Practicing surgical hair restoration within a facial plastic surgery practice offers the opportunity both to assess the size of the forehead as a component of facial aesthetics, and to intervene surgically.
While the ideal balance of the face is theoretically achieved by dividing it into thirds—with the forehead the upper-most third—this is only a guideline that carries far more relevance in women than men, for whom hairline recession is an expected part of aging.
Without exception, a short forehead is a sign of youth and a receded hairline—either along the sides and/or along the frontal hairline—is a sign of aging. Furthermore, in women it is defeminizing. As a result, many patients, inherently recognizing these issues, seek a hairline that is lower and/or flatter, and often associated with a smaller forehead.
The past almost 17 years, during which the author has performed more than 8,000 hair procedures, has been a time of significant developments in improved techniques of hair transplantation. This evolution has enabled physicians to create increasingly impressive and aesthetic results for their patients. Long gone are the scalp flap and scalp-reduction procedures, as well as hair grafting using minigrafts, all of which yielded acceptable but certainly not natural-looking results.
Follicular unit grafting is the most notable development, which since the late 1990s has made possible procedures of 2,400 or more grafts obtained by microscopic dissection, with truly natural-appearing results when transplanted aesthetically. It is this technique which permits for the advancement of high and/or receded frontal and temporal hairlines, all in a single procedure.
Transplanting with these grafts provides the ideal combination of naturalness and density when placed closely together in recipient sites as small as 0.5 mm. Each recipient site is made at precisely the proper angles, which varies considerably in different areas of the hairline. Not only placed in front of the existing hairline, the grafts can also be transplanted into areas of thinning farther back, helping to restore density. These grafts can be placed essentially anywhere, allowing for excellent control in designing the shape of the hairline, whether more rounded, farther forward along the temporal region, flatter, etc.
The other technique for treating the overly high hairline is the surgical hairline advancement. Performed via a single incision right along the hairline, the scalp is undermined back to the vertex to permit the maximum amount of forward extrusion, an amount that can be farther increased through the making of coronal galeotomies (more on this later).
When desired and appropriate, a concomitant browlift/browplasty can be done, with subfrontalis muscle dissection extended as far down as the sub-brow region, permitting elevation of the brows.
EVALUATION AND CONSULTATION
Patients presenting for hairline advancement must be evaluated with a thorough history and examination. This information allows the surgeon to determine whether or not the patient’s goals are realistic, and to determine the possible progressive nature of hairline recession, which can guide in the choice of treatment options.
The first consideration is determining if the patient’s actual concern is over a hairline that is excessively receded, or some other cosmetic issue related to the upper third of the face, such as ptotic brows, an excessively long face in general, or thinning of the frontotemporal regions.
The “ideal” hairline is located so that the face is divided into three similarly sized areas—the lower, middle, and upper one-thirds. This aesthetic goal is of more relevance to females, for in men some degree of hairline recession is considered normal and making the hairline too low can give an unnatural appearance.
While most men 30 to 35 years old and younger would like as youthful a hairline as possible (ie, low and flat), this is often not appropriate. Placing a male hairline too low can result, with further progression of hair loss, in a hairline not appropriate for older age or for the degree of hair loss in the rest of the scalp. In these cases, the surgeon needs to educate the patient, explaining the unnatural appearance that could result and encouraging a more conservative course in terms of hairline advancement. In many cases with younger patients, it is preferable to reinforce a frontal forelock and midscalp region, working within a somewhat receded hairline.
While it is beyond the scope of this article to discuss hairline design in men, suffice it to say that it is critical that a transplanted hairline be designed so that it will be appropriate years into the future. As these patients continue to lose more hair both behind the transplanted hairline, and potentially in the temporal/side regions, the hair restoration has to have been planned out accordingly so that it still looks cosmetically appropriate.
In women, the central aspect of the hairline is usually located 5.5 cm to 7 cm above the root of the nose. As the frontal hairline extends laterally, it rounds out to varying degrees into the temporal region.
Along with the position, the shape of the hairline must be considered as to its contribution to the cosmetic concerns of the patient. In women, frontotemporal recessions can create an unfeminine appearance; whereas in men they can be considered attractive, although most men in their 20s may not agree but need to be educated as to the permanency of the procedure.
The classic feminine hairline varies in its shape, but in general some degree of “roundedness” with narrowing of the horizontal dimension of the forehead is desirable.
