For the frontal third, thanks for the complements!
For the crown,
The goal was not to fill in the crown (although that was an option), but to add light density, turning back the hands of time to early in the hair loss process of the crown.
If you look closely, you can tell which hairs have been long gone, which are about half way through the miniaturization process, and which hairs have just begun to miniaturize.
Instead of thinking in geometric terms (crown=circle, fill in circle.), Dr. Mwamba adds the most density in the areas that have been affected by MPB the longest. Here, you can lend coverage without concern for existing hairs.
In the areas of 50% miniaturization, there is a good chance that they will either A) be lost within about a year naturally, B) loss will be accelerated due to transplanting closely to weakened hairs. These existing hairs are baby fine, and are not lending much for coverage. Transplanting here will likely take the place of native hairs.
In the areas that have more recently begun miniaturization, there are a few options. Either you can A) hit the area with medium-heavy density and most likely lose the existing hairs (due to acceleration of mpb), but retain the transplanted density, or B) attempt to salvage those hairs for as long as possible and the coverage that they lend to the crown by transplanting minimal density to that area. This, in a sense, buys the patient time.
The patient was presented these options and opted to go for a light sprinkling of density to the crown, carefully respecting the existing hairs with plans to return after he observes the results and the coverage obtained with the 770 FIT grafts in the crown.
After making decisions about existing density, Dr. Mwamba must design the crown. This patient has a single-whorl crown, in a clockwise direction, with the center to the upper left quadrant of the crown. The areas of this crown that are most difficult to cover are the center of the whorl and where the hairs are angled nearly straight up. These areas require larger amounts of grafts due to the angulation of hair growth. In the areas to the right of the crown, these hairs lend easily to cover other areas as the hair is grown out.
Higher density on the right, upper, and lower areas of the crown will give good coverage with minimal amounts of hair, successfully covering the majority of the crown while maintaining a natural, thinning look. This approach is two fold because the areas hardest to obtain full coverage are also the areas with hairs early in the miniaturization cycle.
Although the patient’s long term goal was to fill in the crown as much as his hair characteristics and donor hair allowed, the short term goal was to conserve funds, conserve donor reserves with respect to future loss, and further refine his goals for the crown after seeing the results of this first surgery.
The patient has since returned for his second pass to increase the density in the crown, as planned. 800 grafts were added to the crown in this second pass. The grafts were placed mostly in the area that, in the first surgery, had early stages of miniaturization. Revisiting this area of previously transplanted light coverage is not a problem.
Long term effects for this patient:
This patient has been responding well to propecia and rogaine and his hair loss has stabilized for now. Hair loss can be slowed, but it can suddenly accelerate as well, even when on propecia.
If this patient experiences more loss in the frontal third, future surgeries will involve low numbers of grafts. Because the density placed in the frontal third, although the appearance is that of thick coverage, is in actuality no more than 45-50 h/sq.cm. It will take much less donor to match this density should future surgery be indicated. Had this patient desired high density for the frontal hairline and throughout the frontal third, he would run into future issues of donor reserves and cost.
For the crown, if the patient experiences further loss and the crown widens, only very light density to the perimeter will be needed. A lot of future crown loss is not indicated, and some loss in the crown will be easily masked due to his hair characteristics.
This patient will possibly need further hair transplant, he is aware of this. But the amount of future transplanted hair needed has been lessened due to the techniques and densities chosen and allowing the educated patient to decide amongst his best options. When working with a patient that is possibly headed for future loss, a conservative approach is encouraged, and options are presented, but the final decision is really up to the patient.
I am not a doctor. I am a surgical tech trained in hair transplant. My opinions are not necessarily those of Dr. Mwamba. My advice is not medical advice.