Introduction

There have been great advances in the field of hair restoration over the last two decades. The old ‘punch grafts’ once considered the state of the art, are now totally obsolete. The media campaigns have raised the awareness and acceptance levels of the patients.

A good hair transplant is not only about the number of the transplanted hair but also expresses the talent of the performing physician in terms of aesthetic looks. At present, there is no standard criteria which can differentiate and define a ‘good’ hair transplant from a ‘bad’ hair transplant. The reason is a vast diversity in results and lack of defining the standardized terms. There are so many variables which play a role in aesthetically pleasing hair transplant.

Proposed Scale

The author had attempted to develop a standardized hair transplant assessment scale.

It basically consists of certain features which are considered to be vital in a hair transplant procedure. These include the points pertaining to planning, execution and postoperative outcome. The scale has basically five components. Each component is further divided into subcomponents which are graded on the presence or absence of these features. The various components are described below:

A. Anterior hairline: It is the single most important feature of a hair transplant procedure which determines the naturalness of the surgical procedure and includes various features.
1. Location: Location of the anterior hairline is very important. It shows the surgical experience of the performing surgeons and also depicts the understanding of the surgeon. A ‘low’ hairline (less than the distance of nasion to nasal tip) gives unnatutal appearance at an older age. Whereas ‘mature’ hairline (of the same distance of nasion to nasal tip or more) provides an aesthetically pleasing hairline. The ‘rules of thirds and fifths’ provide a guideline. If the patient wants it below, it can always be done after few years in a young patient. Because it is easier to bring the hairline down even more than 1 cm but is a challenging job to raise the hairline to even ½ cm if it too ‘low’.
2. Straight-line effect: An ideal anterior hairline is ‘not’ a ‘straight-line’ rather it has alternate ‘peaks’ which are irregularly irregular in pattern.
3. All single hair: All the hair in anterior hairline are single-hair FUs. Any presence of more than one hair FUs gives an unnatural appearance. There is a zone of transition density 4. This transition zone adds to the naturalness in the result.
4. Unnatural hair angles: The angles of the hair in the anterior hairline is one of the most important factor contributing towards the naturalness of the result. The angles should be as acute as possible. Any angles more than 45o will give an unnatural appearance. The hair growing at acute edges also have an added advantage of augmenting others when combed on sides or backwards. And increase the effect of density.
5. Pitting: Pitting results due to the fact that the epithelium of the grafts is below the level of the epithelium of the surrounding skin while placing the grafts in the slits created. It is purely a technical error. Wither the slits should be made shallow or the skin should be removed from the grafts before placing. Pitting gives a very unnatural appearance and if present in anterior hairline, gives a very odd look.
6. Corn-row appearance: Natural hair grow in random alternate pattern. Any appearance of ‘corn-row’ indicates an unnatural appearance. But if the effect is due to larger hair grafts (3 hair or more), it becomes a challenge to correct the situation.
7. Pimples / cyst / infection: Any presence of cyst/pimples/ infection indicates technical issues especially while grafts preparation and placing. It can be retention cyst or may be due to ingrowing hair.

B. Fronto-temporal angle: Various points depict the naturalness of the results in the fronto-temporal angle.
1. Shape: Any obliteration of this angles results in artificial appearance. The obliteration is normally seen in females. In males, it is triangular in shape made by the conjunction of anterior hairline with the temporal hair. Any roundish to oval shape increases the dimensions of the forehead and results in a broader forehead.
2. Hair Angles: The direction of hair is very critical. It consists of 3 kind of hair angles. The superior part (upper limit of V) has hair directed anteriorly. The lower part (lower limb of V) has hair directed downwards and curling towards the eyebrows. The junction of both limbs (center of V) has hair in both directions with a gradual change from one to the other.

C. Mid-scalp: Various points to be considered include:
1. Hair angles: The hair angles should correspond to the surrounding hair. There is a gradual increase in the angle as these progress posteriorly. Any abrupt change in hair angles results in eye-catching abnormality from a distance.
2. Multi-hair plugs: The presence of multi-hair plugs (more than 4-5 hair) other than normal distribution may result in appreciable deformity on first sight.
3. Pitting: Pitting presents a technical drawback overlooks many times. It has a very unpleasant effect on sight.
4. Scarring: Any visible scarring in the transplanted area is not considered good especially in subsequent sessions. These can result in poor growth.
5. Whorl: This natural features must always be preserved during hair restoration. The presence of scalp whorl creates a feeling of naturalness. The absence of whorl recreation results in artificial looks.
6. Occipital hairline: The posterior part of the mid-scalp should also contain hair in irregular pattern line anterior hairline. The straight line gives an artificial look.

D. Donor Area: The donor area is normally ignored. Various factors affect the quality of donor area in strip or FUE surgery.
1. Wide Donor Scar: The width of the donor scar is very important for the patient as well as for the surgeon. A wide donor scar should be avoided. There are multiple factors which result in wide donor scar. A scar of about 1-2 mm should be aimed to be achieved. And in FUE, the scar should be less than 1 mm.
2. Poor Position: The position of the scar is another important point. The area of maximum density is around the level of superior nuchal line. Any scar above is likely to be visible during the process of hair loss. Any scar below the superior nuchal line is likely to stretch.
3. Mobility: The scar should be mobile enough not to hider the movements. The mobility of the scar also predicts the outcome of the surgical transplant.
E. Temporal Areas: It is one of the challenging aspects.
1. Single hair in hairline: The anterior 2-3 rows of transplanted temporal area must contain 1-hair FU exclusively. Only soft hair should be used.
2. Multi-hair plugs: Any presence of multi-hair (2 hair or more) gives unnatural appurtenance in the results.
3. Hair Angles: The hair angles should be as acute as possible. These angles must blend with the surrounding hair (if present) in such a way that there should be no visible difference. The curved-blade helps to recreate the curve required to achieve this natural angle.
4. Pitting: Pitting in the temporal area gives the unnatural appearance which is almost impossible to correct later on. Care must be observed during the placement of the grafts.