A large part of my practice in hair restoration involves fixing bad hair transplants performed elsewhere. I also correct many types of problems that lie beyond simple male pattern baldness (also called androgenetic alopecia). I have fixed bad scars from trauma, cancer, facelifts, etc. I also work on restoring overplucked eyebrows and lower hairlines in women born with this condition.

There are endless permutations of things I do to restore hair in patients of both genders and all ethnicities and ages. To detail how I correct all of these problems would require a textbook or several, as I have personally written and/or edited 9 authoritative textbooks on hair transplant surgery.

This blog will focus only on how I correct unnatural hairlines — rather than on how I manage donor-site problems like overharvesting, bad linear donor scars, etc. I will not discuss other issues that may be encountered in hair surgery either, but instead, I will break down what makes a hairline natural and what makes a hairline unnatural.

What is interesting is that I have many patients who fear having an unnatural hairline; they view it as a dead giveaway that they’ve had a fake transplant. In fact, I can guarantee that they can only spot a minority of bad hair transplants out there.

The simple reason is the lack of experience and training required to gauge a fake hair transplant. I have been practicing hair transplants for close to 25 years, and it took me 5 years to discern bad transplants that are not obvious to a layperson. You develop an eye for bad work.

We are used to just thinking of 4-mm round plugs (“doll’s head” look) or the linear appearance of the outdated Juri flaps that weirdly arch across the scalp. But we may not think of subtle errors in graft placement like compression, wrong angles, etc., and may entirely miss a hairline that does not follow the basic tenets of design.

Along these aforementioned lines, I will divide hairline concerns into “macro” and “micro” problems. The macro hairline is its overall shape and position. Think of the initial line that is drawn at the beginning of the transplant to show where the proposed hairline will go. Where is its position and what is its overall shape?

The micro hairline refers to the actual transplanted hairs and would be composed of two subtypes of errors:

  • Problems with recipient sites (the little slits that the surgeon makes into which grafts are placed)
  • Graft placement (the grafts that are placed into the surgeon’s design by the assistant team)

We’re also going to just focus on the male hairline since rules are different for men and women in terms of the macro hairline. For the micro hairline, there are universal principles for both men and women but also slight differences that, again, will not be covered in this blog.

Instead, the blog will focus on macro and micro problems in bad hair transplants. By understanding what makes a bad transplant, you will be able to determine what constitutes a good hair transplant.

My wife asked me, “Why does it matter if you are the only one in the room who can tell the transplant looks fake?” My answer was twofold: “Hair transplantation is an art, and the standard should not be compromised based on an onlooker’s inability to tell it is fake. Second, I want the transplant to look so natural that even I cannot tell it was done.” Those are my goals for a natural hairline.

I have told a story many times to my patients. A few years ago, I was on a cruise that prompted my wife’s question. I saw this gentleman who was worth probably $100 million and clearly had a hairpiece that was shabbily maintained as well as asymmetrically positioned. I could see the separation of the fabric from the scalp. He also had bad linear donor scars visible from the back side. Finally, I could see his transplants into his temple revealed poor recipient site design (angles too high) and poor graft placement (too large and also compressed in shape).

I never told the man that I knew his result looked really bad because I didn’t feel the need to embarrass him about a bad result, which he may actually love. However, I did ask my parents and my wife, who were on the cruise with me, if they could see anything that I was talking about. All of them replied that they could not. They thought his hairline appeared 100% natural.

My entire family is super smart. My mom is a genius at math and business. My father is a retired physician. My wife was a theoretical math and astrophysics major because, as she said, they were the easiest majors for her because she never had to open a book. They are not idiots, but they couldn’t tell because they simply do not do hair transplants for a living.

Macro Hairline

Okay, with that preamble in mind, let’s discuss the rules governing a proper macro hairline for a man and how surgeons violate these rules all the time, especially on social media.

