What Your Surgeon Is Really Thinking Before Your Hair Transplant

Hi, it’s Dr. Ken Anderson. I’m here at Anderson Center for Hair. And what we’re going to do today is a little bit of hairline design, and I’m going to show you some of the things that go on during an actual in-person or virtual consultation.

And so, we’re going to jump right in and get started. Our first patient, we’ll call him Nick. Nick is 32 years old.

And let’s just scroll through his pictures here. Here’s a frontal view. Here’s a closeup of his frontal hairline.

And then, a little bit of a top down view, couple oblique views, and then a view of the back of his head. So, of course, I always talk about hair loss prevention at the beginning of the consults. So we’ll assume we’ve done that.

He’s come in, he’s just, he feels he looks older than he is. He doesn’t like the way his hairline has receded in the corners here and he’d like to do something about it. So, what I would first talk about is the rule of thirds.

That’s one of the key cornerstones of where a hairline should go. And if we just I’ll show you what that looks like here. When you look at someone, you’re expecting to see a hairline in a certain position.

And you can estimate that position using the rule of thirds. If we divide the face up into three equal horizontal bars of equal width, we’d end up with where the a correct hairline should be. And so we’ll just do if we look at the bottom of the chin to under the nose, that’s one/3, the lower third.

Between the nose or just under the nose to between the eyebrows. That’s the second third or the middle third. And the upper third is from between the eyebrows to the hairline.

And you can see here we’ve got one at the bottom, two in the middle, three at the top, three equal thirds. And I kind of like where his hairline is right now. A lot of times you’re going to have a little bit of loss in the corners, but it’s typical that he’s got a nice position of his frontal hairline right in the midline.

And so we’re going to keep the midline right there. Now, if you have a look close look here at the hairline, it’s got macro irregularities and micro irregularities. It’s already kind of built in.

And we and then macro irregularities are these larger chunks that are that are varied across the frontal hairline. And then if you dial in really close, you can see little hairs here and there. Those are the micro irregularities.

And so I would just mimic, you know, his existing hairline right in the front and probably augment some of that. And then as we go off laterally, kind of mimic that irregularity, the hair, you know, the hair lines are not straight. And after we’re done reconstructing the hairline, the hair needs to look like it’s always been there and not like somebody put it back.

And the secret to that is kind of an organic, irregular frontal hairline. And can we zoom in? Sure.

And so you can see if we look really close, he’s got some little I’ll call them straggler hairs there. There. Here, these are some of the micro irregularities.

Here’s one going off to the left. And we would give those guys friends and kind of just dot in some hairs ahead of the hairline just to kind of make it look as natural as possible. Over here, you can see he’s got some more of his own and out at the lateral edge.

I call these holdout hairs. These are hairs that even though a lot of the hair loss has occurred up there, you can see he’s got one right here, a couple right here. These are hairs that just are like I am I’m not going anywhere, pal.

So, they’re staying right there. And so, we’ll give those guys some friends all the way across. And then in just looking at this, I’m going to switch colors.

He’s got a fairly well- definfined what’s called a frontal forelock. That’s kind of in this anterior portion. And as we’re going to see a little bit more on the next slide as well, hair loss often occurs in the corners, but then will creep up on both sides kind of behind this frontal forelock, kind of isolating it as it comes in from the front around the back.

And and so we’ll see from the top here. Let’s have a look from the top. This is a good view.

I’ll just go ahead and circle what’s called the frontal forelock. That’s this area right here. Kind of like Charlie Brown.

Remember Charlie Brown? He had that little swirly right in the front of his head. It’s where the front of lock is.

So if we switch back to the blue pen. Okay. So we kind of we already talked about putting the hairline where it is in the front.

And then I would bring it out roughly like that. Now, this is a 3D model or excuse me, a 2D model. But in in real life, what I’m going to use on a patient if they were here for a consult is one of these.

This is a grease pencil and we can actually draw on the scalp and hand the patient a mirror and we can talk all about it. Now going back to this photograph here, he’s got that frontal forelock in green hair loss on both sides. And then like I mentioned previously, the hair loss often creeps up and will kind of meet in the middle back here.

