Indications and Techniques for Hairline Lowering
Warwick J.S. Nettle
Yumiko Kadota
DEFINITION
The ideal length of the female forehead should be approximately one-third of the length of the face (FIG 1).1,2,3,4
The forehead may be elongated congenitally, due to hairline recession with aging or iatrogenic causes, such as coronal incision brow lift.1,4
A high hairline, or large forehead, causes the upper third of the face to be disproportionately larger than the middle and lower thirds.
Young women find that a high hairline masculinizes their faces.4
ANATOMY
The hairline is an extended area consisting of various zones and borders that frame the face.7
The frontal hairline has an irregular border that extends from temple to temple.
The transition zone is the anterior border of the frontal hairline where soft, small hairs are found.7
The defined zone is immediately behind the transition zone, where the hairs become coarser and denser.7
The midfrontal point is the midline, most anterior point of the hairline. This is where the “widow’s peak” is, if it exists in the patient.
The frontotemporal angle is the point where the frontal hairline meets the temporal hairline.7 This angle is the angle of temporal hair recession, routinely found in males and sometimes found in females.
The layers of the scalp from superficial to deep are
Skin: the thickest in the body and most hair-bearing
Dense connective tissue where the blood vessels run
Occipitofrontalis muscle
Galea aponeurotica between occipitalis and frontalis muscles. This aponeurosis blends with the temporalis fascia laterally, just above the zygomatic arch.
The subgaleal space of loose areolar tissue provides a plane for scalp mobility.
Scalp blood supply
Blood supply to the scalp derives from external and internal carotid artery branches, which anastomose freely with each other.
Scalping does not cause necrosis of the underlying skull, which receives blood supply from the middle meningeal artery.
The external carotid artery gives rises to the occipital, posterior auricular, and superficial temporal arteries.
The occipital artery runs from the apex of the posterior triangle of the neck to supply the posterior scalp to the vertex.
The posterior auricular artery supplies the scalp behind the ear.
The superficial temporal artery is a terminal branch of the external carotid artery and supplies the skin over the temporalis fascia and scalp.
The supraorbital and supratrochlear arteries derive from the internal carotid artery and supply the forehead and anterior scalp to the vertex.
Scalp sensation
The greater occipital nerve (posterior ramus of C2) runs with the occipital artery and supplies the posterior scalp to the vertex.
The posterior scalp is also supplied by the third occipital nerve (posterior ramus of C3).
The lesser occipital nerve (anterior ramus of C2) runs with the posterior auricular artery and supplies sensation to the skin behind the ear.
The skin of the temple is supplied by the auriculotemporal and zygomaticotemporal nerves.
The forehead and anterior scalp are supplied by the supratrochlear and supraorbital nerves, which run with the corresponding arteries.
PATIENT HISTORY AND PHYSICAL FINDINGS
High hairline
Good, healthy hair
Lack of cowlicks (posterior exiting hairs)
Good scalp mobility (measured by the ability of the scalp to rock back and forth on the skull)
Absence of scalp disease and previous scalp surgery
No history of stress-induced or unexplained hair loss
No family history of progressive hair loss
SURGICAL MANAGEMENT
Hairline lowering is a day procedure, of about 2-hour duration.
The major steps are as follows:
FIG 1 • A. Frontal view showing ideal facial proportions, undulating incision along current hairline (blue), posterior incision extensions (green), and proposed incision for inferior and anterior advancement of new hairline (red). B. Oblique view showing the same markings as (A), plus the superior nuchal line, a very minor ridge or crest on the posterior skull bone (occipital bone) that provides attachment for the sternocleidomastoid and trapezius muscles, as well as the occipital belly of the occipitofrontalis muscle. C. Overhead view.
The hairline is surgically advanced anteriorly using a posterior scalp advancement flap, to meet the proposed new hairline (FIG 2A-D).
It is easier to advance the central anterior hairline (narrow flap) than the whole frontal hairline (broad flap).
The ellipse of the forehead skin between the pre-existing and new lower hairline is excised (FIG 2C).
The scalp is secured in its advanced position to the underlying bone with sutures through converging outer cortical bone tunnels, Endotines, or other fixation devices (FIG 2C).
Preoperative Planning and Positioning
Marking of the existing and new proposed hairlines is made preoperatively with the patient standing or sitting up.
The marking of the frontal hairline should be in an irregularly undulating fashion, which resembles the natural hairline and helps with camouflage of the incision (FIG 3A).3,4,5
If needed, the incision is made as lateral as possible, to allow for lateral as well as central advancement, and to avoid recession at the frontotemporal angle (temporal recession).
The proposed new, lower hairline traces the superior marking (FIG 3B).
The level is marked according to the patient’s desires while taking into consideration the pre-existing scalp mobility.
Usually 2.5 cm of scalp advancement is not difficult with a moderately mobile scalp.5
The incision continues posteriorly bilaterally, in a shape similar to the arms of a pair of spectacles (FIG 3C).
The patient is positioned supine, on a head ring at the superior most end of the table.
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