Natural Hair Transplant and Hairline

Hairline design is essential for natural hair transplant result. Patients usually worry about surgery outcomes and whether their hair will look natural afterward. Natural hair transplant completely depends on surgeon’s skills. The design of an appropriate front hairline contributes a lot to a natural hair transplants. When does hair transplant give natural result?

• Patient’s Age (Hair transplant may not suite young people due to rapid hair loss cycle).
• Hair loss intensity and inheritance (father, uncle, elder siblings). The family inheritance can provide an approximate image of the intensity of hair loss in a candidate. 
• Face traits and forehead width. The hairline should be designed according to face structure.
• Donor Graft Number. The number of grafts on the back of the head, beard, and body should be determined. The grafts are harvested equally based on hair loss intensity. A hair reserve is left for the possibility of another hair transplants in the future.

Hairline Definitions

There is a general classification of some hairline types. They are suggested by Dr. Shapiro, here they are:

• Frontal Hairline FHL. The complete front hairline belongs to it. FHL ends on whiskers and beard areas.
• Mid Frontal Point MFP. The merge point of right and left hairlines.
• Mid Pupiller Point MPP. It is the midpoint where a line perpendicularly to the pupil meets the front line.
• Transition Zone (TZ). The very front line of the hairline. It should be 1-2 mm wide and consist of only single-rooted hair. It also should be rarer than the rest area. If possible, single grafts to be the thinnest.
• Defines Zone (DZ). The area right after transition zone, 5-8 mm wide. This area should be denser. Usually, double grafts are selected for transplantation to this area. 
• Frontal Temporal Angle (FTA). The connection point of the frontal hairline with whiskers is called FTA. Both areas are separated from the junction by angles.
• The Lateral Hump (LH) or Lateral Fringe. It is the name given to the area where the parietal (side-haired area) and the balding areas meet backward from the temporal hairline.
• Temporal Points (TP). The temporal area is the outer triangles of whiskers.
• FT (Frontal Truft). The round or oval area right after the front line. This area should be the densest. Multiple rooted hairs perfectly suite it. We suggest multiple rooted hair implants to candidates with dark hair since in blonds this density does not create a natural look.  
• Frontal Hairline Region FHR. The area that includes DF, TZ, and FTA. It is located in 2-3 cm from the frontline and quite wide. Approximately 1.000-1.200 grafts are enough. A very high density increases the risk of tissue necrosis.
• Epicanthus Line. It is the vertical line drawn from the lower and upper eyelid junctions to the front temporal point, which we call FTA.

What is Hairline and Natural Hair Transplant?

It is important to understand that the candidate with mid-degree hair loss cannot return the hair density he/she had at the age of 18. It is one of the hair transplant illusions. It is impossible to return the inherited density within one session. You are better to prioritize the natural look of the transplanted hair. This is the result when the difference between transplanted and natural hair does not exist. The candidates considering natural hair look results must be careful in choosing a good center and a doctor. The doctor should evaluate the intensity of hair loss in advance taking into consideration the age.

At later ages (40-50) the hairline should not be very low because it spoils the natural look of the hair. Additionally, a suitable design has to be made for whisker and temporal area. The reason for a  ‘grass man’ look is the improper design of the hairline.

Moreover, the hairline must be designed considering the intensity of hair loss, age, and the donor area capacity. Usually, candidates want the hairline to be in the very front. They bring pictures of themselves at the age of 18 asking the same result. If the transplant is operated in young people whose hair loss is very intense, hair falling out may continue and after a few transplant sessions, there will be no hair left on the donor area too. Unfortunately, the number of grafts in the donor area is limited. An experienced doctor identifies the donor area capacity, determines the hairless area, based on the proportion of these two he creates a suitable hairline.

How to get a natural-looking result? The hair transplant to look natural a very good designed hairline is needed. The best approach is to make a line based on one that was inherited.

