The crown region — sometimes referred to as the “vertex” or the “bald spot” in the back — is an area commonly affected by male pattern hair loss (androgenic alopecia). Because of this, patients often seek hair transplantation in this region. In fact, it’s one of the most common requests we receive during consultations. I’ll often hear patients say: “I can’t stand the ‘bald spot’ in the back; it reminds me of my grandfather’s bald spot; please fix it!” Seems simple, right? This is an area affected by male pattern hair loss and — therefore — can be treated with hair transplants; so why ask if patients should do hair transplants in the crown?
Well, because there are a number of things all patients must consider — and discuss with their doctor — before undergoing hair transplantation in the crown:
Are you thinning in other areas of the scalp?
Although the crown is important for a lot of patients, it’s generally a less “cosmetically significant” area as far as surgery is concerned. In comparison to highly visible regions like the hairline and frontal scalp, the crown isn’t overly noticeable in most normal scenarios. Thankfully it’s up very high on the scalp and located near the back of the head, so most people don’t really see it. The same can’t be said about the hairline or frontal scalp. So if you are thinning in this region as well, it is likely a good idea to address these regions before attempting to do the crown. Even if you’re looking to undergo a mega-session to address both at once, it is usually better to start in the front and work back to the crown. That way if you do run out of grafts, the hairline, frontal scalp, and mid-scalp regions — which are more visible — are done first. But why does this matter? Why can’t all of it be done at once or why can’t the crown (back) be done first? Well …
How much donor area do you have available for transplanting?
The donor region — the area on the sides and back of the scalp where the follicles are harvested — is finite. This means that a patient may not have enough life-time grafts available to cover the entire scalp if he/she aggressively loses hair. When you’re considering a crown transplant with a limited donor region, you must ask yourself the following question: if I use up all my donor transplanting the crown and then thin in the front, what will I look like? In most cases, this would not result in a natural appearance. A very full, thick crown with almost no hair in front of it is not something we see in nature. However, men with thick, full fronts, and thin crowns is something we see naturally. And this is why if you have limited donor and can only transplant one region of the scalp, it is better to use it up front. This will look natural, even if the back completely thins. The same cannot be said for a completely bald front with a thick crown. Now, there are situations where men only thin in the crown and not the front; the donor can be evaluated differently in this case. However, it is difficult to predict how one’s hair loss will progress and it is always wise to make sure there is adequate donor for the front first. Thankfully, when patient’s maximize their life-time grafts with a combination of FUT (follicular unit Transplant) first followed by FUE (Follicular Unit Extraction) or mFUE (modified Follicular Unit Excision), there is usually a lot of donor to utilize. But it does not change the fact that donor is limited and addressing the front first is almost always the safest and most strategic move.
How old are you?
Younger patients should be screened more thoroughly before crown transplantation is considered. Although a “bald spot” can be psychologically tough for a young man, young patients with thinning in this region are likely to have more hair loss. This circles back to the points above: patients with aggressive hair loss and a set number of life-time grafts need to act strategically and use grafts wisely. If a young man is starting to thin in the crown, he is likely to thin in the front as well. This means his grafts are likely better utilized in this region. Even if it’s not apparent, he may be better off waiting on a transplant to see what happens in the front. But I implore patients to consult with a hair restoration physician before making any determinations.
Are you on preventive medications?
There are pros and cons of preventive hair loss medications. And any patient considering these medications should thoroughly research these and discuss them with a doctor familiar with their medical history. However, the preventive medications available today were specifically tested and deemed effective for maintaining hair in the middle and crown regions of the scalp. While these medications don’t permanently stop the hair loss (they “kick the can down the road” a bit), they may help patients hold on to some hair in the crown region — meaning transplants can now be focused in the frontal and mid-scalp regions.
Are you going to start with FUT?
Almost all experts agree that starting with the FUT technique and moving to a non-strip method (like FUE) when no more strip extractions are possible (the patient is “stripped out”) is the best way to maximize life-time graft number. This is because the FUT technique creates the least amount of scarring in the donor area, and leaves the greatest amount of virgin (untouched) tissue. Most patients can undergo several strip surgeries (ranging anywhere from 2 up to 6, 7, or even 8!) before the natural characteristic of the skin deem no more strips should be taken. It is worth noting that each time a new strip is taken, the old linear scar is removed with it. So no matter how many strips a patient has done, there is always only a single scar in the donor region. And all around this scar is perfect, untouched tissue. Now this tissue can be harvested with a non-strip method like FUE. This means the patient can have thousands upon thousands of grafts taken as an FUT, then be a virgin FUE candidate and likely have thousands more. The same cannot be said when a patient only does FUE or stars with FUE and then switches to a strip. But in patients looking to address a large are of the scalp that includes the crown, maximizing life-time graft number is crucial. So these patients should start with FUT first.
Is your crown going to thin much more? Are you willing to have “touch up” procedures if it continues to thin?
Crown hair transplants are tricky partially because the crown is a “moving target.” Crown thinning tends to be progressive, and crowns thin in a spreading, circular pattern. While one procedure may address the entire thinning region today, it doesn’t mean more areas won’t thin and become visible in the future. Fortunately, we can often anticipate this and use the grafts to provide coverage even if thinning occurs in other areas. However, this still does not mean the crown won’t thin beyond the coverage of our transplants, and future (likely smaller) surgeries may be necessary up the road. A patients considering crown surgery should be aware of this.
What kind of coverage are you expecting?
The twisting “whorl” pattern of the crown makes it a naturally thinner and more transparent region of the scalp. Even individuals with no true male pattern hair loss still have visible gaps and thinner areas in certain parts of the crown. And our goal as hair transplant surgeons is to recreate nature. This means there will be regions where the hair appears slightly thinner and scalp can be seen underneath. A crown with no natural breaks or small differences will not look natural. It will look life a hair piece! So patients should expect a natural rebuild of the crown, which will include some of these variations.
So, should you have a hair transplant in the crown? Well, review your answers to the questions above and see how you feel. If you understand the need for a long-term approach and the idiosyncrasies of crown transplantation, you may be a good candidate. Consult with a clinic experienced with transplants in this region (make sure they can show you multiple examples of crown transplants) and make an informed decision with the above in mind.
Here is an example of a patient who met the criteria above and was able to restore his crown. Maybe you will be next!
Hope you found this article informative. Stay tuned for more.
Dr. Blake Bloxham and Dr. Alan Feller
Feller & Bloxham Medical, PC