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«INTRODUCTION Creating a natural hairline has always been one of the most important elements of a successful hair transplant. Our ability to create a ...»

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Ronald Shapiro Md, Facial Plastic Surgery Clinics of North America, 2004, Volume 12, Number 2 :201-218


Creating a natural hairline has always been one of the most important elements of a successful hair transplant.

Our ability to create a natural hairline has dramatically increased over the years. Many of us promise full and undetectable hairlines in our promotional materials. Not unexpectedly patient’s expectations have also increased. Today, patients expect an undetectable hairline that has enough substance (density) to stand on its own after one session. They will no longer t olerate an embarrassing grafty phase.

We are better equipped now, than in the past, to create hairlines that meets these higher expectations. In part, this is simply due to the use of greater numbers of smaller, more natural looking follicular unit grafts (FU’s) in the hairline region. FU’s have given us finer paintbrushes with which to create a hairline. However, equally important has been a better understanding and recognition of the visual characteristics that make up normal hairlines. Simply using FU’s without a deliberate attempt to reproduce these characteristics does not guarantee a normal hairline (Fig.-1). In other words, to create the most natural looking hairline, we cannot simply use a finer paintbrush; we must also know how to utilize this finer paintbrush.

Fig 1: This is an example of a hairline created exclusively with FU’s but still looks too abrupt and straight: Using FU’s does not automatically mean “naturalness”. Proper distribution and placement is also necessary.

The article discusses the principle visual characteristics of a natural hairline and some of the techniques used to reproduce them. In addition, a systematic, step by step approach for consistently creating natural hairlines is described at the conclusion of the article.


“TRANSITION ZONE”, “DEFINED ZONE” AND “FRONTAL TUFT” AREA There are a number of excellent articles that exist on hairline design.[1, 2, 3, 4, 5, 6, 7] However the majority focus only on the most anterior border of the hairline, commonly referred to as the transition zone. In contrast, I find it useful to conceptualize the hairline as a larger, more extended region, approximately 2-3 cm deep, bridging the bald forehead to the area of central density. (Fig.-2) [8. 9] 2 FIG-2: “EXTENDED” HAIRLINE ZONES: I conceptualize an “extended

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This extended hairline region can than be divided into three smaller zones:

The anterior portion which is the traditional transition zone,  The posterior portion called the defined zone.

 A small oval area in the central portion of the defined zone called the frontal tuft area.

 All three zones make their own unique contribution to the overall appearance of the hairline.

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Transition Zone The transition zone consists of the first.5-1 cm of the hairline (Figs.-2 & 3). It should initially appear irregular and ill defined but gradually take on more definition and substance as it reaches the defined zone. Close observation of normal transitions zones reveal a number of specific elements that work together to create this overall affect. They are described below.

Micro-irregularity- It is important to vary the density along the transition zone. Close examination of  normal hairlines reveals that small, “intermittent”, triangular shaped areas of higher density contribute a great deal to the appearance of irregularity. (Fig.-3) This form of irregularity is referred to as “microirregularity” because it is more noticeable under close examination than from a distance. Parsley has called these areas of “intermittent” density “clusters” and the area between them “gaps”. [10] There is a natural tendency to “fill in the gaps” caused by this micro-irregularity in the transition zone. This impulse must be overcome to prevent the creation of a too straight or solid appearing hairline.(Fig.-1) 3 Macro-irregularity - If one stands back and looks at a normal the hairline from a distance the path of the  anterior border is seen to be more serpentine or curvaceous than linear. This form of irregularity is referred to as”macro-irregularity” because it is more obvious when the hairline is observed more globally from a distance (Fig.-3). Martinique has used the term “snail-tracking” to describe this appearance.[11] Parsley has attributed this macro-irregularity to existence of one to three “mound” or “protrusions” along the path of the hairline.[10] He describes one central mound (the widows peak) and up to two lateral mounds on either side of this central mound. Micro- and macro- irregularity work together in the transition zone to create a natural looking hairline.

Only one-hair FU’s should be used in the anterior portion of the transition zone with a shift towards two hair FU’s toward its posterior portion. Occasionally a few isolated,very fine single hairs called “sentinel ” hairs can be found scattered in front of the transition zone The width and density of the transition zone should be adjusted based on the severity of hair loss. The  greater the degree of hair loss, the wider and more diffuse this transition zone should be, mimicking the pattern found when more severe hair loss occurs in nature.

Defined Zone The defined zone is the 2-3 cm wide area that sits directly posterior to the transition zone (Figs.-2 & 3). In this area the hairline should develop a higher degree of definition and density, yet still appear totally natural (undetectable) under close examination. Concentrating two and three- hair FU’s in this area nicely accomplishes both goals. Density in this zone creates a fuller looking hairline by limiting the distance that can be seen past the transition zone. It creates this affect without placing hair directly in the transition zone, thereby limiting the chance of creating too straight or solid appearing a hairline.

Frontal Tuft Area The frontal tuft is a small but aesthetically significant oval area that overlies the central portion of the defined zone directly behind the transition zone in the midline. (Fig.-2 & 3) In addition to being undetectable this area should have an even higher degree of density than the rest of the defined zone. James Arnold impressed upon me the aesthetic importance of density in this frontal tuft area with the following example. [12] He would say “Consider a patient who is totally bald except for a fairly full frontal tuft area... Imagine he is standing in an elevator facing the door with you on one side and him on the other..When the door opens your first impression, looking at him straight on, would be of a person with a fairly full head of hair. It would only be when you walked by him that you noticed he was bald everywhere else.”


