Facial plast Surg 2017; 33(06): 613-620
DOI: 10.1055/s-0037-1608782
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

The Role of Hair Transplantation for Managing Facial Trauma

Jeffrey S. Epstein1, 2, 3, Gorana Kuka4, 5
  • 1Department of Otolaryngology, University of Miami, Miami, Florida
  • 2Foundation for Hair Restoration, Miami, Florida
  • 3Foundation for Hair Restoration, New York City, New York
  • 4Hair Center Serbia, Belgrade, Serbia
  • 5Division of Clinical Research, Foundation for Hair Restoration, Miami, Florida
Further Information

Address for correspondence

Jeffrey S. Epstein, MD
Department of Otolaryngology, University of Miami
6280 Sunset Drive, Suite 504, Coral Gables, FL 33134

Publication History

Publication Date:
01 December 2017 (online)

 

Abstract

Oftentimes, multiple treatment modalities are indicated for the management of trauma to the face. When this trauma involves a hair-bearing area, such as the eyebrow, eyelid, or beard region, hair transplantation can be an effective modality. While most of these facial hair transplants are performed for elective cosmetic indications, advanced techniques of hair transplantation can assure aesthetic outcomes in the optimizing of appearance after trauma. Because hair regrowth requires a good recipient bed, adjuvant therapies to promote vascularization, such as fat transfer and platelet-rich plasma, can be applied in conjunction with hair transplantation. The authors review the indications and the essential techniques of graft harvesting by follicular unit extraction and follicular unit grafting, and recipient site formation and graft planting and management, and present different case examples illustrating these technique.


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While primarily performed for aesthetic indications, hair transplantation can be an effective part of the management of facial trauma. This transplanting of hair to restore eyebrows, eyelashes, beards including sideburns, and even to the scalp hairline region can be done whether the trauma was due to any number of causes, including iatrogenic/surgical, burn, avulsion, laceration, and more.

In general, hair transplanting should be performed once other reparative techniques have been applied to optimize a normal structure, appearance, and shape to the area of trauma, and maximal healing has taken place. These other reparative techniques can include but are not limited to skin resurfacing, fat grafting (which we discuss below as part of optimizing the results of a hair transplant into a scar), primary and complex defect or laceration closure, and scar repairs. In most cases of hair transplanting after surgical repair techniques, it is advisable to wait a minimum of 6 to 8 months to permit sufficient revascularization and healing, but in cases of skin resurfacing as soon as 4 weeks later. Once hairs are transplanted, it is generally not recommended to laser or surgically manipulate the area due to the potential adverse impact on hair regrowth.

Compromised blood supply seen in some scars can compromise growth of transplanted hairs. A way to test for blood supply is to stick the tissue with an 18-gauge needle and observe bleeding. Little to no bleeding even after a minute should be concerning, and in these cases it is likely best to perform a test procedure with a smaller number of grafts to assess for regrowth, rather than undertaking a large procedure. Assuming there is then regrowth of the transplanted hairs after a 6- to 8-month period, a second procedure to further fill in the scar can then be performed with greater confidence. Rogaine applied starting the third week after transplant may increase hair regrowth by its vasodilatory properties.

Overview of Hair Transplantation Techniques

Two Techniques for Donor Hair Harvesting: Follicular Unit Extraction and Strip

Harvesting of hair from “donor areas” of the scalp has evolved considerably from the original techniques of the late 1950s where 4-mm punches were used to obtain the grafts.[1] At present, there are two methods to harvest hair grafts: follicular unit transplantation (FUT) and follicular unit extraction (FUE). Each method has its advantages and indications, but both have in common that grafts are harvested from the “permanent” donor area where hair follicles are immune to the causative factors of pattern baldness.[2] [3] In most cases, the donor area is the back and/or sides of the scalp; however, it is possible to utilize body hair, such as from the beard and/or chest, when indicated or desired.

