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Dr. Barry Eppley

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Archive for the ‘forehead reduction’ Category

Reduction of the Long Female Forehead with a Hairline Advancement

Sunday, February 13th, 2011

One of the important features of forehead aesthetics is its size, which is primarily judged by its height or length. The length of a forehead is the amount of skin that exists between the eyebrows and the frontal hairline. While this is understandably variable in a man, the more stable frontal hairline of a women allows the forehead length to be critically assessed and more aesthetically important. Women with naturally high (long) foreheads often camouflage them with their hairstyles. But some would be interested in forehead shortening or hairline lowering.

The most pleasing amount of forehead show varies amongst women, but the ideal female hairline is usually no more than 6 cms. from the upper edge of the eyebrows. This is usually where the transition occurs into the vertical slope of the forehead. When the hairline is too high, it is displaced behind this transition zone into the more horizontal slope of the forehead. This is a masculinizing look. Some women are able to hide their high forehead with bangs but other women’s hair qualities may not permit such camouflage.

The high female hairline becomes particularly problematic when most forms of a browlift are being considered, particularly the endoscopic browlift. In this type of browlift, the frontal hairline moves backward as the brows move up due to an overall backward epicranial tissue movement. Because of the scalp location of the upward pull, the hairline actually moves back further than the amount the brows are lifted. This makes an endoscopic browlift in a patient with a long forehead aesthetically disadvantageous.

The most important consideration for forehead shortening is one’s scalp flexibility. Some scalps are tightly adherent and will not stretch much. A more loose scalp, as determined by how easily the frontal hairline moves forward, is necessary for a visible amount of forehead reduction. The density and hair shaft quality is also important so that the eventual fine line scar is not noticeable.

The forehead reduction is performed through an incision just inside the fine hairs of the frontal anterior hairline. But putting the incision there, hairs will grow through the scar and help hide it better.Once the incision is made, the skin and forehead tissues are raised down to the bone level a few centimeters to where the projected amount of forehead skin is to be removed. If a browlift is being simultaneously done, then the forehead tissues is lifteddown to the brow bones. Behind the hairline, the entire scalp is freed up all the way back to the back of the head. This adds significantly to any scalp looseness and is necessary in every patient. The scalp is then brought forward and overlapped on top of the forehead skin. The typical amount of advancement obtained is usually around 1.5 to 2 cms. Occasionally it may be as much as 2.5 cms. The edge of the scalp advancement is marked on the forehead skin to safely determine how much can be removed. The measured amount of forehead skin is then removed.

As part of forehead shortening, frontal bone bossing can also be reduced. The bulging outer forehead bone, which is just in front of the high hairline, can be shaved down at least 3 or 4mms. A lower frontal hairline with some upper forehead bone flattening can make a big difference in the appearance of the upper forehead.

One of the key elements of hairline lowering is bone fixation of the scalp and forehead flaps at the time of closure. The forehead skin must not be lifted up and the scalp flap containing the hairline must not be pulled backwards. This requires absolute stability at the union of these two tissue edges. I prefer suture fixation to the bone through angled holes made in the outer cortex of the skull. The galea (deeper layer under the skin) of both the scalp and forehead are sutured down to the bone. The skin is closed independent of these bone fixation sutures and results in a tension-free closure.

This hairline advancement procedure is an extremely effective method of shortening the high hairline in women. With adequate scalp looseness, this is a relatively simple one-stage improvement of the problem. But if the hairline must come forward much more than an inch (greater than 2.5 cms), the concept of tissue expansion and a two-stage approach must be considered. Thisrequires the initial placement of an inflatable balloon behind the frontal hairline. This is inflated over weeks creating a stretch of the scalp that could otherwise not be done. Then the actual forehead reduction can be performed with the extra scalp tissue created. Depending upon how much tissue expansion is done, the frontal hairline can be advanced up to two or three inches.