HAIRLINE Most physicians agree that FU’s should be used in the transition zone. However, in the rest of the extended hairline region (defined zone and frontal tuft), opinions vary with respect to whether FU’s or small slit minigrafts should be used. As stated earlier, these areas of the extended hairline need to be undetectable yet take on a higher degree of definition and density in the first session. In my opinion, properly distributed two-, three-(and if available four) hair FU’s are the most affective grafts for creating this affect. This is because three to four hair FU’s (cut to natural groupings) are smaller than three to four hair small minigrafts (cut to size), with equivalent amount of hairs. ( Fig.-4) They therefore can be placed in smaller incisions, closer together in a single session.[13] An exception to this generalization would be for patients with very fine, or white hair where the use of FU's are not as necessary for the creation of naturalness but may increase the chance of waste.


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USE “PROPERLY” TRIMMED FU’s Saying one should use exclusively FU’s in the extended hairline region (as stated in the previous paragraph) is not explicit enough since all FU’s are not created the same. FU’s containing the equivalent numbers of hairs can also vary significantly in geometric size and shape depending on the skill of the cutter and the specific technique used to create them. In my opinion, FU’s used in the hairline region should be “properly” trimmed.

This does not mean creating “skinny” or “stripped” FU’s. This means creating “tear drop” shaped FU’s that have been trimmed of excess surface epithelium, but leaves a little more tissue around the inferior portion of the graft. (Fig.-5) [14] FU’s units deliberately trimmed in this manner have a number of advantages over

micrografts that are either trimmed too much (stripped) or not trimmed enough:

They are smaller than untrimmed micrografts with equivalent amounts of hair. This enables them to be  placed in smaller incisions that can be made closer together.

The minimal amount of epithelium left on these FU’s limits the potential for pitting, which can still occur  when untrimmed micrografts are placed too deeply.

The extra tissue around the inferior portion of these grafts theoretically makes them less susceptible to graft  trauma and dehydration and therefore increases their chance of survival.

Unseen telogen hairs are at less risk of being discarded. This is particularly advantageous for the two to  three hair FU’s placed in the defined zone and frontal tuft area where a few extra hairs for added density is beneficial.

An instance where more extensive trimming may be desired exists for the one hair FU’s that are going to  be used for sentinel hairs or the most anterior portion of the transition zone. These grafts are trimmed a little more aggressively to ensure they are indeed pure one hair FU’s with no unseen telogen follicles.

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This number of FU’s is based on a conservative degree of “dense packing” (20-30 FU’s/cm2) and one that I think most physicians have accepted as safe for FU viability. Higher degrees of “dense packing”, defined here as 30-40 FU’s/cm2, may produce good hair survival in skilled hands[15], but this is more controversial and usually is not necessary to produce a good cosmetic result.

In reality these 600 -900 FU’s are not evenly distributed throughout the entire hairline region. A deliberate effort is made to mimic normal density gradients and position incisions slightly closer together in areas where higher density is aesthetically significant (i.e. the frontal tuft area, the areas of “intermittent higher density” or “clusters” found along the transition zone and described earlier). (Fig- 3) In these specific areas of the extended hairline region the density will be slightly higher (~25 to 30 FU/cm2) while in the rest of the extended hairline region, by default, the density will be slightly lower (~20 to 25 FU's/cm2).

USE “SELECTIVE SEPARATION” AND “SELECTIVE DISTRIBUTION” Separating and selectively placing one, two, and three-hair FU’s allows us another method of controlling the distribution hair density in order to mimic the density gradients found in normal hairlines. There are some techniques of creating “micrografts” (such as the impulsive graft cutting device described by Mangubat [16]) that do not allow for the separation of different size grafts. In these circumstances one-, two-, and three-hair micrografts are “lumped together” and we lose the benefit of “selective distribution”. I typically use the following selective distribution of grafts in the various zones. (Fig.-6) The anterior portion of the transition zone should contain only one-hair FU’s with a shift to two-hair FU’s  toward the posterior aspect of this zone. If enough one-hair FU’s can’t be found naturally, they can be created by carefully dissecting away finer hairs from existing two and three-hair FU’s. Careful division of hairs within an FU does not appear to impair the viability of the resulting follicles. [17]. One hair FU grafts can vary in thickness. Having your assistants specifically search for and separate approximately 75-100 of the finest one-hair grafts, for use in the most anterior portion of this zone, adds to your ability to produce naturalness. In addition, it has been postulated that using some one-hair FU’s, with the bulb removed, at the most anterior portion of the transition zone, may be useful if hairs of especially fine caliber are needed. [18,19] 6 Larger two to three-hair FU’s should be placed in the defined zone, concentrating a greater proportion of  three-hair FU’s in the midline central portion of this zone (the “frontal tuft” area).

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USE “FOLLICULAR PAIRING” Sometimes more one-hair FU’s are created than are needed, while, at the same time, it may be more desirable to have a greater number of two to three-hair FU’s for the defined zone and frontal tuft areas. In such circumstances, the technique of “follicular pairing” can be useful. This is the process, whereby an artificially larger “paired” FU’s can be created by combining two smaller FU’s and placing them in the same incision.


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Harris has called this technique “Recombinant” FU grafting.[20 A two-hair graft can be artificially created by combining a pair of one-hair FU’s; a three-hair graft can be created by combining a one and two-hair FU; a four-hair graft can be created by combining a pair of two-hair FU’s. These “paired” FU’s can be placed into the same sized incisions that are used for a single FU graft. The minimal extra tissue and small size of the FU’s allows for this process. “Follicular pairing” is yet another method that allows us to selectively increase density in specific critical areas. This method is unique in that it allows us to increase the density in specific areas without making more incisions. (Fig -8) 7


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