Dr. Bloxham: "Warning: Beware the Crown" | 5,800 Graft FUT | NY, NYC, NJ, CT, PA

[Dr Blake Bloxham]

Today, I wanted to do something of a "PSA" about how the crown (vertex) progresses and how this affects transplants.

 

Had a patient come to me (from the UK) for surgery in August of 2016. At that time, he was experiencing very classic male pattern hair loss: patterned thinning in the front, a stronger (but questionable) "bridge" in the middle, and an evolving crown in the back.

 

And the patient made a very classic request: "Doc, I know you recommend doing the front/middle, but it's the back that bothers me! Can't we do the crown?"

 

Here's how the looked the morning of the first surgery:

 

 

Luckily Spex had already done an excellent job discussing the issues with transplanting the crown with this patient, so he had a pretty good understanding of what I would say the morning of surgery.

 

But I told him that transplanting the crown now wouldn't be the best option. The front and middle are more cosmetically significant, and your crown is likely going to progress. We don't want to utilize a lot of grafts before we know what's really going on, nor do we want to fill it now and create an "island" of transplants surrounded by thin scalp as you continue to recede back there.

 

He agreed and we pressed forward with a 3,300 graft transplant aimed at addressing the frontal and mid-scalp. Procedure went great and the patient reported excellent growth a year later.

 

When he got back in contact, he confirmed that the crown (and some of the mid-scalp where the thicker "bridge" was located) had continued thinning and wanted to know if we could address it now. I evaluated everything and believed that we could.

 

Here is how he looked the morning of surgery 2 (pictures purposely highlighting where I worked):

 

 

 

 

 

 

And here is a picture of his FUT scar 12 months after a 3,300 graft procedure:

 

 

But here is where the real "PSA" comes in:

 

Here is how his crown looked only 12 months after the first operation:

 

 

(note, the mid-scalp continued to thin as well and what you see there is a complete loss of his native hair and only transplants -- which were carefully integrated into his native hair previously -- remain).

 

And here is a "side-by-side" for comparison:

 

 

Had I done a dense fill of the open crown area before, the patient would have utilized precious grafts to now have a dense island in the middle of thinned area around it. This would not have looked natural, nor would it have been a good use of his finite donor. What's more, you can see how "doing the front first" always results in a natural appearance from any reasonable angle, regardless of how the patient thins behind.

 

But after a thorough review, I decided it was appropriate to now address the crown (including working into the edges where it may possibly continue to thin -- though unlikely) and reinforce some of the mid-scalp.

 

I performed another FUT harvest and removed an additional 2,500 grafts for the crown. He's now had a total of 5,800 grafts via the FUT technique. The patient can still undergo more strip harvest and then FUE the virgin donor around it if he wants more work in the future.

 

Here he is in the middle of the second surgery:

 

 

And here he is at the completion of the second surgery:

 

 

So remember:

 

1) The crown is an highly unstable area and needs to be evaluated and intervened upon carefully. I definitely understand that it's bothersome, but it is constantly evolving in the active stages of male pattern hair loss and "jumping into it" can be tricky and isn't always the best use of grafts.

 

2) The frontal region is usually the more cosmetically important one and it's usually best -- in patients with loss in both -- to address this region first.

 

3) Utilize the donor carefully. It's a limited resource and must be respected.

 

Hope you enjoyed.

 

Dr. Blake M. Bloxham (Great Neck, NY)

Feller & Bloxham Medical, Hair Transplant Institute

NYC Hair Transplant | NY Hair Restoration | Feller & Bloxham Medical

[hairthere]

Seems like a very good surgical plan. Hairlines are looking awesome, btw!

[Arminius]

Is this patient on any preventative medication? Finasteride?

[Dr Blake Bloxham]

Seems like a very good surgical plan. Hairlines are looking awesome, btw!

 

Thank you for the kind words.

 

I love the way the transplant works aesthetically for this patient. With the right density, his hair just has this natural style to it that really compliments his facial structure and overall style and looks great. So pleased I was able to help him out.

[Dr Blake Bloxham]

Is this patient on any preventative medication? Finasteride?

 

Yes. The patient has been on finasteride for years -- even before the first procedure. Unfortunately, not everyone is a great responder and the drug does tend to lose effectiveness overtime.

 

Another reason why I don't like the term "stabilized" when it comes to things like finasteride and/or minoxidil. While helpful and a definite point of research for any hair loss patient, androgenic alopecia is progressive, sometimes very aggressive, and rarely "stabilized."

 

Thank you for your interest in the case.

[Spanker]

I've always had a bit of an issue with the term stabilized also. However, that's quite aggressive loss for someone on fin in one year. I wonder if he was faithful on his meds? Or got fake fin?

