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Received: 11 October 2019    Accepted: 18 November 2019

DOI: 10.1111/jocd.13242

ORIGINAL CONTRIBUTION

Clinical outcomes and technical tips for eyebrow restoration

using single-follicular-unit hair transplantation: A case series
review

Wenjie Jiang PhD  | Meng Wang PhD | Bo Wang BS

Hair Transplantation Center, Plastic Surgery

Hospital, Chinese Academy of Medical
Sciences & Peking Union Medical College,
Beijing, China
Correspondence
Wenjie Jiang, No. 33 Badachu, Shijingshan
District, Beijing 100144, China.
Email: jwj2019@126.com
Abstract
Background: Clinical outcomes of eyebrow restoration with single-follicular-unit hair
transplantation largely depend on the surgeon's anatomic knowledge, experience,
and technical skills.
Aims: To evaluate the effect of the reconstruction with single follicular unit trans-
plantation on eyebrow loss and provide technical tips.
Patients and Methods: A total of 352 patients with eyebrow loss were recruited. A
template of the restoration region was modeled or specifically designed. The scalp
strips from the back occipital or retro-auricular regions were harvested for single fol-
licular unit hair. The follicles were transplanted by punching recipient area with 21-G
syringe needle. Patients were followed up every 2 months for 4 years after surgery.
Results: Out of 352, 320 (91%) patients had their transplanted hair grow well with
satisfactory direction and appearance. Seventeen patients (5%) experienced encryp-
tion transplantation of a sparse hair for the first 6 months but felt satisfied afterward.
Twelve (3%) patients did a simple make-up on the transplanted hair because there
was an obvious difference between the transplanted hair and the natural one. Three
(1%) patients with burned injury suffered of mild folliculitis and cured by 75% alcohol
inunction. All patients had no obvious scar at the donor sites.
Conclusion: Single follicular transplantation for eyebrow loss resulted in natural res-
torations with excellent satisfaction. The technique is simple, safe, and effective. The
usage of syringe needle, microscope slide forceps, and a magnifier could implant the
hair in a right angle, desired direction and depth, and increase the survival rate.

KEYWORDS

eyebrow, hair Follicle, transplantation

1 |  I NTRO D U C TI O N well-established treatment for eyebrow loss. However, clinical

Eyebrow loss resulting from trauma, burn, surgery, or inappro-
priate eyebrow trimming is a common problem that surgeons
deal with in clinical practice. As an important facial-appearance
mark, the lack of eyebrows usually brings psychological burden
and pressure to patients. Hair transplantation has become a
outcomes of eyebrow restoration with single-follicular-unit hair
transplantation largely depend on the surgeon's anatomic knowl-
edge, clinical experience, and technical skills. This report presents
the clinical results of 352 patients with eyebrow loss successfully
reconstructed with hair transplantation and provides technical
tips.

J Cosmet Dermatol. 2019;00:1–4. wileyonlinelibrary.com/journal/jocd© 2019 Wiley Periodicals, Inc.     1 |

