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Hair transplantation can play a complementary role in the spectrum of gender affirming procedures. Amongst the hair restoration procedures sought by transgender patients, female hairline feminization, beard and eyebrow transplantation, surgical hairline lowering, and body hair transplantation are the most popular. Hairline lowering, hairline feminization, and eyebrow and pubic hair transplantation can play roles for the male to female (MTF) transitiong patient while beard and body hair transplantation can play integral roles for the female to male (FTM) transitioning patient to create a more feminine or masculine appearance and to help conceal prior surgical scarring. This chapter will delineate the role hair restoration plays for the transitioning patient. The various surgical approaches and treatment paradigms will be detailed for the hair restoration surgeon.
In a hair-focused practice, we are provided a unique perspective as to the role that hair plays in gender identification. Addressing the hair concerns of individuals across the gender-identity spectrum allows the surgeon to play an invaluable role in the gender affirmation process. The most common of the procedures performed is feminization of the hairline in the trans female patient through transplantation. However, there are a variety of other key procedures performed that will be described in this chapter, including beard and chest hair restoration in the trans male patient, hairline lowering/forehead reduction surgery in the trans female patient, and finally the use of beard donor hairs- called body hair transplantation (BHT)- to expand the donor supply in trans female patients
Trans Female Hair Concerns
Feminization of the hairline typically means reversing the consequences of progressive male pattern hair loss or male pattern baldness (MPB). A lifetime progressive process, MPB is primarily due to three factors: genetics, aging, and testosterone. The objective of therapy for MPB is typically two-fold: block the effects of testosterone and the metabolite dihydrotestosterone (DHT), and apply surgical techniques to restore hair.
In cis males, blocking the formation of and/or the actions of DHT at the level of the follicle that induce hair miniaturization and cessation of growth is most commonly achieved with finasteride or minoxidil. Other effective therapies include laser light therapy and platelet rich plasma injections. In the trans female patient, the administration of female hormones, testosterone blocking medications, and/or surgical removal of testes obviates the need for these medical therapies. These therapies are intended not merely to prevent progressive hair loss but can reverse many of the secondary sex characteristics promoted by testosterone. In summary, trans female patients are no longer at risk for progression of MPB and the concern of a future diminishing of donor hair supply, allowing for more aggressive approaches that result in better hair transplant coverage.
Feminizing Male Pattern Hair Loss
The progression of MPB is by convention classified by the Hamilton-Norwood scale (Figure 1). The most common patterns are of frontotemporal receding, diffuse miniaturization of the hairs on the top of the head, and crown loss [
]. A variety of other patterns can occur, including recession of the entire frontal hairline, diffuse thinning of the entire scalp, and the most advanced Class 6 and 7 patterns where only hair is left on the lower back and sides of the head. Anatomic location of hair loss further provides further descriptive terminology (Figure 2). With advancement of MPB the size of the potential “donor” area, and the caliber and quantity (concentration) of hairs in this “donor” area can all diminish, resulting in a reduction in the supply and quality of total available donor hairs. Thus, patients who gender transition at a younger age have a better prognosis in terms of the potential outcome of hair feminization that can be achieved- at least until hair cloning or multiplication techniques become available.
The goal of hair restoration in trans women is to restore a more feminine hairline – one that is lower, and/or more rounded, and/or has better density [
]. Hair loss in the crown and/or midscalp areas can also be addressed with transplants, restoring density to areas of loss or thinning. Hair transplantation, also called hair restoration surgery (HRS) is the most common procedure to achieve this, however in certain cases hairline lowering/forehead reduction surgery, as described in the next section, is indicated. The area to be restored with hair is, as mentioned above, limited by the total donor supply. In the scalp, the total potential harvest over a lifetime ranges from 4,500 to 9,000 grafts (also called follicular units, the natural-occurring way hair grows on the scalp in bundles of one, two, three, or even four hairs).
Until the mid to late 2000s, follicular unit transplantation (FUT) was the gold standard for graft harvesting. The excision of a donor strip of hair-bearing scalp from the back, sometimes extending to the sides of the head, provides 1,800 to as many as 3,000 grafts in a single procedure. A second strip can be removed, excising the original donor site scar, as soon as 10 months later if additional grafting is desired. A total of three, sometimes four strips can be removed over the course of a patient's lifetime, providing as many as 7,000 to 8,000 grafts if indicated and desired. The donor site scar resulting from FUT, although usually inconspicuous, is occasionally visible with the hair cut short, and this linear scar brings unwanted attention to the surgical procedure.
