angles and directions: the keys to a natural looking hair transplant
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Angles and directions: the keys to a natural looking hair transplant

In every area of medicine, there are ways to do things more efficiently and effectively. The always evolving practice of hair restoration is no different. Walter P. Unger, MD, Associate Professor of Dermatology at the University of Toronto, Canada, recently conducted a study of hair direction in hair transplant procedures. His study, “Recipient Area Hair Direction and Angle in Hair Transplanting,” was published in the June 2004 issue of Dermatol Surg.

In his study, Unger made recommendations for how to conduct hair transplants in a way that will emulate the natural hair directions and angles that we are all born with, providing those who undergo the procedure with a healthy looking head of hair upon completion. According to Unger, “…the concept of ‘hair direction’ refers to the direction in which the hair wants to naturally fall, whereas hair ‘angle’ refers to the angle at which hair exits the scalp.” Before starting an actual transplant procedure, Unger asserts that patients should undergo a thorough examination of his/her hair patterns. This is necessary because no two human beings have the same hair patterns -- directions and angles are as unique to an individual as their personality and fingerprints.

A patient need not have a lot of hair for a doctor to detect the patterns -- these can be determined by looking at an individual’s vellus hairs, which are very short hairs of only about a centimeter long. Most people have them, even on areas that appear to be completely bald -- they are fine, colorless wisps that don’t grow in the same way as the rest of the hair.

As for any other existing hair on the head, Unger advises that the hair be combed in a variety of directions, repeatedly, to discern the direction and angle of the hair. Unger suggests that a patient cut their hair as short as possible before preparation for, and when undergoing, the procedure. This will help the surgeon in the initial planning stages of the transplant and also in performing it. He cites a study presented at a 2002 Chicago meeting of the International Society of Hair Restoration Surgery (ISHRS) as support for his recommendation. The presenters, J. Wong and V. Hasson, reported that they request their patients to cut their hair because it makes is easier the look at the hair directions over the entire surface of the head.

An individual’s hair does not grow in one or two different directions, it grows in many. To perform a successful hair transplant procedure, Unger notes that a doctor must have this information. The only deviation from the rule of following the natural direction of the hair when doing a hair transplant is when a cowlick is present that appears likely to disappear in the future. In that case, the doctor may choose to ignore it.

As for the steps in the process, they are as follows:

The direction of the hair is marked with needles. Then, incisions are made to match all identified directions and angles. Grafts, or transplants, are inserted in to the incisions. Grafts are hair and follicles removed from an inconspicuous area of the head and divided into units to be placed in the bald areas to be covered. Unger explains that the most commonly employed grafts contain a single-file row of two follicular units (two hairs) or three follicular units (three hairs). These are inserted into incisions made by small blades.

Unger’s study shows that the placement of each graft must be made according to the “map” provided through the examination of an individual’s natural directions and angles. Taking into account previous research and the work of others, Unger makes the following main points about hair placement:

Bald patients who want to part their hair from the left will have all hairs directed along the left side of the hairline towards the middle of the front of the head. As the surgeon works to transplant the “donor” hairs, he/she begins to insert the grafts through the top of the front hairline, directing them towards the front right side of the head. As the surgeon continues to work, the goal is to reorient the sites receiving the transplants so that they head towards the front. If the patient parts his hair on the right, [a doctor] will make the recipient sites in a ‘‘mirror-image’’ fashion, starting on the right.

The recipient sites at the hairline should also be made so that the hair projects out from the scalp, but not in a vertical direction. This is to be done to the entire scalp, with the exception of the sides of the head and at the crown. Here, hair grows at much sharper angles. In individuals with very thin scalps, the angle will be adjusted so that recipient sites will be provided with more room for the grafts without increasing the need for deeper penetration.

Compared to other techniques, the above described procedures allow hair to fall naturally, allowing the patient to style his/her hair easily and as they desire. And since patients are looking for as natural of a look as possible, Unger urges those performing these procedures to consider placing the grafts in such a way as to control the density of the hair -- no one wants hair that is too thin, too thick, tufts in prominent areas of the head, or the “doll hair” effect of visible plugs. The procedures detailed in Unger’s article require a doctor to approach a hair transplant from the perspective of the entire area of the head. Unger states, “…the finer the hair texture and/or the less contrast between the color of the hair and skin and/or the more persisting hair in the recipient area at the time of surgery, the larger the graft can be without being noticeable”.

Unger concludes his article by reiterating that doctors follow hair patterns when performing hair transplants and recommends the hair restoration procedures offered in his text. The prospect of a hair transplant today is far more appealing than it was decades ago, simply because of the advances in method, technique, and procedure follow-up. Unger’s contribution to the practice of hair transplantation is enormous because the main question on every prospective patient’s mind is, “will the procedure really improve my appearance?” Through procedures based on the unique physical characteristics of each patient and an acknowledgment of personal preferences, the answer to this question is a resounding “yes.”


Angles and directions: the keys to a natural looking hair transplant references

  • Unger WP. Recipient area hair direction and angle in hair transplanting. Dermatol Surg. 2004 Jun;30(6):829-36. PMID: 15171759
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