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2       JIANG et al.
2 |  PATI E NT S A N D M E TH O DS
2.1 | Clinical data
A total of 166 men and 186 women, involving 517 eyebrow defects,
were recruited in this study. Among them, 131 (37%) patients had
eyebrow loss due to eyebrow-shaping operations or munsu, 73
(21%) due to injuries, 31 (9%) due to tumor or mole surgeries, and
24 (7%) due to poor eyebrow contouring or congenitally sparse eye-
brows. The age of the patients ranged from 5 to 62 years (mean age:
35.2 years). A total of 165 (47%) patients had bilateral eyebrow loss,
and 187 (53%) patients had unilateral eyebrow loss. Seven (2%) pa-
tients underwent skin grafting in the superciliary arch area, and 15
(4%) patients were provided a skin flap or an expanded skin flap.
All procedures performed in studies involving human participants
were in accordance with the ethical standards of the institutional
and Medical Ethics Review Board of the Plastic Surgery Hospital,
Chinese Academy of Medical Sciences (ZX201913) and with the
1964 Helsinki declaration and its later amendments or comparable
ethical standards. Informed consent was obtained from each patient.
2.2 | Eyebrow design
For bilateral eyebrow loss, the position, length, and width of the eye-
brows and the position of the eyebrow ridges were designed using
the template auxiliary system based on the aesthetic principle of
eyebrows (Figure 1A & C, left). The shape and length of unilateral
eyebrow loss were designed by mimicking the contralateral eyebrow,
and the planting area was labeled using methylene blue (Figure 1B,
left). The area of hair transplantation was carefully outlined using
methylene blue and fixed with 2% iodine after consulting the pa-
tient. For partial eyebrow losses, the transplantation areas were de-
signed to match the shape of the original eyebrow (Figure 1D).
2.3 | Graft preparation
Hair follicles were extracted as grafts by harvesting a scalp strip
from the occipital region near the end of hairline or at the hairline
of the retro-auricular area, when a large amount of graft needed.
Single hair follicles can also be extracted from the occipital area near
the end of the hairline or at the hairline of the retro-auricular re-
gion using micropunches-based follicular unit extraction (FUE) and
an automated device with the inner diameter of 0.6-0.8 mm, if only
a small part of the eyebrow needs restoring. The number of trans-
planted hair follicles was estimated based on the shape of the eye-
brow outlined preoperatively and original density of the eyebrow.
The hair shafts in the donor area were shaved to 1 cm in length. The
surgical procedure was performed in the prone position. The donor
area was infiltrated and locally anesthetized with a solution of 0.5%
lidocaine and epinephrine in the ratio of 1:100 000. The excision
site was sutured using a single layer of 3-0 nylon thread. The scalp
strips or micropunches were excised as single follicular units under
stereomicroscopy and stored in sterile saline at 4℃.
2.4 | Hair implantation
The recipient area was labeled using methylene blue and anesthe-
tized using a local subcutaneous infiltration of 1% lidocaine. The de-
fect area was punched to make holes in the subcutaneous superficial
layer using a 21- or 22-G syringe (Figure 1A), and the hair follicle
shafts were clamped using microscope slide forceps and inserted in
the same direction and angle as the natural hair growth at a density
of 30 U/cm2 for bilateral eyebrow defects and for men with thicker
hair. The hair shafts were cut to 0.5 cm after the transplantation.
2.5 | Postoperative care
Hair was washed with a neutral shampoo on the 3rd postoperative
day, followed by one wash every day. The original living habits could
be completely restored after 3 postoperative weeks. The stitches
were removed on the 14th postoperative day. Transplanted hair
grew with some hair loss, which was normal, without a need for spe-
cial treatments. Patients could trim the eyebrows with small scissors
every 1 or 2 weeks.
3 | R E S U LT S
We implanted 352 patients with single hair follicles of 7-600 U.
Patients with scalp strip surgery and incision suture healed in 10-14
postoperative days, while patients treated using the FUE approach
recovered in 3 days. Patients were followed up every 2 months for
4 years. Out of the 352 patients, 320 (91%) experienced good growth
of transplanted hair with satisfactory direction and appearance
(Figure 1B, C & D, right). Seventeen (5%) patients underwent encryp-
tion transplantation of sparse hair for 6 postoperative months and
were subsequently satisfied with the eyebrow restoration. Twelve
(3%) patients applied a simple make-up on the transplanted hair, as
there was an obvious difference between the transplanted and natu-
ral hair. Three (1%) patients with burned tissues suffered from mild
folliculitis and were cured using 75% alcohol inunction. No patient
had an obvious scar at the donor site.
4 | D I S CU S S I O N
Approaches to restore the eyebrow such as scalp island skin flap,
free skin graft, and local transfer of the lateral eyebrow tissue flap1-3
are gradually being replaced by hair transplantation because of their
obvious disadvantages in clinical practice.4,5 Hair transplantation for
restoration of eyebrows can be planned and performed based on the
defect size, shape, directions, and density of the recipient site, with
JIANG et al. |
      3

F I G U R E 1   Eyebrow restoration using

single-follicular-unit hair transplantation.
(A) Clamping hair shaft using microscope
slide forceps and punching in the
subcutaneous superficial layer using a
21-G syringe for hair implantation; (B) A
26-year-old man with partial eyebrow
loss after autogenous fat injection in the
eyebrow and frontal region for semifacial
atrophy performed a year ago (left). His
eyebrow was restored by implanting
215 U of follicles on the right side after
21 postoperative months (right); (C) A
32-year-old woman with bilateral eyebrow
loss and scars in the eyebrow region due
to facial burn, 3 years ago (left). Eyebrows
were designed using a template and
contoured using methylene blue. Her
eyebrows were restored by implanting
200 U of follicles on each side, after 12
postoperative days (right); (D) A 42-year-
old woman with a poor eyebrow shape
due to inappropriate eyebrow trimming
(left). Her eyebrows were restored by
implanting 100 U of follicles on each side,
after 8 postoperative months (right)

