The female hairline is variable in position. In the ideal situation, the hairline is 5 to 6.5 cm above the brows and usually begins at some point where the scalp slopes from a more horizontal position to a more vertical one. This allows for versatility with hairstyling and the aesthetic vertical thirds of the face are equal, providing facial harmony and balance.
In contrast, there are a number of women who have an hereditary high hairline (or big forehead). These patients have a hairline that is usually stable after puberty and have normal density and volume behind it. Many ,however, are often unhappy with this situation. The appearance of a high hairline makes women look masculine and/or older than their years. The associated big forehead is unattractive and their hair styling is often limited to combing downward (bangs) for camouflage. Occasionally, the hairline is so high and posterior that the hair will exit the scalp at a less acute angle or even perpendicular to the ground. Hair thus does not fall effectively and the upper third of the face can be so disproportionate that patients appear to have hair on only the back half of the scalp. These women with high hairlines will often present to the transplant surgeon requesting lowering of the hairline.
Hair transplantation can be used quite effectively to treat these patients. Follicular unit grafting is an effective treatment that has a low incidence of complications and is certainly the standard for hair restoration work. This technique, however, is labor intensive, time consuming, and can be expensive, especially since these patients often require multiple sessions to achieve the 2-4 cm of hairline lowering required with the full density acceptable to women. In addition, women may have to wait for 2-4 years of growth to see the full result after transplantation.
We present an alternative technique that produces outstanding results rapidly, is readily acceptable to patients, and has rare complications.
The flexibility of the scalp and upper forehead is the single most important factor for the success of this operation. Once it is determined that a prospective candidate has adequate scalp laxity and fits the other criteria for this procedure, a surgery date is selected. We do the operation under “twilight sleep” intravenous sedation and local anesthesia. This is the same totally comfortable routine we use for most of our hair transplant patients.
We start by making a non-repeating, irregular trichophytic incision within the fine hairs of the anterior hairline. Future disguise of the resulting scar depends on hair growing through and in front of it. This incision cuts across the hair shafts but leave the bulbs of the hair follicles intact. This allows hair growth through the edge of the forehead skin virtually concealing any scarring.
We try to create a similar transition zone as seen in follicular unit grafting. The hairline subsequently appears natural and undetectable.
After the incision, the scalp is lifted off of the skull all the way to the back of it . Dissection in this plane is rapid and bloodless. In the forehead, dissection in this same plane is done to just below where we want the hairline. The scalp is then advanced forward and the excess non-hair bearing forehead skin is excised with an incision that is parallel to the beveled trichophytic incision.
The wound is closed in two layers. The deep layer of the scalp is closed for strength and to approximate the wound edges. The skin closure is done with delicate fine stitches. To ensure a good cosmetic result, there is no tension on the skin closure.Other maneuvers such as incisions on the undersurface of the scalp ( galeotomies) and the placement of one or two dissolvable tack-like devices (Endotines) are usually incorporated to get optimal results. A light dressing is placed and removed on the first post-operative day. A cosmetic result is appreciated immediately.The hair may be combed downward and there is minimal bruising and edema. Sutures are removed 4-7 days.
Many patients have resumed working and social actives in 2-5 days. Our out of town patients usually travel home one or two days after surgery.
There are two variations with this procedure that have proved useful. First, if the hairline needs to be advanced a large distance or if the scalp is tight, a tissue expander (a balloon-like device similar to an inflatable breast implant) may be required. This is done as a staged procedure, with placement of the expander as the first stage and advancement of the hairline as the second stage. Typically, the balloon is expanded over a 6-week period, e.g. 75-100 cc per week, to stretch the scalp sufficiently to allow for 4-6 cm of advancement. This is well tolerated by patients aside from the increasing cosmetic inconvenience during the last three weeks of the expansion. Ten percent of patients seem to require this expansion process.
The second variation of this procedure is to combine the hairline advancement with a brow lift. For this procedure, the forehead dissection is extended below the orbital rims and the frown muscles may be cut or cauterized from their undersurface. Before the skin excision and closure , the brows are fixed at the desired level.
The most important concern to this technique for hairline advancement is the possibility of a noticeable or unsightly scar. The technical points of the trichophytic incision are critical in avoiding this complication. As the hair grows and the wound matures, the scar will become virtually non-existent. Hair grafts could later be performed if the scar were visible. This may be recommended preoperatively when there is a pre-existing cowlick at the hairline. Overall, patients tolerate this procedure very well.
Patients always report decreased sensation of the frontal scalp, but this resolves by 6 months. Other complications, such as significant shock loss have been rare, no more so than with dense packed follicular unit grafting.
The cost effectiveness of this procedure is significant when we consider time for hair growth and the absolute number of hairs moved. The average case of a 15 cm hairline moved down 2.5cm relocates over 3000 follicular units or over 7000 hairs. If scalp expansion is required the cost effectiveness goes down somewhat on those with tight scalps but it is counterbalanced by the movement of much more hair in those who require greater than 3 cm of movement