Eyelash Transplantation: Who, Why and How

Eyelashes have an anatomical function of shielding the eye from injury-for example, from dust and grit. Because eyelashes are found throughout the animal kingdom, this protective function presumably has been genetically conserved because it has value.

For modern humans, the eye protection afforded by eyelashes continues to be important, but another principal function of eyelashes is ornamental. They frame the eyes, and together with eyebrows, hairline, cheek bones, nose, lips and chin create the facial appearance that is unique to every individual.

The absence of eyelashes removes one of the salient anatomical features associated with normal facial appearance. A person without eyelashes has an abnormal appearance-that is, lacking one of the important anatomical landmarks of facial normality.

Absence of eyelashes has a number of causes (see Eyelash Surgery for more information) :

  • Physical trauma-facial injury and scarring due to traumatic events such as automobile accidents, industrial accidents, chemical and thermal burns, eyelid tattoos, and traction alopecia associated with long-term use of false eyelashes;
  • Surgical and medical treatments-surgical treatment of injury or tumor that results in removal or eyelash follicles and tissue scarring; radiotherapy or chemotherapy for cancer that results in hair loss;
  • Trichotillomania-compulsive hair plucking of scalp hair, eyebrows and eyelashes, other body hair: and,
  • Congenital atrichia-congenital absence of hair on all parts of the body.

The ornamental value of eyelashes is subject to fashion trends that decrees what "look" is preferred in any given era and culture. Cosmetic aids can enhance eyelash length and color and give the appearance of greater eyelash density when fashion dictates that these are preferred features.

As the availability and success of eyelash transplant procedures becomes better known, more people (more likely women than men) are considering the surgical approach to gain permanent enhancement of eyelash length and density. Eyelash transplantation for esthetic facial enhancement is a relatively recent development; initial use of the procedure was to reconstructively correct loss of eyelashes, and some recognized authorities in eyelash transplantation believe it should continue to be reserved for medically necessary eyelash replacement.

Who Is a Good Candidate for Eyelash Transplantation?
Selection of patients for eyelash transplantation can be considered under two categories:

1. Reconstructive-eyelash transplantation to correct eyelash loss due to trauma or disease. Patients with total absence of hair due to congenital atrichia are not candidates for eyelash replacement as they have no source of donor hair to use as transplantation grafts; the patient with congenital atrichia is a candidate for eyelash prostheses that are fastened to the eyelid with adhesive.

2. Esthetic-eyelash transplantation to achieve an esthetic enhancement of existing eyelashes.

Reconstructive Eyelash Transplantation
In patients whose eyelash loss is due to trauma or disease, factors that the physician hair restoration specialist will consider include (1) biological capacity of injured tissue to be a functional host for transplanted hair and follicles, and (2) existence of an adequate supply of donor hair of the quality needed for eyelash transplantation.

In patients whose eyelash loss is due to systemic or local disease, factors that must be considered include:

  • Course of the disease to date-that is, if the disease is active or in remission, and
  • Medications taken to manage the disease.

If the disease responsible for hair loss is active, eyelash transplant procedures should not be undertaken. If the disease is in remission, it must remain in remission for a specified period of time before transplantation is considered. Remission without recurrence for at least two years is a common requirement.

In patients whose eyelash loss is due to compulsive hair plucking (trichotillomania), eyelash replacement should not be undertaken until the condition is demonstrably under control. The physician hair restoration specialist may consult with the patient's primary care physician and mental health provider (psychiatrist and/or therapist) to determine if or when the patient may be a qualified candidate for eyelash transplantation. A prospective patient may deny his/her compulsive hair plucking, even when there is clear evidence to the contrary-e.g., plucked-out bald spots and broken lashes. The underlying psychopathology of trichotillomania is not entirely clear (it may be a form of Obsessive-Compulsive Disorder); its value to the patient appears to be the relief of overwhelming tension.

In some patients with extensive eyelid tissue damage, eyelash transplantation may not be possible until eyelid tissue reconstruction has been successfully performed.

Eyelid surgery should be performed by a physician with training and experience in surgical techniques and extensive knowledge of eyelid anatomy. The eyelid is a tissue of great complexity.

Anatomy of the Eyelids
Eyelashes are part of a complex eyelid structure of skin, muscles, and glands that secrete tears and oil. Soft skin is the outermost layer. It is skin uniquely different from skin on any other part of the body, and it is easily damaged by physical trauma, chemical or thermal burns, or surgical error. Beneath the skin lie the muscles of the eyelids. The muscles of the upper eyelids are responsible for opening and closing the lids; their actions are synergistically coordinated by signals from the nervous system in the normal, healthy person.

