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J Cosmet Med 2022; 6(2): 110-112

Published online December 31, 2022

https://doi.org/10.25056/JCM.2022.6.2.110

Hairline lowering surgery: how we do it

Tae Ui Hong , MD, Jeonghyun Oh , MD, PhD, Ji Yun Choi , MD, PhD

Department of Otolaryngology-Head and Neck Surgery, Chosun University College of Medicine, Gwangju, Rep. of Korea

Correspondence to :
Ji Yun Choi
E-mail: happyent@naver.com

Received: December 5, 2022; Revised: December 16, 2022; Accepted: December 18, 2022

© Korean Society of Korean Cosmetic Surgery & Medicine

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Hairline-lowering procedures are popular among patients with disproportionately large foreheads because a shorter forehead with a lower hairline is considered more esthetically pleasing. A high hairline is a source of self-consciousness that cannot be overcome by camouflaging hairstyles. Although hair grafting is more familiar to patients, hairline-lowering surgery may be a preferable approach to lower the overly high hairline, whereby an average of 2 cm of lowering can be achieved, equivalent to transplanting as many as 3,000 grafts. Here, we present a case of a high hairline or large forehead in a 46-year-old female who underwent hairline-lowering surgery with bone-tunneling suture fixation. The patients and surgeons were satisfied with the overall surgical results.

Keywords: cosmetics, forehead, hair, surgical procedures

Hairline-lowering procedures are popular among patients with disproportionately large foreheads, as a shorter forehead with a lower hairline is regarded as more esthetically pleasing [1]. Although neoclassical ideals focus on equal vertical lengths of the thirds that comprise the upper, middle, and lower face, at present, patients perceive an attractive face as one in which the vertical lengths of the upper thirds are shorter than those of the middle [2]. A person can appear less attractive and older if the forehead is long and wide compared with other facial parts. Additionally, a large forehead in female may create a masculine appearance [3]. Hair grafting is more familiar to patients; however, hairline-lowering surgery (HLS) may be a preferable approach for lowering the overly high hairline as an average of 2 cm of lowering can be achieved, equivalent to transplanting as many as 3,000 grafts [4]. The hairline-lowering operation is a highly efficient and effective method for reducing the forehead with immediately noticeable results. Herein, we present a hairline-lowering technique using bone tunneling with a brow-lift bone bridge system. Furthermore, we evaluated the results of the procedure based on postoperative complications and measurement of the reduced forehead length.

A 46-year-old female visited our facial plastic clinic complaining of a high hairline. In addition to a high hairline, she had good scalp mobility and hair; no scalp disease including alopecia; and had never undergone forehead surgery, Botox injections, or filler injections. Therefore, HLS was planned. The preoperative and postoperative distances from the glabella to the trichion were identified and used to calculate the reduction in forehead length.

The patient was placed in the supine position under general anesthesia and additional local anesthesia was administered in the operative field. Tumescence with normal saline 40 ml along the hairline substantially reduces bleeding, thereby avoiding the need for epinephrine injection, which can be associated with shock hair loss [4]. The surgery was initiated with a zigzag trichophytic incision along the anterior hairline [5]. The hairline should be marked just posterior to the fine vellus frontal hairs that are too fine to grow effectively through the trichophytic incision. The basis of trichophytic incision is to allow the “clipped” hair follicles to regrow through the thin bevel of the overlying flap. Subsequently, the width determined according to the degree of scalp relaxation was marked from the incision line of the anterior hairline. The degree of scalp relaxation was determined by placing the thumb on the anterior hairline and pushing the scalp as low as possible and then measuring the distance the scalp moves from the hairline. In this case, the patient wanted to reduce her forehead to a maximum of 1.5 cm. Next, a line parallel to the incision of the hairline was created sideways, ending in a temporal recession on both sides of the head (Fig. 1). The incision should not be too long to prevent the crossing of the posterior branch of the temporal artery. Beveling of the trichophytic incision started with 2–3 hairs from the transition point. Next, the full skin layer was dissected until it reached the subgaleal loose areolar tissue layer, and the full thickness was excised (Fig. 2). Bloodless dissection was then performed through the subgaleal plane posteriorly up to 3 cm posterior to the vertex and laterally up to the temporal line to optimize scalp mobility. An elevated scalp flap was pulled forward using three towel clips for 1 minute, and five cycles were applied; and then, the periosteum was incised to create the bone tunnels. Two bone tunnels were created in the bilateral pupil lines, 5 mm above the inferior incision line, using a brow-lift bone bridge system (Fig. 3). After passing 3-0 polydioxanone (PDS) suture through the bone tunnel and galeal layer of the scalp flap, the flap was advanced as much as possible, and the suture was tied. The skin was approximated using 4-0 vicryl subcutaneous sutures followed by 5-0 nylon skin sutures. During suturing, we considered beveling such that the forehead skin covered the denuded hair follicles of the trichophytic incision. Compressive dressing was applied to reduce swelling.

