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 men and women of all races and ethnicities due to various diagnoses, hairline advancement is best suited for individuals, typically women, 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.
Key points
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The ideal patient for hairline advancement is a woman with a congenitally high hairline and no personal or familial history of hair loss.
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A trichophytic incision is key to scar camouflage.
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Preservation of the occipital arteries is crucial.
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The average scalp can be advanced up to 2.5 cm especially if galeotomies are used.
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A 2-stage procedure with scalp expansion before advancement is required in those with minimal laxity or significantly high hairlines.
Introduction
Hairline lowering or advancement (also known as forehead reduction), as a stand-alone procedure, has its origins in maneuvers used 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 were first published by Marten in 1999 in an article stressing lowering the hairline with foreheadplasty for forehead and brow rejuvenation. The authors’ experience is mostly for the purpose of correcting disproportion of the upper third of the face without brow lifting 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 hairstyles. Patients perceive the problem as either a high hairline or a large forehead. The hairline-lowering operation is 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. To achieve optimal results with a single procedure, potential candidates must meet specific preoperative criteria. Otherwise, a 2-stage procedure is required with scalp expansion before hairline advancement in those with very high hairlines or minimal scalp laxity. This situation occurs in less than 10% of the authors’ patients.
Introduction
Hairline lowering or advancement (also known as forehead reduction), as a stand-alone procedure, has its origins in maneuvers used 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 were first published by Marten in 1999 in an article stressing lowering the hairline with foreheadplasty for forehead and brow rejuvenation. The authors’ experience is mostly for the purpose of correcting disproportion of the upper third of the face without brow lifting 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 hairstyles. Patients perceive the problem as either a high hairline or a large forehead. The hairline-lowering operation is 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. To achieve optimal results with a single procedure, potential candidates must meet specific preoperative criteria. Otherwise, a 2-stage procedure is required with scalp expansion before hairline advancement in those with very high hairlines or minimal scalp laxity. This situation occurs in less than 10% of the authors’ patients.
Preoperative assessment and planning
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 to 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 is discussed in greater detail later in the article. 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 greater than 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 2 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 greater than 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 m 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 postoperative scar include widening, visibility with future hair loss, hypopigmentation 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 the authors’ 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.
Hairline marking
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 ( Fig. 1 ). As the markings approach laterally to the downward-directed hairs of the temporal tufts, they should be curved posteriorly into the temporal hair for approximately 2 to 2.5 cm and then inferiorly for another 0.5 to 1.5 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 0.5 to 1 cm above the anticipated neo-hairline to allow for a range of acceptable hairlines intraoperatively, and this should be discussed with the patient before surgery.
Surgical technique
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After hairline marking, the patient is brought into the operating suite and placed in the supine position with the head slightly elevated.
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In the authors’ experience, the procedure is well tolerated with a combination of local anesthesia and intravenous sedation. The scalp and forehead are anesthetized in a ring-block fashion along with tumescence in a manner similar to that performed during an extensive FUT session.
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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° to the natural exit of surrounding hairs.
Surgical Note: A similar concept in pedicle scalp flap surgery has been used 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 ( Fig. 2 ). 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. Slight modifications of the existing hairline shape can sometimes be made.
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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 posttemporal hair ( Fig. 3 ). Bleeding is minimal due to tumescence, especially if care is taken to avoid the posterior branch of the superficial temporal arteries.
