Creating a natural hairline is one of the most important elements of a successful hair transplant. This article discusses the key skills needed to design a natural hairline. These are locating borders of the hairline as well as understanding and being able to mimic the visual characteristics of a hairline. Methods to locate the major borders and how to adjust them based on donor/recipient ratio are discussed. The visual characteristics of different hairline zones are described as well as techniques to recreate these characteristics using follicular unit grafting.
Key points
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Do not make the hairline too low.
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Do not flatten or totally fill in the frontal temporal angle.
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The frontal temporal angle lies and remains on the lateral epicanthal line as hair loss progresses.
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Take future hair loss into consideration when planning the hairline.
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The frontal hairline consists of micro-irregularity and macro-irregularity.
Introduction
Creating a natural hairline is one of the most important elements of a successful hair transplant and many excellent reviews have been written on the subject. Patients expect and deserve undetectable hairlines. We are better equipped now to create hairlines that meet this high expectation ( Fig. 1 A, B ). In part, this is a result of the exclusive use of follicular unit (FU) grafts in the hairline region. FU grafts have given us a finer paintbrush with which to create a hairline. Equally important has been a better understanding and recognition of the visual characteristics that make up a normal hairline. Simply using FU grafts without a deliberate attempt to reproduce these characteristics does not guarantee naturalness ( Fig. 2 A, B ).
In other words, to create the most natural looking hairline, we cannot simply use a finer paintbrush; we must also know how to paint . There are 2 major skills needed to paint a natural hairline:
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The ability to locate the appropriate borders of a hairline and adjust these boarders based on donor/recipient ratio.
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The ability to mimic the visual characteristics of a natural hairline at these boarders.
The authors techniques for creating a natural frontal hairline are presented in the ( [CR] ).
Introduction
Creating a natural hairline is one of the most important elements of a successful hair transplant and many excellent reviews have been written on the subject. Patients expect and deserve undetectable hairlines. We are better equipped now to create hairlines that meet this high expectation ( Fig. 1 A, B ). In part, this is a result of the exclusive use of follicular unit (FU) grafts in the hairline region. FU grafts have given us a finer paintbrush with which to create a hairline. Equally important has been a better understanding and recognition of the visual characteristics that make up a normal hairline. Simply using FU grafts without a deliberate attempt to reproduce these characteristics does not guarantee naturalness ( Fig. 2 A, B ).
In other words, to create the most natural looking hairline, we cannot simply use a finer paintbrush; we must also know how to paint . There are 2 major skills needed to paint a natural hairline:
- 1.
The ability to locate the appropriate borders of a hairline and adjust these boarders based on donor/recipient ratio.
- 2.
The ability to mimic the visual characteristics of a natural hairline at these boarders.
The authors techniques for creating a natural frontal hairline are presented in the ( [CR] ).
Major components of the hairline
The hairline consists of more than its most anterior frontal border. It is an extended area that consists of a number of borders and zones that work together to frame the face and create the final aesthetic look. These components are briefly described as follows and are illustrated in Fig. 3 A, B . They are discussed in greater detail throughout the article.
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Frontal hairline: Frames the front of the face and runs horizontally from temple to temple.
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Mid-frontal point (MFP): The most anterior point of the frontal hairline in the midline.
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Mid-pupillary point (MPP): Point lateral to the MFP where the hairline begins to bend posteriorly on a line drawn vertically from the pupil.
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Transition zone (TZ): The most anterior zone of the frontal hairline. It should appear soft and irregular containing both micro and macro irregularity.
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Defined zone (DZ): Located directly behind the TZ and the point where the frontal hair line begins to appear denser and less see through.
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Frontal tuft (FT): An oval zone overlying the central (midline) portion of the DZ. This is an aesthetically critical area for the appearance of density.
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Frontal temporal angle (FTA): The point where the frontal hairline meets the temporal hairline. It typically lies on a line drawn vertically from the lateral epicanthi of the eye.
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Temporal hairline: Frames the side of the face running from the FTA to the sideburn.
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The lateral hump (LH) or lateral fringe: The strip of hair located on the side of the head in the temporal-parietal region that connects the permanent donor hair below to the mid scalp above. Its anterior border is the temporal hairline.
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Temporal points (TP): A triangular-shaped protrusion located on the lower aspect of the temporal hairline.
Natural characteristics the hairline
The frontal hairline is an area approximately 2 to 3 cm deep that bridges the bald forehead to the hair-bearing scalp. It can be visualized as an extended area that consists of 3 zones: the anterior portion or TZ; the posterior portion or DZ; and an oval-shaped area in the center of the DZ called the FT (see Fig. 3 A, B; Fig. 4 ). All 3 zones make their own unique contribution to the overall appearance of the hairline.