Glands of the eyelids include:

  • Lacrimal glands that secrete the fluid known as "tears". A lacrimal gland produces about 1 milliliter of tear fluid daily under normal circumstances; the amount may increase with emotional stress (grief, joy, etc.), physical or chemical irritation, use of certain drugs, or abnormal conditions of the eye and lids. Tear fluid production may be decreased by medical conditions and medications affecting the lacrimal glands;
  • Accessory lacrimal glands that secrete oily substances that mix with tears to form a protective layer over the eye; and,
  • A "pump and drain" system that washes the entire eye with the glandular secretions, and carries away the fluids and any foreign material they washed from the eye. The innermost tissue of the eyelid is the conjunctiva, the membranous layer that is in contact with the eyeball. Infection/inflammation of this layer is the condition called conjunctivitis; recurrent conjunctivitis should be investigated for its cause, and appropriately treated.

Cancer can arise in upper or lower eyelids; any unexplained lesion on an eyelid should be examined by a physician knowledgeable about diseases of the eyelid. Eyelash transplantation should not be performed until the lesion has been removed and diagnosed. The lesion commonly known as a "stye" is an inflammation of one of the accessory lacrimal glands.

Esthetic Eyelash Transplantation
When eyelash transplantation is performed for esthetic enhancement, the patient's rationale is usually to gain greater eyelash density (adding eyelashes to the eyelid among existing eyelashes), or eyelash length (grafting hairs into the eyelid that have the capacity to grow longer than existing eyelashes). The patient's wishes for esthetic enhancement must be discussed in detail with the physician hair restoration specialist. The physician will determine what esthetic enhancement can be reasonably anticipated, and the physician and patient must agree on a desirable outcome of the surgery. Physicians who believe that eyelash transplantation should be performed only in cases of medical necessity will usually not accept patients for esthetic eyelash transplantation.

The physician may, in some instances, determine that eyelash transplantation is not justified, or is contraindicated for an individual patient. For example:

  • An anticipated, very limited esthetic enhancement does not justify the cost, time and discomfort of the procedure for the patient.
  • The likelihood that the patient manifests Body Dysmorphic Disorder, a condition in which the patient has a distorted view of his/her appearance. They are unduly preoccupied with their appearance and repeatedly seek to "improve" themselves with esthetic surgery. The typical patient with Body Dysmorphic Disorder has no remarkable esthetic deficits to the objective observer, but they feel they do have significant deficits. The possible presence of Body Dysmorphic Disorder may be revealed by routine screening questionnaires and during consultation with the physician. The physician may insist upon consultation with a psychologist or psychiatrist to (1) determine whether Body Dysmorphic Disorder is present, and (2) to differentiate the patient with Body Dysmorphic Disorder from the patient who seeks frequent "tweaking up" by esthetic surgery.

Body Dysmorphic Disorder
Body Dysmorphic Disorder (BDD) is recognized as a psychiatric condition identified as a somatoform disorder (a psychogenic illness exhibiting symptoms resembling physical disease). It also has features associated with Obsessive-Compulsive Disorder (OCD). The person with BDD frequently has symptoms of major depression and substantial impairment of quality of life. Focus on a minor or imagined defect in his/her appearance may preoccupy the person and markedly interfere with ability to form personal relationships or hold a job. If the "defect" is corrected by esthetic surgery, another "defect" will quickly be discovered. The person with BDD may repeatedly seek esthetic surgery, and may have had multiple esthetic surgery procedures.

  • Eyelash transplantation is contraindicated by a medical condition such as aberrant eyelash growth, recurrent entropion (see below), "bulging" eyes due to hyperthyroidism or keratoconus, and undiagnosed recurrent conjunctivitis. Conditions such as hyperthyroidism and recurrent conjunctivitis should be medically investigated and treated.
  • A prospective patient has a history of keloid or hypertrophic scar formation at sites of surgery or injury.

Physical Examination and Medical History
Every person being considered for eyelash transplantation must have a complete physical examination and laboratory tests if indicated, and must provide a detailed medical history. A patient must be physically able to tolerate local anesthesia, surgery and postoperative recovery. The physician hair restoration specialist may consult with the patient's primary care physician regarding any potentially serious risk factors such as poorly controlled diabetes, poorly controlled hypertension (high blood pressure), cardiac arrhythmias or congestive heart failure. The patient's ophthalmologist may be consulted prior to surgery if the patient has a history of eye or eyelid disease.

