Achievable crown density

[MrSteele]

What sort of end result is possible in terms of density for a patient whose hair loss is only affecting the crown?

In other words, if future hair loss were not a factor, and the patient wanted an ultra-dense result, so to speak, how dense could a hair transplant realistically be packed in the crown, if as many grafts as needed could be devoted to the area? Or would it still be just an “illusion” of density?

[Patriot34]

Crowns are particularly challenging. If you aren't experiencing hair loss elsewhere then you might be one of the rare candidates for a crown transplant. Of course it is still an "illusion" because you aren't going to get the same density as you had before.

 

Just my opinion, but crowns are dangerous territory. I have seen so many poor looking crown transplants that I would lean towards a clean bald spot or complete shaving before I would attempt to cover a crown that continues to experience hair loss in a 360 degree pattern. I feel they typically just look reddish. It depends on how much loss you are experiencing and how much more loss you are likely to have.

 

Minox is suppose to work to help maintain hair on the crown. I'd start or keep using that and just accept the loss as it comes. However, you'll see plenty of opinions on here that will say go for it regarding crown transplants. Your call man. Just do your research and try your best to predict future hair loss in that area based on family history.

 

Added: "if future hair loss were not a factor" - Let me address this misconception as a fellow patient on fin/minox. Regardless of what you're taking as far as medication, vitamins, and shampoos; you WILL experience future hair loss. This is even true in people who are not victims of MPB. People want to deny this fact and marketing of medications want you to believe that it is impossible for even one follicle to die if on Propecia, but it is not true. The issue is to what extent. To think you will not experience future hair loss because Propecia or something works amazingly for you is a misconception. You will still lose with Propecia, just not as much and not as fast. Just look at men in their 70's and 80's with or without MPB, do you think any of them have the same hair count as they did as a young man in their twenties or thirties? You will lose hair as time goes on. The key is to try to guess how much and at what rate given all factors. Don't get me wrong, Propecia has been proven to work, but do not over estimate it's effectiveness when going for a crown hair transplant.

Edited October 15, 2013 by Patriot34
Additional information added

[Dr. Michael Beehner]

You have to be careful. The crown (vertex) can be a dangerous place. If you are in your 20's, I firmly believe that the crown should never be transplanted during that age range. If one is in his 30's, then I think any coverage done there should be on the "light" side WITHOUT maximal density. The reason is that often in a man with male pattern baldness, the borders of the crown can expand, such that the square area of the crown zone increases logarithmicly. If a younger man has this zone filled in densely, there is the danger that 10-20 years down the road there could be a 1-2 inch wide "halo" of bald skin around it, which is a very unnatural thing. I have seen many of these from old transplants. Light coverage, on the other hand, fans out in the whorl direction typical of the crown's hairs. If the crown enlarges, they simply fan out a little further to help cover that bald area and it isn't that hard to find some donor hair to fill that space in to match the density of what is already there. But with a dense central part of the crown filled in, you then have to match that extreme density, which is usually impossible to do in the face of a shrinking donor area.

For men over 40 with a small to medium size crown and ample donor stores, I do think it is possible to "dense pack" and "go for it." It is ideal, when doing so, to only do that area, as then the blood supply to the area is very good, without other recipient holes in the front compromising that area's circulation.

Returning again to the younger male, many of them only have hair loss in the crown at the time they see the hair surgeon, but many of them go on to lose the hair on top and in front later on, which is always a more important area to fill in. That is another reason for not using up a large amount of the donor hair in the rear crown.

To give an extreme example, the photos here are of a 45 year old man who came to me many years ago, who at the age of 25 had the small hole in the back that was bald filled in with the grafts that were used at that time, which happened to be the large plugs. As you can see, during those 20 years his crown expanded and a huge halo resulted. The second photo shows the result after I removed all of these grafts and placed FU's at the upper border.

So the message is: Be careful what you wish for. Be conservative in the crown, especially if you are younger.

Mike Beehner, M.D.

[MrSteele]

You have to be careful. The crown (vertex) can be a dangerous place. If you are in your 20's, I firmly believe that the crown should never be transplanted during that age range. If one is in his 30's, then I think any coverage done there should be on the "light" side WITHOUT maximal density. The reason is that often in a man with male pattern baldness, the borders of the crown can expand, such that the square area of the crown zone increases logarithmicly. If a younger man has this zone filled in densely, there is the danger that 10-20 years down the road there could be a 1-2 inch wide "halo" of bald skin around it, which is a very unnatural thing. I have seen many of these from old transplants. Light coverage, on the other hand, fans out in the whorl direction typical of the crown's hairs. If the crown enlarges, they simply fan out a little further to help cover that bald area and it isn't that hard to find some donor hair to fill that space in to match the density of what is already there. But with a dense central part of the crown filled in, you then have to match that extreme density, which is usually impossible to do in the face of a shrinking donor area.