Fig. 1.Peritrichial trichophytic incision was performed in a zig-zag manner, ending in a temporal recession on both sides of the head.

Fig. 2.Full thickness skin flap was excised, periosteal plane was exposed.

Fig. 3.Bone tunneling using brow-lift bone bridge system. (A) Tunneling procedure; (B) bone tunnels, as shown after drilling.

After surgery, compressive dressing changes and ointment applications were performed for 7 days. The patient was discharged from the hospital after the removal of all the skin sutures. During the first month of follow-up, the wound healed well and flap was viable. No wound dehiscence, hematoma, visible scarring, or pain were observed. The 1-month postoperative distance from the glabella to the trichion reduced from 8 to 6.5 cm (Fig. 4).

Fig. 4.A 46-year-old female patient, before (A, C) and 1 month after (B, D) hairline-lowering surgery whereby 15 mm of advancement was achieved.

Many previous studies on facial rejuvenation have focused on the position of wrinkles on the eyebrows and forehead, as well as on one-third of the upper part of the face. However, in the pursuit of a small face, the demand for correcting high hairlines has increased. People with long and wide foreheads appear unbalanced, old, and masculine because one-third of their faces are vertically unbalanced. Various methods have been used to solve the high hairline problem; nonsurgical means include makeup, tattoos, and wigs while the surgical methods include hair transplantation and scalp progression. Hair transplant surgery is traditionally considered the gold standard for lowering hairlines or alopecia. The most common way to improve the hairline is to collect and transplant hair follicles successively during this operation. However, this method is labor-intensive, time-consuming, and expensive. In addition, for the potential retreat of the hairline, the consequences must be followed up for a long time. Surgery is not satisfactory unless the density of hair follicles is maintained for a long period. As an alternative to hair transplantation, a high hairline can be corrected through downward hairline surgery using scalp progression [6].

Beveling was critical because a peritrichial trichophytic incision was placed within the fine vellus frontal hairs. The hairline incision was placed by beveling forward at an angle of approximately 90° to the natural exit of surrounding hairs. An incision was made inferiorly over the forehead with the beveled angle same as that of the hairline. Placing the incision within the hairline permits future hair growth through the scar to improve camouflage and maximize esthetic results [7]. Moreover, an irregular incision was used because a straight line would appear unnatural and result in a far more conspicuous scar.

Anchor sutures were used with the bone-tunneling method. In this method, two V-shaped tunnels are made in the skull using a drill and brow-lift bone bridge system. A thread fixed to the scalp is passed through these tunnels, and the advanced scalp is fixed at an appropriate position. Bone tunneling and PDS sutures provide adequate fixation. During bone tunneling, care must be taken as the drill may penetrate the table inside the skull and leak cerebrospinal fluid. If the flap progression exceeds scalp laxity, excessive wound tension may occur, resulting in enlarged scars and tension alopecia. To avoid these complications and use sufficient fixation points, it is important to measure scalp laxity before surgery.

