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Hair Surgery for
Women
1) Hairline
Advancement
(Shortening of Long
Forehead)
2) Expansion
Assisted Hairline
Advancement
3) Lowering High
Forehead in Women
Without Grafts
Scalp reduction
surgery can be used
to remove balding
areas of skin and
reduce the total
area of the scalp
that needs hair
replacement. This
procedure can only
be done on those
with The balding
patterns in women
differ from those of
men, thus different
procedures may be
indicated. Most
commonly, a diffuse
thinning pattern is
seen, usually more
concentrated in the
top and side of the
scalp. Wigs or
hairpieces are often
a solution for hair
loss or thinning.
While not always
possible, micro- and
mini-grafting can
increase hair
density in an
inconspicuous
fashion— with
natural growing
hair.
Another example of
hair loss in women
is loss of hair in
the temples as a
result of a facelift
operation. This can
be corrected
surgically with
grafts or expanders.
Many women complain
of a high forehead
(long forehead) or a
high hairline. This
is the situation
where there is a
greater than
desirable distance
from the eyebrows to
the hairline. This
distance is ideally
between 5 and 7
centimeters. When
there is a high
hairline, the face
can look elongated
and/or attention is
given to the
forehead rather than
to the eyes and the
rest of the face.
Also, as aging
occurs and the brows
droop, the high
forehead (long
forehead) or high
hairline becomes
still more
pronounced. Hair
stylists recognize
this and invariably
style the hair with
bangs. This is
usually effective in
framing the face in
attractive
proportions. In
some cases where the
hairline is very
high, bangs can be
ineffective.
1) Hairline
Advancement
(Shortening of Long
Forehead)
Those women who have
a high forehead
(high hairline) and
have hair styling
problems from this,
now may have a
simple solution.
Many of these
situations can be
treated with a
simple one-stage
hairline advancement
operation which
would enable the
patient to appear in
public within 2-3
days of the
operation with a
new, lower hairline
with full length
hair.
This operation, in
which we have vast
experience, costs
about 1/3 to 1/2 as
much as the much
more commonly
employed follicular
unit grafting, which
would require two to
three sessions and
take many months
before achieving a
comparable result.
This operation can
also be combined
with a forehead/brow
lift to achieve the
optimal result in
those with both a
high hairline and
aging, drooping
brows.
If the scalp is
tight and more than
3 cm of advancement
is needed, the
following two-stage
procedure can be
considered.
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2) Expansion
Assisted Hairline
Advancement
The first stage of
frontal expansion
surgery consists of
inserting a
semi-circular shaped
expander under the
scalp behind the
frontal hairline.
After a period of
healing takes place
(seven to fourteen
days), the expander
is gradually
inflated by
injecting sterile
water so that the
scalp is gradually
stretched.
Inflations are
performed every
three to five days
during the next four
to eight weeks,
until the desired
amount of stretching
has been achieved.
During the second
and final surgery,
the device is
removed and the
expanded
hair-bearing scalp
is moved forward,
replacing the top
section of the high
forehead. We have
moved hairlines as
far as 6 cm with
this approach.
A tissue expander is
inserted under the
scalp just behind
the frontal
hairline. After a
healing period, the
expander is
gradually inflated,
so that the scalp is
gradually stretched.
The second
procedure: The
device is removed
and the expanded
hair-bearing scalp
is moved forward,
replacing the top
section of the
forehead.
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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 Dr. Kabaker
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.
The female hairline
is variable in
position. In the
ideal situation, the
hairline is 5 to 6.5
cm above the brows
and usually begins
at the point where
the scalp slopes
from a more
horizontal position
to a more vertical
position. At this
location, the hair
exits the scalp at
an acute angle
(0-30°) in relation
to the ground and is
directed anteriorly
or antero-laterally.
This allows for
versatility with
hairstyling and the
aesthetic vertical
thirds of the face
are equal, providing
facial harmony and
balance1.
In contrast, there
are a number of
women who have an
hereditarily high or
big forehead. These
patients have a
hairline that is
usually stable after
puberty and have
normal density and
volume behind it.
These patients,
however, are often
unhappy with this
situation. The
appearance of a high
hairline makes them
look masculine and
older than their
years. The
associated big
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 at a less
acute angle (>30°)
or even
perpendicular 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. This
technique, however,
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 female
density acceptable
to women. In
addition, these
women may have to
wait for 2-4 years
of growth 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.
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.
parallel to the hair
and 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. 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.
By these methods,
this creates a
similar transition
zone as seen in
follicular unit
grafting. It
appears natural and
undetectable.
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.
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 4-6 cm of
advancement. This
is well tolerated by
patients aside from
the cosmetic
inconvenience 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. 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 supraorbital
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 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.
Patients often
report some
decreased sensation
of the frontal
scalp, but this
usually resolves by
6 months. Other
complications have
been extremely rare.
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