Ethnic Considerations inHair Restoration Surgery

Jeffrey Epstein, MDa,b,c,*, Anthony Bared, MDb, Gorana Kuka, MDd

KEYWORDS

� Hair transplant � Follicular unit extraction � Ethnic hair transplant � Eyebrow transplantation� Hispanic hair transplant � Asian hair

KEY POINTS

� Different ethnic groups have specific characteristics of the hair that affects the results of hairtransplants.

� Asian hair, typically of thick caliber and dark, is often more challenging to achieve natural appearingresults.

� Patients of African ethnicity are good candidates for eyebrow and scalp hair transplants, becausethe curly hair and minimal color contrast between scalp and hair facilitate achieving results thatappear natural.

� Follicular unit extraction is the preferred technique for harvesting grafts in patients of African andmost of Asian ethnicity.

INTRODUCTION

Consistent with the trends acknowledged by theother contributors in this issue of Clinics, andconfirmed by demographic shifts in the UnitedStates, the ethnic patient constitutes a growingtrend in the use of plastic surgery, and the spe-cialty of surgical hair restoration is no exception.In our practice, with offices located in 2 ethnicallydiverse cities, most of our patients are non-European/nonwhite. This diversity is further mag-nified by the wide scope geographically in whichour patients reside; more than 70% of them travelfor surgery commonly from throughout LatinAmerica but also the Middle East and Asia,including East Indians and Asians. This ethnic di-versity provided to us by our international pres-ence is duplicated by the ethnic makeup ofour patients, who come from throughout NorthAmerica, not only Miami and New York. In partic-ular, this North American trend includes increasing

The authors have no disclosures to make.a Department of Otolaryngology, University of Miami CClinics, P.O. Box 016960 (D-48), Miami, FL 33136, USA; b

Suite 504, Miami, FL 33143, USA; c Foundation for HaYork City, NY 10021, USA; d Colic Hospital, Surduli�cka 5,* Corresponding author. 6280 Sunset Drive, Suite 504, ME-mail address: jse@drjeffreyepstein.com

Facial Plast Surg Clin N Am 22 (2014) 427–437http://dx.doi.org/10.1016/j.fsc.2014.04.0071064-7406/14/$ – see front matter � 2014 Elsevier Inc. All

numbers of African Americans and also MiddleEasterners, Asians, East Indians, and, of course,Hispanics seeking out hair restoration.

As hair restoration surgeons, we essentiallyperform 1 common procedure: hair grafting, inwhich hair is transplanted from the back or sidesof the head into areas of hair loss, most commonlythe frontal and midscalp and crown regions, butsometimes, into other areas, including the beardand eyebrows. In addition to these hair trans-plants, we perform several other procedures,including hairline lowering surgery (surgical hairlineadvancement [SHA]), in which the hairline isadvanced and the forehead shortened, and therepair of previous plastic surgery procedures,including but not limited to the repair of alopecicscarring and hairline distortion caused by previousbrowlifts and facelifts. With these procedures,ethnic considerations affect not only techniqueand patient candidacy but more subtly and just

ollege of Medicine, University of Miami Hospital &Foundation for Hair Restoration, 6280 Sunset Drive,ir Restoration, 20 East 56th Street, 3rd Floor, NewBelgrade 11000, Serbiaiami, FL 33143.

rights reserved. facialplastic.theclinics.com

Epstein et al428

as importantly, patient motives, expectations, andconcepts of beauty as a result of ethnicity (ie, Mid-dle Eastern men desiring full beards so as toappear masculine). In this article, these consider-ations are presented.

ANATOMIC AND HAIR CHARACTERISTICETHNIC DIFFERENCES

Although there exist a multitude of hair types inthe lay literature, within the medical literature, hu-man hair has been categorized into 3 ethnicgroups according to distinguishable characteris-tics: Asian, white, and African hair. These ethnicgroupings show distinct characteristics in hairdensity, diameter, shape, mechanical properties,and composition.1 The hair follicle itself deter-mines the appearance of the hair. The typicalhair follicle of Asian hair is round, whereas thoseof whites and African are ovoid and elliptical,respectively.2 The shape of the hair follicle is thusbelieved to contribute to the appearance and thegeometry of the hair. Asian hair has a circular ge-ometry, African hair has an elliptical shape, andhair of whites is of an intermediate shape. Thechemical and protein composition of hair doesnot vary across ethnic groups, and there is no dif-ference in the keratin types. However, African hairgenerally has less tensile strength and breaksmore easily than hair of whites. The hair folliclesof Asians are metabolically more active than thoseof whites, and therefore, the grafts of Asians aremore vulnerable to dehydration and a prolongedpreservation period.An important issue when considering ethnic

