There was a cool discussion regarding hairline design in patients with very coarse donor hair. I have included some of my own comments below and hope this adds to your dicussion of hairlines. Interestingly, patients with coarse hair can challenge more established approaches to HT design.
"To me, a soft hairline is one with an irregular pattern of single-hair grafts on the leading edge, with increasing density (in terms of hairs/graft and grafts/cm2) moving into the frontal third. At this point, I think it goes without saying that single hair grouping are necessary for creating a natural hairline. But what about patients with very coarse hair? Can a SINGLE hair unit look pluggy on a patient with coarse hair? A single hair is in no way a “plug,” but in patients with coarse hair we do run the risk of a “surgical” looking hairline. The hairs can be too wiry for the front row and the exit points can stand out. What to do? The lovely feathered patterns and designs that are so natural looking for most patients can be difficult to pull off for those with coarse donor hair.
There are many ways to approach this issue, each with its benefits and drawbacks:
Grafts need to be carefully examined and identified prior to placement. What may look like a single may actually be a double with a hair in the resting phase. We should assume the elite hair restoration clinics will use high magnification to identity and/or manufacture singles for the front row. Magnification also helps in sorting the singles best suited for the leading edge. Keen knowledge of the donor zone is necessary to locate the finest hairs for the front. It should be noted, however, that hairs cycle and appear differently at different times. This may present a challenge.
The extraction of nape hairs (or other hairs that tend to be softer than the clusters found in the traditional strip harvest zone) is a valid solution to the coarse hair dilemma. But we have all seen people with hair loss in the nape area or recessions in the posterior hairline. Therefore, these hairs should be considered transient for some. The patients at greatest risk for loosing nape hairs are those with the potential for extensive hair loss. In other words, the patients at greatest risk tend not to be the best candidates for HT in the first place.
Placing grafts closer together on patients with very course hair is another possibility. Indeed, the coarse hairs that may have stood out with low density can be blended away in a lush carpet of tightly packed singles. The hairline should be undulating but dense enough so as not to draw the eye to any one hair. This is not exactly the transitional zone seen in nature but, in the absence of the perfect donor source, we can rely on the art of illusion.
- Injuring grafts
Single hair grafts can be selectively injured to create a softer look up front. Since the object of hair restoration is to create the appearance of more hair with finite donor source, this approach should be utilized sparingly."