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Background:  The well known proportions of the face are based on horizontal thirds ratios between the upper, mid- and lower face. The forehead or upper third of the face is the easiest to see and assess because it lacks any features other than the eyebrows at its inferior edge. Thus when the forehead is out of proportion it is moat always one of being too big or too vertically long.

The long or high forehead is typically one that exceeds lengths of 6.5cms or greater But the reality is that of the patient thinks the forehead length is excessive them it is. But I have yet to see a female with a long forehead that didn’t exceed this measured length.

By definition when a forehead is long it exposes more of the frontal bone surface area and shape. In some long forehead females the upper frontal bone protrudes forward rather than slopes back as it goes into the frontal hairline. This creates an unaesthetic bulge known as frontal bossing which magnifies the length of the forehead particularly in profile.

The goal of a frontal hairline advancement is not only to shorten the verbal length of the forehead but to cover or obscure the frontal bossing. Reducing the thickness of the frontal bossing reduces its appearance in profile but also enables a bit more room for the frontal hairline advancement.

Case Study: This young female had a long forehead of 7.5cms centrally and frontal bossing which was most evident at the forehead-skull transition area. The goal was to lower the frontal hairline by 15mms and change the forehead profile by bone reduction.

Under general anesthesia and through a pretrichial incision, the forehead tissues were elevated down to just below the level of the frontal bossing. A high speed handpick and burr was used tor emove most of the outer cortex of the frontal bone from one temporal line to the other.

The scalp was fully mobilized at the subperiosteal level from the edge of the pretrichial incision anteriorly all the way back to the nuchal line of the occiput. It was then advanced as much as possible up over the forehead skin which wasn’t then marked and removed. Galeal and skin sutures completed the closure.

The frontal hairline advancement helps cover some of the upper frontal bone to mask the frontal bossing. This is aided by reducing the projection of the frontal bossing so a better transition occurs at the edge of the frontal hairline. This is her result the next after surgery when the head dressing is removed. No long term issues have arisen with the hairline scarline.

Case Highlights:

1) High foreheads can be associated with frontal bone bossing.

2) The combination of a frontal hairline advancement with upper forehead bone reduction shortens the forehead and normalizes its appearance in profile.

3) Frontal hairline advancements, even without periosteal releases of the brow bones, can have a modest brow lifting effect.

Dr. Barry Eppley

Indianapolis, Indiana

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