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Warning to all HT docs


#1

Will you please stop leaving that small bald spot of less than 30cm2 on the crown untouched during the first procedures even when you are covering the front top and back. There is no written rule that says you have to do this. There is no real need for it. It’s not funny and it’s not clever.:confused:


#2

» Will you please stop leaving that small bald spot of less than 30cm2 on the
» crown untouched during the first procedures even when you are covering the
» front top and back. There is no written rule that says you have to do
» this. There is no real need for it. It’s not funny and it’s not
» clever.:confused:

LOL, yeah what s up with that? I thought every doctor is leaving a spot in the crown for their signature there, :stuck_out_tongue:


#3

» » Will you please stop leaving that small bald spot of less than 30cm2 on
» the
» » crown untouched during the first procedures even when you are covering
» the
» » front top and back. There is no written rule that says you have to do
» » this. There is no real need for it. It’s not funny and it’s not
» » clever.:confused:
»
» LOL, yeah what s up with that? I thought every doctor is leaving a spot
» in the crown for their signature there, :stuck_out_tongue:

I reckon you’ve cracked it.:slight_smile: So my choice of surgeon is now so simple. I have to go for a surgery with someone with a short name. I had booked surgery with the brilliant lebonese HT surgeon Dr. Sewarepimawobensica but I may change my mind now. :smiley:


#4

» Will you please stop leaving that small bald spot of less than 30cm2 on the
» crown untouched during the first procedures even when you are covering the
» front top and back. There is no written rule that says you have to do
» this. There is no real need for it. It’s not funny and it’s not
» clever.:confused:

:smiley: I appreciate your humor.

In Hair Transplantationby Unger and Shapiro, there is an interesting perspective that might help. (I am paraphrasing here).

“First, the transplanted hairs must be placed in a whorl arrangement, and second, this area, because of its relatively vertical plane, is highly detectable to viewers, thus requiring a good deal of artistry and (numbers of grafts) in transplanting if it is to appear natural. Third, although we often see what looks like a relatively strong border of occipital fring hair, on closer inspection, especially with wet hair, a peripheral zone of see-through hair frequently exists. Most men eventually progress to lose this see-through hair, thus enlarging the entire circilar area of alopecia more laterally and inferiorly…the patient could eventually be left with an island of transplanted hair surrounded by an alopecic zone.”

What is described here is the nature of the hair in the crown and the way alopecia affects the crown. Because of the whorl pattern and the vertical plane, it takes much more hair to be able to provide coverage than compared to areas like the hair line or frontal third. Although the surface areas can be comparable, the amount of hair needed for coverage is far greater in the crown.

The other problematic aspect is the long term results to the patient. As hair loss progresses in the crown, it is noticible much quicker and it looks very unnatural than when compared with continued loss in the hairline or frontal third. When the recession in the crown continues, it leaves an island of hair in the center of the crown. This is sometimes termed a “devil’s halo”. It forces the patient into further surgeries and can be difficult to keep up with even if time, donor availability, and money are of no concern to the patient.

Because there is a finite amount of donor availability, it is important to prioritize your hair transplant goals. Hair lines and frontal thirds frame the face and establish coverage with less hair. Grafting these areas can often stand alone in a natural appearance even as the hair loss progresses.

Perhaps that helps explain the untouched crown trend that you see.


