86 Hairline Lowering Technique

Sahar Nadimi and Sheldon S. Kabaker

Summary

Hairline lowering or advancement, also known as forehead reduction, is a procedure that has its origins in maneuvers used for scalp reductions and flaps. Although a 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 reducing the forehead with immediately noticeable results and very high patient satisfaction.

A high hairline is more prevalent in certain ethnic and racial groups and is a significant source of self-consciousness that cannot be overcome with camouflaging hairstyles. Patients perceive the problem as either a high hairline or a large forehead. Traditionally, a high hairline has been addressed by hair transplantation. Follicular unit grafts can look natural here but may require a number of procedures, depending on the density and the amount of lowering required. Perhaps 2 years would need to pass before the process is completed. Hairline lowering or advancement (also known as forehead reduction) is an efficient and effective method of reducing the forehead with immediately noticeable results. This surgery has its origins in maneuvers used for scalp reductions and flaps.1^,2,3,4

The ideal patient for the hairline advancement procedure is typically a female with a congenitally high hairline and no personal or familial history of progressive hair loss. A congenitally high hairline 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 two-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 (Fig. 86.1a–d).

86.2 Preoperative Assessment and Planning

To select appropriate candidates for this procedure, the preoperative assessment should include a thorough examination of the scalp with a focus on scalp laxity, direction of hair exit, and frontotemporal points and recessions. These key elements are important for selecting appropriate candidates, and 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. 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 to disguise the scar and achieve optimal results. Hair grafting can be performed 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. A point should be chosen at the glabella at the level of the inter-brow region. From this point, the average female hairline should measure approximately 5 to 6 cm, and hairlines greater than this are generally considered too high, especially if they cause imbalance with the lower third of the face. Adequate scalp laxity can be determined by the relative ease of moving the hair-bearing scalp forward and backward and the pinching of forehead skin. For patients with relatively tight scalps, massaging the scalp in a backward–forward movement for a month before the surgery can improve the forward advancement achieved.

Preoperatively, the existing hairline is marked in an irregular, undulating pattern just posterior to the fine vellus frontal hairs (Fig. 86.2). 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. It is important to create this marking in such a way that division of the posterior branch of the superficial temporal artery is avoided when performing the incision. Of note, women who have undergone prior scalp surgery (such as brow lifts, face-lifts, and follicular unit transplantation) can undergo surgical hairline lowering if their key arteries can be identified by Doppler examination. The desired neo-hairline height is then chosen at a point over the forehead, and a marking is made replicating the natural hairline above.

86.4 Surgical Technique

After hairline marking, the patient is 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 and forehead are anesthetized in a ring block fashion along with 200 mL of tumescent solution. Once the scalp is well anesthetized, the incision is made at the hairline with a trichophytic approach beveling forward at an angle that is approximately 60 degrees to the natural exit of the surrounding hairs (Fig. 86.3a, b).^5,6,7,8 This incision should include only the first two to three hairs behind the point where fine hairs of the anterior hairline transition into more coarse and dense follicular units.

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