A Method for Evaluating and Treating the Temporal Peak Region in Patients with Male Pattern Baldness

IN 1949 Dr. John Hamilton¹ published an article that demonstrated conclusively that the extent and development of male pattern baldness was dependent on the interaction of three factors: androgens, genetic predisposition, and age. Shortly thereafter, in 1951 he published another article that determined the incidence and degree of male pattern baldness in 1000 men at various ages.² In this article, he described male pattern baldness evolving from a Type 1 (no signs of baldness) to an extensively bald Type VII individual. Norwood³ subsequently went on to further delineate the states of baldness (Figure 1) and described the process as follows:

TYPE I: There is no recession or very minimal recession at the frontotemporal region.
TYPE II: Triangulated areas of recession which tend to be symmetrical are present. These bare areas extend no farther posteriorly than approximately 2.0 cm anterior to a line drawn in a coronal plane between the external auditory meatus. The hair at the midfrontal area is sparse, but the extent of baldness is much less than in the frontotemporal areas.
TYPE III: There are deep frontotemporal recessions, which are usually symmetrical. These recessions extend further posteriorly than a point that lies approximately 2.0 cm anterior to a coronal line drawn between the external auditory meatus. The hair is sparser than a Type II at the midfrontal area.
TYPE III VERTEX: Hair is lost primarily at the vertex. The temporal recession is not as deep as a Type III; it is more like a Type II recession.
TYPE IV: The temporal recessions are more severe than a Type III and there is absence of hair beginning at the vertex. The severe recessions and the vertex baldness are separated by a band of fairly dense hair that extends across the top of the head.
TYPE V: The vertex and recession baldness become more severe, and the band of hair across the crown is more narrow and sparse.
TYPE VI: The band of hair across the top of the head is now gone and the baldness is complete, leaving a horseshoe shape of remaining hair along the sides of the head.
TYPE VII: The male pattern baldness is in its most severe form. All that is left is a very narrow fringe of donor dominant hair in a horseshoe pattern.
VARIATIONS: There are numerous variations of these most common presentations, but the above forms are by far the most commonly observed.

Figure 1. Standards of classification for the most common types of male pattern baldness. (From Norwood OT: Classification and incidence of male pattern baldness. In Norwood OT, Shiell RC, editors: Hair transplant surgery, Springfield, Ill, 1984 Charles C. Thomas. Reprinted with written permission.)

NORWOOD STUDIES

Figure 2. In Norwood's study the incidence of Type III, IV, V, VI, VII increased steadily with age.

Figure 3. When Norwood's study was compared to Hamilton's, the figures were similar, but Hamilton's percentages wer consistently higher by 20-30%.

In both of these studies, the process primarily described was the evolution of what was occurring at the top of the head. In neither description is there mention of the gradual recession of the temporal peaks (the triangular tufts of hair that project into the lateral forehead region) and the area immediately posterior to them. Therefore, the thrust of this article is to describe the gradual, thinning process of this very important region and to demonstrate a technique to effectively treat it.

A SYSTEM FOR GRADING TEMPORAL PEAK BALDNESS

Figure 4. Grade A Temporal Peak Baldness. This grade demonstrates vibrant hair at the temporal peaks and the area immediately posterior to it with no signs of thinning.	Figure 5. Grade B Temporal Peak Baldness. The edge of the temporal peak begins to slightly recede posteriorly and the entire peak begins showing a very slight diffuse thinning. When the hair is dry there are no signs of thinning posterior to the temporal peaks, but when the hair is thoroughly soaked with alcohol or water, the extent of future thinning can start to be observed.

Grade B Temporal Peak Baldness
The edge of the temporal peak begins to slightly recede posteriorly and the entire peak begins showing a very slight diffuse thinning (Figure 5). When the hair is dry there are no signs of thinning posterior to the temporal peaks, but when the hair is thoroughly soaked with alcohol or water, the extent of future thinning can start to be observed.

Grade C Temporal Peak Baldness
The peaks have receded significantly posteriorly and the area remaining in the peak is overtly thin (Figure 6). Upon thoroughly wetting the hair, the extent of thinning posterior to the peak is fairly well delineated.