The next consideration is the potentially progressive nature of the hair loss, for this helps not only in deciding which procedure is most appropriate, but also in determining the best position and shape of the hairline. Genetically high hairlines and those hairlines elevated as a result of prior browlift surgery can in most women be considered stable, although there is the risk of future hairline recession with increasing age.
In men, hair loss is usually progressive, most commonly starting by the early 30s but in some men beginning as late as the 50s. As a result, male hairlines can rarely be considered stable, even with the taking of Propecia (which has only limited efficacy, especially in the frontal half of the scalp). Most male-to-female transgender patients who are either surgically and/or chemically castrated can also be assumed to fit into this stable hairline category.
HG AND SHA PROCEDURES
Those patients assumed to have a stable hairline can be treated with either of two surgical approaches: the hair grafting (HG) procedure or the surgical hairline advancement (SHA) procedure.
In most men, with some exceptions, and a minority of females who report progressive hair loss, the risk of further recession of the surgically advanced hairline that would eventually expose a hairline incision scar makes them much more suitable candidates for HG.
In fact, the trauma of the SHA procedure can accelerate frontal thinning, resulting also in exposure of the fine-line hairline scar. Creating a lower hairline with hair grafts in a patient with an unstable hairline will result in a loss of hair behind the permanent transplanted hairs, making it important to plan on a second procedure in the future to fill in these areas.
Another consideration is the flexibility of the scalp, and with it the location of the brows with the possible indication for a browlift. In order that a patient have a reasonable improvement with the SHA procedure, the scalp must have sufficient laxity to allow sufficient advancement. This is assessed by placing the index finger on the central frontal-most aspect of the hairline, and seeing how far the hairline can be displaced forward and backward. As an approximate measure, 2 cm of excursion translates into 2.5 cm of advancement.
While not as measurable as this excursion, the appearance of significant deep folds in the forehead skin with this forward displacement indicates that a more than expected amount of forehead skin can be removed, further giving the appearance of a lower hairline.
In patients undergoing the SHA procedure, this is the ideal time to address the position and shape of the brows, as a browlift can be appropriately performed via this same hairline incision. In the highly motivated patient with poor scalp laxity, the SHA procedure can be performed, aided by tissue expansion that can permit as much as 5 cm or more of hairline advancement, if desired.
Other considerations include the history of prior scalp/forehead surgeries, the potential supply of donor hair, and the density of the existing hairline. If the patient has already had a forehead lift via anything other than a trichophytic hairline incision, it is generally not advisable to perform the SHA—the amount of advancement may be restricted and, more critically, there is a risk of ischemia to the intervening area of scalp between the two incisions. In these cases, HG is usually the procedure of choice.
The supply of donor hair determines the total number of grafts available for transplanting to advance the hairline, but also for future transplanting if there is a progression of hair loss. In some women, especially, this supply can be limited, making procedures of more than 1,600 grafts unlikely. This limits the amount of hairline advancement that can reasonably be achieved.
Finally, the degree (if any) of miniaturization of hairs in the existing hairline needs to be taken into consideration when determining which of the two procedures are most appropriate. These miniaturized hairs will be lost if the SHA procedure is chosen, and thus the hairline incision must be made behind these hairs. One must also consider how aggressively the existing frontal hairline should be filled in behind the new hairline created with a HG procedure, for these miniaturized hairs are at high risk of effluvium.
THE SURGICAL HAIRLINE ADVANCEMENT PROCEDURE
Most of these procedures are performed under local anesthesia with oral sedation, but intravenous twilight sedation is offered.
Patients are told about the limitations, risks, and benefits of this procedure, which include the factors discussed above, and others. For example, there is a risk of a fine-line scar along the hairline that can be truly minimized with trichophytic closure, and any scarring can be well-concealed with hair grafting in the future.
The possibility of performing a hair-grafting procedure several months after the SHA procedure is discussed with all patients. This hair grafting can not only help conceal any visible scarring, but can also create a more rounded shape to the hairline.
As impressive as the results of the SHA procedure are, the ability to round out the hairline as well as fill in any areas of thinning of the temporal region is significantly limited. Therefore, hair grafting can be offered as part of the total procedure plan for those who desire a more rounded hairline.
Prior to performing the procedure, the proposed hairline is drawn in, making sure it meets with patient expectations. Anesthesia can be achieved with blocks of the supratemporal and supraorbital nerves, then extending local infiltration into the temporal regions. The second area of injection is in the vertex region, to where it is anticipated the posterior limit of the dissection will extend. Local infiltration of the hairline and upper forehead minimizes bleeding along the incision lines.