[Melvin- Admin]

I've always had a bit of an issue with the term stabilized also. However, that's quite aggressive loss for someone on fin in one year. I wonder if he was faithful on his meds? Or got fake fin?

I agree, but I believe Dr. Bloxham had said he was taking fin for years, it would be interesting to find out whether he had switched to generic during that year.

[Spanker]

I agree, but I believe Dr. Bloxham had said he was taking fin for years, it would be interesting to find out whether he had switched to generic during that year.

 

I've also seen people get lazy after a good transplant and slow their fin intake. I've seen it quite a few times. This could just be a case of fast loss though.

[Speegs]

I've also seen people get lazy after a good transplant and slow their fin intake. I've seen it quite a few times. This could just be a case of fast loss though.

I take a heightened dose of fin, about a third of a Teva 5mg tablet, so far so good...but stuff like this makes me worry about being complacent.

[Castillo]

how old is he?

[Castillo]

This why FUT still be a good choice for HT!

[Dr Blake Bloxham]

RE: fin questions:

 

To my knowledge, there was no switch and he was consistent with his usage.

 

Some people just don't respond as well to it. More frequently what happens is that people do well for a while, and then start to see a decline. I believe the follicle develops more DHT receptors or the receptors themselves slightly change and the drug is simply less effective because the follicles are now more sensitive to DHT -- though this is just my theory.

 

I usually see this around 7-10 years of finasteride usage. Seems like it was quicker in this patient -- if that is what occurred -- but I've seen it on a quicker scale as well.

 

Preventive measures are still helpful for HT patients regardless.

[Dr Blake Bloxham]

Castillo,

 

He's in his mid-30s.

 

And I agree 100% with your FUT comments. This is a perfect example of why I like starting with FUT. This patient has now done 5,800 grafts and still has at least one more strip. After that's done, he has the option to FUE all the virgin tissue around the scar. Most effective use of the donor for patients with progressive and/or aggressive loss.

[TrixGlendevon]

Dr Bloxham. Would you do a HT on somebody who wasn't taking medication?

[mattj]

Very nice result and a valuable cautionary tale. This is why so many people seeking crown work have to be turned away. The way the crown loss progresses could lead to a very unnatural appearance if the area is treated prematurely.

[Melvin- Admin]

RE: fin questions:

 

To my knowledge, there was no switch and he was consistent with his usage.

 

Some people just don't respond as well to it. More frequently what happens is that people do well for a while, and then start to see a decline. I believe the follicle develops more DHT receptors or the receptors themselves slightly change and the drug is simply less effective because the follicles are now more sensitive to DHT -- though this is just my theory.

 

I usually see this around 7-10 years of finasteride usage. Seems like it was quicker in this patient -- if that is what occurred -- but I've seen it on a quicker scale as well.

 

Preventive measures are still helpful for HT patients regardless.

 

Wow that's definitely unsettling for some guys, his progression was as fast as mine when I wasn't taking anything not even minoxidil, but I guess that's it's best to see how well the medication is working for you, as you said we're not created equal and that's why some lucky guys don't get any sizes and some of us unlucky guys do get sides, some get regrowth and hair loss stops and some as you mentioned may still lose hair. What are your thoughts on the 2.5% topical liposomal finasteride gel? I spoke with Dr. Wong who told me they have about 600 patients on it without any apparent sides, my concern is that there may be no sides because it may not be really working.

[Dr Blake Bloxham]

Dr Bloxham. Would you do a HT on somebody who wasn't taking medication?

 

Yes. The patient must understand that his hair loss is progressive and that he may want more in the future. We also have to start "smart" with respect to where we work, how aggressive we go, etc; and we MUST respect the donor and leave a good amount "in the bank" for future surgeries. But if this is understood, then it's not a problem from my perspective.

[Dr Blake Bloxham]

What are your thoughts on the 2.5% topical liposomal finasteride gel? I spoke with Dr. Wong who told me they have about 600 patients on it without any apparent sides, my concern is that there may be no sides because it may not be really working.

 

The biggest complaints I've heard from people on topical anti-androgens (RU and finasteride) is that those who switched from oral to topical to avoid side effects still experienced systemic side effects. As you pointed out, this is a double edged sword: this does mean that the medication is at least absorbing through the scalp, but it indicates that it isn't staying as local as one would hope. I do believe there can be big issues with stuff absorbing through the scalp and creating/utilizing the correct vehicles to get drugs across the skin has always been a big challenge in pharmacology.

[Steeeve]

Is there any possible update to this? I would love to see how this patient’s crown turned out?

[hairlinehelp]

what is the density per cm2 in crown ?