Aesthetics is from the Greek meaning Things perceptible by the senses. Aesthetics is defined as the science of the conditions of sensuous perception.
Therefore, when recreating the hairline, we must achieve an aesthetic result that appears as natural when viewed by the eye. Nature must be recreated.
However, before we undertake this, we have to judge the patient’s expected degree of hair loss during his life and the limits of his donor hair. Age is a factor. The earlier he starts to go bald, the more severe his hair loss may become as he grows older. The younger the patient, the more demanding he may be. He often wants a lower hairline that may not suit him as he grows older. He may run out of donor hair.
Much time may be required to explain all this to him and to reach a satisfactory compromise.
Many people, such as Norwood, Carlos Uebel, Ron Shapiro, and Dow Stough, have described the hairline placement in the past, and this talk would not be complete without mentioning them.
The words saw tooth, zigzag, no hairline, and the rule of thirds have all been used.
What is a hairline? It is not a line like a brick wall. It is a zone of irregularly placed hairs, gradually increasing in density as we move superiorly. However, there are some constraints in its creation.
- The hairline is 8-9cm above the glabella
- The recession at the temples is in line vertically above the lateral canthus of the eye.
- The line joining these two points, when viewed from the side, is horizontal.
- There is a widow’s peak of some degree.
- There are two lateral peaks
- There are some irregular hairs in the front hairline.
The artistry comes in being able to create the irregularity prevalent in nature, together with the above constraints, to aesthetically frame the face.
The ultimate compliment was offered from a bikie patient, thrilled with the result. I had given him back the hairline he had in his mug shot in 1982!
Some time ago, I devised a method called the snail track technique in which I use two lines to create pockets into which I place different densities of hair.
Snail Track Design
The size of the widow’s peak and lateral peaks varies in families, ethnic groups, and hair color. In summary, the hairline placement is an important and integral part of hair transplantation. If in doubt as to
The placement, place it high as it can always be brought forward later.
Optimal Coverage and Natural Hairline with a Small Number of Grafts
On March 5, 2012, our patient received 1434 grafts into his frontal area. He received ACell and PRP treatment on the day of his surgery. I shot the last two photos on 06-21-13 and was very impressed by his 1434 graft result. Our patient is extremely pleased with his result as well. His hairline and transplanted hair look completely natural, and no one would ever know he had FUE hair restoration surgery. We are commonly seeing much quicker healing and earlier growth in patients who are treated with ACell and PRP. Cross-sectional trichometry at the 15-month mark did not indicate thicker hair caliber, but on the other hand, Hair Check did not indicate miniaturization, which is generally the norm due to the progressive nature of MPB.
This case is an excellent example of how a skilled hair restoration physician can achieve optimal coverage and a hairline that looks 100% natural with a small number of grafts. Dr. Cole’s strategy, expertise, and artistic skill saved our patient a great deal of money.
What is cross-sectional trichometry (CST)?
Cross-sectional trichometry (CST) is a measure of the number of follicles and the diameter of hair follicles. Average CST is 69μm. When the patient has over 120 cm2 of hair loss, they cannot expect full coverage unless the CST is well above average. In this case, the patient is wise to focus on the front. One can obtain the appearance of coverage in the front without matching their original CST in the front because hairs shingle over themselves and add to one another. In the crown, one must often exceed 50% of the original CST to appear full because hairs follow the natural diverging growth angles of the spiral. Those with a greater hair diameter may obtain a fuller appearance with fewer grafts, while those with finer hair require more grafts.
Face Shape and Hairline Strategy
35+ years doing this. Face shape matters more than people realize.
The guidelines below are estimates only. Every patient is different. During consultation, I listen to your specific requests about hairline placement. If your desired placement makes sense for your anatomy and donor supply, I’ll accommodate it.
I’ve developed custom instruments specifically for precise hairline design, including specialized measurement tools (like the Assist to Hair Line Design device) to help determine optimal placement based on your facial proportions.
If you want a lower hairline, and I believe it’s feasible, we’ll do it. These face shape guidelines help inform the discussion, but don’t dictate your final design. Your input matters.
