The hairline above the forehead is perhaps the most characteristic element in the human face, comparable to characteristic eyes or the prominent position of the nose. It is therefore no wonder that a receding hairline can negatively influence someones appearance quite dramatically. This is as spectacular is the re-making, the creation of a new natural hairline.
It is a delicate matter, for only a perfect result is acceptable. The hairline must look completely natural; any deviation is unacceptable. There is no such thing as 'almost natural' or 'a little bit unnatural'; in these cases they actually equal unnatural and thus unsatisfactory.
Indeed, small details lead directly to a hairline that looks unnatural. For example, the use of only a few double hair transplants (the combination of two roots) can clearly create a dolls hair-like effect. Even when only visible in a few spots, the wrong distances between hair that has been implanted, whether too regular, or too far apart, can have a disastrous effect.
On the one hand the prominent place the hairline plays in an individuals face as already discussed above, makes an unnatural looking hairline very noticeable and therefore nearly impossible to hide. In view of the fact that it is an ongoing situation, in some cases the resulting mental stress is worse than the initial suffering due to baldness
On the other hand, correction of an unnatural hairline is difficult and time consuming, and in many cases requires more than one treatment session
The natural results of a transplanted hairline therefore takes the highest priority. It requires a great deal of aptitude, many years of experience and last but not least, artistic talents and a well developed sense of aesthetics on the part of the doctor in question.
The most important rule in recreating a hairline is emulating nature. Countless aspects are derived from this that absolutely must be taken into account in the course of treatment by the attending physician. Some examples are given below:
A natural hairline is not really a straight-edged line but rather a transitional zone with increasing density towards the back; going from a couple of fine single hairs all the way in the front to very dense hair growth only a few millimeters behind this initial fine hairline. That is why the hairline is really a fuzzy border area instead of a sharp line.A natural hairline forms a soft and gradual contrast from the naturally hair-free skin of the forehead to the hairy area on top.
In the following patient, we see a close-up of the side of his scalp where the hair is not affected by DHT. We see mostly groups of full thickness hairs (called terminal hairs) and a few scattered fine, vellus hairs, normally seen in a donor area. The pointer (left) indicates the location on the scalp in the close-up view.
Another basic aspect in designing a natural hairline, is its often mentioned and emphasized irregularity in all of its facets. The hairline meanders in an irregular pattern from place to place and moves in and out in a bold irregular pattern. Side by side, areas with various densities form irregular patterns, completely asymmetrical with irregular, changing distances between them. The single hairs at the very front are positioned in quite irregular combinations, entirely asymmetrical and with variable spacing.
Naturally, the direction in which the transplanted hair grows should follow that of the growth of the original hair. That is to say that the direction of transplanted hair thus needs to be adapted to that of the existing hair. The angle used with the tool (needle or blade) making the recipient sites is therefore of crucial importance, and must be taken into account.
When designing a hairline that are many ways to create one. In almost all cases, my hair-transplant colleagues and I start with the most fundamentally important point that defines and sets the remainder of the hairline, which is the central anterior point. This midline point is the lowest part of the anterior hairline and defines how the remainder of the hairline will be positioned. Just like the stated fact that there are many ways to design a hairline, there are also many ways to decide upon the lowest acceptable point for the central hairline point. This article will not discuss all of the myriad ways to do that but will discuss what I deem to be the most useful and practical method to undertake this strategy. In short, the lowest acceptable point should be situated at the junction of where the horizontal scalp intersects the vertical forehead at a 45 degree juncture. Any hair transplanted lower than this point can look unnatural since it would reside on the forehead. Starting with this lowest point and then adjusting upward based on a patient’s age, facial shape, or other design/safety elements is a good way for a surgeon to strategize the design of a hairline.