Figure 6. Grade C Temporal Peak Baldness. The peaks have receded significantly posteriorly and the area remaining in the peak is overtly thin. Upon thoroughly wetting the hair, the extent of thinning posterior to the peak is fairly well delineated.	Figure 7. Grade D Temporal Peak Baldness. The peaks are completely degenerated and overt baldness has occurred posterior to the temporal peaks. The vellus hair that remains can easily be seen with 3.5x loupe magnification.

Grade D Temporal Peak Baldness
The peaks are completely degenerated and overt baldness has occurred posterior to the temporal peaks (Figure 7). The vellus hair that remains can easily be seen with 3.5X loupe magnification.

Importance of the Temporal Peaks
Why is it important to study this progression and to observe the temporal peak area of the patient presenting to your office for hair restoration surgery? It is the author's view that when the scalp is restored atop the head and the temporal peaks are ignored, there becomes a cosmetic distortion. This disharmony occurs very frequently in individuals who wear hairpieces. In these individuals there is a prodigious amount of hair at the top of the head, but none at the temporal peaks. The human eye subconsciously knows that when a significant amount of hair is on top of the head, hair usually exists at the temporal peak. The cosmesis is thus unnatural and is usually a "dead give-away" that the individual is wearing a hairpiece.

Because of this important relationship between the top of the head and the temporal peaks and because the vast majority of hair restoration surgeons ignore this region, the author describes a technique for evaluating and rejuvenating the temporal peak areas with surgical technology.

Scribing Technique for Temporal Peak Restoration
Because the temporal peaks recede in the vast majority of men experiencing male pattern baldness, it is critical to evaluate this area on all patients presenting for evaluation. As alluded to earlier, this can simply be done by thoroughly wetting the entire head with alcohol or water and then slightly roughing up the hair with a back-and-forth motion in the area being evaluated. This idea of wetting the head may seem ludicrous to a beginner in hair restoration surgery, but if the head is thoroughly soaked on every single patient seen in consultations, the surgeon will soon realize the invaluable information that becomes available to him or her. In a short amount of time, it becomes relatively easy to obtain a fair estimate of future baldness in the majority of patients. Once this soaking is completed, the surgeon should scribe the extent of future baldness that is likely to occur posterior to the temporal peak and the whole scalp in general (Figure 8).

Figure 8. After thoroughly wetting the head with alcohol, the frontal hairline, temporal peaks and the area of future posterior progression must be scribed. The further anterior the hairline is made, the more anterior one should come with the temporal peak reconstruction.	Figure 9. It is critical to measure the distance between the temporal peak and the eyebrow on the first side and then make sure that the same distance is present on the opposite side. The surgeon should then stand away from the patient to make certain that an asymmetry does not exist.

The frontal hairline is first scribed with a surgical marker. Once the frontal hairline is completed, the areas of the temporal peaks can be scribed. The temporal peak drawing can easily be done by using 3.5X expandable field loupes and studying the vellus hair in the region. The old temporal peak is simply reconstructed from the vellus hair pattern existing at the region. In many patients the surgeon may want to move the temporal peak a bit posteriorly, from where it was previously, to coordinate with the placement of the frontal hairline. The more conservative the frontal hairline placement, the more conservative should be the temporal peak placement. Once the peak is scribed, a line is drawn superiorly to meet the frontal hairline and an angle is formed at the temporal recession. The author usually softens the temporal recession angle with one-haired grafts as seen by the rounded line on the photograph (Figure 8).

Once one temporal peak drawing is completed, it is critical to measure the height of this new temporal peak high point in relationship to the eyebrow (Figure 9). After this is performed, this same measurement, in centimeters, should be carried over to the other side. This is one of the most important aspects of the technique because it is very easy to create asymmetry. Thus, it is critical to step back from the patient and look at the high points of the temporal peaks to make certain that there is relative symmetry.

Upon completion of scribing the temporal peaks, the areas of future posterior hair loss, the donor site and the frontal hairline, it is time to begin the surgical procedure.

SURGICAL TECHNIQUE FOR FOR TEMPORAL PEAK RESTORATION

The patient is then taken to the operatory and made to lie prone into a Pron Pillo. It is important that a portion of the donor site be taken from an area where hair is not coarse. The donor site is then field blocked using a combination of 1 % lidocaine hydrochloride with 1 : 100,000 epinephrine and 1/4% bupivicaine. An elliptical donor strip is then excised away with a #10 Bard Parker blade (BD Medical Systems, Franklin Lakes, NJ). The area is sutured with 2.5X magnification using a 0-PDS II in the galea and a 4-0 chromic suture cutaneously. The surgical assistants take the donor strip and excise away the finest one-haired follicular units possible. This is done with the help of a 10X stereoscopic microscope.

