Hairline Densities

[Julius]

See what Dr Paul Shapiro from SMG wrote here:

(promotional link removed)

My concern is that the density that I plant at in the hairline then determines the density that needs to be planted later in a patient’s life as his hair loss progresses. What I am saying is that if I plant at densities of 60 FU/sq.cm., in the hairline then I am committed to plant at the same densities or higher behind the hairline. So if I plant a hairline at the density of 60 FU/sq.cm in a 25 to 30 year old male and he then progresses to a Norwood type 6 or 7 he may not have enough donor to plant at densities behind the hairline that will be cosmetically pleasing unless you stick to just the front 1/3 of the head. And that can look very unnatural. Because if one plants at densities of 60 FU/sq.cm, in the hairline you need to plant at the same densities at least in the central core area and the frontal temporal angles or one will have a very thick hairline with less density behind it. That is not a pattern we see very often in nature.

You say: “ I have seen cases - where you can fade 60 from the hairline down to 50 or 40 as you get further back on the head without it looking unnatural in the least.” I have not seen these examples and the general consensus in the Hair Transplant community is that this is not a natural look. The general consensus is that the central core area should have more density then the hairline.

The hairline has two separate zones the transitional and defined.

Now the average transition zone is 10cm2 and the average defined zone is 30cm2

The transition zone, consisting of the first .5-1.5 cm of the hairline, Only 1 hair follicular units should be used in this area. Finer one hair grafts are separated and placed in the most anterior portion of this zone.

"Defined zone" is a two to three cm wide area that sits directly behind the "transition zone”.Concentrating 2-3 hair follicular units this area accomplishes both goals nicely concentrating the 3 hair follicular units in the mid central portion of this zone (were the frontal tuft is usually located).

To sum up at SMG it is said that a hairline density of 40 to 50 FU/sq.cm is mosty used, which increases as goes back towards the central core.

 

But why do I often see the top clinics doing this:

http://www.hairtransplantnetwork.com/blog/journal.asp?CopyID=6110&WebID=1497

Why is the transition zone planted at such a high density of 80 grafts per cm2 in this instance?

Won’t this hair transplant appear unnatural especially if seen from above?

Two posts ago I highlighted another

Remembering that Dr. Sharon Keene showed that in 'normal' men without male pattern baldness, the average follicular unit hair density at the front hairline was 51 FU/cm2 with a range of 38-78.

But as mattj said:

Well, to create a softer hairline single hairs are usually placed at the very front, with the groups of 2 to 4 hairs used further back where the increased density is welcome. I don't think nature does this. You'll find follicular units containing the full range of hairs at any point on the scalp.

 

http://www.hairrestorationnetwork.com/eve/138357-natural-density-hairline-temple-region-rest-head.html

So

Are the zones just BS? And if they aren’t why are so many top clinics transplanting the hair in these zones at such high densities?

[mr1986]

Great post, it goes to show you really need to think of what the future may hold, otherwise you could end up with a very unatural look to your hair, which defeats the purpose of having a HT.

[Julius]

We are told that density in the transition zone should not be too high so as to look natural and avoid the wall of hair transplant look but in practice it seems not the case

[mahhong]

I think, like a lot of art, a good artist can bend the rules. Your post was really informative and demonstrates a lot of the good working rules for hair transplantation, but there seems no hard and fast rule. After doing thousands of transplants most doctors probably get a gut feeling for what will work from patient to patient.

 

Recreating a head of hair is effectively a form of art. It doesn't necessarily follow that imitating nature will always produce the most natural results, I would imagine. Singles in the hairline seem to be the most popular way to go because it's the easiest way to design a soft and pleasing hairline. Nature probably does things somewhat differently, but natures results are by their very essence natural. Hair transplantation must work within the limits of human ability and so the approach, whilst having the same aim of looking natural, has been artificially developed.

 

This is an interesting subject in hair transplantation and probably something patients need more education and understanding of. From a patient perspective there is a tendency to think that packing as much in in as many places as possible is the goal, but when you start analysing the situation that's neither a realistic goal and probably not even the right sort of goal to have in mind. When I started analysing the hair of other people (a phase we all go through I would imagine) I started realising, when you really get down to the detail of hair, a lot of people's hair looks somewhat "abnormal" compared to what you think is the norm.

 

Of course their hair isn't abnormal, it's perfectly natural. But you start realising a 'gold standard' for hair isn't easily definable. Most people spend most of their time looking at the cumulative effect of hair. If an average person sees a head of hair they'll probably look at it in relation to the rest of the person. Having a good physique is a good comparison. I can't tell you how many people I see who, to my eyes, have a good physique. When it gets mentioned though, they start talking about unsymmetrical biceps and ugly deltoids and not enough definition in their trapezius etc. They're looking for perfection in each component but I'm looking at the whole object and casting a general opinion on it.

 

Hair is just the same. We all worry constantly about our hair on here because we've all noticed it's leaving us and we're all checking pretty much every section of our hair each day, sometimes noticing specific hairs that have fallen! I worry about my thinning hair but if I was to think rationally I would imagine a lot of people haven't noticed it yet, or certainly haven't "thought" about it. People don't really think about 'hair', they think about the hair's effect on you as a person and an entire body. That's why a bald person can look great, because it is a considered part of a look. When I think of my hair I tend to think of it as a lump of slowly failing matter! But most people just see it as a part of my larger physical self and, if it looks in principle like it's all there (which it does), they probably make a quick assumption that it is.

