The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

FUTURE DIRECTIONS
The Role of Platelet-Rich Plasma Growth Factors
in Surgery for Male and Female Pattern Baldness
Baldness surgery with micrografts and minigrafts performed in megasessions was
described in 1989 and 1991, and today it is a widely used technique for treating both
male and female pattern baldness. The procedure transplants great quantities of fol-
licular units harvested from the posterior occipital area of the scalp and places them
in bald regions. These transplanted units carry a good genetic histologic structure,
providing the future hair with the same quality of growth, durability, and charac-
teristics as the donor area. Implanted hair growth has an individual cycle. During
the first 2 weeks of implantation, the catagen phase occurs, marked by an inflam-
matory process in which redness in the scalp and shedding of the hair shaft is com-
mon. The patient then enters the telogen phase, which lasts between 3 and 4 months.
This is followed by the latency period, which precedes the third phase, anagen. In
this phase, the future hair begins to grow. During the resting period, substantial fol-
licular unit loss can occur because of apoptosis. Between 15% and 30% of the im-
planted grafts will either be eliminated or absorbed by the scalp. Therefore only 70%
to 85% of the implanted hair will sprout. Considering this important hair loss fact,
we developed a clinical trial using platelet-rich plasma growth factors obtained from
the patient’s own plasma. This experimental research was submitted to and approved
by the Ethics Committee of the Pontificia Universidade Católica do Rio Grande do
Sul in Brazil, Division of Plastic Surgery.
Platelet Growth Factors and Hair Stem Cells
The first articles on growth factors derived from plasma were published during the
1970s and 1980s describing their application for tissue repair and hemostasis dur-
ing the healing process of ulcers and undermined wound surfaces. More recent works
in orthopedics and odontology demonstrated the role of such factors in bone graft
recomposition and in the osteosynthesis of teeth. Man et al in 2001 and Bhanot and
Alex in 2002 reported new applications of platelet-rich plasma in the wound sites
of cosmetic procedures. The growth factors contained in platelets of blood plasma
are basically three: platelet-derived growth factor (PDGF), transforming growth fac-
674
Part IV  Hair Transplantation

tor (TGF), and vascular endothelial growth factor (VEGF). These are protein mole-
cules that, in contact with their respective receptors, act in tissue angiogenesis, stim-
ulating the healing and growth of new organic structures. The action of growth fac-
tors on the germinative hair cycle has already been studied in both its embryologic
and adult phases; however, it has not yet been studied in hair micrograft implanta-
tion surgery. No clinical trial or experimental protocol had previously been per-
formed to verify the efficacy of those factors in the growth and density of implanted
follicular units.
675
Chapter 20  Micrograft and Minigraft Megasessions in Hair Transplantation
Growth factor
migration
Bulge
VEGF
PDGF
TGF
BETA
Hair
shedding
Rich platelet
gel with
growth factors
Galea aponeurotica
ANAGEN
CATAGEN
TELOGEN
NEW ANAGEN
PHASE
3 weeks
3-4 months
After 4 months
DYSTROPHIC
SHADING PHASE
PROLIFERATIVE
PHASE
This illustration depicts follicular units being implanted and the associated platelet
plasma growth factors, showing the dystrophic shading phase and the new prolifer-
ative phase with an intense vascular endoneogenesis supporting the new hair devel-
opment to the anagen phase. There is an intense growth factor migration into the
stem cells in the bulge area.
These growth factors interact in the bulge area with cells of the matrix, thus activat-
ing the proliferative phase of the hair. Stem cells are more primitive and of ectoder-
mal origin. They give rise to epidermal cells and sebaceous glands. Germinative cells
of the matrix, which are found at the dermal papilla, are of mesenchymal origin.

The hair follicle cycle shows the meeting between matricial cells from the papilla and
the stem cells in the bulge area, starting the growing phase of the new hair follicle.
Both cells need each other, and when they meet through the action of various growth
factors (PDGF, TGF, and VDGF), they give rise to the future follicular unit, which
consists of the hair shaft, sebaceous glands, erectus pilus muscle, and the perifollicu-
lum. Headington described this histologic unit in 1984. It is the complete and de-
veloped follicular structure in the anagen hair cycle phase that lasts from 3 to 6 years
in the scalp.
Experimental Model
Twenty male patients aged 22 to 54 years with male pattern baldness in the frontal,
parietal, or occipital area were selected for this experiment.
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Part IV  Hair Transplantation
Bulge with
stem cells
Sebaceous
gland
CATAGEN
TELOGEN
NEW ANAGEN PHASE
Two symmetrical 2.5 cm2 bald areas were delineated. On the right side of the pa-
tient’s head, follicular units imbibed with platelet plasma growth factors were im-
planted; on the left side, standard follicular units were implanted as a control. In all

patients, both areas were implanted with an equal number of micrografts. All pa-
tients were duly informed about the clinical trial and signed informed consent doc-
uments. This patient is shown 7 months after implantation, with improved hair
growth on the right side.
Surgical Technique
Harvesting of Follicular Units
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Chapter 20  Micrograft and Minigraft Megasessions in Hair Transplantation
In all cases, a hair-bearing ellipse flap was taken from the occipital area of the scalp
above the neck, where the best histologic and genetic quality of hair is present. The
flap size varied according to the amount of follicular units needed. For medium-type
baldness, an ellipse was obtained, usually 15 cm long by 2 cm wide, from which
1200 follicular units could be obtained.
The donor area was closed without tension, using an intradermal or continuous su-
ture, to enable a secondary harvesting of grafts 3 to 4 years later if needed. Two
groups of 180 follicular units were harvested and prepared—one group was imbibed
with platelet plasma growth factors and the other was kept wet with saline solution
on an acrylic surface.

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Part IV  Hair Transplantation
Obtaining the Platelet Plasma Growth Factors
Before surgery, 80 ml of blood was withdrawn from the patient in eight vacuum
flasks, with each one containing 1 ml of anticoagulant, 3.2% trisodium citrate (Vac-
uette; Greiner Bio-One, Kremsmuenster, Austria).
The eight flasks were centrifuged at 1000 rpm for 10 minutes. This slow speed is im-
portant so that platelets are not displaced to the bottom of the flasks. The plasma
was then dispensed into four new flasks for a second centrifugation at 5000 rpm for
10 minutes. The floating platelet-poor plasma was discharged, leaving only 2 ml of
concentrate—the platelet-rich plasma with four to six times more platelets than nor-
mal plasma, and therefore containing a high concentration of growth factors. This
concentrate was then added to the follicular units before implantation. The follicular
units were kept in the platelet growth factor solution for 15 minutes to allow the
growth factors to attach to the stem cells located in the bulge area of each follicular
unit.

