Hairline Lowering
Sheldon S. Kabaker, MDa,b,*, Jason P. Champagne, MDa,c
KEYWORDS High Hairline Forehead Advancement Reduction Lowering
KEY POINTS The ideal patient for hairline advancement is a woman with a congenitally high hairline and no per- sonal or familial history of hair loss. A trichophytic incision is key to scar camouflage. Preservation of the occipital arteries is crucial. The average scalp can be advanced up to 2.5 cm especially if galeotomies are used. A 2-stage procedure with scalp expansion before advancement is required in those with minimal laxity or significantly high hairlines.
INTRODUCTION is one that causes the upper third of the face to be disproportionately greater than that of the middle Hairline lowering or advancement (also known as and lower thirds. To achieve optimal results with a forehead reduction), as a stand-alone procedure, single procedure, potential candidates must meet has its origins in maneuvers used for scalp reduc- 1 specific preoperative criteria. Otherwise, a 2-stage tions and flaps. Although the senior author has procedure is required with scalp expansion before performed this procedure for over 25 years, the hairline advancement in those with very high hair- term “hairline lowering” and its surgical nuances lines or minimal scalp laxity. This situation occurs were first published by Marten in 1999 in an article in less than 10% of the authors’ patients. stressing lowering the hairline with foreheadplasty for forehead and brow rejuvenation.2 The authors’ PREOPERATIVE ASSESSMENT AND PLANNING experience is mostly for the purpose of correcting disproportion of the upper third of the face without To select appropriate patients for the procedure, brow lifting in a younger patient group. The high the preoperative assessment should include a hairline is more prevalent in certain ethnic and racial thorough examination of the scalp with a focus groups and is a source of self-consciousness that on evaluation of scalp laxity, direction of hair exit, cannot be overcome with camouflaging hairstyles. and frontotemporal points and recessions. These Patients perceive the problem as either a high hair- key elements are not only important for choosing line or a large forehead. The hairline-lowering oper- suitable candidates but also to aid in preoperative ation is a very efficient and effective method of counseling and patient decision-making. Forward- reducing the forehead with immediately noticeable growing hairs at the hairline allow for hair growth 3 results. The ideal patient for the hairline advance- through the scar and the highest probability of ment procedure is typically female with a congeni- scar camouflage as is discussed in greater detail tally high hairline and no personal or familial history later in the article. Patients with posteriorly exiting of progressive hair loss. A congenitally high hairline hairs at any point along the hairline, as seen in
Disclosure: The authors have no disclosures. a 3324 Webster Street, Oakland, CA 94609, USA; b Department of Otolaryngology-Head & Neck Surgery, Uni- versity of California, San Francisco, San Francisco, CA, USA; c The Champagne Center for Facial Plastic Surgery and Hair Restoration, 10202 Jefferson Highway, Ste. B-1, Baton Rouge, LA 70809, USA * Corresponding author. 3324 Webster Street, Oakland, CA 94609. E-mail address: [email protected]
Facial Plast Surg Clin N Am 21 (2013) 479–486 http://dx.doi.org/10.1016/j.fsc.2013.05.007
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those with cowlicks, are informed that they might Risks of the procedure as well as potential com- require future follicular unit transplantation (FUT) plications include bleeding, infection, telogen ef- to disguise the scar and achieve optimal results. fluvium (“shock loss”), and scalp necrosis. In Likewise, FUT is recommended for individuals addition, specific problems relating to the postop- who desire coverage of deep temporal recessions erative scar include widening, visibility with future or advancement of acutely, downward-facing hair loss, hypopigmentation or hyperpigmentation, temporal hairs. and the possibility of needing a hair grafting ses- During preoperative consultation, a measure- sion or scar revision to help camouflage the inci- ment of the height of the hairline should be taken. sion site. These scar problems rarely arise in the To help standardize the measurement, a point authors’ experience. All patients are also informed should be chosen at the glabella at the level of that diminished sensation over the frontal scalp the interbrow region. From this point, the average should be anticipated for 6 to 12 months in the female hairline should measure approximately 5 postoperative period. to 6.5 cm, and hairlines greater than this are gener- ally considered high, especially if they cause HAIRLINE MARKING imbalance with the lower thirds of the face. Once the hairline has been deemed high, adequate Preoperatively, the