ABSTRACT
Achieving a natural-looking hairline in hair transplantation requires both artistic skill and surgical precision. This article presents a novel method that utilizes printable design templates to standardize and optimize hairline creation and hair follicle graft distribution in male patients. Two key templates are introduced: Design I for hairline planning, incorporating defined anatomical and aesthetic landmarks (midfrontal point, frontotemporal points, widow’s peak, defined zone, and tuft area); and Design II, a 2 × 2cm recipient area grid that facilitates precise measurement and graft density planning. Templates can be custom-made by the treating surgeon, adopted from other physicians, or modeled after real hairlines, including those of non-bald individuals. These designs are stored in a digital database and printed onto thermal tattoo transfer paper using a dedicated app. Once applied to the scalp with a specialized transfer solution, they provide consistent, reproducible, and aesthetically pleasing guides for surgery. This system enhances accuracy, reduces planning time, and supports less experienced surgeons in delivering high-quality results. Future integration with artificial intelligence could further automate design selection and customization based on individual patient characteristics.
INTRODUCTION
Extensive knowledge and considerable time are required to design a hairline that looks natural and attractive. It is also challenging to divide the recipient area into regions that will receive follicular units (FUs) with different densities. We present here a solution utilizing design templates to make these tasks faster and more precise in men (Figure 1).
Customized hectographic templates allow for the efficient and precise transfer of personalized hairlines, and for dividing the recipient area into regions and quadrants so that specific recipient areas can be marked for different densities and types of grafts (1-, 2-, 3- or more hair grafts).
THE TECHNOLOGY AND PROCESS
Designs can be created and used alone or in combination, and they can be used on multiple patients.
Design I – Hairline (Figure 2)
The design with three key points (MFP, right FTP, and left FTP), defined zone (DZ), tuft area and macro irregularities (widow’s peak and mounds). The transition zone (TZ) is anterior to the frontal line and is not routinely drawn. The FTL is used to measure the distance between the left and right FTPs.
A male hairline design includes three main components: 1) three key points (midfrontal point [MFP] and right and the left frontotemporal points [FTPs]), 2) the frontal line with macro-irregularities (widow’s peak and one or two mounds), and 3) regions such as the defined zone and tuft area.1-3 Other lines can be included according to the surgeon’s preference.
We define the transition zone (for 1-hair grafts only) as the area anterior to the designed frontal hairline. Incisions in this region are made in an irregular pattern to create micro irregularities. Next, another line is drawn approximately 5mm behind the frontal hairline, and the space between these two lines is referred to as the defined zone. This region is exclusively reserved for 2-hair grafts. The frontal tuft area is an oval-shaped region located posterior to the MFP, and it is the defined zone in which we exclusively place grafts with three or more hairs.
This approach ensures that the design not only establishes the position and shape of the hairline but also determines the distribution of specific graft types in each region that produces optimal cosmetic density. The frontotemporal line (FTL) is used to measure the distance between FTPs.
Design II – Recipient Area Grid (Figure 3)
Recipient area grid has quadrants measuring 2 × 2cm.
A design that divides the recipient area into 2 × 2cm quadrants.4 This grid pattern provides a practical and systematic approach to measuring the bald area in square centimeters, ensuring accurate surface assessment and facilitating the appropriate distribution of FUs.
ORIGIN OF THE DESIGNS
Hairline
Using this template technique, a database of different hairline designs can be created. As described above, the design should include the MFP, right and left FTPs, macro-irregularities (widow’s peak and one or two mounds), defined zone, and tuft area.
The MFP is the lowest point of the frontal hairline. Only after determining its precise location can the positioning of the FTPs be established.
There are several excellent reviews that detail how to accurately determine the location of the MFP.5-11 Multiple factors must be considered, including head shape, ethnicity, donor-to-recipient area ratio, age, patient preferences, and the surgeon’s aesthetic judgment.