An irregular, jagged incision is made along the entire hairline in a beveled fashion, transecting through the frontal-most hairs and then extending in a horizontal fashion approximately 2.5 cm into the temporal region, then curving the incision another 2 cm inferiorly.
The incision is made through the frontalis muscle, and the forehead is dissected caudally several centimeters in the subfrontalis muscle plane. If a browlift is to be performed, this dissection is extended down to the brow region in the same plane or, if desired, the subperiosteal plane, according to the surgeon’s preference, allowing for the desired brow sculpting.
Posteriorly, the scalp is dissected in the subgaleal plane 12 cm up to 18 cm—a very easy avascular dissection. In most cases, two to four coronal galeotomies are made to achieve additional advancement of the scalp. Each galeotomy, made very superficially so as to avoid transecting penetrating vessels, can provide an additional 5 mm of advancement, but these incisions can put the vascular supply of the frontal scalp at risk.
The maximally mobilized scalp can now be pulled as far forward as possible, and secured in place with two Endotine hooks that engage the galea, each one 4 cm to 6 cm lateral to the midline, 2 cm posterior to the hairline. These hooks, placed into hand-drilled holes in the cranium, take 4 to 6 months to dissolve, during which time the hairline incision closure can heal, tension-free.
With the entire frontal scalp now securely held in place in its more advanced position, the excess forehead skin it overlaps can be excised. This part of the procedure is done in a stepwise fashion, suturing together the deeper layers, as each small part of the forehead skin is excised in a beveled fashion that mirrors the angle of the hairline incision, so that there is an overlying cuff of skin in the forehead flap that can be sutured in a trichophytic fashion.
Preferred sutures are 2-0 Vicryl for the deeper layers, followed by 5-0 nylon to superficially close the skin edges. Laterally, the temporal aspect of the incision, which is made in a curved fashion to allow the taking up of any dog ear, is closed with skin clips. Antibiotic ointment is applied to the incision, and a light pressure dressing is left in place for 24 hours, after which no dressing is indicated unless a browlift was performed. Sutures and skin clips get removed at 6 to 8 days.
Although considered a less “surgical” procedure than SHA, the HG procedure takes a significantly longer time to perform, typically 5 to as many as 8 hours, depending on the number of grafts, versus less than 90 minutes for SHA.
These procedures are also usually performed under oral sedation and local anesthesia injected along the proposed frontal/temporal hairline, as well as the donor area in the back of the scalp.
The design of the proposed hairline is more involved, for it usually incorporates temporal grafting and there is more control to refine the actual shape of the hairline. Once the patient approves the design, the hair can be trimmed in the donor area, usually located along the mid occiput region, extending to the sides of the head if additional grafts are indicated.
The 10- to 15-mm-wide donor strip is removed, and the incision is sutured closed with either a 3-0 Prolene or the self-dissolving 4-0 Caprosyn. For each square centimeter of donor strip, an estimated 70 to 80 follicular unit grafts can be obtained. Therefore, for a procedure of a planned 1,800 grafts the donor strip measures approximately 22 to 24 square cm.
Dissecting out of the follicular unit grafts is performed under binocular microscopes by a team of assistants. Each graft contains one to four hairs, most commonly two, according to the natural grouping of the scalp hairs. To maintain viability, the donor grafts are kept moist in chilled saline.
The key aesthetic step in this procedure is the making of the recipient sites, using tiny blades typically 0.5, 0.6, and 0.7 mm in size, which allow for the placement of grafts containing one, two, and three hairs, respectively. This is a meticulous process in which each recipient site determines the direction and angle of growth, as well as the distribution of hairs, which change constantly along different aspects of the hairline.
In general, along the hairline the frontal-most three rows of hairs are all single-hair grafts, followed by another three to four rows of two-hair grafts. The rest of the grafts behind these contain three hairs, to achieve a natural progressively denser appearance. Along the temporal sides, most of the grafts contain just one hair, with some two-hair grafts placed along the more posterior and cephalic aspects to ensure naturalness.
The direction of hair growth as discussed above can vary tremendously, and the existing hairline can provide a template from which the more frontal grafts can follow. Hair growth direction, with the exception of cowlicks, which is generally in a frontal direction along the hairline and as one moves laterally, in a more downward—and eventually along the sides—a more posterior direction.
