Norwood 4: What It Looks Like

Norwood 4 shows significant frontal recession paired with a clearly enlarged bald area at the crown. A bridge of thinning hair still separates these two zones, but the overall pattern is unmistakably advanced, typically requiring 2,500 to 3,500 grafts for restoration.

Identifying Norwood 4 Hair Loss

The Defining Visual Characteristics

Norwood 4 represents a meaningful step beyond Norwood 3 and 3V in both frontal recession and vertex loss. The key features that define this stage:

Frontal recession: The hairline has receded well beyond the original temporal points. The M-shape from earlier Norwood stages has deepened, and the central forelock, while still present, may be thinning. The overall frontal hairline sits much higher on the forehead than it did during early adulthood.

Vertex expansion: The bald spot at the crown has grown substantially. Where Norwood 3V shows the beginnings of vertex thinning, Norwood 4 features a clearly defined bald or near-bald area at the crown, typically 6 to 8 cm or more in diameter.

The bridge zone: A band of moderately dense hair still connects the frontal hair to the hair along the sides. This bridge is one of the most important features at Norwood 4 because its preservation (or loss) determines whether the pattern remains Norwood 4 or progresses toward Norwood 5.

Side and back density: The donor area (the permanent zone along the sides and back) remains stable and dense in classic pattern hair loss. This is the reservoir from which transplanted grafts will be harvested.

How Norwood 4 Differs From Adjacent Stages

Understanding where Norwood 4 sits relative to neighboring stages helps with accurate self-assessment:

Norwood 3V vs. Norwood 4: At Norwood 3V, the vertex shows thinning but not full balding, and the frontal recession is moderate. At Norwood 4, the vertex area is clearly bald or nearly so, and frontal recession is more advanced. The transition from 3V to 4 represents a significant increase in total area affected.

Norwood 4 vs. Norwood 5: At Norwood 4, the bridge zone between frontal and vertex loss is still intact (though thinning). At Norwood 5, this bridge has broken down, and the frontal and vertex bald areas begin to merge.

For the full classification system and visual comparisons across all stages, see our Norwood scale complete guide.

Self-Assessment at Norwood 4

To evaluate whether you are at Norwood 4, examine your hair in well-lit conditions using a combination of a bathroom mirror and a hand mirror:

1. Front view: Your hairline sits significantly above where it was in your early twenties. Deep recession at both temples is obvious. The central forelock may be thinner than it used to be.
2. Top-down view: Looking from above (or taking a photo from directly overhead), you can see a distinct bald patch at the crown separated from the frontal recession by a band of hair.
3. Side profile: The overall volume of hair on top of the head is noticeably reduced compared to the sides.
4. Bridge check: Run your fingers across the mid-scalp zone connecting your frontal hair to the crown area. If this region still has moderate density (even if thinning), you are likely at Norwood 4 rather than 5.

Graft Requirements at Norwood 4

Total Graft Count

Norwood 4 typically requires 2,500 to 3,500 grafts for comprehensive restoration. This is a significant increase from Norwood 3 (1,500 to 2,200) and Norwood 3V (2,000 to 2,800), reflecting the larger combined area that needs coverage.

The total count depends on several factors:

• Hair caliber: Thicker individual hairs provide more visual coverage per graft. Patients with coarse hair may achieve satisfactory results with fewer total grafts.
• Hair-to-scalp color contrast: Low contrast (dark hair on dark skin, light hair on light skin) makes the result appear denser at any given graft count.
• Curl pattern: Wavy or curly hair covers more surface area per strand.
• Follicular unit composition: Multi-hair follicular units (2 to 4 hairs per graft) provide proportionally more coverage.
• Desired density: Targeting 35 to 45 grafts per cm2 is typical for a natural-looking result, though native unaffected density is often 50+ per cm2.