Follicular Unit Grafting

Follicular unit grafting (FUG), or the “strip” method, as introduced in the late 1980s by Limmer, requires stereo-microscopic dissection of follicular unit micrografts from a donor strip.[4] [5] [6] [7] This more conventional method still has appropriate indications, but has as its major downside a resultant typically fine-line scar where the donor site was sutured closed. Usually, 2 mm or less in width, the scar can range in length from 5 to 20 cm depending on the number of grafts to be transplanted. From a single strip, hundreds to as many as 2,000 or more grafts can be obtained. Like with FUE, proper handling of grafts during and after dissection is critical since physical trauma and desiccation are believed to be the most common cause of poor hair growth. Today, most transplant cases are performed using the FUE technique, with FUT limited to eyelashes (where the hairs need to be at least 6 cm long to permit threading into the upper eyelid), and some patients, in particular women, with longer hair who have no concerns about a linear donor site scar.


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Follicular Unit Extraction

This more contemporary method of graft harvest involves the removal from the donor area of individual follicular units one at a time.[8] [9] Its main advantage—the avoidance of a linear donor site scar—permits patients to shave the head in the future with hundreds to thousands of tiny dot scars that in more than 60% of patients are undetectable. Two types of punches can be used for FUE, sharp and dull, which can range in diameter from 0.6 to 1 mm, with our preference in most cases a sharp 0.8- or 0.9-mm punch. A variety of motorized drill systems have been developed, including several proprietary devices, all of which rely on the physician to determine which follicular units to harvest and to manually guide the drill as the graft is punched, with the exception of one robotic system.

The donor area for FUE includes the entire area that is for FUG—namely, the central back of the head—and additional zones including the lower back of the head and the upper parietal/temporal regions, areas in which a donor site incision is not advisable. FUE also permits the harvesting of hairs from nonscalp areas, including most commonly the beard and chest, that can provide in hirsute males a large supply of additional donor hairs that can grow similarly to scalp and beard hairs once transplanted. Traditionally, FUE procedures of 800 plus grafts have required a large area of the back and sides of the head to be trimmed to 1 to 2 mm to permit efficient harvesting of grafts. However, the recently developed no-shave FUE technique limits the trimming of the hairs only of the grafts to be harvested, leaving most of the surrounding hair in the back and sides of the head at normal length, allowing patients to be undetectable immediately after a procedure.

To harvest a graft, the punch is placed around the selected follicular unit and then guided through the skin staying parallel to the direction of the hair, to a depth of 2 to 2.5 mm to transect the attachment of the arrector pilli muscle. Stabilization of the surrounding skin both with applied pressure of fingers from the other hand, and sometimes the injection of tumescence, is critical for successful harvesting. The now-released grafts are gently pulled out by manual or suction techniques (we prefer manual), then in most cases the surrounding cuff of skin is carefully trimmed under a microscope to minimize scarring in the areas to be transplanted. As many as 800 FUE grafts can be harvested per hour (except when using a no-shave technique where it is closer to 400 FUE grafts), and when properly performed, grafts of excellent quality are achievable.


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Restoring of Specific Areas

Regardless of the technique for graft harvesting, the technique of hair transplantation to scalp and nonscalp areas is based on the same essential concept—transferring permanent hairs into areas devoid of hairs, that once transplanted, will continue to grow. This donor-dominance concept does have some exceptions, in certain conditions in the recipient area that prevent full or even any regrowth of transplanted hairs. Some conditions that generally do not support regrowth of transplanted hairs include certain nonscarring alopecias including active alopecia areata or totalis, many inflammatory scarring alopecias like frontal fibrosing alopecia (that sometimes has eyebrow loss as the first manifestation) and lichen planopilaris, and areas after trauma that have healed with significant scarring. Note that in the next section, we present the potential uses of cell therapies for addressing the challenges of hair regrowth in some of these conditions. Of note is that some of the conditions that can cause loss of eyebrow hair including hypothyroidism and anemia do not interfere with regrowth of transplants to restore the areas of loss.

