Recent statistics reveal that almost 90% of transgender or gender-diverse people desire hair removal with either electrolysis or laser hair removal. There are also others who seek to to increase hair density in areas such as the hairline, other areas of the scalp, beard or mustache, or eyebrows.
Having increased hair density or a different shape of the eyebrows, beard, or hair line can be an important part of gender-affirming care for many trans and non-binary individuals.
The type of procedure performed and design will depend on the individual patient goals. For instance in individuals transitioning from male to female, they may desire procedures like hairline feminization, surgical hairline lowering, eyebrow transplant, etc. In individuals transitioning from female to male, they may desire procedures like hairline masculinization, beard transplant or eyebrow transplant.
Here are some of the options and solutions that are available and some details about how they work.
Hair Concerns including Hairline Pattern and/or Thinning
As discussed above, individuals may want a procedure to change the pattern, shape, and design of their hairline. Additionally, they may or may not be experiencing hair loss such as patterned hair loss which is a common condition and can be seen more frequently in those on hormonal therapy such as testosterone therapy.
If evidence of hair loss or hair thinning is present, then it may be recommended to start therapies to help thicken the existing hair and decrease further loss. This can include treatments to block the product of dihydrotestosterone (DHT), increase blood flow to the scalp, and provide growth factors to the scalp among others. This can include options such as minoxidil, finasteride, low level light therapy (LLLT), and scalp injections. Always consult with a doctor prior to starting any therapy to see if it is appropriate in your case and to understand the risks, benefits, and alternatives. Another option is to restore the hair with surgical techniques. Often a combination is recommended.
The need for non-surgical therapies such as medications, LLLT, and scalp injections will depend on if there is hair thinning present. If no hair thinning is noted and the goal is to change the shape of the hair line, then it may be that no non-surgical treatments are recommended. If there is hair thinning, then likely non-surgical therapy will be recommended. This is because hair transplant surgery does not prevent further hair loss, thicken the existing hair, or make more hair. It moves existing hair from one area (often the back and sides) to another. Thus therapies that help to maintain the existing hair (called maintenance therapies) are often recommended along with surgery in those with evidence of hair thinning.
These maintenance therapy options include minoxidil, finasteride, LLLT, and growth factor injections for patterned hair loss or androgenetic alopecia which is the most common type of hair loss. Minoxidil works by increasing blood flow to the scalp. Finasteride blocks production of dihydrotestosterone (DHT). LLLT can increase blood flow and decrease inflammation. Scalp injections can help to either reduce inflammation or provide growth factors to the scalp and hair depending on the type of injection. There are also numerous other treatments that are recommended for other types of hair loss.
It may also be important to discuss any hair thinning with any provider prescribing any type of hormonal treatment as many hormones, especially testosterone, can have effects on the hair.
Treatments such as finasteride are especially important in individuals who may be taking testosterone or those who may be producing testosterone to help stop progressive hair loss.
Hairline Surgery for Trans Women
Many trans women desire hairline feminization. This can be achieved through scalp advancement/forehead reduction surgery and hair transplant. If an individual is considering both, then it is recommended that they have the scalp advancement/forehead reduction surgery first and then the hair transplant. This is so that during the hair transplant surgery the scar from the scalp advancement/forehead reduction surgery can also be addressed by the hair tranpslant to increase hair density through the scar.
Scalp Advancement or Forehead Reduction Surgery
Scalp advancement or forehead reduction surgery allows the hairline to be advanced without using hair grafts. This requires sufficient scalp laxity and can significantly reduce the height of the forehead.
Hair restoration surgeons, such as our surgeons at Root Hair Institute, do not perform this procedure. This procedure is often performed by plastic surgeons. If you are considering this procedure, it is important to consult with a surgeon experienced with this type of procedure.
It is important to note that this type of procedure often reduces the height of the forehead. This should be discussed with the surgeon during your consultation. One advantage of a scalp advanced/forehead reduction for many trans women is that lowering the hairline can be combined with achieving other goals such as reducing frontal bone prominence or a brow lift.
