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ORIGINAL ARTICLE
Year : 2022  |  Volume : 30  |  Issue : 4  |  Page : 108-114

Forehead reduction and hairline lowering surgery: Aesthetic implications


Dr. Öreroglu Clinic, Private Practice, Istanbul, Turkey

Date of Submission05-Jul-2022
Date of Acceptance22-Jul-2022
Date of Web Publication09-Sep-2022

Correspondence Address:
Dr. Ali Riza Oreroglu
Maçka St. No: 24/28 Narmanlı Apt. Teşvikiye, Nişantaşi, 34367 Şişli, Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_45_22

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  Abstract 


Background: Forehead reduction and hairline lowering is an underestimated yet important procedure in facial beautification. Proportions of the forehead to the midface and lower face can be corrected with this surgery as well as addressing changes in hairline positioning. Objectives: The aim of this paper was to describe in detail the author's approach to hairline lowering and forehead reduction procedures with emphasis on implications to increase the aesthetic outcome. Methods: The procedure was performed under general anesthesia in a single-stage approach with the following algorithm: pretrichial incision, subgaleal dissection and preparation of a parieto-occipital scalp flap, multiple horizontal galeotomies, scalp advancement and fixation, and finally forehead skin excision and closure. Results: Forehead reduction and hairline lowering surgery was performed on 17 female patients aged between 19 and 42. Forehead length reduction was measured between 1.7 and 4.2 cm. The patients were followed up for 6 months to 3 years. Conclusions: Forehead reduction hairline lowering is an underestimated yet aesthetically important procedure for correcting facial harmony, beautification, and rejuvenative purposes. Following certain planning and technical details can help the surgeon apply the procedure properly, minimizing the risks for major and minor complication and achieving aesthetically successful results.

Keywords: Browlift, forehead reduction, foreheadplasty, hairline lowering


How to cite this article:
Oreroglu AR. Forehead reduction and hairline lowering surgery: Aesthetic implications. Turk J Plast Surg 2022;30:108-14

How to cite this URL:
Oreroglu AR. Forehead reduction and hairline lowering surgery: Aesthetic implications. Turk J Plast Surg [serial online] 2022 [cited 2022 Oct 5];30:108-14. Available from: http://www.turkjplastsurg.org/text.asp?2022/30/4/108/355814




  Introduction Top


Forehead aesthetics is an underestimated yet important aspect of facial beautification, the proportions of which contribute to overall facial harmony and beauty. Balance between the forehead, midface, and lower face can be corrected with corrections of retrognathia/micrognathia, midfacial, or forehead volumizations and changes in hairline positioning.

The “rule of thirds” is a simple yet effective way of determining facial proportions.[1] A practical method, this rule of thumb specifies that a beautiful face should have proportions where the forehead height is a third of the total facial height, and almost equal to midfacial and lower facial thirds.[1],[2] Meanwhile, an elongated forehead can be correlated to aging, leaving forehead reductions a contribution to rejuvenative purposes.[3]

A high hairline, on the other hand, can be more prevalent in certain ethnicities resulting in self-esteem problems. Patients in this group usually seek for a hairline lowering surgery while others request a forehead reduction. The forehead reduction procedure is an effective approach to address these requests with almost immediate and noticeable results.[4]

Various facial rejuvenative techniques for brow elevation including the endoscopic approach can result elongation of the forehead and posterior displacement of the frontotemporal hairline.[5] A proper assessment and analysis of the facial proportions is, hence, mandatory for surgical technique planning in this anatomical region.

This article aims to describe in detail the author's approach to hairline lowering and forehead reduction procedures with emphasis on implications to increase the aesthetics outcome.

[TAG:2]Materials And Method [/TAG:2]

The ideal patient for forehead reduction and hairline lowering surgery is typically a female with a congenital long forehead and a high frontal hairline with no history of progressive hair loss. It should be kept in mind that a long forehead is one that causes disproportionality of the upper third of the face compared to the middle and lower thirds.[1],[2],[3],[4],[5],[6]

Good candidates have a good scalp mobility, no scalp disease, and no prior scalp surgery, all assessable with preoperative examination. Scar quality history should be assessed, and the pros and cons and the placement of the scar discussed in detail with the patient. A patient with a poor scalp mobility and fragile hair is a poor candidate for this surgery. Heavy smokers and patients with a history of stress-induced or unexpected hair loss or those with significant scalp disease (such as alopecia areata) should be considered as contraindications for this surgery.[2]

