Doing the Math

[John P. Cole, MD]

Gillenator, you have always been ahead of your time in both patient education and hair loss solutions. I've known you over 10 years and you have always been ahead of the curve.

You question is excellent. In the past the only indicator of future hair loss was miniaturization. I say indicator because anyone can spot hair loss, which is a loss of density. The initial signs are a loss in diameter and a loss in color (pigment). Diameter changes are quite subtle initially, however. This is where cross sectional trichometry comes into play. We can spot small changes early on when miniaturization really is not evident.

What we are looking for with CST is evidence of loss in other places and most importantly all over the head. If the CST is at or above the donor area in the crown and top of the scalp, you are not showing signs of loss there at this point. there is no reason to consider treatment in these areas. If there is a sign of loss in these areas, one must decide if it is prudent to transplant areas of future loss based on age and the donor area supply.

When i see hair loss in the frontal area, i do my best to treat up into the area where i see miniaturization. I may treat the bald areas with 40 to 60 grafts per sq cm, but in the miniaturizing areas, i try to treat with lower densities of say 20 per sq cm. Lower densities minimize the risk of shock loss. Areas of early miniaturization really look full so we are not trying to completely replace these areas. All we are trying to do is put a handful of grafts there in case that area of early miniaturization really begins to accelerate over a short span of time. The last thing we really want is to have a bald spot develop perhaps behind the hairline area that we built today. This simply requires the patient to come back sooner to fill in the gap. Thus, when i see miniaturization in the frontal area, i go ahead and build at a low density into the areas where i see miniaturization. This approach recedes the frequency of visits by my patients without significantly increasing their cost. Again, a stitch in time saves nine. There is no reason to restore the original density in these behind the hairline areas. you just need to eliminate the potential for a bald zone. In doing so, you eliminate unnecessary follow up visits.

The crown is far more complex. If you build in the center of the crown, later on a patient can loose the perimeter. Now you have hair in the middle and nothing in the perimeter. That's not a good scenario. In some instances it is a precursor to the next procedure. in to others, it is the disaster waiting to happen. You have to individualize this.

I approach all crowns the same way from the frontal area back to the top of the crown. There are two hairlines. One in the front and one in the back. If you build a natural hairline in the front and a poor hairline in the back, anyone sitting behind you on an airplane will see "HAIR TRANSPLANT". ONe must always build two hairlines - front and back.

In the crown, it is better to build from the periphery in. Hair loss begins centrally to out so you want to build from outward to in. Restore natural loss rather than unnatural restoration.

The next point is huge. One with a large caliber hair can loose up to 82% of their original hair mass and look full with longer hair in the front. However, a person with coarse will look think in the crown area after loosing only 50% of their original hair mass. Unfortunately, a person with fine hair will look think after loosing a smaller percentage of their original hair masse, but they must also restore more than 50% of their original hair mass to look full. In other words, crown restoration is remotely possible to completely impossible. Be careful how you proceed here. Work delicately and naturally. Individuals loose diameter first, then hairs per follicular unit, then follicular units. The most natural way to restore this is single hair grafts and 2 hair grafts. Anything larger looks like a transplant. Single hair grafts in the crown look best, but they provide the least coverage. the question you must ask yourself is whether you want natural or more coverage at the expense of appearing to all your friend that you've had a hair transplant. I wish i could sugar coat it, but i can't and your friend certainly will not sugar coat something that is obvious regardless of how hurtful their comments are. Remember, they don't recognize how much hair loss affects you because they don't have it. They kid you only because they don't comprehend the pain you are going through. They embarrass you only because they think it is funny and you obviously don't care because you let something ridiculous happen to you.

Anyway, I try to do the fewest number of grafts where there is miniaturization to first avoid shock loss and second to avoid a repeat visit soon to address these areas. A handful of grafts often puts off a visit for many years. Failure to treat these area with a handful of grafts often results in a repeat visit in a year. I am also very careful in the crown area and i take this on an individual basis. In individuals who are showing evidence of moving to a NW 3V or better, i try to build a second hairline behind the frontal area because i anticipate that this hairline will someday (perhaps quite soon) become evident so we don't want anyone recognizing what we have done as a hair transplant. When i approach a crown, i try to make the result look natural for decades to come.