Patient/Physician Consultation and Agreement
Before eyelash transplantation, the patient and physician must agree regarding:

  • The patient's full understanding of the procedure, including possible complications and postoperative recovery;
  • The anticipated outcome (esthetic enhancement), including understanding that eyelash transplantation can achieve significant esthetic improvement but cannot achieve completely "natural" results associated with natural eyelashes (for example, it is often necessary for the patient to use an eyelash curler and to trim eyelashes for the life of the transplant) ; and,
  • Cost of the procedure and follow-up visits. In the U.S., a cost of $5,000 to $10,000 is a common range.

The patient may also ask the physician for credentials demonstrating adequate training in eyelash transplantation in addition to training in hair restoration surgery. The physician should understand eyelash anatomy and esthetics, and have training and experience in methods of donor hair harvest and eyelash graft placement.

Preoperative Preparation
Every surgical procedure requires preoperative preparation. The most important of these for eyelash transplantation are designed to limit bleeding during and after surgery and to prevent infection:

"For 5 to 7 days before surgery (1) halt intake of anticoagulant drugs such as aspirin and warfarin (Coumadin), and do not resume intake until advised by the physician, (2) stop intake of vitamin E supplements, (3) stop drinking alcoholic beverages, (4) use an antiseptic soap for facial cleansing, and (5) take a course of preventive antibiotics if prescribed by the physician.

The Techniques of Eyelash Transplantation

Donor Hair
The purpose of hair transplantation is to take grafts of "living" hairs and their follicles from a donor area and move them to a hairless recipient area where they will continue to grow. Donor hair transplanted to the eyelid must match the quality of eyelashes as much as possible. The transplanted hair will continue to grow in the eyelid; as it grows, the patient may have to follow a regular regimen of curling the transplanted hair to the "curl" of natural eyelashes, and trim the growing hair to maintain it at the length of eyelashes.

Donor hair used for eyelash transplantation is taken from a donor area selected for the recipient location-in the case of eyelashes smaller, finer hairs are best. Donor areas commonly used include the nape of the neck or the area of the scalp above or behind the ears. A common donor technique is to harvest a small strip of donor hair from the back of the scalp; single donor hairs or follicular units (the natural grouping of hair follicles that form the natural growth pattern of scalp hair) may be dissected from the strip for transplantation. Hairs taken from the eyebrows and legs are also used in eyelash transplantation. When eyebrow hair is used, a composite free graft strip from the eyebrow may be inserted along the eyelid border.

A Brief History of Eyelash Transplantation
The documented history of eyelash transplantation begins about 90 years ago. Dr. Franz Krusius, a German physician, published in 1914 his technique for reconstruction of lost eyelashes by harvesting scalp hair with a small punch and transplanting donor hair into the eyelid with a needle that he designed. A version of the Krusius needle is still used today. Also still in use today is a version of a technique published by German physician Dr. P. Knapp in 1917, inserting into the eyelid border a composite free graft strip from the eyebrow. Papers published from the 1930s through the 1950s, many from Japan, continued to advance techniques of eyelash reconstruction.

In 1980, Emmanuel Marritt, MD, a member of the International Society of Hair Restoration Surgery, published his technique for transplantation of single donor hairs from the scalp into the eyelid for eyelash reconstruction. In the same year of 1980, Robert Flowers, MD, reported a "pluck and sew" technique of eyelash reconstruction that is in use today in revised version by physician hair restoration specialists (a revised version was described by Marcelo Gandelman, MD, in the standard textbook "Hair Transplantation", Second Edition, edited by Walter Unger, MD).

Eyelash harvest/transplantation techniques described earlier and still in use today include:

  • Strip grafts from eyebrows,
  • Donor strips from scalp, from which donor follicles are obtained,
  • Strip composite sideburn grafts,
  • Pedicled flaps from eyebrows,
  • Follicular units harvested from donor area and inserted in the eyelid with a needle,
  • Use of automated needles,
  • Reverse follicular unit harvested grafts using long hair, an
  • d
  • Reverse follicular unit harvested grafts using short hair.

Transplantation Technique
Eyelash transplantation is performed under local anesthesia with the patient awake. Mild sedation is often used to help the patient relax.Care must be taken to protect the patient's eyes during the procedure. The eyelids may be held steady by a special instrument that prevents the natural blink reflex from occurring during the procedure. An eyeball protector may be used to prevent damage to the eye.

