Hair Transplant for the Crown Part 5:  Creating the Right Pattern and Density Allocation

To conclude this blog article series on crown hair restoration, we leave the most complicated part to the end.  This article combines much of the knowledge that has been presented in the first four parts of this article series into a composite whole so some prerequisite knowledge is assumed.  This article will focus on how to distribute grafts across the crown to achieve maximal density.  Since grafts can be uniformly placed across the crown, the question would be why should a surgeon attempt to place them non-uniformly?  The answer is simply to create maximal aesthetic impact.  The reason for this is that there is only a finite number of grafts that can be transplanted at any one time and as the earlier article on the “billboard effect” stated, the surgeon is always in need of more grafts than imagined to get the best results in the crown region.  Therefore, it is imperative to apply the grafts in an artistically sound manner to create the best visual density possible.

The numbers in the accompanying figure describe priority areas to focus on density based on location, as will be explained in a moment.  When talking about density, density can be achieved through two methods:  using larger sized grafts like 3 to 4 hair grafts and by placing these grafts more tightly together.  For the sake of simplicity, consider that density in each of the prescribed areas will be achieved through a combination of both methods for best results.

From Hair Transplant 360, Lam

This article will strive to explain why the priorities on density have been labeled as diagrammed.  Priority 1 is assigned because the hairs in this area serve a triple purpose.  First, they arc upward into the area where the hair parts (shown by the yellow arrows) so that someone viewing the patient from in front should see less baldness coming through the sensitive hair-part area by virtue of the hairs that are transplanted in priority zone 1.  Secondly, the hairs also arc upward to cover the posterior midscalp meaning that the hairs also provide density to the entire back of the head when viewed from the front of the patient.  Third, the hairs in zone 1 also arc over and cover priority zones 2 and 3 and somewhat into 5 in a so-called “cascade effect” manner meaning that each hair in zone 1 covers at least 2 to 3 other zones near it effectively tripling the effect of each single hair graft in zone 1 when it comes to imparting visual density.    Priority zone 2 is next most important because it affects everything that zone 1 does except the hair part.  Zone 3 comes next because the hairs here cover the lower arc of the crown but do not cover the hair part or the posterior midscalp.  Zone 4 is next most important because it arches upward somewhat to reinforce zone 1.  Zone 5 comes next because even though it descends in an area of less cosmetic importance, i.e., the lower arc of the crown, it still rotates over to cover 6 partially.  Zone 6 is the least important because it occupies the lower half of the crown (as mentioned an area being less cosmetically important) and it does not arc over any adjacent area to provide additional cover but instead just descends almost straight downward.  Accordingly, it is important to think of hair restoration as a strategic and artistic endeavor, especially in the complex area of the crown region.

Samuel M. Lam, MD, FACS is a board certified hair restoration surgeon in Dallas, Texas. To learn more about Dr Lam’s crown hair transplant procedures please visit our website www.HairTX.com or call 1-888-866-3388 to schedule a consultation.

Hair Transplant for the Crown Part 4:  Creating the Right Angles and Transitions

To continue our series on crown restoration, this article will focus on creating the right angles and transitions during the procedure.  When viewed from a profile, a patient without hair in the crown looks bald because there is a relative flattening of the crown. To restore the round appearance of the crown it is important to create very perpendicular angles vis-à-vis the scalp.  This stands in contradistinction to the hair angles in the anterior portion of the head and the very low portion of the crown.  In addition, making high angles in the crown allows the grafts that spiral in a whorl pattern to be more tightly packed together, which is very important to create added density.  Finally, density in the crown is enhanced when the angles are perpendicular (unlike the frontal hairline region of the scalp) because the grafts aim skyward away from the scalp allowing the hairs to be tightly bundled and obscure the view of the underlying, bald scalp.  For all of these reasons, it is imperative for the surgeon to create very high angles in the majority of the crown.

