Hair’s the Question

ishrs_logo_3Like all medical specialties, continuing education is critical. For over a year now, Dr. Wasserbauer has been honored to write a column called “Hair’s the Question” for the ISHRS quarterly publication, Hair Transplant Forum International.  Read by thousands of medical professionals around the world, Dr. Wasserbauer offers a Q and A on specific hair transplant techniques and best practices.

Here’s a sample of one of Dr. Wasserbauer’s “Hair’s the Question” columns:

When a surgeon is trying to reproduce a natural hairline, it is most important to know what was natural in the first place. To that end, here are a few questions to test your knowledge about what hair patterns can be expected in nature.

1. According to Dr. Nusbaum’s data concerning female hairline patterns, what percentage of women have a widow’s peak?

a. 72%

b. 81%

c. 35%

d. 98%

B. 81%. Note also that lateral mounds were present in 98% of subjects, an important consideration when rebuilding a female hairline.

2. According to Dr. Nusbaum’s data concerning female hairline patterns, which of the following is true regarding the apex of the widow’s peak in women?

a. The mean distance of the apex to mid-brow line is 5.5 cm.

b. The apex starts between 6 and 8 cm above the glabella.

c. The apex is four fingers’ breadth from the mid-brow line.

d. The precise point of the apex can be found using the “rule of thirds.”

A is correct . All of the other choices are more appropriate for use in males and bear in mind that each hair surgeon has their own “art” of placing hairlines, so no one method is correct for any particular patient.

3. Of the different types of hair loss progression specific to worldwide ethnicities, which contains a progression to an isolated “island” persistent frontal forelock? (Hint: look up the Ebling/Rook Male Pattern Baldness charts)

a. Mediterranean men

b. Nordic men

c. Jewish men

d. African-American men

B, Nordic men. According to these charts (which can be accurate and useful especially when a patient does not fit into the typical Norwood pattern), Mediterranean men progress from the vertex anteriorly and from the frontal area posteriorly to meet at the midbridge, and Jewish men progress from the hairline on back posteriorly to the vertex.

4. According to the Norwood chart for male pattern hair loss, which of the following types preserves hair at the mid-bridge?

a. Type VI

b. Type VII

c. Type V

d. Type Va

C, Type V is correct. Va is toeing the line, admittedly, but still does not have the full midbridge intact according to Norwood. In all but the most severe forms of hair loss, the midbridge is often at least partially preserved.

5. Normal male or female hairlines commonly exhibit all of the following EXCEPT:

a. Mounds – such as lateral mounds or a widow’s peak

b. Nonrandom and straight lines of hair across the frontal area

c. Gaps and irregular groupings of hair spaced at random

d. Single hair follicular units with or without miniaturization

B is the answer since a straight line of hair at the frontal hairline does not exist in nature.

6. Which of the following can be a normal but less common occurrence in the frontal area?

a. Whorls or cowlicks

b. Two and Three-haired follicular units

c. Apex (widow’s peak) at less than 3cm above a male’s central glabellar (mid-brow) line

d. Central (frontal forelock) loss without temporal area (fronto-temporal triangle) thinning

A is the answer, although I have to say I have seen at least ONE instance of a two-haired follicular unit (but not a three) naturally occurring at the frontal hairline and I have the photo to prove it! I made up C and D since I’d never heard or seen any reports showing evidence of this.

7. A normal mature male hair pattern can include all of the following EXCEPT;

a. Temporal (fronto-temporal triangle) recession

b. Temporal peak recession

c. Thinning at the crown or vertex without frontal loss

d. Miniaturization >30% in the donor area

D is not part of a normal male hair pattern. Loss in the donor area would not be normal and would make one suspect DUPA or other less common pathology.

8. In Keene’s survey of the natural hairline density in men, what was the approximate mean density of the frontal hairline?

a. 20 FU/cm2

b. 30 FU/cm2

c. 40 FU/cm2

d. 50 FU/cm2

D is correct with the range being from 38-78 FU/cm2. Of note, the temporal apex and temporal point mean and median were about 40 FU/cm2.



1) Unger WP. Hair Transplantation, 2004. Chapter 3.

2) Hamilton JB. Patterned loss if hair in man. Ann NY Acad Sci 1951; 53: 708-728.

3) Norwood OT. Male Pattern Baldness: Classification and Incidence. South Med J 1975; 68:1359-1365.

4) Keene SA. Natural hairline density in men: findings of a pilot survey. H T Forum Intl. 2009; 19: 1, 47-48.

5) Nusbaum BP., Fuentefria S. Naturally Occurring Female Hairline Patterns. Derm Surg 2009; 35:907-913.