Int. J. Oral Maxillofac. Surg.

2004; 33: 504–508

doi:10.1016/j.ijom.2003.11.003, available online at http://www.sciencedirect.com

Technical Note
Reconstruction
A. Vachiramon1, B. Aghabeigi2,
Eyebrow reconstruction using St-John Crean3
1
2
Private Practice, Bangkok, Thailand;
Department of Oral and Maxillofacial

composite graft and Surgery, Eastman Dental Institute, London,

UK; 3Department of Oral and Maxillofacial
Surgery, University Hospital of Wales,

microsurgical transplant Cardiff, UK

A. Vachiramon, B. Aghabeigi, St-John Crean:Eyebrow reconstruction using

composite graft and microsurgical transplant. Int. J. Oral Maxillofac. Surg. 2004;
33: 504–508. # 2004 International Association of Oral and Maxillofacial
Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. The pivotal role that eyebrows play in facial expression and aesthetics is
widely accepted, along with the difficulties faced by surgeons in reconstructing
defects in this area.The case study presented demonstrates reconstruction of a
traumatic eyebrow defect using a post-auricular composite graft in combination Key words: eyebrow; hair follicle; composite
graft; microsurgery; micrograft; hair
with a microfollicular hair transplant technique. The advantage of the combined transplantation.
approach is discussed with reference to the fine tuning of the adjoining areas
between reconstructed and undamaged hair-bearing regions. The advantages of Accepted for publication 6 November 2003
this technique in control of the direction of hair growth and preservation of hair
density are emphasised. Available online 6 February 2004

The eyebrows play an important role Case report and the wound consisted of loss of hair,
in conveying human emotions such as skin and subcutaneous tissue. In sections,
anger, sadness, happiness and surprise. A 17-year-old boy presented to the A&E the orbicularis occuli muscle was visible.
Loss of eyebrow, partial or complete, department of the Royal Free Hospital, The wound was meticulously cleaned
may produce varying degrees of facial London. He had been involved in a road with normal saline and all foreign mate-
disfigurement, easily recognised by traffic accident and had sustained an rial removed. Arrangements were then
onlookers, much to the annoyance of the avulsion wound of his right eyebrow, made for the patient to be treated under
sufferer. Although female patients are having hit his head on the car dash- endotracheal anesthesia. The patient was
prepared to sacrifice eyebrow tissue for board, snagging his eyebrow on the consented for a post-auricular skin graft
the sake of fashion, males on the whole manufacturer’s badge. and microfollicular transplant.
prefer their eyebrows thick and full. For He was assessed by the A&E staff Under endotracheal anesthesia, the
all patients suffering eyebrow loss, sur- under the advanced trauma life support margins of the wound were excised to
geons should focus on the disturbance protocol, during which he maintained a leave a symmetrical four-sided defect.
in facial symmetry, as well as have a Glasgow coma scale of 15 and displayed The dimensions of the excised areas
clear understanding of the complex no other signs of life threatening injury. were measured using a tin foil template.
anatomy of the eyebrow with respect At this stage, he was referred to the The template was then transposed to
to hair quality, density and growth pat- maxillofacial surgeons. the right post-auricular hair bearing area
tern. On examination, both clinically and and used to provide the dimensions of
Many techniques have been described radiographically, no facial skeletal frac- a composite hair bearing skin graft
in the literature. However, we would tures were noted. The only obvious (Fig. 2). This was performed by dissec-
like to present the first reported case of external injury was a 1:5 cm
2:5 cm tion through the fibro-fatty layers of the
a combination of composite hair skin avulsion injury of the middle third portion scalp down to the galea. This ensured
grafts and microfollicular hair transplant of the right eyebrow (Fig. 1A and B). The complete and safe elevation of the hair
techniques. margins were noted to be very irregular follicles. The composite graft (Fig. 3)
0901-5027/050504 + 05 $30.00/0 # 2004 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
 Eyebrow reconstruction using a combination technique 505

