Creating a Natural Hairline In
Creating a natural hairline is one of the most important
elements of a successful hair transplant. Our 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 session; they will no
longer tolerate an embarrassing grafty phase. This high
"degree" of naturalness can be achieved using
the techniques and the methods described below.
KEY CONCEPTS IN CREATING A NATURAL HAIRLINE
Use Specifically "Follicular Unit" Micrografts
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 microgafts 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 as
much 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 tinier, less traumatic incisions
Additionally, the minimal amount of epithelium left
on follicular unit's limits the potential for pitting,
which can still occur when untrimmed micrografts, placed
Conceptualize A Larger Total Hairline Area
Most discussions about hairline focus only on the first
.5-1 cm anterior border of the hairline, commonly referred
to as the "transition zone". In contrast,
I conceptualize the hairline as a larger, 2-4 cm area
bridging the bald forehead to the mid 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 defined and
dense. Both these zones are important to the overall
appearance of the hairline.
The "Transition Zone"
The transition zone, consisting of the first .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 sever 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 is the 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
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 does this without
placing hair directly in the transition zone thereby
limiting the chance of creating too straight or solid
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 follicular units in the mid central portion
of this zone ( were the frontal tuft is usually 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
Use A Larger Number Of Follicular Unit Micrografts
in the First Session
Sufficient numbers of micrografts 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 sessions. This effect begins
to occur when micrografts are place an average of 1-2
mm apart (or about 20-30 micrografts per square cm).
This calculates to be about 500-700 follicular units
placed in the total hairline area ( combined transition
zone and defined zone) during the first session. Higher
degrees of dense packing (30-40 micrografts per square
cm) are possible with today’s techniques but the
temptation to place grafts this close together in the
hairline zone should be resisted. Otherwise the hairline
area could become denser than the central region and
give an abnormal ring like effect when viewed from above.
In nature the hairline zone is always less dense than
the central region.
Do Not Place The Hairline Too Low
The hairline should be placed at a level appropriate
for the severity of baldness. Standard rules for determining
hairline placement have the potential of placing it
too low, especially in patients with more severe degrees
of hair loss. In these patients, raising the hairline
by as much as 1-2 cm may be appropriate.
Preserve A Soft Frontal-Temporal Angle
The normal angle formed by the juncture of the frontal
and temporal hairlines needs to be preserved. It should
not be cut off or blunted. It should be soft and ill
defined. The apex of this angle needs to be positioned
further back in patients with more severe degree’s
of hair loss. It is important to pay attention to the
change in direction and elevation of grafts positioned
around the apex of this angle.
Planning And Drawing the Hairline Zones (Figure 1,
Mark 3 important reference points: 1) The mid-anterior
border of the hairline (point X),
and 2) Both frontal- temporal angles (points Y). The
mid-anterior border of the hairline (point X) is about
8-10 cm above the glabella and usually at the point
were the forehead changes from horizontal to vertical.
The frontal-temporal angles (points Y) are located with
the help of 2 reference point lines. Line 1 is a vertical
line drawn from the lateral epicanthis. Line 2 is a
vertical line about 1 cm in front of the auditory meatus.
The intersection of these 2 lines is a good starting
point for the apex of the frontal-temporal angle. These
rules give good approximations for the location of these
reference points but may need to be adjusted posteriorly
or anteriorly depending on the severity of hair loss.
After the reference points are marked, draw 3 lines
that demarcate the proposed "transition zone"
and "defined zone" . Line A is the connection
of the 3 points described above. It is the most anterior
border of the transition zone. Check for symmetry of
this line by using a mirror. Line B is drawn about .5-1
cm behind Line A. It is the anterior border of the defined
zone. Line C is drawn about 2 –3 cm behind Line
B. It is the posterior border of the define zone.
Mark off an area in the central part of the defined
zone for the possible placement of
3 hair follicular units.
Making The Incisions (Figure 4, 5, 6)
A key principle when creating an irregular, soft transition
zone is to start with the defined zone and then move
to the transition zone. First "marking" incisions
are made along the anterior border of the hairline (Line
A.) These incisions should be about 1 cm apart and slightly
irregular. Placing some in front and some behind the
line helps create the irregularity. These marks ensure
you will not lose the position of the hairline and allows
you to safely move to the anterior portion of the defined
zone (Line B) Incisions in this zone are placed in a
staggered pattern about 1-1.5mm apart creating organized
disorder (Unger). When small grafts are placed this
close together the eye does not recognize this as a
pattern. This is preferable to random placement which
can lead to skipped areas and uneven distribution of
After the "defined zone" has been established
the following technique is used to methodically create
a framework for the "transition zone". Incisions
are made that create multiple triangular shaped bridges
between the defined zone and the anterior border of
the transition zone. The shape of each bridge resembles
an elongated triangle and contains about 6-10 incisions.
The tips of these triangles are the original marking
incisions that were made on the anterior border of the
"transition zone". The base of these triangles
extends into the "defined zone". When this
is finished a framework has been created for an irregular
pattern in the transition zone. This pattern has been
described as resembling the rays of a sun that become
less intense as they radiate through the "transition
After creating this framework artistic skills are used
for fine-tuning. Several more passes are made through
this "transition zone" filling in obvious
spaces but keeping the same general pattern and being
careful not to get rid of the irregularity.
Grafts are cut under a microscope. The 1.2.3 hair grafts
are separated into different petrie dishes to facilitate
selective placing. In addition assistants are instructed
to look for and isolate finer 1 hair grafts for the
most anterior portion of the hairline (sentinel hairs).
1 hair grafts are used in the "transition zone".
A shift is made to 2 hair grafts at the "defined
zone". 3 hair grafts are used in the mid central
portion of the "defined zone"(the frontal
Frontal Temporal Angle
It is important to pay attention to the change in direction
and elevation of grafts positioned around the apex of
the frontal temporal angle. Incisions become more lateral
and lie flatter. Incisions in the temporal point hairline
should lie flat and have a more posterior direction.
Final "Stick and Place" Fine Tuning
About 100 grafts are usually saved for the end of the
procedure to further fine-tune the hairline. Look at
the hairline and "stick and place" these extra
grafts at points where they are needed. One hair grafts
are put in the transition zone if needed. If the transition
zone is satisfactory then the one hair grafts are paired
to create 2 hair grafts and placed in the defined zone.
Once again it is best to concentrate more grafts in
the frontal tuft region because density in this region
is crucial to an aesthetically pleasing affect.
The principles and techniques outlined in this paper
will help Physician meet the expectations of today’s
patients. We can now establish a natural hairline during
the first surgery that can stand on its own independent
of further sessions. It is not enough to "just
use micrografts". Proper selection and use of follicular
units, combined with artistry and skill, provide us
with the tools to follow natures lead in creating deliberately
irregular, soft hairlines, while establishing the illusion