What if my baldness is more extensive on top?

37 year-old white male with anterior alopecia; the baldness on his crown has been previously eliminated with 2 "scalp lifts"

Same patient, after 4 anterior micrografting sessions

Larger areas of complete or nearly-compete hair loss on the top (crown) of the scalp may be removed surgically. This method has the benefit of saving the donor area for future grafting while covering the crown with the patient's natural hair-bearing scalp. However, only selected patients possess the ideal characteristics for such "scalp reduction" surgery:

*Well-defined bald area on top (crown)

*Tall donor area

*Stable, or slowly progressive, hair loss pattern

*Loose scalp

*More mature patient

*Willingness to undergo two or more scalp lift procedures and 3-4 anterior (frontal) grafting procedures

The terms "scalp reduction", "alopecia reduction" and "male pattern reduction" describe procedures whereby a relatively small elliptically shaped piece of bald scalp is removed via an incision in the midline or on one side of the bald area.

Extensive scalp lifting describes the successive combination or two procedures for removal of bald skin on the top and back of your scalp. After a preliminary vessel ligation, the first procedure, a "bilateral lift", removes a horse shoe-shaped area on the back and sides. With the second operation, a "bitemporal lift", the right and left sides of your hair-bearing scalp are united in the midline, eliminating the baldness on top.

Bilateral lift (lower right) followed by bitemporal lift (lower left) removes baldness on crown (top) or scalp, whereas 4 anterior (frontal micrograft sessions (upper right) provide considerable density along the hairline (upper left)

32 year-old white male with well-defined bald area on posterior crown

Same patient, after 2 extensive scalp lifts, showing complete elimination of the bald area on the crown

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Executive in mid-fifties with extensive (type VI) male pattern alopecia

Same patient, after 3 scalp lifts and 4 hair transplant sessions

Alternatively, SCALP EXTENSION may enable the surgeon to reduce the bald crown area. During an initial scalp reduction, immediately following removal of some of the bald scalp, the hair replacement surgeon inserts a flat, contractile device called an extender (developed by Patrick Frechet, a French hair surgeon). As this memory-possessing device gradually contracts over the next 30-45 days, it slowly elongates, and pulls together, the two hair-bearing sides of the scalp. When the extender is subsequently removed in a second operation, the surgeon can excise the remaining bald scalp while uniting the "stretched" sides of the scalp in the midline. For patients with extensive baldness, the use of one or two scalp extenders can be combined with extensive scalp lifting.

Drawbacks of scalp reduction and scalp lifting include: the generation of surgical scars, which must be subsequently covered with micrografts; the risk that the patient's hair loss may progress beyond the excised areas in years to come, necessitating further hair restoration procedures, and the need for an average of 5-6 procedures instead of 3-4, since the front of the scalp must still be grafted. Patients with a fair amount of remaining hair may not yet be candidates, as they may not wish to remove thinning hair that may nonetheless remain for another few years on the crown of the scalp.