceuticals and vitamin
compounds. Compounds used include minoxidil, biotin, pantethol, finasteride,
dutasteride, tretinoin, and other vitamins and minerals. Further studies are
necessary to determine efficacy and which compounds at which concentrations
are optimal.
■ Platelet-rich plasma (PRP): Very few controlled studies have been completed

to provide evidence-based data on this modality for hair loss treatment.
Nevertheless, anecdotal reports and the experience of credible hair restoration
surgeons (HRS) are encouraging.6
■ There are many approaches being used by HRS for this procedure.
Standardization is necessary and will enable more meaningful evaluation of
the procedure’s efficacy.
■ Typically in our practice, 60 mL of blood is drawn from the patient and
centrifuged to produce PRP. This is then mixed with 25 mg of ACell (an
extracellular matrix derived from a porcine bladder) and injected into the area
of hair loss. It may be used as a stand-alone procedure or to enhance the
results in hair transplant surgery (in the latter scenario, it is also used to bathe
grafts prior to implantation).7
■ When done as a stand-alone procedure for hair loss by one of the authors,
microneedling with a 2.5-mm microneedle is performed prior to injection of
the PRP/ACell.
■ PRP has been demonstrated to increase overall hair counts and hair diameter,
while microscopic findings reveal thickened epithelium, proliferation of
collagen fibers and fibroblasts, as well as greater numbers of blood vessels
around hair follicles in areas that have been treated with PRP (FIG 5C,D).7
■ More studies are needed to confirm the efficacy of this treatment, the ideal
approach to be utilized, and frequency of treatments required.
■ Micropigmentation is a technique that utilizes tattoos to simulate short hairs on
the scalp.
■ It can be used to hide scars and create the illusion of greater hair density in
hair-bearing areas. The type of pigment, color chosen, and depth of ink
placement can impact the long-term appearance of this type of camouflage.
■ Other camouflage techniques include
■ Small hairpieces
■ Powders or hair fibers that camouflage the color contrast between hair and
scalp, thereby making hair appear fuller
■ Alternative hair styling
SURGICAL MANAGEMENT
■ Donor area evaluation is undertaken to determine the area from which hair is
most likely to be permanent and thus will ostensibly persist in the recipient area
long after transplantation.
■ The senior author conducted a study of 328 men aged 65 years or older in

whom areas containing at least 8 hairs per 4-mm diameter circle were
measured.3 The dimensions established from this study represent the region of
harvest that would be “safe” (ie, the hairs would persist) in approximately
80% of patients under the age of 80 years. This persisting region of the donor
scalp was termed the “safe” donor area (SDA) and later the safest donor area
to denote that no area is perfectly “safe” (FIG 6A).
■ These boundaries have since been modified for FUE. Because of the less
visible resultant punctate scarring from this alternative technique, Cole’s
FUE SDA is somewhat expanded (203 cm2) and includes 14 subdivisions
based on hair density but importantly was based on only 94 patients, nearly
all of whom were in their 30s or 40s—and for both reasons, it is therefore
most probably a less reliable guide regarding long-term planning (FIG 6B).
■ Donor harvest approach
■ As previously mentioned, there are two main donor harvest approaches: strip
harvest and FUE.
• TABLE 1 summarizes the benefits and disadvantages of each method.

FIG 6 • Unger and Cole safe donor area.
Table 1 Benefits and Disadvantages of Follicular Harvest Techniques
Method
Pros
Cons
Strip harvest
• Higher FU yield
• Narrow donor area
• Higher follicle survival
• More protective tissue
surrounding hair
follicles and
• Long linear scar that
may be visible when
the hair is cut short
• More painful postop
period
• Longer postop healing

