Frontal Hairline Restoration

Rebuilding the Frontal Hairline

Placement of Hairline
The hairline is often the most visible part of the completed hair transplant. Hairline requirements, however, differ from patient to patient. Some patients want a relatively low and dense hairline. Such a requirement is best met for patients who have less hair loss that has stabilized by itself, no family history of extensive hair loss and good availability of donor hair.

A person in his 30s, may have minimal hair loss (receding temples), and may wish to lower the hairline and fill in the temples. The person must be made aware of the possibility of his hair loss progressing, say, in his 40s, to a level where he may require further sessions of hair transplants. Therefore, young patients requesting a hair transplant procedure must remember that their hair loss may progress, necessitating further and repeated hair transplant procedures.

Hair Recession
Reconstructing a new hairline is a skill requiring surgical as well as artistic skill. It is critically important to one’s appearance that a hairline not only be age appropriate the day of the procedure, but look natural as he ages.

There is a basic principle of hairline design. The hairline in most individuals starts at 1/2 the distance above the eyebrows, from the distance between the eyebrows and the chin.

The height of the hairline can be determined in several ways:

The central hairline can be placed typically 7-8 centimeters
(approximately 3 inches above the top of the eyebrows.

The central hairline is placed 4 fingers above the top of the eyebrows.

The central hairline is placed 2 fingers above the highest forehead wrinkle.

The central hairline is placed at the height where the forehead
moves from a vertical orientation to a posterior orientation.
In other words, at a point where the forehead moves backward.

The lateral hairline is always in line with the outside of the eye called the lateral canthus. The adult hairline differs from the adolescent hairline by being higher on the forehead and receding slightly over the temples.

The frontal hairline must be natural looking and individualized to each patient, but typically 7-11 centimeters above the glabella (area between the eyes centrally). You can always lower a hairline if you think it is too high, yet it is difficult to raise a transplanted hairline.

Single hair follicular units must be used in a soft and even distribution to create a natural hairline. Behind this natural hairline, we transplant different sizes of follicular units to increase the density.

Gentle blending of hair is better than creating a single wall of hair. There must also be the correct blending of the old existing hair with the new transplanted hair.

Placing the hairline appropriately on the forehead, there are no set rules that apply. You may want the same hairline that you had when you were in your teens, but this would look out of place as you grow older. Yet, placing the hairline too high may give the appearance of a tall forehead or baldness.

Hairline and Temple Angle Design

The most important thing in hair restoration surgery is to make the hair transplant appear as natural and undetectable as possible. This requires both science and art. The hairline should be symmetrical and have irregularities (mounds or undulations).

The first phase involves removal of a strip of ‘permanent’ hair over the donor region. Most hair transplant surgeons remove a single, elliptical strip of tissue to reduce transection or destruction of the follicles.

The second phase of the procedure — and more important — is to relocate these follicular units extracted to the balding are where the hair is to be restored.

Angle of Hair Growth

Proper selection and use of follicular units, combined with artistry and skill, can truly provide the patient with exceptional results.

The follicular units must be inserted in the right place at the correct angle to achieve a natural, appealing, undetectable hair transplant which is suitable to each individual.

Some of the key points to creating a natural hairline include these considerations:

Orienting the grafts in the same direction as the native hair.
Utilizing only one haired follicular units in the frontal hairline area.
Using finer hairs in the anterior (frontal) most hairline as well as in the temples.

The second phase of the procedure — and more important — is to relocate these follicular units extracted to the balding are where the hair is to be restored.

Hairline & A Natural Appearance

To create a natural hairline the single hair follicular unit hair transplant is the best method available. The single hair approach of one hair follicular unit graft in the frontal hairline avoids scarring and corn-row appearance.

Producing a natural hairline is one of the most important elements of a successful hair transplant surgeon. The ability to create naturalness has dramatically increased in recent years due to the development of more refined techniques. The “degree” of naturalness expected by patients has also increased along with our abilities. Today, patients expect an undetectable hairline that can stand on its own after one surgery; they will no longer tolerate an embarrassing ‘pluggy’ phase. This high “degree” of naturalness can be achieved using the techniques and the methods described below.

