I’m at thirty-one year old man with a Norwood 6 level of hair loss. I have been losing hair since I was in my late teens. I’m now interested in getting a hair transplant, but many clinics have turned me away. I have now researched body hair transplants (BHT), but I don’t know if it’s worth doing. Can you please explain the strategies and differences between body hair?
In higher grades of baldness, usually, the donor supply from the scalp is not enough to cover the total surface area of baldness with optimum density. Usually, on average, around 7000-10,000 grafts are needed to cover a grade 6/7 bald scalp, depending upon the size of the scalp.
So, if the intention is not to leave any scalp area visible as totally bald, without hair, good grafts have to be placed over the hairless area. To change the appearance from the frontal view, around 3000 grafts must be put over the front and the adjoining mid-scalp.
Sometimes it might go up to 4000 grafts if the scalp is more significant. If the temple is also to be addressed, a minimum of 400-500 grafts are needed. And the posterior side of the mid-scalp and the crown usually need close to 4000 odd grafts. And, depending upon the size of the scalp, the graft number would vary.
In our experience, even with the best donor quality hair, we should not go beyond 5000 grafts in the first sitting, which we do over two consecutive days in our office.
We typically use the rest of the grafts from the beard and give a graded density from front to back, and do not leave any area untouched if the patient desires to cover every bald area and, of course, the grafts in the scalp and beard are good enough.
So, on average, in grade 6/7, we end up using 3000-4000 beard grafts to address the demand.
Why Beard Hair is the Best Hair Next To Scalp Hair
Beard hair is the second best after scalp hair. The Anagen/Telogen phase of the hair cycle of beard hair is close to scalp hair. The rest of the body hairs have different durations of hair cycle stages. And most of these body hair, other than the beard, is unpredictable, and they might not show up after the transplantation. And most of the body hair also does not attain the length that beard hair can grow up to.
Growth Rate and Yield of Beard Hair Transplantation
The growth rate of beard hair after transplantation also varies widely. In some, the grafts go through the expected post-transplant telogen phase, and the new hair grows after a few months, along with the scalp hair. After one month, the planted grafts grow directly without shedding the hair shaft! In some, the resting phase goes for many months after the telogen phase, and the hair does not show up for a very long period. But once all the hair, scalp and beard, have grown to a particular length, they can be managed to be of a particular hairstyle cut to be of uniform length.
Strategy Body Hair Transplant
Whenever we get a higher grade of the bald scalp or which can potentially go to a higher grade of baldness, we strategize utilizing the donor hair and recipient coverage with a futuristic approach. So, we develop the plan of using close to 3000-4000 odd beard grafts in advance grades of baldness. This approach saves the scalp donor from being over-extracted. It covers the total area with optimum density (good enough so that the scalp is not visible), which are the main objectives of hair transplantation for the patients.
Methodology Body Hair Transplant
Usually, beard hair texture is different than scalp hair, and it would be wiry, kinky, and hard. (However, in a few subjects, the texture of the scalp and beard hair match a lot.)
We never put the beard hair on the frontal area and temples for the above reason of texture mismatch. Also, we do not put the beard hair in isolation, even over the mid-scalp or crown, lest they stand out and have a “brushy” look.
We typically don’t place the beard grafts over the frontal 2 inches. And after that, we keep mixing scalp and beard grafts 1:1 so that the beard grafts give strength, darkness, volume and hold the thin and slender scalp hair. And the scalp hair gives a softer texture to the overall hair mass. One more critical aspect of beard hair is the texture of the side locks.
The hair over the sidelocks is very close to the scalp hair, and to a large extent, they do match in quality. In some, we treat this hair as scalp hair. Like the scalp, if strategically planned, up to 40-50% grafts can be extracted from the beard for use. The alternate extraction of the beard hair would allow the patients to flaunt a full-fledged beard after the first round of extraction. This is very routine in our hands, and the experienced teams will never leave any visible ugly scar on the face.
We also try to take the hair evenly from the total beard area. If the total number of grafts required is less than 1000, we restrict the extraction to below the chin. The beard grafts towards the neck are different characteristics than the grafts over the chin, cheek, sidelocks, angle of the mandible. They are more acutely placed, and since the skin over the neck is lax, more skill is required to extract them without handling them much. Mostly the beard grafts contain a single follicle. However, there could be more than one hair in graft in very few. And this is seen around the angle of the mandible.
Be Careful! Beard Hair Transplants
Avoid taking hair from a linear line for beard hair transplants (BHT). The upper margin of the extraction should be feathered out, leaving behind no demarcation line. In pigmented skin, the hypo-pigmented dots of extraction marks can be prominent. So, tremendous experience is required to avoid these cosmetic complications. Though these shade mismatches improve with time, a neophyte physician should not try to extract an overzealous number of grafts from the pigmented skin. There could be post-inflammatory hyperpigmentation (PIH) in some cases.
Yet again, this is common in pigmented skin. Mostly the extraction site wounds heal without many visible sequelae. All the patients should go for photoprotection of the face for a few weeks post-procedure. This UV protection also ensures the decreased chances of development of PIH. The authors use 0.7-0.75 mm sharp (sometimes surrounded) steel punches to extract the beard grafts.
The combination of 1) the right amount of tumescence, 2) traction over the skin, 3) angle of engagement of the punch, and 4) enough scoring into the proper depth (the learning curve is very, very stiff) is needed to be able to extract the beard grafts well. Just because one knows how to extract the grafts, they should not jump to extract the beard grafts. The patient might end up having permanent catastrophic damage on the face.
Those patients with higher grades of baldness usually have a great beard inversely as a blessing in disguise. The authors manage to address these NW 6/7 cases with a strategy of using beard hair and scalp hair. With the experience of using body hair over more than 3000 patients, the authors have gone up to 16,500 grafts (10,000 plus grafts are routine for the higher grades) to cover the bald scalp. Beard is an excellent resource of grafts if the science of embryology, hair cycle, physiology, and anatomy is understood well. And a tremendous skill is needed to use these grafts to cover the larger hairless area.
MD (AIIMS, New Delhi)
Professor Hair Transplantation
Co-editor of “Step by Step Hair Transplantation” book
Co-author of scientific publication of “Direct Hair Transplantation: a modified FUE technique” in 2013