1. Grafts on the front line should be single. The grafts that are implanted in the very first hairline should be single-rooted. Moreover, if possible, these grafts should be the thinnest. The grafts on the back of the head donor area are thicker and they are not appropriate for the front line. The hair on-ear and neck are thinner and single-rooted. They are suitable for the front line transplant and create a more natural look. The transition area called TZ should have an increasing density from the front to the back. The density of the front hairline is 25-30 grafts per square centimeter. It is not correct to transplant a bigger number of grafts per square centimeter. Additionally, this can destroy some hair follicles. The hair on the front line must be implanted randomly and rarely to contribute to the natural result. In opposite, a proper and straight hairline looks artificial.
2. Sufficient and Strong Donor Area. How many strong and healthy grafts can be taken from a candidate not affecting the donor area? The total donor capacity is to be identified first. Then, the receiver area is calculated in square centimeters and grafts number to be transplanted to 1 cm2. It is hard to get a natural-looking result when the case is Norwood 6-7 and donor area capacity is low.
3. Density. To achieve natural results 30-35 grafts should be transplanted to 1 square centimeter. The fewer number of grafts may not create an expected outcome. It is also important to make a smooth transition from the hairless area to the dense. The natural look is spoiled when there are gaps.
4. Design of the proper hairline. Young people usually expect straight hairline because it is difficult for them to realize their hair loss. Yet, at later ages, implanting the hairline on the very front is not correct. The hairline must be properly designed at candidates who have very intense hair loss and similar problems maintain in the family. We do not find appropriate a must for young people to take medicines like Finasterid / Minoxidil to preserve the hairline. To ensure the natural-looking results pop-outs like pitches should be avoided. The best approach to create a more natural look is light, transparent, and wavy implant of the line.

Frontal Hairline Design

The creation of the frontal hairline starts with the identification of a middle point.

Midpoint Determination (MFP Detection)

Two lines help to determine the middle point, they are:

• Glabella Line. The horizontal line from the upper eyelid and nasal flaring.
• SEBL line (Supra eyebrow line). It is a horizontal line drawn from the top of the eyebrows.

It is used to identify the merge point of two lines. The difference between the two lines is 1 cm. Gabella line is 1 cm down.

The perpendicular line to Gabella is drawn upwards. Its length is 7 cm. This 8 cm point, as mentioned above, is called a midpoint. For patients with a wide hairless area, an 8 cm point is not suitable because there may be not enough grafts on top and middle areas. We think that the line should be extended to 10 cm in these candidates. When the SEBL line is taken as a point of departure, the length drops to 1cm. 

The perpendicular line to Gabella is drawn upwards. Its length is 7 cm. This 8 cm point, as mentioned above, is called a midpoint. For patients with a wide hairless area, an 8 cm point is not suitable because there may be not enough grafts on top and middle areas. We think that the line should be extended to 10 cm in these candidates. When the SEBL line is taken as a point of departure, the length drops to 1cm. 

There is also another way of midpoint identification. A horizontal line is drawn from the nose wing upwards vertically and from the top point of the skull. The point corresponding to the angle of 45 degrees from the junction of the horizontal and vertical lines is marked. This is how the midpoint is easily found. Based on the front hairline SEBL it is in 7-7,5cm. As for Gabella, it is in the 8-8,5cm distance. This is the maximum front point of planning the hairline, it is not appropriate to go down further.

The midpoint in candidates with Norwood 6-7 should be 1-2 cm higher. In addition to all, the patient’s hair loss intensity, face structure, expectations, and donor area capacity should be taken into consideration. On the opposite, if the hairline is lifted too high, then the baldness look occurs.

Setting the Slope of the Hairline

The midpoint of the front hairline together with an angle of the temple area merges in a slope. The counter is created in several ways.

• Round hemioval line

The creation of this line is more comfortable compared to other approaches. It is easier for young candidates who are not sure if their temporal line moves backward. The line is planned to remain forehead wrinkle beneath. Yet, this kind of planning may be disadvantageous comparing to other ways. The front centerline is directly connected by bending the temple area junction point.

• Flamed line

The most favorable line to create a natural look. It is round and connected to the temple area. Epicanthus line is merged with the temporal angle. It is marked 1cm below the temple area. This 1cm difference may seem insignificant, but it completely changes the final look of the hair. 