Transition Zone
The TZ consists of the first 0.5 to 1.0 cm of the hairline (see Figs. 3 A and 4 ). It should initially appear irregular and ill-defined, but gradually takes on more definition and substance as it reaches the DZ. Close observation of normal TZs reveals a number of specific elements that work together to create this overall effect. They are described in the following sections.
Single hair grafts
One-hair grafts should be used only in the anterior portion of the TZ with a shift toward 2-hair grafts in the posterior portion. This helps ensure a natural, softer look.
Sentinel hairs
A few isolated, very fine single hairs called sentinel hairs can be found scattered randomly in front of the TZ. Sentinel hairs contribute to softness and irregularity.
Micro-irregularity
Close examination of the TZ reveals small, intermittent clusters of hairs along its border (see Fig. 4 ). These clusters vary in shape and depth but often resemble ill-defined triangles of various sizes. Their existence creates variable and intermittent density along the TZ. This form of irregularity is referred to as micro-irregularity because it is more noticeable viewed close-up than from a distance. Parsley called these areas clusters and the area between them gaps. There is a natural mistaken urge to fill in the gaps between these clusters when working on the TZ. This impulse must be overcome to prevent the creation of a straight or solid-appearing hairline.
Macro-irregularity
If one stands back and looks at a normal hairline from a distance, the path of the anterior border is seen to be more serpentine or curvaceous than linear. This form of irregularity is referred to as macro-irregularity because it is more obvious when one stands back and observes the hairline from a distance (see Fig. 4 ). Martinick used the term “snail-tracking” to describe this appearance. Parsley attributed this macro-irregularity to existence of 1 to 3 “mounds” or “protrusions” along the path of the hairline. Both micro-irregularity and macro-irregularity are needed in the TZ to create a natural-looking hairline.
Defined Zone
The DZ sits directly behind the TZ (see Figs. 3 A and 4 ). In this area, the hairline should develop a higher degree of definition and density. Increasing density in the DZ creates a fuller looking hairline by limiting the distance seeable through the TZ. As a benefit, it creates this effect without placing hair directly in the TZ, limiting the chance of creating an unnatural straight or solid appearance ( Fig. 5 A, B ). Increasing density in the DZ is a safe and effective way to make the hairline appear thicker.
FT Area
The FT is a small but aesthetically significant oval-shaped area that overlies the central portion of the DZ (see Figs. 3 A, B and 4 ). The density in this area should be higher than the rest of the DZ. James Arnold impressed on me the aesthetic importance of density in the FT with the following example. He would say, “Consider a patient who is totally bald except for a fairly full residual FT area. Imagine he is standing in an elevator facing the door with you facing him on the other side. When the door opens your first impression, looking at him face on, would be of a person with a fairly full head of hair. It would only be when you walked by him that you noticed he was bald everywhere else.” Creating fullness in this area has a tremendous influence on the overall appearance of fullness ( Fig. 6 A, B ).
FTA Area
Slight temporal recession or weakness of the FTA is normal in the white male hairline. Therefore, flattening or densely filling in this recession is a mistake and would make the hairline look artificial (see Fig. 2 ). Like the TZ, the anterior border of the FTA should not appear solid but instead soft and ill-defined.
In certain ethnic groups (black, Middle Eastern, Asian, and Hispanic), it is more common to see broader, flatter hairlines with less recession. In these groups, if the donor/recipient ratio is good, a more aggressively filled in FTA may occasionally be acceptable. However, even if a flatter hairline is more common in certain ethnic groups, if the donor/recipient ratio is poor, some temporal recession still needs to be created. Female hairlines are the only true exception. With women, the FTA is more medial, rounded, and filled in.
Proper Angle and Direction
Angle and direction are distinct entities. Angle refers to the degree of elevation that hair has as it exits the scalp. Direction refers to the way hair points (right or left) when leaving the scalp. It is important to pay attention to changes in both angle and direction as one transplants different parts of the hairline ( Fig. 7 A, B ). Often there are residual miniaturized hairs that act as a road map for the physician to follow.
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In the mid scalp, hair usually exits at 30° to 45° and points forward toward the nose.
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As one reaches the frontal hairline, the angle becomes more acute at 15° to 20°, and the direction usually remains pointing forward. On occasion, hair in this area may bend slightly to the left or right.
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As one moves laterally along the hairline, the direction remains forward until nearing the FTA.
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As one reaches and sweeps around the FTA toward the temporal hairline, there is a gradual change in direction from forward to inferior lateral. Simultaneously, a gradual change in angle occurs from approximately 15° in the frontal hairline to almost flat (5°–10°) in the temporal hairline.
