The forehead occupies a major portion of one’s face, up to one third of its vertical height. But when the forehead occupies too much real estate of the face, greater than one-third, it can be too overwhelming and look out of proportion to the rest of the face. By definition the vertical length of the forehead is between the frontal hairline and the eyebrows. (in bald or shaved men the amount that the forehead should occupy no longer applies)
The only method to reduce the vertical length of the forehead (forehead reduction) is a hairline advancement. This is essentially a scalp mobilization procedure that changes the location of the front edge of the hair-bearing scalp through forehead skin removal. Its success depends on how much natural elasticity one’s scalp has. Lowering of the hairline with this procedure can usually be done anywhere from 1 to 2.5 cms in most people.
Since such a forehead reduction is a scalp advancement flap, there will be some tension on the incision line. One of the goals of a hairline advancement is to minimize the tension on the skin closure to avoid postoperative scar widening. Such scar widening would be very obvious as a visible white zone at the edge of the frontal hairline.
A good technique to reduce the tension of the scalp advancement flap is skull fixation. Using outer table burr holes placed with a handpiece and burr, sutures can be placed through the bone tunnels to secure the scalp flap. There are placed at the front edge of the desired advancement edge to maintain its position. This then allows the closure to the forehead flap to be done with little to no tension on it as well as preventing any scalp relapse.
Once the advanced scalp flap is secured by bone fixation, the forehead skin flap is draped over it to determine the amount of forehead skin to be removed. This prevents over resection of forehead skin and serves as the second technique to ensure the best possible frontal hairline scar outcome.
IDr. Barry Eppley