• Straight or slightly round Line

The natural-looking results are easily achieved in candidates with Norwood 2-3-4 and if the hair loss is not very intensive.

Connection of Front Hairline with the Temple  (FTA Determination)

As determined previously the FTA is the connection of the temporal angle with the front hairline. The upper angle point is a merge with the front hairline, while the lower angle side is the beginning of the temporal line.

Lateral Epicanthus Line. The connection point of the upper and lower eyelid is called epicanthus. The line is drawn to the front line. FTA merge angle can be planted on the intersection of epicanthus and temporal lines.

The frontal line from the midpoint (MFP) of the anterior hairline is drawn to the frontal temporal angle that is called FTA should be inclined upward. It must be curved downwards. The hairline planning in women is completely different and we will describe it in another article. The planning is much easier in type 3-4 when the temporal hairline did not disappear totally. As for candidates whose temporal line is lost, planning requires more accuracy.

Determination of the Angle and Shape of the Front Hairline

There are three points that determine the front hairline

• MFP
• FTA
• MPP

MFP and FTA are connected with a single line. The MPP point is the starting point of the backward opening towards the FTA. This opening can be oval or round. In advanced hair loss, a curved inner opening should be made as approaching the FTA.

Usually, the patients want to have the hairline as low as it is possible. It is inappropriate to make when the donor capacity is poor. A very slight wavy line can be implanted to meet the expectations of the patient, this is the only solution.

Other candidates want to have the temporal hairline denser and more explicit. The number of grafts for the temporal area should be distributed very carefully. The number depends on the total graft capacity of the candidate and the wideness of the receiver area.

Hairline Direction Determination

• Angle and Direction Determination

It is not enough to just transplant the single grafts to front hairline, grafts position planning should also be made. The hair on the front hairline should be implanted under 15-20 degrees directed downwards. They can be implanted headed to the right and left. If the candidate’s front hair lost completely, he/she can advise us of the angles and direction. When the front hair still remains, we can implant the grafts in a suitable direction and angle (they are called baby hair). Through practice, we discovered 6 different directions. The non-natural result is obvious when the hair is transplanted under the wrong angle and direction.

1. Direction from right to left. In the middle area, the directions get almost paralleled. The parallel of right hair is reduced as approaching the midline. If the hair is placed straight down to the middle area, it creates a curve towards the right.
2. The opposite side of the 1st direction described above.
3. By opening from the right, it continues until the left temporal joint. The directions are from right to left.
4. The hair from right left and middle lines grow down straight.
5. The opposite symmetrical direction of the 3rd option.
6. The direction of the hair is fan-shaped. Right hair is directed to the right, left to the left. The middle hair implanted straight downwards.

These pictures illustrate these 6 direction options

Temporal Point and Hairline Form

The temporal point is an angle of the triangle. It can be pulled back in time in candidates whose hair loss progresses. When the case is advanced hair loss, it can disappear completely. The movement of the TP back notably opens the face. Hair loss is more noticeable in this case. The professional design should be made when planning the TP point and temporal hairline.

Temporal area hair loss is classified by Mayers. He classifies it as follows

1. Normal (N) The temporal hairline is normal, there is no hair loss.
2. Thinning (T) The temporal area is clear but there is root thinning.
3. Parallel (P). The temporal point started fading. The temporal triangle disappears as approaching to whiskers. There is a flatter and parallel look instead of a triangle.
4. Reverse Look (R) The temporal triangle completely disappeared, moreover, there is a concave look.

Usually, on the 3rd stage, there is still no need to create a temporal point from the beginning. The density increase of the rare area is enough. At the end of the 3rd stage and beginning of the 4th, the temporal area should be designed newly. Let us study how the temporal area designed in candidates who lost the line completely.

A drawing is made to create a temporal triangle. The technique is illustrated in the picture below.

1. The first line is a connection point of MFP and a line drawn from an earlobe.
2. The second line connects a line from a nose tip with an eye pupil.
3. The third line is drawn straight from an earlobe to an MPP point.

