The hairline. Easily one of my favourite aspects of hair transplant surgery. It can easily define the quality of a hair transplant (although a great hair transplant is far from being just an excellent hairline) and it changes everything from the moment you decide on where to place it.

Your hair frames your face in such a profound way that a person can dramatically change his or her appearance just by getting a haircut. We’ve all had that “Wow! You got a haircut! I almost didn’t recognize you!” moment from someone we know, or even caused one ourselves with our bold new, avantgarde haircut.

The hairline is in a way, a surgeon’s signature and one of the things that distinguishes a good surgeon from a great one. It is also one of the most important parts of the surgery. Like I’ve mentioned, hairline placement can make or break a hair transplant and has the most potential to dramatically change the patient’s look…for better or worse.

A great hairline can be defined by three things:

Correct placement of hairs.
Adequacy to the patient’s facial features and age.
Density and coverage.

But TL;DR, I would say that it all comes down to one thing: naturalness.

Naturalness should be the priority of every surgeon. It is the paramount outcome of any hair transplant. This is because naturalness comes from the combination of all aspects that involve a good hairline. You can’t simply get one or two things right and leave the others out of the equation. Harmony between all parameters must be achieved in order to mimic nature in a convincing way.

For example, transplanted follicular units can all be of the correct amount of hairs per graft, implantation can have the correct angulation and the hairline design can be great for the patient, but if the density is sparse, then it still risks looking unnatural. This is because in androgenetic alopecia, hair follicles in a certain area tend to get all affected in varying degrees. It just doesn’t look right to have a fully miniaturized area with thick, healthy follicular units transplanted from an area unaffected by androgens, spread over it with low density.

So we need to be really precise with our planning and not skip on any steps, or we will fail our patient.

If we try to really look attentively and dissect what a natural hairline looks like, we see that:

Hairs aren’t all the same caliber.
Follicular units don’t all have the same number of hairs and density isn’t exactly the same all over.
The hairline itself isn’t straight and hair insertion does not follow a specific pattern.
There is correlation between the frontalis muscle - which extends roughly between your eyebrows and the galea aponeurotica (think of it as what’s above your forehead) - and the insertion of the native hairline.

So lets go even deeper into it:

Hair has a tendency to be thinner in the peripheral areas (for example, hairline, temporal peaks, nape, etc) and thicker in the more central parts. We also have a very obvious distribution of follicular units that tend to increase their number of hairs from peripheral to central. So if we look to the outermost hairs, the hairs that are on the outside of the hairline, they’re all one haired follicular units and are slightly thinner than the next row of hairs. (Now, there is no such thing as “rows and files” in native hair (and there shouldn’t be in transplanted hair either - which is one of the tells of a transplant - but for the sake of illustration, let’s stick with that.)

There is a natural tendency of thinner one-haired follicular units (question: should we actually call them “follicular units” when they’re just one hair follicles?) to blend in with thicker ones as we go deeper into the hairline. The next step as we delve deeper is that we now start seeing two-haired units. You can see this in your own native hairline. (I understand the irony of asking readers to take a look at their native hairline in a hair loss and hair transplant blog. There is a good chance they don’t have it anymore. But I can tell you that more or less we still see a similar pattern in a receded hairline).

Now moving even deeper, we start to see three-haired units blend with the two-haired follicular units (and even more if you’re lucky). These contribute to coverage even if there might be slightly less density in terms of follicular units per square centimeter.

We also see that these “first hairs” aren’t exactly what defines the hairline. You see, they’re so fine that when we look at the hairline, our eyes tend to sort of skip over them and stop at the thicker two-haired units to make out where the hairline is. This is obvious in some hairlines more than others. These fine hairs do however have a crucial role in making the hairline look natural. Having a thick “wall of hair” right from the first row of hairs just doesn’t look right. They also don’t simply line up like a row of soldiers in formation. I’ve seen this in some hair transplant results. It just looks weird and is an obvious tell of a bad transplant.

So, if we look at these guys over here, we see that these rules are pretty much a constant:

Green Line: first hairs;Red Line: more defined hairline; — **Green Line:** first hairs;
**Red Line:** more defined hairline;

The green line marks where the first fine hairs in the hairline can be seen and the red one marks the thicker, more defined zone. The last case has such a big discrepancy because he has product in his hair which makes it look wet…and damp hair has less coverage than dry hair. So his more defined hairline is not as far from the first hairs in the hairline as it looks.