Advancement of the female hairline and shortening of a high forehead is extremely effective, has few complications, and has a quick recovery. Although there is a resultant hairline scar, it usually heals well and is worth the trade-off for the amount of forehead length reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Reduction of the Long Forehead and Frontal Bossing

Saturday, July 17th, 2010

Background: The appearance of the forehead, the upper third of the face, is influenced by several factors. The shape of the underlying frontal bone, the amount of forehead skin that is seen between the hairline and the eyebrows, and the degree of wrinkling in the forehead skin are all factors that create an impression. From a structural standpoint, the bone (whether the forehead is more rounded or flat) and the amount of vertical forehead skin are the fundamentals of forehead aesthetics.

The forehead should have a very slightly convex shape when seen in profile. It is never aesthetically beneficial to have a completely flat forehead but its convexity should only be slight. Too much convexity gives it a bulging or too prominent appearance. A straight line drawn from the frontal hairline to the eyebrows in profile should show only a small amount of forehead skin about it. The amount of visible forehead skin should generally be no greater than 6.5 cms between the eyebrows and the frontal hairline. This is in keeping in line with the well known anthropometric concept of the facial thirds. When it exceeds this vertical measurement, it will usually appear too long in women. For men, a long forehead is more acceptable and often completely unavoidable due to alopecia and hairline recession.

Case Study: This is a case of an 18 year-old female who had been bothered by her forehead since she was very young. She felt that it was too long and had an unattractive bulge to it. It distressed her greatly and affected how she would wear her hair. (never pulled back) She felt it made her look unusual and older than she was.

Examination showed that her hairline to brow measurement was 7.5 cms at her slight widow’s peak in the midline. The temporal hairline was even further back. In profile, there was some frontal bossing in front of the hairline which was quite evident.

The surgical plan for her forehead correction involved three steps. A hairline incision into the upper temporal areas for exposure. Then the forehead skin would be reflected down to just above the eyebrows to allow for burring down of the outer cortex of the forehead skull at its most projecting point from one side of the forehead to the other. The hair-bearing scalp would then be undermined back to the back of her head and then advanced forward. Together, these maneuvers would reduce her forehead bulge and shorten her forehead length considerably.

During the procedure, it is important to note that the forehead bone can only be reduced so much. Only the outer table can be reduced and it is a good idea to leave a very thin layer of cortex over the diploic space. The bone should not be reduced to the point of total diploic space exposure. This makes for a lot of bleeding but also will likely cause overlying forehead irrergularities in the skin as it heals to a non-smooth surface. This means that the forehead can usually be reduced only between 3 to 5 mms.

An important technical point is the need to secure the scalp advancement to the bone once it is brought forward. This is done by securing it with sutures to the bone through drilled holes or suture anchors. This is important to maintain the hairline position as it heals but also take tension off of the closure to prevent scar widening.

This is her appearance the very next day at the time of her dressing removal. While there is some obvious swelling in the forehead skin and eyebrows, the change in the hairline position and shape of the frontal bone is immediately apparent. She may wash and style her hair the very next day. She will not develop any bruising or significant swelling of the eyes. Her scalp will remain numb for months which is typical.

Case Highlights:

1) The long forehead can be reduced by a scalp advancement procedure. This requires an incision along the hairline and a resultant fine-line permanent scar. Forehead bone recontouring can be done at the same time. Often when the frontal hairline is too far back, there will be an accompanying bony bulge.

2) Forehead reduction is very much the close cousin to an open hairline (pretrichial) browlift. It is, in essence, a reverse browlift.

3) While the operation sounds daunting, its recovery is quite quick with much less discomfort than one would think.


Dr. Barry Eppley

Indianapolis, Indiana

The Long Forehead – Combining Scalp Advancement and Browlifting

Tuesday, June 22nd, 2010

Browlifting is often a frequent component of eyelid rejuvenation. The tired look around one’s upper eyelids may be magnified by a low and falling eyebrow position. The combination of a browlift can make an upper blepharoplasty result look eve better and, at the least, reduce the amount of upper eyelid skin that needs to be removed.

