density laterally without a specific connection to the fringe. This mimics a pattern of hair loss seen naturally in many men with significant balding and does not incur significantly more grafting in the future, if many additional grafts are not available.

can be the occurrence of unnatural hair directions and the presence of an obvious scar that needs to be camouflaged. Due to these concerns of unnatural hair direction, the presence of an obvious scar, in conjunction with the excellent results that can be achieved with just one session of FUT placed on a bald crown,

13.9.2 The Crown

The front half of the scalp is the most important area cosmetically for most men. Proper transplantation principles dictate that men roughly less than 35–40 years of age should not have their crown treated. Young men should wait until such time as they are older and their thinning pattern is securely established or they have finished treating a previously bald frontal scalp with transplants.

The crown, if transplanted, adds less cosmetic gain compared to the front. Some men are not concerned about the crown as they do not see it and are disinclined to treat that area. Once the frontal scalp has been transplanted, the posterior hairline is designed to mimic the beginning of a naturally occurring bald vertex. When viewed from the rear of the patient then a non-transplanted crown will appear very natural (Fig. 13.10). Other men are concerned with a bald or thinning crown and want that area covered too. However, in the author’s experience, many men want some good reasonable density and coverage with the frontal scalp, and for the crown they either are not concerned with that area or will settle with a light coverage to take away from the appearance of a bald dome. By limiting crown transplantation to one or two treatments of light coverage, additional donor hair can be left in reserve for any future hair concerns that may develop over time.

Traditional punch grafting performed from decades ago routinely required three or four sessions of plugs to adequately treat an area and would frequently exhaust the donor area. If further treatments were at all anticipated more posteriorly then the use of scalp reductions, flaps, extenders, or expanders to minimize the crown area by whatever means necessary were often utilized. These procedures are still utilized today by some surgeons in the very bald male to minimize the area of alopecic scalp. There is the concern, however, that with extensive scalp reduction of the bald areas and scalp lifting of the permanent fringe, there

a

b

c

Fig. 13.10 (a) A typical frontal hair line has been drawn on with the intent of limiting transplantation to the vertex transition point. (b) After transplantation, when viewed from the front, there is the appearance of a full head of hair. (c) When viewed from the rear the vertex is still untreated but the posterior hairline looks very natural

reductions, flaps, extenders, and expanders are being used much less frequently today for MPB. However, these procedures are still invaluable in the treatment of extensive scalp hair loss due to trauma, burns, and congenital malformations. The indications and proper uses of these techniques are beyond the scope of this chapter and as such the reader is directed to other reference sources for a full description [26–29].

13.9.3 Females

Females with FPHL present their own unique planning challenges. Typical thinning patterns apparent in women with FPHL differ from men in that there is usually frontal hairline sparing with generalized thinning behind. In many women the thinning can involve most if not all of the potential occipital donor region and as such many women do not have sufficient donor areas of adequate density to warrant transplantation. Often there is evidence of generalized miniaturization of hair follicles throughout the scalp. In those women that maintain adequate density with minimal miniaturization of hair follicles in the occipital region, transplantation can be considered. However, as has been previously described, female expectations as to what can be achieved also come into the equation as to deciding the appropriateness of transplantation. Frequently, the areas to be treated are just behind the hairline to the mid-scalp or filling in the frontotemporal recessions to create a more rounded, feminine appearance (Fig. 13.11). With planning, in women the concern is

a

not so much the possibility of ongoing hair loss that could result in total balding, but of what the patient can expect as a reasonable result with one session. The FUT techniques used today allows for the creation of tiny sites made between preexisting hairs, so as to conserve hair, and to not remove hair, as was the case with the use of traditional 3.25–3.5 mm punch grafts. Women should be warned that they should plan for the possible risk of telogen effluvium postoperatively. Generally, sessions should be smaller than their male counterpart, performing approximately 1,000– 1,500 grafts per session. This helps to minimize the risk of telogen and allow for better camouflage using hair in the non-treated area to comb over the temporary crusts in the recipient area.

13.9.4Selection of Donor Area Site and Size

The decision as to where to choose the donor zone and how much tissue to take can be a difficult concept for the novice surgeon to grasp. It is inherent in any successful hair restoration procedure that any grafts removed will be taken from an area that will be permanent and to not develop male or female pattern hair loss in the future. Otherwise the transplanted hair could eventually fall out and a visible scar could eventually become apparent as the surrounding donor hair disappears. When deciding on where to take the strip and how much to take, one needs to consider the age of the patient as well as the family history to aid in predicting

b