hairline should be marked just scalp laxity can be determined by performing a posterior to the fine vellus frontal hairs in a manner simple maneuver with the fingers. A point is cho- that creates an irregular, undulating pattern similar sen over the forehead below the hairline and the to those fashioned for routine hair transplantation fingertip is used to move the tissue as far superi- (Fig. 1). As the markings approach laterally to the orly as possible. The point of maximal tissue downward-directed hairs of the temporal tufts, excursion superiorly is set to zero at the hairline they should be curved posteriorly into the temporal from the glabella. The fingertip is then used to hair for approximately 2 to 2.5 cm and then inferi- push the tissue downward from this point as far orly for another 0.5 to 1.5 cm. It is important to as possible, and a measurement is then taken be- create this marking in such a way as to avoid divi- tween the 2 points. Also, the relative ease of mov- sion of the posterior branch of the superficial tem- ing the hair-bearing scalp forward and backward poral artery when performing the incision. The and the pinching of forehead skin aid in assessing desired neo-hairline height is then chosen at a how much the hairline can be lowered. This dis- point over the forehead and a marking is made tance, which averages greater than 2 cm, very replicating the natural hairline above. A third closely approximates the distance that the hairline marking can be drawn 0.5 to 1 cm above the antic- can be advanced during a single-stage procedure ipated neo-hairline to allow for a range of accept- and equates to a 25% reduction of the forehead in able hairlines intraoperatively, and this should be someone with an 8 m hairline, for example. discussed with the patient before surgery.
Fig. 1. The hairline is marked just posterior to the fine vellus frontal hairs with an irregular, undulating pattern. Laterally the markings are curved posteriorly for 2 to 2.5 cm into the temporal hair and then slightly inferiorly. The desired neo-hairline height is marked at different levels using a replicating pattern of the natural hairline above.
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Fig. 2. Trichophytic hairline advancement. (upper left) Side view of hairline incision design. (lower left) Top view of hairline incision design. (right, top to bottom) (1) Hairline-scalp anatomy. (2) Superiorly the hairline incision is made by beveling forward at an angle approximately 90 to the natural exit of surrounding hairs. Inferiorly an incision is made over the forehead with the same beveled angle as that at the hairline (3) Non-hair-bearing fore- head tissue including skin, frontalis muscle, and galea is fully excised. (4) The scalp is advanced forward to meet the forehead incision line. Transected follicles along the hairline incision line will eventually grow through the scar to provide camouflage along the length of the hairline.
SURGICAL TECHNIQUE In the authors’ experience, the procedure is well tolerated with a combination of local After hairline marking, the patient is brought anesthesia and intravenous sedation. The into the operating suite and placed in the su- scalp and forehead are anesthetized in a pine position with the head slightly elevated.
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ring-block fashion along with tumescence in Dissection can then be performed rapidly in a manner similar to that performed during the subgaleal, bloodless plane taking care an extensive FUT session. to avoid injury to the occipital arteries poste- Once the scalp is well anesthetized, the inci- riorly where visualization becomes more diffi- sion is made at the hairline with a trichophytic cult (Fig. 4). approach as described by Mayer and Fleming,4,5 beveling forward at an angle that is approximately 90 to the natural exit of sur- rounding hairs. Surgical Note: A similar concept in pedicle scalp flap surgery has been used by the senior author since 1975.6,7 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.
The incision is carried to the subgaleal plane and transitions at the temporal hairline to par- Fig. 4. Subgaleal blunt dissection using sponges and elevators proceeds posteriorly to the nuchal ridge. allel the exiting hairs as it is extended into the posttemporal hair (Fig. 3). Bleeding is mini- Undermining should take place posteriorly to mal due to tumescence, especially if care is the nuchal ridge, laterally to the limits of the taken to avoid the posterior branch of the su- galea, and anteriorly to a level approximately perficial temporal arteries. 3 cm above the brow to avoid lifting the brow in the process of wound closure. If the patient desires a brow lift, however, dissection can be easily carried inferiorly to release the brows, 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’Assumpc¸a˜ o clamp or other flap-marking device helps determine the amount of forehead overlap (Fig. 5).
