The crown (or vertex) is that circular area of baldness in the far rear of the balding scalp which lies on a mostly vertical plane. If there is an residual hair in this area, it is directed in a swirl or whorl direction, similar to the spokes on a bicycle. When transplanting this area, the transplants are planted in this same pattern and with the same direction and angle as exists in nature.
In the men whom we do transplant the crown-vertex, in the recent years our policy has been to tackle it as a separate project after first completing the top of the scalp. We made this change in our approach for two reasons: one is that the amount of donor tissue that can be harvested without creating excessive tension on the donor closure is usually the amount necessary to fill in the top region. Secondly, when the entire top of the head is filled in along with the crown it is our experience that the blood supply to the crown area in some patients is slightly compromised and with the growth of the grafts in that area is not ideal. For this reason, our preference in most cases is to tackle the crown in a separate 1-2 sessions, dense packing anywhere from 800 to 1500 Fur’s there per session, depending on the square area of the vertex. When the crown is transplanted by itself, we consistently obtain 90-95% graft survival.
We must emphasize that we deliberately try to “under-sell” what we can accomplish in this back area. We are very good at making it look natural, but we are not usually able to make it appear thick. The only time we can do that is if the man has a relatively small area and a thick, loose scalp – which allows us to perform a scalp reduction before transplanting in the remaining area. The patient below with the gray hair had this approach taken and had one of the rare thick crown transplants we have done.
The reasons why the crown can’t be made dense are as follows:
The hairs are angled in a “whorl” arrangement, by which they are all directed away from one another and not overlapping, as almost all the other hairs on our heads do.
Because the hairs in this region are in a “whorl” arrangement, going way from the center of the whorl, there is a minimal overlap of hairs, which does not lend itself tot he appearance of the fullness. They do, however, appear very natural in this arrangement.
The crown is on a vertical plane and very exposed to the public. Therefore, none of the grafts can be over 2-3 hairs each, or they run the risk of being slightly detectable. Because of this, only very small FU grafts are used in this region.
The crown is not the most important area of scalp. The frontal region and the midscalp are. Therefore, it is always wise and prudent to make sure that whatever donor hair is available is used primarily in these front and top sections first.
In selected men, we can use a “dense packing” approach to the crown and place up to 1000-1500 densely packed FU’s in this region. This can only be done if the other two areas have been taken care of or are fairly certain not to bald later on, as judged by the man’s age and maturity.
The photos in our “Crown Gallery”, which you can click on and view, show what we typically do in the crown area. In all of these patients, we were at the same time transplanting the frontal and midscalp areas and added in the extra FU’s that were placed in the crown, usually around 300-350 per session.
