My personal pioneering experience in the evolution of the hairline lowering/forehead reduction/hairline advancement operation.
My experience with scalp surgery at the deeper level between the galea and the bone (which I call subgaleal scalp surgery) goes back to 1975. Then, I visited Dr. Jose Juri in Argentina who had developed a fascinating operation he called a temporal parietal flap for baldness. To do this operation one had to, in stages, lift a piece of the scalp from the side of the head and move it to the front of the scalp leaving it attached at the temple area. In order to do this, one had to mobilize (undermine) the entire scalp at the subgaleal level (the layer just above the bone) and also undermine the forehead almost to the eyebrows in order to turn the flap, put it into position, and close the donor area by stretching the undermined scalp. It took me at least three years to specialize in this operation. During this time, many adjustments had to be made during surgery and after surgery. This would involve moving the hairline downward or upward utilizing the principles of scalp undermining.
In the late 1970’s and all throughout the 80’s, the operation of Scalp Reduction was routinely performed for the treatment of male-pattern baldness. This was a much simpler procedure, but still involved the lifting of the scalp off of the skull in order to remove a piece of bald scalp and sew the stretched scalp together. Also, during this time, I performed a large number of forehead lifts utilizing an incision that was above the hairline and then eventually one that was at the hairline. This operation was called the Pretrichial forehead/brow lift. With this background, I became very familiar in elevating and moving the scalp and forehead which is the key to doing the hairline lowering procedure.
Throughout the 1980’s, I did a number of hairline lowering procedures in order to adjust the flaps or the foreheads.
During the 1990’s as my practice evolved more into patients seeking remedies for their hair, I saw into a number of women who wanted their hairlines lowered, either because it was their natural hairline or they had had it moved by some type of brow lift. I performed a number of hairline lowering procedures; however, they were not done with the trichophytic incision.
In the past 12 years, I have performed over 350 of actual hairline lowering procedures done with the trichophytic incision.
The trichophytic incision is one that cuts across the hair follicles similar to the de-epithelializing maneuver that was done with Dr. Juri’s flap in the 1970’s. However, this maneuver works so much better with forward-growing hair as exists in most women who want their hairlines lowered. The procedure really had no name. I have to give credit to Dr. Tim Marten, a leading plastic surgeon in San Francisco, who in 1999 published a paper entitled “Hairline Lowering During Foreheadplasty.” He described a number of maneuvers in a procedure that was done mostly on older women who were having a brow lift yet did not want to have their hairline raised or more specifically needed or wanted the hairline lowered. Many of the maneuvers of this operation were similar to what I had done before; only this paper gave it a name.
Since my practice is heavily oriented on people concerned about their hair, I am seeing a younger group of people who are not necessarily candidates for a forehead or brow lift. The operation for this group of patients became simply “Hairline Lowering”. Because of my years of doing scalp reductions and flaps, my attention to the blood supply to the scalp is tantamount. In recent years, the terms “forehead reduction” and “hairline advancement” have been used to describe this operation.
I have incorporated an incision along the hairline that has to extend in the temple, but does not go down to the top of ear as many other surgeons have described. This preserves a good deal of circulation to the scalp from the superficial temporal arteries and which lessens the chance of any loss of skin and lowers the chance of significant shock loss (I have had only one case). Also, because of the length and angulation I design in the incision, there is little chance for a visible or widened scar within the temple area.
Because of the experience we had in scalp reduction with “stretch-back,” I incorporate the use of a fixation device in the front 4 cm to 5 cm of my advanced scalp to theoretically prevent the front portions of the scalp from possibly having any thinner look than it already does.
In the past five years, I have incorporated the use of an operating headlight which allows me to look far back in the dissected area and I used a large retractor which is used for abdominal surgery to give me visualization to the very end of the dissection. We are able to get the maximum advancement of the scalp all the way to the very end of the origin of the galea at the nuchal ridge (the bony prominence at the back of the skull). I found over the years that the galeatomy incisions that are done across the galea (the deep layer of the scalp) from its undersurface allow us to get more movement forward.
I have found that based upon negative experience of other surgeons that it is best to use a cold steel knife blade with a stop on it rather than a cautery as we wish to preserve every bit of the circulation to the scalp as possible. I also incorporate a maneuver of stretching the scalp after galeatomies are done inspired by a maneuver in scalp reduction by my esteemed colleague from France, Dr. Patrick Frechet. We have found through experience that we can gain a few extra millimeters by having a fairly tight closure of the galea which does not affect the circulation to the scalp and has the advantage of closing off any dead space. So, I never use a drain and we rarely have eyelid and forehead bruising.
The postoperative swelling of this operation is surprisingly minimal which I attribute to our deep closures. Also, the deep closure allows the skin stitches and staples to be removed relatively early as they do not significantly hold the wound together.
The deep sutures and the fixation device I use (an Endotine) are made of polyglycolic acid, a material that dissolves in three to six months. The numbness of the scalp which is present behind the incision is to be expected in every patient and because of this, there is not much discomfort afterwards especially in regards to the Endotine. By the time sensation returns to the scalp, the Endotine is likely to have disintegrated and is gone.
Perfecting The Procedure
Over the last five years, I have become increasingly sensitive to the aesthetic anatomy of the hairline, the differences between the male and female hairline, and the blending-in of the front hair to the temporal hair. This is very important to me when I design the irregular incisions which are mirrored by the new lowered frontal hairline. Through the negative experience of others, I found that you cannot get a good scar if you try to advance the temple hairline (acutely downward-growing hairs that sometime extend to overhang the eyebrows) with the hairline lowering operation. If this area needs to be advanced which narrows the forehead, follicular unit grafts are the only way to go in my opinion. A grafting session can be done the same time the hairline is surgically lowered.
Over the years, I found that I can assess the suitability for the one-stage operation for patients by evaluating the mobility of their scalp. This is discussed elsewhere on the website. This is an important clinical judgment that is very hard for me to transfer to someone else so then to have some very general rules.
For those who need a large amount of advancement and have tight scalps, the two-stage operation which involves the first stage of tissue expansion is imperative. With this done, we have moved scalps as far as 10 cm. Also, this modality is excellent for treating people who have large areas of hair loss from injuries, burns, and radiation therapy. I have experience with the scalp expansion going back to the early 80’s which I would think by now is amongst the longest ongoing experience in the world.