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Posts Tagged ‘hairline advancement’

Case Study – Total Forehead Reduction

Thursday, November 26th, 2015

 

Background: The shape of the forehead is affected by various hard and soft tissue components. The forehead is framed by the hairline superiorly, the brows inferiorly and the bony temporal lines to the sides. The projection of the forehead is controlled by the thickness of the frontal bone and its degree of convexity and smothness. The height of the forehead is judged by the vertical distance from the hairline to the brow.

Vertical forehead reduction can be of benefit when the hairline to brow distance is about 6.5 cm and longer. Numbers aside, one knows when the forehead is too long by their own aesthetic sense. Shortening the length of the forehead is done by moving the hairline forward or more inferior through extensive scalp undemining and mobilization. A powerful procedure, the hairline or scalp advancement can make a dramatic difference in the appearance of the upper third of the face.

Bony forehead reduction is done to either narrow the shape of the forehead or eliminate any obvious bony projections. This is a bone burring technique that is usually done to narrow the width of the forehead, reduce the amount of its forward projection (convexity) or smooth down so called forehead horns. This almost always need to be done through an open approach afforded by a hairline incision.

Case Study: This 40 year male had a long forehead due to receding frontal hairline and a wide and bulging forehead due to its bony shape. He had a prior hair transplant procedure with a linear strip scar on the back of his head. His desire was for a shorter forehead length and a less wide and bulging forehead.

Total Forehead Reduction result front view Dr Barry Eppley IndianapolisTotal Forehead Reduction result oblique view Dr Barry Eppley IndianapolisDue to his prior hair transplant harvests from the back of his head, it was elected to do a first stage scalp expansion to ensure enough scalp could be mobilized for the hairline advancement. This was done using 120cc of scalp expansion by fill volume. During the second stage through a hairline incision, the tissue expander was removed, the bony forehead reshaped by burring and the hairline advanced 2 cms. Small temporal rotational scalp flaps were also done to eliminate the temporal recession areas.

Total Forehead Reduction result side view Dr Barry Eppley IndianapolisTotal forehead reduction can be done through bony contouring and a hairline advancement. Using the ‘central’ pretrichial hairline incision positioned between the forehead and the scalp, both forehead reduction procedures can be successfully done. His history of strip occipital harvests for hair transplants did necessitate a first stage scalp tissue expander which would not normally be needed in most cases.

Many patients with high and long foreheads have a combination of a posteriorly recessed hairline and bony forehead bossing. Preoperative computer imaging will show whether the apparent forehead bossing is a function of just a high forehead and an exposed upper forehead bony contour or whether a true excessive forehead convexity exists. A very wide or broad forehead in the frontal view, however, is an excessive bony width problem for which a hairline advancement will not improve.

Highlights:

  1. Forehead bossing is treated by bony reduction of forehead width and projection. (forehead contouring)
  2. Vertical forehead reduction is a soft tissue procedure where hairline advancement is done. (scalp advancement)
  3. Total forehead reduction is when both bony and soft tissue procedures are done simultaneously.

Dr. Barry Eppley

Indianapolis, Indiana

Bony Forehead Reduction with Hairline Advancement

Monday, August 10th, 2015

 

The long or high forehead can be challenging to treat. The vertical length of the forehead is typically judged to be too long if the distance from the eyebrows to the frontal hairline exceeds about 6.5 cms. This is obviously a subjective judgement as the aesthetics of the forehead defies any exact number. But when the length of the forehead violates the 1/3 rule (bigger than the lower middle and lower facial thirds) it will be typically thought of as being too long or high.

Forehead Reduction with Hairline Advancement intraop top view Dr Barry Eppley IndianapolisShortening the height of the forehead is usually done by a forehead reduction procedure known as a hairline lowering. This is really a scalp advancement which is done by undermining and mobilizing the entire scalp all the way back to the nuchal ridge of the occiput. Combined with galeal releases the frontal hairline may be capable of being lowered 2 to 3 cms in many patients. Such forehead reduction is very powerful and can have a dramatic effect on the appearance of the upper face.

When considering a hairline advancement, it is also important to assess the shape of the bony forehead as well. Frontal bossing can be a contributing factor to a large forehead. While bring the hairline forward may begin to cover a bony protrusion it can not completely obscure it.

Forehead Bone Reduction for Frontal Bossing Dr Barry Eppley IndianapolisForehead Reduction with Hairline Advancement intraop side view Ddr Barry Eppley IndianapolisA total forehead reduction procedure consists of both a hairline advancement and bony forehead reduction. They can be done through the same pretrichial incision. By reflecting the forehead skin down to the brow bones, the frontal bone is exposed and can be burred down and reshaped. The limits of the bone reduction are based on the thickness of the frontal bone but usually can be reduced at least 5 to 7mms. Often times it is the slope of the bony forehead that needs changing as much as how far it protrudes forward.

Reducing the bony forehead and changing its slope also provides more room for additional hairline advancement. Its reduction may allow an additional .5cm of hairline advancement to be achieved.

Dr. Barry Eppley

Indianapolis, Indiana

Long-Term Hairline Stability in Pretrichial Browlifts

Saturday, January 11th, 2014

 

When it comes to forehead rejuvenation a variety of browlifting strategies exist. Three of the browlifting methods use a superior or scalp incisional access to do the procedure. The most popular of these is the endoscopic technique which uses a few small scalp incisions and an epicranial tissue shift to create its brow elevation effect. It is popular because of a lack of significant incisional lengths even though it does also result in some forehead lengthening.

Pretrichial Open Browlift Scar Dr Barry Eppley IndianapolisA very effective but less popular browlift method is the pretrichial or hairline technique. Making an irregular incision along the frontal hairline, the brows are lifted but without elongating the forehead. While this does place a scar along the frontal hairline, in the properly selected patient with good frontal hairline density, the scar can heal remarkably well and has rarely been a concern in my experience. There is always the understandable concern, however, if whether this incision negatively affects hair growth after healing and in the long-term. (does hair loss occur along the incision)

In the January 2013 issue of Plastic and Reconstructive Surgery, an article was printed entitled ‘Cessation of Hairline Recession following Open Forehead Rejuvenation’. Over a 15 year period, 31 patients had browlifts done using either the endoscopic (17) or open pretrichial incision (14) approaches. Measured photographs of eyebrow to hairline distances were done at 1 and greater than 8 years after surgery and compared to other cosmetic surgery patients who did not have forehead rejuvenation. Their results showed that over the long-term only the pretrichial group had a stable or improved hairline position without any signs of recession. No separation was seen between the scar and the hairline in the pretrichial incision patients.

This study is very relevant to not only pretrichial browlifts but other procedures that use incisions along the hairline such as a hairline lowering/advancement surgery for forehead reduction. Whether it is a woman or a man (but particularly in men), there is always the concern that hair loss may occur along the incision from surgical trauma or that long-term hairline recession may occur. These findings in this paper allay those concerns and suggest that the incision may have some protective effect in the long-term for follicular preservation…and intriguing but as of yet unexplainable biologic effect.

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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