The Patient's Guide to Hair Restoration - New Hair Institute

A special situation exists when transplanting patients with a persistent
frontal forelock. The density of a forelock is often close to the patient’s original
frontal density, making it impractical to place additional hair into this area.
Although the forelock tends to be very tenacious in some families, it still may
show a slow rate of loss. If lost, a gap would be left in the central portion of the
frontal hairline, making a second procedure necessary.
Goals for the Second Session
The most common reason one plans a second procedure is to enhance
the appearance of fullness. Although follicular units may have been placed as
close as possible in the first session, after healing has occurred, additional units
can usually be added between the first grafts. Another reason for a second
session is to follow the progression of the hair loss. This is often performed in
conjunction with increasing the fullness of the previously transplanted areas.
Usually at the second session, more density is added to the cosmetically critical
front and top of the scalp; the transplant is then extended further back to
compensate for hair loss that has occurred since the first procedure or to add
further areas of coverage, knowing the front and top are secure.
A third goal of the second session is to further refine the hairline. If the
frontal hairline was properly placed in the first procedure, major changes in the
hairline should not be necessary. However, subtle adjustments in the hairline are
often performed during the second session. These refinements include: making
the frontal hairline more dense, increasing the irregularity of the transition zone,
flattening the hairline or blunting the corners, lowering the hairline, establishing a
widow’s peak, or restoring the temples.
The main decision for the second session is whether to transplant the
crown, for once treatment of the area has begun, it can place significant
demands upon the donor supply. Many insightful patients who are significantly
bald realize that crown coverage is not realistic and are satisfied using styling
techniques in conjunction with creatively distributed transplants to maximize
coverage in the lightly or non-transplanted areas. This is especially true in older
patients. On the other hand, a substantial number of people are very bothered by
their bald crown; these patients may be devastated when hair loss occurs in the
front. For most, crown balding is much less important when compared to the
prospect of losing frontal hair, the entire frame of the face. Crown balding or
thinning is also likely to become more acceptable as the patient ages (as will his
hair loss overall). The physician then must be able to assist the patient in setting
priorities that will be appropriate over the long term.
If extensive balding is likely and there is only a modest donor supply, it is
usually best to treat the crown as an extension of the top, rather than as an
isolated region, to ensure that the patient will not be short of donor hair. This is
the reason that the treatment of the crown in a young patient should be delayed.
By the second session, the surgeon is often able to assess if there is enough
coverage of the front and top to attempt the crown. It is important to emphasize
that when crown coverage is considered in the second session, the transplanted
hair in the front and top has already been allowed to grow, so that its cosmetic
impact can be assessed. The patient can thus make his own aesthetic judgments