FUE technique with hair from the body and beard

Orentreich proved that in hair transplantation, follicles taken from androgen-independent areas of the scalp and transplanted into androgen-sensitive areas retain their original properties. He called this characteristic “donor dominance,” and it has since become an axiom of modern Dermatology.

The reverse effect—the influence of the recipient area on the transplanted follicles—was considered negligible, although no studies existed to prove this. It was therefore assumed to be negligible, both because patients who underwent hair transplantation did not lose their transplanted hair over the years, and because patients with eyebrow alopecia who had scalp follicles transplanted to the eyebrows continued to trim the transplanted eyebrow hairs, which grew longer than natural eyebrows.

The truth, however, turned out to be different!

FUE technique with body hair: A bit of history

The suspicion that the recipient area may also affect the transplanted follicles began with Norwood’s observation that the punch grafts he transplanted into the midscalp of his patients, over the years, gradually acquired the “wave” of the hair that originally existed in the midscalp area. Later, Santos et al. reported that in patients with eyebrow loss due to leprosy (madarosis) who had undergone eyebrow transplantation, the frequency of having to cut their eyebrows decreased over the years.

By monitoring 19 patients, the authors showed that in 17 of them, the growth rate of the follicles as well as the duration of the anagen phase had decreased, the diameter of the hairs had increased, and while the hair in the donor area had turned gray or white, the eyebrows retained normal pigmentation. Therefore, the follicles had acquired some of the properties of natural eyebrows, since eyebrows grow at a slower rate than scalp hair, do not grow as long, and turn gray later than scalp hair. In subsequent 3-year experiments conducted by the research group of Lee et al., the influence of the recipient area on follicles was finally confirmed. Initially, follicles from the occipital region were transplanted to the inner surface of the shin of one of the researchers. Within 6 months, it was shown that only 60.2% of the grafts survived, while the growth rate and the duration of the anagen phase decreased by -70%, since the longest hair measured 12 cm, whereas if it had remained in the scalp during the 3 years of the experiment, it would have been at least 33 cm

In contrast, the diameter of the hairs did not change. Over the course of 3 years, the same follicles that had initially been transplanted to the shin were transplanted again to the left side of the neck, and in order to have a comparative control, 24 additional follicles from the donor area of the scalp were transplanted to the right side of the neck. All the follicles survived the transfer, but on both sides the growth rate was reduced to 56% of the normal scalp follicles. That is, in the follicles from the shin, it increased by 14% compared to what it had been on the shin, while in those from the scalp it decreased by 44%, resulting in both sides of the neck having the same growth rates within 6 months. On the other hand, the diameter of the hairs was once again not affected, with the result that, although the hairs on both sides of the neck grew at the same rate as the naturally fine and short neck hairs, they nevertheless remained thicker than those.

With the experiment of Lee et al., it was proven that the recipient area ultimately affects some of the characteristics of the hairs, such as the growth rate, the duration of the anagen phase, the pigmentation, as well as their survival, while it does not affect the diameter of the hairs. Following the above experiments, it was expected that hair transplant surgeons would attempt to transplant follicles from various areas of the body to the scalp, in order to determine to what extent body hair follicles could grow there.

The first report of transferring hair follicles from the chest area to a patient’s scalp was in 1997 by Brandy, but the method used was similar to strip excision/micrograft, that is, by harvesting a strip graft from the patient’s sternum, creating micrografts–minigrafts, and implanting them into the scalp. According to Brandy, the results were excellent, with high survival and an outstanding clinical appearance. However, it is likely that Brandy did not find another patient quite so “determined,” since he never again reported a similar case.

The first to report a case of hair follicle transplantation from the body (BHT FUE technique) to a patient’s scalp, using a method similar to today’s FUE hair transplantation, were the Australians Woods and Campbell, and the “paternity” of the BHT technique rightfully belongs to them. In December 2000, they transplanted 1,200 single-hair grafts from the chest of a 65-year-old patient.

The patient’s name was Justin (he later became “famous” in online forums dedicated to hair transplantation) and he had an extensively scarred recipient area from previous artificial implants (synthetic hairs) and a completely depleted donor area. While the hairs on the patient’s chest were initially 6–7 cm long (anagen phase duration 18–27 weeks), at 22 months after the procedure, the length of the hairs was 12.5–16 cm. The changes in hair length could only be explained by the increase in the duration of the anagen phase of the grafts, a fact that required—and therefore proved—the influence of the recipient area on the physiology of the grafts

Woods et al. published the results of this particular case in a medical journal four years later (2004) and reported that the graft survival was >90% and the hairs did not differ from the patient’s natural scalp hair.

