Longer, thicker lashes—they're what every woman wants. And now a new surgical procedure is offering women a better alternative to eyelash extensions and mascara, with permanent results. Eyelash transplantation (ET) is a breakthrough microsurgical procedure that allows patients to have healthy new long lashes that will last forever.

First developed years ago, ET has been performed primarily by hair-restoration surgeons as a reconstructive procedure to help those suffering from permanent milphosis (eyelash loss, also called madarosis) or alopecia adnata (underdevelopment of the eyelashes). For many women—and the occasional man—who have experienced permanent eyelash loss as a result of alopecia, trauma, or trichotillomania, ET has been the only reconstructive option for regaining their lost lashes, helping them restore a normal appearance and function to their eyelids.

But today, this advanced microsurgical hair-restoration procedure is finding a whole new audience among image-conscious women and the fashionable elite. It has been reported that the procedure is now being requested more often for aesthetic enhancement—to make women's eyes more beautiful—than it is for reconstructive purposes.

See also "Hair Almost Everywhere" by Jeffrey S. Epstein, MD, FACS, in the February 2007 issue of PSP.

In fact, I have observed that today only 20% of inquiring patients require reconstructive services; 80% are seeking the procedure for aesthetic enhancement—a dramatic reversal just within the past 2 years.

It's well known that more than 10 million aesthetic procedures—from abdominoplasty to botulinum toxin Type A injections—were performed in the United States in 2005, according to the American Society of Plastic Surgeons—a 38% increase over the year 2000.¹ ET may well get caught up in the rising tide of this pervasive "aesthetic wave."

According to some news media outlets, eyelash transplants are fast on their way to becoming the new "must-have" aesthetic surgery for women. Feature stories have recently appeared on Good Morning America, Access Hollywood, CNN Headline News, and Fox News programs; and in Newsweek and Reuters reports. The surgery has also become a popular news story overseas and has received ample coverage by television, radio, and online media outlets in Great Britain, Canada, South America, Australia, New Zealand, Belgium, the Netherlands, Sweden, Japan, India, Pakistan, China, and Malaysia.

With all the recent media hype surrounding eyelash transplants, patient demand is expected to rise substantially over the next few years. But this surge in demand could potentially pose a challenge to the hair-restoration industry unless more physicians learn how to safely and effectively perform ET, proactively manage long-term sequelae, and educate patients about potential complications.

What Is Eyelash Transplantation?

ET is a minimally invasive microsurgical hair-restoration procedure performed in an outpatient setting under local anesthesia. Its purpose is to permanently restore or aesthetically improve the eyelashes. The procedure enhances the eyes by adding lash density, length, and volume to eyelids that—for whatever reason—have fewer, thinner, or shorter lashes than "average."

Whereas some women may prefer a glamorous, "Hollywood-style" look with their new lashes, the typical procedure is focused on normalizing the patient's eyelids by implanting roughly 20 to 40 lashes per lid. ET is an effective alternative or adjunct to mascara and eyelash extensions, and a permanent solution for weak or missing lashes.

However, it is important for patients to realize that with this permanence comes a lifetime of responsibility. Because the new lashes are the result of hair follicles transplanted from the scalp, they will continue to grow—just like scalp hair does. As a result, the new lashes will typically need to be trimmed and curled every 4 to 6 weeks for the rest of the patient's life.

The ET procedure can transplant anywhere between 40 to 100 lashes for both eyes. The entire procedure takes 2 to 3 hours to complete, depending on the difficulty of the case.

Traditional ET² involves six fundamental steps and is usually performed by a physician with the help of one surgical assistant:

1. The donor site: To begin the procedure, the surgeon first selects and aseptically prepares a "donor" site at the back of the patient's scalp that will supply the healthy hair follicles for the transplant. As in the case of a traditional hair transplant, the surgeon then administers local anesthetic to the donor area.
   
   
2. Donor harvest: With the hair left long, a small ellipse of scalp is harvested with a scalpel and sutured closed using a trichophytic donor closure, which allows hair to grow through any resulting pencil-line thin scar.
   