To achieve MFP positioning, we generally prefer the technique of drawing a horizontal line at the top of the head and a vertical line at the front. A 45-degree line extending from the intersection of these two lines defines the location of the MFP. The precise identification of these three points is essential for the proper use of the hectographic template, as we will describe later. The designs can be created in one of three ways:
SURGEON’S HAIRLINE (Figure 4): The surgeon draws the hairline on a bald patient, including all relevant points, lines, and regions. The design can be created for multiple cases, considering different skull shapes and sizes. The details may vary from one surgeon to another. The chosen design can be adjusted in width (distance between right and left FTPs, the FTL) and height (the distance from the FTL to the MFP). These modifications (Figure 5) can be made using the Tattoo Printer® App (available in both the Apple Store and the Google Play Store) or selected manually from the original design.
FIGURE 4.In the top row, a hairline was drawn on a bald patient. This same hairline design was copied and used on additional patients (a second standard template was used to divide the recipient area into 2 × 2cm quadrants).
FIGURE 5.The surgeon’s hairline can be modified. The left column shows width adjustments that can be made in the App. A line initially 11cm wide, for example, can be printed at 12cm, 13cm, etc., according to the patient’s dimensions. The right column shows examples of the same hairline with different heights. The original line measured 11.5cm x 5.5cm, and below are the same widths with varying heights: 4.5cm, 3.5cm, and 2.5cm.
ANOTHER SURGEON’S HAIRLINE: A second method would be to use a hairline design created by another physician and available in a shared database. This is an excellent option for beginners. For example, patients can be offered a hairline designed by a renowned surgeon. (Figure 6) For example, hairlines created by renowned surgeons such as the author, Dr. Ronald Shapiro and Russel Knudsen outline macro-irregularities during the hairline design phase. Drs. William Rassman and Bessam Farjo incorporate both macro- and micro-irregularities intraoperatively while creating recipient sites.
FIGURE 6.Hairlines made by experienced surgeons.
MODEL HAIRLINES (Figure 7): In the third method, the design can be copied from the hairline of non-bald men (volunteers or even celebrities). As described above, the defined zone and tuft area can be included. The surgeon selects the most suitable hairline for the patient, and theoretically (debatable), the patient could also have the option to choose. Besides the printed design, real photos of the model’s hairline from different angles can be shown to facilitate decision-making (Figure 8).
FIGURE 7.Hairlines from non-bald men that have been copied and used as models.
FIGURE 8.Non-bald men with naturally existing hairlines. After copying the designs onto a plastic sheet with a pen, the hairlines are digitized and stored.
Recipient Area Grid
Dividing the recipient area into 2 × 2cm quadrants offers several advantages and has been part of our routine for many years.4 Counting the drawn quadrants provides the exact dimensions of the recipient area. This allows for precise determination of the graft density for each region of the recipient area.
We systematically count and record the number of pre-made incisions in each quadrant, ensuring that we always know the exact number of grafts required to complete the surgery.
Although the printed design on the scalp adheres well and can last throughout the procedure, we routinely tattoo all lines with methylene blue12 during surgery to guarantee the permanence of the markings throughout the entire procedure. The sagittal central line of the design should align with the MFP.
CREATING THE DATABASE
Treating Surgeon’s or Another Surgeon’s Hairline (Drawn on a Bald Patient and Copied)
The designs are drawn on bald patients by the treating surgeon or by other physicians who grant permission to replicate their designs.
This method is used when the existing hairline is either too high or completely absent. Its new position and shape must be determined based on the surgeon’s knowledge. Patients with different head shapes and sizes, as well as varying degrees of reconstruction needs (more or less conservative), should be selected to create the templates.
After cleansing the skin, the hairline, including the defined zone and tuft area, is drawn as described above before copying it onto a transparent plastic sheet (Figure 9).
The demarcated lines are copied using a transparent plastic sheet and a pen. On the left, the line of a non-bald model. On the right, the surgeon’s design is on a bald patient.
