Treatment of alopecia of the crown possesses several unique challenges for hair restoration physicians. In this article, the distinctive anatomic features and specific management paradigms related to the crown are discussed. This review also offers details on which surgical technique to implement for obtaining the most natural result possible that also yields the best possible apparent density.
Key points
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The vertex is a complex zone with hair that is arranged as a whorl and is potentially subject to complete baldness.
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It is often virtually impossible to predict with absolute certainty the final degree of vertex balding before ages 40 to 50 years old.
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Due to the unpredictable nature of androgenetic alopecia, vertex treatment must be carefully considered and integrated into a global strategy.
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Ideally, it is preferred to finish treating the frontal and midscalp zones before treating the vertex.
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For most patients, a surgeon should not attempt to achieve maximal vertex coverage but instead restore an acceptable density that maintains donor supply reserves for future needs.
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An unnatural halo of baldness could appear around a vertex transplanted zone if future hair loss progresses.
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There are 2 distinct treatment philosophies for the vertex: (1) minimalist covering and (2) maximalist covering.
Introduction
The vertex, commonly referred to as the crown, is a complex zone with hairs that are arranged in a radial fashion. This zone is subject to more or less complete baldness. The evolution of vertex balding typically starts from the center and evolves at a variable rate toward the periphery. It is no easy task to treat the vertex for several reasons, discussed later.
Balding is often an uncertain situation with evolutionary patterns that may be hard to predict and with a potential for hair loss that is often widespread. The thinning often includes the frontal zone, the midscalp, and the vertex. It is essential to take into account the donor-recipient area ratio. Unfortunately, this ratio is evolutionary. It is never easy to choose the best strategy, knowing the vertex is a secondary zone in comparison with the anterior and median zones.
I describe exclusively vertex alopecia in men. It is exceptional to treat vertex baldness in women. Women almost never have enough graft reserve to treat the vertex.
Introduction
The vertex, commonly referred to as the crown, is a complex zone with hairs that are arranged in a radial fashion. This zone is subject to more or less complete baldness. The evolution of vertex balding typically starts from the center and evolves at a variable rate toward the periphery. It is no easy task to treat the vertex for several reasons, discussed later.
Balding is often an uncertain situation with evolutionary patterns that may be hard to predict and with a potential for hair loss that is often widespread. The thinning often includes the frontal zone, the midscalp, and the vertex. It is essential to take into account the donor-recipient area ratio. Unfortunately, this ratio is evolutionary. It is never easy to choose the best strategy, knowing the vertex is a secondary zone in comparison with the anterior and median zones.
I describe exclusively vertex alopecia in men. It is exceptional to treat vertex baldness in women. Women almost never have enough graft reserve to treat the vertex.
Anatomic description of the vertex
The vertex literally means the highest point . It is a round or oval zone, surrounded at the back and on the sides by the borders of the permanent zone. It is defined as the most posterior part of the area affected by male pattern baldness (MPB). Its limits are the midscalp on the front and the parietal and occipital fringe on the back and on the sides. Hair is arranged there as a whorl or swirl, starting from 1 or 2 centers.
In order to define the limit between the midscalp on the front and the vertex on the back, an anatomic mark, the vertex transition point ( Fig. 1 ), is used. The vertex transition point is the point where the horizontal part of the skull starts sloping downward to become oblique and then vertical toward the back. From this point, a concave curved line is drawn downward that joins the side limits. It is not always easy to locate this point because the surface of the skull is often round without any real point of visible transition. Unger further describes the crown: “… in most men with Type IV and Type V MPB, the anterior outline of the vertex area usually naturally ends at the posterior border of the ‘mid-parietal bridge,’ or the remnant thereof. In the majority of men with vertex Type III as well as Types IV and V MPB, this designated ‘vertex’ area occupies the classic ‘tonsure’ position, thus straddling both the horizontal and vertical planes of the scalp. In balding men with the more severe Norwood Types VI and VII patterns, the vertex has a large, circular (or somewhat oval) shape that rather than straddling both the horizontal and vertical planes, occupies essentially only the vertical plane. This is because its posterior border extends further inferiorly than in Types IV and V, and, therefore, the anterior border of its anterior mirror image is farther posterior than in Types IV and V MPB.”
