Since it is impossible to anticipate how bald a man might become, the surgeon must be extremely conservative during the planning stage if the man is young. I periodically see cases in which a man received transplants several decades ago but who has continued to lose hair and now has the previously transplanted hair in areas which look strange because of his current level of baldness. Typically, either the transplanted hair is too low on his forehead or the transplanted hair is present in an island-like formation surrounded by balding skin on the crown. These are difficult cases to repair because usually these patients are running out of hair to donate.

These days, many balding men choose to go to the other extreme and shave their scalps. I caution patients not to have a transplant if they are considering this because the transplant will leave a fine, linear scar in the back where the donor strip was repaired. Similarly, if the patient wants to keep his hair so short (burr-type cuts) that someone could see through the hair to the scalp, then I warn him that he should expect that the donor scar will likely show through in the back. This is an especially common problem for those in the military. On the other hand, if the patient wears his hair long enough that someone cannot see through to the scalp, the donor scar should not be apparent unless someone is picking through his hair.

With previous forms of transplants, such as minigrafts, repeat procedures were often necessary to hide the resultant “pluggy” appearance. With follicular units, this does not tend to be the case. However, depending on the area of the scalp the follicular units are moved to, additional procedures may be necessary for continued balding (a strong argument for the anti-balding medications) or for additional thickness. I will discuss more on the thickness available with transplants momentarily.

Right now I want to concentrate on the distribution in the recipient area. The patient must be cognizant of how his transplant might look in the distant future as he continues to bald. The transplanted hair is permanent hair, which should not be susceptible to the hair loss associated with normal male pattern baldness. If someone reaches seventy to eighty years of age, he may notice a generalized thinning of all of his hair. This is termed senile alopecia and is unrelated to male pattern baldness. Otherwise, the patient should expect to keep the transplanted hair permanently. This means that when designing a transplant, the surgeon must plan a mature hairline, one that looks normal no matter the patient’s age. Many men, especially the younger ones who see their friends’ low hairlines, will complain that these mature hairlines are too high for their liking. Unless they can find a medicine that stops their hair loss, they cannot forget about the inevitable progression of male pattern baldness.

Even if someone does find a medicine that works, there is no guarantee that it will always work or that the patient will not later develop side effects necessitating the discontinuation of that medicine. The more conservative the patient is willing to be with his hairline, the better. The hairline can always be brought further down at a later time, but the reverse is not true. If the transplant is performed throughout the front and top of the scalp behind a mature hairline, future procedures may not be necessary even as the patients continues to bald. It is very normal in nature to have somewhat of an isolated frontal forelock. If, however, the transplant is performed in isolated areas such as the sides of a receding hairline, one could imagine that it would be very necessary to have additional procedures performed behind the original transplant if the preexisting hair continues to disappear.

In my opinion, it is much, much, cosmetically more beneficial to concentrate initial procedures on the front and top of the scalp rather than the back (vertex). There are some sizeable, potential pitfalls associated with working in the vertex area. From a purely aesthetic standpoint, making the front and the hairline look good is much more helpful then filling in the vertex. There are plenty of men who hate their bald spots in back, but the greatest benefit from a transplant comes with the framing of the face by the hairline and the hair immediately behind it. What we see when we talk face to face with someone is many times more important then what we see when we are sitting behind him. I am repeating this one more time for emphasis—the patient should not even worry about the back before he has the front and top looking good!

Perhaps the greatest risk with performing transplants in the vertex area is the possibility of continued hair loss if medicines are ineffective or not used. If the bald spot in back is filled in, as the patient continues to bald, he will develop a doughnut or halo-shaped area of bald skin around the transplant. This never looks normal. It must be remembered that as the halo enlarges, the donor area is simultaneously diminishing. The patient will naturally feel compelled to return for transplants to fill in the bare area around the transplanted vertex, but he will eventually run out of hair to move. In addition, the more he moves to the back, the less he will have available to move to the front or top if he wants to later (and believe me, he will want to move it there if the hair in front and on top disappears).

There are several ways around this problem in the back if the patient is realistic. One is to diminish the size of the bald spot by transplanting in a crescent shape. If the patient does bald around this, it is much easier to keep up with the bare areas since the surgeon would just be replacing hair lost on the sides. Another option is to only transplant the vertex in a thinning rather than a thick fashion. This way, if the halo develops, it is a not as noticeable and it would take less hair to keep any new areas of hair loss filled in a similar thinning manner. The best option is for the patient to just not worry about the vertex. Instead, he could style his hair so as to comb it back over the bald spot. A few hairs can easily be placed into the bald spot to simply act as anchors for the hair combed back into it.

-Content Provided By Blaine Lehr, MD
Web: http://www.norwood-lehr.com
Email: lehr@norwood-lehr.com
IAHRS Recommended Hair Transplant Surgeon