Follicular unit extraction (FUE) has become, over the past 12 years, the preferred technique for graft harvesting, because it leaves no linear donor site incision scar [
]. Instead, each graft is removed using a small punch, leaving tiny and typically inconspicuous donor site “dot” scars. There are a variety of FUE systems, the preferred ones typically not being the heavily marketed proprietary systems. The lesser marketed systems offer lower rates of graft transection as well as the ability to use smaller punches and therefore result in smaller scars. The two platforms most popular with leaders in the field include the WAW and Trivellini systems, as they oscillate rather than rotate, and utilize fluted (also called “hybrid) rather than sharp-edge punches, resulting in a higher percentage of hair growth and less donor site scarring. FUE has also become quite popular due to certain device manufacturers marketing the procedure as “delegable”, requiring the physician to do little if any of the procedure, a model that if improperly conducted is one that the authors do not condone.
A single FUE procedure can safely yield 2,000 to 2,400 grafts, potentially up to 3,000 to 3400 grafts in those with superior donor supply. Grafts are typically harvested from the back and sides of the scalp. If additional grafting is desired, FUE can be repeated as soon as four months later, for a total of over three procedures representing 5,500 to 7,000 grafts. At higher (4,500 or greater) graft counts, the risk of donor site thinning and visible scarring increases. FUE can be combined with FUT, allowing for as many as 2,000 to 3,000 additional grafts to be harvested beyond the total supply obtained from several strip procedures.
In the trans female patient, as in many cis male patients, there is an additional source of donor hairs, the beard and sometimes the chest. Trans female patients typically prefer to be rid of this body hair, so instead of having the hairs removed by laser or electrolysis, they can be harvested using advanced FUE techniques and transplanted into the scalp. Beard hairs are preferred over chest and other body hair due to relative ease of harvesting, lack of donor site scarring, and greater reliability of regrowth. Notably, due to their coarseness, beard hairs are not used for hairline feminization. Beard and body hairs are typically single follicular unit grafts which can be coupled in their placement with single or double follicular unit hair grafts extracted from the scalp to maximize density behind the frontal hairline. The donor supply of dense beards alone can provide an additional 2,000 or more grafts, providing coverage beyond what could be achieved using just scalp hairs for those patients with a more advanced MPB pattern (Figure 3).
The design of the female hairline is obviously a key part of the hair transplant procedure. While it is beyond the scope of this chapter to go into detail about hairline design, and there are numerous references that can be utilized, the general concept is to create a more rounded hairline, symmetric on each side, with the central-most point located 6 to 7.5 cm above the glabella, usually somewhat along the junction where the vertical forehead meets the horizontal scalp. Several sample cases of hairline feminization among trans female patients are presented (Figures 4and5), showing the variety of designs that can be employed. Notice that all of the designs share common features including closing of the frontotemporal recessions, and from a more micro-basis, the use of all single hairs along the frontal-most hairline that is made irregular rather than linear (the irregularity creating the desired natural look).
The Hairline Lowering / Forehead Reduction Surgery
Hairline lowering or forehead reduction surgery is an alternative technique to hair grafting for lowering the overly high hairline. It permits, in the appropriate patient with sufficient scalp laxity, the advancement of the hairline, and therefore the reduction in height of the forehead, by as much as 18 to 30mm in a single procedure with virtually instantaneous results. To be an appropriate candidate, the patient must have a stable hairline not at risk of future hair loss (typically the case in trans female patients) and sufficient scalp laxity. This laxity can be assessed in consultation by the manual forceful pushing forward of the patient's hairline, recognizing that with the best-technique of extensive undermining in the subgaleal plane back to the upper occiput region, and occasionally the making of a a coronal galeotomy, an additional 4 to 12mm of advancement can be achieved [
As Figure 6 shows, the primary result of this surgery is lowering of the frontal hairline. While some rounding out is achievable, some patients may undergo hair grafting as soon as three months after the surgery to further round out the hairline, and in the around 15% of patients where the hairline scar is somewhat visible (despite the making of a trichophytic incision) to help conceal this scar. Once advanced with surgery, the hairline will stay in its lower position as it is secured to the cranium through a fixation approach, our preferred approach being the placement of Endotine® clips. clips. An advantage posed by this surgery, particularly in the trans female patient, is the ability to combine the hairline lowering surgery with a browlift and or reduction of frontal bone prominence.
