Background: While there are many features they define an aesthetically pleasing forehead two of them are of particular relevance. First the length of the forehead, as defined by the vertical distance between the eyebrows and the frontal hairline, should be proportionate to the lower facial thirds. Secondly the slope of the forehead, the relationship between there forward projection between the upper and lower half, should not exceed 0 degrees in profile.
When the length of the forehead becomes greater than a third of the face and/r the slope of the forehead in profile becomes a negative number these are viewed as unaesthetic features. When these two features occur together, as in the case of the frontal bossing patient, the most severe form of aesthetic forehead deformity is created. These two deformities are synergestic…the high hairline makes the upper bony forehead look more prominent while the upper bony protrusion makes the forehead look longer.
The treatment of frontal bossing with a high hairline is the combined hairline lowering and bony bossing reduction. They can be performed through a single incision and improvement is always obtained in both. The only question is the magnitude of change which is highly influenced by the thickness of the scalp and the bone over the bossing.
Case Study: This thin Caucasian female had long been bothered by the shape of her forehead with a high hairline and prominent bossing. She had worn bangs all of her life to hide her forehead. The length of her forehead was 6cm at the glabella and 7cms at the mid-brow bilaterally. These forehead lengths are a bit beyond normal but not as long as I have seen in some patients. The effect of the prominent frontal bossing made it longer than it was. She also had a very distinct central widow’s peak which was a familial trait.
Under general anesthesia an irregular incision was made along the frontal hairline from side to side crossing into the upper temporal area. Once past the incision down to the bone the location of the frontal hairline was marked onto top the bone for reference later in the procedure.
The forehead flap was raised down to the brow exposing the prominent frontal bossing bulge. It could be seen to stick out further than her brow bones.
Using a high speed hand-piece and burr the left bossing reduction was done until the bone was thin enough to see the dipoic veins underneath. By doing the left side first the amount of bone reduction possible could be seen compared to the right side.
Once the bossing reduction was completed the scalp was undermined back to the bottom of the occiput including on the sides over the deep temporal fascia. Horizontal galeal releases were done at multiple levels back from the frontal hairline edge to create as much scalp flexibility /stretch as possible. To ensure that the frontal hairline actually moved back its original position microscerews were placed into the bone behind the original marking on the bone. Using three point fixation the frontal hairline advancement was secured by sutures to the screws.
With the hairline position secured with maximal advancement the excess forehead flap was draped up over it and the excess forehead skin removed from side to side. A multi-layer frontal hairline incision was then done using small resorbable sutures.
As a thin Caucasian female her hairline advancement was predictable at the 1cm amount. Her scalp was only 3/8” thick so it was not ongoing to allow for a larger advancement.
Similarly the thickness of the frontal bone was also predictability thin so only a 3mm bony reduction was possible. But that was enough to make for a visible difference.
In composite forehead reduction (hard and soft tissues) in many cases of frontal bossing improvement is always obtained…it is just a matter of amount. When the procedure is performed on patients with thinner tissues, which is what will be present in a thin Caucasian female, one has to know in advance there will be some significant limitations. The scalp will be very thin and the forehead bone will also be thin. Since the physical price for the procedure will be a frontal hairline scar one has to be certain that the benefits of the procedure is worth it. A few millimeters of bone reduction and a 1cm hairline lowering may no sound like much. But when combined the aesthetic effect can be greater than it sounds.
Key Points:
1) A long forehead is often associated with frontal bossing, both of which make the other look worse.
2) The non-bony forehead reduction technique of frontal hairline advancement is based on the natural flexibility of the scalp…which is highly influenced by ethnicity and skin pigmentation.
3) How much the bony forehead can be reduced depends on the thickness of the frontal bone which often is thinner in frontal bossing.
Dr. Barry Eppley
World-Renowned Plastic Surgeon