Even in a case of hairline recession, the song remains the same. #seewhatIdidthere

Now, if we direct our attention to a badly transplanted hairline.

We can see how unnatural it looks. There are multiple-haired follicular units on the hairline. All the hairs are in a single file and there are no micro-irregularities with thinner hair to mimic a natural hairline. The hairline is completely see-through and this isn’t even a well lit shot.

And as I’ve mentioned, there are other things that contribute to aesthetics that aren’t the hairs on hairline itself. The facial features of the patient are also crucial for the placement and design. I personally, am not a proponent of symmetry just for the sake of symmetry. Our faces aren’t fully symmetrical, and our hairlines aren’t fully symmetrical either. One eye can be larger than the other, one eyebrow more raised or with a different shape/arch, etc, etc.

One half of a hairline isn’t simply the mirror image of the other half.

We can see this in Cristiano Ronaldo. I’m a big fan of football, by the way. So expect to see more examples with footballers in the future. :D

CR7. Portuguese national team captain and 5 time Ballon d’Or winner. #GOAT

His left side is clearly lower than his right side. His eyebrow is also higher on the right and the arch of it is different as well. And if we look even closer, we see that his eye is higher too… The whole right side of his face is slightly more raised than the left. This asymmetry is perfectly normal. I’m just pointing it out to explain why we shouldn’t just look at a patient’s forehead when designing his hairline.

Another thing to be mindful of are the temporal peaks. These are often ignored, yet they’re crucial for the overall look of the hairline as they’re a big part of the frame of your face. Those little triangles of very fine hair on each side of your temples are so important that they’re usually a big tell of either a hairpiece or a badly designed hair transplant. You see, even for someone who hasn’t got a clue about a natural hairline, when they see receded temporal peaks that are almost flat, but a full head of hair with a medium to low hairline…something just doesn’t look right. It creates a kind of a “lid effect” that is a dead giveaway of one of the aforementioned two.

Temporal peaks usually can make a hairline look much lower or higher than it actually is, just by their positioning - more frontal (shortening the distance between each contralateral peak) or more posterior (increasing their distance). We can rapidly infer from this that the closer they’re together, the smaller the forehead looks and the wider they’re positioned, the opposite occurs.

We can see this pretty clearly if we look at Leonardo DiCaprio and Brad Pitt. This was actually pointed out to me by Dr. Jose Lorenzo when we were discussing hairlines and temporal peaks.

Brad Pitt and Leonardo DiCaprio. Two amazing actors.

If we look closely, the distance from the glabella (between the eyebrows) to the center of the hairline is practically the same. Leo’s might be even shorter, meaning, his hairline might actually be lower than Pitt’s. Yet, Dicaprio’s hairline looks much higher and his forehead much larger. This can be attributed to the temporal peaks. See how much more pronounced and closer together Pitt’s eyebrows are? Now, to be fair, Dicaprio does have slightly more recession on the sides and his face is a bit rounder. However, it’s the positioning of the temporal peaks the biggest contributor to this little difference.

Leo has (finally) won an Oscar. When will Brad’s turn be?

So, temporal peaks are something that should always be addressed. The hairline should flow in an harmonious way from one side of the face to the other. And as a rule of thumb, the lower the hairline, the closer together the temporal peaks should be.

This does not mean however that we always have to rebuild or even touch the temporal peaks as a lot of men do conserve them. Which is great, since these are one of the most challenging parts of the surgery. Hairs are very fine and exit the skin at a very acute angle, almost parallel to the surface. The surgeon must first find out where to harvest similar caliber hair (which isn’t always easy) and then he has to be skilled and meticulous when placing them in the correct angulation (which usually means using a different technique), in very thin skin, at a very shallow depth, whilst ensuring survival of super delicate grafts. Holy precision Batman!

There’s a world of possibilities and things to get into when discussing hairlines (like widow’s peaks, cowlicks, centrifugal versus centripetal fanning, etc), but these are a few of the aspects I find most important to a well designed hairline and that I wanted to share with you in this post.

And as I pointed out at the begging of this article, naturalness is paramount. Everything that brings us closer to it, brings us closer to a better, more aesthetically pleasing hair transplant. A badly designed hairline is unacceptable for today’s hair transplant standards and patients should ensure that their surgeon is skilled in not only advising them, but also delivering the results. And bearing that in mind, we should always remember: better to be bald in a natural way than to have an unnatural hair transplant.