It is essential to record these distances in the database, as they will serve as a reference for the measurements of patients receiving these designs. The measurements obtained from the model patient (a three-dimensional structure) are often not identical to those copied onto the plastic sheet (a two-dimensional structure). However, when transferred back to the patient, they regain the desired shape.
Model Hairlines (Copied from Non-Bald Men)
A headband is used to expose the entire frontal hairline. Photos are taken from three positions: front, right profile, and left profile. Next, the skin is cleaned with gauze and alcohol (to remove oils). A medium-tip pen is used to draw the existing hairline with firm and uniform strokes, marking the MFP and the FTPs. A flexible ruler is then used to measure both the distance in centimeters between the FTPs (the FTL) and the distance from this line to the MFP.
Drawing on the Transparent Plastic Sheet
A transparent plastic sheet is placed and stretched over the hairline (Figure 9). Using a pen, the hairline design is traced and copied. Highlight the MFP, the FTPs, defined zone, and tuft area. In the case of model hairlines, include the defined zone and tuft area on a plastic sheet only after copying the hairline.
Photographing the Transparent Plastic Sheet
The copied drawing on the plastic sheet is placed on a sheet of white paper (Figure 10). The sheet must include the model patient’s name and the respective recorded measurements (FTL and its distance to the MFP). Using a pen, the drawing is transferred onto the white paper to obtain a more defined line. The defined zone and tuft area can be added at this point.
The drawing from the plastic sheet is copied onto the paper with a pen. At the center, the hairline was copied from plastic to paper. On the right, the defined line and tuft area were added to the hairline.
A photo of the paper sheet is taken using a mobile phone. The mobile phone photo app can be used to enhance the definition and clarity of each photo.
Database Creation
The database is divided into various hairlines:
Treating Surgeon’s hairlines
Hairlines from other doctors
Model hairlines
Each entry should include the line’s measurements: width (between the FTPs—the FTL) and height (from FTL to the MFP).
Application for Thermal Tattoo Transfer Paper Printing
For this, we use the Tattoo Printer® App:
The chosen hairline is selected. If it does not exactly match the patient’s measurements, its width (FTL) or its height can be adjusted in the app. The silk sheet is removed from the thermal tattoo transfer paper before placing it in the thermal stencil printer. Printing is quick (20 seconds). The printed hairline is cut out. The remaining paper can be used for other prints. Another option is to print multiple lines and store unused ones for future cases (Figure 11).
FIGURE 11.Thermal tattoo transfer paper with frontal hairline options with different heights (top left); recipient area grid (top right); thermal stencil printer (bottom)
Another thermal tattoo transfer paper is used to print the recipient area grid (Figure 11).
Application of the Hairline Drawing
After photographic documentation and before shaving the hair, the hairline area is cleaned with 70% alcohol. The right and left FTPs are marked with a pen (Figure 12). From the FTPs, the limits of the recipient area are outlined. The hair is then shaved. The scalp skin of the recipient area must be cleaned with alcohol (Figure 13) to remove oil and improve the adhesion of the drawing(s).
Marking the MFP and FTPs before shaving.
After marking the points and defining the recipient area limits, the hair is shaved and the skin is cleaned with 70% alcohol to remove oil and improve adhesion of the drawing(s).
The distance between the FTP points (the FTL) and the distance from the FTL to the MFP are measured with a ruler. These measurements assist in selecting the hairline from the database.
Next, the specialized transfer solution is applied (typically containing water, propylene glycol, stearic acid, triethanolamine, and other ingredients) (Figure 14). This liquid transfers the thermal tattoo drawing onto the skin. This liquid should be spread evenly with gloved fingertips, across the entire area receiving the drawing. A thin layer of the liquid should remain on the skin until the decal is applied. While it’s important to avoid leaving excessive liquid as it can cause blurring of the drawing, it’s important to note that not leaving enough of the transfer solution on the skin will make the design too light.
