Any physician who transplants hair should be an expert in hairline construction.
While we can create a naturally shaped hairline in one session, it is often
necessary to adjust the shape and position in future sessions to meet the
patient’s desires. The cardinal sin is to placethe hairline too low. If the hairline is
higher than the final result, it can still appear natural. The patient can contemplate
the hairline position after one session has matured and if desired it can easily be
lowered in the future. In the majority of my patients some adjusting of hairline
density and location during the second session is necessary not because it is
unnatural but because it can be improved.
The distance between my index and little fingers (four fingerbreaths) is 8cm. Although
this distance has served me well over the years in preventing the creation of hairlines
that are too low, the shape of the patient’s existing hairline and face dictates the distance
above a line connecting the eyebrows. I still have natural hairs in my hairline 5cm above
my eyebrows. Transplants have been placed 6cm above my eyebrows and my hairline
looks natural. Although the 8cm. distance is a good guideline, we must be flexible and let
the patient’s features guide the location and shape of the hairline.
Although the shape of patients’ skulls differs and a horizontal hairline can be appropriate,
I seldom create a horizontal hairline as it appears too bowl shaped. In almost all cases
point A (center of the forehead) is inferior (lower) than point B (temples). This
configuration mimics more closely a mature and timeless hairline. Again we should be
flexible and let the patient’s features guide the shape.
I have never had a patient ask to have a cowlick remade. If fact I’ve often thought that
the only advantage to losing hair is losing a cowlick. The aberrant angulation of the hair
shaft that creates the cowlick presents permanent styling problems. Angling transplants
in the hairline posteriorly (backwards) would recreate a cowlick. With significant hair loss
the superior silhouette, top, of a person assumes the shape of the skull, spherical. This
spherical silhouette causes those men with extensive hair loss to have a similar
appearance, losing some individuality of appearance. Changing this silhouette by that
formed with transplanted hair precludes the spherical shape. Without the play of vertical
against horizontal, there can be no experience of three dimensional space. The exit
angle of the transplanted hair determines the new silhouette. The exit angle varies
throughout the scalp. In the frontal half it normally varies between 30 degrees and 60
degrees anteriorly (forward). Infrequently, in those with natural “bangs”, the exit angle is
less than 30 degrees. If the new angulationis greater than 60 degreesthe patient can
appear to have a “frightened” or unnaturally high new silhouette. As hair volume is lost,
especially in the frontal half of the scalp, prior to assuming a spherical shape, the area
first appears flattened. Angling hair shafts posteriorly (backwards) in the frontal half of
the scalp, when surrounding shafts emerge angled at 30 degrees to 60 degrees
anteriorly (forward), contributes to a flattened appearance. If indigenous hair is present
in the area it is usually safe to mimic this angle with transplanted hair, except when a
cowlick is present.
Patients, especially younger ones, request the hairline to be curved at the corners
(temples) but I resist this temptation is the vast majority of patients. Curving at the
temples can create an unnatural, animal like, appearance. Again, the patients’facial
features should guide hairline configuration.
It is important to create a density gradient at the interface or transition zone from skin to
hairline. To guide me to create a density gradient and soft transitionzone, three parallel
lines separated by 4-5mm each are used. The first zone is the absolute interface and
beginning of the transition zone. This zone contains elongated triangles of single hairs
with low density (10-15 hairs/sq.cm). In the second zone the single hairs are
symmetrically placed with higher density (25-35 hairs/sq.cm). The third zone contains
two hair follicular units, symmetrically spaced, as densely as possible (40-60
hairs/sq.cm). In one session it is difficult to achieve density greater than 60 hairs/sq.cm.
This method allows me to create a natural density gradient in one session. It is often
necessary to increase the density at future sessions.
There is equal distance between follicular bundles, creating a pattern with equal spacing.
Aside from the transition zone at the interface of hair and skin where true randomness is
natural, I take great pains to create small spaces that are equal in size in each tonal
plane. Light reflects with greater intensity from curvilinear surfaces. The location on the
scalp where the hairline is placed is the transition from horizontal to vertical, a curvilinear
surface, or tonal planethat reflects light with greater intensity than flat surfaces.
In our palette we not only have grafts but also spaces between grafts to create the
overall impression. Light reflection from the scalp determines the perception of hair loss
and can be affected in a variety of ways by altering the scalp surface color/texture or
ambient light intensity. We choose to use hair as a natural way of obstructing light
reflection from the scalp. Light reflects from these spaces and if the spaces are small the
light reflection will be less than that from larger spaces. If the spaces are equal in size,
the light reflection will be evenly diffused re-creating the natural symmetrical reflective
The hairline, more than any region of the scalp, defines the result in hair restoration. It is
the signature of the surgeon and becomes that of the patient. Recreating a natural
appearing hairline requires observation, experience, and artistic foresight. If we classify
ourselves as artists we would be photorealists as we attempt to imitate nature. The
hairline can appear as abstract expressionism if we attempt to express ourselves on the
scalp in a manner unlike nature. In painting, sculpture, and architecture the materials
used are inert. We construct a dynamic result with three dimensions when transplanting
growing hair, which requires anticipation. When creating a hairline it is more important to
not get it wrong the first time than to get it finished in one session.