Dr.B,

thank you that was a great response and (somewhat) adressess one of my biggest concerns. I say somewhat because I don't understand how docs treat these young men who become NW7's if the top has been filled in at a younger age and the sides come down substantially...

Now then, in a case such as this there would also appear to be an "island" of isolated hair on top with the sides balding down further in the later years. How do the docs know if there will be enough donor hair to fill the sides up to match the top?

This has always been one of my concerns as Im 28...

would really appreciate an explanation from you on this one as they are always very informative...

Notgoing2gobald,
It sounds like you are asking about what a surgeon does once the damage is done and a presumably now middle-aged or older man who was transplanted when he was younger, now presents with an island of hair on top with a "halo" of bald skin around it and not much donor hair left to correct the problem. Hopefully this unfortunate predictament will become rarer as physicians get smarter about matching their translant patterns with the natural history of male pattern baldness. However, the combined pressure of patients presenting with unrealistic expectations and the physician's eagerness to please or to fill a booking in his/her schedule for financial reasons can lead to young men being filled in densely in a way that can not be sustained in later years and will most likely look detectable as abnormal, particularly when the patient's total available "safe" donor hair was used to do the early work.
Looking at the problem from the early point, that is, when the patient is before the physician and a plan is being laid out - each patient is different and unique. You have to look at their family history, but not rely on it too much. A very important factor, especially in the 29-31 year old, where you start to get tempted to more aggressive, is to look under magnification for miniaturized hairs in the nearby fringe areas to see if it is indeed strong hair with very little miniaturization present. If there IS miniaturization, even just 5-10%, then a conservative, "frontal forelock" type of pattern is a wise course of action and will frame the face nicely. In this mode of planning, the surgeon creates a front-central forelock of density that extends back into the middle portion of the midscalp, and then decreases the density in a gradient toward the sides and toward to back. The idea is to create a pattern that actually exists on some men's heads as they naturally bald - at least 20-30% of men have this pattern as they lose their hair. And if you accomplish this, then twenty years down the road that transplant will not draw attention because it mimics a pattern that exists on many men's heads naturally.
If a man does reach 38 or so and these dire fears don't come true, then everyone can become more aggressive and use the remaining donor hair in a more aggressive manner, simply because it's easier to see the future of a man's hair loss pattern at that later age.
Mike Beehner, M.D.

Sorry, I forgot to complete my answer and say what could in fact be done for the patient who ends up in mid-life with an area of dense transplanted hair surrounded by a halo. By the way, these people often become social recluses and won't be seen outside the home without a hat on. I have met many of them in my career. It is a very sad situation.
The good news is that it is almost always possible to make things better. It usually is necessary to "soften" the density of the areas on the lateral and rear edges of the transplanted hair. This will require some new FU grafts, which can usually be salvaged from what remains of the usual donor areas - often using FUE in the high and low areas where a scar can't be used - and also by simply removing some of the rear and side stronger grafts and using them in a more spread out, sparser pattern around the stronger central hair. The goal is to create a GRADIENT at the two lateral sides and rear, trying to visually bridge the bald ally that separates the mass of hair on top from the side fringes. Oftentimes, this all goes down a lot better if the patient adopts a hairstyle of sweeping it back to one of the rear corners. It also often takes around two sessions to pull this off, as the amount of invasive work you can do at one sitting is limited by blood-supply considerations.
Mike Beehner, M.D.

As the nape hairs are thin in nature and so somewhat similar to temporal area hair, can it be used for temporal area re-construction. I am 54 and has lot of nape hair.