characteristics in evaluating patients for hair trans-plantation is the density of hairs in the donor site.This density is a product of 2 factors: the concen-tration of hairs and the size or caliber of each indi-vidual hair. The concentration of hairs is presentedin the form of follicular units per cm2; a single follic-ular unit is the natural occurring grouping of hairsas they grow in the scalp. A follicular unit, asdescribed by Headington,3 Sperling,4 and Kim,5

consists of 1 to 4 hairs, surrounding by an adven-titial sheath, which also contains some supportivestructures. A hair graft typically consists of a singlefollicular unit, which is the building block ofaesthetic hair restoration. Asian hair has thelargest cross-sectional diameter or caliber,whereas the density of hair is intermediate inwhites (whose highest density of hair follicles is100 follicular units/cm2) and lowest in Africans.This characteristic may be deceptive to the novicehair transplant surgeon, because African hair givesthe appearance of a higher density, given the curlynature of the hair. This characteristic is beneficial

to the patient because the appearance of higherdensity may be achieved with lower graft densityin the recipient area. Asians have a high proportionof single hairs (24%–30% compared with 14%found in whites).

HAIR GRAFTING TO THE SCALPDonor Site Follicle Extraction

We use 2 hair transplantation techniques: thefollicular unit grafting (FUG) or strip techniqueand the follicular unit extraction (FUE) technique.Both use the same basic concept of transplantinghair from more permanent donor areas (usually thesides and back of the scalp, but in cases of severelimited supply of donor hairs, usually as a result ofprevious procedures, the donor area can be thechest or beard) into the recipient areas, wheremore hair is desired. FUG and FUE differ in howthese donor hairs are obtained. FUG is the tradi-tional technique of donor hair harvesting, wherebyparallel incisions are made in the donor scalp areato remove a strip. The length and width of theexcision depend on the amount of grafts beingtransplanted in the procedure. From this strip, indi-vidual FUGs are then dissected under the micro-scope, a process that requires a team of trainedassistants, and separated out based on the num-ber of hairs per graft (1, 2, 3, or 4).In the FUE technique, individual punches, typi-

cally ranging in size from 0.8 to 1.0 mm, are usedto extract individual follicular units from the per-manent donor areas. As the fastest growingcomponent of our practice, the FUE technique isrelevant in ethnic hair transplantation cases. Weperform FUE procedures almost exclusively in pa-tients of African American and Asian ethnicity. FUEobviates the linear scar from a traditional FUG stripprocedure (Fig. 1). Because of the geometry of thehair in Asians, resulting in more a more spikypattern of hair growth, whereby the hairs tend togrow less vertically downward instead of growingmore outward or horizontally, the linear scar in pa-tients of Asian ethnicity can be more conspicuous.Similarly, in the African American patient, FUE pro-vides a cosmetic advantage, because the AfricanAmerican patient can continue to cut his hairvery short and avoid the appearance of a linearscar. The hair transplant surgeon needs to beaware of the geometry of the African Americanhair follicle when performing an FUE procedure.The curliness of the hair does not stop at theskin, so the surgeon needs to be cognizant ofthe potential change in hair direction underneaththe epidermis.In our practice, most of our FUEs are performed

by a specially designed handheld drill and do not

Fig. 1. FUE procedure on an African man. (A) Before; (B) 1 year after; (C) donor site 1 day after; (D) donor site1 year after.