The average patient can achieve around 2 cm of advancement, sufficient to provide a more feminine appearance. If further lowering is desired, grafting can subsequently be done at the same time if there is a desire for further rounding out. The main advantages of hairline lowering surgery are the immediacy of the results (as opposed to the six to eight months or more for the results of grafting to reach sufficient density) and the unsurpassed hair density, as a single hairline lowering is equivalent to 3500 to as many as 7000 grafts.
Like most other facial features, changing eyebrow shape and/or position can create a more feminine appearance. In most cases, plucking of the eyebrows is sufficient to create desired appearance. In the situations wherein this is not adequate a hair transplant to the eyebrows can achieve a more significant result. The typical male eyebrow is relatively flat and somewhat thick, with a conservative peak to the upper border located at a point corresponding to the location of the lateral limbus of the iris. The typical female eyebrow is thinner and more arched, with that arch located between a point more closely corresponding to the lateral canthus [
Many trans female patients will have experience drawing in their eyebrows and can direct the surgeon as to the desired shape. Like with other hair transplants, scalp donor hairs are preferred due to their greater reliability and naturalness. Importantly, these transplanted grafts will require regular trimming to maintain eyebrow appropriate length due to continual growth. A typical eyebrow procedure involves the transplanting of 200 to as many as 375 grafts, equivalent to 300 to 600 hairs, per side. The hairs can be obtained by the FUE or FUT technique, and the procedure may be combined with a scalp hair transplant. The key aesthetic step is the making of recipient sites using small 0.5 or 0.6 mm blades. These must be placed as flat as possible to the surface of the skin and oriented so that the hairs grow in a crossed-hatch direction throughout most of the eyebrow.
Trans Male Considerations
Much less familiar to the gender-affirming community of patients and doctors is the use of hair restoration surgery to create more masculine features in the trans male patient. These procedures most commonly include restoration of the beard and chest, and much less commonly other areas including the pubis and axilla [
]. Exogenous testosterone can produce secondary hair growth to the beard and chest, but in some patients the density is not nearly sufficient for the patient to achieve the desired masculine look. Usually in a single hair transplant procedure, a rather full beard and/or goatee, a moderate amount of chest hair that can help conceal mastectomy scars, or a fuller pubis that conceals gender reassignment scarring can be achieved.
MPB does not typically exist for the trans male patient until he starts taking testosterone, which can result in some hair loss that is usually relatively limited. As with any male patient, FUE is usually the strongly preferred technique of obtaining grafts, due to the absence of the linear donor scar of FUT that could prohibit patient comfort with short hair styles.
Goals in beard design are often established by the patient. Many patients typically present with a specific understanding of the desired appearance of facial hair that can be achieved by transplantation (Figures 7and8). While the typical absence of MPB in these patients ensures an abundant supply of donor hairs, the patient needs to understand that the creation of full beards requires a large number (2,200 or more) of grafts and may require a secondary procedure if further density is desired. It is our experience that scalp donor hair transplanted to the face has a very high and reliable regrowth percentage, and can result in a natural outcome if properly performed [
Depending on the exact design and density, graft counts can range from 250 to 300 grafts to each sideburn, 400 to 1000 grafts to the mustache and goatee, and 300 to 600 grafts per cheek. Patients are seen pre-operatively where the beard design and goals are reviewed. It is very important to review with the patient the exact shape and design they are seeking for their beard. Asking the patient to bring in example photos often helps in this communication prior to surgery. Using the patient's guidelines, the areas to be transplanted are marked out and checked for symmetry. Similar to hairlines and eyebrows, the patient is shown the markings in a mirror and the design is agreed upon with alterations made if needed.
