Grafting the lower crown

[Hair4Days]

In a hypothetical scenario.. if a Norwood 6 or 7 with a weak/limited  donor undergoes surgery, would anymore make the argument to graft the lower crown over the upper crown? I feel like if you graft front to back, leaving the lower crown open and exposed, it would look unnatural As that’s not how balding typically looks. However, you do see isolated upper crown loss everyday. Thoughts on this strategy?

Edited June 30, 2022 by Hair4Days

[Eugenix Hair Sciences]

51 minutes ago, Hair4Days said:

In a hypothetical scenario.. if a Norwood 6 or 7 with a weak/limited  donor undergoes surgery, would anymore make the argument to graft the lower crown over the upper crown? I feel like if you graft front to back, leaving the lower crown open and exposed, it would look unnatural As that’s not how balding typically looks. However, you do see isolated upper crown loss everyday. Thoughts on this strategy?

Please share some scalp pictures and we can give you a detailed evaluation of what us possible in your case. With the use of beard hair, it could be possible to transplant your entire crown (provided there is sufficient donor).

[Rahal Hair Transplant]

Hair4Days,

While there are exceptions to every rule, in my personal opinion, I think it’s always better to graft from front to back recreating as natural looking of a hairline as possible and then covering as much as possible in the back.  

In an advanced case of balding such as a Norwood class 6, there will very likely be thinning in the lower crown area above the occipital ridge.  But, since donor hair is limited and it would be unlikely to cover the entire balding area while re-creating any level of density, the surgeon must evaluate what’s going to create most cosmetic improvement.

While I understand the argument that leaving balding/thinning in the lower crown area may look unnatural with a restored frontal and mid scalp region, the truth is, the vast majority the population wouldn’t notice.

In other words, I don’t think many people are aware that those with thinning  in the lower crown are also typically bald in the front. Allow me to explain  

Most likely, only hair gurus such as veteran hair transplant patients and hair restoration surgeons would even blink if they saw a gentleman with a relatively full looking head of hair but with thinning or baldness in the lower crown area.  The vast majority the population wouldn’t even know that this isn’t a natural way to lose hair  

Ironically, I fit into the above scenario. I have a pretty full looking head of hair with essentially no signs of balding in the frontal and mid region of the scalp and only mild thinning in the crown. But if you look at the back of my head, you can see thinning in the lower crown region as well.  Frankly, nobody has  questioned this or looked at me funny. Most people that I’ve spoke with didn’t even notice the thinning in the back and those that did, just assumed that I thinned out in that area naturally  

Now let’s consider the opposite. Let’s say that an individual feels that it would look unnatural with a full looking hairline in the front and mid scalp regions but with baldness or thinning in the lower crown area. So as a result, The surgeon starts from the back and works their way forward.  At best, the surgeon will likely get to the midregion of the scalp and never even touch the hairline.  While it would certainly look natural according to the Norwood scale the hair loss, The vast majority the population will conclude that this individual is bawled rather than possessing a relatively full head of hair.  

Long story short, people notice individuals from the front a lot more than they do from the back. Somebody with a relatively youthful looking hairline and some thinning or even baldness in the crown would be considered to have a lot more hair from a cosmetic standpoint than somebody with no signs of thinning in the crown and a substantially recessed hairline.

Thus, my opinion remains that it is far better that surgeons take the approach of grafting from the front to the back.

Best wishes,

Rahal Hair Transplant 

Edited June 30, 2022 by Rahal Hair Transplant

[Hair4Days]

2 hours ago, Rahal Hair Transplant said:

Hair4Days,

While there are exceptions to every rule, in my personal opinion, I think it’s always better to graft from front to back recreating as natural looking of a hairline as possible and then covering as much as possible in the back.  

In an advanced case of balding such as a Norwood class 6, there will very likely be thinning in the lower crown area above the occipital ridge.  But, since donor hair is limited and it would be unlikely to cover the entire balding area while re-creating any level of density, the surgeon must evaluate what’s going to create most cosmetic improvement.

While I understand the argument that leaving balding/thinning in the lower crown area may look unnatural with a restored frontal and mid scalp region, the truth is, the vast majority the population wouldn’t notice.

In other words, I don’t think many people are aware that those with thinning  in the lower crown are also typically bald in the front. Allow me to explain  

Most likely, only hair gurus such as veteran hair transplant patients and hair restoration surgeons would even blink if they saw a gentleman with a relatively full looking head of hair but with thinning or baldness in the lower crown area.  The vast majority the population wouldn’t even know that this isn’t a natural way to lose hair  

Ironically, I fit into the above scenario. I have a pretty full looking head of hair with essentially no signs of balding in the frontal and mid region of the scalp and only mild thinning in the crown. But if you look at the back of my head, you can see thinning in the lower crown region as well.  Frankly, nobody has  questioned this or looked at me funny. Most people that I’ve spoke with didn’t even notice the thinning in the back and those that did, just assumed that I thinned out in that area naturally  

Now let’s consider the opposite. Let’s say that an individual feels that it would look unnatural with a full looking hairline in the front and mid scalp regions but with baldness or thinning in the lower crown area. So as a result, The surgeon starts from the back and works their way forward.  At best, the surgeon will likely get to the midregion of the scalp and never even touch the hairline.  While it would certainly look natural according to the Norwood scale the hair loss, The vast majority the population will conclude that this individual is bawled rather than possessing a relatively full head of hair.  