Fig. 3. The frontal trichophytic hairline incision is made by first beveling the scalpel forward at an angle of approximately 90 to the natural exit of surround- ing hairs (black arrows). The orientation of the scalpel Fig. 5. The scalp flap is advanced forward using a transitions at the temporal hairline (blue arrow)to D’Assumpc¸a˜ o clamp to establish a safe forehead skin parallel the exiting hairs in the temporal hair region excision. This procedure is repeated after galeotomies (green arrows). and scalp stretching.
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If the planned hairline height is not reached, One or 2 paramedian Endotines are then galeotomies can be performed to allow for placed in the calvarium in a reverse direction additional advancement (Fig. 6). These ga- to the usual placement during a brow lift at a leotomies are made with the use of a slightly 3 to 4 cm distance posterior to the neo- bent, depth-controlled no. 15 blade to reach hairline (Fig. 8). the more superficial subcutaneous plane while avoiding compromise to the blood sup- ply of the flap. Electrocoagulation blades or needles should not be used for this. Each ga- leotomy provides a gain of 1 to 2 mm, and therefore, several parallel galeotomies may be required to achieve the desired hairline.
Fig. 8. The midline calvarium is prepared for a reverse-positioned Endotine.
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 (Fig. 9). Fig. 6. Galeotomies (arrows) facilitate additional scalp advancement. 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 un- dulating pattern. Non-hair-bearing forehead tissue, including skin, frontalis muscle, and galea, is then fully excised (Fig. 7).
Fig. 9. The scalp flap is advanced forward and the galea is secured onto the embedded Endotine (arrow).
Surgical Note: 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 pos- Fig. 7. The forehead incision is made using the same sibility of postoperative stretch-back. This anterior beveled angle and the same undulating pattern as compression is thought to minimize splaying of that along the hairline, and then non-hair-bearing follicular units and help maintain the full preopera- forehead tissue is fully excised. tive density at the hairline.
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The galea is then reapproximated using both 3-0 and 4-0 interrupted polyglycolic acid su- tures, often with moderate tension, allowing for a tensionless fine closure at the skin edge (Fig. 10). The skin is then closed with both 4-0 interrup- ted nylon sutures interspersed with surgical clips within the temporal scalp and 5-0 or 6-0 nylon or polypropylene sutures over the anterior hairline (Fig. 11).
Surgical Note: Meticulous attention is given to the beveled skin closure at the hairline using 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 Fig. 10. All tension is placed on the galea which is reap- amount of tension on the scalp and the resultant proximated with multiple buried 3-0 polyglycolic acid lack of subgaleal dead space. suture to allow for a tensionless skin edge closure. On infrequent occasions follicular unit grafts can be performed in the same sitting with donor mate- rial harvested adjacent to the intratemporal closure line. These grafts are only used in front of the temple hairs to narrow a wide forehead.
POSTOPERATIVE CARE Immediately postoperatively, long-acting local anesthesia is injected along the incision line to provide patient comfort, and a pres- sure dressing is placed. On the following day, the dressing is removed, and patients can resume most nonstrenuous activities within the first 24 to 72 hours. Edema is minimal, and periocular and fore- head ecchymosis is rare, which is attributed to the strong, layered closure. However, a concurrent brow lift does increase the likeli- hood of periocular edema and bruising. Because 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 pro- longed discomfort from the operation as the scalp is insensate for 6 to 9 months postoperatively, also allowing for the Endotines to be very tolerable. They should be long dissolved by the time sensa- tion returns; hypoesthesia has resolved in all cases Fig. 11. Skin closure is accomplished with interrupted to date. or running 5-0 or 6-0 monofilament suture. (A) The epidermal sutures are placed using unequal bites with the anterior (forehead) bite located farther TISSUE EXPANSION from the wound edge than the posterior (scalp) bite. This placement strategy pulls the forehead Preoperatively, if the scalp is noted to have mini- dermis and epidermis over the denuded hair follicles mal laxity or the amount of advancement required on the scalp side of the incision line. (B) Meticulous to achieve a desirable hairline height is beyond the attention to the beveled skin closure ensures appro- average 2 to 2.5 cm, a 2-stage procedure is rec- priate overlap of the de-epithelialized hair follicles. ommended. The 2-stage procedure involves the
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Fig. 12. Tissue expansion assisted hairline advancement. (left) A tissue expander had been placed several weeks earlier to assist stretching a tight scalp. (right) Results following removal of the expander and final scalp flap advancement.