Next, 10 drops of 10% calcium chloride was added to the mixture to convert fi -
brinogen into fibrin, thereby producing the plasmatic gel that would seal the growth
factors around the micrografts. The follicular units were then ready to be implanted.
Implanting the Follicular Units
The entire bald area on the scalp was massively infiltrated with saline solution con-
taining epinephrine 1:160,000. This tumescent technique, or “scalp ballooning,” with
the vasoconstriction obtained with the epinephrine injection, helps to limit bleeding
and facilitates implantation of the micrografts.
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Chapter 20  Micrograft and Minigraft Megasessions in Hair Transplantation
The units were implanted by the stick-and-place punctiform technique. In the outlined
area to the right, the units imbibed in platelet-rich plasma growth factors were im-
planted; to the left, the units considered controls were placed. The same number of
grafts was implanted on both sides, thus allowing greater control for the clinical trial.

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Part IV  Hair Transplantation
For this procedure, microblades (BD Beaver) and lance tip 15DEG (Ellis Instruments)
and jeweler-type microforceps were used. After the two demarcated areas were im-
planted, the remaining bald area was implanted using standard follicular units. Moist
gauze was applied to the implanted area and secured by an elastic bandage that was
kept in place for 24 hours. After that time, the patient removed the bandage and
washed the entire implanted area with an antiseptic, neutral shampoo.
Endpoint Evaluation
All patients were evaluated monthly for 7 months, and the yield of follicular units
was counted in the outlined areas. An accurate inspection, counting the number of
follicular units within the two areas, was performed by staining four india ink spots.
The final count was performed at the end of 7 months with a magnifying glass by
the surgeon; the hairs were recounted by two assistants for confirmation.
This 38-year-old patient had 150 implanted follicular units. After 7 months, 114 were
counted on the right and 95 on the left—an improvement of 20% for the platelet
plasma growth factor–imbibed side.

Statistical Analysis
The data were summarized using mean standard deviation. To compare the platelet-
rich plasma growth factor protocol and the control group, the paired t test was used,
because data showed a gaussian distribution. Analyses were performed using SPSS
version 12.0 (SPSS, Chicago). The significance level was set at 0.05.
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Chapter 20  Micrograft and Minigraft Megasessions in Hair Transplantation
Patient Characteristics, Implanted and Yield of Follicular Units
per 2.5 cm2 Areas, and Normal and Rich Plasma Platelets (N  20)
Yield of Follicular Units
Platelets
Implanted
Age
Region of
Follicular
Normal
Rich
(yr)
Baldness
Units
Control
Experimental
Plasma
Plasma
35
F
138
117
135
224.000
460.000
45
F
170
129
134
185.000
417.000
49
F
155
92
107
234.000
614.000
39
F
164
92
119
268.000
658.000
31
F
128
72
94
227.000
640.000
50
F
170
121
139
187.000
390.000
29
F
160
102
117
183.000
380.000
36
F
150
95
114
180.000
420.000
32
F
145
99
108
217.000
390.000
48
F
153
94
143
144.000
536.000
36
O
110
86
99
224.000
460.000
32
F
137
92
95
184.000
391.000
48
F, P, O
150
108
121
195.000
600.000
54
F, P, O
137
123
135
150.000
420.000
23
F
121
97
101
311.000
343.000
22
F
125
101
116
270.000
1,202.000
42
O
135
103
107
165.000
656.000
29
F
137
108
127
248.000
1,076.000
38
F
130
108
119
140.000
321.000
39
F, P
125
105
110
200.000
191.000
38  9
—
142  17
102  14
117  15
206.800
528.250
 44.942
 243.586
Data are summarized as mean  standard deviation. F, Frontal; O, occipital; P, parietal.

682
Part IV  Hair Transplantation
Experimental Results
There was a statistically significant difference observed in the yield of follicular units
when the two groups were compared (p 0.001). The experimental group with the
platelet-rich plasma growth factor showed a density of 18.7 follicular units per cm2,
whereas the control group showed 16.4 follicular units per cm2. The difference of
2.3 follicular units per cm2 (95% confidence interval, 1.6 to 3.2 follicular units per
cm2) represented a 15.1% increase in the yield of follicular unit density between the
two groups.
This graph shows the total implanted follicular units and the yield of follicular units
for both experimental and control groups. This means that if there is a 100 cm2 (10 by
10 cm) bald area to be implanted, one can obtain 240 follicular units more, or ap-
proximately 480 hair shafts, assuming two shafts per follicular unit. It is important
to note that some patients had only a 3% increase using the platelet-rich plasma
growth factor protocol, whereas others had a 52% increase in follicular unit density.
5
0
10
15
20
25
30
Implanted follicular units
Yield of experimental follicular units
Yield of control follicular units
Follicular units/cm2
Cases
0
4
8
12
16
20
Group
Implanted
Experimental
Control
Yield of
Follicular Units
22.7
18.7  2.4
16.4  2.2
Effect/cm2
—
2.4
—
95% CI
—
1.6 to 3.1
—
p (Student t)
—
0.001
—

This 32-year-old patient had 125 follicular units implanted on each side; 117 follic-
ular units were counted on the right and 93 on the left; thus 26% more hair was
noted in the area implanted with platelet-rich plasma growth factors. Software im-
age analysis demonstrated a similar density of 28% on the right side.
683
Chapter 20  Micrograft and Minigraft Megasessions in Hair Transplantation
This 78-year-old woman had female pattern baldness and was treated with follic-
ular unit grafts and platelet growth factors. She is shown 14 months postoperatively.

684
Part IV  Hair Transplantation
This 62-year-old man had very thin hair. He was treated with platelet-rich growth
factor follicular unit grafts and is shown 1 year postoperatively.
This 54-year-old patient had very thin hair and was treated with platelet-rich growth
factor follicular unit grafts. He is shown 14 months postoperatively.

This 36-year-old patient had poor hair growth after one replacement procedure. The
results are shown after a second micrografting procedure with platelet-rich growth
factor follicular unit grafts. At 1 year postoperatively, there is approximately a 55%
increase in hair follicles.
Imaging
The use of digital imaging is an important comparative tool for assessing density. For
one patient, a digital camera (5.0-megapixel, 24-bit color) was used at a fixed dis-
tance from the scalp. Photographs in this study were recorded in raw format. Image-
Pro Plus 4.5 image analysis software (Media Cybernetics) was used to perform mor-
phometric analysis and to derive objective measures of the hair color density from
the marked areas on the right and left sides. A color threshold level was selected in-
teractively by an experienced observer and applied on both images from each pa-
tient. The scale used was 40 pixels/cm. The area covered by hair was divided by the
total area measured on every image. The patient shown on p. 683 demonstrates 28%
more density on the right side. By counting the follicular units with a magnifying
glass, an increase of 26% was observed in that area. This indicates that both systems
are practically the same and that the digital program could perhaps be improved in
future studies.
685
Chapter 20  Micrograft and Minigraft Megasessions in Hair Transplantation

