Considerations in Establishing a Natural Hairline

PAUL ROSE, MD

ABSTRACT: The rebuilding of the frontal hairline is a crucial aspect in providing patients with a natural appearing hair replacement result. Often transplant surgeons attempt to con­struct a frontal hairline that is a dense wall. This has an unnatural appearance. The author examines the frontal hairline of individuals who have retained a significant portion of the hair in this area and relates this to a system of planning and constructing a more natural hairline.

 

INTRODUCTION

Many of the patients we observe in hair replacement consulta­tions who have undergone previous surgeries have good to excellent results. However, we notice that many of them appear to have a hairline that looks like an attempt to build a curved wall. Although the basic hairline follows guidelines discussed in the literature, the hairline is of one radius and has no irregularities. Making this initial line very dense and uniform makes it appear even more unnatural. There is no undulation in the hairline and the hairs are not grouped or scattered outside the hairline.

In carefully examination of the hairline of individuals with a significant amount of frontal hair, it is apparent that there are several components to a natural hairline and surrounding area. There can be ethnic variations which one must consider, but in general there appears to be: undulation, grouping of hairs, irregular irregularity, variation in hair thickness, progressive density, and random or isolated hairs outside of the apparent hairline.

UNDULATION

   The hairline in men without frontal alopecia has an undulating contour (Figure 1). The hairline courses in and out several millimeters along the path of a basically curved area or parabol­ic shape. The indentations and projections occur at irregular intervals and vary in depth and width. The pattern is similar to the geographic border of a land mass. To achieve a natural appearing hairline, we should try to duplicate this formation. In Blacks and persons of Middle Eastern origin there can be less undulation.

IRREGULAR IRREGULARITY

Although there may be an appearance of overall uniformity at a superficial glance, there is in fact randomness. The hairs along the hairline and also throughout the scalp are not evenly spaced. Hairs grow at various distances and in different numbers. We also know that hairs row in groups, usually of 1, 2, or 3 hairs. The spacing from one hair to an adjacent hair can vary from less than one millimeter to a couple of millimeters.

Attempting to place grafts at regular intervals works against constructing a natural hairline. A pattern may be a good start, but in the author's opinion, a pattern should not be used throughout the transplant area.

VARIATION IN THICKNESS

At the hairline there are hairs of varying thickness. Thinner hairs tend to be present at the anterior aspect and temporal areas. This is to be expected, as these hairs are often the initial hairs to miniaturize and recede as pattern alopecia unfolds. It is therefore important to utilize the finer donor hairs in these areas. Using coarse hair makes it appear unnatural and the human eye is drawn to this aesthetic aberration.

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GRADATION OF DENSITY

There is an increasing degree of hair density as one moves posteriorly from the actual frontal hairline. The appearance of density actually appears behind the first rows of hairs. This is the perceived frontal hairline. Marked density does not generally begin from the initial row of hairs. Hairs are spaced farther apart at the anterior line and then dense packing occurs behind this. It is particularly important to have density in the central area. Obviously, as one approaches an area of thinning, in the crown, if the area is to remain sparse, smaller grafts should be used at the edges.

RANDOM "ISLAND HAIRS"

When we look at the frontal area, it is apparent that there are some randomly scattered hairs that bear little relation to the cur­rent location of the hairline. In some instances these are simply remnants of where the hairline once existed. Nevertheless, the "island hairs" contribute to a natural appearance.

DISCUSSION