Planning starts with forehead measurement [Figure 1]. A standard point should be marked on the glabella, preferably at the interbrow area or on the medial brow end. The average female forehead measured from this point to the frontal hairline is usually 5–6.5 cm where longer measurements are diagnosed as high hairlines.[7] Mobility of the scalp and forehead should be assessed manually with the aim to plan the extent of the skin to be removed safely. On average, a 2-cm skin reduction is applicable in a single-stage procedure, where on an 8 cm long forehead will contribute to a 25% lowering of the hairline.[7]
Figure 1: Preoperative planning for forehead reduction. A standard point should be marked on the glabella, preferably at the interbrow area or on the medial brow end for standard measurement

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Marking

The incision is marked within the fine vellus hair along the existing hairline strictly following its natural irregular undulating pattern [Figure 2]a. A more posterior (intratrichial) incision planning will result in elimination of the fine hairs and a less natural appearing hairline due to the immediate coarse scalp hair eruptions at the hairline deprived of a natural transition.[1] Laterally, the marking is then curved posteriorly and extended onto the temporal scalp for approximately 2.5 cm and then inferiorly for another 0.5–1 cm to prevent a dog-ear formation [Figure 2]b. Care should be taken to avoid planning the incision over the posterior branch of the superficial temporal artery.
Figure 2: The incision is marked within the fine vellus hair along the existing hairline. (a) The natural irregular undulating pattern is followed, (b) posterior extension onto the temporal scalp should end with a back-cut 1 cm to prevent dog-ear formation

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The new hairline is then marked anteriorly on the forehead reflecting the irregular undulating pattern marked previously. Another marking line in between these previous lines can be drawn to allow for a safe tension-less excision plan [Figure 1] and [Figure 2]a, [Figyre 2]b.


  Surgical Technique Top


The operation is performed under general anesthesia in the supine position with the head slightly elevated to facilitate flap dissection. The incision lines are infiltrated with local anesthesia(2% prilocaine 10 ml, 0.5% bupivacaine 10 ml 0.5 mg adrenaline) for hemostasis and postoperative pain-free comfort.

The procedure is performed in a single-stage approach with the following algorithm: pretrichial incision, subgaleal dissection and preparation of a parieto-occipital scalp flap, multiple horizontal galeotomies, scalp advancement and fixation, and finally forehead skin excision and closure.

The incision is made at the hairline beveling forward or backward (depending on the hair natural exit) at an angle perpendicular to the eruption angle of the hairs hence new hair from the buried follicles will grow through the scar creating a natural scar pattern and help conceal it.[1],[2],[3],[4],[5],[6],[7],[8] This planning is changed to a more parallel incision pattern in the temporal extension to avoid injury to the temporal hair follicles. The incision is carried to the subgaleal plane [Figure 3]a. Infiltration and care to avoid the posterior branch of the superficial temporal arteries will enable minimal bleeding. Extra care must be exercised as the galea is incised over the temporal crest as the deep branch of the supraorbital nerve (nerve of Knize) lies on the periosteum 1–2 cm medial to it.[9] Subgaleal preperiosteal dissection is then performed easily and rapidly posteriorly up to the nuchal ridge and laterally to the limits of the galea, taking care to avoid injury to the occipital arteries [Figure 3]b.
Figure 3: Flap preparation. (a) The incision extends up to the subgaleal space, (b) subgaleal preperiosteal dissection up to the nuchal ridge and laterally to the limits of the galea

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Anteriorly, the forehead is undermined in the same plane up to 2–3 cm above the brow (to prevent elevation of the brows). If a browlift is desired, the dissection can be extended caudally to release the brows, hence superior advancement of the forehead flap while closure [Figure 4].
Figure 4: Dissection extended caudally to release the eyebrows for advancement and elevation of the forehead upon closure

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The elevated scalp flap is then extended inferiorly and galeotomies planned horizontally (1.5–2 cm apart) to allow advancement of the flap caudally [Figure 5]a. Extra care should be taken at this stage to control the depth of these incisions. A #15 blade is used to score the galea under loupe magnification until the overlying subcutaneous fat is visible. It is of great importance not to use electrocautery at this stage to prevent disturbance of the flap blood supply and thermal injury of the hair follicles [Figure 5]b. Each line of galeotomy provides a gain of approximately 1–2 mm flap advancement.
Figure 5: Galea scoring. (a) Galeotomies planned horizontally 1.5–2 cm apart to allow advancement of the flap caudally, (b) each line of galeotomy provides a gain of approximately 1–2 mm flap advancement

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The scalp is advanced inferiorly and anchored to the cranial bones using 3/0 Ethibond sutures with the help of converging cortical tunnels created bilaterally using a 3 mm drill, 2–4 cm posterior to the new frontal hairline [Figure 6]. This is essential to prevent posterior scalp displacement and to relieve the closure line from tension and hence a high-quality scar formation.
Figure 6: The scalp is advanced inferiorly and anchored to the cranial bones. (a) Scalp advancement and stabilization bilaterally 2–4 cm posterior to the new frontal hairline, (b) converging cortical tunnels are created using a 3 mm drill, (c) permanent sutures are used to stabilize the galeal fixation