As far as transitions are concerned, like all parts of the head it is important to create natural, gentle transitions in angles from one part of the scalp to another.  There is no exception to this rule when working in the crown region.  To make areas look as natural as possible each part must be blended to the adjacent area.  Because the crown has a lot of changes in directions it is particularly important to get the transitions right.  In the accompanying figure, the light blue represents the central whorl that radiates out to connect to the surrounding fringe of hair shown in green.  As seen, connecting the two requires gently turning the whorl so that there are no abrupt transitions.  This observation concludes this short blog article on crown hair restoration.

Samuel M. Lam, MD, FACS is a board certified hair restoration surgeon in Dallas, Texas. To learn more about Dr Lam’s crown hair transplant procedures please visit our website www.HairTX.com or call 1-888-866-3388 to schedule a consultation.

Hair Transplant for the Crown Part 3:  Understanding the Regions of the Crown

This brief article will discuss the regions of the crown and why they are important when designing a crown for hair transplantation.  The crown can be divided into three geographic zones that run like bands across the scalp:  the vertex transition zone, or vertex transition point; the upper arc; and the lower arc.  The vertex transition point (VTP) occurs where the scalp transitions from the vertical plane of the crown to the horizontal plane anteriorly of the posterior midscalp.  The hair angles in the VTP aim primarily forward with a bit of slight splaying outward toward the side edges.  However, there is almost no whorl at this point, as almost all the hairs are angling forward.  The upper arc is the arbitrary upper half of the crown that begins above the center of the whorl; and the lower arc is the arbitrary lower half of the crown that begins below the center of the whorl.

Regions of the Crown for Hair Restoration

The VTP and the upper arc are the most important areas to create visual density, a fact that will be mapped out more in detail in the coming blog articles in this series.  The VTP is the area that can look particularly bald because light tends to strike and cast a bald appearance at the transition from the vertical to the horizontal plane of the scalp.  Therefore, stronger grafts across the VTP are very important.  The upper arc is just as important since the grafts in the upper arc sweep up to cover the VTP and sweep down to cover the lower arc.  Therefore, the upper arc is a priority in terms of graft density and stronger graft size.  The lower arc tends to be a less important area since it does not impart as much visual punch and also does not cover anything other than non-balding scalp.  Accordingly, understanding these geographic terms can be very helpful for a surgeon who is planning to allocate grafts for optimal aesthetic impact.

Samuel M. Lam, MD, FACS is a board certified hair restoration surgeon in Dallas, Texas. To learn more about Dr Lam’s crown hair transplant procedures please visit our website www.HairTX.com or call 1-888-866-3388 to schedule a consultation.

Hair Transplant for the Crown Part 2: Types of Hair Loss and Hair Growth in the Crown and The Billboard Effect

For the sake of completeness, it is worth starting our discussion of crown restoration by understanding the types of hair loss that occur in the crown as well as the types of hair growth patterns as well.  Finally, we will discuss the principle of the “billboard effect” which is to say why crown transplants may have a lesser result than transplants performed elsewhere on the scalp.

Crown Hair Loss Patterns
The types of hair loss in the crown can be divided into three patterns:  a round or oval pattern, a kidney-shaped pattern with the indentation at the top, and a coronet pattern with a smaller circle of loss adjacent and below the principal one.  Wetting the hair down and looking very carefully at the crown (especially looking for the coronet pattern that is sometimes hidden below some miniaturized hair) is important when planning and strategizing for a hair-transplant procedure.

Types of Hair Loss Patterns in the Crown

As will be discussed in the upcoming articles in this blog series, the crown typically has a whorl pattern, i.e., a spiral of hair, which must be recreated.  If someone is completely bald, then the surgeon has freedom to create the crown how ever he or she sees fit.  However, if the patient still has existing hair in the crown, then the surgeon must match the angle and flow of the existing hairs in that region.  The most common pattern is a clockwise whorl, or as pictured an “S” pattern.  The next most common is the Z pattern, with far smaller percentage of individuals having two whorls SS or a SZ.  There is however no ZZ pattern found in nature.  The diffusion pattern is much more commonly found in women.

