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The frontal forelock concept was first popularized in the early-1990s by the work of Beehner, Marritt, Stough, and others.(13-16) Recognizing both the progessive nature of hair loss, and the need to provide hair restoration to men already with or at risk for developing advanced hair loss, the frontal forelock was proposed as a natural-appearing solution. What is truly amazing is the ability of some of these pioneers to achieve reasonably natural-appearing results using traditional micrografts and minigrafts

Today, follicular unit grafting offers hair transplant surgeons several distinct advantages over traditional micro/minigrafting. In addition to the fact that hairs are preserved in their naturally occurring bundles, what is especially relevant to the ongoing discussion is the maximal preservation of donor hairs by microscopic dissection. The additional 20% or more hairs can go a long way towards providing more coverage. Other advantages of follicular unit grafting are conferred by the smaller size of the grafts compared to traditional micro/minigrafts. The grafts require smaller recipient sites, which can be placed closer together for greater density, and which result in minimal to no scarring. Follicular unit grafting, however, is merely a technique and not a guarantee of a good result. Success, as measured by the ability to create undetectability, naturalness, and the appearance of reasonable density, is dependent upon the planning, the aesthetic designing, and the proper executing of the restoration.

A number of different forelock patterns have been presented in the literature.(12,15) What they all have in common is a soft transition zone (created by the irregular placement of all 1, and occasionally 2, hair grafts) along the periphery, and the progressive increase in density as one proceeds centrally (once created by minigrafts with 3 to 6 or more hairs, now created with the close placement of 2 to 4 hair follicular unit grafts). The illustration and case presentations serve as examples, illustrating the key fundamentals of frontal forelock design. Much like the design of any hairline, considerations must account for the individual patient's facial morphology, expectations, and hair quality.

The majority of men who undergo the frontal forelock procedure have sufficient cephalic temporal hairlines to connect to the transplanted hairs. However, in certain individuals, recession of the temporal horns requires deciding whether to create an isolated, or a connected frontal fringe. It is the author's experience that the majority of men prefer a connected forelock. A relatively small number of 1 and 2 hair grafts can be judiciously applied to build up the temporal horns to the level of the forelock. Key to aesthetics is placing these grafts at an acute angle to the scalp in order that they grow in an inferior direction. However, in certain individuals, the natural direction of growth is in a more superior or anterior direction.

While the forelock design as presented is specifically for use in men with advanced hair loss, the concepts put forth are applicable to virtually all hair transplants. Until a truly effective medical "cure" for hair loss, such as gene therapy or a new medication, becomes available, almost every individual must be viewed as being at risk for progressing to an advanced degree of hair loss. Adhering to the concepts of conservative hairline design and maximizing density in the central forelock can prevent cosmetic problems in the future. Of course, following a conservative course requires educating the patient. Perhaps the greatest challenge in treating these patients lies not in the actual procedure, but in the counseling process, and getting the patient, especially the young patient at high risk for developing advanced baldness, to willingly agree to undergo a conservative hair restoration.

The price of not adhering to a conservative restoration course in the young patient can be an unnatural appearance in the future, if the progression of hair loss occurs as expected. Possible features of the unnatural appearance, which are almost all due to the exhaustion of hairs for further transplanting, depend upon how the restoration was performed. Inadequate density, with "see-through" hair, can result if all 1 to 3 hair grafts were widely distributed along the entire top of the head. An abnormally low and dense hairline, sharply contrasting with the remaining thin fringe hair, can result if the hairline was solidly filled in and positioned according to the desired features of a young man, not that of a more "appropriate" older man. On the other hand, if in the young individual there is minimal progression of hair loss in the future, defying expectations, nothing has been lost. The conservatively created frontal forelock can be extended laterally, posteriorly, even anteriorly, by the transplanting of hairs that proved to be permanent, withstanding the test of time.

Corresponding author: Jeffrey Epstein, M.D., 6280 Sunset Drive, Suite 504, Miami, FL 33143
EMAIL: [email protected]

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2. Norwood O.T. Alopecia: Classification and Incidence. In: D.B. Stough, R.S. Haber (Eds.) Hair Replacement, Surgical and Medical. St. Louis, Missouri: Mosby-Year Book, Inc., 1996.
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4. DeVillez R.L. Pathophysiology of Androgenic Alopecia. In: D.B. Stough, R.S. Haber (Eds.) Hair Replacement, Surgical and Medical. St. Louis, Missouri: Mosby-Year Book, Inc., 1996
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6. Carson, S. Micrografting in extensive quantities: the ideal hair restoration procedure. Dermatol. Surg. 21:306-311, 1995.
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9. Seager, D., et al. Standardizing the classification and description of Follicular unit Transplantation and mini-micrografting techniques. Dermatol. Surg. 24:957-963, 1998.
10. Dissecting microscope versus magnifying loupes with transillumination in the preparation of follicular unit grafts: a bilateral controlled study. Dermatol. Surg. 8:875-880, 1998.
11. Swerdloff, J., Kabaker, S. Donor site harvest, graft yield estimation, and recipient site preparation for follicular-unit hair restoration. Arch. Facial Plast. Surg. 1:49-52, 1999.
12. Beehner, M.L. A frontal forelock/central density framework for hair restoration. Dermatol. Surg. 23:807-815, 1997.
13. Beehner, M.L. The frontal forelock. Hair Transplant Forum International 5(1):1-5, 1995.
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Figure 1: Illustration of the technique of follicular unit grafting. The single donor strip is then divided into narrow slivers, from which the individual grafts are dissected. All dissection is performed under binocular microscope.

Figure 2: Forelock design with Class 6 hair loss pattern. The central region has the greatest density by closely placing grafts of 2 to 4 hairs. The cross-hatched area lateral to the forelock represents the "temporal horns" consisting of grafts of 1 and 2 hairs which convert an isolated into a connected forelock. The triangular shaped cross-hatched widow's peak is optional; created by grafts of 1 and 2 hairs (similar to the surrounding periphery demonstrated as the clear areas), its effect is to make the hairline appear lower.

Figure 3: 47 year old, before (a, b) and 8 months after (c, d) 1 procedure of 1930 grafts. See text for more information

Figure 4: 50 year old, before (a, b) and 8 months after (c, d, e) 2 procedures of 3800 grafts over 2 procedures. See text for more information.

Figure 5: 58 year old, before (a) and 6 months after (b, c) 1 procedure of 2150 grafts. See text for more information.


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