The publication by Woods and Campbell was followed by that of Hwang et al., who transplanted 9 single-hair FUs from a patient’s chest to the scalp, and 12 months later reported that the hair length was 200% greater than in the original site (56.3 mm vs 28.5 mm), the growth rate had increased by 10%, while the hair diameter had not changed. These results quickly spread among the “hungry” audience of online forums, and once again misguided information was circulated to the public—this time giving hope for a “solution” to the most important problem of hair transplantation: the finite number of available grafts in the donor area. The public was inadequately informed about a “new, revolutionary method that solves the problem of hair loss,” and from 2004 onward, every patient interested in hair implantation asks for information on the BHT FUE technique, believing it to be the solution that suits them—especially if they have many body hairs they want to “get rid of.”

In reality, however, and beyond “commercial” show-off techniques, the BHT FUE technique has very few indications and such unpredictable results that, in fact, very few patients are truly candidates to undergo it.

Technical details of the FUE technique using body hair (Body Hair Transplant)

• he overwhelming majority of body hair follicles are single-hair FUs, unlike those of the scalp where only 20% are single-hair FUs. As will be analyzed in the section “Donor area density”, the aesthetic significance of single-hair FUs is low and they cannot provide an image of cosmetic coverage on the scalp.
• Most hair follicles on the human body (outside the scalp) are in the telogen stage and therefore are not visible for extraction, while each anatomical area of the body has a different anagen/telogen ratio.
• The anagen body hair follicles have been shown to have higher survival rates than telogen ones, although telogen hair follicles are easier to extract.
• When transplanted onto the scalp, body hair follicles tend to increase their anagen phase duration and growth rate, but many life cycles are required before the hairs grow to a satisfactory length.
• Data regarding the change in hair shaft diameter of body follicles, once transplanted to the scalp, are still conflicting and one cannot rely on them to “thicken” over time.
• Body hair follicles transplanted at lower density on the scalp have higher survival rates.
• The depth at which hair follicles are embedded in each anatomical area differs both by region and by patient. In general, follicles on the lower legs are more “shallow,” while those on the back and beard are deeper.
• The quality of body hair is not the same as that of scalp hair, as the hairs are usually thinner and less “lustrous.”
• Hairs from beard follicles are the thickest, with a diameter of 0.66–0.83mm, compared to the single-hair scalp follicles which produce hairs of 0.2–0.25mm in diameter. Follicles from the chest are also quite thick but are still single-hair.
• Body hairs are mainly curved or curly and have a different tendency for pigment loss (graying) compared to scalp hairs.
• Follicles from the armpits, the outer surface of the shins, and the pubic area are the most difficult to transplant. In the shin area, the underlying bone is at very shallow depth and there is a significant risk of infection or even osteomyelitis of the bone, while the follicles are easily destroyed during extraction. The axillary (armpit) region is also risky, as the underlying lymph nodes are close to the surface and infection can easily spread in the form of lymphangitis.
• The use of Minoxidil 5% topical solution on the body donor area 6–8 weeks before the BHT session increases the percentage of anagen follicles and improves the “harvest” of intact grafts.
• Results in the recipient area can often be assessed 6 months after the follicular transplantation, but sometimes regrowth can be delayed up to 24 months.

BHT FUE Technique: The advantages of the FUE technique with body hair

• The “range” of the potential donor area increases dramatically. The male chest has a density of approx. 10–40 FUs/cm² and a hair-bearing surface of approx. 30cm × 15cm = 450cm². Therefore, 4,500–18,000 FUs can theoretically be extracted from a male chest and transferred to the scalp. Moreover, if one also calculates the follicular units from areas such as the epigastrium, arms, legs, back, and even the genital area, this number increases significantly. Some experts speculate that soon no patient will be rejected as a candidate for hair transplantation due to insufficient scalp donor area, since the entire body will represent a potential donor area.
• In the BHT FUE technique, the surgeon does not need to “pre-plan” the order in which FUs will be extracted so that the donor area does not appear “empty.” Instead, all grafts from the chosen anatomical area are simply harvested, without the need to follow a “strategic” 20–25% extraction protocol, which is fatiguing and time-consuming.
• The donor area is covered by clothing, unlike the scalp donor area, so the patient does not need to worry about his appearance, since he can easily shave the respective donor area without any social concerns.
• Many patients desire “radical hair removal” in areas such as the neck, back, and shoulders. The extraction of grafts from these areas serves a dual purpose! Especially when the donor area is the beard, the patient no longer needs to shave again.

