Hairline Design and Frontal Hairline Restoration

40 Hairline Design and Frontal Hairline Restoration

Ronald Shapiro

Summary

Creating a natural hairline is one of the most important elements of a successful hair transplant. This chapter discusses the key skills needed to design a natural hairline, including locating the borders of the hairline and understanding and being able to mimic the visible characteristics of a hairline. Methods to locate the major borders and how to adjust them based on the donor-to-recipient ratio will be discussed. The visual characteristics of different hairline zones will be described as well as techniques to recreate these characteristics using follicular unit grafting.

Keywords: hairline naturalness transition zone defined zone lateral hump frontal tuft frontotemporal angle cowlick lateral epicanthal line temporal point

Key Points

•Do not make the hairline too low.

•Do not flatten or totally fill in the frontotemporal angle.

•The frontotemporal angle lies and remains on the lateral epicanthal line as hair loss progresses.

•Take future hair loss into consideration when planning the hairline.

•The frontal hairline consists of micro- and macro-irregularity.

40.1 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.1^,²^,³^,⁴^,⁵^,⁶ Today’s discerning patient expects an undetectable hairline and, with current techniques, we are able to meet this expectation (Fig. 40.1). In part, this is due to the exclusive use of natural one- to two-hair follicular unit (FU) grafts in the hairline region. FU grafts give us a fine paintbrush with which to create a hairline. However, equally important is 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. 40.2).

Fig. 40.1 Natural transplanted hairline. ( a ) Naturally transplanted hairline immediate postoperative pattern. (b) Naturally transplanted hairline 1 year postoperative.

Fig. 40.2 Unnatural transplanted hairline. (a) Hairline is too straight, grafts are misdirected, and the frontotemporal angle has been abnormally filled in. (b) Unnaturally transplanted hairline. Hairline too straight with no irregularity, even thoughonly one-hair follicular unit (FU) grafts were used.

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 two major skills needed to paint a natural hairline:

•The ability to locate the appropriate borders of a hairline and adjust these borders based on the donor-to-recipient ratio.

•The ability to mimic the visual characteristics of a natural hairline at these borders.

Video 40.1 shows the author’s technique of hairline restoration with additional diagrams and details.

40.2 Components of the Hairline

The hairline consists of more than its most anterior frontal border. It is a region made up of several borders and zones working together to frame the face and create the final aesthetic look. These components are listed below and will be discussed in greater detail later in the chapter (Fig. 40.3):

•Frontal hairline: Frames the front of the face and runs horizontally from temple to temple:

– Mid-frontal point (MFP): The most anterior point of the frontal hairline in the midline.

– Mid-pupillary point (MPP): A point lateral to the MFP where the hairline typically begins to curve posteriorly. It lies on a line drawn vertically from the pupil.

– Transition zone (TZ): The most anterior zone of the frontal hairline. It should appear soft and irregular containing both micro- and macro-irregularity.

– Defined zone (DZ): Located directly behind the transition zone and the point where the frontal hairline begins to appear denser and less see-through.

– 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.

•Frontotemporal angle (FTA): The point where the frontal hairline meets the temporal hairline. It typically lies on a line drawn vertically from the lateral epicanthus of the eye.

•Temporal hairline: Frames the side of the face running from the FTA to the temporal point.

•Temporal point (TP): A triangular-shaped protrusion located on the lower aspect of the temporal hairline.

•The lateral hump (LH) or the lateral fringe: The zone of hair located on the side of the head in the temporoparietal region that connects the permanent donor hair below to the midscalp above. Its anterior downward-sloping border is the temporal hairline.

Fig. 40.3 Major borders, landmarks, and zones of the hairline. The hairline consists of many components that work together to obtain the final aesthetic look. (a) Top view. (b) Side view.

40.2.1 Characteristics of the Hairline

The frontal hairline is the bridge between the bald forehead and the hair bearing scalp. It can be visualized as consisting of three zones: the anterior portion or transition zone, the posterior portion or DZ, and an oval-shaped area in the center of the DZ called the frontal tuft (Fig. 40.3 and Fig. 40.4).¹^,² All three zones make their own unique contribution to the overall appearance of the hairline.

Fig. 40.4 Micro- and macro-irregularity. Normal nontransplanted hairline. The white dotted line separates the transition zone (TZ) from the defined zone (DZ). FT is the frontal tuft. (a) Notice the micro-irregularity within the TZ. (b) The blue dotted line follows the macro-irregular undulating anterior border.

40.2.2 Transition Zone

The transition zone is the first 0.5 to 1 cm of the hairline (Fig. 40.3a and Fig. 40.4). It should initially appear irregular and ill-defined but gradually take on more definition and substance as it reaches the DZ. Close observation of normal transition zones reveals several specific elements that work together to create this overall affect. They are the following:

•Single hairs: Only single hairs are found at the most anterior portion of the transition zone with a shift toward two-hair grafts in the posterior portion of this zone. 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 transition zone. Sentinel hairs contribute to softness and irregularity.