So where those two arrows are kind of pointing at each other in the back here, I would certainly comb through that and look to see if grafts could be placed in that area as well. So if we move on to the next set of photographs here. This is a there we go.

Okay. So looking from the side, you can see he’s got some of his little straggler hairs out here. And just as I mentioned before, we’re going to keep the the in the midline, we’re going to keep the hairline right where it is.

And then as we come out, we’re going to keep it nice and irregular, right? We don’t want any patterned or anything that would lead the viewer to believe that there is something man-made up there. And so I’m not sure I like that actually.

That’s a little better. And we want it to really blend in well with the anterior temporal tuft. And that’s what this is called here.

This little triangle of air. We always have a look at that. And I’m just looking at him.

He may there a lot of times. Actually, I’m going to back up. I want to point something out here.

A lot of times what happens in the corners is that the hair loss occurs not only in a sort of a superior direction as we’re all familiar with, but it can also occur down in this direction. And I’ll switch to green. And we can see kind of a Cshape.

And as hair loss progresses, that C-shape kind of opens up as hair loss progresses sort of in all directions towards this little C-shaped thing I’ve drawn even down here. And you can have loss of the temporal point. This is the temporal point right here.

I’ll put that in red. The temporal point here or the temporal tuft. A lot of times you can have loss there.

So, we’ll carefully inspect that area to see if let’s see. We’ll carefully inspect that area to see if it needs augmentation. And I’m not really sure it I probably would leave it as is.

In some other patients though, so let’s just draw that back on here. In some other patients, we would want to augment the temporal tuft. Come right down there.

So, in some patients, if this part is missing, we would kind of fill that in. So, if we go down to the other side, let’s have a look. Okay.

So, it’s kind of tough to tell, but one thing I’ll do is on the morning of surgery or at an in-person consultation, I’ll use my surgical loops and a bright light and have a really close look right in through here because what you’ll find is these little wee tiny hairs that sort of are indicating that yeah, there used to be a temporal tuft here and so we would want to replace that. But I can’t really tell on this iPad. So if we start in the midline again, we would come out again, keeping it nice and irregular and then work its way into the the temporal tuft.

And again, we would put little straggler hairs. We want to make a really subtle, smooth, and natural transition from the hairless forehead to the hairbearing scalp. I mean, that is where the rubber meets the road as as I sometimes say in hair restoration surgery because you can’t hide that, right?

That’s the the frontal hairline. You’re looking right at it. It’s got it’s literally a work of art every time.

So, I’m happy with that. I kind of want to put on my loops and get in there and and see if there’s little tiny hairs telling me to augment that. But, anyway, we would we would focus more on that on the day of surgery.

Let’s have a look. All right. So, now in the back here, he’s got a an area.

I think there may be room for grafts, although he is only 32 years old. So, this is a little bit outside the scope of this video, but my personal ethical limit for transplanting into this area, which is known as the crown, is 35 years of age. And that’s because of a number of things.

Primarily, the limited number of follicles that can be transplanted over a lifetime. And so what I would encourage Nick to do is use the non-surgical methods we talk about topical medication, laser cap, regenerative medicine treatments to try to encourage this area of the scalp where we’re seeing some scalp here in the crown to regrow its own hair and thicken up on its own. And we’ve had a lot of success here at the practice in in literally reversing this level of hair loss because it’s not bald right there.

And I’m not even convinced there’s room for follicles there. So, and if he was like 37, I would probably have a look and maybe it’s from this picture, it’s hard to tell, but when a lot of times when hair has just started to thin, transplanting on top of of hairs that have just started to thin, if you haven’t already maximized non-surgical therapy doesn’t make as much sense. So, I would want to make sure we had already gone through the non-surgical therapy to see if we could get that hair to regrow on its own and not use up any of the precious supply of donor follicles.

Okay, these are great examples, by the way. If you want to send in pictures, you can see they’re well lit. There’s not a lot going on in the background.