Oval Faces
Most versatile. Can handle almost any hairline design. Widow’s peak or straight, both work. Average temporal recession (1.5-2cm from lateral peaks).
Standard placement: 8-9cm above glabella. Can go slightly lower (7.5cm) on younger patients if donor supply robust.
Round Faces
Need height. Lower hairline makes face appear rounder. Place hairline 9-10cm above glabella. Deeper temporal recession helps (2-2.5cm). Creates visual length.
Avoid pronounced widow’s peak. Keeps horizontal emphasis minimal.
Square/Angular Faces
Soften the angles. Moderate widow’s peak helps (5-8mm projection). Gentler temple recession (1-2cm). More irregular frontal zone.
Standard 8-9cm placement works. Focus on softening transitions.
Long/Oblong Faces
Lower placement acceptable. Can go 7.5-8cm above glabella. Wider hairline helps. Less temple recession (1-1.5cm). Creates horizontal emphasis to balance vertical length.
Heart-Shaped Faces
Wider forehead, narrow chin. Moderate temple recession (1.5-2cm). Subtle widow’s peak (3-5mm). Don’t emphasize width at temples.
Ethnic Variations in Hairline Design
Different ethnicities have distinct hairline characteristics. Ignore this, results look wrong.
Caucasian Hairlines
African/African-American Hairlines
Keloid screening essential. Test graft in inconspicuous area first. Consider larger grafts (2-3 hair units) for efficiency.
Asian Hairlines
Single-hair grafts critical for frontal 3-5mm. Coarse hair creates pluggy look if not carefully placed. High patient expectations for density.
Middle Eastern/Mediterranean Hairlines
Aggressive future hair loss common. Conservative placement critical. Donor supply often excellent.
Age-Appropriate Hairline Design
Age changes everything. What looks good at 25 looks ridiculous at 55.
Ages 25-35
Risks
Unpredictable future loss. High patient expectations. May demand overly aggressive placement.
Strategy
Conservative approach mandatory. Place hairline 8.5-9cm above glabella minimum. Plan for Norwood 6-7 eventual loss. Preserve donor for future needs.
Temple Recession
Minimum 2cm recession at temples. Natural mature hairline appearance. Avoids juvenile look that ages poorly.
My Rule
Never place frontal hairline lower than 8cm on anyone under 35. Exceptions rare.
Ages 35-45
Assessment
Pattern usually established. Future loss more predictable. Donor supply clearer.
Strategy
Can be moderately aggressive if pattern stable 5+ years. Standard 8-9cm placement. Match mature hairline aesthetics.
Considerations
Still plan for some progression. Reserve 30-40% of donor for future sessions.
Ages 45-55
Advantages
Loss pattern set. Donor supply known. Realistic expectations usually.
Strategy
Age-appropriate design crucial. Hairline should show maturity. Subtle temple recession (2-3cm). Avoid overly dense or low placement.
Focus
Frame face naturally. Don’t try to recreate age-20 hairline. Looks fake.
Ages 55+
Reality
Limited donor often. Lower hair growth expectations. Medical considerations more common.
Strategy
Conservative density. Higher placement (9-10cm). Focus on frontal framing only. Crown usually abandoned unless donor excellent.
Key Point
Less is more. Soft, natural framing beats attempting full coverage.
Technical Specifications and Metrics
Numbers matter. Here’s what actually creates natural results.
Density Zones (Grafts per cm²)
Zone 1: Frontal Edge (anterior 5mm)
Exclusively single-hair grafts. 15-20 grafts per cm². Irregular placement pattern. Acute angle 15-20 degrees.
Zone 2: Transition (5-15mm posterior)
Mix of 1 and 2-hair grafts. 25-35 grafts per cm². Increasing density gradient. Angle 20-30 degrees.
Zone 3: Body (15mm+ posterior)
2, 3, and 4-hair grafts. 40-50 grafts per cm². Maximum density zone. Angle 35-45 degrees.