Concluding Thoughts
In this clinical trial of 20 patients with male pattern baldness, there was 15.1% more
hair yield in follicular units and density in the areas treated by platelet-rich plasma
growth factors. This new development for hair transplant surgery demonstrates that
the use of autologous platelet growth factors can improve capillary density with low
cost and low morbidity, using a simple technique—a significant improvement over
conventional techniques. Especially for patients with less density and very thin hair
in the donor area, this technique should be a great contribution. Although these re-
sults are significant, further research, such as a double-blind test, should be per-
formed to evaluate the final results with outside assistance, in asymmetrical areas.
This offers a new perspective on hair transplantation and is an important contribu-
tion to implantation surgery with follicular unit megasessions.
Clinical Caveats
 Careful patient selection and good patient communication are crucial to achiev-
ing optimal results.
 Surgeons should always be honest when discussing the positive and negative aspects
of hair replacement with patients. It is especially important to make the patient aware
that a second procedure may be necessary to maintain the new hairline.
 Hair follicles are harvested from the posterior cervical area where the hair density
is greatest and the quality is best. This is normally 6 to 8 cm from the nape of the
neck.
 A well-trained team is a requisite for a good result.
 Scalp ballooning tumescent technique is important to prevent bleeding during sur-
gery and to maintain the grafts inside the punctiform incision.
 Scalp ballooning at the donor site makes the separation of the follicular units eas-
ier and reduces bleeding in this area.
 The surgeon should avoid division of the sensitive branches in the donor region
to prevent posterior paresthesias or painful processes that can last for months.
 The scalp does not tolerate stretching, so closure of the donor site must be done
gently.
 When preparing the grafts, it is important not to cut the epidermis.
 We recommend implanting a maximum of 1500 follicular units per procedure.
686
Part IV  Hair Transplantation

Annotated Bibliography
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55:456-460, 1975.
Juri describes the temporoparietooccipital (TPO) flap to restore male pattern baldness.
The 20 to 24 cm flap can be rotated to cover frontal or occipital baldness. This unique
technique can provide a versatile solution for increasing hair density.
Marrit E. Single hair transplantation of hairline refinement: a practical solution. J Dermatol
Surg Oncol 10:962-966, 1984.
This article presents the micrograft or single-hair technique to improve the front hair-
line. The author discusses use of the technique to improve hair density and the added
aesthetic benefits.
Nordström REA. Micrografts for the improvement of the frontal hairline after hair trans-
plantation. Aesthetic Plast Surg 5:97-101, 1981.
Nordström discusses the application of the micrograft or single-hair technique to re-
store hair to those with burn injuries.
Orentreich N. Autografts in alopecia and other selected dermatologic conditions. Ann N Y
Acad Sci 83:463-479, 1959.
The author presents the punch technique. He demonstrates the genetic dominance of
the implanted follicular hair and maintains the histologic quality of the donor area.
Uebel CO. Micrograft—a new approach for pattern baldness surgery. Transactions of the In-
ternational Society of Aesthetic Plastic Surgery, Tenth International Congress, Zurich,
Switzerland, Sept 1989.
The author’s first presentation of the micrograft megasession technique was delivered
in 1986. His 1989 article describes the punctiform technique, which allows implanta -
tion of more than 1500 follicular units in a single session. The results are both aes thetic
and natural.
Uebel CO. Punctiform technique with micrografts—a new method for pattern baldness sur-
gery. Presented at Jornada Carioca de Cirurgia Plástica, Rio de Janeiro, Brazil, Aug 1986.
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Surg 15:271-278, 1991.
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Converse JM, Uhlschmid GK, Ballantyne DL Jr. Plasmatic circulation in skin grafts: the phase
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munodeficient mice. J Invest Dermatol 115:200-206, 2000.
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Janes SM, Lowell S, Hutter C. Epidermal stem cells. J Pathol 197:479-491, 2002.
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Limmer BL. Survival of micrografts. In Stough DB, Haber R, eds. Hair Replacement. St Louis:
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690
Part IV  Hair Transplantation

Reoperation, Refinement,
and Treatment of Complications
After Hair Transplantation

JACK FISHER
CHAPTER 21

692
Part IV  Hair Transplantation
H
air transplantation is one of the most frequently performed aesthetic surgery
procedures in men today. The goal is hair restoration that is natural and vir-
tually imperceptible. A poorly designed or executed procedure will result in a highly
visible and unnatural hairline. Despite its popularity, this procedure often results in
unsatisfactory aesthetic outcomes. The causes of these problems and solutions for
addressing them are the focus of this chapter.
Before defining the problems that create bad results in hair transplantation, one must
identify the components of a natural hairline. Without knowledge of what defines
the normal, it is difficult to discuss the abnormal. A successful hair transplant should
look totally natural, with a hairline that is irregular, feathered, and age appropriate.
When considering a patient for hair transplantation, the surgeon must realize that
hair loss is progressive. Probably no single factor is as important or has led to so
many poor results as when the progressive nature of hair loss is ignored. The location
of the frontal hairline is another key factor. What looks good in an 18-year-old male
will usually not be appealing in a 45-year-old. Therefore it is important to design a
frontal hairline that will be aesthetically acceptable over a long period as the pa-
tient’s face matures and hair loss continues. High hairlines rarely look bad, but ex-
tremely low hairlines can be a disaster. One of the most critical anatomic compo-
nents of a natural hairline is the frontotemporal angle. Rounding off this angle with
hair transplants usually leads to a bizarre appearance, especially as the patient ages.
Aesthetic surgeons frequently place a high premium on obtaining symmetrical re-
sults in most procedures. However, in hair transplantation, a perfectly straight, sym-
metrical hairline, even with the use of micrografts, is destined to look artificial,
as can be seen in this patient, who had a large number of transplants placed in an
extremely straight line. Irregularity and asymmetry are the hallmarks of a natural-
appearing hairline.

Common Problems Requiring Reoperation
Unsuccessful hair transplants generally share similar characteristics:
 The hairline is too even and straight.
 The frontotemporal angle has been blunted.
 Large plug grafts have been used.
 The transplanted hair fails to grow.
 The hairline is too low.
 The hair has been transplanted at an incorrect angle.
Transplants done with large plug grafts represent a major problem. Unfortunately,
many individuals have undergone these procedures over the past three decades. Care-
ful analysis is required to correct or improve these difficult cases. Often there is sig-
nificant scarring in the donor site, because a coring device was used to remove grafts
containing 10 to 40 hairs at a time. Frequently the donor site was allowed to heal
by secondary intention, resulting in significant scarring. Many of these patients have
little if any available donor hair remaining for further grafting.
In individuals with adequate donor hair, a significant improvement can be achieved
by excising the old plugs, recutting and recycling this hair, and using small one- to
three-hair grafts for further transplantation. This improvement can only be accom-
plished, however, if sufficient residual donor hair is available. Scalp excisions and
forehead advancement procedures are important adjuncts in these difficult second-
ary cases.
Another problem is the failure of transplanted grafts to take. In healthy patients, the
graft-take rate should exceed 90%. Small one- to three-hair grafts, properly created,
will rapidly undergo neovascularization, and in a healthy patient most of this hair
should grow. However, if the grafts are poorly prepared, the success rate falls off
drastically. It takes a considerable amount of time and experience for a surgeon to
be able to create these small grafts, and a well-trained team is critical for a success-
ful outcome.
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Chapter 21  Treatment of Complications After Hair Transplantation