The patient is now turned in the supine position and a field block is performed anterior to the hairline and temporal peaks and posterior to the line demarcating the extent of possible posterior progression of the temporal peaks. In this area, dots 1 cm apart are made with the surgical marker. The author injects 2% lidocaine hydrochloride with 1 : 100,000 epinephrine into the dots with a 30-gauge needle, waits five minutes, then injects 2% lidocaine hydrochloride with 1 100,000 epinephrine in between the dots. Bupivicaine in. a 1/4% strength is injected in behind the field block for longer-lasting effects. A very superficial tumescence is then performed to the temporal regions with 1 300,000 epinephrine through a 25 gauge needle. This should be performed superficially as to avoid the supertemporal artery and its posterior branch.

At this point in the procedure, it is extremely important for the surgeon to use loupe magnification, preferably 3.SX strength with an expandable field.⁴ This magnification strength is most critical in those patients with early thinning of the temporal peak because the goal is to make tiny 1.0 mm incisions in between the existing hair follicles with a 1.0-mm spear blade (Ellis Instruments, Madison, New Jersey). Normally, the author starts at the most inferior area of the temporal peak then works superiorly so that blood does not obscure the field (as- would happen if one started superiorly and worked inferiorly).

The most important aspect of the incisional technique is to make sure the blade is pointed superiorly at an extreme angle. The surgeon should lay the dorsum of the hand on the cheek, which will allow him or she to push the blade at a 10° or less angle (Figure 10). There is no question that the proper positioning of the hand is by far the most important aspect of the surgical technique. If the incision is made at a steeper angle, the aesthetic result will be unacceptable to the patient because the hairs will stick out of the head instead of shingling in a downward fashion. It is critical to follow the same anterior-posterior direction of the existing or vellus hair that is remaining in the treated areas. The author normally makes approximately 20 incisions per square centimeter, which will achieve a density of 20 hairs per square centimeter throughout the temporal peak. If further sessions are performed, these areas can be further treated depending on whether the aesthetics are satisfactory after one session.

Once the incisions have been made in between the existing hair follicles and into the newly designed temporal peaks, the insertion of the grafts is performed. It is critical that only one-haired follicular units be placed into this area and these grafts should preferably be the finest hairs of the donor harvest. If an individual has coarse hair, it is prudent to take the donor strip from the upper nape hair, where fine, permanent hairs can usually be harvested without creating noticeable scarring. If there is only coarse hair and no fine hair, it may be prudent not to perform temporal peak restoration and just keep the frontal hairline higher to coordinate with the existing temporal peaks.

The individual placing the graft should use at least 2.SX loupe magnification so that increased accuracy and less trauma to the graft is availed to the patient. Upon completion of all of the grafts being placed, a circumferential dressing is placed on the head. The following day the dressing is removed and the patient's head is washed.

Figure 10. When making the 1.0 mm spear blade incisions, it is very important to lie the back of the hand along the patient's head. This allows the surgeon to achieve the sharp 10° angle that is needed in order to create natural cosmesis in this region.	Figure 11. When the frontal hairline is approximately 0-4 cm in front of a line drawn in a coronal plane, between the external auditory meatus, there is no need for temporal peak reconstruction.

DISCUSSION

The key to preventing this aesthetically unpleasing disharmony from occurring is to take one of two approaches. The first approach is to never graft the temporal peaks and routinely keep the hairline extremely high. Conversely, if the surgeon is reconstructing the hairline so that the distance from the hairline to the eyebrows is approximately one third of the face,⁵ the temporal peak areas should be evaluated and most likely treated with one-haired follicular units. The further the hairline is moved anteriorly, the further the temporal peak should be moved anteriorly and vice-versa. If no fine hair can be found in the donor area, it may be prudent to keep the frontal hairline high and not reconstruct the temporal peaks at all.

In general, if the frontal edge of the hairline is placed approximately 0-4 cm in front of a line drawn in a coronal plane between the external auditory meatus, there is no need for temporal peak reconstruction (Figure 11).

If, however, the hairline is placed up to approximately 4-6 cm anterior to a line drawn in a coronal plane between the external auditory meatus, the temporal peaks should be reconstructed to half the distance to where they were at youth, which is determined by the vellus hair pattern (Figure 12).

