RECREATING THE CROWN WHORL - Reprinted from Microtechnology 2000 Vol. 2: 1 Nov 2000

By Robert H. True, MD, MPH, ABHRS -New York

A great hair transplant can accomplished when the surgeon is able to appreciate and reproduce the subtle variations in the architecture of the hair on different parts of the scalp. Appropriately, much has been written about reconstruction of the hairline zone, as it is widely appreciated that this is critical to achieving a "natural" result. Although written about much less frequently, reconstruction of the crown whorl is of nearly equal cosmetic importance.

All people naturally have a whorl or cowlick in their hair on the crown of the head. The whorl is usually located off center to the right side, however there are many variations in location and some people even have two whorls.
The whorl is a spiral in which the hair direction changes 360°. The hair on the front of the scalp is generally oriented forward. The hair direction begins to turn toward one side on the mid portion of the scalp, and on the back (tonsure) the hair faces toward the rear. The whorl is the center of this critical change in hair direction. Its spiral actually extends to involve the majority of the crown of the scalp. For most patients the whorl is actually 4 to 5 inches in diameter.

Not only does the hair change direction 360° in the whorl, the angle at which the hair emerges from the scalp decreases. Thus, the hair does not stand straight up in the center. Rather, it lays flat along the curved contour of the crown. In some ways, reproducing the correct spiral angle while at the same time creating the appropriate "flatness" angle is more technically demanding for the surgeon than a hairline

Recreating the whorl is essential to treating crown baldness. A well constructed whorl is as much a credit to the surgeon's art as an elegant hairline. Both must be approached with equal finesse and have comparable cosmetic value.
The center of the whorl requires single hairs just like edge of the hairline. The receptor sites must properly rotate in the spiral and be properly angled across the curve of the scalp to make the hairs lie flat to the scalp.

Because it is rarely possible to reproduce high density in a crown restoration, it is critical to use only microscopically prepared single follicular unit grafts. Thus with lower density there will be no "plugginess" or unnatural appearance.
Some transplant surgeons will not treat the crown, arguing that the limited donor supply is best focused on the front. However, this is a necessity only for patients with an exceptionally limited donor supply. Most patients with advanced Class 5A to 6 baldness do have sufficient supply to treat some or the entire crown as long as the whorl is reconstructed. The whorl is necessary to produce the layering effect of hair upon hair required for cosmetic coverage.

The crown should not be treated without rebuilding the whorl. To do so would be like restoring the front without a hairline. I also believe that in cases where the doctor and patient make the decision to treat the front part of the balding pattern only, the result will look much better from the rear when the restoration has been carried back far enough that it includes the upper half of the whorl. When this is achieved, the hair drapes much better onto the crown.

Since the mid 1990's scalp reduction has fallen out of favor with hair transplant surgeons. One of the major problems with scalp reductions is that they change the hair direction in the crown, making the hair fall away from the middle of the crown. In other words, they eliminate the whorl. Moreover, it was very difficult to successfully recreate a whorl with transplants once reductions had been done. The center could not be placed in the correct location and the hair direction could not be matched to the remaining native hair on the margin of the scalp reduction.

Without scalp reductions, the size of the area remains large. However, because the native hair direction is reproduced in a carefully reconstructed whorl the cosmetic result is more natural and the coverage is comparable.

The decision about where to put the hair is one that needs to be explored thoroughly with each patient, It is possible to use up all of the donor hair in creating a very thick frontal restoration. At the other end of the spectrum the hair can be evenly distributed throughout the entire balding area in low to moderate density. Another choice is to treat the entire scalp, but place greater density in the front and top, lesser to the crown.

Special care must be taken when treating a young patient whose crown is just beginning to thin in the center. Further treatment will be needed as the balding progresses. Control can often be achieved with Propecia® and/or minoxidil preparations. However, even in these cases the surgeon has to anticipate future needs and make sure that an appropriate amount of the donor supply is retained to complete the crown restoration.

While some patients may choose partial restoration focused on the front and top only, those who want full head coverage or those who want the back edge of their frontal restoration to look natural, may achieve their goal in the hands of a transplant surgeon skilled in whorl reconstruction.