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Dr. Bertram Medical Hair Transplant
眉 髮 醫 學 移 植 中 心 ( 香 港 ) |
( 852 ) 3421-1138
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Hairline Restore - Our Scientific Approach Using A Patent Laser Device
| Related Topics on Hairline |
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The result of this study was presented in the 2008 Asian Workship ( Korea ), 2008 ESHRS Meeting ( Rome ), and 2009 ISHRS Annual Scientific Meeting ( Amsterdam ). It was also published in International Forum ( Sep/Oct 2008 Volume 189, No. 5).
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Laser beam is the best tool in defining hairline
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Symmetrical hairline can be drawn in seconds
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Our patent laser device
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Adjusting the beam
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Drawing a man hairline
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Drawing a female hairline
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Hairline placement is important. It frames the face and has the most impact on a patient's appearance. The reconstructed hairline bears the signature of the surgeon, giving the first impression of his or her work quality.
Symmetry remains the first criteria in proper hairline placement. Differences in symmetry from one side to the other as well as differences in height impair facial attractiveness.1,2 The shape of the hairline is also crucial. It should match the individual face to give the best aesthetic result. A monotonous "universal" bell-shaped hairline misses the artistic part of hair restoration.
Proper hairline placement can be very time consuming. The patient only sees the hairline after it is drawn and may not accept the design. The surgeon has to rub off the marking and repeat the whole process. Regardless the time spent during the consultation, it is difficult to record the exact hairline design on drawings or photographs. The entire procedure has to be repeated again on the day of the surgery.
Use of Landmarks in Hairline Placement
As not every surgeon is gifted in drawing symmetrical curves, facial landmarks are commonly used to assist hairline placement.3,4 When drawing the frontal hairline, the glabella and lateral epicanthus are first projected vertically to locate the mid-frontal point (MFP) and the frontotemporal apex (Apex), respectively.
A symmetrical curve is then drawn to connect these three points. Norwood advised resting the palm on top of the scalp behind the proposed hairline as the center point; drawing with a marker somewhat like a compass.5
For the temporal hairline, two pairs of landmarks are used to trace the nasal tip-pupil line (NTP line) and the MFP-Ctip of earlobe line (MFP-E line). The intersection marks the temporal point from which the superior and inferior temporal hairlines are created. 6,8
In real practice it is difficult to project these 2-dimensional straight lines on paper onto a 3-dimensional surface; the lines bend significantly on the forehead. Flexible tape measure helps but cannot be totally trusted to reach the exact measurement on both sides.3 Any slight deviation results in asymmetry. Better tools are therefore needed.
The Origin of Laser Level in Hairline Design
In 2007, Shiao reported the use of a professional-grade laser level in designing a symmetrical frontal hairline and donor incision.7 The patient was seated in an upright position. A laser level mounted on a tripod cast a horizontal plane of light that "turned corners" and followed the contour of the forehead or occipit. This provided a visual on the potential position of hairline and donor incision. A perfectly symmetrical guideline was instantaneously created. The result was impressive; however, there are some practical problems in using a professional- grade laser level :
- A large room is needed to tripod the device at a certain distance from the patient
- The patient has to be maintained in a perfectly horizontal position
- The head has to be tilted in different directions and angles to find the desired sloping of the guideline
- The level cannot create a feminine hairline in a normal sitting position
- The patient has to wear a protective eye-shield or glasses to prevent accidental laser exposure (see amendment)
Stimulated by Shiao's work, we have been working on a portable laser device that can overcome the above limitations. The first prototype was built in March 2008 and we found it helpful in rapid hairline placement.
Our Patent Laser Device
The model consists of a class IIIA horizontal beam laser module (3 volt, maximum power 5mW, 650nm wavelength) wired to a battery box. The current model is the 5th generation. In order to overcome the previous problem of unsteadiness and tilting, we mounted the laser on one end of a 15 cm supporting frame. This new design also makes it unnecessary to maintain the patient in a rigid sitting position.
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Instruction of Use
The assistant holds the device directly in front of the patient. The end of the frame is rested firmly on the patient's forehead.Switch on the device and casts a beam on the forehead. The surgeon tilts the patient's head in different angles to find and mark a curve most pleasing to the eyes. By changing its position along the midline and angle of beam projection, different hairline shapes can be visualized.have been overcome. No support of a tripod is required.
