Hair transplant is a fusion of art and science to restore the identity of a person.
The reconstructed anterior hairline should look natural in terms of location and shape.
While planning hair transplant, the future progression of hair loss should be kept in mind.
There is a great discrepancy between the donor area supply and recipient area demand for donor hair follicles, especially in higher grades of baldness.
The proper calculation of available donor hair follicles, and recipient area planning are mandatory, and patients must receive detailed counselling about the post-transplant density, the probability of additional hair transplantation in the future, and the necessity of ongoing medical treatment.
Frontal framing of the face is the top cosmetic priority, followed by the mid-scalp and then crown coverage. Although this may vary as per patients’ priorities.
It is preferable to place the anterior hairline at relatively higher level on forehead rather than at a lower level. To create an illusion of lower hair line, a widow’s peak in the centre can be created which is an economical use of grafts. Usually, the anterior hairline is placed at the junction of the vertical part of forehead and the horizontal surface of scalp.
The anterior hairline is not just a line, but it is a zone, that has subzones: a transition zone, a defined zone, a frontal tuft area, and a few sentinel hairs.
To create a natural looking anterior hairline, single hair follicle grafts should be used to create micro and macro irregularities in the transition zone.
The frontotemporal junction should be placed in line above the lateral canthus, and the level of junction with the temporal hairline should be at the same level or slightly higher then mid frontal point (but never lower)
In advanced grades of baldness, where the parietal hump has receded downward, there is a need to reconstruct the parietal hump.
In advanced stages of hair loss where the temporal peak point and frontal temporal fringe has receded significantly, there is a need to restore the side framing of the face.
Mayer’s guidelines help in the placement of the temporal points.
The reconstructed temporal peak point should be 3 cm lower than the mid-frontal point.
The grafts are implanted in a gradient of density from anterior to posterior to create the appearance of fuller hair.
It is preferable to avoid coverage of vertex in younger individuals less than 30 years old.
Medical management is the preferred treatment modality for vertex hair loss in younger individuals less than 30 years old
Introduction
Proper planning for coverage of the existing bald area and the design of the anterior hairline are crucial aspects of hair transplantation. A well-known fact about hair transplantation is that there is a discrepancy between the demand of hair follicles and the supply of donor hair follicles. The another challenge for the surgeon is that hair loss is a dynamic process, and the patient might need more grafts to cover his future bald area.
Zones of Balding Scalp
Usually the male androgenetic alopecia follows the Norwood -Hamilton patterns but there can be diffuse pattern, Ludwig’s pattern, vertex pattern and forelock pattern.
The balding area of the scalp can extend from anterior hairline to the upper border of the occipital fringe. It is divided into three zones. Frontal area, mid-scalp area, and the posterior-most balding area is the vertex or crown which includes the whorl.
The balding area of the scalp can extend from anterior hairline to the upper border of the occipital fringe. It is divided into three zones. Frontal area, mid-scalp area, and the posterior-most balding area is the vertex or crown which includes the whorl.
Frontal Area
Most frontal balding areas extend from anterior hairline to an imaginary line joining the apex of the frontotemporal angle. The posterior border is a little curved.
Mid-scalp
This is the topmost horizontal area of the scalp. The anterior border is a curved line joining apex of both frontotemporal junctions; the posterior border is anterior border of vertex which includes vertex transition point. The lateral borders on both sides are limited by the temporal and parietal fringes.
Vertex (crown)
This is the posterior-most area of the balding scalp in male pattern hair loss. This is usually oval, round or oblong as per the whorl pattern of the crown. It starts from vertex point to the posterior curved parieto-occipital fringe of hair. Usually, this is a sloping round to the vertical posterior surface of the scalp.
Lateral ledge (hump)
This starts from the lateral border of the mid-scalp area (usually the “natural hair part-line” ) slopes downward on both sides. The location on both sides is aligned to lateral canthus of the eye. The direction of hair also gradually changes from forward to laterally downward. In the male pattern baldness, these lateral humps also becomes alopecic and needs restoration to bridge the gap between mid-scalp and parietal and occipital fringe.
Frontal hairline Zone
This is the anterior border of the frontal area, usually 2 centimetres in width, commonly called anterior hairline. This zone is further subdivided into irregular transition zones including macro and micro irregularities, defined zone and forelock.
Frontal tuft (Forelock)
This is an oval to circular area, located centrally in the frontal zone, just behind the defined zone of the anterior hairline. This is an aesthetically important area, as it plays an important role in the framing of the face. This needs relatively high-density transplantation.
Posterior-parietal triangle zone
These are triangular in shape, situated in the posterior lateral portion of mid-scalp. The boundaries of these triangles are anterior – mid-scalp, posterior – vertex and lateral – occipital fringe. These are sloping laterally.