   

Figure 1. Ready for transplanting: Two hair follicles are threaded through the surgical eye-needle.

Figure 2. Implanting a hair follicle into the upper eyelid.

3. Graft preparation: A surgical technician carefully dissects individual follicles from the surrounding tissue under microscopic magnification, leaving the hair shafts long.
   
   
4. Loading phase: The hair shafts are threaded through the ends of surgical eye-needles (Figure 1).
   
   
5. Implantation Technique: After appropriate surgical preparation and a safely performed local anesthetic block of the eyelid, a sewing motion is used to place the follicle into the skin of the lid—with careful attention to the appropriate lash position, direction, and curl orientation (Figure 2).
   
   The sewing technique was described by Robert Flowers, MD,³ and Marcelo Gandelman, MD,⁴ and is very different from the traditional hair transplant: The long hair (at least 10 cm, with the follicle at the end) is threaded through a curved French eye-needle, one or two at a time. Under high-powered magnification, the needle is carefully inserted superficially into the lid, approximately 6 to 10 mm from the lid margin. The needle is advanced superficially toward the lash line, exiting between any existing lashes, and leaving a "tunnel" through which the hair, and eventually the follicle, is pulled.
   
   A delicate and precise pulling technique leaves the follicle embedded in the lid with the implanted lash exiting at the correct angle, orientation, and position. After each follicle (or pair of follicles) is properly oriented and adjusted, the hair is trimmed and the process is repeated.
   
   
6. Postprocedure: The implanted lashes are trimmed slightly to help prevent accidental displacement. The patient is sent home with a neck pillow and goggles to sleep with, and instructed to return the next morning for follow-up.
   
   

Postoperative Eyelash Care

A patient may be finished with surgery, but she still has a lot to do in caring for her new lashes. Newly implanted lashes require special care and treatment, and patients should be instructed how and when to begin the gentle postoperative care and cleansing of the eyelids and lashes—as well as the scalp donor site—to minimize infection, injury, and other complications.

Most importantly, patients should be extra careful with their eyelids in the first few days after surgery. For the first 4 days, patients should wear sunglasses to protect their eyes. At night, they should wear protective goggles and use a neck pillow to prevent them from rolling over or lying face down, which could displace the implanted follicles.

Patients should regularly apply a moisturizing agent (such as shark liver oil) to their eyelids to provide a healthy environment for healing, starting 24 hours postoperatively. The donor areas should also be properly cleaned twice per day.

In addition, eye makeup (including mascara, eyeliner, and eye shadow) should be strictly avoided for 1 week. And patients should not use eyelash curlers at all for 2 weeks, or risk damaging the new lashes.

Patients should also know what to expect in the days and weeks following surgery:

• Mild swelling or bruising in the eyelid area may last up to 2 weeks.
• The absorbable stitches in the donor area may take up to 1 month to dissolve completely.
• The new lashes will typically shed in the first or second week after surgery. This is normal, because the hair follicles enter a resting phase after implantation.
• It takes about 6 weeks for the transplanted follicles to start to grow—and about 10 months before the full result can be seen.

Once the hair follicles are imbedded in the eyelids, they will grow quite long. Patients need to be fully aware of this and be prepared to trim and curl their new lashes every 4 to 6 weeks. An "eyelash perm" is also recommended for patients with straighter hair.

A Case Study

A 30-year-old Asian American patient sought evaluation and treatment for what she described as "weak" eyelashes. It was noted during her examination that her eyelashes were short, thin, and very straight—this is fairly common in Asian populations.

The patient's eyelashes detracted from her overall facial appearance and would benefit from aesthetic eyelash transplantation. The surgical plan for this patient called for a single session of eyelash transplantation.

Before & After

Figure 3. A 30-year-old Asian American patient before and immediately after implantation of 25 hair follicles in the right eyelid.

Figure 4. A 35-year-old female patient before and about 12 months after implantation of 28 hair follicles in the right eyelid.