There’s not a big bright window behind this gentleman’s forehead and we can see what’s going on very clearly. Next, we have a young man named Paul that he has photographs here. He is 30 years old and we’ll just scroll through his photographs to check out what he has going on.

Now, this is interesting. You can see something very common in hair loss is that it can be asymmetrical. It’s actually more common than than most people realize.

You can see on his right, he’s got a lot more loss than on his left in the frontal hairline. And here’s a couple oblique views. On the top is his left.

You can see he’s got some loss there, but much more so on right on the right. Similar view here. And here’s what he has going on in the back.

Let’s have a look in through here. Okay. So, let’s start with the first photograph.

As I mentioned previously, we could start with the rule of thirds. Now, in just looking at him, it looks like he’s got a little bit more recession in the midline than perhaps Nick did previously. One third, 2/3, 3/3 is somewhere in that region.

But I I just can tell he probably could use a little bit of tiny bit of conservative lowering in the midline. So there are our 3/3. Looking good.

Let’s have a look at the next photograph. And a little closer up view of his hairline. Okay, I’m going to look real close.

These are the the straggler hairs. Remember I was talking about micro irregularities. If we look really closely at his frontal hairline, he’s got, you know, a couple of hairs through here that are kind of hanging out a little bit below the rest of the hair up top.

And that’s natural. And that’s kind of what we duplicate when creating a hairline. So, in terms of where I would bring it down, I would use these little straggler hairs as a guide.

So, I’d probably just bring his hairline down just a bit in through here. And you can see some skin behind there. And we would kind of fill that in.

So, no, I’m not sure I like that. Not sure. It’s got to be Nope.

That’s better. Okay. And as we come over to the other side, we want to make sure it’s a nice and even.

Yeah, that’s not bad. And you can see we would fill in this area behind the blue line all the way across all this skin. You can see here we’re going to see a little less of that.

And then of course I would add little stragglers, little weeding hairs in front of the hairline to make a perfectly natural transition from the hairless forehead to the hairbearing scalp. All right, let’s have a look at his next photograph. Okay, this is an interesting one here.

You can see as mentioned on his right quite a bit more hair loss. So, if we we’re going to bring it down here, just going to kind of bring it to the lateral edge of the frontal forelock. Remember we talked about that with our last patient.

I’ll just circle that in in green again. His frontal forelock is pretty much right there. And then just like with our previous patient, I would look up in behind the frontal forelock to see if there’s any room for follicles in that area.

And then in terms of creating the rest of this frontal hairline, we want it just kind of a natural transition into the temporal tuft. And then same thing on this side. No, you want to make sure I always when I have a patient in the chair, I’ll tilt the head down to make sure that the the two edges are even side to side.

That would be like this area here and this area here. We want them to kind of be nice and even with each other. And you can see and then I want to get to the next photograph because it really nicely demonstrates.

Now remember I talked about how you can have loss of the temporal tough and that C-shaped area of expansion that can occur. You can see up in the on his left he’s still got the kind of the that shape going on almost a number seven but down here we’ve had loss up in this direction that direction and this direction kind of opening up that C-shaped area as it as the hair loss expands in all directions not just straight up but a little bit backwards and even down onto the temporal point. And you can kind of see if we look up at the top photograph here, the contour of his temporal point.

If we kind of draw it out, you know, it’s more or less a nice straightish line. But down here, you can see he’s got a little bit of a a cavity going on. And as you can see, the hair loss kind of taking a little cookie bite out of the leading edge, the superior edge of his temporal point.

So, we would certainly want to augment that. So, if we go to the top here, remember, I was going to start a little bit lower where the temporal or excuse me, where the little straggler hairs are and fill that in. And then we’d come across like this.

Let’s see what would look good. Kind of something like that. And I think his temporal tuft on this side is good.

If we peeled the hair back in this region right here that I’ll circle in green, if we peeled that hair back, I bet I bet any dollars to donuts, as my dad would say, that in through here we there would be some room for follicles kind of that C-shape that opening up. It will sort of head lateral as well. The hair loss will down here.