Patterns of Hair Growth in the Crown

The Billboard Effect

The “billboard effect” describes why hairs transplanted into the crown may have per transplanted graft less visual punch than the same number of hairs transplanted into the frontal hair area.

"The Billboard Effect"

First of all, hairs transplanted into the crown region lie on the vertical plane of the scalp.  Like a billboard that is a vertical structure, you are looking straight on at the naked scalp.  Compare this with the top horizontal plane of the scalp where you are not looking straight on at the bald scalp but from an angle.  Therefore, hairs transplanted into the crown still can show visibility of the bald scalp since you are looking straight on at it.   Secondly, hairs that are transplanted into the crown in a whorl pattern are going in all different directions meaning that they splay open and thereby can show more bald scalp.  For both of these reasons, it is always important to undersell a patient what a transplant in the crown can do.  I typically admonish a patient that at times I need two full sessions to accomplish a remarkable result in the crown region, but obviously not always.

Samuel M. Lam, MD, FACS is a board certified hair restoration surgeon in Dallas, Texas. To learn more about Dr Lam’s crown hair transplant procedures please visit our website www.HairTX.com or call 1-888-866-3388 to schedule a consultation.

Hair Transplant for the Crown Part 1:  Understanding the Importance of the Crown

Hair transplant into the crown is one of the most complicated areas to understand for both patients and for beginning surgeons.  In order to comprehend the benefits and limitations of crown hair transplant in a comprehensive and clear manner, it is better to split this into a 5-part series, with each article focused on one particular element of crown hair restoration. This article will focus on the fundamental reason of who should get it, who should not, and why aesthetically hair restoration in the crown area is important.

Hair transplant into the crown is one of the most complicated areas to understand for both patients and for beginning surgeons.  In order to comprehend the benefits and limitations of crown hair transplant in a comprehensive and clear manner, it is better to split this into a 5-part series, with each article focused on one particular element of crown hair restoration. This article will focus on the fundamental reason of who should get it, who should not, and why aesthetically hair restoration in the crown area is important.

Crown hair restoration is important to provide visual density from all angles: frontal view, side view, and back view.

First, let’s discuss safety, i.e., who could be a potential patient and who probably should not be.  Unlike the frontal area, the crown is a region that takes many more grafts (see the next article) and has the risk of being exposed over time as hair recedes around it in a halo effect.  This is why a very young patient probably should not get a crown hair transplant for fear that there will not be sufficient donor hair to cover future hair loss that occurs around the transplanted crown.  In general, I like to say I do not like to transplant a crown in anyone under 35 years of age.  However, I have violated that rule in certain circumstances in which the person has a relatively smaller crown exposed and has tremendous donor density that would be able to be used to cover future hair loss.  Good clinical judgment and discussing everything openly with a prospective patient is the key when deciding to do hair restoration in the crown region for someone.  The younger the patient is the more important that the surgeon extend the transplant beyond the confines of the area of baldness to accommodate for future hair loss.

Let’s now discuss objectives for crown hair restoration.  The obvious reason to do a crown transplant is to restore the lost hair in the back when someone views you from the backside.  However, this is only one reason.  Since the upper portion of the crown has hairs that aim upward, they also provide increased visual density when someone is looking at you from the front too.  Finally, the side, or profile, view of someone who has crown baldness is obvious because there is a flatness effect on the back where the hair would be.  In someone with a full head of hair the crown area is full and rounded.  Accordingly, crown hair restoration can help an individual look better from all views:  front, side, and back.

Samuel M. Lam, MD, FACS is a board certified hair restoration surgeon in Dallas, Texas. To learn more about Dr Lam’s crown hair transplant procedures please visit our website www.HairTX.com or call 1-888-866-3388 to schedule a consultation.