Vertex transition point
This point is situated between the posterior-most border of mid-scalp and upper border of occipital fringe. This is the point where the horizontal portion of the scalp starts sloping down and becomes vertical.
Anterior temporal point
These are the sharp angled anterior-most points of the temporal fringe situated in front of the ears. These play an important role in the framing of the face.
Frontotemporal triangle
These typically become deeper and more receded as part of male pattern baldness. These are alopecic areas situated anterolaterally between the lateral aspect of the frontal area (hairline zone) and temporal fringe. The posterior apex of the triangle is aligned to the lateral canthus of the eye.
Anterior temporal fringe
The anterior-most vertical portion of temporal fringe. Commonly also called the temporal triangle, making an important contribution in the framing of the face.
Superior temporal fringe
The small anterior superior border of temporal fringe, which starts from the apex of the frontotemporal triangle to an imaginary line aligned to the tragus of the ear.
Parietal fringe
The superior border of the parietal fringe starts from the posterior border of superior temporal fringe (an imaginary line aligned to the tragus of the ear) to the start of occipital fringe.
Occipital fringe
The superior border of occipital hair which is the inferolateral border of the alopecic vertex area.
Mid frontal point (Trichion)
This is the anterior-most central point of the hairline. It is an important aesthetic point and landmark which plays an important role in designing an anterior hairline.
Density of Transplanted Hair
The density of transplanted hair depends on following factors, the size of the bald area, the number of grafts required to give particular density, and the reserve capacity of donor hair follicles. While determining the target density for the present bald area, surgeons must balance graft utilization with what will be needed for future progression of balding,
Density can be defined in two ways-
1. Numerical density- the number of hairs or follicles and follicular units (FUs or grafts).
Follicular density or hair density is the number of follicles or hairs per cm2. As each hair arises from one hair follicle, the number of follicles and hairs are the same.
FUs/graft density–Number of follicular units (FUs)/ grafts per cm2.
2. Visual density (Cosmetic density) is the visual impact of the hair in covering the scalp. Cosmetic density depends on hair thickness, curl and colour, and the angle and pattern of implantation. Thicker hairs, those with curl, and hairs that are similar in color to the scalp all have more coverage value and visual impact. A staggered pattern of implantation will also have more impact on visual density compared to grafts are implanted aligned in rows.The more acute the angle of hair emergence, the better the scalp is covered.
The Volume of Transplanted Hair
The volume of hair denotes the quantity of three-dimensional space occupied by hair over and above the scalp. The volume of the hair depends on the number, thickness, and length of hair over the scalp. A formula for calculating the volume of hair is:
Volume of hair = LN R2
l – length of hair, n – number of hairs, r – thickness of hair.
Example-suppose average length of hair is L= 50mm. Number of hair N=15000, Diameter ( 60 micron= 0.06mm)
Volume of hair = 50 X 15000 X (0.06)2 = 2700 Cubic mm
By doubling the thickness of hair, the volume of hair can be increased four times. The volume of hair increases also by increasing the length of hair while keeping the number and diameter of hairs constant.
Factors Influencing High Density Implantation
Higher implantation density provides satisfaction to the patient and the surgeon, but not everyone can have high-density implantation. Higher density requires a more skilled surgical team, good quality instruments for implantation according to the surgeons choice, a good donor supply, and recipient slits sizes according to graft dimensions and factors intrinsic to the patients’ skin for the survival of the grafts. An inexperienced surgical team attempting high-density grafting has a significant risk of damage of grafts and the vascular bed on the scalp with a poor cosmetic outcome.
Calculation of Recipient Area
The most common method to estimate the recipient area is the Chang method.
CHANG METHOD
A transparent plastic foil (plastic food wrap) is mounted on a ‘China round embroidery frame’. Then the tracing of the bald area of the scalp is taken on this transparent foil, then this is copied on a graph paper using a carbon paper and the total bald area is calculated in square centimeters.
PLANNING OF GRAFT IMPLANTATION
Planning of graft implantation is done according to bald scalp zones. As described earlier, the frontal,mid-scalp, and vertex are three major zones and every zone has sub-zones in it.
Frontal area
-anterior hairline zone-Forelock and remaining frontal area
-Temporal triangle
Mid-scalp, parietal hump
Vertex (crown)
Frontal area
Anterior hairline (AHL) Design
The anterior hairline is designed in a way that not only fulfills present demand but also suitable for the patient’s future appearance. The reconstructed hairline should be natural looking with enough density and be undetectable and being grafted. The most common demand by patients is a hairline like they had in their teenage years. In such circumstances the surgeon should try to explain the following aspects to the patient:
The hairline should be appropriate for the age. With advancing age the facial features change and the receding of the AHL to a higher level is expected The level of the AHL should be planned accordingly.
