Crown hair transplant: The hair whorl, direction and density

What are the crown and the hair whorl?

The crown is the area at the top and back of the head that looks round when viewed from above; in medical terms, it is also called the vertex. Here, the hair does not grow in a single direction but spirals outward from a center; this center is called the hair whorl. In everyday language, the whorl itself is often called the “crown” too, and people with two whorls are said to have a “double crown.”

The position and direction of the whorl are set in the womb, during the period when the hair follicles (the small structures that produce the hair) form, and they usually do not change throughout life. Even when hair thins, the direction in which each follicle emerges from the skin tends to stay the same; that is why, even if your crown has become sparse, the remaining fine hairs often still show where your whorl is and which way it turns.

In male pattern hair loss, thinning often begins at the temples and the crown; thinning at the crown is usually first noticed around the whorl. In female pattern hair loss, on the other hand, the thinning spreads more over the top of the head and around the part; the front hairline is often preserved.

Single whorl, double whorl and direction of rotation

Most people have a single whorl; viewed from above, the hair spirals outward from it either clockwise or counterclockwise. Clockwise rotation is reported more often, although the proportions vary depending on the group studied. Fewer people have two separate whorls.

The shape of your whorl does not, on its own, rule out a hair transplant; what matters is that the transplanted hair follows the pattern of your own whorl, not a general template.

Why do the grafts follow the direction of the whorl?

In a hair transplant, we place each graft (a small piece of tissue containing one or a few hairs) into a channel opened for it or with an implanter pen, at a set angle and in a set direction. A hair grows in the direction in which it emerges from the skin. At the front, the hair mostly emerges forward and to the side, in similar directions. At the crown, however, the direction changes step by step as you move around the whorl, so we adjust the placement direction accordingly across the whole area.

Following the direction correctly matters in three ways:

• Coverage: Hairs that lie in the same direction overlap and cover the skin better. Hairs that grow against the direction of the hair around them, on the other hand, may stand up or leave the skin between them exposed.
• Blending: There is often still some of your own hair at the crown; if the transplanted hair grows in the same direction, it blends in with it, and if it grows in the opposite direction, the hairs may cross each other and draw attention.
• Styling: How the hair lies and how it can be combed depends largely on the direction in which it emerges. It is not easy to correct the direction of transplanted hair afterwards.

Even in people who have not lost any hair, the skin at the very center of the whorl is often a little more visible, because the hairs there grow away from each other. That is why our aim is not to cover the center completely, but to create a spiral that resembles your own whorl.

If there is still some of your own hair in the recipient area, we place the grafts between these hairs, taking care not to damage them. Some of this hair may fall out temporarily in the weeks after the transplant (shock loss); hair that had already become thin may not always grow back. We describe the approaches we can use when transplanting between existing hairs on our hair transplant methods page.

Why might the crown need more grafts?

The same number of grafts often looks sparser at the crown than at the front. There are several reasons for this:

• The hair fans outward: Because the hair coming out of the whorl spreads in every direction, it does not overlap as much as it does at the front; the skin between the hairs can show more easily.
• It is lit from above: The crown is often seen from above; when light from the ceiling or the sun falls directly on the skin and reflects off it, sparseness becomes more noticeable.
• The area can be large: The crown is a dome-shaped area with no clear edges. When the diameter of a circular area doubles, its surface area quadruples; that is why a widening bare area adds more to the number of grafts needed than you might expect.

The thickness and curl of your hair, and the contrast between your hair color and skin color, also affect how dense the hair looks. That is why we do not give a fixed number of grafts for the crown in advance; we determine the number during the examination, based on the size of the area, your donor capacity and the density we aim for. We explain the factors that affect this calculation in our article on how many grafts are needed.

Hair loss at the crown may continue to progress

In male pattern hair loss, the bare area at the crown can widen over the years; in some people, it eventually merges with the receding area at the front. A hair transplant does not stop this process. The transplanted hair usually keeps the donor area’s lower sensitivity to hair loss; however, your own hair between and around the grafts may continue to thin.

That is why, when we plan a crown transplant, we think not only about the current bare area but also about how things may look in the future. If today’s bare area is filled in densely and the hair around it then thins, the transplanted area may look like an island surrounded by bare skin; fixing this may require transplanting into the surrounding area as well, which also draws on your donor supply.

It is not possible to say for certain in advance how far hair loss at the crown will progress; at a young age, this is even less certain. That is why we are more cautious when planning a crown transplant at this age. We discuss the role of age in the plan in our article on age and hair transplants. For thinning at the crown, medications are also among the options; whether they are suitable for you is determined by your doctor’s assessment, so do not start taking them on your own.

If donor hair is limited, which comes first: the front or the crown?

Follicles taken from the donor area are not replaced by new ones. If your donor capacity is not enough to fill both the front and the crown with the density you want, we need to decide which to prioritize. We explain what donor capacity depends on in our article on the donor area and donor dominance.

In this case, priority is often given to the front. The front hairline frames your face; it is the first thing you see in the mirror, and the first thing people notice when they face you. The crown, by contrast, is seen mostly from behind and above, and can be covered to some extent by the length of your hair and the way you style it.

Even so, this is not a rule that applies to everyone; we set the priority together, looking at:

• Where your hair loss started and how well the front has been preserved
• Your age and how fast your hair loss is progressing
• The density of your donor area and the characteristics of your hair
• Which area bothers you most, and how you wear your hair

For someone whose front is preserved and whose hair loss is at the crown, the crown may be the main target of the transplant. When donor hair is not enough, planning a lower density for the crown, limiting the transplant to part of the crown or leaving the crown for a later assessment are also among the options. We decide together during the examination which one suits you.

What do we not know yet?

• What determines the number and direction of whorls? This is not yet fully understood. Factors other than genes are also thought to play a role; it has been reported that even identical twins can have different directions of rotation.
• Is the whorl linked to handedness or personality? A link between the direction of rotation and handedness has been suggested, but later studies have not shown this consistently. Nor is there any scientific evidence supporting popular beliefs about having a “double crown.”
• What is the ideal density for the crown? There is no measure that applies to everyone; doctors’ approaches also differ.

How do we plan the crown during the examination?

We begin planning by examining your crown from above and from different angles; examining the scalp with a magnifying device (trichoscopy) can also help. Together, we look at:

• The position and number of your whorls and their direction of rotation, and the direction in which the remaining fine hairs emerge (if the crown is completely bare, the hair at its edges and old photos of you can also give an idea)
• The size of the sparse area, and whether there are follicles at its edges that have thinned but still produce hair
• The condition of the front, and whether a bare area has opened up between the two areas
• The density of your donor area and the characteristics of your hair
• The cause of the hair loss and how it is progressing

Not all thinning at the crown is male or female pattern hair loss; if another cause is suspected, we recommend that you first see a dermatologist for diagnosis and treatment.

If the transplant is in the crown area, your sleeping position in the first few nights may be different. We state the position that suits you in your written aftercare instructions; these instructions always take precedence over general information. At the crown, new hair may take longer to grow and thicken than at the front; this period also varies from person to person. We describe the process in our article on when transplanted hair grows.

Whether you are suitable for a hair transplant is determined during the examination, and results vary from person to person.