#5

» » Will you please stop leaving that small bald spot of less than 30cm2 on
» the
» » crown untouched during the first procedures even when you are covering
» the
» » front top and back. There is no written rule that says you have to do
» » this. There is no real need for it. It’s not funny and it’s not
» » clever.:confused:
»
» :smiley: I appreciate your humor.
»
» In Hair Transplantationby Unger and Shapiro, there is an
» interesting perspective that might help. (I am paraphrasing here).
»
» “First, the transplanted hairs must be placed in a whorl arrangement, and
» second, this area, because of its relatively vertical plane, is highly
» detectable to viewers, thus requiring a good deal of artistry and (numbers
» of grafts) in transplanting if it is to appear natural. Third, although we
» often see what looks like a relatively strong border of occipital fring
» hair, on closer inspection, especially with wet hair, a peripheral zone of
» see-through hair frequently exists. Most men eventually progress to lose
» this see-through hair, thus enlarging the entire circilar area of alopecia
» more laterally and inferiorly…the patient could eventually be left with
» an island of transplanted hair surrounded by an alopecic zone.”
»
» What is described here is the nature of the hair in the crown and the way
» alopecia affects the crown. Because of the whorl pattern and the vertical
» plane, it takes much more hair to be able to provide coverage than compared
» to areas like the hair line or frontal third. Although the surface areas
» can be comparable, the amount of hair needed for coverage is far greater
» in the crown.
»
» The other problematic aspect is the long term results to the patient. As
» hair loss progresses in the crown, it is noticible much quicker and it
» looks very unnatural than when compared with continued loss in the
» hairline or frontal third. When the recession in the crown continues, it
» leaves an island of hair in the center of the crown. This is sometimes
» termed a “devil’s halo”. It forces the patient into further surgeries and
» can be difficult to keep up with even if time, donor availability, and
» money are of no concern to the patient.
»
» Because there is a finite amount of donor availability, it is important to
» prioritize your hair transplant goals. Hair lines and frontal thirds frame
» the face and establish coverage with less hair. Grafting these areas can
» often stand alone in a natural appearance even as the hair loss
» progresses.
»
» Perhaps that helps explain the untouched crown trend that you see.

I agree with some of these comments. There is certainly an expansion of the crown hairloss and the weakened area is detectable even if the fringe area is robust on superficial inspection.

The rest of this does not add up. A “devils halo” is one thing but these surgeons transplant to the crown just leaving a bald spot in the middle. Further egression with this philosophy will look a lot more stupid than a devils halo, it will look like a floating ringed donut!

I think that the truth is that many Ht surgeons struggle with the angulation of the crown whorl or are too lazy to put the effort, justifying the decision with the comment that you have quoted. A notable exception is Dr. Hasson who ensure the worl is covered and the angulation is fine. The idea that it takes more graft is erroneous since a thin whorl is O.K and looks a lot more sensible than the mandatory bald spot.


#6

»
» I agree with some of these comments. There is certainly an expansion of
» the crown hairloss and the weakened area is detectable even if the fringe
» area is robust on superficial inspection.
»
» The rest of this does not add up. A “devils halo” is one thing but these
» surgeons transplant to the crown just leaving a bald spot in the middle.
» Further egression with this philosophy will look a lot more stupid than a
» devils halo, it will look like a floating ringed donut!

I like the term “floating ringed donut”! It is very descriptive. Can I start using it?

I think the purpose to grafting the perimeter of the crown is to return the patient to an earlier stage of crown loss because there is not enough hair available to create a full crown. It depends on the patient’s situation, degree of loss, etc. But, when grafting the perimeter, extreme care and planning has to take place to make sure that either A) you are grafting into areas of existing hair in the perimeter that will probably be lost in the future or B) the patient is fully aware and in agreement with the fact that they are going to need further surgery to keep up with the perimeter.

» I think that the truth is that many Ht surgeons struggle with the
» angulation of the crown whorl or are too lazy to put the effort,
» justifying the decision with the comment that you have quoted. A notable
» exception is Dr. Hasson who ensure the worl is covered and the angulation
» is fine. The idea that it takes more graft is erroneous since a thin whorl
» is O.K and looks a lot more sensible than the mandatory bald spot.

I mostly agree. It could be several reasons like laziness or lack of knowledge and skill. It could be that they don’t want patients to have to live their lives looking unfinished or unnatural if some unforseen event prevents them from touch up sessions to keep up with the loss.

Thin coverage is a much better expectation for the crown when the loss is significant, but even thin coverage in a whorl takes more hair than areas with less circular patterns.

I have heard before that Dr. Hasson has good crown angulation. Do you have any pics or links? I think it would be helpful to the board, even if it is a repost.


#7

»
» I have heard before that Dr. Hasson has good crown angulation. Do you
» have any pics or links? I think it would be helpful to the board, even if
» it is a repost.

not the best but a good example


#8

BTW, just to demonstrate how closely this aligns to nature, I had a shot taken from outer space which shows a remarkable resemblence of this crown work to huricane DEAN.:wink:


#9

» »
» » I have heard before that Dr. Hasson has good crown angulation. Do you
» » have any pics or links? I think it would be helpful to the board, even
» if
» » it is a repost.
»
» not the best but a good example

That is a great example of the correct angles for crown transplant. You can also see the miniaturization around the perimeter of the crown. Great example; nice find, marco!


