Why Do Crown (Vertex) Hair Transplants Fail?

Though hairlines add to your physical appeal, crown baldness affects you psychologically. So when a patient feels, a doctor delivered a crown hair transplant result that was not up to his expectations, he feels disillusioned and dejected. And then a common belief in the patient community builds up and they assume:

1. Crown hair transplant does not work.
2. Crown area does not accept grafts
3. Crown is the black-hole of hair transplant

Norwood Scale of Crown Baldness:
Though most patients that present with crown baldness, also have hairline and mid-scalp thinning / baldness (NW IV-VII), there are some varieties that only have isolated crown baldness (NW II-III).

Definition of Crown & Vertex:
The words crown and vertex are used synonymously today but they are anatomically different.

The vertex is the highest point of the head and is best used in the fetal context (Fig. 1). The vertex is the highest point of the head and in the fetus for labor dynamics, is used to measure the longest distance that engages during the second stage of labor when the fetus is in the womb.

It is pertinent to say that the term ‘vertex’ is a verb during early life since this is the center point of dynamics of labor and becomes a noun afterward, in adult life. The crown is a noun in early human life, and as in adulthood baldness develops, it changes from a noun to a verb as baldness proceeds since it is the center of the dynamics of male pattern baldness.

So briefly, the crown is the area that dips down from the highest point of the head and the area that contains the crown.

The crown is a swirl like structure (whorl, pin-wheel) that has hair fanning out in different directions, radially oriented, growing out in a centrifugal manner in a clockwise manner. A crown can be higher up, lower down, or away from the center (eccentric). A crown can be single or double. It determines the pace of the direction of hair as hair pan out towards the vertex, mid-scalp, and along with the shingling points.

The crown in the center has a small circular see-through spot which is natural due to the unique outward direction of hair arranged as a swirl and constitutes a natural and esthetic crown and this does not require treatment. A crown without this natural disruption in the hair coverage will always look natural and will resemble a hairpiece where crowns are not apparent and is one of the give-away signs of the wig!

Why do hairlines look denser than crowns after hair restoration?
To answer this you need to imagine you are standing in front of a forest and it looks dense. You cannot see through it. There is not light that passes through and you cannot distinguish one tree from the other. If you climb up a hill and see the same forest, it appears so much less dense that you wonder if it is the same forest you saw from the road. Well, that is the illusion that is appropriate for hair transplant results as well. Since you see the hairline from the same plane as the hair are arranged, it looks so much denser since one hair strand falls behind the other. It gives an illusion of high density even though the plantation density is less than 50% in most cases of surgical hair restoration.

However, since the crown area is seen end-on (much like viewing the forest from the top of a nearby hill), it looks much less dense. Theoretically speaking, even if you plant the hairline and crown with the same density, the hairline shall look much denser than the crown due to this reason. So it makes the crown look as dense as the hairline, you will consume almost double the number of grafts!

Evidence through Maths:
When the Grade 6 crown/vertex area balds, it looses around 30,000 hairs. The area of a modest Grade 6 bald crown is 80 sq cm (diameter 10 cms). If a hair transplant falls for the patient’s request to deal with the crown first and to fill up with as much density as possible and even when the hair transplant surgeon stays conservative and plants grafts in a density of 40 grafts per sq cm, the total number of grafts consumed in covering the crown will be-

80 (sq cm) x 40 (grafts/ sq cm)= 3200 grafts.

That is a huge number, given the fact that an average scalp donor has just 5500-lifetime grafts in Grade 6 baldness. So how many grafts would this leave for the hairline, the mid-scalp, and for the crown itself as it balds further in a centrifugal manner over the years.

Adding limitless grafts in the crown area without deliberating on future evolving baldness, is a recipe for disaster in surgical hair restoration; and will add to one more unhappy patient who will feel and will add fuel to the myth-

‘hair transplant in the crown is a failure’. Worse is, when these grafts grow out, the illusion of dense coverage will still be a distant dream.

So, indiscriminate high-density crown coverage of Grade 6 baldness crowns, to meet unrealistic expectations of a client will always lead to disillusionment and erosion of trust. Rather than falling for such a request, time should be spent on counseling a patient, and if the irrational expectations cannot be toned down, the patient should be hinted that the surgery may be refused.

As crown area baldness advances, there will appear a halo-like area around the planted grafts in the crown from the last procedure. This area shall need to be covered with the same density used to cover the crown in the first instance. The density should match perfectly. If 40 rafts were used per sq cm, no less than 35 should be used now, or else it will give an island effect. An island of high density in the center amidst an ocean of baldness! Usually as the crown expands, the area to be covered is 1-2 times of the area which was first dealt with. So to think one has an endless supply of grafts available that can in Grade 6 patients fulfill requirements for the whole head is living in a fool’s paradise, both for the adventurous amateur surgeon and his irrational though hapless client.

The crown is in fact correctly referred to as the “Blackhole” of hair transplant. It is a moving target that cannot be deliberated upon accurately while planning hair restoration for the long term. Baldness here is ever-evolving and unpredictably dynamic. It consumes grafts like the blackhole does heavenly bodies and very little to show for it.

The patient must be informed that we merely create an illusion of density. We can never match God’s creation. With minimal grafts, we can merely make the bald spot in the crown look denser but it will never be like before in the vast majority unlike what online posted results tell you or hint at.

There are far too many variables from one patient to another in surgical hair restoration. Some are in the surgeon’s control and others are not.

Every person has dissimilar lifetime grafts available, unequal graft characteristics, different grades of baldness, and variable expectations from the procedure; not even mentioning the skills of the surgeon chosen.

These are the reasons why hair transplant surgeons are never as gung-ho about the crown area.

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