As many as 20% of all women have what can be described as a high hairline. It usually is a hereditary and natural characteristic. Most modern hairstylists are trained to recognize this and will style the hair combed forward in bangs and thereby disguise it. A high hairline is considered a masculine trait. A hairline that measures its mid-point between 5 cm and 6 cm above a line drawn across the brows is what most classify as a typical and desirable female hairline. A mature male hairline usually is 6-8 cm above the brows.
It has been noted that a high proportion of women with high hairlines have are descendants of peoples of Great Britain or China. Although I have not reviewed any published statistics on this, it has been my clinical observation for the past 30 years. Of course, high hairlines are seen in women from a wide variety of backgrounds. A notable group of women who have high hairlines are African Americans who have a combination of hereditary factors and traumatic factors from straightening the hair and pulling it back, therefore, at times pulling out the weaker hairs in the front and the temples. Usually there is a history of straightening the hair and pulling it tightly back in various hairstyles, i.e., corn rows, tight braids or buns, One should note that in almost every predominantly African American neighborhood, there are a disproportionate number of women’s wig stores which cater to older African American women who want to have the appearance of a full head of hair.
The high inherited hairlines that we often seen from those women of Anglo Saxon ancestry can be exemplified by the history and paintings of Queen Elizabeth I, the great Tudor queen, the daughter of Henry VIII, who reigned for 45 years. She had a naturally high hairline, which is revealed in many portraits. Also, one can find many portraits of women of English nobility of her time who emulated the queen by actually shaving back an inch or so of their hair to more resemble the queen. This was especially true of the women who were in her court. It should be noted that Bette Davis, in portraying Queen Elizabeth, had to shave her hairline back for such a movie role. She played Queen Elizabeth twice once when she was a younger actress, and as an older actress playing the older queen, the hairline had to be kept proportionate, though Ms. Davis’ hairline had receded naturally with age.
Most women who have high hairlines have a compensatory hairstyle or have little concern with it. Those who have suffered teasing in their formative or teenage years regarding a “big forehead”, “looks like a light bulb”, or looking more like a boy, carry this burden into early adulthood. I find this similar to people who suffered severe acne in their teen years and become psychologically traumatized. Even small acne scars throughout adult life often can obsess them.
In addition to the common hairstyles to disguise the high Tudor-like female hairline, surgery can be performed. A simple, but sophisticated one-stage hairline lowering (forehead reduction) operation can usually bring down the hairline approximately one inch. An appropriate candidate for this operation who desires lowering of a high hairline has to have an appropriate amount of scalp laxity. Alternatively, modern follicular unit hair grafts can be done to achieve a similar effect. The graft operation often has to be repeated to attain the desired density and a 12-18 month period is necessary for growth to be long enough to be incorporated into all but the shortest of female hair styles.
For those who need great advancement of the hairline or who have a very tight scalp, a two-stage procedure wherein balloon-like expander devices are inserted under the scalp in the first stage. The scalp is stretched over a six to eight-week period by gradually inflating the balloon. This allows us to bring the stretched scalp downward as much as we need. In some cases, it has been lowered up to 10 cm.
Although the concept of this hairline advancement surgery is not revolutionary, the sophistication of it is really a modern development.
Hairline Lowering FAQ’s
Q: Does your hair thin following hairline lowering operation?
A: There is a lot of discussion as to what changes occur in the hair after the scalp is stretched and the hairline is lowered. Lowering the hairline, as we do in forehead reduction, stretches the scalp and the hairs actually have to thin out to an imperceptible degree. The same thinning occurs in hair transplantation. We do not give anybody more hair. We take care from one place and put into another. With the hairline lowering operation, however, the change is very subtle and is distributed throughout the scalp rather than having the thinning just in the back. And, the resulting hair density in the front of the scalp is much greater than with hair transplants.
There appears to be many concerns about this especially when the discussion of “shock loss” enters the picture. As an aside, shock loss occurs with almost any scalp surgery, especially with follicular unit hair transplantation. By standard definition, however, “shock loss” means that there will be recovery of hair growth starting in three months and being completed by 9 to 12 months to where hair is again long enough to be incorporated into hair styling. Significant shock loss occurs in less than 2% of patients having hair transplants or hairline lowering.
To lessen this effect of thinning, a number of maneuvers can be done. I have, routinely, for the last 12 years inserted a small dissolvable device, called an Endotine, which anchors the scalp onto the skull within 3 cm of the hairline. This has the effect of taking tension off the closure and, as our recent study has shown, it compresses the hair in the front rather than stretches it. This probably accounts for an infinitesimal more stretching of the scalp behind, but it is spread over the scalp behind for about 25 cm to 30 more centimeters. We have scientifically proven that the use of the Endotine compresses the hair in the front and eliminates frontal thinning that would occur from the scalp being stretched in the front 3 cm of the hairline.
Q: How is it you are determined to be the expert in this operation?
A: In addition to performing this operation and similar operations for almost 40 years, I, to the best of my knowledge, am the only one who has contributed to the medical literature on this particular procedure for a high hairline or, as some see it, a tall forehead. My publications have been in recognized in peer-reviewed medical journals, in textbooks and Wikipedia.
Q: Will my hair be thinner after the operation?
A: All hair restoration surgeries will microscopically thin the scalp hair. The hairline lowering operation is no exception; however, the thinning is distributed throughout the top and back of the scalp, so it is imperceptible. I will be conducting scientific studies to actually measure this. Our initial impressions have been that the whole scalp is stretched about 10- 20% and therefore, the density goes down between 10% and 20% on the top and back. Therefore, if you have 100 follicular units/cm2 (as many women do), the hair density would become about 85 follicular units/cm2 after a 3cm hairline advancement. This difference would be imperceptible to the naked eye. Other hair restoration procedures such as follicular unit grafting by FUT, strip harvesting or FUE thin the hair similarly, but the recipient area rarely cannot get that degree of density unless multiple procedures are used.
Q: Is there long-term itching (pruritus) following a Hairline Lowering Surgery?
A: Most patients experience some temporary itching as sensation returns to the frontal scalp. Personally over my 25 years of experience, I have never had a patient report that he/she developed long-term itching following a hairline lowering surgery.
Q: You are considered by many to the world’s most experienced and senior hairline lowering surgeon. Since you are retiring, where can I find someone like yourself to do my surgery?
A: since 1986 I have been a co-director of a Facial Plastic Surgery fellowship. A number of my past fellows have considerable knowledge and experience with my personal approach and technique to this surgery. Amongst them is Dr.Jason Dudas of San Francisco who is a plastic surgeon in The Pacific Plastic Surgery Group that is acquiring my practice. Dr Dudas has worked with me on over 100 hairline lowering cases going back to 2012. Although retired from full time practice I will, on a limited basis, be available to assist and consult with Dr. Dudas for those patients who might want my personal input with their care.
To see more information about hairline lowering and forehead reduction please visit the Hairline Lowering FAQ’s. This section will provide you with additional valuable information about the hairline lowering procedure. If you have any further questions about this or any procedure feel free to contact the office (415) 379-9015 and our staff will be glad to assist you.