The anatomical areas of the eyebrows, eyelashes, and beard/sideburns all have unique characteristics in terms of hair angulation, direction, position, design, and density, and the surgeon should be familiar with them to achieve the most aesthetic result.[10] Cases of unilateral or asymmetric hair loss, usually resulting from trauma—cancer surgery, burns, lacerations—provide the surgeon an opposite side normal “template” that can guide the restoration of the affected side, with the goal being as close to a symmetric result as possible. Most scar tissue does not have the same characteristics of normal tissue, which can affect the making of recipient sites. When the tissue is thick with reduced blood supply, recipient sites need be made sufficiently deep to draw blood. With tissue that is friable, tearing easily, the recipient sites must be made particularly atraumatically and not densely packed. Hypotrophic tissue calls for more acute recipient sites to allow the recipient site to be sufficiently long to permit the entire length of the graft to be placed. Pretreating scar tissue with fat transfer can potentially improve the vascularity and depth of tissue.

Special graft considerations when transplanting into scar tissue to maximize hair regrowth include the use of more of two- and three-hair grafts rather than one- and two-hair grafts, respectively. The logic behind this approach is based on the concept that if the typical percentage of hair regrowth in certain types of scar tissue is anticipated to be 60% (versus 90% in normal tissue), the one additional hair in these grafts can compensate for this lower regrowth, without a compromise in naturalness. As with any facial hair transplant, proper graft preparation is important to minimize scarring. This entails the trimming of the cuff of skin at the edge of the graft, which if left in place could result in tiny bumps and/or hypopigmentation around each transplanted hair.


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Specific Areas

Eyebrows

While the majority of eyebrow transplants are done for elective cosmetic purposes to restore fuller more aesthetic eyebrows, the repair of traumatic scarring and deformity is a fairly regular indication. Dog bites, reconstruction after cancer or craniofacial surgery, burns, and avulsions/lacerations are the most common etiologies, and in most cases involve only a part of one eyebrow.

The primary goal with these procedures is to create symmetry, but at the same time some change in the shape and/or density of both eyebrows can be achieved at the same time. This must be discussed with the patient at the time of the consultation, which is also when the patient is educated on the challenges of creating perfect eyebrows, particularly in cases of hypertrophic scarring. As with all areas of scarring, prior to transplantation the scar should have undergone optimal surgical and medical management (see [Fig. 1]).

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Fig. 1 An Asian female, tried to self-remove prior micropigmentation tattoo to her eyebrows, resulting in a severe burn that left significant scarring (A). She underwent excision of the affected eyebrow scars and at 3 months (B) was sufficiently healed to undergo a hair transplant procedure of 300 grafts per side, that at 1 year (C) showed significant improvement.

In a typical procedure, 350 to 425 hair grafts are indicated to restore each eyebrow. We prefer to use primarily two-hair grafts, with one-hair grafts placed in the medial-most aspect of the eyebrow (the inner “head”) typically in a more vertical direction as described in the next paragraph, so as to create a soft feathered look. Smaller procedures of 100 to 225 grafts are indicated where a portion of the eyebrow is missing, while linear scars can be treated typically with 25 to 50 grafts (see [Figs. 2] [3] [4]). In many cases where only a portion of the eyebrow is missing, to assure a more even appearance across the entire eyebrow, a small number of grafts can be placed spread out across the nonaffected portion of the eyebrow and even into the opposite eyebrow, but this is not always indicated nor desired in some patients.

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Fig. 2 A 10-year-old who had lost the lateral portion of his right eyebrow (A) treated with 150 grafts shown 1 year later (B).
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Fig. 3 An Asian female with extensive facial scarring from oil burn (A), underwent transplant of 275 grafts per eyebrow shown 1 year later, with attempt made to achieve as much symmetry as possible (B).
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Fig. 4 Small linear eyebrow scar (A), immediately (B) and 1 year after 90 grafts (C).