One of the most difficult problems to correct successfully is a hairline that has been
placed too low. As the patient ages, the hair recedes, leaving a bizarre, isolated frontal
hairline. Often the only solution is an aggressive procedure that involves resection
of these grafts combined with a forehead lift with regrafting.
Finally, there is the group of patients who have had cosmetic surgery and experi-
enced secondary hair loss, such as after a face lift or a coronal brow lift. In a patient
who has undergone a face lift, temporal hair loss is the most common; it is caused
either by excess skin tension or superficial undermining with direct damage to the
hair bulbs. Hair loss is usually related to tissue ischemia. In many of these patients,
the hair will regrow after 6 to 9 months, and a conservative approach is best. In
some individuals the hair fails to regrow, and transplantation is an ideal solution.
Traumatic alopecia, which usually occurs from hair bulb ischemia, may be caused
by factors other than cosmetic surgery. Prolonged pressure on the scalp, such as in
a comatose patient, can also lead to hair loss without ischemia of the scalp. The skin
is more tolerant of ischemia than the hair bulbs are.
Evolution of Technique
In 1959 Orentreich published a landmark report on the use of punch grafts to treat
male pattern baldness, thereby establishing punch grafts as the standard treatment for
almost three decades. Although results achieved with this technique may have been
reasonable at that time, the abnormal cornrow appearance they produced was far
from aesthetic. These grafts were harvested with a 3.5 to 5.0 mm punch, producing
plugs containing a large number of hairs. This technique created two major prob-
lems: (1) a severely scarred donor site in the posterior scalp because the donor holes
were allowed to heal by secondary intention, and (2) an unnatural recipient site with
the classic cornrow appearance.
Eventually, smaller plugs containing six to eight hairs were used, but this still re-
sulted in an unnatural appearance. It was not until the early 1990s that physicians
began to recognize that donor grafts containing the follicular units (naturally occur-
ring clusters in which hair grows) of one to three hairs were the key to producing
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Part IV  Hair Transplantation

natural results. By transplanting the hair in these smaller units, the cornrow appear-
ance is avoided.
The other great advance in the evolution of hair transplantation occurred with the de-
velopment of the technique for transplanting large numbers of hairs in one session.
Pioneers such as Carlos Uebel and others developed techniques whereby 1000 to
2000 follicular units could be transferred at one time. Thus the combination of small
grafts composed of anatomically correct one- to three-hair units and the ability to
rapidly transfer a large number of grafts in a single “megasession” produced a rev-
olution in hair transplantation.
Indications and Contraindications
The patient’s age, family history of hair loss, current hair pattern, amount of hair
remaining, and expectations are all important factors in selecting potential candi-
dates for reoperative hair transplantation. Patients with minimal hair loss are the
best candidates for primary—and in particular secondary—hair transplantation pro-
cedures and are much more likely to be satisfied after hair transplantation.
Patients in their late or early twenties and those in their teens are rarely appropri-
ate candidates. These young patients often develop a receding hairline later in life
and may wish to fill in the anterior hairline they previously had. Such a procedure
is usually a major mistake, because with progressive hair loss the patient will be left
with an isolated frontal fringe with balding areas behind the transplanted rows. An
attempt to create a juvenile hairline by rounding off the temporal recession is also
a mistake in a young patient. Patients who demand an inappropriate hairline should
be excluded from surgery; otherwise, both the patient and the doctor at some time
in the future will regret the procedure.
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Chapter 21  Treatment of Complications After Hair Transplantation
This patient had plug grafts to thicken his frontal hairline in his early twenties. As
the hair surrounding the unsightly plugs fell out with aging, the large plug grafts be-
came exposed, creating this noticeable deformity.

Another common problem when a young patient undergoes a hair transplantation
procedure at too early an age is the creation of a permanent frontal fringe with ex-
tensive baldness behind it. The use of large plug grafts makes the deformity even
more noticeable. However, in this patient, even if small natural grafts had been in-
serted originally, the effect would still look unnatural because of the extensive bald-
ness that evolved over the years behind the grafts. The major point demonstrated
by this case is not to perform transplantations too early.
A patient with extensive hair loss with only a thin posterior and lateral remaining
fringe is also a poor candidate for reoperative hair transplantation. Such a patient
can be given a frontal hairline, but if complete coverage of the area of alopecia is
the goal, the patient will likely be disappointed after the procedure. Caution should
also be exercised when attempting hair transplantation in the occipital area. In young
patients or those with extensive hair loss, overly aggressive transplantation in this
region can lead to a strange “halo” pattern, with a permanent tuft of central occip-
ital hair surrounded by a bald ring or halo that progresses as the patient ages and
hair recedes. It is important to explain to the patient the possible ramifications of
overly aggressive hair transplantation in this area. Thus in younger patients it is pru-
dent to graft the frontal and superior regions of hair loss initially and to observe
over time the evolution of the patient’s hair loss. If a young patient with fairly ex-
tensive hair loss rejects a high hairline with temporal recession, this patient is not a
good candidate for transplantation.
As in all aesthetic surgery procedures, it is essential that the patient be fully informed
to ensure ultimate patient satisfaction. This is even more important in an unhappy
patient who has had a poor result and wants revision. Realistic expectations must
be established before the surgeon considers reoperating on such patients, based on the
results of previous surgery and what available donor hair tissue remains. The pa-
tient with a poor result from 20 years ago who expects a miracle should be excluded
from surgery. Some of these patients must resign themselves to wearing a hairpiece
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to cover up either a poor result in the recipient area or to cover excessive scarring
in the donor site from previous punch grafting. In other areas of cosmetic surgery,
such as a face lift, the procedure can be repeated over time. However, a patient with
male pattern baldness has limited donor hair; therefore it is critical to set appropri-
ate goals with the patient based on this simple anatomic fact.
Preoperative Assessment
Preoperative assessment focuses on the recipient site to evaluate the results of the
transplantation, as well as the donor site to assess residual scarring and the amount
of available donor hair. The recipient site should be examined to determine whether
the hairline was placed in the correct location—not too high or too low—and
whether it was properly created. That means it has an irregular line with a natural
temporal recession. A common problem after hair transplantation, especially in the
past, was creation of a straight hairline. Hairlines need to be irregular; even a prop-
erly located hairline with small grafts in the correct location will look unnatural if
it is perfectly straight.
After assessing the recipient area, the physician must critically evaluate the poten-
tial donor site if further grafting is to be considered. Initially, donor grafts were har-
vested with punches, and the residual donor area was allowed to heal by secondary
intention, creating a significant amount of scar tissue. Eventually, physicians began
to use linear excision of the donor site with primary closure. This became the stan-
dard, which significantly reduced scarring in the donor area. Unfortunately, in the
past and even today, some surgeons make multiple parallel incisions each time they
harvest donor hair, which results in multiple transverse scars in the posterior recip-
ient area. This technique is rarely necessary. Most patients can undergo at least two
or three repeat procedures over time using a single donor site and creating a single
scar. If multiple transverse parallel donor scars are too close together, further exci-
sions run the risk of tissue devascularization and scalp necrosis.
The course of hair loss should also be considered. Hair loss is both progressive and
unpredictable. It is this unpredictability that is the single most important issue in
evaluating patients as candidates for these procedures. In designing the hair pattern
to be transplanted, the surgeon must take into consideration the patient’s progres-
sive postoperative hair loss over the ensuing decades.
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Part IV  Hair Transplantation
The individual characteristics of the patient’s hair and skin color must also be ex-
amined. The less the contrast between skin and hair color, the more natural the fi-
nal result will appear after transplantation. Thus light hair with fair skin or dark
hair with dark skin will have a low contrast. Dark hair on light skin, however, has
a high contrast, and grafts with several hairs will look more unnatural in these high-
contrast patients.
The phenomenon called compression is particularly noticeable in patients with a
high-contrast situation. Compression is a condition in which there are too many
hairs exiting a single hole, thereby creating a “bouquet” appearance, with the hair
spreading out distally from a central site. To avoid compression of individual grafts,
it is particularly important to use small micrografts or follicular units in dark-haired
patients. The texture, density, and straightness versus curliness of the hair should
also be assessed. Curly hair provides better coverage of the scalp than straight hair
after transplantation. Fine hair gives less coverage than thick hair.
Preoperative Planning
In secondary hair transplantation, as in other types of revision surgery, planning is as
important as the execution of the surgery itself. In patients with adequate donor hair
who had previous unnatural-looking plug grafts, a two-step procedure is suggested.
First, the plug grafts are excised, recut, and replanted as small, natural-looking grafts;
then donor hair is harvested from the posterior scalp and implanted as small follic-
ular units in between the previous plug grafts to fill in the spaces.

