Recreating the Vertex

42 Recreating the Vertex

Jerry Wong

Summary

Crown transplants should be avoided if there are any signs pointing to advanced Norwood VI or VII pattern. Consistently good crown growth indicates a highly skilled surgical team that is functioning at a very advanced level. Presented are ideas and techniques that have improved crown growth with our team.

Keywords: shallow harvest incision skin hook dissection venous preservation hair direction and angle response to finasteride

Key Points

•Intact venous circulation is essential for good growth.

•Acute angling of grafts is important.

•It is technically challenging and will reflect any weakness in surgical technique.

•It is crucial to combine with medical therapy.

42.1 Introduction

Given that hair loss is ongoing and progressive throughout a person’s lifetime, it is impossible to accurately predict the exact extent of a patient’s hair loss pattern. The best we can do is provide an educated guess based on physical examination and family history. Once a transplant has been performed, even a conservative hairline reconstruction, we deny that person’s ability to bald in a natural manner as they age. A vertex transplant in a patient who will develop a Norwood VI pattern adds the problem of further donor depletion because the circumferential donor fringe will recede over time. One needs to be selective and choose candidates for crown transplantation with care.1

Aside from age and future expected Norwood pattern, the hair restoration surgeons (HRS) need to look at the density, texture, width, and length of donor hair. If the donor hair is good, is there sufficient laxity to remove enough hair for transplantation? The ideal patient for vertex hair restoration is someone in their 40s with a small area of crown baldness requiring perhaps 1,000 to 1,500 grafts and everywhere else the hair is strong and unlikely to be lost. Individuals with just a small area of crown thinning are the minority. Most prospective patients have much more extensive hair loss.

We also need to factor in the efficiency of the surgical team. How much hair is lost with strip removal, graft dissection, and, most importantly, what is the percentage of growth? If the surgeon and the team do not lose more than 3% from the strip removal, dissection, graft handling dehydration, etc., and the growth rate is greater than 95%, then patients will receive amazing coverage and density. Even the best and most experienced will have growth issues from time to time and it is always wise not to do the crown with the first surgery but concentrate on the front and mid-scalp (Video 42.1).

42.2 Surgical Planning

The approach to hair restoration in the vertex region is variable among HRS. Ranging from those who almost never operate in the crown to those who will treat the crown with high densities. There is considerable debate in the hair restoration field regarding the optimal size surgery, number of grafts transplanted in one surgery, ideal density of sites, and general surgical planning. Some points of view are discussed in more detail in Chapter 25.. A few will be described in this section, including the author’s preferred approach.

If a surgeon has determined that the long-term donor-to-recipient ratio allows for treatment of the vertex region, they may still proceed with caution. Those surgeons either “shrink” the alopecic region, concentrating grafts in the periphery and treating the center very lightly, or not at all. Reducing the balding area from all sides will create a more natural look than simply bringing the transplant further back (Fig. 42.1).¹^,²

Fig. 42.1 Extensive hair loss and wide crown. Strip session of 4,663 grafts with frontal half dense packed. Lateral aspects of crown transplanted to narrow the bald spot.

This approach works best in patients with favorable hair characteristics, including minimal contrast between the color of the hair and scalp, hair of finer caliber, and ideally hair with some wave or curl. Alternatively, the conservative surgeon may treat the entire crown with an even light coverage throughout. This latter approach leads to a naturally lighter coverage in the center because of the whorl directions. The author prefers to avoid this approach because a light coverage with strong coarse terminal hair stands out as somehow unnatural, as nature only allows for a light coverage with vellus or miniaturized hair.

There are relatively few circumstances in which high density is advisable in the crown region. In those circumstances, the author favors the following surgical planning. In patients with strong donor hairs on the side and back with good laxity, the potential donor yield is over 10,000 follicular units (FU). The first surgery consists of 4,500 to 6,000 FU and grafts are densely packed in the front and mid-scalp. The following numbers are estimates of what is used in the author’s practice: 4,000 to 4,500 FU should cover the frontal and mid-scalp area. About 5,000 to 5,500 FU should cover up to the crown swirl. About 6,000 to 6,500 grafts will usually cover the swirl and 1 to 3 cm past the swirl. Patients need exceptional density and laxity to generate 5,000+ grafts, so it is only with these patients that we can generate sufficient hair to cover the front, mid-scalp, and crown with one surgery. Other HRS feel that these numbers are higher than ideal in one surgery, and their opinions are presented elsewhere in the textbook.