Recipient site creation is the key aesthetic step. To assure the flattest growth of the hairs, a small blade is used to make the recipient sites as flat an angle as possible to the skin. We prefer to use small beaver-type blades that we cut ourselves that measure 0.5 mm for one- and oftentimes two-hair grafts, and 0.6 mm when needed for two-hair grafts, and for the occasional three-hair graft when indicated. Hair growth direction most importantly should be consistent with the direction of the surrounding hairs as well as the contralateral eyebrow. In most cases, this means that in the “head” portion of the eyebrow—the medial-most 5 to 8 mm—the hairs generally grow in a vertical direction except for the top row hairs which grow essentially horizontal. In the “body” portion of the eyebrow—the largest portion, usually measuring 3.5 to 4.5 cm—the hairs grow in a crossed-hatch pattern with the superior hairs growing lateral and slightly downward and the inferior hairs growing lateral and slightly upward, so that where they meet there is a maximizing of density. In the lateral-most section of the eyebrow, the “tail” that measures ∼1 cm, the hairs grow primarily in a horizontal direction. When making recipient sites, caution must be taken not to go in a direction different than the surrounding hairs, otherwise it risks damaging the existing hairs as well as having the direction of growth of transplanted hairs different than that of the existing hairs.

A typical procedure takes 2 to 5 hours to perform, depending on the number of grafts and the skill of the surgeon and team of assistants. Most of these cases are performed under oral sedation and local anesthesia. Planting of grafts is done in a meticulous fashion, and once all the recipient sites are filled, the surgeon reassesses the appearance of the eyebrow(s) and makes adjustments as indicated, adding more hairs as necessary. Once the procedure is completed, the patient is instructed to keep the eyebrow(s) dry for 5 days, after which gentle washing can be resumed. In the majority of cases, the patient is presentable at 4 to 5 days, and the transplanted hairs fall out at 2 to 3 weeks, and then start to regrow at 4 months. Because the transplanted hairs in most cases come from the scalp, they will need to be trimmed on a once weekly basis to assure a clean neat look.


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Eyelashes

Eyelash transplantation is now commonly done for purely aesthetic purposes ([Fig. 5]), but originally this procedure was performed to restore lashes lost as a result of trauma, most commonly from cancer surgery or burns. This is a very different technique than other transplant procedures, as the hairs are not placed into the recipient sites but rather are placed into the upper eyelid using a curved French-type needle, the hair(s) of the graft threaded into the eye of the needle. When restoring a full amount of upper eyelashes, 50 to 60 two-hair grafts are placed into each upper eyelid, with the hairs exiting at or just above the normal lash line. In cases of scarring, usually only a portion of the lashes are missing from one eyelid, thus a much smaller number of grafts are placed.

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Fig. 5 Result of eyelash transplant, shown before (A) and 1 year after 55 grafts or 110 hairs (B).

From a small donor strip with the hairs left long, two-hair grafts are dissected, then the two hairs of each graft threaded into small French-type needle. These grafts are then “sutured” in place into the portion of the upper eyelid to be transplanted that has already been anesthetized, the needle entering typically 6 to 8 mm above the lash line, then exiting just at that line. Ideally, the hair has a bit of a curl that can be directed to have the hair grow upwards as it emerges from the lid margin. The hair gets pulled so that the complete follicle is fully under the skin, then the excess hair trimmed shorter to the length of a normal eyelash. Additional grafts get placed until the defect is sufficiently filled.

In general, lower eyelids are not to be transplanted, as the threading technique can result in hairs that will grow into the globe, injuring the cornea. This is a risk of upper eyelid transplant but usually can be avoided. We have done several lower eyelid transplants, and in these cases the hairs get placed into very carefully made recipient sites.

Beard/Sideburns: There are many etiologies for a patchy or thin beard, usually genetic, making beard transplants a relatively common procedure. It can be a very effective way to conceal facial scarring in men as a result of acne, surgery, or trauma such as a burn or laceration, assuming the patient is willing to wear a beard.