The donor hairs are typically harvested by FUE (Figure 9) in most cases of all types of hair transplantation in males and in many females. Hair follicle anatomic knowledge is fundamental to the procedure (Figure 10). The scalp donor area is typically shaved, unless a no-shave approach is used where each graft to be harvested first has its individual hairs trimmed without trimming of surrounding hairs, and patients are placed in a prone position. The smallest possible drill size avoiding graft transection, usually 0.85mm, is used for the extractions. The donor area consists of the occiput only in smaller cases and extends into the parietal scalp for larger cases. Over-harvesting of the donor area is avoided, reducing the risk of focal alopecia for the patient. Once the extractions have been completed from the occipital area, the patient is then turned to lie in the supine position, unless posterior crown work is to be performed, in which case these grafts are planted with the patient still prone to facilitate placement.
Scalp Hairline Restoration
When transplanting the female hairline, various parameters are to be followed. As described above, the location of the central-most hairline is 6.5 to 8cm above the glabella, with a 15mm transition zone between the vertical forehead and horizontal scalp. Extending laterally, a variety of designs and shapes can be utilized, depending on patient preference as to whether a more rounded versus more square hairline appearance is desired.
The key components in recipient site formation is to achieve proper graft angulation, direction, and distribution. The use of the smallest possible blades for making recipient sites, usually in our practice 0.5mm for single hair, 0.5 or 0.6mm for two hair, and 0.6 to 0.7mm for three hair grafts, assures not only the quickest healing and least scarring but also enhances the ability to acutely angle and direct the hairs to look natural. In general, along the sides the angulation of the grafts is particularly acute/flat, the the direction is downward and usually slightly posterior. Along the hairline, angulation is usually acute and the direction usually anterior, however a variety of pre-existing patterns of these parameters must be followed, in some cases where there can be a “swirl” with on one side of the hairline the hairs actually grow posterior. By following these pre-existing patterns of the natural hairline, and replicating them at a lower position for the lowered hairline, the most aesthetic result be achieved. Unfortunately, with posterior growth or the presence of a “swirl”, achieving the appearance of good density is most challenging.
Anesthesia of the recipient areas with 1 or 2% lidocaine with 1:100,000 epinephrine is usually achieved with a ring block but in certain cases a supraorbital and supratrochlear nerve block can be used. The procedure is performed under usually oral sedation and local anesthesia, although nitrous oxide anesthesia can be utilized, and in some cases twilight sedation - particularly in cases when the chest is the donor or recipient area - is provided.
In terms of the element of distribution when making recipient sites, naturalness is more than merely placing a few rows of all single hair grafts along the frontal most hairline, behind placing a few rows of all two hair grafts, and finally filling in the rest of the restoration with all three and four hair grafts that are either natural follicular units or the coupling of two one or two hair grafts to create three and four hair grafts. Rather, the key element in most cases of hairline design is the creation using two hair grafts of clusters or triangles, such that there is a thicker alternating with thinner irregular pattern. Once this desired irregularity has been achieved with these two hair grafts, “feathering” of the hairline is then typically achieved by the random irregular placement of one hair grafts that somewhat follow and therefore reinforce the irregularity achieved with the two hair grafts. Meanwhile, behind the typical three to five rows of two hair grafts the three and four hair grafts are then placed to create maximum density.
When restoring the crown, it is crucial especially in the posterior crown to follow the natural “swirl” that commonly exists. Outwards from this swirl, the angulation and direction of grafts continues to that most of the hairs anterior to the swirl grow anteriorly and sometimes somewhat laterally, while the hairs posterior to the swirl largely grow posteriorly (thus the easier planting with the patient prone.
Graft placement is usually done after the recipient sites have been made. To facilitate graft placement, dull implanters are loaded with a graft that can then be inserted into the recipient site atraumatically and one at a time. This is our preferred approach, however some doctors use sharp implanters, where the recipient site is made and the appropriate graft inserted in a single motion of “stick and plant”. Graft placement proceeds, and as required additional recipient sites can be made to refine the appearance, maximize density, and assure symmetry. In a typical procedure of 2000 grafts, an experienced team using implanters can plant 400 to 500 grafts per hour. Although increasing the time required for recipient site creation and graft placement, it is not necessary that the patient trim the pre-existing hairs in the recipient area.