#10

» BTW, just to demonstrate how closely this aligns to nature, I had a shot
» taken from outer space which shows a remarkable resemblence of this crown
» work to huricane DEAN.:wink:
»
»

The best way to create a natural look is to imitate nature itself. Another very cool pic, marco.


#11

Marco I totally agree with you, besides I would rather have a thin look all over than a thick hairline with the crown bald. I never buy the reasons the doctors use for leaving the crown bald. Some of the excuses they invented are absurb but since they are doctors everyone just goes along with it.


#12

» Marco I totally agree with you, besides I would rather have a thin look all
» over than a thick hairline with the crown bald. I never buy the reasons the
» doctors use for leaving the crown bald. Some of the excuses they invented
» are absurb but since they are doctors everyone just goes along with it.

i agree with the docs on this one
why waste valuable grafts even to thinly cover the crown when the halo is probabaly more likely than not to be coming, and sooner rather than later
it traps you into lifetime transplants, chasing your expanding halo
whereas if the rest of the hair recedes, it could look ok if the trans was just in the frontal hairline
like that one senator…joe biden
looks a bit strange if you look behind the hairline, but not totally unreasonable and freakish,


#13

» i agree with the docs on this one
» why waste valuable grafts even to thinly cover the crown when the halo is
» probabaly more likely than not to be coming, and sooner rather than later
» it traps you into lifetime transplants, chasing your expanding halo
» whereas if the rest of the hair recedes, it could look ok if the trans was
» just in the frontal hairline
» like that one senator…joe biden
» looks a bit strange if you look behind the hairline, but not totally
» unreasonable and freakish,

Well, how about this and it is a serious proposition. A transplanted line including the swirl in the middle of the crown from back to front leaving bald spots on both sides. Actually I think that is a very natural configuration during the baldong process and could take further expansion of the bald spot. I am almost certain that I will go for a variation of this but include a very thin coverage on either side of this line.


#14

» » i agree with the docs on this one
» » why waste valuable grafts even to thinly cover the crown when the halo
» is
» » probabaly more likely than not to be coming, and sooner rather than
» later
» » it traps you into lifetime transplants, chasing your expanding halo
» » whereas if the rest of the hair recedes, it could look ok if the trans
» was
» » just in the frontal hairline
» » like that one senator…joe biden
» » looks a bit strange if you look behind the hairline, but not totally
» » unreasonable and freakish,
»
» Well, how about this and it is a serious proposition. A transplanted line
» including the swirl in the middle of the crown from back to front leaving
» bald spots on both sides. Actually I think that is a very natural
» configuration during the baldong process and could take further expansion
» of the bald spot. I am almost certain that I will go for a variation of
» this but include a very thin coverage on either side of this line.

when the crown begins to thin, it thins from the center of the circle, outwards, the circle expands ever larger diameter,l but it does not bald with a filled in center to the circle, at least not normally
it this what you are proposing

personally with the costs of transplants , the uncertainty of scarring and especially future thinning, considering the limited donor
I have decided not even to get one done
rather have a naturally bald crown than screw up my whole head and bank account trying to look 20 yrs younger


#15

» when the crown begins to thin, it thins from the center of the circle,
» outwards, the circle expands ever larger diameter,l but it does not bald
» with a filled in center to the circle, at least not normally
» it this what you are proposing
»

I am not suggesting to transplant the centre of the circle, I am suggesting transplanting a line similar to a mohican (with a cross on the vertex where the hair is often resistant to balding). I know It sound totally ridiculous but I will have to draw it out.