One important consideration in a browlift procedure is it’s impact on forehead length. Of the different types of browlift techniques that are available, most will lift the brows at the expense of lengthening the forehead. This is because any browlift method that uses an incision behind the frontal hairline, albeit a long transverse incision or even an endoscopic approach, pulls back the hairline. As the brows move up, the hairline moves back. By actual measurement and based on proximity to the point of pull, the hairline moves back further than the brow moves up. (this is because the brow is furtherest from the point of pull)

For the women with an already long forehead, the proper browlift technique is done at the hairline. Known as a pretrichial or hairline browlift, the brows are lifted and the excess skin removed right at the hairline. As a result, the frontal hairline does not change. This does result in a very fine line scar right along the frontal hairline but with good hair density and hairstyle, it is not noticeable.

But what of the patient who already has a long forehead and is in need of a browlift? Long foreheads can be shortened by forehead skin removal and bringing the scalp flap forward. But can this be done at the same time as a browlift? The answer is yes. One may wonder how two skin flaps, with diametric movements, can converge and be stable. The key is to secure both skin flaps to the frontal bone. To prevent undesireable scar widening and some degree of flap relapse, a secure anchoring point is needed. The bone fixation point is generally about 2 cms. in front of the existing hairline. Using either outer cortical bone holes or suture anchors, sutures are used to secure the deep layers of both scalp and forehead skin flaps to these points after skin removal and dual flap elevation. The scalp flap can usually be advanced 2 cms. (hence the bone fixation point). The forehead flap which lifts the brow does not usually need to be elevated more than 7 to 10 mms, lest one develop the ‘deer in the headlights’ look after surgery.

Browlifting can and should incorporate forehead reduction in the patient who already has a long forehead. Shortening a forehead adds a rejuvenating effect that nicely complements the correction of brow ptosis. When properly done, it does not increase the risk of unfavorable scarring and any other risks of the procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Common Questions on Forehead Reshaping and Contouring

Monday, February 8th, 2010
  1. What influence does the forehead have on one’s appearance?

The forehead is a very prominent and visible facial area. While it is not the most dominant facial feature, it does have an influence on one’s appearance in numerous ways.

The forehead does have an influence on gender appearance. In men, the brow ridge (bossing or prominence above the eyes) is stronger and the forehead angles more steeply away from the eyes. In women, the forehead does not have a prominent brow ridge, tends to be more round, and angles more vertical above the brow rather than more backward sloping as in men.

A forehead can often be seen as too ‘big’ because of the distance between the eyebrows and the frontal hairline. When more than 6.5 cms exists between the two, the forehead will look elongated or large. This may be the result of frontal hairline recession in men or the natural position of the hairline in women. 

2. How is forehead reshaping done?

Changing the shape of the forehead can be done in three ways. Brow ridge (bossing) reduction, brow ridge augmentation, or altering the slope or shape of the forehead between the brow bone and the top of the skull under the hairline are the common changes requested.

They all share one common theme, the need to use a coronal or scalp incision for access to do the procedure. This is a more significant aesthetic consideration in men. Surgically changing the brow bone uses different techniques depending upon whether one is reducing or building it up. While some minor bone alterations may be able to be done endoscopically (from above) or through the upper eyelids (from below), major changes require the liberty of unfettered access by the turn down of a scalp flap.

3. How is brow bone reduction done?

In brow bone reduction, the anatomy of the prominent brow must be appreciated. The cause of a prominent brow is that the underlying frontal sinus cavity is expanded. (pneumatized) Because the frontal sinus is air-filled, the prominent brow ridge only has  thin bone covering it. It can not just be burred or shaved down in most cases. Only the tail of the brow ridge, where the frontal sinus does not exist, can be simply reduced by shaving.

In the setback of frontal bossing, the thin plate of overlying must be removed, reshaped, and put back in place with small titanium plates and screws (1mm profile) to hold the bone in place while it heals.

