Planning the hairline is one of the most important aspects of design. Proper hairline placement requires artistry, imagination, and experience. Many factors must be considered; these include an age of the patient, the amount of future hair loss, the colour of hair, the pattern of remaining hair, desires of the patient, postoperative hairstyles, and the number of anticipated reductions.
Conservative, high hairlines are favoured by nearly all experienced surgeons for the following reasons:
1. The slightly unnatural graft edge is easier to conceal with any remaining hair if the hairline is placed well back on the forehead.
2. A high hairline can always be brought forward later, but it is difficult to change a hairline that is too low.
3. The grafted hair is usually angled anteriorly so that a full-haired appearance can be created without an actual low hairline.
4. The third dimension created at the hairline when the hair grows creates the illusion that the hairline is lower than it was a simple flat line.
Straight lines should be avoided. A slightly curving hairline, beginning anterior- medially and sweeping posterolaterally to the existing hairline. Most surgeons tend to create the same hairline, varying it only to fit the existing pattern. Design and placement of hairlines become almost a signature for the surgeon and his patients.
Angling and Direction of Grafts
The proper angle and direction of hair growth are almost as important as graft placement. The surgeon should consider at what angle and direction he wants the hair to grow so that it will provide the most apparent density and coverage. The angle and direction must be coordinated with the anticipated hairstyle and should be carried throughout the entire design. Changes in the angle and direction from one area to another should be gradual and flowing. Generally, the anterior and radial direction of the vellus hair is correct, but sometimes increasing the angle or slightly changing the direction is advisable, particularly at the hairline and at the calyx.
Location of Grafts and Probable Hairstyle
The best quality grafts should always be placed where they will afford the most coverage. This is particularly important in marginal candidates or in patients with limited amounts of donor hair. Consideration of the future hairstyle is particularly important in this aspect of the procedure. Grafts should be concentrated and even crowded into the front hairline particularly on the side where the hair is parted. Parts through the grafted hair usually appear unnatural and so should be avoided. Care must be taken to place the grafts so all the hair will comb in the same direction. Occasionally, however, this rule can be broken. In individuals in whom the existing hair is low on the sides of the head, and reductions for one reason or another have not been performed, parting through grafted hair can be done. This should definitely not be the routine, but with carefully selected patients the appearance is satisfactory.
The policy of concentrating the grafts on the sides of the part should be followed even on the vertex and crown. After the crown and vertex have been reduced, there is always a scar, and with central reductions, the hair may tend to radiate away from the scar. The grafts should be placed adjacent to and down the centre of the scar with the hair angled and directed so that it will provide the most coverage and conform most naturally with the proposed direction of hairstyling.
It is not possible to produce a completely natural grafted hairline, although in some cases the appearance may be excellent. The patient must be warned of any anticipated problem and the grafts placed in such a way that the future hair growth may be combed forward and across to conceal the grafted hairline.
This rule can be broken with salt and pepper gray hair and occasionally with blonds. These hairlines often look so naturally they can be fully exposed.
In some patients, because of the pattern and extent of the alopecia, the only available hairstyle will be straight back even after reductions have been performed. In these patients, grafts should be screened extremely carefully before commencing, as the final density will not be great. A few well placed, natural natural-appearing grafts providing even sparse hair go a long way towards enhancing the appearance. On the other hand, poor or improperly placed grafts can have just the opposite effect.