There is no consistent pattern to follow when planning incisions in this group of pa-
tients. When large, unsightly grafts are visible, they need to be excised, and wher-
ever there is residual donor hair, it needs to be harvested. For more extensive cases,
a more aggressive approach may be necessary, with radical excision of the previous
recipient plugs, followed by secondary grafting. Badly scarred donor areas can be
improved in selected patients as long as there is adequate hair in the area to cover
up scarring from further excisions. Wide donor scars can frequently be improved by
simple reexcision with primary closure. In more extensive cases, tissue expansion or
flap rotations can be used to improve unsightly donor scars.
The goal of reoperative hair transplantation is to produce an overall hairline that is
both natural and undetectable. Therefore, when planning revision surgery, the surgeon
should avoid placing the transplanted hair too low and rounding off the temporal
recession. The emphasis should be on creating a high hairline at least 8 to 10 cm
above the glabella with a natural-appearing frontotemporal angle.
Proper angulation or direction of the transplanted hair is another key anatomic fac-
tor in producing a natural result. Hair grows at different angles at different loca-
tions on the scalp. Along the frontal hairline, the hair should be angled in a slightly
anterior direction. Too much anterior angulation appears abnormal, as does poste-
rior angulation. Hair in the temporal area needs to be angled downward, whereas
hair on top is directed straight upward and hair in the posterior scalp is directed
downward. Incorrectly angled hair requires revision surgery.
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Chapter 21  Treatment of Complications After Hair Transplantation
In this case, hair was transplanted along the patient’s right frontal hairline at the
wrong angle. Even though the grafts were small and natural appearing, because of
their incorrect angulation, they created a strange appearance. This patient requested
correction, which required excision of the scalp in the area marked by the ellipse.
After this area healed, grafts were inserted at the correct angle, solving the problem.

This patient’s hair grafts were inserted at too acute an angle. The hairs are growing
straight forward from the scalp, yielding a very unnatural appearance. To correct
this problem, excision, recycling, and new grafting were all required.
Options for Reoperative Hair Transplantation
There is no single operation for management of poor results or complications from
previous hair transplantation. Management of these complex cases requires a com-
bination of techniques. In some cases, simple excision of unsightly plugs alone can
yield a reasonable improvement, especially in a patient who wishes no further graft-
ing procedures or one who no longer has any usable donor hairs.
However, in most patients with unsightly plugs, it is necessary to excise the plugs
and recut and recycle them as small follicular units or micrografts. Excision of old
plugs is performed under loupe magnification (2.5 or 3.5) using a No. 11 blade
or a 1 or 2 mm biopsy punch. It is important to keep the tip of the blade parallel
with the hair shaft and follicle to avoid injury to the entire hair unit. Improper angu-
lation of the knife blade will damage the follicle or may leave it in its original loca-
tion, only to regrow another unsightly plug. Once the entire plug is removed, it is
carefully recut into small individual units for regrafting. Typically, only 50% to 75%
of the hairs removed in the old plugs can be made into new, acceptable small grafts
because of scarring. However, in patients with limited donor hair, every hair counts.
The best solution is to combine this technique with further harvesting of posterior
scalp donor hair to create more small grafts for filling in between previous grafts.
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Chapter 21  Treatment of Complications After Hair Transplantation
Partial plug removal
Plugs removed to be recycled into minigrafts
Additional micrografts and minigrafts
Immediate postoperative result

Patients with unnatural hairlines may present special problems, such as improper
angulation of the original grafts, or hairlines placed too low, too high, or too straight.
Again, a proper preoperative evaluation is critical, depending on which of these four
problems is present. In a patient with improper angulation of previous grafts, sim-
ply filling in between with new grafts will not solve the problem. These grafts must
be excised carefully, as previously discussed; regrafting of the entire area is the best
solution using both the old recut grafts along with new ones. In patients whose hair-
lines are too low, more aggressive treatment may require scalp excision and a fore-
head lift in addition to plug excision and graft recycling.
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Part IV  Hair Transplantation
Hairline
too high
MANAGEMENT OF SECONDARY CASES
Cornrow correction
Hairline
too low
Recutting plugs and
recycling as micrografts
Excision
of old grafts
Micrografting
between plugs
Traumatic hair loss
(after cosmetic
surgery)
Combining scar excision
and micrografting
Scar excision
Micrografting
Unnatural hairline
Improper
hair angulation
Hairline
too straight
(proper location)
Micrografting with
creation of irregularity
Excision of
previous grafts
Forehead lift
with excision graft
Recutting grafts
and recycling

Patient Examples
Cornrow Plugs
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Chapter 21  Treatment of Complications After Hair Transplantation
Avoiding Donor Site Problems in Patients With Previous
Transplant Procedures
 The tension in the donor site closure should be minimized.
 Scalp elasticity should be evaluated in patients with multiple donor site scars.
 The closer the previous scars are to the lower neck hairline, the better the elasticity,
because it is possible to recruit neck skin.
 The higher the previous donor site scars and the closer to the fixed occipital scalp, the
less elasticity will be available. This makes further donor site excisions more difficult
to close.
 Patients who had previous plug grafts harvested from the donor area have stiffer
donor tissue, making closure of strip excisions more difficult.
 Multiple previous transverse strip excision donor sites should be noted because of the
risk of tissue devascularization associated with further harvesting of donor tissue.
This patient presented with noticeable plug grafts along the hairline. Because the pa-
tient had a high-contrast component with dark hair and light skin, the plugs seemed
even more obvious. Correction of this common problem was accomplished using
three different techniques. First, the old plugs along the outer edge were excised as
previously described; next these plugs were cut into small follicular units to be re -
inserted. At the same time, an ellipse of posterior scalp measuring 1.8 cm wide and