  1. Jung JH, Rah DK, Yun IS. Classification of the female hairline and refined hairline correction techniques for Asian women. Dermatol Surg 2011;37:495-500.
    Pubmed CrossRef
  2. Zhao Q, Zhou R, Zhang X, Sun H, Lu X, Xia D, et al. Morphological quantitative criteria and aesthetic evaluation of eight female Han face types. Aesthetic Plast Surg 2013;37:445-53.
    Pubmed CrossRef
  3. Crowley JS, Kream E, Fabi S, Cohen SR. Facial rejuvenation with fat grafting and fillers. Aesthet Surg J 2021;41(Suppl 1):S31-8.
    Pubmed CrossRef
  4. Epstein J, Epstein GK. Hairline-lowering surgery. Facial Plast Surg Clin North Am 2020;28:197-203.
    Pubmed CrossRef
  5. Nimatu J 3rd. Post-trichial trichophytic incision in subcutaneous brow and forehead lift. Am J Cosmet Surg 2008;25:110-1.
    CrossRef
  6. Min JH, Jung BK, Roh TS, Kang YW, Oh DS, Lee DE, et al. Hairline lowering surgery with bone tunneling suture fixation: effectiveness and safety in 91 patients. Aesthet Surg J 2019;39:NP97-105.
    Pubmed CrossRef
  7. Vila PM, Somani SN, Wafford QE, Sidle DM. Forehead reduction: a systematic review and meta-analysis of outcomes. Facial Plast Surg Aesthet Med 2022;24:34-40.
    Pubmed CrossRef

Article

How We Do It

J Cosmet Med 2022; 6(2): 110-112

Published online December 31, 2022 https://doi.org/10.25056/JCM.2022.6.2.110

Copyright © Korean Society of Korean Cosmetic Surgery & Medicine.

Hairline lowering surgery: how we do it

Tae Ui Hong , MD, Jeonghyun Oh , MD, PhD, Ji Yun Choi , MD, PhD

Department of Otolaryngology-Head and Neck Surgery, Chosun University College of Medicine, Gwangju, Rep. of Korea

Correspondence to:Ji Yun Choi
E-mail: happyent@naver.com

Received: December 5, 2022; Revised: December 16, 2022; Accepted: December 18, 2022

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Hairline-lowering procedures are popular among patients with disproportionately large foreheads because a shorter forehead with a lower hairline is considered more esthetically pleasing. A high hairline is a source of self-consciousness that cannot be overcome by camouflaging hairstyles. Although hair grafting is more familiar to patients, hairline-lowering surgery may be a preferable approach to lower the overly high hairline, whereby an average of 2 cm of lowering can be achieved, equivalent to transplanting as many as 3,000 grafts. Here, we present a case of a high hairline or large forehead in a 46-year-old female who underwent hairline-lowering surgery with bone-tunneling suture fixation. The patients and surgeons were satisfied with the overall surgical results.

Keywords: cosmetics, forehead, hair, surgical procedures

Introduction

Hairline-lowering procedures are popular among patients with disproportionately large foreheads, as a shorter forehead with a lower hairline is regarded as more esthetically pleasing [1]. Although neoclassical ideals focus on equal vertical lengths of the thirds that comprise the upper, middle, and lower face, at present, patients perceive an attractive face as one in which the vertical lengths of the upper thirds are shorter than those of the middle [2]. A person can appear less attractive and older if the forehead is long and wide compared with other facial parts. Additionally, a large forehead in female may create a masculine appearance [3]. Hair grafting is more familiar to patients; however, hairline-lowering surgery (HLS) may be a preferable approach for lowering the overly high hairline as an average of 2 cm of lowering can be achieved, equivalent to transplanting as many as 3,000 grafts [4]. The hairline-lowering operation is a highly efficient and effective method for reducing the forehead with immediately noticeable results. Herein, we present a hairline-lowering technique using bone tunneling with a brow-lift bone bridge system. Furthermore, we evaluated the results of the procedure based on postoperative complications and measurement of the reduced forehead length.

