Hairline lowering or advancement, also known as forehead reduction, is a procedure that has been adapted and honed from scalp reduction and flap techniques. Although the high hairline can be found in both males and females of all races and ethnicities due to various diagnoses, hairline advancement is best suited for individuals, typically females, with a lifelong history of a high hairline and no familial or personal history of progressive hair loss. It is a procedure that is both effective and efficient in lowering the congenitally high hairline with very high patient satisfaction. Occasionally, a two-stage procedure will be required for the individual with a very high hairline or minimal scalp laxity. A thorough knowledge of the relevant anatomy and surgical limitations as well as a detailed history and physical exam is imperative to achieve desirable outcomes.
Hairline lowering or advancement, as a standalone procedure has its origins in maneuvers utilized for scalp reductions and flaps. Although the senior author has performed this procedure for over 25 years, the term "hairline lowering " and its surgical nuances was first published by Marten in 1999 in a paper stressing lowering the hairline with foreheadplasty for forehead and brow rejuvenation. Our experience is mostly for the purpose of correcting disproportion of the upper third of the face without browlifting in a younger patient group. The high hairline is more prevalent in certain ethnic and racial groups and is a source of self-consciousness that cannot be overcome with camouflaging hair styles. Patients perceive the problem as either a high hairline or a large forehead. The hairline lowering operation is both a very efficient and effective method of reducing the forehead with immediately noticeable results.
The ideal patient for the hairline advancement procedure is typically female with a congenitally high hairline and no personal or familial history of progressive hair loss. A congenitally high hairline is one that causes the upper third of the face to be disproportionately greater than that of the middle and lower thirds. In order to achieve optimal results with a single procedure, potential candidates must meet specific preoperative criteria. Otherwise, a two-stage procedure is required with scalp expansion prior to hairline advancement in those with very high hairlines or minimal scalp laxity. This situation occurs in less than 10% of the authors’ patients.
In order to select appropriate patients for the procedure, the preoperative assessment should include a thorough examination of the scalp with a focus on evaluation of scalp laxity, direction of hair exit, and frontotemporal points and recessions. These key elements are not only important for choosing suitable candidates but also aid in preoperative counseling and patient decision-making. Forward-growing hairs at the hairline allow for hair growth through the scar and the highest probability of scar camouflage as will be discussed in greater detail later in the chapter. Patients with posteriorly-exiting hairs at any point along the hairline, as seen in those with cowlicks, are informed that they might require future follicular unit transplantation (FUT) to disguise the scar and achieve optimal results. Likewise, FUT is recommended for individuals who desire coverage of deep temporal recessions or advancement of acutely, downward-facing temporal hairs.
During preoperative consultation, a measurement of the height of the hairline should be taken. To help standardize the measurement, a point should be chosen at the glabella at the level of the interbrow region. From this point, the average female hairline should measure approximately 5 to 6.5 cm, and hairlines above this are generally considered high especially if they cause imbalance with the lower thirds of the face.
Once the hairline has been deemed high, adequate scalp laxity can be determined by performing a simple maneuver with the fingers. A point is chosen over the forehead below the hairline and the fingertip is used to move the tissue as far superiorly as possible. The point of maximal tissue excursion superiorly is set to zero at the hairline from the glabella. The fingertip is then used to push the tissue downward from this point as far as possible, and a measurement is then taken between the two points. Also, the relative ease of moving the hair-bearing scalp forward and backward and the pinching of forehead skin aid in assessing how much the hairline can be lowered. This distance, which averages over 2 cm, very closely approximates the distance that the hairline can be advanced during a single-stage procedure and equates to a 25% reduction of the forehead in someone with an 8 cm hairline, for example.
Risks of the procedure as well as potential complications include bleeding, infection, telogen effluvium (“shock loss”) and scalp necrosis. In addition, specific problems relating to the post-operative scar include widening, visibility with future hair loss, hypo- or hyperpigmentation, and the possibility of needing a hair grafting session or scar revision to help camouflage the incision site. These scar problems rarely arise in our experience. All patients are also informed that diminished sensation over the frontal scalp should be anticipated for 6 to 12 months in the postoperative period.
Preoperatively, the hairline should be marked just posterior to the fine vellus frontal hairs in a manner that creates an irregular, undulating pattern similar to those fashioned for routine hair transplantation. As the markings approach laterally to the downward-directed hairs of the temporal tufts, they should be curved posteriorly into the temporal hair and then inferiorly for approximately 2 cm. It is important to create this marking in such a way as to avoid division of the posterior branch of the superficial temporal artery when performing the incision. The desired neo-hairline height is then chosen at a point over the forehead and a marking is made replicating the natural hairline above. A third marking can be drawn 1 cm above the anticipated neo-hairline to allow for a range of acceptable hairlines intraoperatively, and this should be discussed with the patient prior to surgery.
The patient is then brought into the operating suite and placed in the supine position with the head slightly elevated. In the authors’ experience, the procedure is well tolerated with a combination of local anesthesia and intravenous sedation. The scalp is anesthetized in a ring-block fashion along with tumescence in a manner similar to that performed during an extensive FUT session. Once the scalp is well anesthetized, the incision is made at the hairline with a trichophytic approach as described by Mayer and Fleming, beveling forward at an angle that is approximately 90 degrees to the natural exit of surrounding hairs.