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rely on automated extraction tools or robotic de-vices. We find that extracting the follicles in thisway allows for minimal graft transection, evenwhen using smaller punch sizes, which have asan advantage the reduction in scarring of thedonor area. In the case of African American curlyhair, blunt dissection is critical to avoid excessivegraft transection. The remainder of the graftextraction then may be facilitated by forcepsextraction. Hair follicles of Asians are not onlystraight but also tend to be longer than those ofwhites, and therefore, the probability of transec-tion during FUE is higher. We suggest using asharp punch when dissection is limited tothe dermal layer (dermal papilla is on average5–6 mm from the skin surface in Asians comparedwith 4–5 mm in whites), and the rest of the extrac-tion is facilitated by forceps as well. Postopera-tively, patients apply antibiotic ointment for5 days to the donor area.

Hairline Design and Recipient Site Formation

As in every cosmetic procedure, realistic expecta-tions need to be communicated to the patient dur-ing the initial consultation. The 2 most common

goals of patients are a natural appearance andthe achievement of maximum density, both ofwhich are now described in terms of ethnicconsiderations.

The appearance of density is a factor of thefollowing: the concentration of hairs (number offollicular units times the number of hairs in eachfollicular unit in a given area); the thickness orcaliber of each hair; the color contrast betweenthe hair and the scalp; and the angulation of thehair with the scalp (the more acute the angle, thegreater the appearance of density). Some of thecharacteristics that maximize density also helpwith providing a more natural appearance (lesscolor contrast between scalp and hair, more acuteangulation), whereas others are associated withmaking appearances more difficult (thick caliberhairs) (Fig. 2). Probably in no ethnic group is thisshown so well as in the Asian patient, in whomthe color contrast between the hair and the scalpand the geometry of the hair make the achieve-ment of density and natural appearances moredifficult (Fig. 3). The opposite holds for the AfricanAmerican patient, in whom the curl of the hair andthe similarities in color between the scalp and thehair make the achievement of density easier

Fig. 2. Before (A) and 1 year after (B) FUG/strip procedure on Hispanic man. Note the irregular hairline with hairsacutely angled anterior.

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(Fig. 4). With the East Indian and dark-skinnedHispanic and Middle Eastern individual, the lackof color contrast helps with density and natural-ness (Figs. 5–7).The recipient sites in patients of African and

Asian ethnicity tend to be larger than those foraverage hair of whites. This difference is causedby the geometry and the thickness of the hair folli-cles.Whether obtained by FUE or FUG, follicles arepreserved in their naturally occurring follicularunits, and recipient sites are sized so that theymatch up with the size of the grafts. For fine-haired patients, 0.5-mm blades work for single-hair grafts, 0.6 and 0.7 mm for 2-hair grafts, and0.7 and 0.8 mm for 3-hair grafts, In Asians andmost East Indians, each of these blades needs tobe 0.1 to 0.2 mm larger. In most African patients,these recipient sites also tend to need to be larger.Asian hairline design is treated similarly to thewhite hairline, in that sites are made in anirregular-regular manner tomimic a natural hairline.

Fig. 3. Before (A) and 18 months after (B) FUG/strip procedgrafts consisted of 1-hair and 2-hair follicular units.

In the African American patient, although thesingle-hair grafts tend to fit into 0.6-mm recipientsites, 2-hair grafts and 3-hair grafts are typicallyplanted into recipient sites 0.8 to 1 mm in size,primarily because the grafts are large as a resultof the curliness of the hairs. This curl of the Africanhairs allows for a hairline to appear natural.Although beyond the scope of this article, natu-

ral appearing hairlines are generally created by theirregular distribution of single-hair grafts into smallirregularly made triangles. Behind these severalrows of single-hair grafts, 2-hair then 3-hair and4-hair grafts are successively placed. An excep-tion to this irregular triangle distribution is typicallyin patients of African ethnicity, in whom a moreeven, straighter hairline is usually preferable,because the curliness of the hairs makes the hair-line appear natural. In Asian patients, it is rare touse grafts larger than 2 hairs, because of theunnaturalness that can be created by the use of3-hair grafts, except in the most unusual

ure on Asian man. To achieve naturalness, most of the

Fig. 4. Before (A) and 1 year after (B) FUG/strip procedure on African woman for hairline lowering.

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circumstances. For the same reason, in no otherethnic group is forward angulation of grafts moreimperative. Likewise, in African patients, this for-ward angulation is not so important because ofthe curl of the hairs.