Native Scalp Comparison
Natural density: 70-100 follicular units per cm². Transplant achieves 50-60% native density maximum. Optical illusion of fullness relies on strategic placement.
Graft Angles by Location
Frontal Zone
15-25 degrees. Acute angle critical for natural appearance. Hair lies flat against forehead.
Mid-Scalp
30-40 degrees. Gradual transition. Matches native growth.
Crown
40-50 degrees. Steeper angle. Follows whorl pattern. Requires precise radial planning.
Temporal Points
10-20 degrees. Very acute. Hair sweeps back naturally.
Graft Calibration for Hair Characteristics
Fine Hair (50-70μm)
Need 20-30% more grafts for perceived density. Less coverage per follicular unit. More grafts required in frontal zone.
Medium Hair (70-90μm)
Standard protocols work. Average density targets sufficient.
Coarse Hair (90-110μm)
Can use 15-20% fewer grafts. More coverage per unit. Risk of pluggy appearance if over-packed.
Curly Hair
Provides 30-40% better optical coverage. Can reduce density targets. Angle less critical due to curl.
Straight Hair
Requires precise angles. Shows imperfections easily. Higher density needed for fullness.
Donor Supply Planning and Limitations
Everyone has limits. Ignoring them creates disasters.
Safe Donor Area Assessment
Permanent Zone
Occipital region: 8-10cm width × 15-18cm length. Temporal regions: 3-5cm width × 8-10cm length (each side).
Total safe donor area: 140-200 cm² average.
Density Matters
Average donor density: 70-90 follicular units per cm². High density (90-110 FU/cm²): Excellent donor. Low density (50-70 FU/cm²): Limited donor.
Lifetime Extraction Limits
FUE maximum: 25-35% of safe donor area over lifetime. Translates to 3,500-7,000 grafts total (multiple sessions). FUT maximum: 30-40% of occipital strip width.
My Conservative Approach
Never harvest more than 20-25% first session. Reserve remainder for future loss and repairs if needed.
When Donor Supply Insufficient
Body Hair Transplant
Chest, beard, back hair options. Coarser texture. Use behind hairline, not in frontal zone. Adds 1,000-2,500 additional grafts.
Realistic Expectations
Can’t achieve full coverage with limited donor. Focus on strategic framing. Crown often sacrificed for frontal coverage.
Scalp Micropigmentation Adjunct
Creates illusion of density. Pairs well with sparse transplant. Cost-effective extension of limited grafts.
Temple and Forelock Strategy
Temples and forelocks make or break naturalness.
Temporal Point Design
Natural Anatomy
Temporal points project anteriorly. Located above lateral canthus of eye. Create M-shape when viewed frontally.
Recession Depth
Young mature (25-35): 1.5-2cm recession. Middle-aged (35-50): 2-3cm recession. Older (50+): 2.5-3.5cm recession.
Shape and Angle
Rounded, not pointed. Gradual transition to frontal hairline. Very acute angle (10-15 degrees). Single-hair grafts mandatory.
Common Mistakes
Too square creates unnatural corner. Too deep looks prematurely aged. Straight connection to frontal hairline (should be curved).
Forelock Considerations
What Is It
Central frontal tuft. Projects slightly anterior. Common in certain ethnicities and families.
When to Create
Patient had prominent forelock historically. Photos show strong central peak. Ethnic background includes high forelock prevalence.
When to Avoid
Limited donor supply. Advanced age (looks juvenile on older men). Unstable hair loss pattern.
Execution
5-10mm projection from central hairline. Gradual taper on sides. Slightly higher density (5-10% more grafts).
Repair Scenarios and Corrections
40% of my patients are hair restoration repairs. Here’s what goes wrong and how to fix it.
