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Background:  Since the forehead occupies 1/3 of the total face surface area it has a significant aesthetic influence on the perception of one’s appearance. While the forehead lacks any of the dynamic landmarks that make up the rest of the face (eyes, nose and mouth) one might assume that it has few aesthetic features to change. Some of the  most aesthetically landmarks of the forehead are at its perimeters…the northern frontal hairline, the southern eyebrows/brow bones and the temporal line or width of the forehead at its sides…all of which can be surgically altered. Lying within these borders is the also important contour of the featureless forehead shape between them.

In reducing excessive features of the forehead the two most common concerns are frontal bossing and a vertically long forehead. Frontal bossing refers to an excessive projection or roundness of the bone which is most significant at the upper half of the forehead. It may also refer to frontal bossing’s smaller cousin…forehead horns which are more limited areas of upper forehead projections. The vertically long forehead is the result of a high or retro positioned hairline. Such a hairline often falls behind the curve of the upper forehead as it transitions onto the top of the skull. The number of 6.5cms between the eyebrows and the frontal hairline is often referred to as the upper limit of forehead length and almost anyone that feels they have a high forehead is at or exceeds this measurement.

While correction of frontal bossing/horns and the vertically long forehead are separate operations they often are done concurrently. The vertically long forehead is frequently associated with some degree of frontal bossing or excessive upper forehead convexity. Since the use of a frontal hairline incision is essential to a hairline advancement/lowering procedure for the vertically long forehead it provides convenient access to address an overly prominent bony forehead at the same time. They are also synergistic procedures in that moving the frontal hairline forward/down, even a small amount, helps make the upper forehead look less prominent.       

Case Study: This young female was bothered by a high hairline and an overall wide and overlying projecting forehead. Her frontal hairline was behind the upper curve of the forehead as seen in side view.

The markings for a combined frontal hairline advancement and reduction of frontal bossing were made. Through this frontal hairline incision a guarded high speed handpiece and burr were used to reduce the bone from side to side across the bony temporal line until the diploic space was encountered.

In performing the frontal hairline advancement the scalp is initially widely undermined all the way back to the back of the head and further released by gall scoring. The front edge of the cut scalp is then advanced up over the upper forehead skin as much as it will go and the skin then marked. This determined how much and the shape of the upper forehead skin that can be safely removed for the hairline advancement.

The intraperative results of the combined forehead reduction procedure are seen. It is important for patients to understand that there are anatomic limits as to what can be achieved with each forehead reduction procedure. The frontal bone is not that thick, particularly in females so most frontal bossing reductions will be in the 3 to 4mm range at most. How much hairline advancement is possible is controlled by the flexibility of the scalp which is linearly related to its thickness. Fair completion females usually have the thinnest scalps with the least amount of scalp mobilization, limiting their immediate advancements to the 1cm range. The need for greater amounts of hairline advancement in such patients requires a first stage scalp expansion procedure.  

Case Highlights:

1) Forehead reduction can be for frontal bossing, shortening of a long forehead or both.

2) The frontal hairline incisions provides access to do combined bone and soft tissue forehead reductions.

3) The limits of bony forehead reduction is the thickness of the frontal bone and that of vertical forehead shortening the flexibility/stretch of the scalp. 

Dr. Barry Eppley

Indianapolis, Indiana

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