Strategic Graft Distribution

At Norwood 4, the surgeon must allocate grafts across a larger area than earlier stages. A typical distribution plan might look like:

Many surgeons recommend prioritizing the frontal hairline because:

• It frames the face and defines appearance in most social interactions
• The crown is more responsive to medical therapy
• A well-designed hairline with lower density at the crown is more natural-looking than the reverse

Single Session vs. Multiple Sessions

Whether 2,500 to 3,500 grafts can be completed in one session depends on the technique:

• FUE: Up to 5,000 grafts per session with a 0.7 to 1.0mm punch. A Norwood 4 procedure comfortably fits within a single session.
• FUT: Up to 4,000 grafts per session via strip excision. Also achievable in one session for most Norwood 4 patients.
• DHI: Up to 3,500 grafts per session using the Choi implanter pen. The upper end of the Norwood 4 range approaches the single-session limit.

Some surgeons prefer splitting the procedure into two sessions (hairline first, crown 6 to 12 months later) to achieve higher density in each zone. This approach also allows the patient to evaluate the first session's results before committing to the second.

Treatment Options at Norwood 4

Surgical Options

Hair transplant surgery is the most effective method for restoring visible coverage at Norwood 4. The three primary techniques each have distinct advantages:

FUE (Follicular Unit Extraction): Individual grafts are extracted with a 0.7 to 1.0mm punch. Recovery takes 7 to 10 days. No linear scar, which is advantageous for short hairstyle wearers. Graft survival rates of 90 to 95% are standard. In the US, expect $4 to $6 per graft ($10,000 to $21,000 total for Norwood 4). Turkish clinics typically charge $1 to $2 per graft.

FUT (Follicular Unit Transplantation): A strip of donor tissue is removed and dissected into individual follicular units. Recovery is 10 to 14 days. Leaves a linear scar concealable under hair longer than a #3 guard. Graft survival rates match FUE at 90 to 95%. Often slightly less expensive per graft than FUE.

DHI (Direct Hair Implantation): Uses a Choi implanter pen that loads and places grafts in a single motion. Recovery is 7 to 10 days. Up to 3,500 grafts per session. Offers precise control over angle, depth, and direction, which is particularly valuable for recreating natural crown whorl patterns.

For detailed pricing at this stage, see our Norwood 4 transplant costs guide.

Medical Therapy (Essential Complement to Surgery)

At Norwood 4, medical therapy is not optional, it is a critical component of any restoration plan. Without medication to halt ongoing loss, the areas surrounding your transplanted grafts will continue to thin, eventually undermining the surgical result.

Finasteride (1mg daily):

• Halts further hair loss in 80-90% of men
• Produces regrowth in approximately 65%
• Particularly important for stabilizing the bridge zone between frontal and vertex loss
• Sexual side effects occur in 2-4% of men
• Should ideally be started before surgery and continued indefinitely

Minoxidil (5% twice daily):

• Produces 40-60% moderate regrowth
• Most effective at the vertex (crown)
• Can be applied to the transplanted area starting 2 to 4 weeks post-surgery
• Must be used continuously; gains reverse upon discontinuation

Combined protocol: Using both finasteride and minoxidil together often produces better results than either alone. The medications work through different mechanisms (DHT reduction vs. vasodilation and growth cycle extension) and their effects are complementary.

Non-Surgical Alternatives

For patients who are not ready for surgery, prefer to avoid it, or want to explore other options:

PRP (Platelet-Rich Plasma): Injections of concentrated growth factors from your own blood. Sessions every 4 to 6 weeks initially, then maintenance every 3 to 6 months. Cost: $500 to $1,500 per session. Best as a supplement to finasteride and minoxidil, not a standalone treatment at Norwood 4.

Low-Level Laser Therapy: FDA-cleared devices deliver therapeutic light wavelengths to the scalp. Modest evidence base compared to pharmaceutical treatments. Best used as an adjunct.

Scalp Micropigmentation (SMP): Cosmetic tattoo that creates the appearance of a closely-shaved head or adds the illusion of density to thinning areas. Does not restore actual hair but can dramatically change the visual presentation. Costs $1,500 to $4,000 for 2 to 3 sessions.

Hair systems: Modern hair systems (sometimes called toupees or hair pieces) have improved significantly in realism. They attach to the scalp via adhesive or clips and can be styled, washed, and worn during exercise. Not a permanent solution but can provide immediate coverage.