Figure 12. When the hairline is moved to approximately 4-6 cm anterior to a line drawn in a coronal plane, between the external auditory meatus, the temporal peaks should be reconstructed approximately one halfway to the point of youth (which can be described by the vellus hair growth).	Figure 13. When the hairline is moved to a point that is approximately 6.0 cm to 8.0 cm anterior to a line joining the external auditory meatus, the temporal peak shouild be fully reconstructed in most cases.

Conversely, if the hairline is placed from approximately 6 cm to 8 cm anterior to a line drawn in a coronal plane, between the external auditory meatus, the temporal peaks should be fully reconstructed (Figure 13). The frontal edge of the hairline should never exceed a point where the face is divided into thirds.⁵

When performing these reconstructions, the author averages 20 incisions per square centimeter and has found the density to be satisfactory in most patients due to the shingling effect of the overlapping hair shafts. If additional sessions are performed on top of the head, this address can be further enhanced if further density is required.

Figure 14. (A)A patient with Grade C Temporal Peak Baldness before surgery, before lines were scribed. (B)Same patient with drawings on the head. (C)After one session of one-haired grafts inserted at a 10° angle reconstruction the temporal peak with approximately 20 hairs per square centimeter. This stabilizes posterior progression of temporal peak baldness, which would have made this result look worse with time. During a second session to the frontal hairline, further reinforcement of the temporal peak could take place.

If hair restoration surgeons start evaluating on their previous patients the relationship of the temporal peaks to the frontal hairline, it can almost be guaranteed that a definite cosmetic disharmony will be noted in many of these individuals. The physician will be doing these individuals a tremendous service by performing a session of one-haired follicular units to reconstruct this crucial area. A more aesthetic harmony will thus result (Figures 14 and 15).

A SYSTEM FOR GRADING TEMPORAL PEAK BALDNESS

Figure 15. A)A Patient with Grade D Temporal Peal Baldness. (B)After two sessions, the frontal area and temporal peak regions have been reconstructed to create a proper cosmetic balance.

Likewise, if a patient presents to the hair restoration surgeon's office with type VII male pattern baldness, is wearing a hairpiece, and is also found to be a noncandidate for a full restoration, it is appropriate to suggest to that patient that he or she may want to undergo a session of one-haired follicular units to the temporal peaks and nothing else. This patient would, of course, still wear the hairpiece. This simple maneuver can transform a hairpiece from looking aesthetically unpleasing to extremely natural.

SUMMARY

REFERENCES

COMMENTARY

In the past few years, I find that I am transplanting this anterior temporal region in approximately 30% of my male patients and in over 90% of my female patients. I think it is important to have an "age cutoff" under which one would not transplant in this area, so that extensive alopecia progression and diminished safe donor stores don't leave these transplanted hairs isolated in an awkward location with no supporting hair behind or above it. For me, this cutoff is somewhere between 35 and 40 years of age.

Each surgeon develops his or her own unique approach to this area, but I agree strongly with Dr. Brandy's point to make the entry angle of the graft very acute and flat with the skin, and also the recommendation to augment the thinning hairs that are present, but not to strike out into new ground anteriorly, as this carries the risk of creating an unnatural result. The only way I differ from Dr. Brandy's approach is that I don't initially transplant with the density he does, but prefer to divide the task over 2-3 sessions so that I can make artistic touches as I watch things develop. I also routinely use some two-hair follicular units behind the front one-haired ones, as I think they provide a nice density to the work done. With coarse, dark hair I would also confine my grafts to the one-hair F.U.'s only.

One final valuable tidbit: while I also love using the dark blue Pilot Marker for all of my transplant work (and in fact learned of it from Dr. Brandy many years ago), I had two females with fair white skin who developed tiny blue tattoo dots at the anterior border of the transplanted temporal hairs, caused by needle incisions through the Pilot Marker ink. These obviously needed to be punched out and closed with fine nylon sutures. Since that time, in the temple area I have always placed my Pilot Marker outline anterior to where I actually place the grafts. It is important, when showing the patient this outline, to tell him or her that the hair will be behind this line, and that the line being drawn in this way may make it look as if the hair is being transplanted further anterior than will actually be done.

MICHAEL BEEHNER, MD
Saratoga Springs, NY