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Part IV  Hair Transplantation
16 cm long was excised and cut into 1200 follicular units. These small grafts plus
those that were recycled were then placed between and in front of the remaining
plugs. The excised plug sites, which usually measure 5 to 6 mm in diameter, are closed
with a single 5-0 nylon suture that is left in for approximately 1 week. At 1 year
postoperatively, the patient is healed and has had complete correction of the artificial
plug look. The results here demonstrate that hair transplants should not be recog-
nizable but should resemble natural hair.
Isolated Frontal Forelock
Some patients develop an isolated frontal forelock as they age. When connecting this
forelock with the hair posteriorly, it is important not to drop the hairline too low.
It may be necessary to begin transplanting behind the frontal forelock.
This patient demonstrates the appearance of an isolated frontal forelock. He has
two isolated tufts of hair on his head, creating a bizarre, unnatural appearance. To
correct this problem, a single session of 1500 follicular grafts was used to connect
the two isolated forelocks with the hair posteriorly. This approach produced im-
proved framing of the face and a much more normal appearance to the hairline.
Also, the hair was placed in an irregular pattern, which produced a more natural
appearance.

Temporal Alley Defect
In patients who have had previous transplants along the superior scalp and occipi-
tal area, a gap or “alley” may develop as the hair recedes inferiorly along the sides
of the head. In this situation, a combination of procedures is required, including ex-
cision of the scalp as well as further grafting.
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Chapter 21  Treatment of Complications After Hair Transplantation
A common problem after scalp excision, however, is the phenomenon of “stretch
back.” This refers to the progressive widening over time of the excised area as a re-
sult of tissue relaxation.
This patient presented with a temporal alley defect after an unsuccessful attempt at
hair transplantation.

The defect was excised and a hole was created for the Mitek suture fixation device,
which was placed on either side of the defect.
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Part IV  Hair Transplantation
The sutures were then crisscrossed to pull the edges of the defect together, thereby
reducing the amount of stretch.
At a separate session 4 months later, approximately 1200 follicular grafts were placed
in the area, completing the restoration and significantly improving the appearance
in the temporal area.

Abnormally Low Hairline
One of the most difficult problems to correct is a hairline that has been placed too
low, especially if unsightly plugs were used. In this situation, the old plugs must be
carefully excised and recut into small grafts. Scalp excision and forehead lift may
also be required. In these complex cases, multiple stages are frequently required.
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Chapter 21  Treatment of Complications After Hair Transplantation
Correction of a Low Hairline: Operative Overview
1. The frontal hairline scalp, including the old unsightly plugs, is excised as a circum-
linear ellipse.
2. The galea is left intact and the ellipse of skin with its old plug grafts is recycled, as
described earlier, creating new, small, one- to two-hair grafts for replanting.
3. Next, a forehead lift is performed while the excised hair is being recut.
4. Unlike a traditional forehead lift, in which the goal is elevation of the eyebrows and
upper lids, this forehead lift advances the forehead skin superiorly to raise the new
future hairline, leaving the eyebrows alone. This is accomplished by not dissecting
below the superior orbital ridges and releasing these tissues.
5. The frontal forehead is stretched superiorly by making numerous parallel, horizon-
tal releases in the periosteum in a subperiosteal dissection or in the galea in a subcu-
taneous dissection.
6. Next, deep sutures of 3-0 Ethibond are used with the Mitek fixation device, outer
table drill holes, or the Endotine device (Coapt Systems, Inc.) to fix the forehead in
an elevated position. (I have used all three techniques with excellent results.)
7. The suture fixation device is placed several centimeters above the new future hair-
line to allow maximal elevation while it is being tied.
8. Once the forehead has been adequately elevated along its superior aspect, the skin is
closed with 3-0 Vicryl sutures and a running 3-0 or 4-0 Monocryl suture.
9. The old plugs, which have been recut into small grafts, are now reinserted behind
the suture line.
10. After the skin is adequately healed in 3 to 4 months, large-volume grafting is begun
to create a new, natural hairline.

This patient presented with an abnormally transplanted hairline, with the grafts
placed too low in the temporal region. Besides the original transplanted hairline be-
ing too low, the grafts had also been placed incorrectly in a curved line so that the
temporal area was rounded off, thus losing a normal frontotemporal angle.
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Part IV  Hair Transplantation
A more aggressive approach was required for this revision. A radical excision of the
previous plug grafts was done, along with excision of a segment of scalp along the
frontal and temporal areas. Holes were then made at multiple sites for insertion of
Mitek devices.
The Mitek device with 2-0 Ethibond sutures attached was inserted. The sutures were
tied with significant elevation of the forehead in both the midline and the temporal
area. The incision was allowed to heal for several months, and then the patient un-
derwent micrografting to the area.

Postoperatively a significant elevation of the forehead is evident, with creation of a
normal frontotemporal angle. The patient has a visible scar in the temporal area
from the forehead lift. However, this scar could not be avoided, because further graft-
ing in this area would have recreated the abnormal appearance.
High Hairline
In males, hairlines that are too high are rarely a problem, and as long as donor hair
is available, further sessions of grafting, using small grafts with an appropriate ir-
regular hairline, solve these patients’ problems. However, in females who had an
overly aggressive forehead lift, a high hairline can create an abnormal appearance,
especially if it also creates a masculinizing acute temporal recession.
Straight Hairline
Another problem that presents a reoperative challenge is a transplanted hairline that
is extremely straight. Hairlines need to be irregular; even in patients with small grafts,
straight hairlines are noticeable. Obviously, if the straight hairline includes unsightly
plugs, these must be excised and recycled, as previously described. In many of these
patients, as long as the hairline is not too low, it can be improved by placing small
one- to two-hair grafts in an irregular pattern in front of the previously grafted ar-
eas. It is easier to improve the hairline in patients with light skin and light-colored
hair, because the color contrast is less obvious than in patients with dark hair and
light skin. In high-contrast patients with dark hair and light skin or light hair and
dark skin, a greater number of grafts will be required to mask the previous proce-
dure and create irregularity. This is true for all corrective procedures. Color contrast
is a subtle but important issue when performing secondary hair restorations.
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Chapter 21  Treatment of Complications After Hair Transplantation