A very large number of grafts are required to restore a full beard and goatee with mustache, upwards of 2,000 or more in patients who have a somewhat thin beard. However, in many of these cases of scarring, a smaller number of grafts are required, such as to fill in a linear scar such as from cleft surgery repair or patch of scar that is missing hair ([Figs. 6] and [7]). Oftentimes, these patients have undergone attempted prior scar repair with disappointing results, and present for a salvage procedure in which hair transplantation would have been the best approach all along ([Fig. 8]). Typically, one- and often two-hair grafts are transplanted into recipient sites made with 0.6 and 0.7 mm blades. These sites are made following the direction of the surrounding existing hairs, keeping the angle of the site as acute as possible so the hairs will grow flat along the skin rather than sticking out. In the sideburn, this is most commonly done after rhytidectomy that did not utilize a trichophytic technique, but also for cases of burns and other trauma. It is not uncommon for the direction of hair growth to differ somewhat between the two sides, oftentimes with one side having the hairs grow in a more posterior direction with the other side hairs growing more downward. Usually, single hair grafts are used in the outer 2 to 4 rows of hairs, while the central aspect of the sideburn achieves greater density using primarily two-hair grafts ([Figs. 9] and [10]).

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Fig. 6 Cleft lip scar (A), shown 1 year after 100 grafts (B).
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Fig. 7 Cleft lip scar with diffuse thinness of the goatee region (A), shown immediately after (B) and 10 months after (C) 650 grafts to fill in the scar and restore density to the goatee region.
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Fig. 8 Linear hypertrophic scar along the left side of the jawline that was unimproved after attempted plastic surgery repair (A). Shown 10 months after 800 grafts to the beard (B).
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Fig. 9 Loss of sideburns with scarring, the result of prior transplant (A), restored with a transplant procedure of 300 grafts per side, results shown 1 year later (B).
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Fig. 10 Loss of left temporal hairs as a result of burn scar (A), shown immediately after (B) and just 5 months after (C) 450 graft transplant procedure.

Care for the beard is like that after the eyebrow transplant, with the area kept dry for 5 days. The hairs will then fall out at 2 to 3 weeks, and then can be expected to start to regrow at 4 months.


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The Role of Adjuvant Cell Therapies

Fat Transfer and Platelet-Rich Plasma as an Adjuvant to Hair Transplantation

Fat grafting into facial defects to improve contour irregularities is not a new concept. It dates from the end of 19th century when Gustave Neuber used adipose tissue from the arm to the lower margin of the orbit to improve adherent scars due to osteomyelitis.[11] Since then, many authors have emphasized the role of fat for various clinical and reconstructive applications. In 2013, Klinger published results of a large study on 694 subjects that measured improvement of the quality of scars both from an aesthetic and functional point after fat injections.[12] [13] He noted improvement in scar hardness, flexibility, elasticity, and even color. Histologically, autologous fat grafting has shown the ability to regenerate the dermis and subcutaneous tissue.

Trauma in hair-bearing areas can not only result in alopecic but also hypotrophic or hypertrophic scars. Both may be challenging for hair transplantation reconstruction due to either an insufficient subcutaneous layer in hypotrophic scars or a thick collagen pattern in hypertrophic scars. Furthermore, keloids show a quantitative reduction in blood vessels compared with hypertrophic and surgical scars which helps understand their hypoxic nature.[14] Compromised blood supply in scar tissue can be a cause of poor regrowth. Since adipocytes can enhance the neovascularization in ischemic tissue,[15] we have developed an approach injecting fat into scars prior to transplantation to improve blood supply in scars. This is a two-step procedure to maximize hair regrowth, where fat injections are performed first followed by hair transplantation 3 months later.

The surgical procedure to harvest fat is typically performed under local anesthesia and oral sedation. The selected area, usually the abdomen, is infiltrated with 20 to 40 mL of a tumescent solution containing 2% Lidocaine and 1;100,000 epinephrine. A 3-mm diameter, 15 cm long, 3-hole distal opening blunt-tipped cannula attached to a 10 mL syringe is used to harvest the adipose tissue, then the fat is processed by gravity separation for 15 minutes and then washing with lactated Ringers solution to remove oil, blood, and debris. Platelet-rich plasma (PRP) is usually added to the fat to potentially enhance soft tissue restoration.[16] This adipose tissue with PRP is then put in 1 mL Luer-lock syringe connected to a 17-gauge blunt cannula, then injected into the immediate subdermal/subcutaneous layer of the scar through multiple tunnels running in different directions ([Fig. 11]). This technique also seems to help release scar adhesions to deeper tissue.