The average patient will generally yield 3,500 to 4,500 FU in the first surgery and the author dense packs the frontal area and possibly the mid-scalp. The patient is then advised to take Proscar (we recommend Proscar instead of the generic as we feel the brand name is more effective) one-fourth tab every other day. Some of these patients will push for crown coverage even if it is a very light coverage. These patients need to understand that if they do not have sufficient hair to obtain good cosmetic coverage for the crown, light coverage with transplanted hair generally does not look natural. The exceptions to this include patients with favorable hair characteristics, those who plan to use concealing fibers into a sparse crown transplant, which adds a nice three-dimensional effect to a sparse crown transplant, and potentially those who are combining the sparse transplant with scalp micropigmentation (SMP). The author uses only single- and double-hair grafts to avoid a potentially “pluggy” look.

Patients are encouraged to use Proscar to at least slow down and maybe stop further crown loss. At the yearly follow-up, the growth from the first surgery is evaluated and a decision is made as to whether any more hairs are needed to fill in thin areas, adjust the hairline, or temple points, etc. At this point, it is possible to determine the patient’s commitment to the long-term use of Proscar and their response to the medication can be evaluated. If the first transplant results in good growth and the patient is happy, they may not be as concerned about the crown. Proscar will give the majority of patients a minor improvement and they are usually content to continue the drug and hold off on crown transplants. Even a minor improvement indicates a positive response to medical therapy and if patients are committed to long-term use of Proscar, it does alleviate some of the worry of ongoing hair loss. Patients who are unwilling or unable to use the drug because of side effects present a risk and are usually advised not to transplant the crown. Although Proscar does not work long term for everyone, the author feels it does work well enough for the majority of people to be a factor in surgical planning.

For the lucky minority, who have sufficient hair to cover the crown after the front and mid-scalp are done, the surgical plan the author prefers is fairly straightforward. Dense pack the very center of the swirl with 75 to 100 single hairs. Dense pack the doubles at 40/cm² and the three to four hair grafts at 30/cm² to get good cosmetic coverage. Occasionally patients need to come back for a second pass of 200 to 300 grafts into the swirl. The author aims to leave at least 3,000 FU in reserve after the crown transplant is completed. Patients need to understand that cosmetic coverage is far from “full” coverage. Anytime they look at their transplants under a bright light or when their hair is wet, they may be unhappy or disappointed. They will often push to have another surgery to add more density, which is acceptable provided there is sufficient donor hair. For the second pass, we will usually strengthen the swirl and the upslope area (any area where the hair direction is facing anterior). The down slope (posterior hair direction) usually shingles very well and when combined with a strong rebuilt crown swirl does not require a lot of density for coverage.2

42.3 Survival of Grafts in the Vertex: Open Strip Excision Technique

The author noted that in past surgeries, in which 5,000+ FU were transplanted and were sufficient for some crown coverage, the grafts in the vertex grew hair at a slower rate and had a somewhat lower survival rate as compared to those in the front and midscalp. With smaller sessions of 1,500 to 2,000 grafts just into the crown itself, the growth is usually fine. Obviously, 5,000+ grafting sessions can be very stressful to the entire scalp, but this did not explain why the vertex was worse than other regions of the scalp. The long strip usually went around the entire crown, but HRS were careful to avoid disruption to larger arteries. Unfortunately, perfusion is impacted by both arterial vessels and vascular drainage.

From the beginning of strip surgery up until several years ago, the initial strip incisions were usually to the bottom of the bulbs and the cuts used to bleed quite a bit, which was understandable since the scalp is very vascular. The bleeders were cauterized and the thought was that all was well so long as no major arteries were cut. Several years ago, the author changed the strip harvesting technique to a modified version of Pathomvanich’s “open technique.” Instead of making the initial incision the full depth of the follicle, a partial depth incision is made and cut down to about half to three-fourths of the follicular depth. Using skin hooks to retract the edges, we separate and dissect the bottom half to one-fourth of the follicles using scalpel blades. The purpose of the technique was to reduce transection of follicles by dissecting the lower part of the follicles under direct vision. This technique not only reduces transection but also allows us to see the large veins lying just deep to the bulbs avoiding them being cut (Fig. 42.2). Now we could dissect out the veins and preserve them as the strip was being lifted out. That allows us to save the venous clusters over the temple areas plus the two to three large veins in the parietal occipital region (Fig. 42.3). The bleeding decreased dramatically and we no longer needed to use cautery. Eight months to a year later, we began to see improvements with crown growth.