After a comprehensive review of the risks and benefits of the procedure, the patient was prepped and administered mild oral sedation. I then selected a donor site at the occipital scalp and used a scalpel to excise a small ellipse (approximately 30 mm x 5 mm) to yield satisfactory follicles for implantation. Upon removal of the ellipse, the donor site was sutured closed using a trichophytic donor closure—a technique that diminishes the risk of visible scarring.

Next, a surgical technician dissected the individual follicles, making sure to leave the hair shafts at least 10 cm long. The surgical technician then loaded each follicle by threading the hair shafts through a French-eye surgical needle.

After the eyelids were carefully anesthetized, a sewing motion was used to carefully implant the follicles into the skin of the eyelid. For the implantation, I used two new techniques I have developed, one called "follicle-pairing"—loading two lashes per insertion—and a "puppeteering" method to provide the most accurate orientation of the curl. I paid meticulous attention to lash position and direction to ensure the most aesthetic and natural look.

Immediately following surgery, the patient's implanted lashes were trimmed to reduce the risk of injury or displacement in the short-term postoperative period.

Figure 5. Thicker, fuller eyelashes adorn the eyes of this 34-year-old female patient 3 years after she underwent aesthetic eyelash transplantation.

Overall, this patient received 23 follicle implantations into the left eyelid and 22 implants into the right eyelid (Figure 3, page 24). The single-session procedure lasted shortly under 2.5 hours.

The mild bruising and minimal swelling resolved in a matter of days. As expected, within 2 weeks of the surgery her new lashes were shed as the transplanted follicles entered a dormant phase. New growth from eyelash transplants is expected to start approximately 6 to 10 weeks after surgery. It will take up to 1 year for her to see the full final aesthetic result of her procedure.

For additional examples of eyelash transplantations, see Figure 4 (above right) and Figure 5 (at right).

Rising to New Challenges

Figure 6. A 35-year-old female patient who suffered from damaged eyelashes is shown before and about 12 months after implantation of 28 hair follicles in the right eyelid.

The growing popularity of eyelash transplants for aesthetic enhancement offers a wealth of new opportunities and challenges to plastic surgeons, cosmetic surgeons, and hair-restoration specialists. An increasing number of women will be asking their physicians about this procedure, and it is important that more physicians become qualified to perform it.

Even surgeons who do not intend to perform ET themselves should be fully cognizant of the procedure so they can dispense accurate medical advice to patients. ET is a remarkable procedure that can benefit a variety of patients, from trauma victims to middle-aged women in search of a more comprehensive antiaging solution. For trauma patients in particular, ET may be the only option for them to repair lost lashes and make strides toward regaining normal form and function (Figure 6, page 26).

Alan J. Bauman, MD, is a hair-restoration physician and the founder and medical director of the Bauman Medical Group in Boca Raton, Fla. He received his medical degree from New York Medical College and had extensive residency training in general surgery at Beth Israel Medical Center and Mount Sinai Medical Center New York City. He can be reached at (877) BAUMAN-9 or via his Web site, www.baumanmedical.com.

References

1. American Society of Plastic Surgeons. 2000/2004/2005 National plastic surgery statistics. Cosmetic and reconstructive procedure trends. Available at: www.plasticsurgery.org/media/statistics/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=17870. Accessed January 31, 2007.
   
   
2. Gandelman M, Epstein JS. Hair transplantation to the eyebrow, eyelashes, and other parts of the body. Facial Plast Surg Clin North Am. 2004;12:253–261.
   
   
3. Caputy GG, Flowers RS. The "pluck and sew" technique of individual hair follicle placement. Plast Reconstr Surg. 1994;93:615–620.
   
   
4. Gandelman M. Eyelash reconstruction. Hair Transplant Forum Int. 1996;6(5):18.
   
   

The First ISHRS Regional Eyelash-Surgery Workshop

Bauman implants a new hair follicle into the upper eyelid of a patient at the ISHRS’s first regional live eyelash-transplantation surgery workshop, October 23, 2006, in Los Angeles.

