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Dr. Barry Eppley

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Posts Tagged ‘hairline browlift’

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

Case Study: The Hairline Browlift in Women

Wednesday, November 17th, 2010

Background:  Aging of the upper face primarily involves that which appears in the forehead. Falling of the eyebrows onto or off of the brow bone and the appearance of horizontal and vertical wrinkles are the classic, and quite frankly, only aging signs that can appear. The amount, if any, of brow sagging is the key to whether one considers having a browlift. If one isn’t concerned about the position of the brows, then the non-surgical approach of Botox injections is a good treatment for wrinkle reduction.

In considering browlift surgery, there are numerous options based on the location and type of incision and how much muscle work can be done or is needed. The older traditional approach of a coronal or scalp incision browlift is today quite uncommonly done. The trade-off of a long scalp incision for higher brows is appealing to just a minority of patients. Browlift options in women, other than the scalp incision approach, is using a limited incision endoscopic technique or changing the scalp incision to the hairline. (pretrichial incision)

Case: This 58 year-old woman was tired of ‘looking tired’ and felt that her forehead was a major reason for this appearance. Her brows were positioned at the level of the supraorbital rim and became lower with forehead muscle action, particularly with frowning. She had numerous levels of horizontal forehead wrinkles and an inverted Y wrinkle pattern between the eyebrows. (glabella) Her forehead was fairly long and measured 6.5 cms in length between the central eyebrow arch and her frontal hairline. She needed a browlift technique that lifted her brows but did not make her forehead any longer.

While she underwent other simultaneous facial rejuvenation procedures, a browlift was planned for the upper part of her ‘facelift’. The browlift was approached through a hairline incision to prevent the forehead from becoming longer. Preoperative markings were done delineating the forehead wrinkles and an irregular hairline incision was diagrammed at the very edge of the frontal hairline.

During surgery, the forehead skin was folded down along the bone from the hairline incision. The dissection was carried down to expose and preserve the supraorbital nerves. In the glabellar region, muscle was removed  between the two exiting nerves in the inner brow area. In the forehead, the frontalis muscle was removed in strips between the horizontal skin wrinkle marks. The brows were then lifted and the excess skin along the edge of the frontal hairline was then removed and the incision closed. To prevent the frontal hairline scar from possibly widening later, the deeper tissues underneath the incisional closure  were secured down to the bone with sutures for stability and to relieve wound tension.

All browlifts cause no bruising and minimal swelling…in the forehead. It is all driven down to the eyelids where swelling and bruising of the lower eyelids and upper cheeks will take several weeks to completely go away. The brows were nicely elevated, but not overly so, and the forehead remained perfectly smooth for months. Eventually some muscle action and wrinkles do return but generally about 50% less than what one started with prior to surgery

While having a scar along the hairline seems worrisome, those scars heal remarkably well and have never proven to be a bothersome issue to patients.

Case Highlights: 

1    The single most important factor in determining what type of browlift is best for a woman is the length of the forehead between the hairline and the brows. The density of the frontal hairline and the amount and depth of forehead and glabellar wrinkles are also important considerations.


2)      The hairline browlift offers the advantages of not lengthening one’s forehead while allowing optimal forehead and glabellar muscle removal. The frontal hairline can also be brought forward during closure to shorten the length of the forehead as well if the patient desires. The healing of the hairline scar is excellent and rarely needs any scar revision work.

3)      The hairline browlift is also readily combined with other upper facial procedures such as forehead reshaping  and midface lifts due to the good access and exposure provided.


Dr. Barry Eppley

Indianapolis Indiana

The Hairline Browlift – Its Advantages and Recovery

Sunday, September 26th, 2010

While the eyes are a major attraction point in conversation and as an indicator of facial expression, what lies about them has a major influence on them. The upper third of the face is largely composed of the brow, the forehead, and the frontal hairline. (at least in women) The position of the eyebrows along the supraorbital rim of bone and the length of the forehead skin are the important considerations in this important zone of facial real estate. Low hanging eyebrows and numerous and deep horizontal wrinkles in the forehead are common aging issues.

Browlifting (forehead rejuvenation) is often done in conjunction with eyelid tucks. (blepharoplasty) In many patients, the combination of these two produces a better periorbital rejuvenation effect that either one alone. Conversely, it is actually very uncommon to ever just do browlifting alone without blepharoplasty.