Low Hairline Repairs
| Problem | Solution Options | Prevention |
|---|---|---|
| Never go below 7.5cm unless patient under 35 with stable 5+ year pattern AND excellent donor. | Camouflage with irregular grafts above existing line. Accept limitation, focus on density improvement. | Never go below 7.5cm unless patient under 35 with stable 5+ year pattern AND excellent donor. |
Straight-Line “Picket Fence” Repairs
| Problem | Solution Options | Prevention |
|---|---|---|
| Uniform straight hairline. No irregularity. Obviously transplanted appearance. | Place irregular single-hair grafts anterior to existing line. Creates transition zone. Softens appearance. Requires 200-400 additional grafts. | Irregular placement protocol from start. No straight lines ever. |
Poor Angle Repairs
| Problem | Solution Options | Prevention |
|---|---|---|
| Grafts placed perpendicular to scalp. Hair sticks straight up. Unmistakable plug appearance. | Can’t fix without removing grafts. Sometimes laser hair removal considered. Often require camouflage with correctly angled grafts around existing poor grafts. | Acute angles mandatory. No exceptions. |
Over-Harvested Donor
| Problem | Solution Options | Prevention |
|---|---|---|
| Previous surgeon extracted 60-70% of donor area. Visible scarring. Nothing left for repairs or future sessions. | Body or Beard hair transplant only option. Scalp micropigmentation for donor scarring. Realistic expectation setting crucial. | Conservative harvesting. Never exceed 25-30% lifetime extraction from safe donor. |
Unnatural “Plug” Graft Placement
| Problem | Solution: Plug Redistribution | Prevention |
|---|---|---|
| Old strip procedures (FUT) created large, unnatural “plug” appearance. 4-6 hair grafts placed as single units. Looks like doll hair. Becomes more obvious as surrounding native hair thins. | Specialized CIT (Cole FUE) technique to extract the old plugs. Break them down into natural 1-3 hair follicular units. Redistribute properly with correct angles and irregular placement. | Choose FUE over strip methods from start. Demand to see surgeon’s actual patient results. Avoid any clinic still doing large multi-hair grafts in frontal zone. |
CIT® particularly effective for this. Minimal invasiveness allows plug removal without additional scarring. Precision placement creates natural-looking hairline.
Learn more about plug redistribution procedures.
Frequently Asked Questions
How much does hairline design affect final outcome?
Difference between natural and obviously transplanted. Good graft survival with poor design looks fake. Moderate survival with excellent design looks natural.
I’ve fixed countless cases where growth was good but design was terrible. Can’t fix bad design without additional surgery.
Can I see my hairline design before the procedure?
Yes. I draw the hairline with surgical marker while patient sitting upright. Patient approves in the mirror before we start taking photos for reference.
Some surgeons use temporary tattoo markers for multi-day consideration. I find same-day approval works fine with thorough consultation beforehand.
No permanent marks made until patient completely satisfied.
What if I want a lower hairline than you recommend?
I explain the risks. Show photos of older patients with overly low hairlines. Discuss donor limitations.
If the patient insists, I document their request and my recommendations in writing. Sometimes I decline the case if the requested design is clearly inappropriate.
I’ve been doing this for 35+ years. Trust matters. If you don’t trust my judgment, find another surgeon.
How do you decide widow’s peak size?
Look at family photos. Brothers, father, grandfather if available. Check patient’s eyebrows and facial hair pattern. Consider ethnic background. Assess face shape proportions.
Some families have prominent widow’s peaks. Others have minimal to none. Match natural family characteristics.
Average widow’s peak projects 5-8mm from central hairline. Range: 0mm (straight) to 15mm (pronounced).
Does hair transplant hairline change over time?
Transplanted hairs permanent. Don’t fall out. But native hair behind transplant continues thinning if you have progressive androgenetic alopecia.
Creates “island” effect if not managed. Minoxidil or finasteride helps maintain native hair. Future sessions may be needed to fill gaps.
This is why conservative initial placement matters. Preserves donor for future needs.
Dr. Cole’s Design Philosophy
15,000+ procedures taught me this: Conservative placement, irregular execution, age-appropriate design.
Patients want teenage hairlines. I give them hairlines they’ll still be happy with at 65. Sometimes that means saying no to their initial request.
Better to gradually lower a conservative hairline over multiple sessions than to fix an overly aggressive single-session disaster.
The best transplants are invisible. No one should know you had surgery. That starts with proper hairline design.