Traumatic Hair Loss
One of the most common causes of traumatic hair loss is aesthetic facial surgery.
This can be caused either by direct damage of the follicles from superficial elevation
of the skin flaps or by excessive tension leading to ischemia. The skin may not visi-
bly show signs of ischemia after aesthetic surgery, but there may be enough relative
decrease in tissue perfusion to damage the follicles. In most patients, the hair re-
grows after 4 to 6 months, but in some cases the hair loss is permanent.
In some patients, simple excision of the non–hair-bearing scar can be successful.
However, this maneuver often fails, because the new scar may also lose its hair, and
reexcision, because of the risk of undue tension, will lead to ischemia and further
hair loss. For these reasons, many patients with traumatic hair loss require hair trans-
plantation to fill in the defect. Remarkably, small hair transplants placed directly
into scar tissue consistently grow. The problem with placing small grafts into scar
tissue is mechanical. Unlike normal scalp, which is relatively thick, areas of hair loss
with or without scar tissue are frequently thin, and it can be difficult to insert the
grafts in these areas. Using a tumescent technique in the recipient areas is particu-
larly helpful in this situation. The tumescent fluid creates the depth necessary for
graft insertion. In some of these patients the grafts cannot be placed as close together,
because the scar is thin and relatively ischemic. In these patients several sessions per-
formed over a period of time may be more useful.
Most patients with traumatic hair loss have their hair restored in two sessions of
grafting. Combining excision with grafting may be the ideal situation, because ex-
cising a portion of the non–hair-bearing area produces a smaller area requiring graft-
ing. When combining these two procedures, the surgeon should excise the skin con-
servatively, because further tension and ischemia will lead to more hair loss and may
create a relatively hypoxic environment in which few of the transplanted grafts sur-
vive.
One of the benefits of today’s micrografts or follicular grafts is their high success
rate. These small grafts have fewer metabolic demands than the larger grafts previ-
ously used and usually do well in areas of scar tissue and even in skin grafts. The
older-style plugs, especially those with 10 to 20 hairs in each plug site, had less tol-
erance for ischemia. Frequently, patients with old plugs have sites or areas within
the plugs with poor hair growth. One also sees scars from the old plugs creating a
“cobblestone” appearance, with little or no hair growth. This occurs because the
skin of the plug graft was neovascularized and survived, but the follicles within never
successfully grew hair. This cobblestone look is unsightly, and excision of the
non–hair-bearing skin plugs is frequently the best solution, followed by further graft-
ing when possible.
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Part IV  Hair Transplantation

This woman had posttraumatic hair loss in both the preauricular temporal area and
the posterior neck–postauricular area after a face lift. In one session, 350 grafts were
placed in the temporal area and 400 in the posterior neck–postauricular area. Care
was taken to properly angulate the hair grafts; this maneuver is essential to achiev-
ing a natural result. In the temporal area, hair naturally grows in a downward and
slightly posterior direction. In the posterior neck, the hair needs to grow downward
and slightly backward. Following these guidelines, significant improvement can be
achieved in a patient with traumatic hair loss after aesthetic surgery.
Postoperative Care
Of all the areas of aesthetic surgery, hair transplantation, whether primary or sec-
ondary, is one of the easiest procedures to deal with in the postoperative period.
Every physician has his or her own protocols. I put patients in a protective head
dressing, similar to a face-lift dressing, for 24 hours and then remove it. Where there
is a donor site closure with sutures, the patient washes this area in a normal man-
ner. Where the grafts have been inserted, I instruct patients that after the first 24
hours, they should blot a mild shampoo on the recipient site once a day and rinse
the area using a cup, avoiding a direct shower stream hitting the recipient grafts. Af-
ter 6 days patients can wash the recipient areas without any restrictions, since the
small grafts are well fixed at this time. I usually leave sutures in for 10 to 12 days in
the linear donor site area and where the forehead lift has been performed because
of significant tension. Otherwise, nothing unique is required in the immediate post-
operative period for management of these patients.
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Part IV  Hair Transplantation
Concluding Thoughts
Many factors go into creating a successful hair transplant. Avoiding complications
before they occur is obviously the optimal situation. Many of the problems associ-
ated with less than satisfactory results after hair transplantation are more often as-
sociated with mistakes in judgment and less likely the result of errors in surgical
technique. To avoid an unnatural result, the surgeon must realize that hair loss is
progressive in nature. It is important to design a hairline that will be aesthetically
acceptable over time as the patient matures and hair loss continues.
Clinical Caveats
 The following four characteristics are associated with unsuccessful hair transplan-
tation: (1) large, unnatural plug grafts, (2) an extremely straight hairline, (3) a
blunted frontotemporal angle, and (4) a hairline that is too low.
 Surgical correction of large, unnatural plug grafts requires graft excision, recut-
ting into individual one- and two-hair grafts, reimplantation of new small grafts,
and closure of individual donor sites with single small sutures.
 Surgical correction of a hairline that is too straight involves removal of periodic
grafts along the hairline if plugs are present, with recycling farther back, and use
of small single-hair grafts to create a feathered, irregular hairline.
 Surgical correction of a blunted frontotemporal angle includes removal of hair
grafts and elevation of the temporal skin, with advancement superiorly and pos-
teriorly.
 Surgical correction of an abnormally low transplanted hairline requires excision
of frontal grafts, with reimplantation farther back, excision of skin along the trans-
planted hairline, and a forehead lift and closure of the defect.
 Color contrast is a subtle but important consideration when performing second-
ary hair restorations.

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Chapter 21  Treatment of Complications After Hair Transplantation
Annotated Bibliography
Barrera A. The use of micrografts and minigrafts for the correction of the postrhytidectomy
lost sideburn. Plast Reconstr Surg 102:2237-2240, 1998.
Posttraumatic alopecia is commonly seen in patients who have undergone forehead lifts
or face lifts. This report discusses the use of small, neutral-appearing grafts for the cor-
rection of temporal and sideburn hair loss in face-lift patients.
Bernstein RM, Rassman WR. Follicular transplantation. Patient evaluation and surgical
planning. Dermatol Surg 23:771-784; discussion 801-805, 1997.
Hair grows in units of one, two, or three layers. This article discusses the use of small,
natural grafts based on these small units and their application in hair transplantation.
The authors describe the improved results obtained by this technique compared with
other methods.
Epstein JS. Revision surgical hair restoration: repair of undesirable results. Plast Reconstr
Surg 104:222-232; discussion 233-236, 1999.
An evaluation of patients in whom hair transplantation has failed, emphasizing the avail-
able surgical techniques employed for satisfactory correction. Specific cases are used to
demonstrate the surgical options.
Uebel CO. Micrografts and minigrafts: a new approach to baldness surgery. Ann Plast Surg
27:476-487, 1991.
This article set the standard for large-number grafting procedures using small natural-
appearing grafts. It established the concept of performing 1000 to 1500 follicular unit
graft procedures, paving the way for fewer sessions and creating a more natural result.
Vogel JE. Correction of the cornrow hair transplant and other common problems in surgi-
cal hair restoration. Plast Reconstr Surg 105:1528-1536; discussion 1537-1541, 2000.
A thorough description of the various techniques used to correct unsuccessful hair trans-
plants is presented. The technique of plug graft excision with recutting into smaller grafts
for recycling is discussed in detail, as well as scalp excision techniques.
Suggested Readings
Barrera A. Hair Transplantation: The Art of Micrografting and Minigrafting. St Louis: Qual-
ity Medical Publishing, 2002.
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Part IV  Hair Transplantation

BROW LIFT
PART V

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Clinical Decision-Making
in Brow Lift