I really like using the idea of a shoreline to educate my students and my patients on the proper design of a hairline. A shoreline from a great distance looks relatively straight but the closer you get to the shoreline, the more jagged and imperfect the contour becomes. This is a very good way of understanding how to create a natural hairline. I oftentimes see hairlines that are simply way too straight or others that are way to curvy. A natural hairline is neither. It is principally straight (the so-called macro hairline seen from a distance) and it is principally irregular (the so-called micro hairline when seen up close). The macro hairline is created by drawing a line on the head at the beginning of the case. The micro hairline is created by making the recipient sites into which the grafts will be placed. The goal of the micro hairline is to create little irregularities into the originally designed macro hairline. I personally like to build my hairlines from an area of the central midscalp/central forelock going forward rather than drawing the hairline in and then going backwards. The reason for this is that if you design the anterior most line of the hairline first, the tendency is to make the hairlines too rigid and straight. By starting a few centimeters behind the anterior-most line of the hairline, the recipient sites can be made so that as the anteterior-most line of the hairline is reached, the line progressively becomes more irregular. To really appreciate a beautiful hairline, it is important to see one from a distance and up close. Remember the concept of the shoreline when doing so.
When we discussed the bell shaped design of the hairline, we talked about a point known as the “lateral, anterior point”. This point is relatively aligned with the mid-pupil and it represents where the shape of the hairline goes from convex toward the midline and concave toward the outer portion. After evaluating a lot of natural hairlines, the mid-pupil became the most recognized natural landmark for this transition point. The reason for trying to create some kind of transition at the mid-pupil is several fold. First, it breaks the relatively straight line of the hairline into two components, thereby making the hairline potentially look more natural since it is less straight. Second, it conserves grafts since fewer grafts are required toward the outer, concavity. Third, it can conserve grafts in the temple since the temple can also have a more suppressed concavity to match. Fourth, it can fit faces better that are narrower and would match the shape of the bell curve.
Although we have discussed the bell and the round patterns for hairline design in other blog articles, we did not discuss what the impact is on the temple hair when creating these types of hairline shapes. When the temple hair is not simultaneously created and only the front hairline is made, then the design of the central hairline can impact the future position of the temple hair. Let me explain. The bell curve ends with the outer portion jutting toward the temple hair fixing the temple position where the hairline ends. This is contrasted to the round hairline that ends tapering backward (on the left side of the illustration) so that the temple could be positioned farther back. Although the round hairline design requires more grafts to be used since it is more convex and less tapered, it allows for a more conservative temple design in the future. Obviously, if the temple is going to be transplanted at the same time, then the point is moot since the temple position will already be fixed by the new transplanted temple hair. The reason to bring up this subtle point is to educate the reader on the many artistic and technical judgments that enter into an experienced hair-transplant surgeon’s mind when designing hairline shape and position.
When I design a hairline I not only stand in front of the patient, but I go to every angle of the patient to make sure my design work looks good, symmetric, and natural. The side view of the hairline is so very critical as part of a total evaluation. When designing the hairline from the front, it is very easy to fail to check the appearance from the side view, something I always do early on during the design work as a cross check. In short, the hairline must either appear flat horizontally (which is a more aggressive design) or slope upward from the central anterior point. It must never slope downward, which is a dead giveaway of an unnatural result. This is a very important component to designing an overall natural hairline result that should appear that way from all inspected angles
In the past decade, attending almost every meeting of the International Society of Hair Restoration Surgery (ISHRS), I have witnessed topics of growing interest. I believe that temple restoration or also known as temporal point restoration has become a very major part of creating aesthetically pleasing and balanced hairline work.
As mentioned in previous articles, the temple must per force be transplanted when the anterior hairline is aggressively transplanted and the temple hair is not, leading to an unbalanced appearance that can resemble a toupee. The illustration on the left shows a conservative hairline design that does not mandate a temple reconstruction. The illustration on below shows a more aggressive hairline reconstruction that with the current position of the temples does not look natural. The lightly shaded gray shows a proposed temple reconstruction that will make the anterior hairline appear natural and balanced.
