Follicular Unit Transplantation in Women

As in men, the exclusive use of naturally occurring, individual follicular units represent the ideal way to restore a woman’s hair. However, to successfully perform hair transplantation in women the surgeon must understand the subtle, but important aesthetic differences between the sexes.
Hair transplant surgeons generally have more experience with men, and some of this experience is not directly transferable to women. As with all processes, one must start with observation.
A normal female hairline is much different that of a man’s hairline. In men, the hair in the frontal hairline usually started 3/4 inch above the highest crease of the furrowed brow, while the woman’s normal hairline position lies at this point. The hair direction is different as in men, the hair points predominantly forward, with a change in direction only as one approaches the temples. A woman’s hairline is more often characterized by “whorls” and “licks” that give the frontal edge its interesting “character” and it does not point forward in its normal position but rather to the sides. These abrupt directional changes can be recreated, but it requires very fine instrumentation and meticulous attention to the depth, angle and spacing of the recipient sites in which the grafts are to be placed as well as a skill-set from a knowledgeable doctor.
In women, a “vellus blush” produced by finer hair, is often noted at the leading edge of the frontal hairline. In men, the aesthetic contribution of these vellus hairs is much less significant, if they are present at all. Therefore, using one-hair follicular units will often be sufficient to produce a natural appearing frontal edge of a man’s hairline (except in those with the coarsest hair). In women, however, finer hair is sometimes needed and this can be produced by removing the bulb (cutting off the bottom) of a normal terminal follicle. This will decrease the hair shaft diameter and make the appearance of the frontal hairline softer. It is also useful when transplanting the temples and restoring the eyebrows.
Some transplant surgeons feel that the nape of the neck, or just behind the ear, is a good source of this finer hair and they make the donor incision in these areas. I strongly advise against this practice because the incidence of unacceptable scarring is quite high and the hair in this location may not be permanent, since it is more subject to androgenetic and age related changes.
Another interesting characteristic of the female hairline is the higher occurrence of “Widow’s Peaks.” The Widow’s Peak is not simply a triangular dip at the midline, but a series of variations in the hairline that can add elegance and drama and is a remnant of the recession of the original child’s hairline upward, leaving a pointed tuft in the mid-line. In constructing a Widow’s Peak, the following should be noted: 1) the peak is often bounded on at least one side by a concave (rather than convex) hairline, 2) it is often slightly off center, 3) it is usually asymmetrical, and 3) the hair often points to the side rather than forward when present in women consistent with the direction of the juvenile hairline before it receded.
In contrast to the male hairline that normally recedes approximately 1/2 to 3/4 inch from the highest crease of the furrowed brow at the midline and 2-4 cm at the temples after puberty (even without any genetic balding), the female hairline tends to hug the upper brow crease (upper forehead wrinkle) throughout life. This gives the frontal presentation a more rounded look and a more complete frame to the face. But, in order for the hair to frame the face well, the subtle changes in hair direction must be reproduced exactly as it occurs is nature. This is a technical challenge since the hair direction shifts from being forward at the midline, to pointing backwards and downward at the temples, with the hair emerging almost perfectly flat to the surface of the skin.
Another technical challenge in transplanting women is that any bulkiness to the grafts will create unevenness in the skin. The skin of many women is so thin, especially in the region of the temples, that even one-hair follicular units must be trimmed closely with all the extraneous tissues removed. This, of course, can only be performed with precision, using the dissecting stereo-microscope. Unfortunately, many hair transplant surgeons do not understand the subtle techniques that must be employed when transplanting the temple peaks. Their results often have dimpling and small tufts of skin surrounding each graft making temple transplants very detectable unless everything was done perfectly at the time of the surgery.

Note the slightly asymmetric, saw-toothed normal female hairline.
Understanding the nuances of temple restoration is mandatory for doctors attempting hair transplantation to women, since, in contrast to men where the temples are rarely transplanted, in women it is almost always required. Whether the balding is from a face or brow lift, due to traction, or inherited, the temples are almost always involved.
A final characteristic of the female hairline is that it is extremely irregular and often asymmetric. The surgeon must fight his “natural instinct” to be well organized and orderly when determining the placement of the sites, as this will detract from the naturalness of the result. But, beauty in all living things is defined, in part, by their “symmetry.” This is an evolutionary marker signifying good health that is noted throughout the animal kingdom. The surgeon must, therefore, posses the artistic sense to strike just the right blend of asymmetry and balance, and of irregularity and perfection.