Donor Area Considerations at Norwood 4

Supply and Demand Balance

The 2,500 to 3,500 graft requirement at Norwood 4 represents a more substantial draw on the donor area compared to earlier stages. With a typical lifetime supply of 6,000 to 8,000 extractable grafts, a Norwood 4 procedure uses 30 to 60% of available reserves.

This makes donor preservation particularly important. Patients at Norwood 4 should discuss with their surgeon:

• How many grafts will remain available for future sessions
• Whether there is a realistic scenario where additional surgery might be needed
• The role of medication in reducing future surgical demand

Assessing Donor Quality

A thorough donor assessment at Norwood 4 should evaluate:

• Density across the permanent zone: Measured in follicular units per cm2 at multiple points
• Miniaturization: Any thinning within the donor area may indicate diffuse alopecia rather than classic pattern loss, which can affect graft longevity
• Scarring or prior procedures: Previous surgery (FUT scars, for example) affects available supply
• Scalp laxity: Important for FUT planning

Living With Norwood 4: Practical Considerations

Styling Strategies

While pursuing treatment, several styling approaches can minimize the visual impact of Norwood 4:

• Shorter cuts: A close crop or buzz cut reduces the contrast between areas of density and thinning
• Matte products: Styling products with matte finishes make hair appear thicker than glossy products
• Hair fibers: Keratin-based concealers can add the appearance of density, particularly in the bridge zone and vertex
• Avoid comb-overs: Long strands swept across bald areas rarely look convincing and often draw more attention to the loss

Psychological Impact

Hair loss at Norwood 4 is significant enough that most men experience some degree of self-consciousness. Research consistently shows that hair loss can affect confidence, social interactions, and self-image. Acknowledging this impact is important, and seeking treatment is a reasonable response.

If hair loss is causing significant distress, speaking with a mental health professional alongside pursuing restoration options is a valid and helpful approach.

Planning Your Norwood 4 Restoration

Establishing a Timeline

A practical restoration timeline at Norwood 4:

1. Month 0: Begin finasteride and minoxidil. Document your baseline with photographs.
2. Months 1 to 3: Schedule consultations with 2 to 3 board-certified hair restoration surgeons.
3. Months 3 to 6: Evaluate medication response. Some patients see enough improvement to adjust their surgical plan.
4. Month 6 to 12: Undergo transplant procedure. By this point, medication has stabilized your loss pattern and the surgeon has a clearer picture of your trajectory.
5. Months 12 to 24: Monitor transplant growth (full maturity at 12 to 18 months) while continuing medication.

Getting Started

If you are unsure whether you are at Norwood 4 or want a preliminary assessment of your treatment options, the free AI evaluation at myhairline.ai can analyze your hair loss pattern, estimate your Norwood stage, and provide guidance on graft requirements and treatment approaches. This can help you prepare informed questions before your first surgical consultation.

Frequently Asked Questions

What does Norwood 4 look like?

Norwood 4 features significant frontal recession beyond the Norwood 3 stage combined with a clearly enlarged bald spot at the vertex (crown), typically 6 to 8 cm or more in diameter. A band of moderately dense (but often thinning) hair still separates the frontal and vertex loss zones. This bridge between the two areas is a defining feature of Norwood 4, as its breakdown marks the transition to Norwood 5.

How many grafts at N4?

Norwood 4 typically requires 2,500 to 3,500 grafts for comprehensive restoration covering both the frontal hairline and the vertex. The exact count depends on hair characteristics (caliber, color contrast, curl), desired density targets, and how aggressively the surgeon plans to treat the crown versus relying on medication for that zone. Single-session procedures are feasible with all three major techniques (FUE, FUT, DHI).

Best treatments?

The most effective approach at Norwood 4 combines hair transplant surgery (2,500 to 3,500 grafts) with ongoing medical therapy. Finasteride 1mg daily halts further progression in 80-90% of men, which is critical for preserving the bridge zone and native hair surrounding transplanted grafts. Minoxidil 5% twice daily adds 40-60% moderate regrowth, particularly at the crown. Starting medication before surgery stabilizes the loss pattern and can improve overall outcomes.