A rapid and effective technique to lower the female hairline
 
Dr. Sheldon S. Kabaker, Dr. Alexander L. Ramirez
(USA)

ESHRS Journal. Volume 4 - Number 1. Spring 2004.

INTRODUCTION
There are a number of women who have hereditary high hairlines. These patients have a hairline that is usually stable after puberty and have normal density and volume behind it; however, these patients are still distressed. The appearance of a high hairline makes them look masculine and older than their years. The associated large forehead is unattractive and their hair styling, often limited to combing downward for camouflage, is difficult¹. Occasionally, the hairline is so high and posterior that the hair will exit the scalp parallel to the ground or even at an obtuse angle to the ground. Hair does not fall effectively and the upper third of the face is so disproportionate that patients appear to have hair on only the posterior half of the scalp. These women with high hairlines will often present to the transplant surgeon requesting lowering of the hairline.
 
Hair transplantation can be used to treat these patients. Follicular unit grafting is an effective treatment that has a low incidence of complications and is certainly the gold standard for hair work. However, this technique is labor intensive, time consuming, and can be expensive, especially since these patients would require multiple sessions to achieve the 2-4 cm of hairline lowering required with adequate density acceptable to women. In addition, patients will have to wait 2-4 years to see the full result after transplantation. We present an alternative technique that produces outstanding results rapidly, is readily acceptable to patients, and has little complications.
 
TECHNIQUE
Our preferred method for lowering the female hairline consists of an irregularly irregular trichophytic incision made within the fine hairs of the anterior hairline. Two points are critical to the success of this incision. First, the incision should not be placed pre-trichial (e.g. at the junction of the hair bearing and non-hair bearing skin in a direction parallel to the existing hair). Future disguise of this incision depends on hair growing through the scar. To assure this occurs, the incision is placed within the fine hairs of the hairline and it is beveled perpendicular to the hair. This incision will then transect the hair shafts but leave the bulb of the hair follicle intact within the superior wound edge of the proximal flap. (Fig. 1) This allows hair growth through the distal flap virtually concealing the incision². Second, this incision should not be linear and it should not be in any predictable pattern. It may match the existing irregular hairline but must be irregularly irregular to avoid attention by the discriminating eye.
 
After the incision, the scalp is undermined bluntly toward the vertex in the subgaleal plane and the forehead is undermined in the same plane to the level of the brows¹. Dissection in this plane is rapid and bloodless. In the forehead, dissection in this plane protects the supratrochlear nerve and the superficial branch of the supraorbital nerve by keeping these vital structures superficial and free from injury. The scalp is then advanced anteriorly and the excess non-hair bearing forehead skin is excised with an incision that is parallel to the trichyophytic incision. This can be achieved using a flap splitting technique or by using a flap marker. During flap elevation, no cautery is used and the flap is handled with toothed forceps or skin hooks to avoid crush injuries to the existing hair.
 
The wound is closed in two layers. The galeal is closed for strength and to approximate the wound edges. The skin closure concentrates on wound eversion. To ensure a good cosmetic result, there should be no tension on the wound. If necessary, serial galeotomies may be made on the scalp flap in a direction parallel to the incision³. This allows adequate advancement of the hairline and wound closure without tension. However, these must be done with great caution because the scalp's blood supply lies immediately superficial to the galeal and may be compromised. A light dressing is placed and removed on the first post-operative day. A cosmetic result is appreciated immediately because the hair may be combed downward and there is minimal bruising and edema. Sutures are removed in seven to ten days (Fig. 2).
 
DISCUSSION
There are two variations with this procedure that have proved useful. First, if the hairline needs to be advanced a large distance or if the scalp is tight, a tissue expander may be required³. This is done as a staged procedure, with placement of the expander as the first stage and advancement of the hairline as the second stage. Typically, the balloon is expanded over a 6-week period, e.g. 75-100 cc per week, to stretch the scalp sufficiently to allow for 46 cm of advancement. This is well tolerated by patients aside from the cosmetic inconveniencc during the last three weeks of the expansion and the only complication over a 10-year period has been the occasional case of telogen effluvium.
 
The second variation of this procedure is to combine the hairline advancement with a browlift (Fig- 3). For this procedure, the forehead dissection is extended subperiosteally below the orbital rims by releasing the arcus marginalis medially and by releasing the conjoined tendon laterally often with an added temporal incision and dissection below the temporoparietal fascia. The deep division of the supraorbital nerve runs laterally almost at the temporal line within the deep layer of the galea here; therefore, a subperiosteal approach is required to leave it undisturbed4. A periosteotomy is often required along the suprorbital ridge area to obtain full release and elevation of the brows and the corrugators and procerus may be cut or cauterized from the subperiosteal direction. With the skin excision, closure of the wound will move the brows superiorly to a lifted position. A fixation device such as the Endotine^TM by Coapt Systems, lnc. (Palo Alto, CA) is often useful to prevent stretch back and to secure the forehead and/or the scalp advancement in their new position.

The most important disadvantage to this technique for hairline advancement is the possibility of a noticeable or unsightly scar. The two mentioned technical points are critical in avoiding this complication. The trichophytic hairline incision must be non-linear; it is an irregular non-repeating pattern that by itself makes the scar less noticeable. And, it is critical to bevel the incision perpendicular to the direction of the hair as described. This allows the hair growth through the scar to further enhance its disguise. As the hair grows and the wound matures, the incision will become virtually non-existent². Hair grafts could also be performed if the scar were visible. Overall, patients tolerate this procedure well and other complications have been extremely rare.
 
CONCLUSION
All transplant surgeons will be faced with the female patient who requests lowering of a high hairline. Although transplantation with follicular unit grafts is an option, we recommend an alternative technique. This technique has been used by the senior author for over 20 years and has proved to be almost immediately effective, well tolerated by patients, and associated with minimal complications. Although it is associated with an incision, the presented techniques can be used to make the scar virtually invisible, making patient satisfaction extremely high.

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