predictable graft
quality
• Harvest stays within
the confines of the
safe donor area
• Ability to choose the
size of the grafts
• Donor not visible
under hair from day 1
postop
period with some
exercise restriction
• Potential for loss of
dormant follicles—
greater in unrecognized
cases of telogen
effluvium
FUE
• Shorter postop
healing
• Less painful postop
period
• Minute punctuate
scars that are less
visible even with the
hair worn short
especially with less
contrast between hair
and scalp color
• A good complement
technique when scalp
laxity is limited or for
repairs
• Less tissue discarded
with potential dormant
follicles
• Lesser FU yield
• Wider donor area
harvested (some HRS
extend past the safe
donor area to achieve
higher graft yield)
• Less tissue around hair
follicles (skinny grafts)
and less predictable
quality, contributing to
lower follicle survival
• Usually requires
shaving the donor area
for larger sessions
• Lowers the density in
the donor area
perceptibly after larger
harvests or multiple
procedures
• Ideally, HRS should have all tools available to tailor the procedure to each
patient’s individual needs.
■ Both methods of harvest primarily use follicular unit (FU) grafts almost
exclusively in the recipient area.
• One of the authors sometimes uses double follicular units (DFU) when a
strip harvest is use and the area to be treated has pre-existing permanent

hair. This very frequently pertains to women with thinning behind the
hairline zone and older males with minimal hair/skin color contrast.
■ Donor strip harvest
• Goals
• Minimize the amount of hair follicle transection as the strip is excised and
dissected.
• Extract donor strip widths with prudent caution in order to minimize
closing tension.
• Produce only a single scar regardless of the number of sessions performed
on a single patient.
• Assessment of scalp laxity prior to surgery is of tantamount importance; this
can be done with calipers or manually.
• The donor strip should be removed from the densest zone of the fringe hair.
Any subsequent strip excision should include the previous scar so only one
thin linear scar remains.
■ FUE
• Goals
• Maximize the amount of hair removed from the most permanent hair-
bearing fringe while minimally altering the architecture of the donor area.
Keep in mind also that the fringe hair will continue to decrease in density
somewhat over the patient’s lifetime.
• Minimize transection during extraction, yet try to harvest with some
protective tissue; this should be a goal even if the technique involves
fractional harvesting of follicular groups.
• Minimize the amount of scar tissue within the donor area by varying punch
diameters to keep it as small as possible (without increasing transection
rates) and try to evenly disperse the harvest sites.
• FUE grafts may be removed from the Unger’s traditional SDA and should
ideally have a tapering zone superior and inferior to make the density
change more subtle. The temporal regions may also be harvested more
extensively with this technique than with strip harvesting.
• FUE may be used to harvest hairs from the beard area on the neck and
inferior to the lower mandible.3 These grafts can be used to camouflage
scars and to thicken regions that already have been transplanted. Other body
hair survival is much more unpredictable.

■ Recipient area approach
■ The authors strongly believe in planning that includes treating current areas
of hair loss simultaneously with future areas of loss in the zone of the
recipient area being addressed (front, midscalp, or vertex).
• Although patients may intend to return to “complete things,” they may be
unable to do so because of life events. A well-planned hair transplant should
look natural over the patient’s entire lifetime.
• On average, 25% to 30% of grafts may be placed in future areas of loss—
this number is obviously higher in patients treating their MPB very
proactively and is lower in those who present with more advanced hair loss.
■ Other physicians believe that transplanting a maximum portion of currently
noticeable hair loss is more important than concomitantly treating the less
noticeable future areas of loss. As long as the patient is fully informed, this
policy is reasonable: it gives the patient more immediate satisfaction, and the
future areas of loss can be treated when needed.
■ The authors do not ask patients to change their hairstyle or usual length of
hair for the procedure. This hair serves as a guide for the placement of hair to
be transplanted and also provides postoperative camouflage.
■ Some surgeons shave the recipient area to facilitate the completion of larger
surgeries with greater ease and within a more reasonable time frame.
Preoperative Planning
■ Preoperative instructions include the discontinuation of medications or
substances that may increase bleeding.
■ In particular, 10 days before surgery, acetylsalicylic acid (ASA), or any drugs
containing it that influence platelet activity, should be discontinued—this
instruction is suspended in patients taking ASA or anticoagulation for
therapeutic purposes. The patient is also asked to abstain from alcohol
consumption for 1 week preoperatively.
■ Twice-daily application of topical minoxidil to the recipient area is started 1
week prior to surgery due to the theoretical increase in blood flow that may
decrease the likelihood or severity of temporary hair loss.
■ Patients with limited scalp laxity having strip surgery are instructed on how
to massage their scalp during the 4 weeks prior to surgery in order to increase
the laxity within the donor area, thus enabling a wider strip harvest and a
greater FU yield.
■ Prophylactic perioperative antibiotics are given to patients 1 hour prior to

surgery and 6 hours later as a precaution.
■ The surgical design is drawn the morning of surgery and discussed again with
the patient (FIG 7A).
FIG 7 • A. Markings for hairline and borders for surgery.
B. Preoperative period after donor area hair has been
trimmed. A scar from the previous surgery is visible in
the center of the trimmed region.