How to Avoid Tilting
When the laser beam is cast to join the glabella and the nasal tip, more than one possible centerline can be seen when the device is moved sideways. While 2 points can define a straight line in a 2-D plane; 3 points are required to define a unique projection in a 3-D setting. For this reason, we added the philtrum as the third point. Also, we replaced the single-beam module to a cross-beam laser. By aligning its vertical beam with the three mentioned points, a non-tilted horizontal hairline can be ensured. |
The Use of Our Laser in Different Hairline Design
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Placing a Feminine Frontal Hairline
The term "feminine" is used instead of "female" as this pattern can sometimes be desired by men. The feminine frontal hairline is characterized by an inverted U as opposed to the horizontal or upward U in the male pattern. The patient is seated in front of a mirror and asked to mark the lowest point of the desired hairline as point A . Its position is adjusted according to the age, budget, preference, and available donor hair. The centerline is then checked by aligning the vertical beam with the glabella, nasal tip, and philtrum. The intersection of the centerline and point A marks the MFP. The device is then positioned on the frontal region behind the MFP to cast a downward beam. Different shapes of hairline can be created by 4 simultaneous steps :
- Moving the device along the centerline
- Tilting the device forward or backward
- Keeping the center of the crossed beam on the MFP
- Joining the lateral extension of the beam with the anterior border of the sideburns
As the device is positioned above eye-level, the patient can actually look into the mirror to choose amongst the different visualized curvatures (Figure 3). The selected hairline is traced after it is inspected from different angles to ensure symmetry. For those requesting a round mound in the center, the device can be repositioned on the forehead to trace a second line.
The patient re-examines the completed drawing. The shape of the hairline is changed accordingly to suit the overall appearance. Finally, in order to create a natural looking irregular hairline, "macro-irregularities," "micro-irregularities,"3 or "V" entrances6 are added.
Placing a Male Frontal Hairline
The centerline and MFP are first located in the same manner. The device is then positioned on the forehead below the MFP to cast a horizontal or upward beam. Different shapes of hairline can be created by three simultaneous steps (Figure 5):
- Moving the device along the centerline
- Tilting the device forward or backward
- Keeping the center of the crossed beam on the MFP
The selected hairline is inspected from the front to ensure symmetry, and from the sides to confirm that the lateral portions do not fall below horizontal.3 The frontal hairline and the temporoparietal fringes can then be related in two different ways :
- Connected with or without flare, or
- Remain unconnected as a frontal forelock. On completion, symmetry of the apices is best checked by inspecting from behind the patient. Once again the laser can be used in a similar fashion (Figure 6 ).
Temporal Hairline
Existing vellous hair can guide to locate the temporal points.7 For Mayer Class P and R, and those demanding a low frontal hairline, temporal hairline reconstruction is required. The laser device can be used either from a distance or positioned on the patient face. With the eyes closed, the NTP line and the MFP-E line are marked . Intersection of these two lines locates the temporal point (TP). The laser is then positioned along the centerline to confirm that both TPs lie along its horizontal beam. They should also be equidistant from the centerline. The superior temporal hairline is defined by drawing an up-sloping line from the TP and parallel to the nasal bridge. The inferior temporal hairline is defined by a down-sloping line parallel to the lateral eyebrow.6
Eyebrows and Moustache
The device is first positioned along the centerline to cast a horizontal beam. Onto the supraorbital ridges, the eyebrows uppermost points are checked. As the shape of an eyebrow is an inverted "U," the device should be positioned to cast a downward beam: the symmetrical lateral extensions trace the outer curvatures of the eyebrows (Figure 8). The moustache can be created in a similar way.
Donor Site
Some patients demand revision of donor scars. They prefer to show a symmetrical wound when wearing very short hair. Scar revision, however, is difficult. Attempt should be made in marking a symmetrical strip in the first place. This can easily be achieved by using the laser device. |
Laser-assisted hairline placement is simple and time-saving in creating symmetrical hairlines. However, this is just a tool. No device can replace the human perception of beauty. Our surgeon's artistic judgment is still the most crucial in the design and placement of hairlines. Since the first prototype was developed in March 2008, the device is used in our daily practice on all patients. We are happy with the results. Modification and refinement have continuously been made, both in the device and the technique. It has been on sale since 2008
Advantages of using the laser device
- Portable
- Simple to operate. It can be operated by just one person regardless of the position of the patient
- Less danger of direct exposure to laser as the device is operated above or below eye level
- The patient can open his or her eyes throughout the procedure and provide immediate feedback
- Time saving
- Reproducible hairline design. On recording three selected measurements (e.g., glabella to MFP, lateral canthus to apex), the original hairline can be retraced on subsequent visits.
- Individual design. Traditionally, there is no rule how to shape the hairline. The surgeon simply draws an arbitrary curve according to his or her artistic imagination. On the other hand, the laser device describes a hairline predetermined by the individual facial contour. Every point along the hairline carries the same transit angle where the sagittal plane of the skull changes from horizontal to vertical. This is unique in each individual.