The first rule is that the lateral end of the hairline must end at the lateral canthus, that is, a vertical line drawn upwards from the outer edge of the eyelid. Unfortunately, I have seen far too often this line drawn further laterally (that is, toward the ear) to accommodate excessive temporal hair loss.

As the founder and ongoing director of my St. Louis hair transplant course for 16 years, I can tell you that beginner-to-intermediate students make this error routinely. In fact, this past year, I had a student who had been practicing hair transplants for 5 years break down in nervousness when she consistently drew the hairline too far laterally by about a centimeter.

Is a centimeter a lot? Absolutely! Even 2-3 mm lateral to this hairline will not look right, at least not to me. Am I a harsh judge? Yes. But hairline design has no room for compromise when you want to achieve absolutely seamless and natural results.

The second most common error I see with bad macro hairline design is a downsloping hairline from the side view. What does this mean?

Think of it as a rounded corner of the hairline, something very commonly seen on social media posts touting great results (or even more frequently, men coming into my office asking for the side of the hairline curved downwards). This hairline is egregiously fake and is what I call a “female hairline.”

Any man after puberty does not have a rounded hairline, with two exceptions:

  • Someone who has had a bad transplant
  • Someone who actually retained this natural curve after puberty (about 1% of the population)

In fact, I had a male staff member with this hairline shape. However, you would never design this hairline in a male with recession because it would not naturally exist in someone with a balding pattern. The two conditions (balding scalp and non-balding hairline) simply do not co-exist.

You also risk that, as the recession continues, this hairline will continue to look progressively unnatural and may not be fixable if you have expended so many grafts to create it that you run out of hairs over time. There are so many subtle problems of the macro hairline that I have filled textbook chapters explaining them. But these are two simple yet significant mistakes that I wanted to highlight in this blog.

Micro Hairline

What are examples of micro hairline problems? The first I see that is very common is a hairline that actually looks like a line; that is, it’s simply too straight. A hairline, in reality, is not a line, even though you initially draw it as a line with an eyebrow pencil. The closer you get to it, the less like a line it actually looks.

Think of a coastline. From a distance, it looks relatively straight. But the closer you zoom into it, the more irregular it appears. There are small outcroppings and islands as you approach the coastline more closely. That is how I describe to my students how a natural hairline should appear.

Angulation and Direction

Another problem that involves bad recipient site design concerns the angulation and direction of the recipient sites. When the sites are too vertical, they look “surprised.” That is, standing upright, which reduces visual density and also looks starkly unnatural.

Recipient sites should also flow naturally in the direction of the hair and not be splayed open or misdirected asymmetrically. A detailed description of every permutation of bad recipient sites lies beyond the scope of this blog.

However, one important point is that poorly designed recipient sites not only make the placed grafts look unnatural but can also make graft placement unduly traumatic because inconsistent angles make it impossible for the graft placer to know how to place the graft into the site.

If the graft does not perfectly fit the site, then there can also be many negative consequences:

  • If the graft is too large, it may not survive or could become compressed so that the natural spacing between follicles disappears and the graft looks like an old-fashioned plug graft.
  • Conversely, if the site is too large for a smaller graft, then the graft will fall into the site and cause pitting where the skin surface looks like a sunken dimple.
  • If the site is too shallow for the graft, then the graft may look “cobblestoned,” meaning that it causes a bumpy, irregular skin surface.
  • If the graft is traumatically inserted, it may grow out crinkly, like pubic hair. If grafts that are too large are placed in the hairline, the hairline will look grafty and unnatural.

These are just some of the many problems that can result from an inexperienced team and/or inexperienced surgeon.

Recap

As one can see in this blog, an unnatural hairline can be created from any number of missteps leading to anywhere from minor to devastating problems. Hairline design requires an artistic eye, technical skill, and an excellent team with commensurate skills, with perfection executed in every step.

My team and I at Lam Institute For Hair Restoration look forward to taking care of you, whether it’s to create a natural hairline or to fix one. Contact us today to schedule an appointment.