FIG 8 • Zones of treatment regions, including current
and future areas of alopecia.
■ Many photographs are taken on the morning of surgery, an even greater
number if the recipient area contains pre-existing hair.
■ Results are optimal and reproducible when photos are standardized. A ceiling
or photographer’s light immediately behind the photographer and a uniformly
bright background color enhance the viewing of the scalp by creating contrast,

thus outlining the peripheral boundaries of progressing alopecia and hair.
■ The laxity in the donor area is evaluated carefully with the neck in a neutral
position.
■ The donor area hairs to be harvested are trimmed to 2 to 3 mm in length to
facilitate implantation and orientation of the hair at that time (FIG 7B).
Hairline Design
■ The hairline design is arguably the most important step. There are no firm
rules.
■ The contour should be consistent with a natural aging hairline (different
among ethnic groups). In most male patients, this involves incorporation of
temporal recessions.
■ The major anatomic landmarks, borders, and zones of normal hair-bearing
scalp need to be well understood and effectively reproduced (FIG 8).
■ With the increased demand for HRS among young adults in the early stages
of MPB, one of the most important principles of hairline placement is “do not
place a hairline too low.”
■ A guideline for locating the anterior midpoint of a hairline is to look
somewhere in the zone between the vertical and horizontal planes of the scalp.
Discuss with the patients their wishes and desired hairstyle as this may
influence somewhat the position of the superior “frame” of the face.
■ To create the illusion of a slightly lower hairline without expending too many
FU, surgeons may construct a “widow’s peak.”
■ From the anterior midpoint, the frontal hairline should run more or less
parallel to the ground or slope slightly upward when viewed from the side until
it meets the temporal hairline at a point drawn from the lateral epicanthus to a
point where it meets the remaining temporal hair.
■ Throughout the hairline, the transition zone (the anterior 0.5- to 1-cm region)
should contain both microirregularities (intermittent density clusters more
noticeable under close examination than from a distance) and
macroirregularities (protrusions along the path of the hairline that cause it to
appear less linear when viewed from a distance).
■ It is important to note that the macroirregularities may change the contour of
the hairline and thus need to be chosen carefully.
■ It is generally not advisable to advance temporal points in young male patients
who may experience a progressive posterior recession of their temples that

their limited donor reserve may not be able to sufficiently address once the
transplanted hair is placed too far anterior to the progressively receding
temporal hairline (thus leaving an unnatural “island” of transplanted hair).
■ When the donor-to-recipient ratio allows, however, temporal points should be
advanced no farther than to an intersection of two lines: one drawn from the
tip of the nose, over the pupil to the anterior tip of the temporal point, and a
second line drawn from the most anterior midpoint to the tragus.
■ In addition to hairline design varying with degree of hair loss, ethnic
considerations should be made when creating this anterior-most pattern.
■ Caucasians generally have dolichocephalic, or ovoid, skulls; East Asians tend
to have brachycephalic, or rounded, skulls.
■ The hairline design in East Asians is comparatively wider and flatter, with
curved (rather than sharp) frontotemporal angles. The relatively higher caliber
of East Asian vs Caucasian hair may make multihair FU more noticeable. It is
therefore important to camouflage these higher-caliber haired FUs with
additional rows of single-haired grafts anteriorly.
■ Patients of African descent tend to have mesocephalic skull shapes of
intermediate length and width that support hairlines that are flatter than
Caucasian patients, but not as flat as those found in most East Asians. Unlike
East Asian patients, however, a natural hairline appearance is more easily
achieved in patients of African descent due to not only the hair curl and the
finer caliber hair but also the minimal contrast between the color of the hair
and skin and the frizz, which creates an illusion of density and any tendency
for grafts to be noticeable.
■ Appropriate facial framing in female patients often entails a more rounded
hairline design that incorporates observations derived from examination of 360
female volunteers (FIG 9).