- Best Results12 months+
- Treatment Recovery7 days
- Procedure Time2 hours
- Skin SpecialistDavin Lim
- Duration of ResultsVariable
- Back to Work1-2 days
Frontal Fibrosing Alopecia - Eyebrow Transplantation
FUE eyebrow transplantation has transformed how we manage this condition. The procedure involves transferring single units of hair follicles from the unaffected back scalp to the eyebrows. The success rate is good, however patients should be mindful of recurrence & progression over time.
FactsFacts On FFA & Eyebrow Hair Transplants
- FFA or frontal fibrosing alopecia frequently affects the eyebrows
- Eyebrow hair loss occurs early in this condition. Regrowth is highly unlikely
- Hair transplantation gives good results for the first few years following FUE
- Long term studies show that there is a steady decline in follicles after several years
- Newer pulsed medical therapies can, in theory, preserve hair follicles post transplantation
- FUE is not performed unless remission is longer than 2 years
What is FFA or lichen planopilaris?
FFA or frontal fibrosing alopecia is a variant of lichen planopilaris. This entity was first described by a famous Australian pathologist, Dr Kossard from Sydney. This is a common disorder. Though we don’t know exactly why it happens we know that-
- Women are more susceptible
- It occurs in mid to elderly patients, most commonly post menopausal
- There has been a genetic link to FFA
- It involves the frontal scalp & eyebrows
- Though progressive, hair loss generally is confined to the ‘frontal’ areas
Who is a good candidate for FFA hair transplantation?
The consensus is that frontal fibrosing alopecia should be dormant or in remission for at least 2 years before consideration of hair transplantation. This applies to both eyebrows & scalp transplantation.
Remission can be defined in several ways, most importantly no inflammation in the eyebrows, frontal & temporal area of the scalp. Serial photography will confirm remission. Additionally, there will be an absence of physical signs such as perifollicular scaling, redness & casts (your medical dermatologist will examine & guide you). Additionally, clinical symptoms such as itch will be absent.
What is involved in eyebrow transplantation?
Eyebrow FUE involves taking hair from the back part of the scalp & transferring it to the eyebrows.
In the context of FFA, the harvesting technique is strip FUE. This means we only take a 1-2 cm area of follicular units without the need for shaving the scalp. I only take single follicular units as this gives a more natural appearance to the brows. Once harvested, the single follicular units are placed on chilled saline gauzes awaiting transplantation.
The eyebrow is designed, & recipient sites are angled accordingly. I then place the harvested single units one by one into the area.
Where are the hairs harvested from?
Healthy hairs are harvested from the back of the head known as the occipital scalp. This area is usually free from inflammation that destroys the hair follicles.
Before any transplantation, a close dermatologic examination is required to exclude inflammation. In some cases, a scalp biopsy is performed to exclude microscopic inflammation.
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How is eyebrow FUE hair transplantation different from scalp?
The design & harvesting of hair follicular units are different for eyebrow transplantation.
The medial & lateral brows (either ends of the eyebrow) contain one follicular unit. This gives a more natural look. One to two follicular units are used in the body of the brow. Additionally, the angle of placement is more acute.
The donor site for females is the posterior occiput of the scalp, whilst in males, body & beard hair is frequently used.
How many hair follicles are transplanted in one sitting?
Between 160 to 300 units (predominantly single units). Frontal & temporal scalp requires 1200 to 1800 units (single, double).
How long does it take to perform eyebrow transplantation?
FUE eyebrow transplantation takes 1 to 3 hours to perform, depending on the number of grafts. On average 160 to 300 single follicular units are transplanted for the brows.
How long will it take before hair grows?
4-6 months with best results taking 10-12 months. There is an initial ‘hair fall’ stage followed by regrowth.
Will I need to be on medications following eyebrow FUE?
Ideally yes, as this gives the highest rate of graft survival. You should be followed up by a medical dermatologist for possible oral medications.
I prescribe topicals including calcineurin inhibitors & or pulsed CS therapy post surgery. These are continued for at least one year.
What is the success rate following eyebrow FUE transplantation in FFA?
The success rate of eyebrow FUE for FFA is high, approximately 80% at one year. New data however has shown that follicular dropout usually occurs post 24 months. The challenge is to find ways to maintain hair growth in these areas (pulsed CS/tacrolimus/PRP/ LLLT/ Thulium lasers).
In the context of scalp FUE for FFA, the long-term survival rates are more promising, approximately 87% at one year, 60% at three years, & 50% at 5 years.
Will I require maintenance to keep eyebrow length?
Yes. As eyebrows are harvested from the back of your scalp, you will require trimming every 10 to 16 days. The transplanted hair follicles mimic the healthy follicles from the donor site.
Will creams and lotions help with eyebrow & scalp regeneration?
There is a dearth of research & reports of topicals for eyebrow & scalp hair regrowth for FFA patients. Your dermatologist will guide you accordingly. Some combinations include-
- Minoxidil 5%- 7%
- Minoxidil + Finasteride 0.1- 0.25%
- Oral minoxidil
- Anti-inflammatory topials including CS, tacrolimus, pimecrolimus *
- Reports of other topicals that contain caffeine, papain, & others
*Medical therapy is the mainstay for active inflammatory FFA. This is supervised by your medical dermatologist.
Can PRP help regrow hair?
PRP can be adjunctive therapy for FFA, however the long term benefits are still unknown. In the context of eyebrow growth there are no significant studies. Regardless, this is a banal procedure & can be adjunctive to medical & surgical intervention.
Can lasers be used to treat hair loss in frontal fibrosing alopecia?
Yes, there are reports of thulium 1927 lasers as well as fractional CO2 lasers helping retain & in some cases, grow hair in FFA.
Lasers do not regrow hair to the point of regaining your previous frontal hairline, however they can give a documented improvement in overall hair counts. Laser research is still relatively recent, more studies will be out in the near future.
Can Low Level Laser devices work?
Much like higher power lasers, devices in the 600 to 1050 nm spectrum can help slow down the progression of FFA. Ideally these devices are combined with medical therapy.
Who to see for medical management of FFA?
A medical dermatologist is your first port of call. They can diagnose your condition. In some cases they may take a skin biopsy to confirm or exclude FFA. Dermatologists can also prescribe medications including topical CS, tacrolimus or start you on systemic agents.
I am a procedural dermatologist, namely my job role is to provide input with the suitability for FUE eyebrow transplantation of the eyebrows & scalp. I will liaise with your medical dermatologist as to your progress post procedure. Ideally you should be on medication to halt the progression of FFA.
Why is this treatment partially covered by Medicare?
Medicare subsidies follicular unit hair transplantation for medical causes of hair loss. This includes FFA & other inflammatory conditions. A partial rebate applies.
*FUE hair transplantation is not claimable if you have male/female patterned hair loss.
Davin’s Viewpoint on FFA & eyebrow transplantation
FFA is very common. It is a form of LPP or lichen planopilaris. This condition is more common in women, rarely seen in men. Eyebrow loss is one of the first clinical signs, followed by hair loss in the frontal scalp.
We now have data regarding follicular unit extraction follow ups spanning 5 years (in the context of scalp hair). Studies show good uptake at 12 months, with a steady decline of follicles thereafter. We are now undertaking methods to preserve follicles using pulsed topicals. This can potentially improve graft survival rates.
Do not consider FUE if you are not compliant with topical & or systemic medication (as guided by your dermatologist). It’s akin to an organ transplant without immunosuppressive agents (chances are it will fail). Eyebrow transplantation should only be considered if your FFA is stable, with a remission rate of longer than 2 years.
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