Transgender hair restoration is a niche within a niche, and a very rewarding one at that | Plastic Surgery Practice November 2014
By Jeffrey S. Epstein, MD, and Gorana Kuka, MD
Transgender male to female (MTF) or female to male (FTM) body surgeries tend to grab their fair share of headlines. Equally important but often overlooked, however, are transgender hair-restoration procedures of the scalp, face, and body that can help further refine the transgender process. The most common are hair transplants to feminize masculine hairlines, followed by beard and/or chest hair restorations, hairline-lowering surgery, eyebrow transplants, and the concealing of scars from prior plastic surgery and genital conversion surgery through hair grafting.
These procedures are made possible through the techniques of follicular unit grafting (FUG) and follicular unit extraction (FUE), both of which involve the transplanting of microscopic grafts into tiny recipient sites ranging typically from 0.5 to 0.8 mm in size. The transplanting of such small grafts helps minimize scarring and also provides a large amount of control over the direction and pattern of growth. This is important for achieving aesthetic results, particularly in such refined areas as the eyebrows and mustache.
BEARDS, GOATEES, AND MUSTACHES
While the administration of hormones in most FTM patients results in facial hair growth, the density is not always up to expectations. A goatee and strong sideburns create a more masculine appearance and are the most selected areas in which to concentrate, but the transplant design must be individualized. With the cheek region, the choice is between a beard that is high up or one that is a more narrow “strap beard” that runs along the jawline. The desired density as well can vary: Some patients seek a thin, diffuse coverage that looks good with several days’ growth, and others desire the fullest possible look that entails a larger number of grafts.
It is important to caution patients about risks of transplanting into the central lower lip (the “soul patch”) and chin mound as small bumps can form around the transplanted hairs. Typical procedures consist of 500 to 700 grafts into the goatee, 250 grafts into each sideburn, and anywhere from 400 to 550 grafts into each cheek beard.
EYEBROW RESTORATION IN TRANSGENDER PATIENTS
With the eyebrows, 225 to as many as 325 grafts are transplanted into each side. Attention to the direction and angle of the recipient sites will help assure a natural appearance. In general, the hairs in the medial one-third grow in a vertical direction, then grow in a crossed-hatch direction through the rest of the eyebrow to achieve density. The creation of a more arched, sometimes fuller look can transform the eye region to one that is much more feminine.
HAIR RESTORATION TO THE SCALP
Male pattern hair loss occurs in approximately 50% of all men by age 50, but can start as early as the late teens in around 20% of men. Chemical or surgical castration can arrest this progressive process in the MTF patient. Similarly, testosterone supplementation in the FTM patient can result in the development of male pattern hair loss for which finasteride can be prescribed. In either case, both the MTF and FTM transgender patient can present as an appropriate candidate for a hair transplant procedure.
For the MTF patient, whatever hair that was lost prior to the conversion process can be restored to create a more feminine appearance. FUG is commonly performed because these patients are unlikely to ever shave their heads, but the FUE procedure is always an option. A typically more aggressive approach can be taken with these patients to fill in the crown and/or lower the hairline because their hair-loss pattern can be considered to be stable. By contrast, the hair-loss process can be considered to be progressive in the FTM patient as long as they take testosterone.
CHEST AND PUBIC HAIR RESTORATION
Transplanting hairs to the chest in the FTM transgender patient can create a more masculine body appearance and conceal any scars along the lower chest region where breast reductions were performed. For the chest, the greatest density is usually over the sternum. This coverage can be extended caudally toward the lower chest region to conceal any breast removal scarring.
A large number of grafts are usually required to achieve any sort of reasonable density, with procedures ranging in size from 1,200 to 1,500 grafts for limited central and upper chest coverage, to as many as 3,200 or more grafts for a greater amount of coverage. Patients must be advised before undergoing the restoration as to the large number of grafts that may be required to achieve any sort of satisfactory result. Pubic hair restoration similarly can conceal the scarring resulting from genital surgery in both MTF and FTM patients.
RECOVERY, RESULTS, AND REWARDS
These procedures are usually performed under local anesthesia with oral sedation. Postprocedure care includes analgesics and antibiotics for several days. Nonscalp-transplanted areas must be kept dry for the first 5 days to assure proper graft setting. Hair washing is permitted on the second day after a scalp hair transplant. Hair regrowth can be expected to start at 4 months, with final results typically achieved at 10 to 12 months. Maintenance is required, because scalp hair transplanted to the eyebrow, chest, and pubic region will continue to grow and will therefore need to be trimmed on a regular basis.
Treating the transgender patient population and helping them refine their appearances can be a particularly rewarding component of the hair transplant surgeon’s practice.
Jeffrey S. Epstein, MD, FACS, is the director of the Foundation for Hair Restoration, and maintains full-time offices in Miami and New York City. He is also a voluntary assistant professor at the University of Miami. Gorana Kuka, MD, is a plastic surgeon in practice at Colic Hospital in Belgrade, Serbia. They can be reached at PSPEditor@allied360.com.
Original citation for this article: Epstein, J. S., Kuka, G. The ins and outs of transgender hair restoration. Plastic Surgery Practice. 2013; Winter: 20-21.