Long story short, people notice individuals from the front a lot more than they do from the back. Somebody with a relatively youthful looking hairline and some thinning or even baldness in the crown would be considered to have a lot more hair from a cosmetic standpoint than somebody with no signs of thinning in the crown and a substantially recessed hairline.

Thus, my opinion remains that it is far better that surgeons take the approach of grafting from the front to the back.

Best wishes,

Rahal Hair Transplant 

Thank you for the detailed response. Much respect. I am on board with grafting starting from the hairline and working back as the front should be everyone’s priority. What I’m mainly referring to in this hypothetical, is a client with an advanced pattern with complete deep lower crown loss. ( more of that horse shoe look where the lower crown has that ring look. ) At times, surgeons will relay that patients must compromise on density in the crown, if any grafts at all. I was curious  if it would be a better idea to implant those grafts in the lower crown, instead of the upper crown on top of the scalp. You see more bald spots in the top of the crown ( see Manu Ginobli) than you do in a lower crown region that will have that ring ‘swoop’ effect. With the lower crown grafted (after the  hairline and midscalp is taken care of of course), you will have the opportunity to slick your hair back and cover that upper zone easily. I do agree this must be considered once your hairline & midscalp is already worked on. I will show an example of a photo showcasing what i mean by hair everywhere except the lower crown looking odd. Let me know 

 

 

 

[RandoBrando517]

Are you looking to fill in the scar too

[sukh123]

what caused your donor to have that baldness btw 

[Hair4Days]

This isn’t my head. It’s an example i found from a YouTube video showing the application of hair fibers. I’m pointing out that he has deep lower crown loss and hair from the hairline -> top of the crown which looks outrageous. My argument would be to Graft the lower crown instead of the upper crown if you had to decide between the two.

[Eugenix Hair Sciences]

13 hours ago, Hair4Days said:

Thank you for the detailed response. Much respect. I am on board with grafting starting from the hairline and working back as the front should be everyone’s priority. What I’m mainly referring to in this hypothetical, is a client with an advanced pattern with complete deep lower crown loss. ( more of that horse shoe look where the lower crown has that ring look. ) At times, surgeons will relay that patients must compromise on density in the crown, if any grafts at all. I was curious  if it would be a better idea to implant those grafts in the lower crown, instead of the upper crown on top of the scalp. You see more bald spots in the top of the crown ( see Manu Ginobli) than you do in a lower crown region that will have that ring ‘swoop’ effect. With the lower crown grafted (after the  hairline and midscalp is taken care of of course), you will have the opportunity to slick your hair back and cover that upper zone easily. I do agree this must be considered once your hairline & midscalp is already worked on. I will show an example of a photo showcasing what i mean by hair everywhere except the lower crown looking odd. Let me know 

 

 

 

 

10 hours ago, Hair4Days said:

This isn’t my head. It’s an example i found from a YouTube video showing the application of hair fibers. I’m pointing out that he has deep lower crown loss and hair from the hairline -> top of the crown which looks outrageous. My argument would be to Graft the lower crown instead of the upper crown if you had to decide between the two.

Based on the picture that you have shared, it is possible to cover the lower crown as you have asked. However, if beard grafts are used along with the scalp donor, then it is possible to cover the entire crown area. Having said that, it is different in different cases. The donor available in the picture that you have shown could be completely different from yours. The donor density matters a lot. It is impossible to give any recommendations for you without evaluating your particular pictures.

[Al - Moderator]

On 6/30/2022 at 9:28 AM, Hair4Days said:

In a hypothetical scenario.. if a Norwood 6 or 7 with a weak/limited  donor undergoes surgery, would anymore make the argument to graft the lower crown over the upper crown? I feel like if you graft front to back, leaving the lower crown open and exposed, it would look unnatural As that’s not how balding typically looks. However, you do see isolated upper crown loss everyday. Thoughts on this strategy?

Yes. Not so much for NW 6 because they don't have a bald crown that goes far down the back of the head, but for a NW 7 I feel it's better to transplant the lower and sides of the bald crown and leave the upper portion of the crown with less grafts. I am a NW 7 and am in this situation. It would look totally ridiculous if I leave the lower crown completely bald.

 

[gillenator]

In the photo example that you provided, there is not only extensive crown loss, but there is also retro-alopecia invading the donor area...do you by chance have retro-alopecia in your own case?

