Hair loss is a common complication of face and brow lifts, but this is rarely explained to the patients considering these procedures. Alopecia from face and brow lifts can be due to a number of factors:

• Destruction of hair from incisions not parallel to the follicles

• Destruction of hair from suturing

• Destruction of follicles from undermining

• Excessive skin tension

• Disruption of the vascular network in the skin

• Stretched scars devoid of hair

• Distortion of the normal hairline

• Decreased density from stretching the scalp

• Telogen effluvium from the trauma of the surgery

• Telogen effluvium from the anesthesia

• Acceleration of androgenetic alopecia

It is tempting to perform the hair restoration procedure soon after the face-lift. However, it is preferable to wait at least one year so that the surgical scars can mature, scalp laxity can return to normal and, most important, so any hair loss from post-surgical effluvium has had time to regrow.

A problem intrinsic to treating alopecia from face-lift procedures is that the hair may be transplanted into the same spot where future face-lift incisions will be placed. If the hair loss from the face-lift is not excessive and/or there is a question about long-term donor supply, it may be preferable to postpone the repair until after the second face-lift. This is especially important in younger patients where multiple face-lifts are anticipated. If such surgeries are anticipated, and if hair loss in the area surrounding the surgical incisions is the primary problem (rather than the scars themselves), one may place hair only in the surrounding areas of thinning and not in the actual scar. Another way to circumvent this problem is to avoid "aggressive" lifts or postpone aspects of the face-lift procedure that are more likely to result in hair loss, such as a brow lift.

A second problem arises when the signs of androgenic alopecia are not present (or if present, not taken into account) when the decision to perform a face-lift is made. In a patient with no apparent hair loss, potential androgenic alopecia may be suspected from a positive family history or the presence of miniaturization greater than 20% in the front or top of the scalp. This can be assessed using a hand-held Densitometer (see the section Low Donor Density). Miniaturization greater than 20% in the back or sides of the scalp ("the permanent zone") suggests that the patient will likely develop diffuse hair loss and, therefore, is not a good candidate for hair transplantation.

Once it has been established that a face-lift patient has little risk of significant androgenetic alopecia and the decision to perform a transplant has been made, the patient should be advised that it would take a minimum of two procedures to accomplish the restoration. The goal of the first procedure is to restore the shape of the original hairline and to add as much density as possible. Subsequent sessions should be used to add further density and, when necessary, to soften the hairline's frontal edge.

When hair loss follows a face-lift procedure, the entire frontal hairline extending down to the sideburn area often needs to be restored. In this hair transplant procedure, it is important to maintain the rounded female hairline. The hair direction in the female frontal hairline is usually more varied than the predominately-forward direction of the frontal hairline seen in males. The female hairline is often characterized by "licks" and "peaks." These should be restored for optimum results. Especially in the case of brow lifts, there may be broad areas of thinning both anterior and posterior to the coronal incision. These regions should be filled with follicular units as closely spaced as the physician is comfortable with, as transplanted hair, compared to the more dense hair directly behind it, will generally appear too thin. Once the first few millimeters of the hairline have been transplanted with smaller units, the largest follicular units should be used to achieve the greatest frontal density possible. In spite of this, it may still take multiple procedures to achieve satisfactory density.

In contrast to men, many women have fine, vellus hairs at their frontal hairline. Since donor hair is generally harvested from the mid-portion of the permanent zone, the diameter of this hair may be too great for the frontal hairline or temples. If the match is not right (a situation that is more often seen in women with darker, coarse hair) finer hair should be used. It is not recommended to use the fine hair located on the posterior scalp or behind the ears for this purpose. Scars placed below the occipital ridge will tend to stretch, and those behind the ear may interfere with further face-lifts. The preferred method of these authors for generating finer hair is to remove all or part of a terminal hair's bulb prior to implantation. This can be accomplished using a # 10 scalpel blade under a stereomicroscope. The single, split-hairs should be placed at the very frontal edge of the hairline and temples at an angle so acute that it is practically flush with the skin surface.