Once made, the recipient sites are filled with grafts, placed one at time using jewelers’ forceps. Experienced assistants will understand the distribution pattern of grafts, and smaller recipient sites permit greater control by the surgeon of the size of the grafts that can be placed into each recipient site, as well as the direction and angle at which the hairs will grow.
Smaller recipient sites also minimize the damage to existing hairs when transplanting into areas of thinning. In a typical procedure, 1,400 to as many as 2,200 (or even more) grafts will get transplanted. No dressings are placed, and most patients return to the office a day after the procedure for a hair wash.
With some creative hairstyling (especially in women with long hair) or the wearing of a hat, patients are presentable the next day. Crusts usually fall off within a week, and sutures get removed at 10 days. Regular exercise is permitted on the sixth day.
Regrowth of the transplanted hair begins at 3 to 5 months, after which it continues to grow at the rate of 1 to 1.5 cm per month. Typically, 8 to 10 months pass before there is a cosmetically significant improvement, and patients are advised to wait a minimum of 12 months before deciding if a second procedure is indicated to achieve any desired greater density.
Approximately 20% of patients choose to undergo a second procedure, and the majority of these patients are advised ahead of time that they are likely to be in this category due to the expressed desire for maximum density and/or the presence of a low donor supply density.
Over the past several years, the SHA has become more popular than in the past, due to the increased awareness of the advantages of the technique. While few surgeons offer it with regularity, it has as its main advantage the dramatic and nearly instantaneous results of a lower hairline. HG remains, however, the more common procedure.
The overwhelming majority of the hairline advancement procedures performed have been on women, due to their much lower risk of progressive hair loss, and especially since most of the patients who undergo this procedure have high hairlines most commonly due to genetics, and also from prior plastic surgery. Procedures on men have involved restoring the entire frontal region and frontotemporal recessions, with some conservative advancing of the hairline when appropriate. Just one SHA was performed on a male, in his mid 50s with a stable hairline.
Approximately 20% of the hairline advancement procedures have been performed on women of African ethnicity. This appears to be due to the high incidence of traction and genetic alopecia, and the good results achievable with just a single HG or SHA procedure. Despite concerns of scarring, to the contrary the SHA and HG procedures have not been characterized by these problems. Furthermore, many women of African ethnicity seem to have quite elastic scalps, making 3 cm to 5 cm of advancement possible with the SHA procedure.
In certain patients of Asian ethnicity, thick hairs that seem to be common can make HG a challenge to achieving soft, feathered, natural-appearing results. However, this challenge can be overcome with the transplanting of primarily single-hair grafts and careful angulation of recipient sites.
The amount of advancement with SHA has ranged from 2 cm to 6 cm. This amount of advancement, especially when combined with browlifting, can significantly shorten the forehead. With tissue expanders, SHA procedures have achieved in these relatively inelastic scalps advancement of on average 5 cm, with one patient (who had a prior SHA procedure with extensive scarring) achieving 7 cm of advancement. Satisfaction with the SHA procedure has been very high, with the main downside being numbness of the frontal scalp. Fewer than 25% of patients have had subsequent HG after the SHA to help round out the hairline and/or to minimize any hairline scarring.
Similar to SHA, satisfaction with HG has been very high. Approximately 20% of patients have needed or desired touch-up procedures to enhance density. Most of these patients have had lower than the 90% expected rate of hair regrowth. Most of these lower-regrowth cases have been where more than 2,200 grafts (going as high as 3,300) have been transplanted in a single procedure, perhaps compromising blood flow.
Every patient needs to understand the advantages and disadvantages of the two procedures, as well as be evaluated for potential candidacy for each. The main advantages of SHA, besides the ability to achieve virtually instant results, are the most efficient utilization of available donor hairs, and unsurpassed frontal density. However, the fear of a fine-line scar along the hairline understandably creates unwillingness in many patients to undergo the procedure. Furthermore, the limit in scalp laxity, and in others the desire to have a more rounded appearance and not just a lower location of the hairline, makes HG the procedure of choice. The ability to offer patients a choice between these procedures ensures the highest degree of satisfaction in meeting expectations.
Jeffrey S. Epstein, MD, FACS, is the director of the Foundation for Hair Restoration, and maintains full-time offices in Miami and New York City. He is also a Voluntary Assistant Professor at the University of Miami.