The recent introduction of the follicular unit excision (FUE) technique with long hair, or “preview long hair FUE,” has represented a major advance in hair transplantation. We describe a patient in whom “preview long hair FUE” was used to repair an unsatisfactory eyebrow result after three previous transplants performed with classic FUE and shaved hair.

A 30-year-old man consulted our Hair Disorders and Hair Transplantation Unit in June 2022 requesting surgical correction of an unsatisfactory result. The patient had undergone 3 hair transplants in 2015, 2017, and 2020 at another center, using the conventional FUE technique, with shaved hair, for reconstruction of cicatricial alopecia in the body of his left eyebrow secondary to an accident. Examination revealed a 2-cm tuft of hair with very thick hairs compared with the rest of the eyebrow, in addition to aberrant directions, angulations, and curvatures of the hair shafts, as well as the presence of numerous multiple follicular units (FUs) (Fig. 1). Furthermore, the implanted hair extended beyond the anatomical limits of the eyebrow, distorting its morphology. Psychological assessment of the patient showed severe impairment of his daily life, obsessive thoughts, and depressed mood. Two-stage surgical reconstruction was proposed: extraction of all implanted FUs, followed by implantation of the new FUs 6 months later using “long hair FUE.” However, the patient did not wish to have an alopecic area during this time; therefore, both procedures were performed simultaneously. This was a significant limitation: it was not possible to remove all previous FUs, because there would not have been enough space for the new incisions, since punch defects dilate within the first few hours and contract in the following days.

Fig. 1.

(A) A 2-cm tuft of hair in the body of the left eyebrow distorting its normal anatomical morphology. (B) Detail of the unnatural area, showing multiple and thick-diameter follicular units, as well as aberrant directions, angulations, and curvatures of the shafts.

Individual extraction of 90% of the unesthetic FUs was performed with a multiphasic micromotor using a 0.8-mm punch, with 100-ms rotational movements followed by 200-ms oscillation (Fig. 2A). Because the directions and angles of these hairs were incorrect, the defects created with the punch could not be used to implant the new FUs, and new incisions were made with a flatter angle, 15°, and a more natural direction. Subsequently, 180 single-hair, fine, long, uncut FUs were extracted from the supra- and retroauricular regions using only 180° oscillation movements to preserve shaft length. Finally, the FUs were inserted with blunt implanters, leaving the natural direction and angle of shaft curvature positioned over the eyebrow (Fig. 2B). One year after surgery, the patient exhibited an eyebrow with anatomical morphology, natural directions, curvatures, and shaft angles, and a natural appearance compared with the rest of the same eyebrow and the contralateral eyebrow (Fig. 3).

Fig. 2.

(A) Intraoperative image after individual extraction of 90% of the unesthetic FUs with a multiphasic micromotor using a 0.8-mm punch. The new incisions with the correct directions and angles can also be observed. (B) Immediate postoperative “preview” of the possible future final result. Due to long-hair implantation, the direction and angle of hair-shaft curvature can be determined and therefore positioned naturally.

Fig. 3.

One year after surgery, the patient has a normal-appearing left eyebrow that is symmetrical to the contralateral eyebrow.

Since its description in 2002,1 the FUE technique represented a revolution because of its novel concept of individual FU excision. However, its limitations include the need to shave the donor-area hair and, consequently, the impossibility of predicting the direction in which the curvature of the shaved hair will grow in the future. In eyebrows, this may result in a “disordered” and “ungroomed” appearance. For this reason, Pitchon2 described long-hair transplantation using the follicular unit strip surgery (FUSS), or strip, technique, which allowed “previewing” of the future final result, that is, visualization of shaft curvature, from the time of surgery.3 However, the FUSS technique leaves a residual linear scar, which is undesirable in a young male patient such as ours.

The novel surgical technique of FUE with long hair, “preview long hair FUE,”4 despite being slower and technically very complex,5 has managed to correct the limitations of the previous techniques. Compared with conventional FUE, with “long hair FUE” the hair is not cut in any area of the scalp, which facilitates return to social and working life, and the direction and growth of shaft curvature can be observed from the intraoperative period, providing a “preview” of the result.6,7 Compared with the FUSS technique with long hair, a linear scar is avoided. In addition, in the opinion of the authors of this article, the “long hair FUE” technique provides finer and more natural results than FUSS, because it allows selection of single-hair FUs with the finest shaft diameter from the scalp, specifically from the supra-retroauricular regions and the nape. These are indicated for extremely delicate areas such as the eyebrows, temporal triangles, and frontal hairlines. By contrast, the strip extracted with FUSS is centro-occipital, where FUs with a larger number of shafts are found and where each shaft is also thicker.

In conclusion, the “preview long hair FUE” technique provides additional benefits over shaved-hair FUE for achieving maximum refinement and naturalness in eyebrow transplantation.