#16


#17


#18

» » » i agree with the docs on this one
» » » why waste valuable grafts even to thinly cover the crown when the
» halo
» » is
» » » probabaly more likely than not to be coming, and sooner rather than
» » later
» » » it traps you into lifetime transplants, chasing your expanding halo
» » » whereas if the rest of the hair recedes, it could look ok if the
» trans
» » was
» » » just in the frontal hairline
» » » like that one senator…joe biden
» » » looks a bit strange if you look behind the hairline, but not totally
» » » unreasonable and freakish,
» »
» » Well, how about this and it is a serious proposition. A transplanted
» line
» » including the swirl in the middle of the crown from back to front
» leaving
» » bald spots on both sides. Actually I think that is a very natural
» » configuration during the baldong process and could take further
» expansion
» » of the bald spot. I am almost certain that I will go for a variation of
» » this but include a very thin coverage on either side of this line.
»
» when the crown begins to thin, it thins from the center of the circle,
» outwards, the circle expands ever larger diameter,l but it does not bald
» with a filled in center to the circle, at least not normally
» it this what you are proposing
»
» personally with the costs of transplants , the uncertainty of scarring and
» especially future thinning, considering the limited donor
» I have decided not even to get one done
» rather have a naturally bald crown than screw up my whole head and bank
» account trying to look 20 yrs younger

Ya i dont know why they do this either, I saw a after pic just recently and the crown was completely bare with a perfect line across the centre vertex of the head, it looked completely unnatural.


#19

» Will you please stop leaving that small bald spot of less than 30cm2 on the
» crown untouched during the first procedures even when you are covering the
» front top and back. There is no written rule that says you have to do
» this. There is no real need for it. It’s not funny and it’s not
» clever.:confused:

Dear Marco,
I think it’s important for men losing their hair that read these hair sites to realize the important reasons that hair surgeons almost never do include the “crown” (vertex) along with doing the top horizontal area of hair loss all in one session. There are three important points I think are valuable for you to understand:
The first one is that, if you are a young male, say, under the age of 30 or even 35, that small circular area you see presently can over the next 10-20 years increase in size logarithamicly to a huge area, leaving previous transplant work looking like a splotch of hair with a halo around it and no donor hair remaining to fill in the halo. Male pattern baldness is progressive throughout our lifetimes.
Secondly, if a person does in fact require transplanting throughout the frontal and midscalp areas, which in itself is a huge area, in order to do justice to filling in that area at the first session, to add onto that getting enough grafts to also fill in the crown in back is asking for an awful lot of donor hair, which means that the donor strip taken will have to be very long and very wide, which sets up the very real risk for a wide, ugly donor scar that will be hard to hide.
Third, even if one could get the needed donor hair to do all three zones - the frontal, midscalp, and crown regions - I have discovered in my own practice that the growth and survival of the FU grafts placed in the crown is diminished. I did a study of one particular fellow in whom the growth was poor in the vertex after his first two procedures, in which I did in fact try to fill in all three areas. I then had him come back for a third procedure, in which I only transplanted the crown (vertex) with 1500 FU’s and tattooed off a study box to calculate the exact survival, and found there was excellent growth. The exact reasons for poor growth some of the time when the whole head is tackled is not clear. My own suspicion is that it is just asking too much of the blood supply to the scalp, especially in the back, where you have the donor scar beneath those grafts and in front of it you have the thousands of grafts necessary to do justice to that area.
If a person is old enough to have all three zones filled in and has enough donor hair, my preferred method is to do the top (front two zones) at the first two sessions and then do the crown separately at a third visit 10 months or more later.
Mike Beehner, M.D.
Saratoga Springs, New York


#20

» Third, even if one could get the needed donor hair to do all three zones -
» the frontal, midscalp, and crown regions - I have discovered in my own
» practice that the growth and survival of the FU grafts placed in the crown
» is diminished. I did a study of one particular fellow in whom the growth
» was poor in the vertex after his first two procedures, in which I did in
» fact try to fill in all three areas. I then had him come back for a third
» procedure, in which I only transplanted the crown (vertex) with 1500 FU’s
» and tattooed off a study box to calculate the exact survival, and found
» there was excellent growth. The exact reasons for poor growth some of the
» time when the whole head is tackled is not clear. My own suspicion is that
» it is just asking too much of the blood supply to the scalp, especially in
» the back, where you have the donor scar beneath those grafts and in front
» of it you have the thousands of grafts necessary to do justice to that
» area.

Very intersting so it makes sense to do smaller sessions over time which thank goodness is the approach I am planning to take anyway. Can other doctors comment on this blood circulation theory ?