FOAD NAHAI
CHAPTER 22

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Part V  Brow Lift
Aging changes
Skin
Subcutaneous tissues
Deep tissues
Morphology
Shape
Size
Bony prominences
Volume
EVALUATION OF THE FACE
Evaluation
We evaluate the entire face rather than isolated zones. The hallmark of a youthful face
is the smooth transition from zone to zone; for example, brow to eyelid, eyelid to
cheek, cheek to perioral area, perioral area to jawline, jawline to neck. For best re-
sults, procedures are planned to rejuvenate all of these areas and to restore a har-
monious transition from zone to zone.
It comes as a surprise for a patient seeking an “eyelid lift” to be advised that in ad-
dition to blepharoplasty, a brow lift is also recommended. Most patients will accept
the surgeon’s recommendation, yet others resist, saying they only want to remove the
excess skin or bags from their eyelids. For some it becomes a financial consideration,
with concerns that each added procedure will increase the cost. Regardless, we ex-
plain to the patient that regional or full facial rejuvenation would be the best option
rather than localized, isolated procedures. We leave the final decision to the patient.
In my practice, an isolated brow lift is a rarity. I consider a brow lift to be one com-
ponent of periorbital rejuvenation, encompassing the brow, upper and lower eye-
lids, lid-cheek junction, and midface. No brow or forehead rejuvenation is complete
without considering rejuvenation of at least the upper eyelids, if not the entire peri-
orbital area. When evaluating a patient’s face, I make note of the morphologic struc-
ture and anatomic features, then I evaluate the changes resulting from the aging
process. Morphology refers to the study of the shape or form of an anatomic struc-
ture; thus it is the morphologic structure of the face, breast, and body that we change
through aesthetic surgery rather than the anatomy. Yet a detailed knowledge of the
anatomy of the structures themselves is essential in aesthetic surgery. This includes
bony prominences, eye prominence, nasal prominence, and hairline shape, whereas
aging changes include changes in the skin, subcutaneous tissues, deeper soft tissues,
and even the bones.
Anatomic Features
The convexity of the forehead and any supraorbital bony prominence is noted. The
thickness of the retroorbicularis oculi fat (ROOF) is assessed. The hairline and height
of the forehead are noted. We also note how thick the hair is and areas where the
hairline is receding.

Evaluation of the Aging Forehead and Brow
Features to Assess
 Brow position—lateral and medial
 Crow’s-feet
 Rhytids—horizontal and vertical,
 Lateral orbital crowding
at rest and on animation
 Skin
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Chapter 22  Clinical Decision-Making in Brow Lift
Evaluation should include an assessment of the position of the brow laterally and
medially, the relationship of the brow to the upper eyelid, and the distance from the
upper lid sulcus to the hair-bearing brow. Horizontal and vertical forehead and glabel-
lar rhytids are assessed at rest and on animation, as are the crow’s-feet. (Horizontal
forehead rhytids are more common in men.) The quality, elasticity, and thickness of
the forehead skin are also evaluated. Lateral orbital bunching or crowding is noted
with the eyebrow at rest and when elevated.
AGED
YOUTHFUL

Evaluation of Brow Position
The medial brow is usually lower than the lateral brow, with a variable arch in be-
tween. The position of the brow is judged based on the relationship of the hair-bear-
ing brow to the supraorbital rim. A lower brow position is typically seen in men; in
fact, brow position varies with sex, age, and ethnic background. The ideal brow po-
sition also varies according to fashion and culture. High-arched brows are more com-
mon and more desirable among those of Hispanic, Latin, and Mediterranean ori-
gins. Low brow position is associated with a tired, unhappy appearance, whereas
excessive brow elevation is associated with a frightened or surprised look.
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Part V  Brow Lift
Low brow
Medium brow
High brow
Brow height does not necessarily signal youth. Brow fullness and shape are far more
important than height, as indicated by the three images of young women shown here.

Evaluation of Rhytids, Crow’s-Feet,
and the Lateral Orbital Area
The patient is asked to frown, elevate the brow, and tightly close his or her eyes so
that the glabella, forehead, and crow’s-feet rhytids can be assessed. Brow position
and the lateral orbital area are also evaluated during each of these facial movements.
By observing these muscle contractions in relation to brow, eyelid, and lateral or-
bital movement, the surgeon can assess muscular interactions. Success in relocating
the brow to the desired position will largely depend on modification of this muscle
balance.
Evaluation of Skin
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Chapter 22  Clinical Decision-Making in Brow Lift
The quality and quantity of the skin on the forehead, upper eyelid, and lateral or-
bital area are evaluated for thickness, elasticity, and the presence of rhytids. The depth
of the rhytids and the skin texture are noted. Any excess skin is also noted, includ-
ing determining whether the skin excess is real or apparent, with particular atten-
tion to whether there is excess skin in the glabella over the nasal radix.
Aging changes
Brow position, medial and lateral
rhytids, at rest and on animation
Crow’s-feet
Lateral orbital crowding
Skin
Quality
Quantity
Anatomic features
Frontal bone convexity
Supraorbital rim prominence
Forehead height
ROOF (retroorbicularis oculi fat)
Hair
Hairline
Thickness
EVALUATION OF THE FOREHEAD

Treatment Options
There are a variety of surgical and nonsurgical options as primary procedures. Ad-
junctive treatments such as resurfacing may be performed at the same time to en-
hance the results. Treatment options range from toxin injections to the traditional
open coronal forehead lift.
Options for Forehead Rejuvenation
The goals of forehead rejuvenation are to reposition or reshape the brow into a more
youthful position or desired shape. Brow shape is far more important than brow el-
evation. Injection of toxins is effective not only in elevation of the brow, but also in
reshaping (see Chapter 13 on toxin injections). Surgical rejuvenation of the brow
leads to brow repositioning or shaping through a combination of steps, including
mobilization of the brow and modification of muscles to assist in maintaining brow
position and ameliorating rhytids. The open coronal lift was for years considered the
standard procedure and now, with several options available, it is considered the
benchmark procedure to which all others are compared. In the table below, I have
compared the various procedures, including injectables, in terms of ease of exposure
of the anatomic structures, muscle excision, and forehead mobilization. Scalp exci-
sion is included, because at one time it was the only option for fixation. I have found
the endoscopic approach to be as effective as the coronal, and in selected patients
the combination of a lateral approach with transpalpebral muscle excision has also
proved satisfactory.
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Part V  Brow Lift
Selection of a technique is based on aging changes and the patient’s anatomy. As im-
portant in this selection process is the surgeon’s familiarity and experience with each
procedure, and in the final analysis, we will each select a procedure that in our hands
will produce the best result with minimal morbidity.
Options for Forehead Rejuvenation
Release of
Forehead
Scalp
Exposure
Adhesions
Muscle Excision
Mobilization
Excision
Open coronal





Endoscopic





Direct approach





Transpalpebral




—
Lateral approach


—


Toxins
NA
NA
Temporary paralysis

NA
Degree of effectiveness indicated by the number of pluses.
NA, Not applicable; dash, not possible.