The possibility of progressive hair loss over the remaining frontal and mid-scalp region might give the AHL an unnatural look if the AHL was placed at a lower level.
An AHL placed low on the vertical part of the forehead generally consumes many more grafts for the hairline alone to provide a natural look. This may hamper the optimum availability of grafts to the other balding regions.
Design of Anterior Hairline
The shape of the hairline.
Location of hairline including mid frontal point (MFP)
Frontotemporal triangle
Zones of the anterior hairline
The shape of the hairline
The aesthetic curvature of the forehead shall be transformed into the shape of the hairline. The most common shapes are triangular, oval, flat, and crescent. For a male, the triangular and oval are commonly designed but not crescent or flat hairline.
Location of hairline including mid frontal point (MFP)
Placement of an Anterior hairline is important for the present and future aesthetic point of view. It is better to place it at a higher level than on the lower side. A high-placed hairline can be shifted lower but the reverse is not possible.
Practical tips to decide the location of MFP:
1) Four finger width above the glabella.
2) 7 to 10 cm above the glabella
3) A point on the forehead where the vertical plane of forehead and horizontal plane of scalp meets.
The final placement of AHL is to be individualized depending on the size and shape of the head, degree of alopecia and sometimes the patient’s wish. The patient’s desire for a low hairline can be fulfilled by properly constructed “widow’s peak”
Frontotemporal angle
The frontotemporal angle is formed by frontal and temporal lines and it is characteristics of male pattern hair loss Properly positioning of this point and recreating a soft frontal-temporal angle is one of the most difficult and important aspects of hairline creation. The reconstruction is aimed to restore them in the same proportion in which they have receded Blunting this angle or placing it too low will cause an unnatural look.
Guidelines for estimating frontotemporal point( FTP )
Drawing a line from the lateral epicanthus of the eye back towards a point where it meets the remaining temporal hair.
Make sure the hairline created by this point does not slope downward toward the ear but looks parallel or slopes upward, which means the level of the frontotemporal point is higher or at the same level as the mid frontal point.
.The frontotemporal point shall be placed in line with the lateral epicanthus.
In mild to moderate hair loss, where there is only a little loss of temporal hair, the existing temporal hair can be placed as the inferior border of the frontotemporal triangle while the future anterior hairline becomes the superior border of the triangle. The apex of the triangle lies on the line that was drawn superiorly from the lateral epicanthus of the eye.
In a more severe degree of hair loss when temporal hair has receded and lateral fringe has dropped. In such cases, there is a need to reconstruct the lateral (parietal) hump. The lateral hump is a semi-circular area of hair that is located superior to the ear and bridges the lateral fringe to the mid-scalp region. The newly reconstructed lateral hump will give the lateral epicanthal line a target to intersect. They usually meet near the top of humpor at the junction of two lines, one line is drawn vertically approximately 1 cm anterior to the external auditory meatus (EAM) to intersect the other line from lateral epicanthus towards the existing temporal hair.
Zones of the hairline
The anterior hairline is not just a line but it is a zone. When looking closely at the hairlines of younger men, we see an irregularless dense front row of hairs which gradually becomes denser deeper in the hairline zone. The anterior hairline includes the following 3 subzones,
The anterior-most portion which is the transition zone (TZ).
The posterior portion called the defined zone (DZ).
A small oval area in the central portion of the defined zone called the tuft area.
Collectively all three zones contribute to the overall appearance of the hairline zone.
Transition zone: – It is the anterior-most zone of the hairline which is approximately 0.5 to 1 cm. wide. It is an irregularly irregular zone of hair and merges with a defined zone. It consists of micro and macro irregularities.
While grafting the AHL single hair FUs are used to create the transition zone and two haired FUs for the remaining part. Occasionally a few isolated, very fine single hairs called ‘sentinel’ hairs can be found scattered in front of the transition zone.
The width and density of the transition zone should be adjusted based on the severity of hair loss. The greater the degree of hair loss, the wider more diffuse this transition zone should be, mimicking the pattern found when more severe hair loss occurs in nature.
DEFINED ZONE
The defined zone is generally around 2-3 cm in width and located directly posterior to the transition zone. In this area, the hairline should develop a higher degree of definition and density. Yet still appear totally natural, undetectable under close examination, concentrating two and three hair FUs in this area nicely accomplishes both goals. Density in this zone creates a fuller-looking hairline by limiting the distance that can be seen past the transition. The widths of the hairline zone and how many singles are needed vary according to hair shaft thickness. Patients with coarse hair need more singles and a wider zone than those with fine hair to maintain naturalness.
FRONTAL TUFT AREA
The frontal tuft area is a small but aesthetically significant oval area that overlies the central portion of the defined zone directly behind the transition zone in the midline. This area has an even higher degree of density than the rest of the defined zone.