For men over 40 with a small to medium size crown and ample donor stores, I do think it is possible to "dense pack" and "go for it." It is ideal, when doing so, to only do that area, as then the blood supply to the area is very good, without other recipient holes in the front compromising that area's circulation.

Returning again to the younger male, many of them only have hair loss in the crown at the time they see the hair surgeon, but many of them go on to lose the hair on top and in front later on, which is always a more important area to fill in. That is another reason for not using up a large amount of the donor hair in the rear crown.

To give an extreme example, the photos here are of a 45 year old man who came to me many years ago, who at the age of 25 had the small hole in the back that was bald filled in with the grafts that were used at that time, which happened to be the large plugs. As you can see, during those 20 years his crown expanded and a huge halo resulted. The second photo shows the result after I removed all of these grafts and placed FU's at the upper border.

So the message is: Be careful what you wish for. Be conservative in the crown, especially if you are younger.

Mike Beehner, M.D.

 

I understand that argument regarding crown procedures. Was that patient using finasteride in combination with surgery? Might the crown expansion be prevented in this way?

[Dr. James DeYarman]

I agree with Dr Beehner that the crown has to be treated with care. For the last several years people have been saying it is hard to grow hair in the crown. As you can see from Dr Beehner’s photo of the plugs, there seems to be no trouble with growth. The question is, why there was better growth back with the plugs and I think it is because there is was not as much destruction of the blood supply as with a strip procedure. I feel the best procedure is a FUE procedure with punches smaller then 1mm. Because of the small punch there is no vascular damage and the FUE grafts will have more hair giving more coverage. I start in the center of the whirl with ones and fan out following the patient hair direction. Finally you have to tell the patient there will most likely be another procedure in the future it will be obvious where to transplant as we are dealing with density. With the FUE you can match donor density to transplant density by thinning and transplanting, you cannot do this with strip procedure.

[Spanker]

I agree with Dr Beehner that the crown has to be treated with care. For the last several years people have been saying it is hard to grow hair in the crown. As you can see from Dr Beehner’s photo of the plugs, there seems to be no trouble with growth. The question is, why there was better growth back with the plugs and I think it is because there is was not as much destruction of the blood supply as with a strip procedure. I feel the best procedure is a FUE procedure with punches smaller then 1mm. Because of the small punch there is no vascular damage and the FUE grafts will have more hair giving more coverage. I start in the center of the whirl with ones and fan out following the patient hair direction. Finally you have to tell the patient there will most likely be another procedure in the future it will be obvious where to transplant as we are dealing with density. With the FUE you can match donor density to transplant density by thinning and transplanting, you cannot do this with strip procedure.

 

When you do this, do you not run a great risk of transplanting hair that is not permanent? It seems that to thin out the donor area to reduce contrast in a transplanted crown that you would be pulling close enough to the balding area the sides and back could drop causing you to lose the hair that was transplanted in order to blend the transplant. If this is not possible, can you explain why? I know that there is currently an FUE/strip study going on. I hope that they included this to see if in fact you do get better growth in the crown with FUE. It would very interesting to see data on this. Thanks.

[Shampoo]

It is ideal, when doing so, to only do that area, as then the blood supply to the area is very good, without other recipient holes in the front compromising that area's circulation.

 

Thank you Dr. Beehner for that information because that is exactly what I have been struggling with. I am 54 years old and planning on a followup "crown-focused" session to my surgery last year, but I have been wondering "since I am flying from Texas all the way to Vancouver and having an incision done, maybe I should go ahead and get more grafts placed in other areas besides my crown". But it sounds like it may be best to just concentrate on my crown and not try to do get more bang for the buck just because I am out there.

[Dr. William Lindsey]

Crowns are a black hole that have the potential to suck up every hair put in them and still leave only a medium quality result.

