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Dispelling the Myth of the Required High Hairline in Follicular Unit Hair TransplantationDermatological Surgery 2000; 26: 884-887 Synopsis | The Advent of Mini-Micrografting | The Introduction of More Efficient Donor Techniques | Significance to Hairline Position | Normal Hairline Evaluation | Results | Discussion | Summary Dominic A. Brandy, M.D.- Pittsburgh, Pennsylvania BACKGROUND: Hair restoration surgeons have historically taught that the hairline should be placed high on men undergoing hair restoration surgery. OBJECTIVE: To evaluate the position of the anterior most aspect of the frontal forelock on men experiencing Type III to Type V male pattern baldness. METHODS: Twenty men, ages 20 to 46, with Type III to Type V male pattern baldness were evaluated for the distances between the chin to nose, nose to eyebrows and eyebrows to frontal forelock. RESULTS: The mean distance from chin to nose was 6.96 cm. The mean distance from nose to eyebrows was 6.55 cm. The mean distance from eyebrows to hairline was 6.8 cm. The distance from chin to hairline was 20.3 cm. Therefore, the eyebrows-to-hairline distance was 33.4% of the whole. CONCLUSION: When using follicular transplantation, it may be appropriate at times to divide the face into thirds at the time of hairline development. Since the author attended his first seminar on hair replacement surgery in 1983, prominent hair restoration surgeons have taught that a man's hairline should be higher than the ideal hairline referred to in the writings of Leonardo DiVinci, which state that the perfect face is one that is divided into thirds - the chin to the bottom of the nose equals the bottom of the nose to the eyebrows, equals the eyebrows to the hairline. In spite of DiVinci's observations, hair restoration surgeons continue to teach that a man's hairline should be adjusted several centimeters superior to this ideal.
THE ADVENT OF MINI-MICROGRAFTINGHair restoration surgery changed dramatically in 1981 when Nordstrom introduced the concept of using 3-6 haired grafts at the anterior hairline for softening effects. With this innovation, the process of hair transplantation began its rapid evolution into a very refined art form. Bradshaw2 was the first to initiate the idea of covering the entire head with very small hair-grafts called quarter-grafts. These quarter-grafts were created by taking 4.5 mm donor-grafts and dividing them into four sections. These grafts, which consisted of approximately six hairs, were then placed into #15 blade incisions. Shortly afterwards, others like Lucas, Swinehart, Uebel and the author created variations of Bradshaw's theme. The idea of inundating the frontal hairline with one and two-haired micrografts was initiated by Marritt. As of late, the concept of follicular unit transplantation has taken hold, which involves transplanting units of 1, 2, 3, or 4 hairs as they occur in their original hair bundle. This latter approach yields the most natural results to date.THE INTRODUCTION OF MORE EFFICIENT DONOR TECHNIQUESIntroduction of More Efficient Donor Techniques Donor techniques were also evolving at a rapid pace at the same time that these major improvements were being made on the recipient site. Bisaccia developed a multiple-bladed knife for the development of 4 mm x 4 mm square grafts in 1990. Two years later, Brandy introduced a beveled multi-bladed knife with 3 mm separations that was used to create 3 mm x 1.5 mm rectangular grafts. Since that time many other blades have become available14. Many surgeons merely remove a fusiform-shaped area from the donor site and close the open area with a double-layered closure technique. In addition to the improvements in harvesting, the availability of maximum donor hair removal has been greatly enhanced by the utilization of a single scar donor harvesting technique. This technique allows multiple procedures to be performed with only one scar remaining. Thus, the only variable to evaluate when performing successive procedures is hair density.
SIGNIFICANCE TO HAIRLINE POSITIONToday, the restricting effects of older techniques on hairline position are not as great of a concern primarily due to the improvements in hairline refinement and the greater availability of donor hair. Because of these improvements, there are several questions that must now be answered by the surgical hair restoration community in reference to hairline positioning: 1) Now that we are able to develop extremely refined hairlines, are we justified at times to move the hairline inferiorly so that the face can be divided into thirds? 2) Since more donor hair is available, can the hairline be moved into a lower position on some patients? 3) Are we justified in shifting the hairline to a lower level in some of cases now that we are not using as many hairs for hairline development as in the past?NORMAL HAIRLINE EVALUATIONTo help answer the above questions, the author used 20 consecutive virgin Norwood Type III to Type V hair transplant patients (ages 20-46) and measured the distance from the perceived forelock hairline to the eyebrows; the distance from the eyebrows to the bottom of the nose; and the distance from the bottom of the nose to the bottom of the chin. This task was given to a very reliable nurse who had absolutely no idea what the study was about. The goal was to find the hairline position in relation to the chin, nose and eyebrows on patients with early thinning (that which might be present after a follicular unit reconstruction). Norwood Type VI to Type VII patients did not quality for the study.RESULTSTable 1. Patient Facial Measurements
DISCUSSIONIt appears from these measurements that the majority of men with Type III to Type V male pattern baldness still maintain a hairline that follows DiVinci's rule of thirds even though the hair is much thinner than their teenage counterparts. From the observations in this article, it is apparent that we no longer need to always limit ourselves by the unfounded idea that all hairlines must be higher than the one-third position. Since we use follicular units and the feathered frontal hairline zone, we do not use up a tremendous amount of donor material for each additional centimeter of inferior placement. We are also not dealing with the harsh hairline of old that would almost always attract attention even at an extremely superior position. Conversely, we still need to always think about future hair loss and how that may affect the patient's appearance 20 or 30 years down the road. Additionally, with the single scar donor harvesting techniques, we are now able to extract a large number of donor hairs without significantly affecting the appearance of the donor site. Taking all of this advanced technology into consideration, it should now be our goal to reconstruct a hairline that, at the very least, takes the rules of thirds into consideration.SUMMARYEven though most men experience male pattern baldness, hair usually remains at the frontal forelock. In this article, the frontal forelock was found to start an average of 6.8cm from the eyebrows in 20 men ages 20 to 46. The average hairline to chin distance was 20.3cm. The hairline to eyebrow distance was therefore 33.4% of the chin to hairline distance. These measurements demonstrate that may be appropriate at times to divide the face into thirds when developing the hairline in men undergoing follicular unit hair transplantation.
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