Key steps to achieving optimal regrowth is proper storage of the grafts and keeping them moist to avoid damaging desiccation, careful graft extraction and placement, and proper care of the transplants particularly over the first three days when they are most vulnerable to damage. The first three days post-procedure the patient takes antibiotics and every 30 minutes sprays the grafts with saline plus ATP. With FUE there is typically minimal discomfort. Normal hair washing and exercise is permitted after five days. Crusts in the recipient area can usually be rubbed off after one week. The donor area is kept moist with an antibiotic ointment, while for the beard and chest donor areas an antibiotic and mild steroid cream mixture is used.
Local anesthesia is applied to the face starting in each sideburn and cheek area with direct infiltration. The perioral region is anesthetized using a combination of mental and infraorbital nerve blocks coupled with direct infiltration. In most cases this perioral region is not worked on until after lunch to permit the patient to eat. To assure hemostasis, in most cases 1:60,000 epinephrine is also directly infiltrated into the recipient area. The recipient sites in the sideburn and cheek area are made first, using most commonly 0.5mm for most one and two hair grafts, and if three hair grafts are to be used using 0.6mm blades In most cases the direction of these hairs is flat and downward.
In most cases a combination of one and two hair grafts are used with the one hair grafts placed along the periphery/upper borders of the beard/goatee, and two hair grafts in the more central regions for greater density. Exceptions of course exist, and in cases of thick caliber straight and or dark donor hairs, such as in many Asian patients, most if not all single hair grafts are used to assure naturalness. The direction of growth is generally downward, but more centrally closer to the mouth/goatee region, the vector can be oriented somewhat infra-laterally. In the cheek area, mostly single and double hair grafts are used. Occasionally among patients with fine and light colored hairs or curly donor hair, three hair grafts can be used to allow for the achievement of greater density. As soon as recipient site formation is done, the grafts can then be placed one at a time, according to the aesthetic vision of the surgeon.
After the patient eats lunch, the area around the mouth is anesthetized and the nerve blocks and local infiltration placed. Incisions in the goatee and mustache area are then made, with the mustache hairs typically growing slightly laterally and then transition downward along the goatee. Once again, it is very important to make these slits at acute an angle as possible to the skin. The grafts in the mustache region can have a tendency to grow a bit less acute, particularly centrally in the philtrum, so extra attention must be paid when making the recipient sites. The transition from the mustache to the goatee is an important area for the creation of density, which is usually created by the maximal dense placement of double hair grafts.
Graft placement continues, and towards the conclusion of the case, the patient is given a mirror before the final grafts are placed. Given that the immediate appearance closely replicates the final results, it is helpful for the patient to view the beard in order to assess the design and density of the grafts. This allows for feedback, fine-tuning and alteration before the conclusion of the case.
Patients are instructed to keep the face dry for the first fivedays after the procedure to allow the grafts to set properly, helping ensure the maintenance of proper angulation. Patients can wet the face after fivedays with soap and water, starting to remove the dried blood and crusts. Shaving is permitted after 10 days. On average, like with the scalp, the grafts start to regrow after three to five months and final results can be expected 10 to 12 months following the procedure.
Chest and Pubic Hair Restoration
Restoring chest hair in the trans male patient has two main benefits- the creation a more masculine appearance, and the ability to conceal potential scars from prior mastectomy as part of the affirmation process (Figure 12). Likewise, pubic hair transplants have a potential role in helping to conceal scars from prior gender reassignment surgery.
In both of these areas, the natural pattern of growth is characterized by a more dense central region, which is achieved by cross-hatching of the hairs along the sternum and central pubis. [
]. Flat angulation of grafts, primarily consisting of one and two hair grafts, assures naturalness and adequate density. are used. Among patients with fine textured and/or light colored hairs, a key aesthetic step includes the cautious use of three-hair grafts, which must be propered directed. In a typical procedure, 2,000 to 3,000 grafts can be used to restore a moderately full chest area, while 900 to 1,300 grafts can be effective with the pubic region. In the chest, scarring from prior mastectomy typically is positioned just below the nipple line. Focusing graft placement in these areas provides optimal coverage, and filling in the surrounding areas achieves evenness . In most genital gender reassignment surgeries, the midline scar is usually located at the level of the pubis, and similarly focusing graft placement here is similarly important.
As with all other non-scalp transplants, the area is to remain dry for the first five days, after which resumption of normal activities and washing is permitted. Hairs will need to be trimmed once every 10 days or so as part of the maintenance.
