This is a condition called Lichen Planopilaris (LPP) which is a form of a scarring alopecia that destroys the hair follicle and then replaces it with scarring, resulting in permanent hair loss. The skin is shiny and mottled (this does not show well in the photo), and the hair ostea have some plaques around them. All this is typical of this disease. This man is 62 years old and had two hair transplants (1994 and 2006 totaling 2300 grafts in the frontal hairline). Three years ago, he had a nice frame to his face and a good hairline, but that hairline slowly disappeared. I am concerned than another hair transplant will likely fail. I recommended that he see his dermatologist and get an appropriate biopsy which will likely confirm the diagnosis. These biopsies require a doctor skilled in the microscopic evaluation of a biopsy. I always tell patients that it is very important to have a skilled doctor make your diagnosis.
Too many hair transplant surgeons see each potential patient coming into their office as a down payment for a BMW, rather than a person who has a problem (possibly a disease or a financial problem) so getting to know the patient well, doing a proper examination is critical to the over all care of the patient.