Temple Hair Design Based on Anterior Hairline Position (from Dr. Lam’s book, Hair Transplant 360) Many considerations must be taken when deciding on temporal point reconstruction. If the person is very young, the fear would be that over time that person would run out of hair to maintain a natural result in the temple area. Therefore, the surgeon should be careful not to build the anterior hairline so aggressively that the temples would need to be rebuilt at the same time or very soon with further hair loss. Someone with a very narrow face may look even narrower with an aggressive temporal point design. In general, artistically the surgeon must decide with the patient to what extent the temples should be rebuilt. I have also performed isolated temporal points in someone who has had previous transplants in the anterior hairline where now the temples have faded back making their transplant result look less natural or balanced.
Although there are many types of hairlines that can be designed, for the sake of simplicity I try to discuss two basic shapes when I lecture to students at my hair-transplant course in St. Louis every year. They are the bell-shape and the round-shape. The bell shape is a narrower design that changes from a convex center to a concave outer portion with the transition occurring somewhere midway at the mid-pupil line, known as the lateral, anterior point. The bell-shape works for a narrower head so that the bell matches the shape of the head, and it also works to conserve grafts and requires less aggressive a temporal hair reconstruction to match it. For these reasons a bell shape is preferred. A round shape is good for a wider face like on an Asian or some Hispanic faces, for example. Because it requires more grafts to undertake and more grafts allocated to the temple area it may be less ideal for the very young patient who would require more hair-transplant sessions to maintain the result with a greater number of grafts. Obviously, some hairlines are a hybrid design, i.e., principally round with a little transition from convex to concave. Alternatively, the hybrid design could be a more suppressed round shape that lacks the transition from central convexity to lateral concavity.
Is hair restoration an artistic endeavor? Or in fact is it simply a rudimentary technical procedure in which hair is placed into the head and only the sheer number of grafts count? I will explain in a point-by-point manner why hair restoration is truly artistic in my opinion, focusing on three major elements: macro hairline design, micro hairline design, and recipient site creation/graft distribution. Macro hairline design – Macro hairline design refers to creating the overall shape and position of the hairline, i.e., what is initially drawn on the head as a template upon which the micro elements of the hairline (see below) will be fashioned. Every surgeon making a hairline will create a slightly if not significantly different hairline based on experience as well as artistic interpretation. When I design a hairline, I am always looking at how that hairline shape would best match a facial shape, ethnicity, and gender. I also make sure that it will age well for someone. Every hairline I design I consider a work of art to make it not only look seamlessly natural but also wonderfully shaped to match a patient’s head to the best of my ability. Micro hairline design – The micro hairline refers to the recipient sites that go into the general hairline. When designing the individual sites, it is important that the hairline look natural from a distance but also even close up. I really spend an inordinate amount of time during the procedure looking at my work from multiple angles to ensure that my hairlines look as natural as possible. I really consider the micro hairline the final expression of my artistic design for the macro hairline. Recipient site creation and graft distribution – To me the recipient site creation is one of the ultimate expressions of one’s artistry controlled down to the very site angle and distribution. After I am done making my sites, I sit back for a minute, take a deep breath, and enjoy the glory of my creation. I simply love seeing my sites before the grafts go into them because they are a work of art. That is why I have so many photos and videos showing my recipient sites. I consider showing you my sites is like showing the seams of a handmade suit so that you can see the quality that goes into the production. I love blending in the technical and the artistic elements. When I attain a number of grafts for a given size given to me by my assistants from their graft preparation (e.g., 600 2 hair grafts, 500 3 hair grafts, etc.), I like to sit down and figure out how best I am going to allocate those grafts in a creative way for optimal effect for a patient. In fact, after I have created my work I always make a color-coded guide for my staff to know how to place the grafts but also so I have a written record of my distribution so when I see a patient come in with the grafts growing in nicely I can remember w hat I did.