Fig. 13. Hairline advancement procedure using the trichophytic incision showing excellent long-term scar camou- flage. (A) Frontal view. Preoperative (left); 2-week postoperative (center); 11-year postoperative (right). (B) Right oblique view. Preoperative (left); 2-week postoperative (center); 11-year postoperative (right).
Fig. 14. Long-term scar camouflage 11 years after hairline advancement using the trichophytic incision and closure. (A) Left; (B) center; (C) right.
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Fig. 15. Hairline advancement of 3.3 cm using a trichophytic incision. (A) Front view—preoperative (left) and postoperative (right). (B) Lateral view—preoperative (left) and postoperative (right).
initial insertion of a tissue expander with expansion follicular units can be advanced. Either procedure of the scalp performed gradually over the following is generally well-tolerated with minimal morbidity, 4 to 10 weeks using similar methods as those and the end result, whether achieved through a described in the literature.8 During the expansion one-staged or 2-staged approach, has been met period, patients have concealed their ever- with excellent overall patient satisfaction. enlarging scalps with adornments ranging from wigs to oversized hats. A second procedure, REFERENCES which, with the exception of removal of the expander, is exactly as that described earlier, 1. Kabaker SS, Yu KC. Ancillary surgical procedures: takes place when desired expansion is achieved flaps. In: Unger W, Shapiro R, Unger M, et al, edi- (Fig. 12). In the senior author’s experience, this tors. Hair transplantation. 5th edition. London: In- method has allowed for up to 10 cm of hairline forma Healthcare; 2010. p. 496–503. advancement. 2. Marten TJ. Hairline lowering during foreheadplasty. Plast Reconstr Surg 1999;103(1):224–36. SUMMARY 3. Ramirez AL, Ende KH, Kabaker SS. Correction of the high female hairline. Arch Facial Plast Surg 2009;11: With attention to detail and careful preoperative 84–90. planning, the single-stage hairline-lowering proce- 4. Mayer TG, Fleming RW. Aesthetic and reconstruc- dure performed on a scalp with average laxity will tive surgery of the scalp. St Louis (MO): Mosby- allow for up to 2.5 cm of advancement with excel- Year Book; 1992. p. 121–4. lent long-term results (Figs. 13 and 14). Very lax 5. Mayer TG, Fleming RW. Hairline aesthetics and styl- scalps have allowed for up to 3.5 cm advance- ing in hair replacement surgery. Head Neck Surg ment with this one-stage approach (Fig. 15). 1985;7(4):286–302. This brief (1.5 hour) operation, which in the au- 6. Kabaker S. Experiences with parieto-occipital flaps thors’ experience has no more morbidity than an in hair transplantation. Laryngoscope 1978;538:73. extensive FUT session, moves an average of 7. Kabaker SS. Juri flap procedure for the treatment of 3000 follicular units at one time. The 2-stage pro- baldness: two-year experience. Arch Otolaryngol cedure, despite having the disadvantages of pro- 1979;105(9):509–14. longed, progressive deformity and the cost of an 8. Kabaker SS, Kridel RW, Krugman ME, et al. Tissue additional operation, is still efficient and cost- expansion in the treatment of alopecia. Arch Otolar- effective considering the fact that up to 12,000 yngol Head Neck Surg 1986;112(7):720–5.
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