The most important factors that influence successful hairline design and hair restoration are natural appearance and creating adequate density.

Other important points that will affect a surgeon’s hairline decision making include
– The patient’s age
– Anticipated severity of eventual hair loss
– Position of supporting temporal hair
– Patient’s unique head and facial anatomy
– The patient’s preferences and goals

In viewing the hairline, the viewer immediately has a sense of whether or not the person’s hair looks natural or not. It must be emphasized that within certain boundaries there is a great deal of variation as to the manner in which the frontal hairline is planned.

A hair restoration surgeon will obviously be incorporating a lot of his / her own artistic biases, but will try to make clear boundaries, beyond which a surgeon takes a risk in harming the patient or creating an unnatural transplant result, either now or at a future time in the patient’s life.

The patient’s age is a critical factor. It is so important that it affects whether to transplant the patient in the first place or not. The patient’s age and the degree of hair loss (both now and anticipated) dictate the basic design and transplant pattern, eg. will it be side-to-side “fill-in” or is it safer to use one of the Forelock Patterns. Most hair restoration surgeons have a “cut-off-rule” under which age they will not transplant. This is mostly around the 23 year age mark. For a patient in their early twenties the best policy is to create a central forelock with central density.

Because of the unknown future degree of balding when a man is in his twenties or thirties, it is wise to be more conservative in several areas, such as the hairline height; the overall density of the transplant; strong consideration must be given for a forelock type design; avoidance of transplanting the crown area.

Family history is also somewhat useful, but cannot be relied on totally to predict the patient’s future degree of alopecia.

Other factors that influence the height and contour of the hairline design are the patient’s race or nationality. In general in African Ethnic males, Asians and some people from the Middle East a flatter and sometimes lower a hairline may be designed. It is still important to be conservative in a man in his twenties and thirties because the future position of the temple hair and overall later degree of hair loss is unknown.

The position of the anterior temple hair is also of great importance. The Temporal Points help to “frame” the face with the Anterior Hairline. The Temporal Points “hold up” the frontal hair as it were. If the hair in the temporal area under the frontal hairline is weak or non-existent, then it creates a “lid-effect” in appearance and is very unnatural looking. It may even look similar to a not-so-good hairpiece system.

For patients in their twenties and thirties we have to assume that their temple hair will recede approximately by a half an inch to one inch posteriorly over a lifetime. Temporal points which are present, will disappear. The above relates most importantly to the location at which the frontal hairline intersects into the existing hair on the side of the patient’s head.

The patient’s unique anatomy also plays an important role. Some patients have short foreheads and others have tall foreheads. Likewise, some have wide heads and others are narrow and elongated. We also keep in mind that many patients have asymmetry of their bony facial and head contours, and also asymmetry of the location of their temporal hair and fonto-temporal angles.

The patient’s input and preferences are also very important. Most young patients want the hairline as low as you can make it. Others want it very high, or narrow so that people around them don’t sense a big difference occurred. Some again are bothered by deep fronto-temporal recesses and others are not. Within the limits of what is safe for a particular person’s future hair loss pattern, the surgeon should try to incorporate the patient’s wishes into formulating and designing the hairline. In patient’s over 40 years of age, future hair loss and patterns are much easier to predict and this gives more freedom with regard to hairline design.

In the younger patient, the surgeon must resist pressure from the patient to do the following: Filling in across fronto-temporal angles in a flat manner; placing the hairline too low; making the hairline too flat; filling in anterior to the temporal points.

Da Vinci’s Rule of Thirds:
The face can be divided into approximate one thirds when viewed frontally as follows – from the area of the proposed hairline or more exactly, where the hair of the newly transplanted hairline falls on the forehead to the mid Glabella area (the area between the medial aspects of the eyebrows and above the nose bridge) is One Third; then from the Glabella to the Columellar-labial angle (basically the bottom of the nose’s attachment to the skin above the upper lip) is also One Third; And then the distance from the columellar-labial angle (from below the nose) to the Mentum (Chin) is also One Third.

Sources:
– ISHRS Basic Lecture Notes 2014/2015 – Lecture on Hairline Design by Dr. Michael L Beehner
Hair Transplantation, 5th Edition, Unger; Shapiro
– Hairline design lecture, ISHRS Conference 2011, Anchorage, Alaska, Dr Shapiro, Dr MacAndrews, Dr Beehner

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