Hair and hairline feminization


What is hairline surgery?

To achieve the best possible hairline feminization results, both the forehead and the hairline shapes must be treated as a single unit. From this point forward, the forehead region must be approached taking the patient’s hairline shapes into account. Only in this way can the most suitable treatment be selected according to each patient’s individual needs. The new hairline is designed to look natural, paying attention to parameters such as density and unevenness.

Hairline: Hair transplant variations

The overall condition of the hairline –format, height and hair density– must be evaluated in order to select the ideal treatment for every single case.

The hairline shape can follow different patterns: rounded (without recessions), M-shaped (presence of side temples) and undefined (marked front line and temple recessions due to advanced alopecia). The distance between the interpupillary line and the hairline determines the height of the hairline. Hair density refers to the number of follicular units (FU) per cm2 (FU/cm2) on the scalp.

Taking the three elements into consideration, and based on the observation and analysis of the hairlines of every transgender patient treated by our team, we have established 5 hairline variations:

  • Type I. Hairline with normal height and rounded format.
  • Type II. Hairline with normal height and receding side temples, often called an M-shaped hairline.
  • Type III. Naturally high hairline.
  • Type IV. High hairline due to alopecia, which is usually associated with side temples.
  • Type V. Undefined hairline due to advanced alopecia.

Type I

Type II

Type III

Type IV

Type V

Hairline: Hair transplant options

At the moment, FACIALTEAM offers four alternatives for hairline feminization:

Redefinition of the hairline: hair transplants

This procedure is primarily recommended for patients with sufficient hair density and without active androgenic alopecia (ideal for Type II hairline). While hair transplantation primarily focuses on recessed hairline areas, the central section of the hairline can also be attended to if hair density there is an issue or if a small advancement (up to 1 cm) of the hairline is desired (Type IV and Type V hairlines).

Hair follicles can be obtained using two different techniques: FUSS or FUE. With the FUSS technique (Follicular Unit Strip Surgery) the follicles are obtained from a strip of scalp, while with the FUE technique (Follicular Unit Extraction) the follicles are obtained one by one without any need for an associated surgical process. The latter technique usually requires more experience given its technical complexity and generally takes longer.

There is no set rule for the best time to undergo hair transplants in relation to Facial Feminization Surgery. However, these are the three common scenarios:

  1. Before FFS. Either by FUSS or FUE techniques. Our recommendation is to wait at least 12 months after transplants so that the grafts are in optimal conditions and therefore follicle viability is assured.
  2. Simultaneously with FFS: Forehead Reconstruction and Simultaneous Hair Transplant (FR and SHT).

If the patient is a candidate for hairline treatment via hair transplant and also a candidate for forehead reconstruction, our team has developed a Simultaneous Hair Transplant (SHT) technique. This technique consists of taking advantage of the strip of scalp obtained in the modified coronal approach, which we have used to access the frontal region. This allows us to harvest the hair follicles on this strip in the same way that they are obtained with the conventional FUSS transplant technique described above. Once the forehead reconstruction is done, a new hairline is designed and the hair follicles obtained are grafted in place (there is an average of 2,000 follicular units -FU- per strip, meaning some 3,900 hairs). To reduce risks associated with prolonged general anesthesia, the patient is woken up and kept under light sedation for the duration of the SHT procedure. Thanks to this technique, the entire upper third can be treated as part of the same surgical process, which is highly advantageous for many patients. Androgenic alopecia must be completely stabilized before this technique can be used. In cases where there has been notable hair loss from the area where the strip of scalp would normally be obtained, we can simply position the coronal incision further back – even in the back ofthe head if necessary. The number of follicles that can be obtained from the strip is limited, so if the result of the SHT does not fully meet the objective of closing the side temples, or if more density of hair is required, a second standard hair transplant procedure (FUSS or FUE) can be performed some months later.


Type I

Type II

Type III

Type IV

Type V

Blue indicates the surface area to cover with SHT
Yellow indicates a surface that could benefit from a second hair transplant session (unassociated with the forehead reconstruction), when necessary

  1. After FFS: Delayed Hair Transplant

Either the FUSS or FUE technique. We recommend a minimum of 6 months after feminization of the facial bone structure, to ensure proper healing and consolidation of the soft tissues in the operated regions.