Operation technique and patient presentation

A 46-year-old female visited our facial plastic clinic complaining of a high hairline. In addition to a high hairline, she had good scalp mobility and hair; no scalp disease including alopecia; and had never undergone forehead surgery, Botox injections, or filler injections. Therefore, HLS was planned. The preoperative and postoperative distances from the glabella to the trichion were identified and used to calculate the reduction in forehead length.

The patient was placed in the supine position under general anesthesia and additional local anesthesia was administered in the operative field. Tumescence with normal saline 40 ml along the hairline substantially reduces bleeding, thereby avoiding the need for epinephrine injection, which can be associated with shock hair loss [4]. The surgery was initiated with a zigzag trichophytic incision along the anterior hairline [5]. The hairline should be marked just posterior to the fine vellus frontal hairs that are too fine to grow effectively through the trichophytic incision. The basis of trichophytic incision is to allow the “clipped” hair follicles to regrow through the thin bevel of the overlying flap. Subsequently, the width determined according to the degree of scalp relaxation was marked from the incision line of the anterior hairline. The degree of scalp relaxation was determined by placing the thumb on the anterior hairline and pushing the scalp as low as possible and then measuring the distance the scalp moves from the hairline. In this case, the patient wanted to reduce her forehead to a maximum of 1.5 cm. Next, a line parallel to the incision of the hairline was created sideways, ending in a temporal recession on both sides of the head (Fig. 1). The incision should not be too long to prevent the crossing of the posterior branch of the temporal artery. Beveling of the trichophytic incision started with 2–3 hairs from the transition point. Next, the full skin layer was dissected until it reached the subgaleal loose areolar tissue layer, and the full thickness was excised (Fig. 2). Bloodless dissection was then performed through the subgaleal plane posteriorly up to 3 cm posterior to the vertex and laterally up to the temporal line to optimize scalp mobility. An elevated scalp flap was pulled forward using three towel clips for 1 minute, and five cycles were applied; and then, the periosteum was incised to create the bone tunnels. Two bone tunnels were created in the bilateral pupil lines, 5 mm above the inferior incision line, using a brow-lift bone bridge system (Fig. 3). After passing 3-0 polydioxanone (PDS) suture through the bone tunnel and galeal layer of the scalp flap, the flap was advanced as much as possible, and the suture was tied. The skin was approximated using 4-0 vicryl subcutaneous sutures followed by 5-0 nylon skin sutures. During suturing, we considered beveling such that the forehead skin covered the denuded hair follicles of the trichophytic incision. Compressive dressing was applied to reduce swelling.

Figure 1. Peritrichial trichophytic incision was performed in a zig-zag manner, ending in a temporal recession on both sides of the head.

Figure 2. Full thickness skin flap was excised, periosteal plane was exposed.

Figure 3. Bone tunneling using brow-lift bone bridge system. (A) Tunneling procedure; (B) bone tunnels, as shown after drilling.

After surgery, compressive dressing changes and ointment applications were performed for 7 days. The patient was discharged from the hospital after the removal of all the skin sutures. During the first month of follow-up, the wound healed well and flap was viable. No wound dehiscence, hematoma, visible scarring, or pain were observed. The 1-month postoperative distance from the glabella to the trichion reduced from 8 to 6.5 cm (Fig. 4).

Figure 4. A 46-year-old female patient, before (A, C) and 1 month after (B, D) hairline-lowering surgery whereby 15 mm of advancement was achieved.

Discussion

Many previous studies on facial rejuvenation have focused on the position of wrinkles on the eyebrows and forehead, as well as on one-third of the upper part of the face. However, in the pursuit of a small face, the demand for correcting high hairlines has increased. People with long and wide foreheads appear unbalanced, old, and masculine because one-third of their faces are vertically unbalanced. Various methods have been used to solve the high hairline problem; nonsurgical means include makeup, tattoos, and wigs while the surgical methods include hair transplantation and scalp progression. Hair transplant surgery is traditionally considered the gold standard for lowering hairlines or alopecia. The most common way to improve the hairline is to collect and transplant hair follicles successively during this operation. However, this method is labor-intensive, time-consuming, and expensive. In addition, for the potential retreat of the hairline, the consequences must be followed up for a long time. Surgery is not satisfactory unless the density of hair follicles is maintained for a long period. As an alternative to hair transplantation, a high hairline can be corrected through downward hairline surgery using scalp progression [6].