It’s a different story. We’re going to be a little bit more of a I mean we’re going to keep it Nope. We’re going to keep the hairline nice and organic looking.

But we’re gonna want to bring it forward a little bit from the back. One of the interesting thing is that if we look way at the bottom of this, let’s blow it up a bit. The anterior part of his sideburn, that should be when you go straight up from the sideburn about equal to where the temporal recession should end.

And so we’ll kind of come around here and then we’ll come as far back as that line drawn up from the sideburn. And then I would want to fill in a little bit. So, if we switch to the green here, we’re going to augment the top part of his temporal tuft in through here and then sort of advance the hair this way and fill in a little bit at the posterior part of his temporal recession.

And then, of course, all through the top here, all where we’re seeing skin there, we’re going to fill that in as well. In addition, I want to talk about reconstruction of the temporal point can be tricky. Okay, if we look up top here, it’s not really okay, you can kind of see in the distance there the angle the angle that the the hairs are coming out from the scalp.

Well, it’s a thick pen, isn’t it? Let’s see here. Not sticking straight up, but kind of angling forward a little bit.

But it’s not really a a narrow acute angle. But if we look at the hairs on the on the temporal tough, these hairs are coming out and then just kind of sking right along the skin surface. Are kind of just very very acutely positioned along the scalp which presents a bit of a challenge in terms of reconstructing that area.

Really got to pay attention to the angles there to make sure that the hairs lie nice and flat in that region. So if we switch to this one here, this is a direct lateral view again at the top. I’m going to bring it down slightly and then perhaps I would have to look, but perhaps again in this area there would need to be a little bit of reconstruction.

And then if we look at this one, I’m going to say the if we look at the the way down the bottom here, I’m going to say the anterior part of his sideburn is right about there. And it’s probably pointed back. So if we draw a straight line coming up from that, it’s probably going to be about there.

And so that we’d want to fill in all this area through here. So I would start just about there. Bring it in through here nice and irregular.

And then kind of curve that down. Bring it in down through here. And then as we have a closer look here, I think I probably would place some some follicles at the superior edge of his temporal point and fill in this area through here just to kind of give him a much more.

Now you can see we’ve gone from a much more C-shaped area of loss to now a much more youthful masculine almost a reverse number seven loss. And we would fill the area there in between the two green lines. I think that he’ll really enjoy that look.

Now, same thing here. This this man is 30 years old, and that’s just too young to be doing surgery in the crown. And I’m not even sure if there would be room for follicles in this area.

So, again, we would maximize non-surgical therapy, including topical medications, plated, topical exosomes. We could talk about using laser caps, regenerative medicine therapy, and I would want to exhaust that therapy for up to 12 months really to see the final results from that. But really, he’s got about a half a decade before I would be willing to go into the crown area.

Interesting case. Now, as you know from looking at his photographs, he’s got curly hair. Now, the character of the hair, curly versus straight, has a lot to do with how effective the coverage is going to be.

I call curly hair, I call that hard working hair, right? It comes out of the scalp and instead of like my hair is more or less straight. It’s lazy.

It comes out of the scalp and just kind of goes straight out into space. Hardworking hair like this, like Paul’s curly hair, it comes out and it starts curling around and and working hard to cover scalp. And so with when hair has a little bit more of a curl to it, typically you can get better coverage because the the hairs work all the hairs work hard and swirl around to cover more scalp than if the hair was straight.

Very good. So I think that’s going to give him a much more youthful look. You can’t really see his left temporal point or right temporal point on this this angle, but I think he’d be very pleased with that.

Now, he is only 30 years old, so I would definitely be insistent that he be engaging in effective hair loss prevention because the hairlines are permanent, right? He’s going to have that hairline forever and we don’t want to chase our tail with with having more surgery as hair loss progresses. So, he’s got a many years to live and many years of hair loss to contend with.

So, effective prevention, is always very important when talking about, male pattern hair loss. If you’d like me to evaluate your photographs, check the link in the description below. Send in a a comparable set, you know, well lit with the various angles we have, presented, and I’d love to have a look at them.