Hair and hairline feminization


What is hairline feminization surgery?

To achieve the best possible hairline feminization results, the forehead and the shape of the hairline should always be treated as one.

That’s the way we can decide upon the most suitable treatment according to each patient’s individual needs.

A new hairline is always designed to look natural, taking things such as density and unevenness into account.

Hairline transplant surgery variations

The overall condition of the hairline –including shape, height and hair density–must be assessed in order to decide on the ideal treatment in each case.

The hairline shape typically comes in 3 different patterns. For example, hairlines may be rounded (without recessions), M-shaped (presence of side temples) or undefined (marked front line and temple recessions due to advanced alopecia).

The distance between the eyes 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 these three elements into consideration and based on experience, we have distinguished 5 distinct hairline types:

  • 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. A 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

Hair transplant: Hairline options

Facialteam currently offers four alternatives for hairline feminization:

Redefining 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).

Hair transplantation primarily focuses on recessed hairline areas. This normally occurs in the corners, or “entries” that cause an M-shape. However, the central section of the hairline can also be dealt with if hair density is an issue there. In cases requiring a “lowering” to bring your hairline forward, grafts may advance the center by up to 1cm (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. With the FUE technique (Follicular Unit Extraction) the follicles are taken one by one without any need for surgery. The latter technique usually requires more experience given its technical complexity and generally takes longer.

There’s no set rule for the best time to undergo MTF hairline surgery in relation to other Facial Feminization Surgery. However, these are the three main scenarios::

  1. Before FFS. Either by FUSS or FUE Using either the FUSS or FUE techniques. We recommend waiting at least 12 months after transplants so that the grafts are well settled. This way we can also be sure that the follicles are viable.
  2. At the same time as FFSForehead Reconstruction and Simultaneous Hair Transplant (FR and SHT)..

If the patient is a candidate for hair transplant and forehead reconstruction, our team has developed a Simultaneous Hair Transplant (SHT) technique.

This technique takes advantage of the strip of scalp which is removed in order to access the forehead region during the modified coronal approach.

This allows us to harvest the hair follicles from this strip in the same way that they are obtained with the conventional FUSS transplant technique described above.

Once the forehead surgery is complete, a new hairline is designed and the hair follicles 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 throughout the SHT procedure.

Thanks to this technique, the entire upper third of the face can be feminized during one surgical procedure. This is advantageous for several reasons, considering number of trips abroad and hospital stays. Androgenic alopecia must be completely stabilized before this technique can be used. In cases where there is significant hair loss in the crown area (where the strip of scalp would normally be taken) we can simply position the incision further back. It can even be at the back of the head if necessary.

The number of follicles that can be obtained from the strip is limited. If the SHT cannot fully fill in the temples with sufficient density, a second hair transplant may need to be performed. Usually, it is recommended to wait a few months between sessions. .


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

Some patients delay the hair grafting portion of surgery to a posterior session, for a myriad of reason. This may be performed with either the FUSS or the FUE techniques. We recommend a minimum of six months after feminization of the facial bone structure. This ensures proper healing of swelling and bruising and consolidation of the soft tissues in 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