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