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Fig. 11 Fat transfer into a scarred right eyebrow, performed to improve regrowth of a hair transplant to be performed four months later.

Three months later, a period that we believe is critical to ensure graft survival and optimal neoangiogenesis, the hair grafts can be transplanted into recipient sites made into the scar tissue. PRP injections can be done with the transplant into both the recipient area to potentially further improve graft regrowth, as well as into the donor sites to accelerate healing. We have observed that many of these scars treated with fat not only feel softer, but also demonstrate more bleeding than before the injection of fat ([Fig. 11]). Furthermore, hypotrophic scars after fat are thicker and have a fuller subcutaneous layer, critical for optimal graft survival ([Fig. 12]).

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Fig. 12 Temporal scar from chemical burn, treated elsewhere with a hair transplant with poor regrowth. Underwent fat transfer, and then 3 months later, 250 grafts transplanted into each side.

If no fat transfer is to be performed, PRP injection at the same time as the transplant is still usually performed. Injected into the recipient area at the time of the transplant, the PRP can only optimize hair regrowth.


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Conclusions

Hair transplantation can be a useful adjunct to the management of scars of the face. In cases where there is a concern that hair growth can be compromised, fat transfer can be performed to enhance vascularity and texture of the skin, thus enhancing potential hair regrowth.


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No conflict of interest has been declared by the author(s).


Address for correspondence

Jeffrey S. Epstein, MD
Department of Otolaryngology, University of Miami
6280 Sunset Drive, Suite 504, Coral Gables, FL 33134


Zoom Image
Fig. 1 An Asian female, tried to self-remove prior micropigmentation tattoo to her eyebrows, resulting in a severe burn that left significant scarring (A). She underwent excision of the affected eyebrow scars and at 3 months (B) was sufficiently healed to undergo a hair transplant procedure of 300 grafts per side, that at 1 year (C) showed significant improvement.
Zoom Image
Fig. 2 A 10-year-old who had lost the lateral portion of his right eyebrow (A) treated with 150 grafts shown 1 year later (B).
Zoom Image
Fig. 3 An Asian female with extensive facial scarring from oil burn (A), underwent transplant of 275 grafts per eyebrow shown 1 year later, with attempt made to achieve as much symmetry as possible (B).
Zoom Image
Fig. 4 Small linear eyebrow scar (A), immediately (B) and 1 year after 90 grafts (C).
Zoom Image
Fig. 5 Result of eyelash transplant, shown before (A) and 1 year after 55 grafts or 110 hairs (B).
Zoom Image
Fig. 6 Cleft lip scar (A), shown 1 year after 100 grafts (B).
Zoom Image
Fig. 7 Cleft lip scar with diffuse thinness of the goatee region (A), shown immediately after (B) and 10 months after (C) 650 grafts to fill in the scar and restore density to the goatee region.
Zoom Image
Fig. 8 Linear hypertrophic scar along the left side of the jawline that was unimproved after attempted plastic surgery repair (A). Shown 10 months after 800 grafts to the beard (B).
Zoom Image
Fig. 9 Loss of sideburns with scarring, the result of prior transplant (A), restored with a transplant procedure of 300 grafts per side, results shown 1 year later (B).
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Fig. 10 Loss of left temporal hairs as a result of burn scar (A), shown immediately after (B) and just 5 months after (C) 450 graft transplant procedure.
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Fig. 11 Fat transfer into a scarred right eyebrow, performed to improve regrowth of a hair transplant to be performed four months later.
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Fig. 12 Temporal scar from chemical burn, treated elsewhere with a hair transplant with poor regrowth. Underwent fat transfer, and then 3 months later, 250 grafts transplanted into each side.