sufficient blood supply. In addition, the transplanted hair can grow
in designed directions and resemble those of the natural eyebrows.
Therefore, autologous hair transplantation has become prevalent
in the reconstruction of eyebrows.6-8 In this case series review, we
summarized some aspects of hair transplantation including selec-
tions of donor and recipient areas and provided technical tips for
hair implantation.
We chose the donor area with similar diameter, color, and ra-
dian of hair as those of the natural eyebrows. Although temporal
hair resembles eyebrows better than the standard donor area (SDA)
hair does, the lower occipital region of SDA was chosen as a donor
site to prevent scars. Retro-auricular regions and other parts of the
body could be chosen as the donor area, but FUE from these re-
gions would also generate undesirable scars.9-12 There are many
punching devices such as the Choi drilling machine and implanting
needle for recipient site preparation.13,14 Although these commonly
used approaches can improve implantation speed, we preferred a
21- or 22-G syringe, as we only transplanted a small amount of hair.
Based on our experience, reconstruction of complete eyebrows
mostly requires an average of 200 grafts for women and 300 grafts
for most men. In addition, a needle with a different diameter can
be chosen based on the diameter of hair and can be manually bent
with ease to implant hair at a controlled angle, direction, and depth
using a head magnifier. In contrast, neither a drilling machine nor
an implanting needle can be bent as desired. Further, application of
microscope slide forceps can protect the follicles from damage and
help transplanted hair grow. The grafts should be transplanted to re-
semble the natural features of eyebrows to enable growth of differ-
ent length and density in different areas and avoid a dull or unnatural
pattern of reconstructed eyebrow.
The patients with post-traumatic injury could be divided into 3
categories: scar skin, free grafting skin, and skin flap or expanded
skin flap. The scars in the eyebrow could be categorized as super-
ficial, hypertrophic, or atrophic. The soft tissue of the superficial
scar can be subjected to the same reconstruction of eyebrows as the
normal skin, 6 months after wound healing. However, hypertrophic
scars make the transplanted hair difficult to survive. In such cases,
the hard texture of the scar needs to be excised and replaced with
a skin flap, and the eyebrow reconstruction could be performed
6 months later, after the grafted soft skin has healed. For most pa-
tients with atrophic scars, hair can be implanted with a tough texture
and loose base, but for those with “stick” scars, eyebrow reconstruc-
tion can be performed after excising the atrophic scar and replacing
the skin using a skin flap transfer.15,16
For patients with the superciliary arch area subjected to skin
grafting, the recipient area is characterized by thin soft tissue
and relaxed skin. In such cases, the grafts easily rebound and are
tightly fixed in the incision area, when a low density of hair is first
implanted, and the eyebrow can be re-transplanted after 6 post-
operative months. For patients whose superciliary arch area was
repaired using a flap or an expanded skin flap, the recipient area
is characterized by a thick and elastic but loose skin. Therefore,
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4       JIANG et al.
the angle of needle insertion needs to be as small as possible for
the skin to not retract and the hair to not be implanted at an un-
wanted angle. For patients with conspicuous shift and many resi-
dues of eyebrows, eyebrow implantation should be performed after
surgical correction. When the shift is not obvious or the eyebrow
residues are fewer, eyebrow contour is designed using the routine
procedure. Eyebrow shape can be improved by trimming the re-
maining eyebrows. For patients with dermatochalasis of upper eye-
lid after eyebrow embroidery, eyebrow reconstruction should be
performed 6 months later, after excising the eyebrow tattoo site.
Eyebrow embroidery is often performed using a variety of pigments
that are difficult to completely remove using laser surgery. In such
cases, eyebrow reconstruction can be directly performed, without
removal of the pigments, as the pigmentation can be hidden in the
implanted eyebrow.
In conclusion, this study demonstrated that single follicular
transplantation for eyebrow loss resulted in natural restorations
with excellent satisfaction. Our technique is simple, safe, and effec-
tive. The usage of syringe needle, microscope slide forceps, and a
magnifier could help the implanted hair grow in a right angle, desired
direction and depth, and increase the survival rate.
AC K N OW L E D G M E N T S
The authors declare that they have no conflict of interest.
ORCID
Wenjie Jiang  https://orcid.org/0000-0002-7856-6544
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How to cite this article: Jiang W, Wang M, Wang B. Clinical
outcomes and technical tips for eyebrow restoration using
single-follicular-unit hair transplantation: A case series
review. J Cosmet Dermatol. 2019;00:1–4. https​://doi.
org/10.1111/jocd.13242​