The merge of the 1st and the 2nd lines, or the 2nd and the 3rd can be identified as temporal points (TP). People who do not suffer from hair loss have a Temporal triangle point. This point is very problematic and extreme. An experienced doctor can easily determine the temporal triangle points based on age, donor capacity, and hair loss intensity of the candidate.

The hair transplanted to the temporal area should be almost attached to the skin, they are implanted under 5-10 degrees. Also, the hair direction should be towards ears or down.

Correct Angle Hair Transplant

This is one of the main factors in the natural look of transplanted hair. We can answer the question about natural look results in transplant hair in one sentence. This is to imitate the same hair design and angle as was inherited. The hairstyle can be determined in a candidate when his/her photo is taken from the top of the head. The candidate should have a 2nd or 3rd shaving type. Let us examine the hair angles:

1. Whiskers Area: transplant is made under a 5-10 degree angle. Pen implanter is the best option in this case. Grafts are implanted almost attached to the skin. The hair in the head front and sides is placed directed down, this creates the image of an opened fan.
2. Front and Temporal Hairline Angles: A 10-20 degree angle is appropriate for these areas. More vertical angles do not give a natural look.
3. Middle and back area angles: Angles at degrees like 25-35-45-55 are implanted gradually.
4. Vertex (Crown Area). Certain experience is needed to transplant in this area. Implant direction reminds a spider.

Hairline Design for Natural Hair Transplant Results

We already mentioned that a candidate face traits are the main factor for design. Face shape can be wide, round, or oval. The hairline level is adjusted according to the width of the forehead.

The age and grafts number are also very important. Placing the hairline too low can also cause problems further. A static hairline results in a natural look.

Another thing is that the line should nor be very straight. Some doctors do transplants very zigzagged like a blade trying to get a natural look. Unfortunately, this does not give the expected outcomes. The natural look results can be achieved by implanting slightly wavy.

Mathematical calculations are needed in planning the hair design. The operation doctor should determine the ratio of chin, nose, and hairline.

Do not forget that there is no connection between natural results in hair transplants and the FUE or Fut techniques. Type of the operation is different from natural outcomes.

DHI Method and Natural Hair Transplant Results

It is easier to achieve natural results with the Dhi Hair transplant which is the pen implanter method. The Dhi helps to implant grafts under a very low degree. It is the best option for a natural-looking hair transplant. due to thin tooltips, there are no scars left. An opportunity to implant dense is a big advantage as well.

As for the channel method, firstly, the channels are opened and roots are placed into them in the DZ area. Then, the hair is implanted into the TZ, which is an advantage in creating a proper hairline. This is because it is easier for operation doctor to start surgery with simple area and progress to sensitive further. This approach leads to an easy channel opening and hair implant in the TZ area. There is no need for the Dhi hair transplant in this method.

Briefly About Natural Hair Transplant

• First of all, a hairline is marked with a pen
• Later, the MFP, MPP, and FTA points are merged, as mentioned above.
• To determine the width of the TZ area MFP and MPP are connected and a slight curve is drawn to join the FTA.
• Then the symmetry of the right and left areas should be adjusted. The symmetry is easily identified in front of the mirror or camera lenses. The horizontal line from the MFP point is drawn by a regular pen. No need for perfect symmetry in planning, the design should be made based on the inherited hairline, there is always a slight difference between the right and left sides.
• A ratio between total donor capacity and receiver area width should be calculated. Will the hair cover hed top and the back when the hairline is implanted low? An operation doctor should do proper proportions.
• A candidate’s opinion in hair design should be considered. If there are a candidate’s relatives, friends, additional advice can be taken from them. 

Dr. Hakan Doganay is a leading hair transplant specialist not only in Turkey but also in the World. You can find here the natural look results of his hair transplant.

Frequently Asked Questions

References

1. Hair transplantation in patients with hair loss or scar deformity in the side hairline after midface lifting surgery. Arch Plast Surg. DOI: 10.5999/aps.2018.00591 https://journals.lww.com/annalsplasticsurgery/Fulltext/2019/03000/Nonshaven_Follicular_Unit_Extraction__Personal.3.aspx