It can almost be said: ‘‘If you get the front hairline right, you get the whole thing right.’’
The contour of the hairline and the appropriate proportion of the forehead to the entire face are essential factors for a balanced and attractive face. Hair transplantation for hairline reconstruction is gaining popularity in women with frontotemporal thinning and congenitally high hairlines and those who have undergone cosmetic facial procedures.
An estimated 225,800 hair restoration procedures were performed worldwide in 2006 (a 34% increase from 2004).
- In the United States, 100,445 hair restoration procedures were performed.
- In Canada, 12,625 hair restoration procedures were performed.
- In Europe, 29,818 hair restoration procedures were performed.
- In Asia, 57,542 hair restoration procedures were performed.
Although naturally occurring male hairline patterns have been described, they do not achieve appropriate facial framing and a ‘‘feminine’’ look when applied to women. Moreover, although baldness progression is an essential consideration for employing receding hairline patterns in men, non-receding patterns are appropriate for female hairline restoration. There is a general lack of detailed information describing natural hairline patterns in women.
Some facts about hairlines in women:
- Female hairlines are naturally low 5.5cm above the glabella (point of intersection of eyebrows).
- Male hairlines are 6 to 8 cm above glabella.
- Higher hairline masculinizes the face.
- The lower hairline is neotenous and feminizes the face.
- Forehead rounder and larger are more neotenous.
- Females have the same amount of frontotemporal (front and sides of forehead) hair loss as much as men do.
Women often have more cowlicks (a lock or tuft of hair growing in a different direction from the rest of the hair) in the frontal region compared to men.
Classification of Hairline Contours
Round: An overall round shape without a frontotemporal recess.
M-shaped: A male hairline pattern with a deep and retruded frontotemporal recess forming the shape of the letter M.
Rectangular: A square-shaped hairline in which the upper forehead is parallel to the temporal recess
Bell: Forehead width is normal, but the vertical height is more than 1cm higher than normal (6.38 cm).
Triangular: A hairline without a temporal recess and a straight line from the midfrontal point to the temporal point.
Anatomy of the Hairline
Widow’s peak is a distinctive, V-shaped hairline that is genetic for the most part and is not in itself a sign of balding. The mean width and length of the widow’s peak were 1.83 and 0.80 cm, respectively. A widow’s peak was present in 81% of the subjects.
Lateral mounds are the extensions of hair onto the foreheads at the temples. The mean width and length of the lateral mound were 2.12 and 0.83 cm, respectively, on the right and 2.07 and 0.80 cm, respectively, on the left. Lateral mounds were identified in 98% of the subjects; 86% had bilateral lateral mounds, and 12% had unilateral mounds.
Of the Cowlicks, 70% had the cowlick on the left and 17% on the right, and 13% had midline cowlicks.
The lateral mounds are important structures that should be incorporated into the female hairline design to impart a ‘‘feminine’’ look to the transplanted hairline.
The mean distance from the mid-eyebrow to the frontal midpoint or apex of the widow’s peak (ME-FMP) was 5.54 cm.
The mean frontal midpoint to lateral mound distance was 3.74 cm on the right (FMP-RLM) and 3.97 cm on the left (FMP-LLM).
The mean distance from the apex of the lateral mound to the apex of the temporal point was 3.78 cm on the right (RLM-RTP) and 3.51 cm on the left (LLM-LTP).
The mean sum of (FMPLLM) 1 (LLM-LTP) was 7.48 cm, and the mean sum of (FMP-RLM) 1 (RLM-RTP) was 7.51 cm.
Pitfalls for an Unnatural Hairline
The following are all planning or technical mistakes that lead to an unnatural hairline appearance and give it away as being transplanted:
- ‘‘Pitting’’ of grafts: This is a dark, sunken appearance to the base of the transplanted graft. It is caused by placing the grafts too deep into the recipient site. Its occurrence is facilitated by recipient sites that are too deep.
- Overly straight hairline border: Such a hairline features no microcontouring/macrocontouring or sentinel hairs. This is more easily noticed with a rounded hairline contour.
- Overly dense hairline border: There should be a ‘‘soft,’’ feathered appearance to at least the outer 3 to 5 mm of the hairline’s depth. This mistake very often coexists with the ‘‘overly straight’’ error.
- Angle of grafts too perpendicular: Transplanted hairs look more unnatural in this orientation. In addition, styling is more difficult, and the cosmetic advantage of overlap is forfeited.
In 350 female patients with an M-shaped forehead, which is a wide forehead with a deep frontotemporal recess, hair transplant was performed to correct the hairline. First, the frontotemporal recess area was calculated by applying Dr. Farjo’s triangular concept, A1 was defined as the midfrontal point and A2 as the temporal point, and the length of Line A (A1–A2) was obtained. B1 was defined as the apex of the frontotemporal recession and B2 as the midpoint of Line A, and the length of Line B (B1–B2) was obtained. The area of this triangle was A B/2, and the frontotemporal recess area of both sides was A B. Based on the area obtained in such manners, the number of follicular units (FU) required was calculated.
(A) A 25-year-old woman with a deep frontotemporal recess and an M-shaped hairline. (B) One year after the hair transplant was performed using the method described in Figure 5, the deep frontotemporal recess was corrected, and the round hairline contour was shown.
(A) A 19-year-old woman with a deep frontotemporal recess, an M-shaped hairline, and a wide infratemporal portion. The frontotemporal recess was corrected, and the infratemporal portion was narrowed by 1 cm. (B) In the photograph taken 1 year later, the round hairline was well maintained.
In creating the front hairline contour for a woman, always include the sweep down into the temples. Begin by marking the MFP, which is always set lower than in males, usually somewhere between 5 to 6 cm above the SEBL (6 to 7 cm above the glabella). Then mark a spot on each side that is aligned with the epicanthal line and is positioned 1 to 1.5 cm further posterior than a line drawn horizontally across through the MFP. Draw in two marks at the anterior aspect of the anterior temporal fringe, usually positioning these 0.5 to 1.5 cm anterior to the two marks just described in the frontotemporal region. Then simply connect these five points with aesthetic, gently curved lines. Cowlicks are common in the frontal scalp of women and, unless the hair is extremely miniaturized, hence following their angle and direction is recommended.