The vertex transition point does not correspond to the center of the whorl ( Fig. 2 ). It is situated several centimeters above. It is necessary to be precise when discussing treatment of the vertex or crown. A transplant of the posterior part of the scalp, centered on the whorl, often includes not only the vertex but also the posterior part of the midscalp.
The posterior and side edges of the vertex, the occipital and parietal fringe, do not correspond to anatomically precise entities because they are at the evolutionary limit between the thinning zone and the hair-bearing area. These borders are an important area because they move over time.
It is useful to try to foresee as precisely as possible the future peripheral limit of the balding of the vertex. The current surface to be transplanted or the potentially bald one is often large. When baldness is advanced, it can be identified as the area where the hairs of the donor zone give way to predominantly miniaturized hair. When balding is incomplete, it is often easier to determine this limit in a macroscopic manner by wetting hair and by using a good light to visualize the skin through the hair. This region is often named, the evolving area ( Fig. 3 ).
There are anatomic variations, in particular, the existence of 2 swirl centers. There is often a small area of loss in the low part of the occipital fringe, inferior to the larger crown pattern, that Arnold named, the coronet (see Fig. 2 ). It is important to take the coronet into account because it encroaches and thus reduces the safe donor zone.
The exit angle of the vertex hair compared with the skin is also variable and high in the center of the swirl and becomes more acute toward the periphery.
How does vertex baldness evolve?
Vertex balding is a part of general baldness. Most of the time it appears later than balding of the anterior and midscalp zones. According to age, hair loss on the vertex is generally perceived as of greater importance (younger patients) or of lesser importance (older patients). Vertex balding is present in stages III vertex, IV, V, VI, and VII of the Norwood scale ( Fig. 4 ).
A study of 999 men by Norwood correlated the incidence of vertex MPB and found a consistent progression based on patient age.
| Ages in Years | Incidence |
|---|---|
| Between 18 and 29 | 5% (9 of 185 Individuals) |
| Between 30 and 39 | 21% (35 of 165 Individuals) |
| Between 40 and 49 | 33% (55 of 165 Individuals) |
| Between 50 and 59 | 42% (65 of 156 Individuals) |
| Between 60 and 69 | 56% (84 of 149 Individuals) |
| Between 70 and 79 | 54% (55 of 102 Individuals) |
| Over 80 | 65% (50 of 77 Individuals) |
A study by Unger showed that men above 60 years old had a prevalence of vertex baldness from 65% to 73%.
Patients rarely lose their hair only at the level of the vertex. Hair loss of the vertex begins mostly from the center and propagates toward the periphery. It evolves in the form of a circle or an oval, which grows gradually toward the outside. The surface of a circle evolves exponentially with the increase of its diameter. For this reason, it is necessary to be cautious when judging an unfinished hair loss. The surface area of an emptied vertex of 5 cm in diameter quadruples when it grows to a diameter of 10 cm.
Clinical examination
It is thus important to observe exactly the situation of the vertex before any decision making. The use of the cross-section trichometer is recommended. It allows quantifying exactly the scale of loss. Also, a fine observation of the emptied zone through quality magnifying glasses of magnification 5 or 6 is recommended to help define the topography of the miniaturization in this area. One should also attempt to highlight the thinning peripheral zone, which frequently begins several years before the definitive balding. Wetting hair and using a strong light is often an effective method.
Unfortunately, before ages 40 to 50, it is often impossible to predict with absolute certitude what degree of balding will be reached. It is necessary to be aware of the unpredictable nature of future hair loss and to explain this risk to the patients so they can approve, in full knowledge of the facts, the final therapeutic choice.
The vertex is not visible in front view, unless patients are seated and slightly bowed forward. On the contrary, from profile and back view, vertex baldness is visible.
Anamnesis
A precise evaluation of family history is often useful. It is necessary to try to find the degree of balding of the vertex of the father and the grandparents and of the collateral family, keeping in mind that this comparison is not always reliable. The surgeon should attempt to identify a member of the family having had the same type of evolution in severity and in age. It is patient age that often guides surgical intervention in the vertex region ( Table 1 ).
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