The shape of the hairline can often be changed some, but it is not uncommon for individuals (often women and trans women) who undergo this procedure to then later have a hair transplant surgery to further round the shape of the hairline and/or to help increase hair density over the resultant linear scar.
It is often recommended to allow time to pass (such as three months but check with your surgeon for your individual case) after a scalp advancement or forehead reduction before performing a hair transplant.
Follicular Unit Excision (FUE)
One type of hair transplant is FUE. The difference between FUE and the strip procedure is how the grafts are obtained. The FUE method leaves behind dot scars throughout the donor rather than a single linear scar.
There are many FUE systems. It is important to choose a surgeon who is experienced with FUE procedures. FUE technology continues to evolve so it is important to find a clinic and surgeon using state of the art technology and who is experienced performing the procedure. There are multiple considerations with FUE including decreasing transection and obtaining the highest quality grafts possible. This requires using the optimal punch size, punch type, depth, settings, etc. It is also important to avoid overly aggressive surgeries especially at a young age as your hair even in the back could thin over time and the sides/back where the hair is taken from could be “overharvested” if too aggressive of a surgery is performed or the hairs are not spaced out appropraitely. It is also important to discuss maintenance therapy options with your surgeon especially if you have hair thinning.
In some cases body or beard hair could be taken via FUE to be transplanted into another area; however, the hair does not usually match scap hair in terms of texture, thickness, curl, and other characteristics. Thus using scalp as donor is often preferred when possible.
Follicular Unit Strip Excision (FUSE)
The other type of hair transplant is a follicular unit strip excision (FUSE). In this type of hair transplant a strip of scalp is removed from the sides and back of the scalp. The strip is then dissected under the miscroscope into individual follicular units or grafts. The area where the hair was taken from is then sutured together to leave as thin of a scar as possible. This leaves behind a linear scar over the back and sides.
With both FUE and FUSE the individual follicular units (or grafts) are then placed one by one into the recipient area (where increased hair density is desired).
Hairline Design of a Feminine or Masculine Hairline
Hairline design for hairline masculinization or feminization is key. Females typically have different shapes but a more rounded hairline is more common. Male hairlines are typically more angulated especially at the “corners” or frontotemporal angles and with more pronounced temples. It is important to discuss your individual goals for your hairline design based on your face shape and preferences, so that your surgeon can create the appropriate plan for your individual case.
Eyebrows are another area that many individuals look to change the appearance of as part of their gender affirming care. Typically females have a more arched and thinner brow while males have a thicker and flatter brows. If the eyebrows are thick enough, then plucking, waxing, trimming, threading, and other forms of grooming can be used to achieve the desired shape. However in some cases there is not enough hair to achieve the desired shape, and eyebrow transplant may be considered.
It is important to understand that eyebrow transpants require regular trimming as these hairs can grow long. Either FUE or FUSE treatment can be used to obtain the hairs.
Many trans male patients have increased facial hair with hormonal therapy. Some may try medical therapies to thicken the hair such as topical or oral minoxidil. If this is something you are interested in, make sure to discuss it with your doctor.
However, some may not achieve their desired look with non-surgical therapy alone and may look to beard restoration surgery. The goal will vary by each patient, but generally, the aim is to increase hair density in certain parts of the beard, mustache, or goatee.
Experts in Hair Restoration and Hair Loss
When looking for hairline, beard or eyebrow restoration, you need personalized treatment and expert care. Make sure to consult with an experienced hair restoration surgeon if you are considering a hair transplant.
Our fellowship-trained hair restoration surgeons at Root Hair Institute (RHI) are here to serve you. RHI is located in the Greater Seattle Area and offers both FUE and strip excision hair transplant procedures for the scalp, eyebrow, and beard.
If you are interested in discussing your options and if you could be a good candidate, then schedule your consultation with Root Hair Institute today to learn more.