Hairline design in hair restoration surgery

When conducting hair transplants, critical hairline design techniques can make all the difference between a long-term, natural looking outcome and a head of hair that looks awkward and artificial.

Patients often desire a much more youthful appearing and thick hairline, but when doctors oblige to those wishes, they are eventually doing the patient a grave disservice, because the greater goal of patients and doctors alike for a natural appearance is usually compromised, says Paul McAndrews, M.D., clinical professor at the University of Southern California School of Medicine.

"Every corrective hair transplant patient says the same thing - 'I never wanted more hair if it wasn't going to look natural,' and their desire for a natural, undetectable hair transplant eventually trumps all other concerns," Dr. McAndrews says.

"It is tempting to try to solve the patient's acute goals, however, it's much more important to use foresight and consider how this hair transplant will look 20 to 30 years from now."

For hair transplants to be successful in the long-term, it is critical to consider that patients are limited by the amount of good genetic hair that can be transferred to the balding area, and the establishment of the hairline will ultimately dictate the amount of balding scalp that will eventually need to be covered.

Hairline design

In designing that hairline, Dr. McAndrews says there are four key factors to consider: the anterior, starting point of the frontal hairline; the lateral portion, or width, of the frontal hairline; hair direction; and irregularity of the hairline.

Regarding the anterior starting point for transplants, surgeons have long followed some general rules, including dividing the face into thirds, starting 8 cm to 10 cm above the glabella, or starting at the point where the steep angle of the forehead meets the flat angle of the top of the head. And while the rules can be useful, they aren't necessarily universal, Dr. McAndrews says.

"You can't apply these rules to every patient," he says. "It's important to be conservative and not put the point too far forward, because it could eventually look like a hair piece."

Instead, the anterior point of the hairline should be placed in relation to the position of the patient's temporal points, which will recess over time and make the anterior point look progressively unnatural if it is not also recessed.

While the anterior hairline and temporal points are aesthetically important in viewing the hair-framed face from the side, the lateral portion of a hairline is critical to a frontal view, and a key consideration should be the rule that, in all humans, the apex, or tip of the temporal recession, lines up directly with the lateral part of the eye.

"That's how the face is naturally framed and if you look at a human and that framing is off, you'll notice that something is wrong right away," Dr. McAndrews says.

Then there is the shape of the lateral hairline - to truly represent the natural pattern of the aging hairline, the lateral hairline should be distinctively concave and puckered in on the side, as opposed to bowl-shaped.

"The lateral hairline becomes more concave as a person's hairline recedes, but it's very common to a transplant that is bowl-shaped," Dr. McAndrews tells Dermatology Times. "That doesn't look natural because it's not what we see with someone losing their hair."

Another common mistake in hair transplantation is to have hair coming straight out of the scalp, whereas, with natural growth, the hair in fact comes out of the scalp at an angle that is more acute as the hairline gets closer to the forehead. That effect helps give a layered look when the hair is combed backwards, Dr. McAndrews explains.