A similar concept in pedicle scalp flap surgery has been utilized by the senior author since 1975. This method is crucial for achieving hair growth through the eventual scar and providing optimal camouflage in the future. Another important aspect of this incision is that it should include only the first 2 to 3 hairs behind the point where fine hairs of the anterior hairline transition into more coarse and dense follicular units. The incision is carried to the subgaleal plane and transitions at the temporal hairline to parallel the exiting hairs as it is extended into the post-temporal hair. Bleeding is minimal due to tumescence, especially if care is taken to avoid the posterior branch of the superficial temporal arteries. Dissection can then be performed rapidly in the subgaleal, bloodless plane taking care to avoid injury to the occipital arteries posteriorly where visualization becomes more difficult. Undermining should take place posteriorly to the nuchal ridge, laterally to the limits of the galea, and anteriorly to a level approximately 3 cm above the brow in order to avoid lifting the brow in the process of wound closure. If the patient desires a brow lift, however, dissection can be easily carried to the brow, and superior advancement of the forehead flap is performed in the usual manner described for brow elevation.
Once fully elevated, the scalp is advanced, and the use of a D’Assumpção clamp or other flap marking device helps determine the amount of forehead overlap. If the planned hairline height is not reached, galeotomies can be performed to allow for additional advancement. These are made with the use of a slightly-bent, depth-controlled #15 blade in order to reach the more superficial subcutaneous plane while avoiding compromise to the blood supply of the flap. Electrocoagulation blades or needles should not be used for this. Each galeotomy provides a gain of 1 to 2 mm, and therefore, several parallel galeotomies may be required to achieve the desired hairline. After determining the level to which the scalp can be advanced, an incision is made over the forehead with the same beveled angle as that at the hairline while replicating the undulating pattern. Non-hair-bearing forehead tissue including skin, frontalis muscle and galea is then fully excised. One or two paramedian Endotines are then placed in the calvarium in a reverse direction to the usual placement during a brow lift at a 3 to 4 cm distance posterior to the neo-hairline. The scalp is then advanced with the use of 5-prong retractors over the course of 1 to 2 minutes to allow for tissue creep before securing the galea to the Endotines.
The Endotines, in theory, help to relieve tension at the neo-hairline and work to allow the anterior 3 to 4 cm of scalp to be relatively compressed thus distributing the subtle stretch of the scalp disproportionately and reducing the possibility of postoperative stretch-back. This anterior compression is thought to minimize splaying of FUs and help maintain the full preoperative density at the hairline. The galea is then reapproximated using both 3-0 and 4-0 interrupted polyglycolic acid sutures, often with moderate tension, allowing for a tensionless fine closure at the skin edge. The skin is then closed with both 4-0 interrupted nylon sutures interspersed with surgical clips within the temporal scalp and 5-0 or 6-0 interrupted nylon or polypropylene sutures over the anterior hairline. Meticulous attention is given to the beveled skin closure at the hairline utilizing loupe magnification to ensure appropriate overlap of the de-epithelialized hair follicles. An evacuation drain has not been found to be necessary due to the amount of tension on the scalp and the resultant lack of subgaleal dead space.
Postoperatively, long-acting local anesthesia is injected along the incision line to provide patient comfort, and a pressure dressing is placed. On the following day, the dressing is removed, and patients can resume most non-strenuous activities within the first 24 to 72 hours. Edema is minimal, and periocular and forehead ecchymosis is rare. This is attributed to the strong, layered closure; however, a concurrent brow lift does increase the likelihood of periocular edema and bruising. Since tension is borne by the deep closure, removal of skin sutures and clips is permitted within 5 to 7 days. Due to the initial incision, there is minimal prolonged discomfort from the operation as the scalp is insensate for 6 to 9 months postoperatively. This also allows for the Endotines to be very tolerable, and they should be long dissolved by the time sensation returns; hypoesthesia has resolved in all cases to date.
Preoperatively, in the event that the scalp is noted to have minimal laxity or the amount of advancement required to achieve a desirable hairline height is beyond the average 2 to 2.5 cm, a two-stage procedure is recommended. This involves the initial insertion of a tissue expander with expansion of the scalp performed gradually over the following 4 to 8 weeks using similar methods as those described in the literature. During the expansion period, patients have concealed their ever-enlarging scalps with adornments ranging from wigs to over-sized hats. A second procedure, which, with the exception of removal of the expander is exactly as that described above, takes place when desired expansion is achieved. In the senior author’s experience, this method has allowed for up to 10 cm of hairline advancement.
With attention to detail and careful preoperative planning, the single-stage hairline lowering procedure performed on a scalp with average laxity will allow for up to 2.5 cm of advancement with excellent long term results. Very lax scalps have allowed for up to 3.5 cm advancement with this one-stage approach. This brief (1.5 hour) operation, which in the authors’ experience has no more morbidity than an extensive FUT session, moves an average of 2000 to 3000 FUs at one time. The two-stage procedure, despite having the disadvantages of prolonged, progressive deformity and the cost of an additional operation, is still efficient and cost-effective considering the fact that up to 12,000 FUs can be advanced. Either procedure is generally well-tolerated with minimal morbidity, and the end result, whether achieved through a one- or two-staged approach, has been met with excellent overall patient satisfaction.
Article written by Dr. Sheldon Kabaker in Oakland, CA.