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 â€œcomb-overâ€ 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.
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 â€œNeanderthalâ€ 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 patients 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.
Repair or revision of the poorly done hairline is one of the most rewarding facets of the hair surgeons 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 dollars 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 â€œbowl-likeâ€ 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 (FUCs) 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 â€œrandomnessâ€; itâ€™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 widows 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 patients ethnic or racial background, then these concavities may be moderated by adding FUCs; this will render the margin â€œflatterâ€. 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 â€œtuftedâ€, 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.