 

Echoing other sentiments above, I strongly encourage people to address a thinning front, OR wait for the front to be ready for surgery rather than use a lot of good donor hair to improve a balding crown. Fortunately I have lots of pictures of guys who came in for the crown, who, when shown, decided to do the front. At the 1 year pictures ALMOST all felt the front was such an improvement that the cost benefit ratio of adding hair to the crown was not worth proceeding. Now perhaps to maximize income we ought to do the crown first as I think people would eventually agree that the front would need addressing...but from an honest perspective, one runs the risk of depleting the donor area for the crown and not having enough hair to do a good job up front later on. And unless a person has nice thick bushy hair and wears it a little longer, a perfect crown result is very challenging.

 

So to summarize...I recommend folks sleep on it and consider addressing the front if that is a concern at all.

 

Dr. Lindsey McLean VA

[Dr. James DeYarman]

I think you are missing the point, the man is concerned about his bald spot and tell him not to treat means he is missing out on a good positive change. The trick is do the FUE procedure and not a strip procedure you will see a much better outcome.

[Spanker]

I think you are missing the point, the man is concerned about his bald spot and tell him not to treat means he is missing out on a good positive change. The trick is do the FUE procedure and not a strip procedure you will see a much better outcome.

 

 

I am very interested in your take on this. Are you finding that when you did FUT on the crown that you had poor yield? What would you estimate the yield was? What would you estimate that your FUT crown yield is? Have you published your findings on this yet? Do you do FUT anymore and if you do, do you only chose to do the front half?

 

Sorry for all the questions, but I am interested in where this is going and what the general consensus is on this throughout the community. Thank you.

[Spanker]

You have to be careful. The crown (vertex) can be a dangerous place. If you are in your 20's, I firmly believe that the crown should never be transplanted during that age range. If one is in his 30's, then I think any coverage done there should be on the "light" side WITHOUT maximal density. The reason is that often in a man with male pattern baldness, the borders of the crown can expand, such that the square area of the crown zone increases logarithmicly. If a younger man has this zone filled in densely, there is the danger that 10-20 years down the road there could be a 1-2 inch wide "halo" of bald skin around it, which is a very unnatural thing. I have seen many of these from old transplants. Light coverage, on the other hand, fans out in the whorl direction typical of the crown's hairs. If the crown enlarges, they simply fan out a little further to help cover that bald area and it isn't that hard to find some donor hair to fill that space in to match the density of what is already there. But with a dense central part of the crown filled in, you then have to match that extreme density, which is usually impossible to do in the face of a shrinking donor area.

For men over 40 with a small to medium size crown and ample donor stores, I do think it is possible to "dense pack" and "go for it." It is ideal, when doing so, to only do that area, as then the blood supply to the area is very good, without other recipient holes in the front compromising that area's circulation.

Returning again to the younger male, many of them only have hair loss in the crown at the time they see the hair surgeon, but many of them go on to lose the hair on top and in front later on, which is always a more important area to fill in. That is another reason for not using up a large amount of the donor hair in the rear crown.

To give an extreme example, the photos here are of a 45 year old man who came to me many years ago, who at the age of 25 had the small hole in the back that was bald filled in with the grafts that were used at that time, which happened to be the large plugs. As you can see, during those 20 years his crown expanded and a huge halo resulted. The second photo shows the result after I removed all of these grafts and placed FU's at the upper border.

So the message is: Be careful what you wish for. Be conservative in the crown, especially if you are younger.

Mike Beehner, M.D.

 

Good write up. When I read this, all I think is that I hope that there is something cure-like for baldness in 20 years and this will not even be an issue. Of course we should plan like there will not be.

[Shampoo]

The trick is do the FUE procedure and not a strip procedure you will see a much better outcome.

 

Dr. DeYarman....if a patient has plenty of donor hair and needs only crown work done....how many FUE grafts can a patient typically recieve in a single crown focused surgery at your clinic? I guess I am asking....can you and have you on a regular basis done 2000-2500 FUE grafts in a single day?

[Dr. James DeYarman]

Spanker

I have been hair transplants long enough that I started out doing plugs and converted to strip. The large grafts grew in the crown better then follicular units do in the crown and I feel it is due to vascular damage when you remove the strip.

Shampoo

I depending on your age and the size of the bald spot would determine the amount. I have been using less grafts per square centimeter because there are a lot of multi-hair grafts. The second time you have to start balancing out densities between transplanted and un-transplanted hair. I have found 1500-2000 is needed the first time in the crown. I can do up to 2000 in a day and for 3000+ it is a two day procedure.

[Shampoo]

Thanks Doc!