Discussion

Loss of eyebrow is easily recognised

due to the resultant disturbance in facial
expression and aesthetics7. All maxillo-
facial surgeons dealing with loss of this
region must appreciate the complexities
of the tissue, e.g., the hair of an eye-
brow is thinner, has complicated direc-
tional changes, has an acute angle
between the skin and hair shaft, a smal-
ler diameter, slower growth, as well as
changes in orientation. Many reconstruc-
tive methods have been described, which
include:
Punch hair graft, a technique used to
reconstruct regions of the eyebrow where
skin integrity is maintained and multiple
stages are often required. Micrografts
of 1–2 mm are sutured into the recipient
site created by a stab incision. Uneven
skin surface results have often been
reported with this technique16,25.
Scalp grafts have been used for many
years, but suffer from poor rates of suc-
cess because of the subcutaneous posi-
tion of the hair follicles21. Burn and
explosive injuries often require compo-
site grafts17. Large skin and hair defects
have been repaired using combined
composite, e.g., post-auricular, grafts
initially proposed by LONGACRE et al.15.
These grafts are hampered by the risks
of necrosis and hyper pigmentation has
been reported in Caucasians. However,
as in this case, the composite post-auri-
cular scalp graft has been used with
great success over the years and has
Fig. 1. (A) and (B) Photographs demonstrating the right eyebrow defect. been advocated by surgeons interested
in the field26. One advantage of the
post-auricular site (donor site) especially
was then transferred onto the eyebrow recipient skin in the direction of the hair in males, is the possibility that the hair
defect and fixed into position with 6/0 transplant. The needle was then rotated in this region does not respond to hor-
prolene suture. The donor site was until sufficient space was available to monal changes unlike areas on the
closed primarily after triangular excision implant the transplant under loupe mag- crown of the scalp.
of the superior and inferior margins. nification, using microsurgical jeweler The delayed peninsular scalp flap15,18,
A strip of excess donor tissue was iso- forceps, following which, the needle was is a procedure which requires a three
lated from the composite graft prior to removed. The process was repeated until stage operation. Bi-pedicled scalp flaps
final suturing. The hair follicles, with sufficient hair coverage was achieved. In are useful in bilateral eyebrow recon-
some attached tissues, were dissected total, 25 hairs were transplanted medi- struction, but hair direction is much
from the graft material with the aid of ally and laterally, making a total of 50 harder to match22. Scalp flaps inevitably
6
magnifying eye loupes (Fig. 4). Dur- hair follicles. The operating time for require multi-stage procedures, and often
ing dissection of the follicles, excision microsurgical follicular hair transplant deemed excessive for partial eyebrow
was made along the long axis of the hair was 60 min. At completion of the proce- reconstruction.
in order to preserve the hair follicles dure, the transplanted hairs were dressed An answer to this problem is provided
underneath. The dissected hair follicles with vaseline gauze (Tullegras) and the by the superficial temporal artery and
were then transplanted to the borders of patient was woken. Post-operatively, vein scalp flap. This can be used with or
the composite graft to improve transition instructions were given to leave the without a cutaneous pedicle, which would
from graft to normal hair. At this stage dressing in situ for 2 weeks, and a 5 day obviously necessitate a second procedure
(Fig. 5) the direction of the eyebrow course of oral Augmentin was pre- for pedicle division. This flap is more
hair could be matched exactly with the scribed. The patient was regularly technically demanding as it requires care-
surrounding undamaged tissue. Trans- reviewed. On review at 6 months, a very ful dissection of the vessels and tunneling
plantation was performed using a gauge satisfactory result had been obtained to the recipient site, making every effort
16 needle, which was used to pierce the (Fig. 6). to avoid vessel injury6,24.
506 Vachiramon et al.

