Where to Design The Frontal Hairline?

Very often my patients that are in their 20s, or early 30s disagree with me on the hairline I recommend. They pull up their photos before they start having male pattern baldness AKA androgenetic alopecia and request that I restore their hairline close to the one in their photos. I of course try to logically make them understand why this is not a good idea. In this blog post, I will try to explain why for the majority of patients restoring a low “youthful” hairline is not recommended.

Understanding the Reasoning Behind Doctor’s Recommendation

For this, one needs to understand the following surgical facts and laws of naturalness.

  1. Surgical hair restoration has limitations; the biggest one is the available donor area is usually not adequate to cover advanced baldness.
  2. People who retain their youthful hairlines into advanced age such as Ronald Reagan, or Brad Pitt also have very high density throughout their scalps with almost no signs of miniaturization. Creating a hairline like this along with high density behind it in the remaining scalp is almost impossible due to #1. If a young patient, in his short-sighted impulse, was to choose a low hairline and an unethical clinic was to honor it, he would most likely be stuck with low density or even baldness in the scalp behind it which will undoubtedly appear unnatural.
  3. A well-done hair restoration appears natural and is not detectable by the general public. The corollary to that is an unnatural-appearing hair restoration will draw unfavorable or negative attention from the general public. People will ask under their breath “What is up with this guy’s hair?”
  4. Density = # of Follicular units/ Surface area covered. If the number of follicular units stays the same, spreading them over a larger area will decrease the density. As a result, to cover a large area with “high” density will require a large number of follicles.
  5. In young patients, the pattern of baldness has usually not established itself. It is critical for these patients to reserve grafts for future areas of hair loss.

Having seen countless patients in person as well as in clinical photos who had transplants 5 to 30 years ago, what I have come to realize is that a high hairline with good density cosmetically will trump a low hairline with low density.

The recommendations I make to my patients are based on my knowledge of surgical limitations, progression of the disease, and clinical experience. Only a small minority of patients seeking hair restoration have the luxury of selecting a low youthful hairline. These patients usually have a minimal degree of hair loss and are often on a heavy medical stabilization regimen consisting of finasteride or dutasteride.