A plain lateral skull film or cephalometric x-ray will show how much frontal bossing is caused by air vs. actual bone. 

4. How is brow bone augmentation done?

Building up a deficient or over-reduced brow ridge requires the use of synthetic materials which are added on top of the bone. The two most commonly used cranioplasty materials are acrylic (PMMA) and hydroxyapatite. (HA) Each material has its own advantages and disadvantages and either one can work in experienced hands.

PMMA incurs less cost to use and has a very high impact resistance. HA is more expensive with a lower impact resistance to trauma. Both can be impregnated with antibiotics and shaped during the procedure. How much material to add and where to place it is very much like sculpting and requires a thorough discussion before surgery with the patient.

Solid implants, composed of silastic, Gore-tex, or Medpor, can also be used. They require more effort at shaping and must be held in place with tiny titanium screws. Their cost is intermediate between PMMA and HA.

5. Can other areas of the forehead be reshaped besides the brow bone?

The forehead (frontal bone) between the brow ridge and the front of the hairline can also be reshaped. It can be made flatter, more round, narrower, or wider. Changes can be done in either profile, width, or both. This is done through either burring of the prominent areas, adding material on deficient areas, or a combination of both.

6. What is the recovery after forehead reshaping? What complications can occur?

Aesthetic forehead surgery is usually done as an outpatient procedure. Depending upon what other procedures may be done with it, it may require an overnight stay in the surgical facility. A wrap-around forehead dressing is put on at the end of surgery and is removed the next day. In some cases, a drain may be removed (not commonly) and it is removed the next day also. Ther6e is some mild pain afterward but much of the forehead skin will be numb for awhile. Pain is easily controlled by pills. There will be some swelling afterwards which is driven downward by the dressing and gravity which affects the eyes and upper cheeks. It is most evident by two days after surgery and is largely gone within seven to ten days after surgery. Most patients return to work in two to three weeks. Dissolveable sutures are used in the scalp so there is no need for suture remocal. One can return to working out in two weeks after surgery.

Complications of significance are very rare with forehead surgery. The forehead skin will be numb but normal feeling will return in most patients within six to eighty weeks after surgery. It is possible to not get back all of your feeling. The biggest concern is aesthetic…did we achieve what our goal was? Is the forehead contour smooth and even? Is it too much or too little?

7. What can I do if my forehead is too long?

Usually a long forehead is a female concern. It is evident when the distance between the eyebrows and the frontal hairline is aesthetically too long, usually greater than 6.5 or 7cms in length.

The length or size of the forehead skin can be reduced by a scalp advancement (hairline lowering. This is conceptually a ‘reverse browlift’. An incision is made at the frontal hairline and the scalp behind it is loosened and brought forward over the fixed forehead skin. The underlying forehead skin is then removed and the hairline closed in its new lower position. A frontal hairline can be advanced between 1 and 2.5 cms, which often makes for a significant difference. 

Dr. Barry Eppley

Indianapolis, Indiana

Combination Browlift and Forehead Reduction in Women

Thursday, July 16th, 2009

Browlift surgery is a common plastic surgery procedure for rejuvenation of the upper third of the face. Gravity and facial expressions work together to create a low downward progression of the eyebrows in some people. This lengthens the forehead skin between the frontal hairline and the eyebrows. (for those patients that still have a frontal hairline!)This Taken together both can give one a tired and aged appearance.

Browlifts can be done in variety of ways which differ primarily in where the incision is made. Most browlift surgeries, however, produce an upward elevation of the eyebrows at the expense of actually lengthening the forehead skin or distance between the eyebrows and the hairline. In many patients, this forehead lengthening is not significant or irrelevant given their preoperative forehead length. However, for those with a long forehead to start, a longer forehead may not be a good aesthetic trade-off for higher brows.