Planting grafts into the recipient sites can bemore challenging in patients of East Asianethnicity, because of the challenges in visualizingthe sites. For reasons that are unknown, the graftsof Pakistani patients tend to be soft or mushy,making them more difficult to plant. This difficultyis exacerbated because these patients tend to

Fig. 5. Before (A) and 1 year after (B) FUG/strip procedure

have a higher incidence of bleeding from the recip-ient sites.

HAIR GRAFTING TO THE BEARD

This procedure has increased dramatically inpopularity over recent years. This popularity in-crease has 3 causes: the popularity of Americanmen sporting beards (epitomized by the Brooklynhipster trend, which goes beyond white urbanAmerica); the information provided through theInternet as well as a deluge of media coverage

on man of East Indian ethnicity.

Fig. 6. Before (A) and 1 year after (B) FUG/strip procedure on woman of East Indian ethnicity.

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that this procedure is available; and the not insig-nificant numbers of men of certain ethnicitiesdesiring fuller beards. In addition, consistent withthe increasing numbers of men in general seekinghair transplantation procedures because of theavailability of the FUE technique, part of thegrowth in requests for beard transplantation isfrom men who shave or cut the scalp hair veryshort who also want more facial hair.Hair transplantation to the beard consists of

transplanting hair from usually the scalp to theface, where the hairs continue to grow (just likeregular facial hair); if the procedure is performedproperly and aesthetically, the hairs appear natu-ral. A wide variety of requested patterns is desired,ranging from longer sideburns, to a strong goateeand mustache, to a narrow strap beard, to a fullthick beard, including sideburns and goatee/mustache. The most common cause of a defi-ciency of facial hair is genetics, but other lesscommon reasons include scarring from trauma(eg, burns) or previous surgery (eg, cleft lip repair,skin cancer, facelifts) and previous laser hairremoval.

Fig. 7. Before (A) and 1 year after (B) FUG/strip procedure

Both the FUG and FUE techniques can be usedfor obtaining the donor hairs; FUE is becomingmore popular. Similar to the ethnic considerationsfor choice of technique with scalp hair transplantprocedures, men of African and Asian ethnicityare usually best served by the FUE technique (Af-rican American because of the popularity ofshaving the hair short, Asians because the typi-cally spiky direction of hair growth in the back ofthe head makes it more likely that even a well-healed narrow linear donor site scar could bevisible at nearly any hair length).Whether obtained by the FUE or FUG technique,

preparation of the grafts for transplanting includestrimming the surrounding epithelium from theedges to minimize the chance of scarring wherethe grafts are placed, and when indicated, subdi-viding the naturally occurring 3-hair and 4-hairfollicular units into 2-hair and 1-hair grafts toensure a more natural nontransplanted appear-ance. This subdividing is especially important inpatients who have thick straight donor hairs,such as Asian men, in whom every hair is particu-larly visible, given the combination of thick hair

on man of Middle Eastern ethnicity.

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caliber and the contrast of the dark hair color withlight skin color, which is exacerbated because thegoal of most Asian men is not a full thick beard butrather a well-defined but thin goatee or sideburnsor strap beard, which leaves each graft to bemore visible (Fig. 8). The transplanting of 3-hair(never 4-hair) naturally occurring FUGs can bebeneficial to maximizing density in men with finelight-colored hairs or in some Middle Eastern andmost East Indian men, in whom the goal is oftenthe thickest possible beard (thus limiting the visi-bility of an individual graft), and many men of Afri-can ethnicity, in whom the curliness of the hairsmakes them even less visible as individual follic-ular units.

Patients need to be aware that because thetotal number of donor hairs is limited, any hairstransplanted to the beard are no longer availablefor transplanting into the scalp into areas ofexisting or future male pattern baldness. Thenumber of grafts needed for the face is a factor

Fig. 8. Before (A) and 1 year after (B) FUE procedure to thefree of detectable scarring.

of the areas to be filled in and the desired full-ness and size of these areas (ie, narrow strapbeard vs full cheek beard), which must be recon-ciled (and explained to the patient) with the safenumber of available donor supply, keeping inmind the likelihood of further hair loss. Thefollowing is an approximate graft count neededfor filling in areas of the face, and the numbercan be 40% higher or lower; higher, for example,when maximum coverage is desired (ie, MiddleEastern or East Indian men) or when donor hairsare thin in caliber (ie, more white or EuropeanHispanic men); lower, for example, when only athin amount of coverage is the goal (ie, Asianmen):