Hair and hairline densification with MICROFEMINIZATION®

MICROFEMINIZATION® by Aprils Touch is a combination of newly developed techniques, skillful artistry, unique contouring and highlighting using specialist needles and pigments in tandem with cosmetic, medical and aesthetic procedures, to enhance and feminise the face and body.

For upper face feminization we use MICROFEMINIZATION® techniques to thicken hair, lower the hairline and feminize the eyebrows. With these techniques we create fuller, thicker hair, by placing pigmentation stokes into the dermis of the scalp to replicate hair follicles and hair strands, achieving a very natural looking appearance. This procedure can be used where hair is receding, fine or thinning and in conjunction with hair transplant techniques.

MICROFEMINIZATION® techniques are indicated for patients with low frontal hairline density, for example, after a Simultaneous Hair Transplant (SHT) as an alternative to a Delayed Hair Transplant.


Hair Replacement System

Hair Replacement System by Cesare Ragazzi Laboratories is an advanced, non-invasive, dermatologically-tested, full or partial hair replacement system that restores beautiful hair – seamlessly.

The Hair Replacement System (HRS) is a natural hair thickening system, which consists in producing a “second scalp”, a clone membrane personalized by each patient’s needs and characteristics. The HRS is particularly indicated for patients with extreme alopecia or a Type V hairline (undefined hairline due to advanced alopecia).

Once the model has been produced, which highlights the morphology and the contours of the area that will be thickened on the patient, an“epithesis” or clone membrane is produced. The base of the clone membrane is constituted by a special polymer resin that has been dermatologically tested and designed to provide comfort and stability. Natural human hair is selected from donors with high-grade hair and with similar hair characteristics to those of the individual. The hair is sewn by hand, one by one, with precise distribution, inclination and direction of the patient’s natural hair.

Once completed, the clone membrane is integrated onto the scalp using a special medical adhesive, dermatologically tested at the Cosmetology Centre at the University of Ferrara (Italy).


  • Phase 1. Scalp mapping: computer mapping of the scalp and alopecic area.
  • Phase 2. Cast production: cast created using specialist computer imaging, cloning the contours of the skull and scalp.
  • Phase 3. Cloning and pantone matching: clone membrane created by robotic technology, replicating exact shape, lines and pantones of patient’s scalp.
  • Phase 4. Hair selection and matching: meticulous selection of high-grade human hair to replicate colour and texture.
  • Phase 5. Implanting: hairs implanted individually into membrane, mirroring original direction of growth.
  • Phase 6. Non-surgical grafting: the membrane is non-surgically grafted onto the scalp before professionals complete a final styling.
  • Phase 7. HRS system fully integrated.

You may pursue normal activities, including swimming and high impact sports. On-going care with the guidance of your dedicated Cesare Ragazzi Laboratories consultant.


Hairline Lowering Surgery (HLS)

This is mainly recommended for patients with a Type III hairline (high rounded or curvilinear hairlines without side temples). Patients with Type IV hairlines (high hairlines with side temples) may also be candidates for this treatment, bearing in mind that the lowering will not substantially change the format, only decrease the height of the forehead. Therefore, these patients may be candidates for a second autologous hair transplant operation to close the receding areas or cover any visible scar remaining from the scalp advancement.

The HLS technique consists of removing a strip of skin from the forehead, advancing the scalp approximately 1 to 2 cm. The scar is placed some 2 mm inside the hair, following the implantation line. The objective of HLS is two-fold: to decrease the overall height of the forehead and to serve as an access point to reconstruct the frontonasoorbital complex.

In most cases, there are a number of disadvantages to this technique:

  1. The possibility of leaving a visible scar in a highly exposed part of the face;
  2. The possibility of leaving an excessively short forehead in the center region, which could produce unnatural results;
  3. Potentially limited results if surgical closure of the side temples is attempted due to excessive tension in the scarring area.

According to our analysis, HLS is suitable for one out of every 50 patients.


If you are interested in learning more about the Simultaneous Hair Transplant technique, please read our scientific article titled:

Facial Feminization Surgery: Simultaneous Hair Transplant during Forehead Reconstruction

Luis Capitán, Daniel Simón, Teresa Meyer, Antonio Alcaide, Allan Wells, Carlos Bailón, Raúl J. Bellinga, Thiago Tenório and Fermín Capitán-Cañadas
Plastic and Reconstructive Surgery
March 2017