Any physician who transplants
hair should be an expert in hairline construction. While
we can create a naturally shaped hairline in one session,
it is often necessary to adjust the shape and position
in future sessions to meet the patient's desires. The
cardinal sin is to place the hairline too low. If the
hairline is higher than the final result, it can still
appear natural. The patient can contemplate the hairline
position after one session has matured and if desired
it can easily be lowered in the future. In the majority
of my patients some adjusting of hairline density and
location during the second session is necessary not
because it is unnatural but because it can be improved.
The distance between my index and little fingers (four
fingerbreaths) is 8cm. Although this distance has served
me well over the years in preventing the creation of
hairlines that are too low, the shape of the patient's
existing hairline and face dictates the distance above
a line connecting the eyebrows. I still have natural
hairs in my hairline 5cm above my eyebrows. Transplants
have been placed 6cm above my eyebrows and my hairline
looks natural. Although the 8cm. distance is a good
guideline, we must be flexible and let the patient's
features guide the location and shape of the hairline.
Although the shape of patients' skulls differs and a
horizontal hairline can be appropriate, I seldom create
a horizontal hairline as it appears too bowl shaped.
In almost all cases point A (center of the forehead)
is inferior (lower) than point B (temples). This configuration
mimics more closely a mature and timeless hairline.
Again we should be flexible and let the patient's features
guide the shape.
I have never had a patient ask to have a cowlick remade.
If fact Iâve often thought that the only advantage
to losing hair is losing a cowlick. The aberrant angulation
of the hair shaft that creates the cowlick presents
permanent styling problems. Angling transplants in the
hairline posteriorly (backwards) would recreate a cowlick.
With significant hair loss the superior silhouette,
top, of a person assumes the shape of the skull, spherical.
This spherical silhouette causes those men with extensive
hair loss to have a similar appearance, losing some
individuality of appearance. Changing this silhouette
by that formed with transplanted hair precludes the
spherical shape. Without the play of vertical against
horizontal, there can be no experience of three dimensional
space. The exit angle of the transplanted hair determines
the new silhouette. The exit angle varies throughout
the scalp. In the frontal half it normally varies between
30 degrees and 60 degrees anteriorly (forward). Infrequently,
in those with natural "bangs", the exit angle
is less than 30 degrees. If the new angulation is greater
than 60¡ the patient can appear to have a "frightened"
or unnaturally high new silhouette. As hair volume is
lost, especially in the frontal half of the scalp, prior
to assuming a spherical shape, the area first appears
flattened. Angling hair shafts posteriorly (backwards)
in the frontal half of the scalp, when surrounding shafts
emerge angled at 30 degrees to 60 degrees anteriorly
(forward), contributes to a flattened appearance. If
indigenous hair is present in the area it is usually
safe to mimic this angle with transplanted hair, except
when a cowlick is present.
Patients, especially younger ones, request the hairline
to be curved at the corners (temples) but I resist this
temptation is the vast majority of patients. Curving
at the temples can create an unnatural, animal like,
appearance. Again, the patients facial features should
guide hairline configuration.
It is important to create a density gradient at the
interface or transition zone from skin to hairline.
To guide me to create a density gradient and soft transition
zone, three parallel lines separated by 4-5mm each are
used. The first zone is the absolute interface and beginning
of the transition zone. This zone contains elongated
triangles of single hairs with low density (10-15 hairs/sq.cm).
In the second zone the single hairs are symmetrically
placed with higher density (25-35 hairs/sq.cm). The
third zone contains two hair follicular units, symmetrically
spaced, as densely as possible (40-60 hairs/sq.cm).
In one session it is difficult to achieve density greater
than 60 hairs/sq.cm. This method allows me to create
a natural density gradient in one session. It is often
necessary to increase the density at future sessions.
There is equal distance between follicular bundles,
creating a pattern with equal spacing. Aside from the
transition zone at the interface of hair and skin where
true randomness is natural, I take great pains to create
small spaces that are equal in size in each tonal plane.
Light reflects with greater intensity from curvilinear
surfaces.The location on the scalp where the hairline
is placed is the transition from horizontal to vertical,
a curvilinear surface, or tonal plane, that reflects
light with greater intensity than flat surfaces.
In our palette we not only have grafts but also spaces
between grafts to create the overall impression. Light
reflection from the scalp determines the perception
of hairloss and can be affected in a variety of ways
by altering the scalp surface color/texture or ambient
light intensity. We choose to use hair as a natural
way of obstructing light reflection from the scalp.
Light reflects from these spaces and if the spaces are
small the light reflection will be less than that from
larger spaces. If the spaces are equal in size, the
light reflection will be evenly diffused re-creating
the natural symmetrical reflective pattern.
The hairline, more than any region of the scalp, defines
the result in hair restoration. It is the signature
of the surgeon and becomes that of the patient. Recreating
a natural appearing hairline requires observation, experience,
and artistic foresight. If we classify ourselves as
artists we would be photorealists as we attempt to imitate
nature. The hairline can appear as abstract expressionism
if we attempt to express ourselves on the scalp in a
manner unlike nature. In painting, sculpture, and architecture
the materials used are inert. We construct a dynamic
result with three dimensions when transplanting growing
hair, which requires anticipation. When creating a hairline
it is more important to not get it wrong the first time
than to get it finished in one session.