 

I guess that's why, when a lot of people get a transplant, people usually say "you look different" rather than "you have hair!". The cumulative effect on yourself changes, but people barely notice the individual elements. For all they know you might have lost weight or started wearing coloured contact lenses or had a nip and tuck.

 

So, in short, I think most doctors usually think about the hair as one part of your overall self. Designing, for example, a perfect hairline is not as important as designing the right hairline for you with the resources available. 99% of people, even some of the closest to you, will probably only ever glance at it anyway, and their brains will make a snap judgement about your physical appearance overall. That's why having a great body is desirable; people look at you and tend to think "phwoar, fit!", if you get what I mean! It almost seems people don't look at faces or specifics, they just latch on to an overall image and make their impressions on that.

[j1j9j85]

personaly i would rather have a thick front 1/3 with feathering behind as this will give the illusion of density! i dont agree that the same density has to be applied all over the scalp as in nature this isnt the case...........

 

if you have a thick hair line and front 3rd then feathering out at the back then this will look fuller to any one looking directly and there for require less grafts as the back in many men unless they have advanced balding stay thicker than the front any way!!!!!

 

also propecia seems to have better results on the rear than the front any way??? from what ive seen....

 

also a high density of the hairline can be mostly singles where as a lesser density with multiple hair grafts can have the same effect behind there for creating a better illusion again.

 

[Julius]

Thanks for the replies

I do think the central core needs to be denser or of the same density as the frontal hairline, though the crown can have less density as in nature, but the difference should not be stark.

Any doctor want to chime in about why hairlines are regularly dense packed

[mattj]

Not a doctor, but... special attention is paid to the hairline because it's generally the area that patients want to 'go all the way with' and restore as closely as possible to a pre-balding state. The hairline frames the face and it is from a face-on angle that we look at ourselves in the mirror. It's the angle that we most often present to people that we are interacting with. Most patients are aware that with a transplant they cannot have 100% of their original density throughout the whole balding area, and choose to prioritize the hairline.

 

Why do you feel that the top could require even more density that the hairline?

[Cant decide]

With all due respect to Dr. Shapiro, the above makes no sense in my unprofessional opinion. I think it is standard now adays for the hairline to be transplanted mostly with singles. One needs to consider the amount of hair per graft and not just grafts per sq sm. If I plant 60 per sq cm in the hairline, thats 60 hairs per sq cm. If I plant at 55 sq cm immediately behind that with 2 hair grafts, thats 110 hairs per square centimeters which means the density is actually getting greater as we go back. If you plant at 45 sq cm in the vertex with twos and threes, on average, you get 112.5 hairs..... In the end, what you have is a sort of evening out of densities in terms of actual hair count even though grafts per sq cm is decreasing as you go back.

[Zup]

Here is our take….

 

Hairlines are in complement with how much hairs behind them, if one has a strong transitional zone and one progresses to bald and they do not reestablish full coverage with an appearance of fullness the hairline in time may look peculiar. It is a trait, that represents a full head of hair and generally only found on adolescent kids or men that have bucked the system and maintained a full head of hair.

 

In regard to nature, heads of hair are like bodies of water along the shore line the water is shallow as you move into the water the water gets deeper. This is similar to a head of hair along the hair line, and this is around the entire head, the density is less and made up of more 1-2hairFUs as you move into the hair the density increases and there are more 3-4 hairFUs. At our clinic, if a patient has a high potential to maintain a full head of hair the transition zone will be more narrow, if the hairline is on a patient with more thinning the transition zone will be deeper. Our hairlines have two zones a transition zone; made up of all ones hairs, irregularity and in the pockets of irregularity, various degrees of densities. So nothing to consistent. One doesn’t want a perfect hairline, one wants perfect imperfection. Behind the transition zone is a Defined Zone made up of 1-2 hairs planted generally as close as possible. For years we have dealt with patients that want the most natural, along with full hairline, in establishing the fullness we build a hairline to approx. 40-50fus generally (Defined Zone)and build a strong front core, the foundation to the front, this will block the light and make the hairline look fuller, while following nature. After establishing a hairline at 40-50FUs if the patient is interested in greater density we generally are not packing the hairline with more hair, we are building more density behind the hairline. If one packs a hairline and the frontal core is thin the hairline will appear see through. The same as if you were looking into a forest, if there are twenty rows of trees densely packed but an open prairie behind it, one will see through the trees and see light. If the hairline is established and the frontal core is thick, the hairline will appear full.

 

With corrective work we’ve done on patients over the years, especially with old work, the hairline was packed with hair, with less density behind it and when the hair is wet and many times even when it wasn’t, the hairline appeared as a speed bump. We would call it ring around the hairline, and we would thin out the hairline and build the density behind it to improve the appearance.

 

Side note: I agree with Mahhong’s evaluation, over the last 20 years I have found people look at themselves as made up of parts and they critic every part individually, others view them as a whole, and many times even with hair loss and receded hairlines, the whole looks pretty good, even though, there may be many imperfections with each part the total combined looked good and attractive.

 

Regards, Matt Zupan

Edited November 11, 2010 by Zup