Sideburns: 250 to 350 grafts per sideMustache: 250 to 450 graftsFull goatee (including mustache): 450 to 750grafts

Cheek beard: 300 to 650 grafts per side

beard on Asian man. Note the donor site at 1 year (C)

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One of the most important keys to achieving anatural appearing result is angling the recipientsites so that the transplanted hairs grow as flatas possible to the facial skin to avoid them stickingout from the face. This goal is best achieved by theuse of the smallest possible recipient site blades(0.6 or 0.7 mm when possible; sometimes,0.8 mm, when 3-hair grafts are used), which mini-mizes the rotational movement of the grafts withhealing, thus keeping them at the intended angula-tion. It is imperative to keep the blade handle atthis shallow angle to the facial skin, especially inthe mustache, where the lip border often slightlyprotrudes because of the normal shape of the lip,which can undesirably push up on the bladehandle.Beard design varies tremendously amongst

ethnic groups, because of ethnic considerationsof masculinity as well as individual desires. ForEast Indian and Middle Eastern men, a thick beardis desired to enhance masculinity; for many men inIndia, this can improve the prospects of an ar-ranged marriage; for some Hispanic men, a thickmustache is particularly desirable; for the HassidicJew, a beard is almost essential for social accep-tance; for some Asian men, a well-defined yet notparticularly dense sideburn as well as goatee,which can extend to a narrow strap beard thatruns along the lower jawline, can provide a desiredlook, which is sported by some magazine modelsand actors.

HAIR GRAFTING TO THE EYEBROWS ANDEYELASHES

Like with beard transplantation, restoring hair tothe eyebrows depends on careful graft dissectionand then placement in the proper angulation toachieve natural appearing results. Most eyebrowtransplants are performed for women who haveoverplucked, but there are also men and womenwho have lost their eyebrows because of genetics,thyroid disease, trauma, and other causes.The procedure typically requires the transplant-

ing of primarily 1-hair, sometimes 2-hair grafts intorecipient sites, made most commonly with a0.5-mm width blade. These grafts are most oftenobtained by the FUG/strip technique, in which anincision 6 cm long can provide under microscopicdissection 600 to 750 grafts to allow for satisfac-tory filling in of the eyebrows. For patients whowish to keep their hair cut short, in particularAfrican American men, and those at risk for avisible donor site scar, such as Asian men withcoarse hair that is spiky such that it grows moreoutward than downward from the scalp, it is bestto obtain the grafts by the FUE technique. Caution

needs to be paid when dissecting down 2-hair andespecially 3-hair FUGs to obtain the more typicallydesired 1-hair and occasionally 2-hair grafts, sothat the surrounding supportive tissue is left intactto ensure hair regrowth.As with other hair transplants, those individuals

with dark straight hair with light-colored scalpsare more challenging, because the color contrastenhances the visibility of each graft and also in-creases underlying skin show, which is associatedwith the appearance of lower density. Thickstraight hair is also more challenging than hairthat is fine or curly, because it is difficult to makestraight hair lie flat and thus grow in a moreanatomic direction. Given these criteria, it can bededuced that the patients who typically achievethe most aesthetic results are those of lightcomplexion and light-colored hair, or hair that isfine, or those with dark curly hair, especially thoseof dark complexion, such as those of Africanethnicity. Although the hairs are more difficult toharvest and dissect, and the grafts require morecare in placement into recipient sites to ensurethat the native curl complements the desired di-rection of hair growth flat onto the brow skin, thesepatients can expect good results (Figs. 9 and 10).Other ethnic groups in whom results are typicallymore impressive include East Indians and someMiddle Eastern individuals of darker complexion,whereas working with many Asian patients canbe the greatest challenge (Fig. 11).

