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Creating a Natural Hairline
FOR PUBLICATION IN TEXTBOOK ON HAIRLINE EARLY 1999
Ron Shapiro M.D.
CREATING A NATURAL HAIRLINE IN ONE SESSION
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 closer together.
Additionally, the minimal amount of epithelium left on follicular unit's limits the potential for pitting, which can still occur when untrimmed micrografts, placed too deep.
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 an appearance.
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 in nature.
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, 2, 3)
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 density.
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 zone". (Zupan)
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 tuft area).
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 of density.