When creating a hairline for a particular individual, it is important to consider many factors, one important element is ethnic sensitivity. Hairlines differ based on gender, facial shape, and age as well, and these are starting points for any physician in his/her design work. However, ethnic differences will be the focus of this article, as we explore how the shape of a hairline has certain general patterns based on one’s ethnicity.
We will start with Asian hairlines first, since I am Asian myself. Asian faces tend to be broader and rounder than their Western counterparts, especially Chinese and Korean faces. The hairline shape matches the face shape in that the hairline tends also to be broader and rounder in shape. There tends to be less of a widow’s peak in the center but a subtle presence of one can serve to break up the roundness of the design. The shape of the hairline also has less lateral suppression, i.e., it tends to stay rounder even toward the fronto-temporal region. Because Asian hairs grow out straight and black, if the angles of the hair grafts are not kept very low vis-à-vis the scalp the result can look unnatural. In addition, the novice surgeon is more prone to book leaf open i.e. create splaying of the recipient sites rather than aim them forward that can truly compromise density and create an unnatural result, especially in a very broad, round hairline design. (For more information view ourAsian hair transplant page.)
For the African hairline, the shape tends to be straighter with very little to no fronto-temporal recession. It can be almost a straight right angle at the fronto-temporal angle and still look very natural. Depending on the degree of hair loss and the feasibility of creating this shape, the surgeon should consider creating a squared off frontal shape of the hairline. Clearly, with more advanced hair loss the fronto-temporal angle will most likely need to be rounded to make the total result both attainable and also natural, which will also accommodate further hair loss as one ages. Obviously, facial shape can influence the artistic design of the hairline but the above parameters can serve as a basis for one’s design work. Fortunately because of the curly nature of the hair shaft, the travel distance to cover bald scalp for each hair follicle is good so that hair density can be more easily achieved with fewer total grafts used. (For more information view our African hair transplant page.)
The Hispanic hairline can be influenced more by the exact genetic makeup of the so-called Mestizo identity. The White individual from Spain will have a hairline with a natural fronto-temporal recession like their White counterparts. However, the person hailing from Central or South America may have a different ethnic makeup owing to centuries of intermarrying. For instance, the sugar trade that brought African slaves over to the Caribbean may have individuals that look more African than other types of races. The Dominican Republic and Haiti are good examples of a population that is primarily darker in aspect and in which hairlines would probably match more what was described above for African individuals. The indigenous Indian populations of Central America have more an Asian appearance because originally they crossed over the Bering Straight through Alaska to arrive in Central America. Therefore, some hairlines can resemble what I described above for Asian hairlines. This Mestizo hairline therefore must be considered as an amalgam of different races and adjusted based on which race is the predominant presence in a particular individual. (For more information view our Hispanic hair transplant page.)
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The Middle Eastern hairline also proves to be a bit elusive since there is considerable variability in the term “Middle Eastern”. However, for simplicity’s sake, the facial shape and hairline design more closely matches that of the neighboring white, European hairlines, i.e., the typical fronto-temporal recession and suppressed lateral hairline shape. Obviously, again it is important to overlay a considerable degree of artistic judgment marrying age, donor density, hair caliber/curl/color, and facial shape plus aesthetic desires of a patient (so long as they are reasonable). Of note, the above hairline shapes are primarily focused on male-pattern baldness. Women have an altogether different shape that is more universally rounder and closed off at the fronto-temporal angle and are outside of the discussion of this article. (See womens hair loss page for more info.)
With ever increasing rates of interracial couples, these hard and fast lines that were established above are beginning to blur. I have managed many half black half white hairlines with some veering toward the black and some veering toward the white depending on the prevalence of their overall facial features and hair quality to influence my design work. This is also true for mixed Asian individuals that I have worked on. So the term “Mestizo” today really applies almost to all races owing to the intermarrying that is more prevalent today. Using these basic guidelines is still a helpful starting point for any novice or skilled hair transplant surgeon.