HAIRLINE LOWERING SURGERY

There are 2 techniques for advancing the overlyhigh hairline in women. The more common is hairgrafting, but the SHA technique has a definiterole, with several advantages. Also called the hair-line lowering or forehead shortening procedure,SHA involves making an incision along the hairline,then advancing the entire frontal scalp by as muchas 3 to 5 cm, excising the overlapped foreheadskin so that the hairline is now in a lower position.Endotine hooks are inserted into the frontal bone,positioned so that they engage the galea to securethe frontal scalp into its forwardly advanced posi-tion, and then, the incision is reapproximated in atrichophytic fashion so that the hairs can growthrough what is typically a fine line scar. Althoughthe procedure is most often performed under localanesthesia and oral sedation, the occasionalpatient chooses twilight sedation. If desired, abrowlift can be added, performed in the subfronta-lis muscle plane, to achieve a more youthfulappearance.Although wide undermining is performed in

the subgaleal plane back to the vertex and 2 or

Fig. 9. Before (A) and 10 months after (B) eyebrow transplant on African woman.

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3 galeotomies are made in the coronal plane tomaximize the total amount of advancement, thisprocedure is indicated for patients with a flexiblescalp that allows for sufficient advancement.Scalp laxity can be assessed by placing a fingeron the midaspect of the prospective patient’s hair-line and observing how far anteriorly and posteri-orly it can be moved, which approximates theamount of advancement that can be achieved,with each galeotomy typically adding another 2

Fig. 10. Before (A) and 18 months after (B) FUG/strip procplant, on African woman.

to 3 mm. For patients with an inflexible scalp, ifhighly motivated, a cycle of balloon tissue expan-sion of the frontal scalp over a 4-week to 6-weekperiod can allow for as much as 5 to 6 cm of addi-tional advancement.

Other indications for SHA, in addition to a suffi-ciently mobile scalp, include a stable (nonthin-ning), reasonably dense frontal hairline, bestassessed through physical examination and his-tory. Patients with an inelastic scalp or thinning

edure to advance hairline, along with eyebrow trans-

Fig. 11. Before (A) and 1 year after (B) eyebrow transplant on Asian woman.

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hairline are better candidates for hair grafting. Inaddition, for patients who desire a more roundedhairline, hair grafting has to be performed, whetheras a staged second procedure several months af-ter SHA or as a stand-alone treatment. These hairgrafts can also be transplanted into the hairline toboth soften it as well as help further conceal thefine line scar that may be visible in the occasionalpatient.

Fig. 12. Before (A) and 4 weeks after (B) SHA/forehead sh

SHA is appropriate for patients of all ethnicitiesbut seems to be particularly popular for patientsof African ethnicity. The reasons for this situationinclude the observed higher prevalence of geneti-cally large foreheads associated with high hairlinesthat would require many grafts to sufficiently lowerthe hairline to where desired, and many Africanethnicity patients having a mobile scalp that allowsfor 3 to 5 cm of advancement (Fig. 12).

ortening procedure on African woman.

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Hypertrophic or keloid scarring of the hairline inci-sion does not seem to be a problem, and hairgrafting can help conceal these fine line scars.Hair grafting in patients with dark skin (whichblends in well with the dark hairs), whether of His-panic, East Indian, or African ethnicity, usually re-sults in a fuller look, a phenomenon enhancedwith curly hair, making hair transplantation agood option to SHA. Similarly, light-colored haircoupled with fair skin color is another favorablecombination for achieving denser appearancesfrom hair grafting.

The more commonly chosen procedure toadvance the overly high hairline is hair grafting.This is a typically less surgical procedure, involvingthe transplanting of 1200 to 2400 grafts (depend-ing on how much lowering is desired) in a singleprocedure, taking 3 to 8 hours to perform (it is ameticulous procedure). Every graft is placed intotiny recipient sites (0.5–0.8 mm in size), each onemade by the surgeon; these sites then determinethe direction, pattern, and angulation of growthto ensure a natural appearance. The transplantedhairs typically fall out within 3 weeks, then startto regrow at 4 months, taking a full 10 months orlonger for final results. The hair grafting procedure

is ideal for hairlines that are thin or thinning out, forthose who want a hairline that is not only lower butalso more rounded, and for those who opt not tohave or are not good candidates for SHA. Somepatients desire a touch-up after 10 months or soto achieve greater density, but most do not needthis touch-up.

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