the anastamosed pedicle and advanced

into the recipient site. Good results have
been reported although the authors do
recommend that no flap harvesting
should be performed before 2 weeks.
Another method described is the par-
ieto-temporal fascial flap, originally
reported in 1919 by ESSER8. The flap can
be raised with an island of hair bearing
skin and advanced into areas of major
periorbital and malar defects to repair
not only eyebrow tissue, but surrounding
soft tissues as well19.
One method not described in any
detail in the maxillofacial literature, is
the use of microfollicular hair transplant.
This technique has been in use since the
1980s, but has been more contempora-
rily described by BERNSTEIN et al.2 and
RASSMAN and CARSON20. The micrograft-
ing technique has been shown to be an
improvement over larger micrografts,
although when originally introduced by
FUGITA for scalp transplantation9, it
received criticism for (a) producing thin
Fig. 2. Post-auricular graft donor site with tin foil template.
hair, (b) inconsistent graft growth, (c) a
need to transplant extra skin into a wider
Numerous authors have, however, advancement flaps with Burrow’s trian- recipient area. To improve the aes-
advocated that the optimal hair for gles4. thetics, hair density and growth control,
replacement of the eyebrow is the eye- HYAKUSOKU10 described a secondary BERNSTEIN et al. have recommended fol-
brow hair itself and various VY vascularised hair bearing island flap licular implantation2. In our case study,
advancement flaps from within the eye- which involved harvesting of the inferior the transplants used had either one or
brow body have been described3,11. The epigastric artery and accompanying ves- two follicles in situ, and the small phy-
advantage of these procedures is that sels, anastamosing them microvascularly siologic implants could be implanted
they are single staged and can be per- to the superficial temporal vessels and with very small needles with minimal
formed as an outpatient procedures. burying the unanastamosed ends into the inter-follicular tissue. This allows for a
More recently, a ZZ rhombic technique post-auricular subcutaneous tissues. greater density of hair transplant per unit
has been described4,5. Other localised After a period of about 2–3 weeks a area of defect. It is also felt that such
eyebrow techniques include transverse post-auricular graft is raised, based upon wounds heal faster. Even micrografts
containing 2–3 hairs may carry with
them unnecessary intervening tissue,
inevitably reducing the density of trans-
planted hairs. Surgeons should be aware
that if microfollicular grafts containing 2
or 3 hairs are difficult to further dissect
they should resist from doing so as
further growth could be compromised. It
is imperative to maintain all germinative
and support structures of each hair folli-
cular unit. The germinative center of
the hair follicle lies along the region of
the follicle, extending from the sebac-
eous glands to the dermal papillae12,13.
Other elements of the follicular unit
are required however, for maximum
growth23. It is imperative to maintain the
whole structure as a biological unit and
thus the optimal surgical methods for har-
vesting and dissecting follicular units is
to use the stereoscopically assisted micro-
scope or high magnification loupes, as in
this case14.
Follicular transplantation relies on
Fig. 3. Post-auricular composite graft demonstrating the germinative center dissection. the fact that hair grows from scalp in
 Eyebrow reconstruction using a combination technique 507

well-organised groups called follicular

units, containing between one or four
terminal hairs2. This allows surgeons to
remove large quantities of hairs to
mimic hair patterns of many varieties.
When grafting eyebrows in small target
areas of hair in the medial portion, sur-
geons must be concerned about the
upward direction of natural hair growth.
Mid and lateral brow follicles grow with
central convergence in a flat direction
almost parallel to the skin. In addition,
surgeons must inform patients treated in
this manner that unlike natural eye-
brows, transplanted hair tends to grow
and require gentle trimming periodi-
cally1.
This case has demonstrated the excel-
lent results that can be obtained in the
Fig. 4. Follicular units dissected from composite graft. reconstruction of difficult defects such
as eyebrow loss. Combining traditional
composite scalp grafting with microsur-
gical follicular hair transplanting techni-
ques allows for the fine control needed
to reconstruct this complicated region.
We would advocate this technique
which not only gives satisfactory surgi-
cal outcome, will not unduly delay the
surgical anesthetic time.
In conclusion, the repair of eyebrow
defects using post-auricular grafts has
been previously described, but the use
of microsurgical hair follicular transplant
to adjunct the grafted region is reported
here for the first time. Whereas the bulk
of hair can be replaced by a standard
composite graft, the adjoining regions
between graft and natural hair demand
the fine control available with micro-
grafting. Before attempting such surgical
techniques however, the surgeon must
be familiar with the hair follicular unit.
Fig. 5. Follicular units transplanted into the transitional region between the post-auricular Any compromise of this principle will
composite graft and the natural eyebrow. inevitably result in failure of the micro-
surgical transplant.

Acknowledgments. We would like to thank

Ferdinand Duarte for his help with the
photographs and Alison Elmes for her help
in the preparation of this document.

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