In recognition of the growing demand for eyelash transplantation (ET), the International Society of Hair Restoration Surgery (ISHRS) cohosted the first regional live eyelash-transplantation surgery workshop on October 23, 2006, near Los Angeles to educate 40 international hair-restoration surgeons in this procedure.

Marcelo Gandelman, MD, Sao Paulo, Brazil; Jennifer Martinick, MBBS, FACCS, Perth, Australia; and I demonstrated live eyelash transplantations at the educational workshop, hosted by Paul Straub, MD, of Torrance, Calif, a cofounder and past president of the ISHRS. Gandelman, in particular, was an early pioneer of ET and has helped to perpetuate and perfect the modern technique. Martinick presented a novel technique that included lower-lid eyelash implantation, which is a new concept.

Physicians from around the world attended the workshop to observe these advanced new ET techniques. Some of the physicians in attendance had some experience performing eyelash transplantation, but many had not performed a single procedure. It is expected that this newly educated group will help to expand interest in the procedure and opportunities for patients, who, up to now, have been able to turn to only a small number of surgeons.

The workshop—dubbed the "World's First Eyelash Transplant Workshop" by the news media—was covered by Good Morning America, Extra!, and Reuters, and was very well received by the US and international press. News about this event has likely exposed millions of people worldwide to what was once a relatively unknown procedure. The event also was an excellent opportunity for the ISHRS to showcase the detailed nature of its educational activities, and opened many doors for surgeons to discuss the advances in hair restoration that the ISHRS has helped spearhead in recent years.

As with any procedure that is increasing in its demand, patient selection is an important issue. During the lecture portion of the workshop, all faculty physicians addressed the pitfalls of aesthetic eyelash transplantation with regard to patients suffering from body dysmorphic disorder.

—AJB

The Eyelash-Extension Risk

Few realize it, but fake eyelash extensions can potentially pose a serious risk of permanent eyelash damage for many women. Eyelash extensions—both semipermanent and the newer, trendier synthetic extensions—are glued directly to a woman's existing eyelashes and may pose a risk of "eyelash baldness" if used improperly or too often over a long period of time.

Certain women with weaker hair follicles may be at risk for permanently losing their lashes if they use extensions too frequently. Over the years, I have personally treated several female patients who experienced significant lash loss as a result of eyelash extensions—and most required ET to correct the disfigurement.

A female patient suffers from missing eyelashes as a result of permanently damaged hair follicles in the upper eyelids.

Eyelash extensions can be problematic for some women because they can lead to "traction alopecia"—hair loss caused by physical trauma to the hair follicles. Three factors may contribute to follicle damage:

• repeatedly pulling off extensions, injuring the follicles;
• extra weight added to the lashes, increasing follicle tension; and
• solvents used to dissolve the sealant glue, potentially harming follicles and irritating the eyelids.

ET is the only effective way to correct eyelash "traction alopecia" that results from eyelash extensions.

Eyelash extensions have become more popular recently, due to the development of synthetic eyelash extensions that last up to two months and cost $300 to $500 per application.

—AJB

Recommended Reading

Barrera A. Hair Transplantation: The Art of Micrografting and Minigrafting. St Louis, Mo: Quality Medical Publishing Inc; 2002.

Gandelman M. Eyelash Reconstruction and Aesthetic Augmentation, in Hair Transplantation. Barrera A, ed. St Louis, Mo: Quality Medical Publishing Inc; 2002:168.

Hernández Zendejas G, Guerrerosantos J. Eyelash reconstruction and aesthetic augmentation with strip composite sideburn graft. Plast Reconstr Surg. 1998;101:1978–1980.

Marritt E. Transplantation of single hairs from the scalp as eyelashes. Review of the literature and a case report. J Dermatol Surg Oncol. 1980;6:271–273.

Unger WP, Shapiro R. Hair Transplantation. 4th ed. New York, NY: Marcel Dekker; 2004:580.