The crown region of a patient’s scalp has, for many years, been considered the “taboo” region for surgical intervention. This is due to several reasons. The first of which is that even the most efficient donor area management plan could not allow for enough hair to be allocated for a meaningful cosmetic improvement. In short, there just was not enough hair that could be realistically harvested over one or many surgeries to address the crown sufficiently.
The development of modern follicular unit strip surgery by Dr. Bobby Limmer changed this. With practice and experience, the use of stereoscopic microscopes allowed for an average yield increase of 30% which meant more hair could be transplanted and more hair would be expected to survive the transplantation process as a whole. This allowed for doctors to more safely venture into the crown region to treat this area of hair loss for their patients as more hair could be harvested and more hair would be expected to grow for the patient.
Another reason why the crown has been difficult to master is because the angles and directions of growth vary widely in a relatively small area. This has traditionally presented a challenge for hair restoration doctors due to older hair transplant technologies and a lack of understanding the details of this aesthetic. However, the rest of the scalp, including the vertex, mid-scalp and frontal zone/hairline, have a fairly easy to read pattern that doctors can mimic on a consistent basis. Hair in the crown grows in a rotational direction, sometimes referred to as a “whorl”. For the majority of patients this whorl rotates in a clockwise direction with the pattern expanding wider, away from the whorl center. It is a little known fact that the whorl pattern expands and dictates the direction of hair growth on the entire scalp. Hair along the left side, above the ears, generally grows in a forward direction toward the forehead and the hair on the right side of the scalp grows in a reverse direction toward the back of the scalp.
When a doctor understands how hair in the crown region flows from one central whorl then the overall approach can be more comprehensive in scope. The doctor can consider the factors that go into proper and safe donor area management and combine this with the artistic necessities that the crown demands. If the donor area management is ignored or misunderstood the crown can have a very unnatural appearance that may be very difficult to camouflage and hide. Medical therapy is almost universally required by doctors for their patients to prevent a negative cosmetic impact that can result from continued crown loss.
It is because of the increased efficiency of donor harvesting and the subsequent refinement process introduced by the use of microscopic dissection that we currently have the ability to reproduce natural appearing crowns through surgical means. The challenge that remains however is still one density and the amount of hair required. The total surface area of a typical bald crown is not very large compared to the rest of the scalp. However, due to the nature of hair direction placement required for a natural result the crown takes more hair to get a cosmetically acceptable degree of coverage and density when compared to any other area of the scalp. Some leading hair loss experts believe that the crown takes just as much hair to get a satisfactory result as the front and mid-scalp regions, combined! This is due to the sharp change in graft direction required to create a rotational whorl pattern. The frontal and mid-scalp regions benefit from having a compounding effect from an overlapping of placement similar to shingles on a roof. Such overlap is not possible when each graft is placed with a sharp directional change such as is necessary for natural crown whorl reconstruction. This is why addressing the crown region in any hair transplant treatment plan should be the last consideration. If too much hair is placed into the crown early on then the other areas of need will not have enough hair for a sufficient cosmetic recovery.