TEMPORAL FRINGE (TRIANGLE)
Hair loss in the temporal area causes loss of the temporal point and recession of the anterior temporal hairline, resulting in a larger forehead. A large forehead significantly affects the aesthetic appearance of the face. Until around 2000 there was a reluctance to perform reconstruction of the temporal lines and temporal points because of the poor technique of hair angle implantation giving unnatural results, a shortage of grafts, and future loss in the temporal area. Now reconstruction of the temporal line and the point has become necessary because of the important contribution of the temporal area to facial aesthetics. This also resolves the problem of lowering the hairline.
MID SCALP
This is a horizontal, slightly curved area of the scalp. Hair is facing forward in the central area and turns laterally toward the side. If existing hair is present follow the angle and direction. The hair angle is 25 to 35 degrees. Usually recommended density is 20 to 30 grafts per square centimeters depending on the available donor area. Multi hair follicular unit grafts should be used for grafting in the mid-scalp area.
CREATION OF PARIETAL HUMP OR FRINGE.
In the advanced grade of baldness, the lateral fringe drops to a point where the lateral end of the frontal hairline may be disconnected. In such a case there is a need to uplift or restore the lateral hump (temporoparietal fringe). The direction of hair changes in the lateral fringe area. In the upper area, the hairs face forward then turn inferiorly as we move lower. The anterior portion of the parietal hump blends into the upper temporal line. The existing hair always helps in deciding the angle of implantation of the follicle shows a case of hair in the mid-scalp zone, with a lowering of the lateral hump and receding of the temporal area. All three areas were reconstructed.
VERTEX
The vertex is the posterior zone that lies between the mid-scalp and permanent occipital hair zone. Hair loss in the vertex has less impact on the appearance of a person but has an impact on his feelings. It is a debate about whether to transplant vertex considering progressive hair loss with limited donor hair availability. Yet there are no clear guidelines to direct restoration of the vertex. The pattern of hair loss, age, family history, and donor availability have a significant impact on the restoration of this area. Generally, it is said that “vertex is like a black hole’ where hundreds of hair follicles are utilized resulting in a minimal cosmetic effect. Restoration of the facial frame by transplanting the front area of the scalp has primary precedence, especially in young individuals. At a younger age, the vertex is best treated by oral medication and topical solution. The luxury of transplanting vertex can be taken after completion of the restoration of the facial framework of the frontal and mid-scalp.
Though the vertex does not play a large role in the appearance of the patient, by not restoring the crown, the hair restoration of the scalp is incomplete. As of now, techniques of harvesting and implantation have improved, and it is possible to use non-scalp donor areas to provide extra hair follicles which improve our ability to cover the vertex.
A detailed discussion with the patient is necessary before taking any of the above options. It is very important to visualize future hair loss in the vertex before undertaking a hair transplant. The easy way to assess this is to wet the patient’s hair. This simple procedure will give useful information about future hair loss, visualization, and demarcating the thinning zones becomes easier with wet hair. These regions can be marked and by. blending grafts into this area of hair thinning will limit the chance of showing an unnatural balding halo as a result of progressive hair loss.
Hair architecture in the vertex
Hair distribution and pattern in the vertex are unique and complex. Restoring normalcy means maintaining a normal existing hair pattern. It requires careful observation of existing patterns and loss with anticipated patterns of hair loss. There are different patterns of hair arrangement in the vertex (Ziering’s ). There can be a so-called “S” pattern that describes a clockwise whorl. Another is the “Z” pattern in which anti-clockwise whorl, a combination of the two with adjacent whorls, viz a ”SS”or a “SZ” and there can be diffuse patterns.
Planning the vertex transplant
The best guide is the existing vellus (“ghost” hair).Most of the time there are few thin hairs left which help in determining the native hair patterns in the vertex. If a patient does not have any whorl left, it is better to place a single whorl off-centre, precisely on the side of the part with the arc matching the part like. If the patient parts his hair from left to right the whorl should be designed clockwise on the left side of the head, so that the upper limb of the vertex arc matches the hair part. Also, matching the same direction of the hair part facilitates hair styling.
Slit creation in vertex
Slit creation and implantation are best done with the patient either in a prone position or in a sitting position with the patient reclined approximately 45 degrees and the surgeon standing. This position can be very well maintained on the Thai massage chair. Another option is with the patient lying in the lateral positions.
The angle of implantation in the vertex
The natural angle of hair emergence increases from the nape of the neck to the anterior-most area of the upper zone of the vertex at which point the angle of emergence lessens over the mid-scalp, frontal area to the anterior hairline. This pattern of hair maintains the smooth roundness of the head when we look in a lateral view. During implantation gradual transition of angle needs to be maintained to get a good aesthetic outcome. In the lower zone, it is 10 to 20 degrees and near the vertex transition zone, it may go up to 35 to 45 degrees of implantation.