[Rahal Hair Transplant]

Hair4days

I think a case can be made for most scenarios. I’m a firm believer that there are exceptions to every rule and that there are certainly times where it may be appropriate to at least use some of the available during her hair to fill in the lower crown in particular in cases where it’s fully bald.  In my case, I only experienced moderate thinning in the lower crown so it really wasn’t noticeable. I think by filling in the upper crown and the entire top of the scalp without at least using some of the donor hair for the lower crown might look a little awkward. 

Now this is just my personal opinion and not necessarily that of Dr. Rahal’s (I’d have to ask him his opinion on this) but in a case such as the photo you presented above, I would personally suggest grafting from front to back like we discussed but stop around the midsection of the scalp with a gradual fade of course.

Then, having left enough donor hair for what’s next, I’d suggest possibly use some donor hair to shrink down the size of the bald crown by adding some hair in or around the upper crown region and then cover the lower crown with lower density so that the lower crown is no longer bald but just thin.

Ideally however, there would be enough donor hair to cover both the upper and the lower crown even if it’s low density. This will illuminate the bald spots  And the entire crown region would just appear thin.

Now, if the patient is a Norwood class seven or an advanced class six, they’re probably would not be enough don’t know how to do it I’m suggesting unless they have exceptional amounts of donor hair   In cases like this, I would say one or two things. First, these individuals may not be good candidates for her transplant surgery at all or, they would have to have exceptionally realistic expectations and deal with the reality that there’s going to be some areas of the scalp that can’t be covered.  

So in extreme advanced cases, these hair loss suffering men likely wouldn’t be good candidates for surgery. Thus, the scenario as to whether or not to start grafting front to back or to use that donor hair for the lower crown wouldn’t even exist   Only if what I suggested above is possible (which means they either have enough donor hair or not as advanced balding) would they possibly even be candidates for surgery in the first place.

like I said originally though, there are exceptions to every rule. There are always cases to be made for and against surgery even for extreme cases.  But the above is my opinion as a general rule for those types of cases.  

Best wishes,

Rahal Hair Transplant 

[Hair4Days]

8 hours ago, BeHappy said:

Yes. Not so much for NW 6 because they don't have a bald crown that goes far down the back of the head, but for a NW 7 I feel it's better to transplant the lower and sides of the bald crown and leave the upper portion of the crown with less grafts. I am a NW 7 and am in this situation. It would look totally ridiculous if I leave the lower crown completely bald.

 

Exactly my point 

[Hair4Days]

4 hours ago, Rahal Hair Transplant said:

Hair4days

I think a case can be made for most scenarios. I’m a firm believer that there are exceptions to every rule and that there are certainly times where it may be appropriate to at least use some of the available during her hair to fill in the lower crown in particular in cases where it’s fully bald.  In my case, I only experienced moderate thinning in the lower crown so it really wasn’t noticeable. I think by filling in the upper crown and the entire top of the scalp without at least using some of the donor hair for the lower crown might look a little awkward. 

Now this is just my personal opinion and not necessarily that of Dr. Rahal’s (I’d have to ask him his opinion on this) but in a case such as the photo you presented above, I would personally suggest grafting from front to back like we discussed but stop around the midsection of the scalp with a gradual fade of course.

Then, having left enough donor hair for what’s next, I’d suggest possibly use some donor hair to shrink down the size of the bald crown by adding some hair in or around the upper crown region and then cover the lower crown with lower density so that the lower crown is no longer bald but just thin.

Ideally however, there would be enough donor hair to cover both the upper and the lower crown even if it’s low density. This will illuminate the bald spots  And the entire crown region would just appear thin.

Now, if the patient is a Norwood class seven or an advanced class six, they’re probably would not be enough don’t know how to do it I’m suggesting unless they have exceptional amounts of donor hair   In cases like this, I would say one or two things. First, these individuals may not be good candidates for her transplant surgery at all or, they would have to have exceptionally realistic expectations and deal with the reality that there’s going to be some areas of the scalp that can’t be covered.  

So in extreme advanced cases, these hair loss suffering men likely wouldn’t be good candidates for surgery. Thus, the scenario as to whether or not to start grafting front to back or to use that donor hair for the lower crown wouldn’t even exist   Only if what I suggested above is possible (which means they either have enough donor hair or not as advanced balding) would they possibly even be candidates for surgery in the first place.

like I said originally though, there are exceptions to every rule. There are always cases to be made for and against surgery even for extreme cases.  But the above is my opinion as a general rule for those types of cases.  

Best wishes,

Rahal Hair Transplant 

I agree cutting the density down significantly in the mid scalp and grafting at a lower density to obtain coverage in the upper AND lower crown. I was actually behind someone in line at the store today and he appeared to be a Norwood 6, however, he had a bald upper crown with some hair in his lower crown. Not much, but enough where it wasn’t completely bare. I was able to see the overall shape of the horseshoe but the hair he had in the lower crown made a massive difference. The way the hair lays in the lower crown is like a curtain. It falls straight down. I’m guessing this is a good thing as far as coverage and the illusion of density. i would assume a small number of Grafts in this lower crown zone would go a long way.