The Importance of the Hairline
The frontal hairline is singularly the most important
feature of the entire head of hair. It is the aspect of
our hair/skin interface that we, and others, see first.
When we look in a mirror, or walk into a room, when someone
sees us and makes eye contact for the first time, the
hairline stands out. On a subconscious level, beyond the
rational, it speaks volumes about our age, attractiveness,
suitability as a mate, even about our health and vitality.
Why is the hairline of such significance? It frames the
face. This simple statement belies the artistic and cosmetic
impact of this all-important frontal zone. One of the
reasons that many men with frontal balding instinctively
go for the "comb-over" effect, is that it creates
a hairline of sorts; it frames the face at the top and
at the temples. The problem is that it is so patently
obvious to everyone else as an attempt to disguise the
balding.
Framing of the face is an artistic metaphor. Imagine a
painting without a frame. It may be a pleasing image,
but it is incomplete. Add a nice, tasteful frame and voila!
You have a complete, aesthetically appropriate presentation.
Similarly, frontal hairline balding takes away the frame;
restoring the hairline restores the frame. The resulting
appearance is one of youth, vigor and vitality.
Planning the Hairline
Often, hairline planning is a compromise between the patient
and the surgeon. This does not imply that the patient
does not know what is best for him, or that the physician
is wiser. What it does imply is that people have a tendency
to want the hairline too high or too low. The low, rounded
adolescent hairline will look inappropriate on a 40 year-old
man. In fact, it may lend a caveman or "Neanderthal"
appearance to his visage. Young men in their early twenties
may require repeated explanation of the reasons for not
creating an adolescent hairline for them. They still remember
quite vividly (unlike the middle-aged man) their own,
low hairline at the age of sixteen. Often, they are rather
distraught about their loss of hair, and do not identify
with their future selves at thirty, forty, or fifty. This
is where the ethical hair restoration surgeon must explain
and counsel for the patient’s benefit, rather than
playing on fears and illusions in order to make a quick
profit.
Conversely, a middle-aged man seeking hair restoration
surgery may fear that a hairline that is not adequately
receded at the temples may seem unsuitable for his age.
The fact of the matter is, that a hairline placed too
high accentuates the balding, by focusing attention on
the wide, high expanse of the forehead and frontal area.
This concept may be easy enough to visualize if properly
explained.
At any rate, if one must err slightly to the extreme,
it is always better to start slightly too high, than with
a hairline that is too low. One can always, in a second
session, bring the hairline down by artfully adding follicular
units in front of the existing border. Still, it is much
more desirable to get the hairline right on the first
try. After all, the primary goal of almost all first hair
transplant sessions is to re-establish the hairline and
frontal region, in order to frame the face. This facial
framework achieves the most dramatic cosmetic and visual
effect of hair restoration surgery.
Hairline Repair or Revision
Repair or revision of the poorly done hairline is one
of the most rewarding facets of the hair surgeon’s
art, and often one of the most challenging. The border
may be overly regular, with a symmetry that defies nature;
conversely, it may by so disordered and asymmetrical as
to be unnatural. Again, it may appear tufted, revealing
the so-called doll’s hair effect. It might be too
high, or more likely too low. Sometimes, the hairline
is so overly rounded across the forehead as to be "bowl-like"
in nature.
All of these deficiencies can be corrected to some extent.
The most difficult to correct is the low hairline. Even
if the grafts are large ones, and can be cut out and dissected
into follicular units (FU’s) for use elsewhere,
scarring will result. This can be partially treated with
dermabrasion and possibly lasers, but unless hair from
further back can be styled forward to cover them, the
scars will be detectable to some degree. We see here a
graphic example of the necessity for good, rational, artistic
planning when dealing with the hairline. Again, get it
right the first time!
The unnaturally straight or regular frontal border may
be revised with the careful, selected placement of follicular
grafts in front of, and among, the existing grafts; also,
large grafts within and behind the hairline may be excised
and re-used if necessary, with the hair around them acting
as scar camouflage. "Softening" of the hairline
is accomplished with the judicious use of single hair
FU’s, in a more random pattern, which is harder
than it sounds. Humans have a tendency when performing
repetitive tasks, (such as making recipient incisions),
to fall into a pattern of some regularity. It requires
skill and effort to defeat this tendency and to achieve
"randomness"; it’s not truly random, however,
but more a "controlled disorder".
There are several possible remedies for an overly rounded
hairline. One can blunt the fronto-temporal angles at
the sides of the head to apply a more graceful curve to
the margin. Alternately, a "widow’s peak"
may be constructed at the middle of the forehead, which
will soften and break up the arc of the frontal border.
In the event the hairline has temporal recessions that
are inordinately deep for the patient’s ethnic or
racial background, then these concavities may be moderated
by adding FU’s; this will render the margin "flatter".
Finally, a repair session can be exploited to increase
the density of the frontal area, if adequate donor reserves
exist. This technique can also be employed to fill in
around mini-grafts that look "tufted", or just
to augment the density after an initial, successful follicular
unit transplant.
To reiterate, the frontal hairline is the most important
area to be considered in most men with pattern baldness.
Reestablishing the hairline has a great cosmetic impact,
regardless of the degree of balding, and should generally
be the goal of the first session of follicular unit transplantation.
It must be remembered that reconstruction of the frontal
area will have a profound aesthetic impact on the balding
person, even if there is a limited store of donor hair