BHT FUE Technique: The Disadvantages of Hair Transplantation with Beard and Body Hair

The Body Hair FUE technique is still in its early stages of clinical application and there are significant disadvantages. The “omnipotence” of the donor dominance theory may have been “damaged,” but we still do not know which mechanisms influence the physiology of the grafts in the recipient area—that is, whether it is vascularization, skin thickness, tissue tension, innervation, or some other parameter that differs in the scalp compared to other hair-bearing areas of the body.

• There is still no extensive experience regarding the long-term behavior and survival of BHT FUs. Cole specifically mentions that FUs from the body have a survival rate of 38–60%, while when an attempt is made to achieve high density in the recipient area with BHT FUs, survival may be as low as 5%. In 2012, Umar published a case study with 2 patients who “received” about 1000 FUs from the shins to the hairline, and after 4 years of follow-up a survival rate of 70–80% was observed. However, these results have not been confirmed by other specialists, and Cole directly disputes them.
• BHT FUE is useful only for low densities in the recipient area, and when attempts were made to achieve high density with BHT FUs (>20FUs/cm²), they failed miserably.
• Healing in donor areas of the body is slower than in the scalp, and complications such as folliculitis, ingrown hairs, and cyst formation are much more frequent than with the scalp FUE technique.
• A smaller percentage of follicles from those transplanted will ultimately grow compared to the percentage of follicles transplanted from the scalp donor area. The reasons are unknown and are not due to the surgical technique.
• The aesthetic outcome cannot be predicted, regardless of surgical skill, the number, and the quality of transplanted follicles.
• The extraction of FUs outside the scalp is clearly more difficult for the surgeon, due to ergonomics, difficulty of extraction, and skin quality—factors that are not balanced out by the fact that no “strategic” extraction of FUs is required.
• There is a lower rate of successful graft extraction per punch incision, meaning the phenomenon of capping is very frequent.

Indications for the BHT FUE technique

Very few experts worldwide successfully apply the technique of body hair transplantation BHT FUE, and even they cannot claim consistently and predictably satisfactory results in the recipient area.

For this reason, they believe that the BHT FUE technique should be considered a last resort and only under the following indications:

• Repair of scars from previous hair transplants, for which the patient does not want to “spend” FUs from the scalp or no longer has grafts available in the donor area of the scalp, due to depletion from earlier transplants.

• Improvement of density in individuals with a completely depleted scalp donor area.

• Improvement of density using follicular units from beards in individuals who have already undergone follicular unit transplantation and have very fine hairs in the scalp donor area.

• Use of single-hair and fine follicular units from the body in areas where a less dense result is required, such as the hairline, temples, eyebrows, etc.

• Transplantation in areas with scarring alopecia.

• Transplantation in other areas of the body, such as BHT from the neck to the beard, mustache, or eyebrows.

Complications of the FUE technique with body hair

Complications in the donor area during the BHT FUE technique are frequent, and not even experts can promise consistently invisible intervention in the donor area, without marks, visible thinning, and complications.

The most common complications are:

• Severe bruising and bleeding in the donor areas

• Hypopigmentation (white spotting): in some individuals hypopigmentation appears at the points where follicular units were removed

• Hyperpigmentation: a rarer phenomenon is the appearance of pigmentation in the donor area

• Ingrown hairs: a fairly common phenomenon in every body donor area

• Infections: especially in “unclean” areas such as the armpit and pubic region, but also on the chest due to slow healing.

BHT FUE Technique: Summary

The BHT FUE technique is the most modern hair transplant technique, and when it first appeared in 2005, some believed it to be the solution to the most important problem of hair transplant surgeries: the lack of sufficient grafts in the occipital donor area. In reality, however, and beyond “commercial” techniques of impression, the FUE technique with hairs from the body has very few indications and such unpredictable results that, in practice, very few patients are truly eligible to undergo it. The results are still uncertain, and the testimonies of a handful of surgeons and a few patients do not yet address the justified concerns of the medical community. Gaining experience from a larger number of surgeons, long-term follow-up of cases that underwent BHT FUE, and an evidence-based approach to the data will hopefully provide positive insights in the future.

Written by Dr. Konstantinos Anastasakis

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