Facial hair restoration using long hair follicular unit extraction – A case of beard to moustache transplantation

INTRODUCTION

Facial hair plays a crucial role in defining an individual’s aesthetic and cultural identity. For patients with facial scars, especially in the moustache region, reconstruction is both a technical and artistic endeavor. The mental impact made by scars is often disproportionate to the size of the scar, emphasizing the importance of reconstruction in scarring alopecia cases.^1,2 Long hair follicular unit extraction (FUE) offers the advantage of immediate visualization of the transplant outcome by utilizing intact hair shafts during the procedure. Despite its extensive use on the scalp in the recent past,^3-7 the application of this technique in moustache reconstruction remains unexplored. This report presents a successful case of moustache reconstruction using long hair FUE with beard hair as the donor source, overcoming the unique challenges posed by this approach.

CASE REPORT

A 32-year-old male presented with a 2 cm × 0.5 cm scar in the central moustache region resulting from a prior cleft lip repair surgery. The absence of hair in this area significantly affected his appearance and self-esteem. The patient sought a surgical solution to restore natural hair density and esthetics to the scarred region.

The pre-operative evaluation included a detailed medical history, physical examination, and assessment of both the donor and recipient areas. The lower neck beard was selected as the donor site, given its compatibility with the moustache in terms of hair texture. Informed consent was obtained, and the patient was thoroughly educated about the procedure, its risks, and the expected outcomes.

Surgical technique

For complete surgical technique, readers are requested to refer to Video 1.

Video 1:

Video 1:Overview of moustache reconstruction using the long hair follicular unit extraction technique.

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Donor hair harvesting

Infiltration with local anesthesia was done in both the donor and recipient areas with a mixture of 2% lignocaine with adrenaline with 0.5% bupivacaine and normal saline in a 1:1:1 ratio.⁸ Beard hair extraction was performed using the Zeus U-Graft system with an 18-G punch, chosen for its precision in addressing the acute angulation and thicker shafts of beard hair. The Zeus U-Graft system performs the extraction of individual hair follicles through a precise three-phase process: The first phase involves an incision of the epidermis to create an entry point, the second phase advances the punch through the dermal plane and releases the follicle by cutting the arrector pili muscle, and the third phase entails minimal dissection of perifollicular tissue. In this case, we utilized the parameters as depicted in Figure 1.

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Figure 1:

Parameters of all three phases of extraction used during beard long hair follicular unit extraction.

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Phase 1: Low-torque, wide-amplitude oscillations enabled the punch to glide smoothly along the hair shaft, thereby minimizing the risk of transection.

Phase 2: Increased oscillation amplitude facilitated tissue dissection as the loose dermal tissue permitted the hair shaft to retract from the advancing punch.

Phase 3: Minimal dissection of peri-follicular tissue was performed to ensure follicular integrity and reduce trauma. A total of 12 follicular units were harvested with their intact shafts without any partial or complete transection of grafts [Video 1].

Results

Surgery concluded successful implantation of grafts. Antibiotic cream was applied to the donor area, and a dressing was applied. The patient reported minimal discomfort postoperatively, and no adverse events were observed. Follow-up was done on the 3^rd day postoperatively and at 2 weeks. Both the donor and recipient areas showed satisfactory healing, as can be seen in Figure 2. The patient expressed high satisfaction with the outcome.

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Figure 2:

The upper image depicts the baseline appearance of the patient, highlighting the scar in the moustache region resulting from a cleft lip repair. The lower image illustrates the results at 2-week post-procedure, demonstrating significant improvement in hair coverage and integration in the treated area.

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DISCUSSION

This case demonstrates the practicality and effectiveness of using long-hair FUE for moustache reconstruction, offering a viable solution for addressing facial scars. A key advantage of the long hair FUE approach is its ability to bypass the need for shaving the donor and recipient areas, a requirement in conventional FUE.¹⁷ This is particularly important in facial hair restoration and/ or where a small number of grafts need to be extracted, where preserving the surrounding hair provides better immediate esthetic outcomes and avoids additional psychological distress for the patient and social downtime due to shaving.

The unique technical challenges associated with harvesting beard hair, such as its acute emergence angles and thicker shaft diameter, were effectively managed using the phased extraction technique of the Zeus U-Graft system.

In addition, the use of PRP and liposomal ATP as adjunctive measures in this procedure provided potential benefits in graft retention and reduced effluvium. While authors are conducting further studies to standardize the use of these interventions, their incorporation in this case appears to support the overall success of the procedure.

This report represents the first documented case of moustache reconstruction using long hair FUE with beard hair, adding a novel application to the existing body of hair transplantation literature. This case establishes a foundation for future investigations into the broader applications of long hair FUE and its role in complex facial hair reconstruction scenarios.

CONCLUSION

Moustache reconstruction using long-hair FUE with beard hair represents a promising technique for addressing facial scarring and restoring natural aesthetics. The use of long beard hair follicles, combined with supportive biostimulatory measures, can prove as a revolutionary approach in delivering early results. Further studies are warranted to standardize this approach and explore its broader applications in facial hair restoration.