Key to a Natural Hairline
Most physicians will say that only micrografts should be used in the hairline area. However, this statement is not specific enough since all ‘micrografts’ are not the same. “Follicular unit” micrografts are the ultimate micrografts for the hairline area because they have specific characteristics that enable them to achieve the highest degree of naturalness on a consistent basis.

Follicular unit micrografts are trimmed of excess tissue and epithelium as safely possible and are therefore, smaller than untrimmed micrografts with equivalent numbers of hairs. Their small size enables them to be placed in much smaller, less traumatic incisions closer together.

Additionally, the minimal amount of epithelium remaining on follicular units limits the potential for pitting, which can still occur when untrimmed micrografts are placed too deep. In our office, we call one hair follicular units monografts (meaning only one hair follicle) to distinguish from typical micrografts which could contain 1-2 hairs and sometimes 3 hairs.

Conceptualize a Larger Total Hairline Area
Most discussions about hairlines focus only on the first 0.5-1.0 cm anterior border of the hairline, commonly referred to as the “transition zone”.

In contrast, we conceptualize the hairline as a larger, 2-4 cm area transitioning the bald forehead to the anterior frontal region. This larger area is divided into two smaller zones. The anterior portion or transition zone” should be soft and irregular. The posterior portion or “defined zone” should be more definite and dense. Both these zones are important to the overall appearance of the hairline.

Best Frontal Hair Transplant Doctor

The “Transition Zone”
The transition zone, consisting of the first 0.5-1.5 cm of the hairline, should be irregular and ill defined. Only 1 hair follicular units should be used in this area. The greater the degree of hair loss the wider and more diffuse this “transition zone” should be, mimicking the pattern found when more severe hair loss occurs in nature. A natural tendency to “fill in the spaces” in this area must be overcome to prevent a too straight or solid appearing hairline. A systematic method that aids in accomplishing this goal is described later in the text.

The “Defined Zone”
The “defined zone” is a two to three cm wide area that sits directly behind the “transition zone.” In this area, the hairline should develop a higher degree of definition and density, yet still have the highest degree of naturalness under close examination. Concentrating 2-3 hair follicular units within this area accomplishes both goals nicely. Density in the defined zone contributes to the illusion of a fuller looking hairline by limiting the distance that can be seen past the transition zone. It accomplishes this without placing dense hair directly in the transition zone, thereby limiting the chance of creating too straight or solid an appearance.

Separate and Distribute Specific Size Follicular Units in Specific Locations
Separating and selectively placing 1, 2, and 3 hair follicular units allows us precise control over the distribution of hair density and naturalness. The transition zone should contain primarily 1 hair follicular units. Finer one hair grafts are separated and placed in the most anterior portion of this zone.

Larger 2-3 hair follicular units should be placed in the defined zone, concentrating the 3 hair and if available 4 hair follicular units in the mid central portion of this zone (where the frontal tuft is typically located). Creating density in this frontal tuft area has a high aesthetic impact, contributing a greater illusion of density overall and mimicking a pattern commonly found in nature.

Using a Larger Number of One Hair Follicular Units in the First Session
Adequate numbers of one hair follicular units should be placed in the first session to ensure that the hairline will be natural and have enough substance to stand on its own independent of further surgeries. Since the hairline frames the face, it is critical to have enough grafts transplanted to give the illusion of an intact hairline.

This effect begins to materialize when one hair FUs are placed an average of 1-2 mm apart (or about 30-40 FUs per square cm). Typically, we transplant approximately 600-900 one hair follicular units in the hairline during the first session. The hairline is probably the most important transplanted area on the scalp since it is the first thing you see when speaking or looking at an individual. It doesn’t matter if the rest of the transplanted scalp looks great; if the hairline is detectable our eyes will focus on the unnatural hairline.

This is one reason why a hairpiece is noticeable; the hairline is too straight, too thick, or camouflaged. As men age, they usually expose their naturally thinning, recessed hairline. Any attempt to cover the hairline is viewed as a ‘comb-over’. Therefore, every effort is made to create a natural hairline not only for the patient at his current age, but also to look age appropriate 10, 20 or 30 years in the future.

An Undetectable Transplanted Frontal Hairline

Exposing the Transplanted Frontal Hairline with a comb.

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Frontal Hairline Restoration

Rebuilding the Frontal Hairline

About Dr. Shelly A. Friedman