Hairline hair transplant surgery is the most important type of hair transplant surgery that can be performed today. The hairline result gained from hair transplant surgery defines the overall success or failure of the entire procedure even if additional areas are addressed. If the hairline is not cosmetically pleasing the entire procedure can be considered a failure even if the rest of the recipient areas show a satisfactory yield. The success of any hairline hair transplant surgery depends on many factors. Some of these factors include doctor selection, patient understanding of hairlines and their final expectations, as well as surgical technique.
Hairline Doctor Selection
Choosing the right hair transplant doctor for your hairline hair transplant surgery is the single most critical factor for the short term and long term success of a hairline result. Your doctor should have several years of experience so that your particular characteristics do not present a challenge. The following are the key points a hairline hair transplant doctor should consider with each patient.
Age - Hair transplant patients are getting younger on average and most wish to have their original hairline back. The problem with younger patients is that their hair loss experience is only beginning and their final hair loss pattern may not be obvious. This means that if too much hair is used to build the ideal hairline then the patient will not have enough hair to adequately address all areas of future hair loss as they become realized. Understanding the balance of the donor area and the recipient area, both current and future, is known as “donor area management”.
Family history - This too can fall under the category of donor area management as to understand the family history of hair loss is to understand the probability of additional and potentially aggressive hair loss. It is a myth that the genetic marker for hair loss is only carried down from the mother’s side of the family as hair loss is influenced by both the maternal and paternal sides of one’s family. Therefore it is important to know which family members of each side of one’s family have lost hair and to what degree this loss progressed or is progressing. If there is an obvious degree of hair loss in a majority of family members then it is responsible to assume that a similar degree of loss will be experienced by the patient.
Medical Therapy - Hair loss is progressive and surgical hair transplantation does not stop hair loss. It merely fills the voids that has been created by hair loss. Without medical therapy the loss is likely to continue which will lead to more surgery in the future. Responsible hair transplant doctors will evaluate and in most cases recommend a medical regimen to prevent or at least greatly slow any additional hair loss. Currently there are only two FDA Approved medications that can and do successfully fight hair loss. They are Propecia® and Rogaine®. Even in cases where signs of more aggressive hair loss can be seen the use of one or both of these medications can help to alter the surgical plan knowing that the patient’s rate of loss is greatly slowed or even halted.
Patient Expectations - This is an extremely important issue that many doctors do not properly consider. Patient expectations can and do influence the success or failure of the procedure and if a hair transplant doctor does not properly evaluate a patient's expectations the procedure can be a failure before it begins. Cases can include patients not understanding the realities of density and what can be achieved in a single procedure, proper angles and directions, and donor scarring from FUE and FUSS. It is up to the doctor to make the determination if a patient has proper expectations and if not then it is the doctor’s job to educate them to the point that appropriate expectations can be achieved. If this does not appear likely then the patient should be turned away from surgery to protect them from harm.
Hairline Patient Considerations
The advantage that surgical hair restoration provides for hair loss sufferers that separates it from every other hair restoration option is that it is a permanent solution for most patients and it is this advantage that can be a severe disadvantage without a proper understanding by the patient. Younger patients in particular are the most vulnerable to the dangers of misunderstanding this problem. Younger men that suffer from hair loss remember their original hairlines more easily than older men. They have not had the same amount of time to accept or to get used to their hairline recession and the appearance of maturity if the recession is not indicative of male patterned baldness. Therefore they are usually more eager to regain the hairline they only recently lost. This makes the younger patient more susceptible to promises of high density with fully closed temples typically found on females and juvenile males.
Donor Area Management
Donor area management is of the utmost importance when dealing with hairline restoration as the total amount of donor hair that one has is finite and cannot be increased or renewed. Therefore when considering hairline restoration a balance must be achieved between what a patient believes to be the ideal result vs. a natural and cosmetically appealing result that retains enough donor hair to address further loss. The challenge lies in the aggressive, high density hairlines previously referenced. If placed too low or with excessive temple angle closure approximately thirty to fifty percent of all available donor hair can be used. For the patient that is destined for aggressive hair loss this can be a cosmetic death sentence. The frontal region will be strong with a juvenile frame for the patient’s face but the areas behind the hairline, mid-scalp and crown, will have a thinner and see through appearance. This potential scenario does not take into consideration the prospect of hairline surgery with unnatural results or poor growth, which is much worse to deal with and will only use more grafts for repair in the future.
What makes a hairline natural? This has been debated for decades but with the advent of stereoscopic dissecting microscopes in follicular unit hair transplantation hairlines have become more natural on an order of magnitude beyond previous technologies. It is widely accepted that the most natural hairlines are those which have had graft refinement through the use of dissecting microscopes. Natural hairlines typically have single hair follicles mixed with velous, fine hairs that are much smaller and finer than normal scalp hair. There is an occasional two hair or three hair follicle in a typical hairline but they present no negative cosmetic impact. Current technology does not allow for reliable and consistent transplantation of vellus hairs for the ultimate natural result but we can transplant, and even create, single hair follicles for naturalness.
There are three challenges present in modern hair transplant technologies.
Many clinics have adopted FUE as their primary method of surgical hair restoration. With FUE the use of dissecting microscopes is assumed to be irrelevant. The challenge lies in the lack of refinement that further dissection under magnification can offer, such as that found with follicular unit strip surgery (FUSS). With stereoscopic microscopes technicians can see if a one hair follicle is really a two or three hair follicle. By properly identifying these larger follicles fewer will be placed into the hairline.
Single hair follicles from the healthy donor zone rarely mimic the single hair follicles found in a natural hairline. The texture can be more coarse and the diameter of the individual hair shafts can be larger thus single hair follicles, no matter how refined they may be, can still look artificial or “pluggy” when viewed after placement and subsequent growth has been realized.
Natural hairlines retain a percentage of vellus hairs that serve the cosmetic function of softening. They offer a transition from the bare, hairline forehead into the thick full hair of the human scalp. Current technology has the ability to transplant vellus hairs but the survival rates of these hairs is erratic and unpredictable and many times leaves a cosmetic deficit due to potential scarring and inconsistent growth.
While the challenges exist there are methods that clinics can develop to minimize and reduce the visual impact that these challenges present but until these challenges are directly overcome there will always be indicators, regardless of how minor, that the trained eye can notice as being indicative of surgery.