Beveling was critical because a peritrichial trichophytic incision was placed within the fine vellus frontal hairs. The hairline incision was placed by beveling forward at an angle of approximately 90° to the natural exit of surrounding hairs. An incision was made inferiorly over the forehead with the beveled angle same as that of the hairline. Placing the incision within the hairline permits future hair growth through the scar to improve camouflage and maximize esthetic results [7]. Moreover, an irregular incision was used because a straight line would appear unnatural and result in a far more conspicuous scar.

Anchor sutures were used with the bone-tunneling method. In this method, two V-shaped tunnels are made in the skull using a drill and brow-lift bone bridge system. A thread fixed to the scalp is passed through these tunnels, and the advanced scalp is fixed at an appropriate position. Bone tunneling and PDS sutures provide adequate fixation. During bone tunneling, care must be taken as the drill may penetrate the table inside the skull and leak cerebrospinal fluid. If the flap progression exceeds scalp laxity, excessive wound tension may occur, resulting in enlarged scars and tension alopecia. To avoid these complications and use sufficient fixation points, it is important to measure scalp laxity before surgery.

Conflicts of interest

The authors have nothing to disclose.

Fig 1.

Figure 1.Peritrichial trichophytic incision was performed in a zig-zag manner, ending in a temporal recession on both sides of the head.
Journal of Cosmetic Medicine 2022; 6: 110-112https://doi.org/10.25056/JCM.2022.6.2.110

Fig 2.

Figure 2.Full thickness skin flap was excised, periosteal plane was exposed.
Journal of Cosmetic Medicine 2022; 6: 110-112https://doi.org/10.25056/JCM.2022.6.2.110

Fig 3.

Figure 3.Bone tunneling using brow-lift bone bridge system. (A) Tunneling procedure; (B) bone tunnels, as shown after drilling.
Journal of Cosmetic Medicine 2022; 6: 110-112https://doi.org/10.25056/JCM.2022.6.2.110

Fig 4.

Figure 4.A 46-year-old female patient, before (A, C) and 1 month after (B, D) hairline-lowering surgery whereby 15 mm of advancement was achieved.
Journal of Cosmetic Medicine 2022; 6: 110-112https://doi.org/10.25056/JCM.2022.6.2.110

References

  1. Jung JH, Rah DK, Yun IS. Classification of the female hairline and refined hairline correction techniques for Asian women. Dermatol Surg 2011;37:495-500.
    Pubmed CrossRef
  2. Zhao Q, Zhou R, Zhang X, Sun H, Lu X, Xia D, et al. Morphological quantitative criteria and aesthetic evaluation of eight female Han face types. Aesthetic Plast Surg 2013;37:445-53.
    Pubmed CrossRef
  3. Crowley JS, Kream E, Fabi S, Cohen SR. Facial rejuvenation with fat grafting and fillers. Aesthet Surg J 2021;41(Suppl 1):S31-8.
    Pubmed CrossRef
  4. Epstein J, Epstein GK. Hairline-lowering surgery. Facial Plast Surg Clin North Am 2020;28:197-203.
    Pubmed CrossRef
  5. Nimatu J 3rd. Post-trichial trichophytic incision in subcutaneous brow and forehead lift. Am J Cosmet Surg 2008;25:110-1.
    CrossRef
  6. Min JH, Jung BK, Roh TS, Kang YW, Oh DS, Lee DE, et al. Hairline lowering surgery with bone tunneling suture fixation: effectiveness and safety in 91 patients. Aesthet Surg J 2019;39:NP97-105.
    Pubmed CrossRef
  7. Vila PM, Somani SN, Wafford QE, Sidle DM. Forehead reduction: a systematic review and meta-analysis of outcomes. Facial Plast Surg Aesthet Med 2022;24:34-40.
    Pubmed CrossRef

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