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Once the desired advancement is reached, the strip of skin to be removed is excised meticulously matching the undulating and beveled pattern of the hairline incision [Figure 7]a. This excision should be a composite including the skin, frontalis muscle and galea [Figure 7]b.
Figure 7: Skin excision. (a) Facelift skin excision measurement instrument can be used to facilitate skin excision planning, (b) excision includes the skin, frontalis muscle and galea

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The galea is reapproximated using interrupted 4/0 Monocryl stiches allowing a tensionless fine closure at the skin edge [Figure 8]. The skin is then closed using a 6/0 Prolene suture in a continuous over-and-over fashion at the frontal hairline and using surgical staples at the temporal incision. No drain is placed [Figure 9].
Figure 8: Galea re-approximation for a tensionless fine closure at the skin edges

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Figure 9: Skin closure

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Long-acting local anesthetics administered during the surgery along the incision lines help to increase patient comfort. Edema is usually minimal and periocular and forehead ecchymosis are rare. Extending the dissection onto the eyebrows for the purpose of brow elevation however can increase the edema and bruising in this area. Finally, suture and staples can be removed 4–6 days after the surgery, keeping in mind that it is the deep layer holding the flaps together.


  Results Top


Forehead reduction and hairline lowering surgery was performed on 17 patients over a 5-year period. Patients ranged in age from 19 to 42, all being female. Forehead length reduction was measured in the 1.7–4.2 cm range [Table 1]. Significant improvement in facial proportions was demonstrable subjectively corresponding to a high patient satisfaction level, questioning the patient about the overall results with forehead reduction and hairline lowering and the quality of the scar [Figure 10], [Figure 11], [Figure 12].
Table 1: Demographic data of the patients

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Figure 10: A 20-year-old female patient undergone forehead reduction hairline lowering surgery combined with browlift. (a) Preoperative frontal view, (b) preoperative right oblique view, (c) preoperative right lateral view, (d) postoperative result frontal view, (e) postoperative result right oblique view, (f) postoperative result right lateral view

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Figure 11: A 19-year-old female patient undergone forehead reduction hairline lowering surgery combined with bilateral browlift. (a) Preoperative frontal view, (b) preoperative right oblique view, (c) preoperative right lateral view, (d) postoperative result frontal view, (e) postoperative result right oblique view, (f) postoperative result right lateral view

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Figure 12: A 39-year-old female patient undergone forehead reduction hairline lowering surgery combined with forehead lift and ethnic rhinoplasty. (a) preoperative frontal view, (b) preoperative right oblique view, (c) preoperative right lateral view, (d) postoperative result frontal view, (e) postoperative result right oblique view, (f) postoperative result right lateral view

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Complications and risks in this procedure include bleeding, infection, telogen effluvium (stress hair loss) and scalp necrosis.[7] In addition, minor complications such as postoperative scar widening, scar visibility, future hair loss, hypopigmentation, hyperpigmentation, and the requirement of hair transplantation options should be discussed with the patient preoperatively. No major complication was observed in the series. Frontal scalp sensation alterations can last for months and hence should also be discussed with the patient in detail before the operation. One patient complained of persistent scalp paresthesia. No scar revision has been performed till today. Patients were followed up for 6 months to 3 years, the average being 1 year 8 months.


  Discussion Top


Although a pretrichial (hairline) incision may seem aggressive to some patients seeking this surgery, it is in fact a very safe and effective yet beautiful scarred surgical approach. Immediate results are satisfactory for the patient whereas a good planning and surgical technique yields to high-quality and acceptable scars. Nevertheless, not every forehead is appropriate for this technique, and it should not be considered as a universal approach to every hairline lowering.[1],[5],[10]

A high hairline can look disproportionate to the face and can be recognized as an aged appearance. Therefore, a forehead reduction surgery aims at both a rejuvenative and a beautification goal. Combining this with management of the eyebrows enables achieving more aesthetic results with the same approach. A proper consultation and planning with the patient beforehand enables customization of the approach to every individual keeping in mind that every facial anatomy has its own proportions that need to be addressed individually. Nevertheless, transverse crease reduction, frown line corrective procedures and brow positioning maneuvers can be incorporated as part of the foreheadplasty procedure. The surgeon should not underestimate the procedure and focus mainly on a hairline lowering target. These adjunct results should be discussed thoroughly with the patient, and their importance emphasized with this surgery.

