Donor Area Management
Donor area management is of the utmost importance when dealing with hairline restoration as the total amount of donor hair that one has is finite and cannot be increased or renewed. Therefore when considering hairline restoration a balance must be achieved between what a patient believes to be the ideal result vs. a natural and cosmetically appealing result that retains enough donor hair to address further loss. The challenge lies in the aggressive, high density hairlines previously referenced. If placed too low or with excessive temple angle closure approximately thirty to fifty percent of all available donor hair can be used. For the patient that is destined for aggressive hair loss this can be a cosmetic death sentence. The frontal region will be strong with a juvenile frame for the patient’s face but the areas behind the hairline, mid-scalp and crown, will have a thinner and see through appearance. This potential scenario does not take into consideration the prospect of hairline surgery with unnatural results or poor growth, which is much worse to deal with and will only use more grafts for repair in the future.
What makes a hairline natural? This has been debated for decades but with the advent of stereoscopic dissecting microscopes in follicular unit hair transplantation hairlines have become more natural on an order of magnitude beyond previous technologies. It is widely accepted that the most natural hairlines are those which have had graft refinement through the use of dissecting microscopes. Natural hairlines typically have single hair follicles mixed with velous, fine hairs that are much smaller and finer than normal scalp hair. There is an occasional two hair or three hair follicle in a typical hairline but they present no negative cosmetic impact. Current technology does not allow for reliable and consistent transplantation of vellus hairs for the ultimate natural result but we can transplant, and even create, single hair follicles for naturalness.
There are three challenges present in modern hair transplant technologies.
1. Many clinics have adopted FUE as their primary method of surgical hair restoration. With FUE the use of dissecting microscopes is assumed to be irrelevant. The challenge lies in the lack of refinement that further dissection under magnification can offer, such as that found with follicular unit strip surgery (FUSS). With stereoscopic microscopes technicians can see if a one hair follicle is really a two or three hair follicle. By properly identifying these larger follicles fewer will be placed into the hairline.
2. Single hair follicles from the healthy donor zone rarely mimic the single hair follicles found in a natural hairline. The texture can be more coarse and the diameter of the individual hair shafts can be larger thus single hair follicles, no matter how refined they may be, can still look artificial or “pluggy” when viewed after placement and subsequent growth has been realized.
3. Natural hairlines retain a percentage of vellus hairs that serve the cosmetic function of softening. They offer a transition from the bare, hairline forehead into the thick full hair of the human scalp. Current technology has the ability to transplant vellus hairs but the survival rates of these hairs is erratic and unpredictable and many times leaves a cosmetic deficit due to potential scarring and inconsistent growth.
While the challenges exist there are methods that clinics can develop to minimize and reduce the visual impact that these challenges present but until these challenges are directly overcome there will always be indicators, regardless of how minor, that the trained eye can notice as being indicative of surgery.