Hairline lowering surgery (HLS) is best utilized in a patient with a high hairline but otherwise adequate hair density. It is a desirable approach to hairline management in facial feminization surgery given the same incision can be utilized for HLS and frontal cranioplasty. Once on hormone therapy, trans women can maintain a stable hairline, but should hair loss progress there becomes risk of hairline scar exposure.
The hairline is most typically located about 7-9 cm superior to the nasion but the facial vertical thirds can be used help position its ideal location. The hairline shape is similarly important to the forehead height. For trans women, conversion of an angled M-shaped hairline to a rounded hairline is ideal.
In order to achieve adequate scalp advancement, the mobility of the scalp should be assessed in pre-operative evaluation, as this is a reasonable estimation of degree of surgical advancement. An additional 3mm of advancement can be gained from each galeotomy. In the correct and amenable patient, scalp tissue expansion can be performed but hair density will decrease.
The hairline incision is best described as an irregular trichophytic incision and is posterior to the fine vellus hairs. As it is important to maintain vascularity to the elevated flaps, a deep understanding of the arterial and venous anatomy of the scalp is essential (Figure 13). The irregular nature of the incision is an gentle undulating wave instead of sharp, narrow waves. The scalpel is angled anteriorly so that a beveled incision cuts through the hair follicles and then straight down through the galea (Figure 14). A supraperiosteal elevation is bluntly performed to the vertex of this avascular plane. Extension of the dissection to 2-3 cm posterior to the vertex, where dense fibrous attachments exist. Similarly, this plane of elevation is extended to the lateral parietal area to further facilitate elevation. A coronal galeotomy is made about 25mm posterior to the trichophytic incision, taking care to cut only through the galea and avoiding the superficial tissues and vessels. Towel clips are placed on the scalp advancement flap to apply a firm pulling force for 60 seconds to facilitate further advancement via mechanical creep. Two to three rounds of mechanical force are applied, providing approximately 3mm of advancement. Securing the scalp flap in its anterior position to bone decreases unwanted tension from the incision. Absorbable bone anchored clips or bone bridged sutures that engage the galea can hold the scalp in its forward position and bearing tension of the closure. Based on the amount of advancement, the forehead skin is removed, typically 20-25 mm can be achieved but needs to be under no tension. The transverse forehead skin incision is similarly beveled anteriorly at 45 degrees and similar wave pattern. Closure of the wound relies on a 2-layer closure with deep sutures bearing the tension of the incision. Superficial skin is closed with a non-absorbable monofilament. To promote hair growth through the incision, the forehead skin is overlapped over the hear bearing scalp by de-epithelializing 1-2 mm of the scalp skin leaving the underlying follicle to grow through the incision (Figure 14). Alternatively, or in addition, interrupted sutures are placed such that the forehead aspect of the bite is further from the incision than the scalp aspect to promote pulling of the forehead skin over the de-epithelialized / beveled scalp without creating an incision mismatch. This overlap allows the hair follicles to grow through the scar.
Visible scarring is a troublesome complication but can be mitigated by a number of factors that aim to reduce excess tension on the closure. First, bone anchored suspension as described above is important to create a tension-free skin closure. Use of deep and superficial sutures that have less reactive potential and the avoidance incorporating hair into the skin closure can reduce excess incisional inflammation and granulation. Peri-incisional hair loss can occur if cauterization near the follicles is performed; therefore, local anesthetic with 1:100,000 epinephrine and tumescence solution are used to reduce and control bleeding. Despite these efforts and although uncommon, some patients will experience hair loss surrounding the incision. In these patients, hair grafting, as outline below is a useful adjunct procedure and can be performed as early as 3-4 following HLS. Adjunct hair grafting among trans women who have undergone frontal cranioplasty with HLS can be used to further fill in temporal recessions and round the hairline.
In our practice focused on treating hair loss, it is extremely gratifying to play a role in the gender reaffirmation process of these patients, who are typically very grateful for our contribution. This experience indicates the important role hair restoration has in the gender affirmation process. Through careful planning and consideration, hair procedures designed for transgender and gender nonbinary patients can consistently and reliably deliver pleasing and affirming results.
The authors report no potential conflicts of interest. (Author: please confirm complete and correct)