Only one type of browlift can simultaneously lift the eyebrows and shorten the forehead length. (and even bring the frontal hairline down lower if desired) Known medically as the pretrichial browlift, it is better described as a hairline browlift. Rather than make a traditional browlift in the scalp behind the frontal hairline, the incision is made just at or a few millimeters behind the leading edge of the hair. This approach provides not only a shorter distance down to the muscles between the eyebrows but does not change or move back the hairline when the brows are lifted. The extra forehead skin (caused by the amount that the brows are lifted) is then trimmed and closed at the hairline.

For those patients with a long forehead, this is the only good browlift option. Understandably, one would be concerned about the appearance of the scar since it is not ‘hidden’ completely in the scalp hair. One of the factors to consider in deciding if this is a good option is to look at one’s hairstyle. For those who wear bangs or have a side sweeping hair pattern or style, then the scar is not an issue. For those who always wear their hair back (and most women who have long foreheads usually do not prefer that hairstyle), then one has to think twice.

The hairline scar, however, really turns out well for most patients. While it is red for a few months after surgery, it fades quite quickly and ends up as a very fine line, white scar. This scar is particularly well hidden in light to medium colored hair and skin. By contrast, it may be more noticeable in dark hair and skin colors.

The power of the hairline browlift lies in its combination browlift and forehead skin reduction. It can be a very effective procedure in the right patient with a  good quality frontal hairline and a long forehead with or without temporal recession. While it is most commonly used for female cosmetic surgery, it is also the browlift of choice in facial feminization surgery.  

Dr. Barry Eppley
Indianapolis, Indiana


Lowering the Female Hairline (Forehead Reduction) by Scalp Advancement

Thursday, May 14th, 2009

There are some females who have a very long forehead and they may desire lowering of such a high hairline. Although hair transplantation is an option, that approach is tedious, fairly costly, and may take a long time to see the final result. An alternative and my preferred approach in my Indianapolis plastic surgery practice is to use a modification of a hairline browlift procedure.

The female hairline is ideally about 6 cms. above the brows and is usually where the forehead starts to slope backward into the scalp. The length of the forehead (hair to brow distance) should represent about one-third of the vertical height of the face. When the forehead is too long, and the hairline is too high, it is quite obvious. The appearance of a high hairline lends to a more masculine look and can make one look older as well. If the hairline is high enough, the hair will exit the scalp in an unnatural manner, limiting the type of hairstyle that one can wear and creating a balding look.
A good technique that can lower the hairline 1 inch or more is to use a modification of a traditional hairline or trichophytic browlift procedure. By making an irregular incision just inside one’s existing hairline across the front of the scalp, the forehead skin flap is dissected downward. The posterior scalp flap is then widely undermined as far back as one can go with instruments. The loosened hair-bearing scalp is then advanced as far forward and down as possible over the forehead skin. After marking, the forehead skin above the marks is removed thus advancing the frontal hairline downward. Before closing the incisions, I prefer to stabilize the advanced scalp by securing its underlying galea layer to burr holes in the forehead skull with permanent sutures. This allows adequate advancement of the hairline and closure of the incisions without tension which is an important key to a good-looking and very narrow scar. The skin is closed with very small sutures that are removed in 7 to 10 days.
This hairline lower procedure, or ‘reverse’ browlift if you will, produces an immediate result. A scalp dressing is used for just one day and one can shower and wash their hair the very next day. There is no bruising and only a small amount of swelling. The biggest issue is that the scalp will be numb behind the incision and may be so permanently.I have used this hairline lowering approach most commonly when a browlift is needed. By definition, a high hairline with low brows needs a hairline browlift approach anyway. So brows can be lifted and the frontal hairline lowered at the same time.
The hairline lowering procedure is an uncomplicated procedure that can very successfully lower the hairline at least an inch to inch and a half. The biggest issue is the scar but an irregular incision that is relatively tension-free usually turns out quite well. By the way the incision is made, hair growth usually occurs through the scar helping aid in its disguise.
Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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