The specialized transfer solution is applied, facilitating the transfer of the thermal tattoo drawing onto the skin.
The hairline drawing is applied to the frontal region (Figure 15). The MFP and FTPs should align with the same points previously marked on the skin with a pen. Pressure is applied to the thermal tattoo transfer paper for approximately 10 seconds. Then, the paper is carefully removed.
The hairline template is chosen and applied, ensuring the MFP and the FTPs marked on the patient match the corresponding points on the drawing. After applying pressure for 10 seconds, the paper is removed, revealing the printed hairline on the skin.
The printed drawing should dry for 10 minutes. During this time, the surgeon may, for instance, mark the donor area.
Application of the Recipient Area Grid
A plastic sheet is placed over the recipient area, and its boundaries are copied with a pen. This plastic sheet is then cut and placed over the thermal tattoo transfer paper, which is trimmed to the same shape (Figure 16). The specialized transfer solution is applied again to the recipient area. The cut thermal tattoo transfer paper is carefully placed on the recipient area, ensuring the sagittal line aligns with the MFP. After applying pressure for 10 seconds, the paper is removed. The printed drawing is inspected, and if necessary, a pen can be used to reinforce any gaps and connect the hairline drawing with the recipient area grid.
The recipient area boundaries are copied onto a transparent plastic sheet. This sheet is placed over the thermal tattoo transfer paper for cutting. After applying the transfer solution and pressing for 10 seconds, the paper is removed, revealing the printed quadrants on the recipient area.
Documentation of the Printed Drawings and Fixation
After further photographic documentation, a fixative spray (usually containing hexamethyldisiloxane, trimethylsiloxysilicate, cyclopentasiloxane, dimethicone, polydimethylsiloxane) is applied, creating a thin protective layer to preserve the marking, ensuring it remains unchanged even until the following day (Figure 17).
A fixative spray is applied to keep the drawing intact.
CONCLUSION
A database with standardized designs that can be printed on thermal tattoo transfer paper and transferred to the patient’s scalp is a new and remarkable tool, beneficial for both experienced and novice hair transplant surgeons.
Having hairline templates available will facilitate the ability of beginners to provide patients with a truly natural hairline. Additionally, the division into regions with different densities and the specific selection of FUs with one, two, or more hairs will also greatly enhance the naturalness and density of the results.
Head shape varies from person to person. Therefore, the ideal hairline for each patient may have unique characteristics. If there is a slight difference between the drawing measurements and the patient’s measurements, adjustments can be made in the app. Ideally, the database should contain different designs to allow for an appropriate and personalized selection for each patient. Our database is continuously expanding. Our goal is to have different hairline designs to accommodate as many patients as possible.
The hectographic template is a remarkable tool that has the potential to revolutionize hair transplantation. In addition to enabling the replication of standardized frontal hairlines, it allows the selection of different designs, whether created by the physician or other practitioners, or whether it comes from an extensive array of models.
Additional potential applications include the precise replication of a temporal hairline and its contralateral counterpart. Similarly, it could enable the accurate duplication of one eyebrow’s design and its reproduction on the opposite side.
The database could also be expanded to incorporate a variety of female hairline patterns, hairline designs tailored to different ethnic backgrounds, and templates adapted to various cranial shapes. The same principle applies to beard designs.
The entire process is still highly manual, requiring time and skill to replicate and store different hairline designs. The future lies in utilizing artificial intelligence to accurately document various hairline patterns and tailor them to patients based on their individual physical characteristics.
Ultimately, the possibilities are vast, offering the potential to refine and transform one of the most critical stages of hair transplantation, hairline design, as well as to help optimize graft distribution and surgical planning.
Footnotes
This article is open access and may not be copied, distributed, or modified without written permission from the International Society of Hair Restoration Surgery.
- Copyright © 2025 by the International Society of Hair Restoration Surgery
This article is open access and may not be copied, distributed, or modified without written permission from the International Society of Hair Restoration Surgery.
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