Plugs placed in the crown and vertex can be managed with PR & R as well. The main difference in managing plugs in this region is the determination of whether they should be removed entirely or simply reduced and the surrounding area grafted. The deciding factor is based on patient preference, the degree of crown vertex alopecia, and the amount of occipital donor supply. In cases where plugs are to be removed and no additional grafting is planned, punches size equal to or slightly larger than the plug should be used. When plugs are removed the residual scar that remains in the crown alopecia can be imperceptible or can remain with variable degrees of prominence. Patients requesting removal of plugs in the crown region need to be aware of the unpredictability of the plug excision scar. In most cases, removal of the plugs with additional grafting is a more desirable option since the remaining plug excision scars are well hidden by the recycled grafts.

When crown vertex plugs are to be reduced and recycled the eccentric plug excision technique is similar to that applied to the anterior hairline. Usually the most posterior 1 cm of plugs in this region are reduced, sutured, and recycled. Recycled plug grafts and newly harvested grafts from the occipital donor area are transplanted in areas of alopecia between the existing plugs and closed reduction sites. Instead of creating an irregular anterior hairline a gentle taper zone of grafts containing 1-3 hairs per graft is created extending posteriorly from the reduced line of plugs. This buffer of smaller grafts softens the transition between the bald non-transplanted posterior scalp and the transplants in the crown vertex area.

Case 3: (fig 6) 38-year-old male who was dissatisfied with the anterior and posterior view of his hair transplant. The approach to correct the posterior aspect of his forelock was to perform plug reductions and recycling to the posterior 3 cm of plugs and graft into the surrounding areas of alopecia. In addition a posterior zone of grafts was developed to soften the transition between the total alopecia of the occipital region and the dense appearance of the plugs in the mid crown. Approximately 25 plugs were reduced and 800 grafts containing 1-3 hairs were transplanted in two sessions. Results are seen 5 months following the second procedure.

Fig. 6. Results seen in a 38-year-old man who underwent two sessions of plug reduction and recycling to the crown, as well as grafting to the posterior fringe, to create a soft transistion to the vertex alopecia.

Case 4: (fig 7) 45-year-old male who had plug transplants to the frontal and anterior crown region. The anterior hairline was the first cosmetic priority for the patient and following two sessions of PR&R to this area he requested a similar approach to the posterior region. A leading edge of approximately 18 plugs were reduced, closed, and recycled. A posterior transition zone of 400 grafts containing 1-2 hairs per graft were placed posterior to the plug reduced area. The results are seen 10 months following this single session in the crown area. The patient is likely is undergo an additional procedure in this area

CLICK IMAGES FOR CLOSER VIEW			Fig 7. 45 year old male who underwent a single session of PR &R with grafting in the crown region. A pre existing scar on the left became more noticeable when the plugs were thinned out.
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