A common technique is to use a surgical needle to puncture the eyelid at the margin, where a hair and its follicle are to be transplanted. The hair graft is placed into the eyelid at the puncture point. Grafts are carefully placed for proper spacing and to prevent trichiasis (turning in of the hair against the eyeball). The number of hairs transplanted in each eyelid is sufficient to accomplish the desired result (the normal upper eyelid contains about 100 lashes, the lower eyelid about 60 lashes). Interspersion of a few hairs among existing hairs can appreciably increase the appearance of eyelash density. In reconstructive eyelash surgery, placement of about 20 hairs can create an appearance of normality. Transplantation of as few as six hairs in a physically injured, badly scarred eyelid can create an acceptable "natural" appearance. In the hands of some surgeons, recent advances in eyelash transplantation allow the transplantation of as many as 60 hairs per eyelid in a single session.

An eyelash transplantation session is typically performed in one to three hours. Depending on technique and individual patient characteristics, a desirable result may be achieved in one, two or three sessions. The number of sessions is highly dependent on patient characteristics, desired result, and the surgical technique.

Postoperative Recovery and Care
Pruritus (moderate to intense itching) of the eyelids frequently occurs immediately after surgery and may persist for one or more days. Persistent itching beyond one day may indicate a postoperative complication that requires the physician's attention. Itching should be differentiated from discomfort; discomfort beyond one day is normal. Because scratching of the eyelids will easily dislodge transplanted hairs, itching should be relieved as much as possible by ophthalmic ointments, mild analgesics such as acetaminophen (Tylenol), and ice packs. The patient is urged to wear goggles while sleeping to prevent inadvertent eyelid scratching. Some physicians recommend keeping the eyes bandaged for the first 24 postoperative hours. Anticoagulant drugs such as aspirin and warfarin should not be resumed until risk for postoperative bleeding is minimal. About 7 to 14 days is required for complete postoperative recovery.

Transplanted hairs may begin to grow immediately or soon after transplantation. If inserted at a critical angle, transplanted lashes will grow outward and away from the eye in the manner of natural lashes; otherwise, they must be "trained" to behave as eyelashes. Typical training includes coating the new eyelashes with lash oil and using an eyelash curler to encourage proper curl. The new lashes also must be trimmed regularly to proper length.

Potential Complications
Complications of eyelash transplant procedures can include:

  • Eyelid infection; rapid recognition and treatment is essential to prevent spread of infection to the eye and adjoining tissue;
  • Bruising and swelling in the operated area, common to any type of surgery;
  • Graft displacement caused when the patient scratches itchy eyelids;
  • Ingrown hair grafts, usually remedied easily by the physician;
  • Ectropion-eversion and downward pull of the lower eyelid, causing the eyelid to fall away from the eye; may be caused by surgical trauma, scarring or chronic dermatitis that causes skin retraction;
  • Entropion-a turning in of the upper or lower eyelid margin; may be caused by surgical trauma and scarring. Trichiasis (turning in of the eyelashes against the eyeball) may be associated with entropion; and,
  • Poor placement or poor quality of eyelash grafts due to (1) use of coarse hair as grafts, or (2) placement of grafts that fails to achieve the desired esthetic result.

Medical Treatment for Eyelash Enhancement?
A class of drugs known as prostaglandin analogues have engaged interest for their potential use a medical approach to eyelash enhancement. The best known of these drugs is latanoprost, currently administered in eyedrops to treat the increased eyeball pressure of glaucoma. Ophthalmologists noted that latanoprost stimulated growth of existing eyelashes and darkened the eyelashes of treated patients. The drug does not stimulate growth of new eyelashes.

Eyelash growth and darkening is a side effect in glaucoma patients. The effect has been studied by dermatologists and hair restoration specialists as a possible medical approach to increasing the appearance of greater eyelash density. Investigators who studied hair regrowth in animals after latanoprost application suggested that the drug be evaluated as a treatment for androgenetic alopecia (hereditary male-pattern and female-pattern hair loss).

When applied to the eye in eyedrops, latanoprost and similar prostaglandin analogues increase the outflow of aqueous fluid from the eye, an effect that reduces the intraocular pressure characteristic of glaucoma. Side effects include blurred vision, eyelid inflammation, permanently darkened eyelashes, thickening of the eyelashes, permanent darkening of the iris of the eye, and a temporary burning sensation.

The use of prostaglandin analogues for reasons other than glaucoma treatment has not been thoroughly investigated. Their use for eyelash enhancement should be approached with great caution


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