The importance of a pretrichial approach versus an endoscopic browlift or forehead lift technique should be differentiated properly for the patient. Sometimes, patients are unaware of the differences these techniques have and their effects on the hairline position. Although both can elevate the eyebrow, the surgeon should make sure the patients understands the hairline lowering and balancing capability of the forehead reduction surgery as compared to the unintended and unwanted elevation of the probably already high hairline in the endoscopic approach. This can eventually lead to a more disproportional facial anatomy and trigger an aged look.

The use of a galea aponeurotic plication technique[5] with a pretrichial incision can prevent posterior displacement of the hairline during foreheadplasty, however this technique will result only in shortening of the forehead and not true hairline lowering. A mobilized scalp flap with release of the galea is the only way to make true hairline lowering possible.[2]

It is important to recognize that the hairline lowering and forehead reduction surgery is mostly beneficial to patients with a scalp redundancy and good scalp mobility. Not every patient will benefit equally from this procedure. A healthy scalp skin and hair is one of the key important factors for good results. Patients who have undergone prior scalp surgery, previous foreheadplasty, hair transplants or those who are heavy smokers are less likely to benefit from this procedure. Patients undergone previous endoscopic temporal lifts, however, can be good candidates as these procedures are typically performed in the subperiosteal plane.

Hairline lowering can also be utilized for indications in hair transplant surgery. This approach can reduce the number of transplants and total sessions required for frontal hairline reconstruction. Meanwhile, it can also help correct postsurgical deformities resulting from poorly operated previous hair transplant procedures.[2]

Hairline lowering forehead reduction is a time-consuming and technically demanding procedure, promising aesthetic improvement and balance to facial proportions while dealing with a scary incision and potential scar. Promising results can be achieved should one follow a few simple practical implications:

Incision

Undulating and the irregular pattern of the frontal hairline should be strictly followed with proper incision beveling enhance through-scar hair ingrowth [Figure 13].
Figure 13: Scar quality 4 months after surgery. Note growth of buried fine hair follicles through the scar

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Tension

Closure should be strong, but tension should be restricted specifically to galea. The skin should be tensionless while galea should be stabilized to the calvarium.

Scoring

Meticulous care should be given while scoring the galea to prevent ischemic complications and postsurgical alopecia.

Dogear

The temporal extension of the incision should include a back-cut top enable proper flap extension and prevent a dog-ear formation.

Browlift

The position of the eyebrows and required lifting should be planned in advance and the forehead/brow lift incorporated into the surgery. This enables achievement of multiple aesthetic outcomes with a single procedure.

Selection and customization

Not every patient is a good candidate for this surgery. Proper patient selection and customization of the surgery for their individual anatomy is an important key in achieving aesthetically pleasant results.


  Conclusions Top


Forehead reduction hairline lowering is an underestimated yet aesthetically important procedure for correcting facial harmony, beautification, and rejuvenative purposes. Following certain planning and technical details can help the surgeon apply the procedure properly, minimizing the risks for major and minor complication and achieving aesthetically successful results.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Connell BF, Marten TJ. The male foreheadplasty. Recognizing and treating aging in the upper face. Clin Plast Surg 1991;18:653-87.  Back to cited text no. 1
    
2.
Marten TJ. Hairline lowering during foreheadplasty. Plast Reconstr Surg 1999;103:224-36.  Back to cited text no. 2
    
3.
Ricketts RM. Divine proportion in facial esthetics. Clin Plast Surg 1982;9:401-22.  Back to cited text no. 3
    
4.
Ramirez AL, Ende KH, Kabaker SS. Correction of the high female hairline. Arch Facial Plast Surg 2009;11:84-90.  Back to cited text no. 4
    
5.
Hamas RS, Rohrich RJ. Preventing hairline elevation in endoscopic browlifts. Plast Reconstr Surg 1997;99:1018-22.  Back to cited text no. 5
    
6.
Connell BF. Facial rejuvenation. In: Brent B, editor. The Artistry of Reconstructive Surgery. St. Louis: Mosby; 1987.  Back to cited text no. 6
    
7.
Kabaker SS, Champagne JP. Hairline lowering. Facial Plast Surg Clin North Am 2013;21:479-86.  Back to cited text no. 7
    
8.
Mayer TG, Fleming RW. Aesthetic and Reconstructive Surgery of the Scalp. St Louis (MO): Mosby-Year Book; 1992. p. 121-4.  Back to cited text no. 8
    
9.
Knize DM. A study of the supraorbital nerve. Plast Reconstr Surg 1995;96:564-9.  Back to cited text no. 9
    
10.
Connell BF, Lambros VS, Neurohr GH. The forehead lift: Techniques to avoid complications and produce optimal results. Aesthetic Plast Surg 1989;13:217-37.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]
 
 
    Tables

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Abstract
Introduction
Materials And Method
Surgical Technique
Results
Discussion
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