There are four different types of browlifting techniques which primarily differ in the location and length of the incisions used. One of the more commonly used in my Indianapolis plastic surgery practice is the hairline or pretrichial browlift. This is used exclusively in women who have a good frontal hairline pattern and a normal or long forehead length. While each patient is unique, foreheads that have 6 cms or more vertical length between the hairline and the upper part of the eyebrow are considered to have a long foreheads. Numbers aside, it is also important to look at how the patient’s frontal hairstyle pattern. Women how feel that their foreheads are too long or prominent, or are bothered by deep forehead wrinkles, will have bangs or a frontal swoop for partial camouflage.

The hairline browlift offers several advantages, particularly in the long or marginally long forehead. By making the incision at the hairline, this assures that it will not be pulled back as the brows are moved upward. The hairline serves as a block unlike if the browlift incision was placed back in the scalp in the traditional or coronal browlift technique. It is the forehead skin that is removed and not that of hair-bearing scalp tissue. Its second advantage is that the forehead can actually be shortened if desired. By undermining the hairline behind the scalp, it can be brought forward up to 1 to 1 ½ cmsas the brows are also lifted. This requires a position on the frontal bone to be located so that both the advancing scalp and the uplifting forehead (after skin is removed) can be secured to this predetermined position.

Recovery after a hairline browlift is the same as every other browlift method. One can expect swelling of the eyelids that will be fairly significant when blepharoplastiesare done at the same time. Bruising will always occur but it is not where one would expect. It will develop along the lower eyelids and the cheek. This is because of gravity and the forehead pressure dressing which forces everything ‘south’. The forehead will not bruise. It is not a particularly painful procedure as the forehead will largely be numb. This is the result of the muscles removed around the supraorbital and supratrochlear nerves in the brow area for furrow and wrinkle improvement. Stretching these nerves causes them to stop working for some time after surgery causing the loss of skin feeling. The feeling will eventually return to normal in a few months. The other area in which skin feeling is lost is behind the incision in the front part of the scalp. This is a peculiar feeling that patients comment on as they comb their hair. This also goes away but takes longer than that of the forehead skin.

Patients define recovery from any facial procedure as what I can ‘social’. How long until I look like I haven’t had surgery? For the hairline browlift one can expect 10 to 14 days until one looks non-surgical. The area that takes the longest to go away is the line of bruising along the lower eyelid-cheek junction. This can take as long as three weeks to go away. In the interim, foundation or mineral makeup will make it undetectable .

Dr. Barry Eppley

Indianapolis, Indiana

Advantages of the Hairline (Pretrichial) Browlift

Tuesday, September 1st, 2009

The best, and often only, option for upper facial rejuvenation is the browlift. Some may consider an upper blepharoplasty (eyelid) part of the upper face, and I would not disagree, but we will exclude that procedure for this discussion. The browlift rejuvenates by elevating the position of the brows (sometimes changing the shape of the brow arch) and reducing the amount of forehead wrinkling.

Browlifts can be done through four specific surgical techniques, largely differing in the incisional approach. Three of these four browlift types are based on using scalp incisions. One of these scalp browlift options is the pretrichial approach where the incision is made just at the edge of the frontal hairline.

The pretrichial browlift, a close cousin to the traditional coronal or scalp browlift (incision significantly behind the frontal hairline), offers one very specific advantage over all other forms of browlifting. Since the incision is at the hairline, any amount of upper forehead movement (brow elevation) will not move one’s frontal hairline back or make the forehead longer. This is a real significant issue for some potential browlift patients who already have a long forehead. It is the one single physical finding that can solely determine the type of browlift chosen.

The endoscopic browlift, while dramatically shortening the length of incisions used, produces brow elevation at the expense of a longer forehead. This is the same issue as in the coronal browlift which lifts the forehead with a trade-off of a strip of scalp hair being removed…and moving the frontal hairline back.

The hairline browlift also allows forehead wrinkling to be reduced through muscle removal of the forehead and between the eyebrows. Because the distance between the incision and the various muscle regions is the shortest of all the upper approaches, I find that the muscle is a little easier to remove and a more thorough job of that can potentially be done. Any form of open browlift, however, removes muscles of facial expression.

Despite leaving a scar that may be the most ‘visible’, the healing of the hairline scar can be quite good. In my Indianapolis plastic surgery practice, I have even performed it in women who comb their hair back or to the sides without a postoperative  problem. In theory, the density and quality of hair and its orientation of growth in relation to the forehead should be very important to the most inconspicuous scar. However, I have done hairline browlifts in women who have fine thin red hair to dark, coarse and curly hair with equally good scars. 

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


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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