The Vertex: Planning and Decision-Making

25 The Vertex: Planning and Decision-Making

Russell G. Knudsen

Summary

Transplantation of the vertex can be challenging, especially in the younger patient. It should be avoided if there are signs or family history indicating that an advanced Norwood pattern is likely to develop. Significant graft numbers are usually required and patient expectations can be hard to meet if hair characteristics are not ideal. Careful planning and explanation of the likely outcome are critical in setting realistic expectations. Careful attention to hair direction as well as density planning is crucial to getting a satisfactory result.

Keywords: planning realistic expectations spiral pattern of whorl future balding shingling

Key Points

•Vertex transplantation is challenging from both technical and planning perspectives.

•Only advanced surgeons and surgical teams should consider tackling this area.

•Medical therapy should be strongly encouraged in conjunction with surgery.

25.1 Introduction

Any discussion regarding recreation of the vertex must begin with a discussion of the philosophy of planning this particularly challenging region of the balding scalp. Congenital loss, or noninflammatory cicatricial loss in the vertex scalp offers no particular challenges philosophically as they may be regarded as stable areas of alopecia. However, vertex balding as an aspect of pattern hair loss is most certainly not a “stable” alopecia unless the surgeon anticipates the areas of future loss and treats those as already alopecic.

25.2 Vertex Planning

The operating philosophies of surgeons can range from conservative to aggressive. It is revealing that very few senior experienced surgeons aggressively transplant the vertex except in very specific circumstances. Less experienced surgeons should carefully consider why this is so. Many refer to the vertex as the “black hole” as it “sucks in” every available graft if we have not planned carefully. This is the inevitable consequence of 1 360-degree variation of hair direction beginning with the whorl and radiating peripherally in a spiral pattern requiring greater densities if high-level coverage is required,² the likely future centrifugal expansion of the balding vertex that increases the diameter thus logarithmically increasing the surface area (A = πr² is a rough approximation of the math even though the vertex is more elliptical rather than circular in shape (Fig. 25.1). Patients underestimate the amount of bald area because it is hard to visualize and therefore frequently underestimate the number of grafts required. For men with Norwood VI and VII, the total area of vertex balding can equal the frontal and midscalp areas combined.

Fig. 25.1 Graft numbers required for expanding the vertex.

There are no absolute rules for deciding whether to transplant the vertex, but patient characteristics (age, degree of balding, family history, and hair characteristics), together with patient expectations, make a carefully detailed consultation imperative. The author’s most common complaint from patients regarding transplantation in the vertex is that they were “expecting greater density” (especially in the whorl). The curvature of the surface in the vertex significantly reduces the visual impact of any given graft numbers. The illusion of density is somewhat easier to achieve in the anterior vertex on the horizontal portion of the vertex. Failure to meet patient expectations is the most commonly encountered problem, even after a detailed consultation.

Younger patients, who usually come to us with high expectations, should be avoided unless they have hair characteristics that make lower densities possible (e.g., low hair to scalp color contrast and significant curl). Aggressive vertex grafting in a young patient may result in inadequate remaining numbers of grafts for future frontal hair loss. Patients with dark hair will likely require large numbers of grafts (placed at densities of 35–40 follicular unit [FU]/cm²) to achieve a satisfactory outcome and thus require an abundance of donor hair.

The donor area-to-recipient area ratio informs us whether a patient has enough donors to adequately treat current and future balding. The author likes to refer to himself as an “operating pessimist” as it informs decision-making. The patient will likely lose more hair than expected, and at a faster rate than expected, by both surgeon and patient. Hair restoration surgeons (HRS) rarely overestimate future balding in the crown; usually, they underestimate. The use of finasteride or minoxidil rarely changes the author’s surgical plan as two requirements would have to be met¹: continued use of medications and indefinitely² continued success of medication to stop future hair loss. Experience has taught us that only a minority of patients will satisfy both these criteria. Nonetheless, any patient considering vertex grafting is strongly encouraged to commit to finasteride or minoxidil to try and slow or decrease future hair loss, and therefore reduce the requirements for future grafting in this area. The younger they are, the more important is this aspect. The author also explains that grafting the entire crown commits them to further grafting when (not if) future hair loss occurs. If we only graft the anterior vertex, it is often possible to ignore future hair loss in the inferior or lateral vertex. It is also important to remember that patients can change their views as the age. Any discussion of “not caring” if they were older is a red flag for proceeding with vertex grafting.

Other advantages of older patients are their generally more realistic density expectations and the effect of graying that reduces the hair to scalp color contrast. Older patients generally need lesser graft numbers because of this and future balding extension is unlikely to be as great as for younger patients.

Another aspect to managing patient expectations is to encourage the patient to prioritize the importance of different areas of alopecia, encouraging patients to regard the frontal and midscalp as of greater importance visually so that the plan can incorporate appropriate graft numbers in these areas before considering the vertex. This has the added advantage of delaying vertex treatment until the patient is happy with the frontal and midscalp coverage. As a consequence, most donor hairs should be allocated to current and future use in these areas. In addition, once the patient has seen the framing of the face restored, and the youthful effect this creates, he or she may decide that vertex coverage is less of a priority.1

An exception to this practice is the patient with isolated crown alopecia consistent with a family history of this pattern. Our worst case scenario occurs when overtreatment of the vertex leaves us with too few donor hairs for future frontal hair loss. In addition, the probable future peripheral expansion of the vertex makes a future “halo effect” surrounding the grafts quite likely. In this case, a lower vertex density is helpful to leave grafts to treat the retreating margins and provide better evenness of coverage. The worst case scenario is a patient returning after vertex transplantation with a halo effect and a depleted donor area that leaves us few options. Clearly the decision to operate here was a poor one.²

The increasing popularity of follicular unit excision (FUE) transplantation (indeed many newer surgeons have elected to restrict themselves exclusively to FUE) potentially creates another problem with vertex planning. FUE evenly spreads donor harvesting over a much larger area and attempts to avoid leaving areas of significantly greater density including the donor area closest to the current periphery of the vertex margin. In younger patients with large alopecic vertex areas, the mathematics of donor harvesting by FUE puts long-term graft survival of donor hairs closest to the margin at risk and makes it more likely that the punctuate scar remaining may be problematic. See Video 42.1 for details on vertex design and planning.

25.3 Vertex Design

The great majority of patients present to us with at least some fine miniaturized (vellus) hairs that indicate the original pattern of hair in the vertex (Fig. 25.2). This serves as a template for recreating the vertex and especially the whorl. In patients with no vellus hairs (extremely rare), a whorl has to be designed provided there is adequate donor supply. If the supply is insufficient, it may be best to work from the periphery inward to essentially “shrink” the vertex alopecia.