•Micro-irregularity: Close examination of the transition zone reveals small, intermittent clusters of hairs along its border (Fig. 40.4a). These clusters vary in shape and depth but can resemble ill-defined triangles or linear protrusions of various sizes. Their existence creates an appearance of irregularity and variable density across the hairline. This is referred to as “ micro-irregularity” and is more noticeable viewed close-up than from a distance. There is a natural mistaken urge to fill in the gaps between these clusters when working on the transition zone. 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.” Not creating macro-irregularity is a common mistake that leads to unnaturally straight or bowl-shaped hairlines (Fig. 40.4b). Martinick⁷ used the term “snail-tracking” to describe this appearance. Rose and Parsley attributed this macro-irregularity to the existence of one to three “mounds” or “protrusions” along the path of the hairline with the middle mound being the widow’s peak.⁴ Both micro- and macro-irregularities are necessary for the most natural hairline.

40.2.3 Defined Zone

The DZ sits directly behind the transition zone (Fig. 40.3a and Fig. 40.4). In this area, the hairline should develop with a higher degree of definition and density. Increasing density in the DZ creates a fuller-looking hairline by limiting the distance seen through the transition zone.¹^,² As a benefit, it creates this effect without placing hair directly in the transition zone, limiting the chance of creating an unnatural straight or solid appearance (Fig. 40.5a). It is a safe and effective way to make the hairline appear thicker.

Fig. 40.5 The importance of density in the defined zone. (a) The defined zone is thinning and the hairline appears see-through. (b) The hairline looks much fuller, but NO hairs were added to the transition zone. Hair was only manually compressed in the defined zone, making it less see-through. This indirectly made the transition zone look fuller.

40.2.4 Frontal Tuft Area

The frontal tuft is a small but aesthetically significant oval-shaped area that overlies the central portion of the DZ (Fig. 40.3 and Fig. 40.4). The density in this area should be at least as high if not higher than the rest of the DZ. James Arnold⁸ impressed upon me the aesthetic importance of density in the frontal tuft with the following example:

Consider a patient who is totally bald except for a fairly full residual frontal tuft 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 would be of a person with a full head of hair. Only when you walked by him would you notice he was bald everywhere else.

Creating fullness in this area has a tremendous influence on framing the face and the appearance of fullness of the hairline (Fig. 40.6).⁵

Fig. 40.6 The importance of the frontal tuft. (a) From a frontal view, the patient appears to have a fairly full head of hair thanks solely to this tuft. (b) From the top view, he looks bald.

40.2.5 Frontotemporal Angle Area

Slight temporal recession or weakness of the FTA is normal in the Caucasian male hairline. Therefore, flattening or densely filling in this recession is a mistake and will make the hairline look artificial (Fig. 40.2a).⁶

In certain ethnic groups (blacks, Middle Easterners, Asians, and Hispanics), it is more common to see broader, flatter hairlines with less recession. In these groups, if the donor-to-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-to-recipient ratio is poor, some temporal recession still needs to be created (see Section VII: Special Ethnic Considerations” of this book). Female hairlines are different than male hairlines with the FTA located more medially and filled in (see Chapter 26).

40.2.6 Proper Angle and Direction

Angle and direction are distinct entities. Angle refers to the degree of elevation 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. 40.7). Often there are residual miniaturized hairs that act as a road map for the physician to follow. Typically, the following pattern is seen:

•In the midscalp, hair usually exits at 20 to 45 degrees and points forward toward the nose.

•As one reaches the frontal hairline, the angle becomes more acute at 15 to 20 degrees, and the direction usually remains pointing forward. However, hair direction can to turn slightly to the left or right, especially in the midline, anterior to the frontal tuft (Fig. 40.7).

•As one moves laterally along the hairline, the hair direction remains forward until nearing the FTA.

•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 change in angle occurs from approximately 15 degrees in the frontal hairline to almost flat (3–5 degrees) in the temporal hairline.

•From a side view, the pattern resembles a fan pointing forward and changing from a medial to lateral direction at the level of the FTA (Fig. 40.7).

•As one continues down the temporal hairline toward the TP, the direction can change to more posteriorly and the angle should be as flat as possible. Coronal incisions should be used in the temporal hairline to ensure a more acute angle.

Fig. 40.7 Changes in angle and direction. Exit angles are different in the midscalp (30–45 degrees), frontal hairline (15–20 degrees), frontotemporal angle (10–15 degrees), and temporal hairline (5–10 degrees). Notice the gradual fan-shaped change in direction from medial to inferior/lateral around the frontotemporal angle. (a) Lateral view. (b) Top view.

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