Limitations of the laser device
- The laser beam loses sight amongst hair, thus, it is unable to outline a hairline on areas with plenty of existing hair
- Not all our tested laser modules can produce an accurate 90-degree cross-beam. Even a slight deviation can affect the overall symmetry of the described hairline. The beam calibration of each module should therefore be checked before use
- Aligning the vertical beam with the centerline is a good idea to outline a symmetrical hairline, as long as the facial contour is symmetrical. In some patients, the hairline placed using the normal protocol just looks out of place. The most likely explanation is an asymmetrical forehead. Under this circumstance, the vertical beam should best be ignored, or a single horizontal beam module is used instead
A More Artistic Level of Hair Transplantation
Hair transplantation is also called Hair Restoration Surgery, with the objective to restore the patient's previous look before loss of hair. With the recent advance in follicular unit transplantation, we should be able to upgrade our work from restoration to enhancement. The patient can be more attractive than he or she ever was.
The perception of beauty follows certain patterns, depending on how the different parts (eyes, nose, hairline, lips) are proportionally positioned on the face. Da Vinci introduced the Golden Rule of Three. Greco has an excellent article in the use of "phi" and the "Golden Rectangle" to define the focal points. Art and mathematical principles can become part of facial framing and hair restoration design.10 Pictures of celebrities can also be studied to search for the "pattern of beauty." The laser device can define landmarks instantly and facilitate the transfer of the complicated 2-D design onto the face.
AMENDMENT: Safety Precautions in Using a Class 3A Laser Pointer11
Lasers are classified into four main classes-1, 2, 3A & 3B, 4-to identify the associated risk. Class 3A has a power output less than 5mW and can damage the eye in a time less than the blink reflex. Exposure of a person's eyes to a momentary sweep of the laser beam can result in temporary flash blindness, afterimage, and glare, which can be particularly dangerous if the individual is engaged in a vision-critical activity. There are documented cases of retinal damage following multi-second exposures.
Safety precautions must be taken in its use :
- Only purchase pointers where the output power, laser hazard classification, and a warning about potential eye hazard are shown on a label or included in the instructions for use
- Never look directly into the laser beam
- Never aim the pointer at people or at reflective surfaces such as a mirror. The assistant should not stand behind the patient in case of accidental exposure
- Wear a protective eyeshield or glasses if the patient cannot be trusted to close his or her eyes when facing a laser beam
References
1. Rose, P. Hairline design. Hair Transplant Forum International September/October 2002; 12(5).
2. Springer, I.N., et al. Facial attractiveness. Visual impact of symmetry increases significantly towards the midline. Annals of Plast Surg August 2007; 59(2):156-161.
3. Rose, P., and W. Parsley. Science of Hairline Design. In R. Haber and D. Stough, editors. Hair Transplantation 2006. Elsevier Saunders; 55-71.
4. Simmons, C. Five old lines and three new lines that can help when designing a male temporal hairline or when transplanting the frontotemporal apex. Hair Transplant Forum International November/December 2004; 14(6).
5. Norwood, O.T., and B.J. Taylor. Hairline design and placement. J Dermatology Surg Oncol June 1991; 17(6):510-8.
6. Mayer, M., and D. Perez-Meza. Temporal points: Classification and surgical techniques for aesthetic results. ESHRS Journal 2003; 3(2):6-7.
7. Shiao, T.K., and I.S. Shiao. Laser-guided hairline design and donor strip marking. Hair Transplant Forum International March/April 2007; 17(2):53-54.
8. Basto, F.T. Irregular and sinuous anterior hairline: Prior technique refinement and male and female trace parameters. Hair Transplant Forum International January/February 2005; 15(1):15.
9. Brandy, D.A. A method for evaluating and treating the temporal peak region in patients with male pattern baldness. Dermatol Surg May 2002; 28(5):394-400.
10. Greco, J. Facial framing: "It's not all about the hair, it's about the eyes"! Utilizing art and mathematic principles in facial framing and hair restoration design. Hair Transplant Forum International January/February 2005; 15(1):11.
11. Statement on the use of laser pointers source of information: University of Toronto, Environmental Health and Safety. http://www.ehs.utoronto.ca/services/laserpg/laserptr.htm.
Editors' note: The authors of this article noted that this laser device is not yet commercially available. They have designed a few models, tried over the past 6 months, and now have a design ready for production. It will be sold over the Internet by mail order in the near future. Further information can be found at www.hairtransinter.com.
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